DNR/DNI

It's been a long time since I've last posted! I've quickly come to realize that being an intern is FAR more time consuming than it was to be a medical student!

I've finished nights, worked a few shifts in the ED, and now back on the wards. I definitely love the wards the most!

I'd like to touch on a topic we discussed in conference today- the issue of DNR/DNI. For those that may not know, this is the "Do NOT resucitate/ Do NOT intubate". When a patient is admitted into the hospital, as housestaff (and I can only say this for medicine, since i'm with the Dept of Medicine), at the end of our progress notes, we put down code status. This should be in our admission notes and our daily progress notes. This is done so that we know, as well as cross covering doctors know, the patient's wishes. That being said, it is definitely not an easy task to do. Of course, if I have a younger than 50 year old patient, I automatically assume that the patient is full code. This is definitely not the right way to approach this, but for the most part, a young, healthy individual should NOT want to be DNR/DNI, otherwise, I would probably get a psych consult.

But for our older patients (and of course as the population ages and we see more in the hospital), it is not such an easy task. For some patients, it's clear that they should be DNR/DNI. Their quality of life would be so significantly impaired if they were to code and survive, although most likely, these very sick patients wouldn't survive. But for others patient's it's not so clear. And even in those that we think are "clear", we as physicians don't decide, it is left up to the patient.

So the question now is, what is the right way to approach a patient about their code status? You would hope that for older patients, especially those with multiple medical problems or end stage diseases, this topic should be brought up well in advance to a hospital admission, preferably in the ambulatory care setting, but unfortunately, this isn't always the case. I have now walked in to quite a few patient's rooms on admission, and when I asked them if anyone has ever talked about their code status, they say, "no". This puts me in a bind. This person has never met me, and here comes this young doctor asking if they want hospital staff to do "everything they can" to keep them alive. Often, patient's are not even quite sure what that means. Some even think that by becoming DNR/DNI, that means withholding care- which is definitely NOT the case.

I had a patient the other day who was quite old, more than 90, with severe COPD, diabetes, and multiple other medical problems. This kind of patient is SO common in the hospital! Well, she was definitely "with it", no dementia, very alert. So I brought up code status with her, especially since she was having a COPD exacerbation and very well may need intubation if she starts to deteriorate. She told me that no one had ever talked to her about it. So I sat down and explained to her what "coding" meant, what we do, and that she can refuse these treatments. I tried not to be too graphic, but of course, it's hard to explain to a patient what a chest compression is without actually saying that we pump the heart by pressing on the chest, likely with enough force to break the ribs. I tried to explain as non-medicalese as possible what the process what, and she could opt out if she'd like. She decided that she would like to be DNR/DNI since she would not want a tube put down her throat to assist her breathing.

How much should be told to the patient? Should we even discuss the actual process and what it entails? Or should we just discuss what their expectations of "life" is, and whether they feel that by being on a ventilator, they wouldn't not be happy living their lives the way they'd like?

I'm not exactly sure of the answer to these questions, and apparently, I wasn't the only one. Even the residents didn't have a "great" way to do this, and they've done it WAYY more times than I have. So if there are any readers out there who have any insight to this, I'd greatly appreciate it. I know there are books and papers out there on this, but I think hearing it from the public may be the best answer.

Cross Coverage?

As I mentioned in my last post, I am currently on night float, and my responsibility is to cross cover all of the patients on the floor. I've learned some really important things over this last week and a half on night float.

1) Patients, especially really sick patients, get even SICKER at night
2) My upper level residents are great and always willing to help me out no matter WHAT time I call them
3) Cross coverage can lead to many issues that remain un-resolved and may actually impair patient care

This post will focus on dealing with the last point the most. As many people are now aware, residencies are required to adhere to an 80 hr work week for their residents (thank goodness for that!) But, there are some logistics issues with this that make it difficult to come up with the "perfect" system where both the residents are happy, doing good work, and patient care is not being compromised. The way things are set up at many hospitals to make sure the 80 hr rule isn't violated is to keep residents from taking overnight call, and instead having a cross-coverage come in and watch the patients. This is not a bad system in that in decreases the work load on the residents during the day allowing them to work better and more efficiently when they are at work. Everyone needs rest. BUT, the shortfall to this system is when the patients are signed out to cross-coverage without adequate information passed along to the night float, or even any other cross-coverage that occurs on other days/weekends as well. Little things get missed and not passed on from person to person which may end up adding to a big problem. Some things are avoidable, and other times when a patient starts to crash in the middle of the night, nothing could have been done to prevent it. My point is for those situations where SOMETHING could have been done earlier.

To make a comparison here: at my medical school, the on-call team actually admitted patients overnight, and cared for their own patients as well, while a nightfloat took care of all the other patients on the floor. Here, at this hospital, the on-call team does not stay overnight, therefore a nightfloat covers all the inpatient teams and admissions are also done by nightfloats. Both systems have their shortfalls and benefits. First is that with the second system, residents get more time off to make sure 80 hrs is not violated, and they are well rested and in a good state of health the next day for week. The shortfall is that every night, ALL inpatients are taken care of by a night-float who is not intimately involved with the patient's care. With the first system, residents are tired the next day after being on call all night, but at least their inpatients were taken care of by the actual team making sure that their issues are well known to the team. But, on the other hand, all the other teams' patients are covered by a nightfloat, so still the same problem exists. There really is no way to resolve this issue since a nightfloat coverage is needed otherwise EVERYONE would have to stay EVERYNIGHT to cover for their patients. It seems the best thing would be to make sure everything that needs to be done, followed up, etc be done PRIOR to the team leaving and not leaving tasks like that to be done by night float. A good, informative sign-out document should be passed on so that night-float knows what's going on with the patient if he/she gets called in the middle of the night.

I wonder how other programs have addressed this issue, or maybe this is just a problem across the board now with the 80 hrs. So that's my issue for the day. Soon, I'll be back on days, and no longer have to sleep in a coffin during the day and will hopefully get to see the sunlight!

Becoming a Vampire

Well, after some time on the wards, which turned out to be a great two weeks learning experience, I have now changed my rotation to nightfloat. I essentially work 8:30 PM-7:30 AM for the next two weeks. My job is to cross cover (ie: take care of all the inpatient teams) and keep the patients alive until the primary team gets back in the morning.

My first night was from hell. The pager did not stop going off until about 3 am. And even after that, I barely had time to sit down and think. That was offset by last night which was much smoother. I had plenty of time to do the work I needed to do, respond to intermittent pages, and even do a little reading! Yes, reading up on disease management etc. is NOT an easy thing for an intern to fit into the schedule. One must be SUPER efficient to actually be able to get some reading done, or have a nice, calm, night. That being said, I hope I didn't just jinx myself.

So in contrast to my last post, where I was having difficulty deciding on whether a plan of action was just too much for a patient, I had an interesting experience from the opposite perspective the other night. One of my patients actually was going downhill, and FAST. We were running out of options on the floor, and decided the patient probably needed to be transferred to the ICU for further managment. At this point, we had to think about what was our best plan of action. This patient was 90+ years old, but the family wanted FULL CODE status. The patient also had severe dementia making it difficult for us to establish was a baseline mental status was, although according to the daughter and the nurse, by the time I saw the patient at his/her worst, he/she was apparently well below baseline. My resident and I both felt that an ICU transfer should be done since the patient was full code, but the odds were not in the patient's favor of survival. On the other hand, the family insisted we do "everything we can" to save the patient's life. I can't pass any judgement on issues such as these for a few reasons. First, I have never been a family member in this particular situation so I wouldn't know how I'd react myself. Second, I don't have enough experience as a physician to compare to other situations where another patient's status was similar, and an outcome had already been established. That being said, I felt that this patient probably would be best managed without invasive treatment, do everything we can minus full code, and provide comfort care if it came down to that. This is opposite to what the family wanted. So of course, without any other advanced directive, this patient had to be transferred to the unit and most likely required intubation and a host of other invasive treatment modalities.

That was just one piece of my first night as a night float. On top of that, this occured 10 minutes BEFORE my shift should have ended, which means I ended up staying at the hospital much later than I anticipated. I hope all turned out well for the patient and the family, but I'm not quite sure what happened.

On a happier note, I did get to go to the Charles River to watch the fireworks display last week! It was beautiful. Even despite the rain, and the cold weather, we managed to have a good time and enjoy the company around and the show. Boston truly has some spectacular scenery. I also got to spend some time out by the pool on Sunday on my day off. That was nice. During the end of my last year of medical school, I managed to spend many hours by the pool, or on the beach in the carribean, and 3 weeks of work in the hospital under flourescent lights has already managed to rid me of my tan and make me look like a ghost, or better yet, a vampire since I'm now awake all night- and sleep during the day (but I promise I do NOT sleep in a coffin!!!)

When is too much really too much??

When I was a medical student, I felt that my "job" really consisted of 2 things. 1) I was responsible for talking to a patient. Getting to know them. Taking a great history, doing a full physical. Trying to gather EVERY single little piece of data possible to try to figure out how our team could possibly help this person suffering from whatever ailment they would have. 2) I would put the above information together, and come up with a differential diagnosis, diagnostic studies, labs that needed to be ordered, as well as come up with a treatment plan based on what I've learned in the countless hours I've spent reading books, notes, journal articles, etc. What I never really had to do as a medical student was actually IMPLEMENT most of what I would write down as my plan. We have the luxury of putting all types of treatment, no matter how invasive or possibly unnecessary it was. All it was for us was a learning experience, and it was to help us think of all the possible options.

Now as an intern, things are definitely different. First thing is, I don't have NEARLY the amount of time I used to have as a medical student to spend time chatting with my patients, gathering every piece of information I could possibly gather, and doing a COMPLETELY thorough physical exam. Of course, I will get as much history as I can, especially the information that would be pertinent to the case, and I do a complete physical, but focus it primarily to those organ systems involved with the disease process for each specific patient. ll of this while being paged by the nurses that someone's heart rate is in the 150s and someone else's potassium is too high. Then comes the diagnostic imaging, labs, and treatment plans. Cost is now something that I need to think about too. Before, it didn't matter what I wrote on the chart really, but now, when I order something (radiology, blood work, etc), someone's got to pay for it. This makes me think of the best approach to take, without wasting resources to come to a diagnosis. As for treatments, some patients should not have the most invasive procedure available just because it's an option, but rather based on each clinical situation.

Case in point. I will change some of this information around so that I don't violate any HIPPA rules here. Plus, I'll be vague. A patient that I'm following is nearly 100 years old. Although there are medicines that treat his/her condition, he/she seems to be failing these treatment options currently, and I'm starting to feel like I'm not getting anywhere. I've spent HOURS researching his/her disease, coming up with treatment options, deciding what path is next, discussing the options with my resident and attending, and even the patient's family. Of course, there is some definitive treatment, BUT it's highly invasive and for this patient, it just may not be appropriate at 100 years old. Plus, there is the whole issue of DNR/DNI. As a medical student, we learn about these ethical issues, but we don't need to actually DEAL with them. Now, I'm being faced with making some decisions of whether taking more invasive routes with this patient is really worth the risk. Of course, as an intern, I'm NEVER left alone to make these kind of decisions (THANK GOODNESS!!) and I have an extremely supportive resident and attending to help in this process.

The question becomes, when do you just cut your losses and decide that enough is enough?? Is the right thing to just try and manage this patient with medicine, despite the fact that it hasn't worked as well as we had hoped so far, and just see what happens? Also, there's the issue that the LONGER a patient like this stays in the hospital, the more likely they are to get sick with some kind of infection, pneumonia, etc.

Needless to say, this patient is very cute at around 100 years old. I've had this patient since my first day on service as a real doctor. Losing him/her would probably be a big blow for me, considering how much time I've invested in the treatment, planning, discussions, and research for the best option available to him/her. Our team is doing our best to help this patient get back to him/her previous status, but it seems like a rough road so far. We'll just see what happens....

And in response to the comments left by Paul, I am VERY careful when I cross the street at Brookline and Longwood :) I find that despite the "walk" signal across the street from me, I still dodge traffic every time I cross the street! Also, yes, the CIO must be great!

First Day of Work!

Wow! That 3 letter word just about sums it up. What an experience! Being an intern is extremely different from being a medical student. People actually EXPECT you to DO stuff for them, like give pain meds, talk to families, etc. Things that medical students weren't paged for before.

That being said, my first day went by great! I have a phenomenal resident who took the time to sit down and go through EVERYTHING with me. Everything from how to use the computer, manage my time efficiently, and even what to say/do for the pages I got as the cross-coverage intern (covering other teams patient's after they left since I was on call). Surprisingly, we made it home by 11 PM, MUCH earlier than expected. I even ended up doing 2 admits, AND two discharges along with all the other work for the day!

Some things of note.
1) The computer system is AMAZING!! Everything is efficiently at your fingertips. All the systems seem to complement each other, data is constantly saved, and putting in orders for your patient are easy as a few clicks. Even printing out prescriptions is automatic, I just click the print button, and sign away!
2) Ancillary and nursing staff are second to NONE! They truly are the backbone of this hospital. If the physician wants ANYTHING done, he/she can put the order in, or tell the appropriate person, and it's DONE! This is definitely something that wasn't as easily done back down south. Although, of course, this has something to do with personnel staff, and sheer numbers of them.

Well- apparently internship also causes a person to not be able to complete posts!! So now, I've basically gone through a whole cycle on the wards, gotten a better grasp of the computer system, and trying to improve my clinical knowledge!

Some interesting differences between my new hospital vs my old is the way the teams are made. At my medical school, once a patient is admitted to a hospital inpatient service, that patient is now the patient of the ward attending. All the residents, interns, medical students, etc all work with only that ONE attending on the service. This makes things much easier. My understanding was this hospital that I am currently at was more or less like that system as compared to an older system where many different attendings could admit to a ward service. I guess my assumption was incorrect. Although MOST of the patients on our service does get covered by our firm attending, despite them having an outside physician, there are still some patients who are followed by an outside attending which means I've got to call them and inform them of the status of their patient. THAT'S annoying. I don't feel like I'm learning much on those patients from the attending. I'm teaching myself about those patients and their conditions, and of course my superb resident who is also a great teacher teaches me as well.

Oh, one last thing, the upper level residents I've worked with so far are AMAZING! Their clinical knowledge is phenomenal for their level of training... I am very impressed. And, this also makes me hopeful that one day, I can be like them!

Hello Bean Town!

So I'm finally here! It's definitely been a huge adjustment to move up here from the south. First thing to note is... last week, on thursday, it was in the upper 50s!! For the middle of June, that's downright insane! And, of course, I don't have any clothes for that kind of weather with me here such as a light jacket... oh well. It's better now.

Living in the city has been great. To be able to walk everywhere, use the T, and to have the whole city just under your fingertips is absolutely amazing. What a great concept! Of course, being a southerner, I could not part with my car so I've left it with family in the suburbs. Although I don't expect to use it much, when I do, I will be grateful to have it and not rely on public transportation to take me from state to state.

The hospital is amazing. That being said, the whole medical/academic area in Boston is amazing! To have that many hospitals, higher education schools, and research centers jammed into a 3 block area is fascinating. The work that comes out this area is simply phenomenal, and blows my mind away. The hospital itself is impressive. Although they are older hospitals, there have been many renovations, new buildings, improvement, and countless pieces of technologies built into the system that makes it truly a first class hospital. Everyone that I've met so far has been very nice, welcoming, and seem to be great people to work with. Although I haven't actually started working yet, that will start this coming weekend.

My apartment is perfect from the hospital. Less than a 10 min walk! Now THAT'S a novel idea. I would never have had that luxury in Louisiana where I had gone to medical school, or even to the ones in New Orleans. Living within a 10 minute walk of either location is probably not the safest places to be. To make things even better, at nights, I can hear the crowd at the Red Sox games!

Well, that will conclude this post for now. I will add more as we get deeper and deeper into the hospital and orientation wraps up. Oh, just a side note, we have been asked to choose our "benefits" package. For me, this is a first. I've never held a job where I've had to do that... what a strange concept! It REALLY is a REAL JOB! Which also means, I've got to become a REAL doctor soon enough!!!

hiatus

Sorry- have been MIA for a while. Will be on vacation for at least a week. I expect to have some new topic probably after I get back!

Thanks Ancillary Staff!

Today, I just wanted to briefly discuss the importance of ancillary staff in a hospital system. Sometimes, we forget (yes, even the med students) how important the ancillary staff is within our hospital systems. There are many things about our hospital that surely need some change, improvements, modernization, etc. but one of the really great things about our hospital is the efficiency of our ancillary staff (phlebotomists, respiratory therapists, transport, etc.). I did an away elective in a large, public hospital in NYC (which will go unnamed), and never have I seen such inefficient, and unavailable ancillary services. When I thought our hospital was not great, this made ours look like a gem. Transport was impossible to find (I had to wheel patients down to scans, interventional suites, ultrasound rooms, etc). Blood draws were done every 6 hrs (I believe), and if you needed a blood draw at any other time, a nurse would not do it, it was the MD or student's job to draw the blood. Not that I am opposed to the idea of doing blood draws, but as an intern or a resident, spending an hour or more a day drawing blood is not time well spent. For a medical student, it is a learning experience that I am willing to do, but I also have work that I need to complete in order to complete the requirements of my rotations. At our hospital, the patient's nurse will draw the blood if it is needed at times other than phlebotomy rounds.

Of course, nursing staff can be very varied (from excellent, to awful), but the same can be said about the doctors too. There are also some nurses who will ignore, or even yell at, medical students when we ask them for something. If I ask politely, and it is really something that I cannot do or do not know where to find, would it hurt to be helpful?? I don't think so. That's all I have to say about that really. I think the problem really lies in the type of hospital, institutional funding, and nurse's pay. I can understand how at a private hospital, not only the nurse's but also everyone else, needs to work their hardest in order to make the better pay, and keep their job. At the public hospital, apparently, that's just not the case. So all we (as medical students and residents) can do is just swallow it and deal with it. Either increasing nursing pay, or increasing nursing staff, may help alleviate some of the problems, but quite frankly- I don't know what else can be done in a public hospital where in order to get fired, you'd basically have to intentionally kill someone.

So that's all I have to say about this topic for tonight. I just wanted to remind everyone that next time, you see someone from ancillary staff doing their jobs "behind the scenes"- thank them for a job well done. It makes the hospital run much more like a well oiled machine. And for those poor residents and students in NYC- I feel for you, but then again, I was smart enough to turn down my interview offers for greener pastures :)

Handwashing

So today, I thought I'd vent a little about one of my biggest pet peeves- the LACK of handwashing that I observe all the time. This is not strictly pertaining to the healthcare community, but I'll focus mostly on them, and add a few words for everyone else.

As we all know (or hopefully know), handwashing is one of the BEST ways to prevent spreading infections from one person to the other. Some history "The first progress in combating infection was made by the Hungarian doctor Semmelweiss who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweiss, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths" So, everyone should know that by washing hands between EVERY patient, we can decrease infection rates throughout our patient populations. Hospitals are now trying to track data, educate employees, have signs, etc all of which should help improve handwashing rates- but it seems that we're still not anywhere near 100% compliance. Everytime we walk into a patient room, the FIRST thing that should be done, while saying "hello!" should be handwashing. As a medical student, we must do standardized patient exams (fake clinical encounters with real actors/actresses which are then graded) and as part of the evaluation, you get one check mark for washing your hands before touching the patient. I also have a habit of washing my hands when I exit the room- the way I see it, I've performed a physical exam on the patient, probably have some type of bacteria, virus, fungi, whatever, on my hands, and should take it off right away. Even if my next stop is to the nurses station, I want my hands clean- I definitely don't want to get sick by carrying microbes with me everywhere I go.

Of course, handwashing takes about 30-45 seconds or so. One can also opt for the antimicrobial gels, lotions, creams, etc that also work quickly without having to waste time at a sink, followed by drying hands and wasting paper towels. Of course, those antimicrobial agents are expensive for the hospital when you consider how much would be required if everyone just used those rather than handwashing- but what is the extra expense when you compare it to the cost of ONE line infection that requires the patient to stay and extra 5-7 days, PLUS antibiotics? I'm sure the benefits outweigh the risk in this case.

To further elaborate, I have seen all "fishes of the food chain" not adhere to handwashing rules. That goes for medical students, nursing students, PAs, PTs, nurses, residents, attendings, and chiefs. I am pointing no fingers at any one person, we are all guilty (and I am by no means a saint- I'm sure I've forgotten sometimes as well). The important thing is that we must try to make changes and improve our compliance. Some things that I've seen and/or read about that seem to help are: The VA system has an anti-microbial foam at the entrance to each room- just one dab and you're good to go. Sure- these are somewhat costly, but again, doesn't it seem that the cost would still be less than the cost of increased hospitalization time? I've also seen signs posted around the floors- maybe there needs to be more signs, maybe even signs in the patients rooms, on the doors, chart racks, wherever people would be more likely to see them. I've even read that some hospitals who allow staff to issue "tickets" to people who are caught not washing their hands- these "tickets" must then be signed by their supervisor which would surely not be a good thing.

I don't know which way is the best way, but different measures need to be taken to improve this issue. Surely, there are other ideas floating around somewhere.

As I mentioned before, this does not only apply to healthcare workers. I also see people walking in and out of the bathroom (men's bathroom in my case) who will use the facility, and then walk out without washing their hands. In our microbiology class, I had the pleasure of plating some of that "stuff" from the handles in the bathroom, and let me tell you- it's NOT pretty. I even go the extra mile and have the paper towel ready to go, so that after I wash my hands, I will turn off the faucet WITH the paper towel, and also use the paper towel to open the door. Sure, maybe that's excessive since once I get outside, I touch things again, but hey- better than nothing. People eat at restaurants, leave the establishment without ever washing their hands. Same goes for handling babies, or pets. It's something small to remember, but can make a HUGE impact.

I'll close with this link that has some good information on handwashing and infection rates. Also, it links to some real data that backs up the statements made. Let's all try to improve infection rates one handwash at a time.

$4 prescription plans

Disclaimer: I am in no way affiliated with the companies mentioned below, nor do I receive any kind of reimbursement for endorsing any of their programs.

Ok- so now that's out of the way, I'd like to discuss the $4 Rx plans put in place by Target and Wal-Mart. Although I am definitely not a big fan of the corporate world "big fish eating the little fish", when it comes to medications for our patient population, this is a great plan!

Basically, the premise of this program is that both companies offer certain medications that are available in the generic form as a $4 a month Rx, regardless of insurance plan (or for that matter uninsured), or income levels. I cannot express the number of times I have walked into our clinics, ER, inpatient rooms, etc and taken a patient's history only to realize that many of the times, the reason they are in the hospital is because of medication non-compliance. Although I've never actually performed any statistical data on it, I believe the most common reason I get from my patients for not taking their meds is "doc- I just couldn't afford it". That being said, I do note that many of our patients continue to smoke, drink, chew tobacco, etc. all of which are pretty expensive habits anyway- further decreasing their funds for purchasing medications. Well- now we have a plan that allows our patients to purchase their monthly supply for only $4! We have had other Rx plans available to our patients, long before these plans were available, that allowed them to receive certain medications in a 3 month supply for only $20. Well, with this plan, a 3 month supply still SAVES them $8! Not only do I recommend my patients who do not have insurance to start filling their meds that are available for $4 at either of these two stores (I don't prefer one over the other- as long as they take advantage of the savings), but I also have started to recommend it to my patients who do have insurance, my parents, family friends, etc. Many insurance plans offer copays of $15, $20, or $25 and up for 1 month supplies, when some of these medications are available for $4 regardless of insurance type.

Of course, the downside is some of these medications are older medicines, and new meds in the same class are now in the market with studies backing them up that show better efficacy- but how does better efficacy help a patient who can't afford the medicine in the first place? I'd prefer to put them on the older medicine that they will be able to afford, and improve compliance, and have a SLIGHTLY diminshed efficacy- overall, it still benefits the patient more than not taking any medicine.

So what did I do last month while I did an inpatient rotation?? I carried a list of those medications in my coat pocket (short coat of course), and discussed with my patients about changing some of the medications that they were having problems affording to comparable ones that they would be willing to pay only $4 for. Turns out, I changed some medications for quite a few of my patients on the wards, with the hopes that with the decreased cost, they'd have better compliance rates, and hopefully keep them out of the hospital for longer periods of time. Interestingly, this can be something that can easily be studied- determine compliance in a survey prior to the changes in medicines, measure objective parameters of overall health, determine reasons for admission to the hospital, then on follow up after discharge, see how the objective parameters improve and do a repeat survey to see if compliance has improved. Also, you can determine if the time between admissions increases most likely due to improved compliance especially for our "chronic admissions" that we all see at most hospitals.

In short, I would like to say Kudos to both Target and Wal-Mart for such a great plan. I hope that this may help our patients (from all income levels) improve their compliance due to overall decreased costs. That being said, MDs have to also do their part in reviewing a patient's medications, and determining if changing the medications to a less expensive alternative is a feasible option.

I suppose after I move to Boston, I will see whether or not the patients over there (where I assume many DO have insurance) have similar comliance issues because of cost. Does anyone else have any opinions on these plans? Do any of you take advantage of the $4 plans?

And it Begins...

Hello all!

I just wanted use my first post to briefly introduce myself and explain the rationale behind why I've created this blog. I am currently a fourth year medical student- about to graduate and become a "real doctor" in just about a month. I'm fairly new to the blogging world, and I've tried before to have a blog that was more about me- and realized that writing about me wasn't as interesting as I had hoped. So instead, what I've decided to do is write about my transition from becoming a medical student to becoming a doctor and what changes that I have to go through. On top of that, I want to write about healthcare issues that I have seen everyday during my last few years in medical school, and issues that I will be faced with in the upcoming years as an intern, resident, and full fledged physician.

As for some background info on me- I have been fortunate enough to have experienced many different places during my 25 years on this planet. I've spent the first half of my life in different parts of NJ, the second half in a suburb of New Orleans, with a short stint in North Louisiana for medical school. I will be starting a residency in Boston this summer, with the hopes of experiencing a new and exciting way to learn and practice medicine which I may one day be able to bring back to Louisiana when I'm all done.

What I would like to do on here is recall and write about things that I've seen, both positive and negative, with the healthcare system that I've been exposed to as a medical student. During my residency, I will be able to compare my medical school experiences to those experiences I will have in Boston, and hopefully draw some conclusions as to how we can make improvements in the delivery of healthcare in Louisiana. Although I know this is constantly discussed on the news and such, as a person who will have the opportunity to experience such a big difference in location, I hope that I can add a different perspective to the mix.

Most people who know me will attest to the fact that I talk "too much". Although I don't quite agree (well, maybe a little), I think using the WWW as another medium for my thoughts may help to curb the excessive verbage from my mouth :)

Lastly, I'd really like to hear input from others who may read my blog (if any...) The perspectives from both medical, and non-medical people are important factors when trying to implement changes that affect people on both sides of the line.