Monday, September 20, 2010

RESOLVED, Joining the AMA

So far, I have been to two events associated with the AMA (American Medical Association). 

One event was the first local chapter meeting, held by the Massachusetts Medical Society (probably best known for its publication, The New England Journal of Medicine).  It was one of eight annual meetings, entirely student-run, and attended by several dozen students from the four medical schools in Massachusetts--Harvard, Boston University, Tufts, and the University of Massachusetts.  After giving the newcomers an overview of the organization's history, membership, and goals, the governing councilors had break out sessions to learn more about advocacy and policy, community service, leadership, and membership.

Our school chapter receives quite generous funding from the AMA and the MMS to hold events and lectures, organize community service activities, and attend national conferences. 

The AMA has a shaky reputation for being overly conservative to some, both among inside and outside the profession.  At its peak in the 1960s (when it spent heavily to block Medicare), it encompassed about 70% of physicians.  Today, it represents less than one third of physicians, and about half of those are retired.  The AMA remains opposed to any national insurance health care plan.  Although it eventually supported the recent health care reform bill, it successfully lobbied against the 5% tax on elective cosmetic surgery.

The AMA founded the Student American Medical Association (SAMA) in 1950, to provide medical students a chance to participate in organized medicine.  However, in 1967, SAMA cut ties from the AMA and became the independent and student-governed AMSA (same words, rearranged).  The organization took stands on more typically social justice medical issues, such as civil rights, universal health care, and global health.

Both the AMA and AMSA are represented here at HMS.  I understand the reasons for creating a separate student chapter that consists of more like-minded members (such as pursuing certain goals without facing resistance at each step), but I want to stick with the AMA.  I believe the best way to help control a system is to do it from within.  The AMA is an organization that reflects the views of its members, and if we want certain views represented, then it is best to participate.  The AMA encompasses students.  It specifically has different chapters for medical students, residents, "young physicians," and physicians, in which each group can mingle with those in their own or those outside their own.

Recently, drafts of student resolutions (which will eventually be passed along to the AMA) were due.  Over 40 ideas were presented, including an opt-out organ donation policy, improved student health insurance standards, disability resource services, promoting a standard nutrition education for primary and secondary schools, interstate Medicaid cooperation, and broader regulation of direct-to-consumer genetic testing.  Interestingly, only about one fourth of the resolutions applied to medical students.  The rest applied to society at large.

Though I am certain I want be a participating member of the AMA, that doesn't mean I don't have mixed feelings about the organization in general.  The AMA is a special interest group, and it protects the interests of its members.  Because of its lobbying efforts, I will enjoy a high salary, job security, and a certain amount of autonomy.  But tell someone (even another physician) that you are part of a lobbying effort to keep doctors' salaries high, and you are painted in a certain light.  Somehow, I get the feeling that unions for other professions are seen as more necessary and "legitimate" than unions for doctors, since we are seen as more privileged and powerful. 

But to get to where we are today, a lot of people needed to be self-interested.  To stay where we are, a lot of people still do.  Admittedly, I probably would not enthusiastically undertake these efforts myself, but I will be the first to admit that I appreciate the benefits, whether I approve of the methods or not.  I am grateful that because of them, I have the opportunity to help shape policy for those in less fortunate positions.  At the local chapter meeting, a second year student from HMS submitted a project grant application requesting funding for a community service activity in which medical students prepare and serve dinner for a local residence for cancer patients and their families.  It was unanimously granted.  It's a small step, of course, but I can firmly say this represents my views.

Saturday, September 11, 2010

Testing, Testing

Our first exam is on Monday.  It covers two weeks' worth of biochemistry and molecular biology, which is about the equivalent of half a semester's worth in undergrad.

It is pass/fail, only out of 40 points, and we get nearly unlimited in-class time for it.  It's not really a matter of getting a high grade on it.  I guess, in the back of my mind, I am worried that I am going to fail.  Fear--not neuroticism or gunnerism or pride--is what's motivating me to study for hours on end.  I need to prove to myself that I didn't get in here solely because my application was "unique"--that I did cool things like science journalism, that I wrote a passionate personal statement, that I was able to charm my interviewers.  I need to know that I can also master the material itself, which is the real reason I am here (despite what I hear from others about how "necessary" or "relevant" the nitty gritty details are to practicing medicine).

Our class has gone above and beyond in cooperation.  On our class email list, old midterms, study guides, flashcards, and group meeting opportunities circulate.  It's actually possible to feel overwhelmed by those alone (and I do!).  With a pass/fail system, there is no reason to hide anything--we share the mentality that we do what we have to do to get ourselves and our classmates to pass.

It is interesting living in a nearly all medical/dental student dorm, where everyone is on the same schedule.  We are away from the main campus, so we study here, in our class building across the street, or at the library next to that.  We live on a block filled with hospitals.  Basically, within this radius, it is all medicine, all the time.

So far, I've gone out to greater Boston at least once a week.  This is the first time I've stayed within this medical bubble.  It is very different from undergrad, where you could hear what you were missing right outside your window.  (Now, all we hear are hospital sirens and helicopters.)  You don't have roommates or classmates on different schedules tempting you to go out for the night.  Here, it is perfectly acceptable to say to the girl you see in the bathroom on Saturday morning that all you did was study last night.

My classmates had originally scheduled a global health meeting for today and just cancelled it because we have a test on Monday.  This is starkly different from undergrad and from "real life," where opportunities present themselves and you have to make decisions about them.  Here, with 200 others in precisely the same boat, we don't have to make those choices and can pause things at will.  This isn't the kind of reality I am used to.

Monday will be the new Friday, and I mean that as literally as I can.  Here, we set our own calendar and thus our own reality.  The world--undergrads, grad students, patients, people--is not our world right now.  We're a class--a cult in the best sense of the term.  I love the cohesion, but at the same time I am concerned.  I had forgotten that today was September 11.

I already feel myself not having the energy to explain the details of my day to my outside family and friends.  Maybe after this exam is over, that will change.  But after dozens more, will it still?

Tuesday, September 7, 2010

An Arm Inside and Outside the White Coat

The last few months have been filled with firsts. On the second day of school, we received our white coats, initiating us into the profession. A few weeks later, we wore those white coats to interview our first patients in the hospital. We have taken our first (and second and third) finals. We have attended clinics, listening to patients struggle with Huntington's disease, alcoholism, and androgen insensitivity syndrome. We have made our first incisions on our cadavers' backs... and our last ones to get to their eyes.
In other words, we are becoming acculturated.
Right now, there is not much that separates us from the patient that is in room 206 of Massachusetts General Hospital, other than the fact that we anticipate one day caring for a patient in a room 206 somewhere. With that anticipation comes a code of behavior that we are learning now, years before we enter that room.
It is not merely about respecting the patient, listening to our colleagues, empathizing, and so on. As members of a profession--a medical culture--we actively shape the image we present to the public, and that image reaches beyond the confines of the workplace.
Our professor gave an example of this new responsibility. "Let's say one day you're on the shuttle with your classmates and you're talking about what you observed in the ER. 'It was the coolest thing!' you might say. 'There was blood everywhere and this guy's leg almost came off and...' It's perfectly normal--and not bad at all--for you to feel that way; you're excited by what you're learning and experiencing. But think of the passengers on the shuttle who overhear your conversation. They are going to think that you--and that doctors--sound incredibly callous."
It is an interesting concept: that our professional identity follows us even during after hours, and that there are boundaries that have been drawn--fairly or unfairly--not directly by us. Is there ever a reprieve? Should we watch what we say at the gym? In the supermarket? To our non-medical friends at a dinner party? Did I really sign up for something so all-encompassing?
For me, the question became pertinent fairly quickly as I realized that blogging fell into one of those gray categories. Before my first post, I solicited advice from my professor about the levels of appropriateness. Certainly, explicit details about patients were off-limits (due to violating HIPAA), as well as specific names of professors or individuals. But what about opinions on medical education or patient care, drawn from my observations in classrooms or on the wards? What about recounting a good patient encounter? And--more difficult--what about a bad one?
My professor told me that being a medical student means that others are very interested in hearing about our experiences as "insiders." She told me that I have to remember that when I am writing for others, what I say reflects on the profession and even may shock some, and so I should be sensitive about what I share. When I asked my society advisor, she admitted it was a tricky question and suggested that I ask permission from those I mention fairly explicitly. "People aren't going to trust you enough to talk to you if they think you'll have no restraint in writing what they say," she said. (Oh, the irony that I now quote her!) "The classroom would no longer be a safe place."
But otherwise, there is little policy or precedent with regard to social media. It is new turf, and its boundaries are being tested by those of our generation.
Are we really writing from inside the white coat? It's a grandiose claim, and one I surely don't deserve nor want yet. But I am not taking it entirely off either, because what I write about is inextricably linked to knowledge accessible only because I am allowed inside this coated world. What exactly does my pen owe that world?
Many questions remain. With time (and with some faux pas, no doubt), I hope to strike a balance. Maybe I'm only partially dressed at times, with one arm inside the coat and acculturating and one arm outside, writing about it.
So we write and interact in this new medium, with what I hope is caution, thoughtfulness, and sensitivity. It is the best we can do for now.