Friday, January 29, 2010

My Sister's Keeper

I just watched My Sister's Keeper and I did like the movie- I enjoyed watching it and felt it was a thought provoking story- but the glaring in-accuracies threaten to send the wrong message regarding the use of Pre-Implantation Genetic Diagnosis and the ethics surrounding solid organ transplant.

Now, Pre-Implantation Genetic Diagnosis (PGD) is a technology that can be used to select certain embryos for implantation in the mother. Just as described in the movie, a sibling may be "created" in this manner and specifically selected to be an HLA match to an ailing child.

But, normally, the cord blood is harvested, and that's typically where the use of the new sibling for "spare parts" ends. Once the cord blood has been used in a transplant, the sibling would not typically serve as a bone marrow reservoir. If the bone marrow transplant failed the sibling would NOT be a repeat donor.

Also, from my limited experience with transplant medicine, I've seen that PGD is NEVER used for the purpose of solid organ transplants. The doctor in the movie seemed that he would be on-board with the transplant, and the use of the younger sibling for this purpose. In real life, a doctor would NOT agree to this. Kidney donors are carefully selected, not just for their biological compatibility, but also for the emotional ability to cope with being involved in the transplant process. Organs are NEVER taken from an unwilling individual.

So, it was a sad and moving story, and I enjoyed the move for that, but it sends the message that PGD is used to create "spare parts" and gives the illusion that this technology presents ethical quandaries that in fact do not exist. Anyone reading this blog can be assured that American children are not currently being forced to give up their spare kidneys. Even if a (minor) child begged to give his or her kidney to an ailing sibling, the kidney would not change hands (abdomens?).

Monday, January 25, 2010

Health Care Issues

I watched a Dateline episode yesterday; the subject was Healthcare and the detrimental effect it's having on patient care. It really brought to light some of the actual problems with an insurance industry hell-bent on profits, but it also brought to light some of the problems that surround end-of-life care and the expectations of families.

There was a heartbreaking case- a man with cancer wanted to enroll in a study that promised cutting-edge treatment unavailable through other channels. Of course, the study covered costs directly related to the study, but outside of that, the man's insurance was supposed to kick in. And, his insurance company refused to pay for expenses related to the desired experimental treatment. There were some appeals, and the insurance company ultimately decided to cover him. But, by that time, the man no longer qualified for the study as he had gotten sicker.

The patient got sicker and sicker, and his wife spoke of a traumatic day when he took a turn for the worst, and she was supposed to make decisions regarding his code status.

The insurance company managed to avoid paying some potentially large bills by delaying the man's care. But, the wife seemed under the assumption that this care would be life saving, and that the insurance company had in essence killed her husband. And then, for reasons unknown to me (based on the fact that I was only watching this on television and have only one side of the story), the wife seemed unfamiliar with DNR/DNI and code status. She described the day her husband took a turn for the worse; a "crash cart" had appeared and she was reportedly asked to make some fast decisions.

From being in the hospital, I remember talking to the family of an end-stage cancer patient. They did not want to make the patient DNR DNI because the patient's daughter had seen a code when she was with her mother in the emergency room, and as she said, "It really works!" Her mother was virtually comatose, and a code was likely to bring nothing more than broken ribs and more heartbreak. The family saw DNR DNI as equivalent to doctor assisted murder.

The insurance companies are so hell bent on profit that care is often refused or delayed; but millions are spent every year on end of life care for patients for whom a medical code is more cruel and pointless than anything else.

But, as someone who believes that discussion of a patient's code status is important, and furthermore that DNR/DNI is sometimes a good thing as opposed to a failure of medical care, I am a card carrying Death Squad member.

I feel terrible for the woman on Dateline; while I think that the case illustrated important issues surrounding code status, it also shows that families of the critically ill are forced to argue and fight with insurance companies. A lot of wasted time and heartbreak, and the big picture is lost.

Friday, January 1, 2010

Step 2 CS

There are 3 board exams required for licensing. USMLE Step 1 is the first. This is taken after the second year of medical school and covers all the knowledge acquired during the first two years. Neuroscience, genetics, pathology, pharmacology, physiology, epidemiology, and microbiology are some of the subjects included. It's the hardest of the 3 exams, and the score counts the most. The average score is roughly 220. That's the three digit scores. Then there's the two digit score, a mysterious number that isn't a percentage or a percentile. 75 is passing. I have a 230, which correlates to a 98. I'm not sure how one relates to the other.

Some residency programs have "cut off's" and supposedly won't even consider lower scoring applicants. These tend to be the more competitive programs- the ones on the "ROAD" to happiness (Radiology, Ophthalmology, Anesthesiology, Dermatology) as well as Ear Nose and Throat, and Neurosurgery. I'm really not sure how hard and fast these cut-offs are, but I do know that when our Step 1 scores were released, one of my classmates sadly decided that Neurosurgery wasn't in the cards for him. Another was convinced he would never be an a Radiologist. The former chose another field, the latter is a second year Radiology resident.

Step 2 is taken after third year of medical school, the clinical year. It comes in two parts, CK, or Clinical Knowledge, and CS, or Clinical Skills. It's a little easier, and covers mostly clinical medicine. The score for Clinical Knowledge is also given out as a three digit, and the mysterious two digit, score. It's mostly important for those who feel they didn't do well enough on step 1. My score was again, a 230, and this time, my two digit score was a 95. Step 2 Clinical Skills tests students on their patient interactions. Each student must pay over a thousand dollars to interview, and perform physical exams on, actors.

Step 3 is the final test, usually taken during, or after, intern year. It's supposedly the easiest of the three steps, and supposedly, the score counts the least.

Anyway, I'm studying for CS right now. The patients are actors so in many cases they don't have actual physical findings. So, they act. If a patient is supposed to have a heart murmur, he or she will say "hush hush hush" when you put the stethoscope over the chest. No air going into the left lung? The patient holds his breath while moving his shoulders up and down as you hold your stethoscope over the left lung.

And, if you laugh, this means you lack empathy. Laughing puts you in danger of failing, in which case you will have to pay over a thousand dollars to take the test again.

I hope I don't laugh.