Oh...Dr. Brooke?

There's something that happens once you start medical school and you go home to visit your family for the holidays. Every family member asks you about their health, no matter that you usually have no idea what they are suffering from. No matter when you explain you are just a student, only in your third year, and that you really won't learn anything until you finish residency, and at that point, you will only know what you specialize in. No matter, you still get barraged with questions. One family member launched his questions just as I stepped into the door with the statement, "Dr. Brooke what's this thing growing on my upper lip." So I peer in between the gray hairs of the mustache, looking intently like I am trying to decide from a long list of possibilities what this little growth may be, and have to admit, "I don't know what it is, you need to go see you doctor." Then I get an incredulous look, with the underlying and implied response being, "God don't you know anything?", and "What are you paying all that money for?" and "Are you sure you're in medical school?"

And in fact, I am constantly being reminded at how little I know. Sure I knew at one point, right before I took a 4 hour exam, and right after which it all disappeared from my short term memory in preparation for the next cram session. The things that have stored themselves in my long term memory at this point are only the diseases that are associated with actual patients that I have seen and taken care of in the last 6 months. And because I have just started the third year of clinical rotations, there are not a lot of patients and their stories in my head quite yet. There is really something to be said for apprenticeship however, it works! Too bad I can't just start an apprenticeship in physical medicine and rehabilitation. Nope, have to continue learning all about all aspects of medicine, and if I did a rotation in dermatology, then I may be able to answer my family member's question about that little growth on his upper lip.

So sometimes I have no idea what my family member is suffering from, and at other times, I hear my family talking about medical things that are way off from the actual truth, and then I have to figure out how to explain it in a way that is not condescending. Take something another family member said to me, "You know there are cancer cells in mother's milk." I just took a deep breath, and thought about correcting her, and then thought about how I would go about explaining what cancer really is...and gave up before I even tried. So many times I have heard people in my family say that medicine will never cure cancer because "they" make too much money off of cancer! That's one statement that I have no interest in even taking a bite of, so I just nod my head, and say something lame like, "You know cancer is not one disease. It depends on which type of cancer you have, and each one is so different, and it depends on the cell type...." all the while watching the eyes glaze over, and my family member moves on to their next attack on the health care system.

Today I heard about how ridiculous it is for a blood test for testosterone to cost $600. Of course I do think that's an insane amount of money, but I couldn't come up with a good reason why it would even have to cost that much. Must be a very specific test, one that has to be sent out to some special lab. I just bought my husband a book called "Money Driven Medicine, Why US Health care Costs So Much," and I'm hoping to read it myself, and maybe I will be able to answer the question about a testosterone test costing $600, maybe not.

I think what I am realizing is that I thought that once I started learning medicine I would start to KNOW things, you know, like what is that growth on the upper lip, or what cancer is, or why a hormone test is so expensive. Instead I am constantly feeling like a visitor in a foreign country. The language sounds familiar, and I've heard the words before, but my short time in the medical world means I still don't know the answers. And even if I did, maybe when I am here visiting family on vacation, I would choose to not know the answers, just so I could have a break, and be the person I used to be.

PM and what?

So I'm here in Bend OR for a rotation, but this time I get to help others heal not their minds (did a psych rotation back in Sept), but their bodies.....Vague, yes, because that is the problem I am having when it comes to telling others what kind of medicine I would like to pursue. It's unfortunate that I can't just roll off one word from the tip of my tongue, like surgeon, or pediatrician, with the subsequent complete understanding of the receiver. Everyone knows what a surgeon is and what they do, and the same applies to pediatricians, OB/GYNs, family docs, cancer docs. I'm sorry to say that I can't so easily just roll one word off the top of my head to describe the very very very specialized type of doctor I would like to become.

If you have been following this blog for awhile (not sure if any of you are still out there), then you probably know or at least have heard before about physical medicine and rehabilitation, or physiatry, or PM & R. Now, I am fortunate that most doctors know what I'm talking about when I say that is my chosen field of practice. But a lot of my fellow students don't know about it, most likely because my medical school does not have a residency in this area of medicine, which translates to there being ZERO exposure to the field. There are two advisers at my school that are physiatrists, twin brothers in fact, and they have been my tenuous link to this field in the past two years. I did find out about another doc in this field over at the VA, but after I had already been at OHSU for almost 2 years. I met with him once for 15 minutes, but was unable to continue the connection (he never returned my emails, so I gave up).

I'm very happy to say that I have been working for the past 3 weeks in Bend with a group of (get this) 6 physiatrists, and they have been fantastic. Each one has gone to a different residency program, so they have been a wealth of information about the training programs, as well as about the field in general. I haven't seen anything yet to turn me away from the speciality - in fact, I so enjoy going to work everyday with them that I can't imagine myself doing anything else.

So what do they do exactly? The PM&R Association website states "rehabilitation physicians are medical doctors who restore maximal function lost through injury, illness, or disabling conditions, and are experts in diagnosing and treating pain." That about sums it up, and there is a long list of conditions that physiatrist treat including stroke, spinal cord injury, traumatic brain injury, amputations, arthritis, work injuries, back and neck pain, to name just a few. So the question is, how can I easily describe what I want to be to those that are not in the medical field? I tried to tell my husband's cousins once, and after using way too many words, one of them replied, so you're going to be a physical therapist? Oh ya, and if I cut it way down and say I'm going to be a rehab doctor, most lay people think I mean drug or alcohol rehab. Sigh....

Understand that it's important for me to figure out how to describe what I will be doing for the rest of my life because I already feel such a great divide between myself and those in my life that are not in the medical field. With each new medical concept I stuff into my brain, I find it harder and harder to talk about everyday things. It's like my husband and other spouses of my fellow medical students notice about our medical school parties - we all get together and talk about medicine.

So I would like to take a vote for all those who are still reading this blog. Here are some ideas about short succinct ways to describe a physiatrist. Let me know what you think!

I'm going to be:

1. A doctor of physical disability

2. A doctor of muscle and nerve injuries

3. A doctor of physical medicine and rehabilitation (this hasn't worked so far)

4. A pain doctor

5. A doctor in between a neurologist and a orthopedic surgeon

6. A doctor of physical function

7. A doctor of injury

8. A doctor of musculoskeletal medicine

Any other ideas, just shoot them my way! Cheers!

Money

A friend of mine in med school recently said to me that "you need to be rich to go to medical school," in response to the financial struggles she has had in the last few years. While I don't think you do have to be rich, there is an element of truth to her statement. Either you have money, or are able to borrow as much money that is needed for this long process. And the payback for this grand investment is not so great these days, as physician salaries have not keep up with the increasing cost of being educated. The American Medical Association reports that public medical school tuition went up 133% since 1984, and up 50% for private medical schools, preventing low income/minority students from entering medical school, and therefore decreasing the diversity of our physicians.

A patient of mine last week asked me if I was going to be a doctor so that I could be rich, and I had to chuckle.....the days of being rich as a doctor are way over, unless you 1. are incredibly bright and want to spend 10 more years after medical school learning how to cut into people's brains (neurosurgeons make the most, averaging $541,000 per year), 2. you create some durable medical device that can make money on the side, 3. you get paid by pharmaceutical companies to market their product (which is going by the wayside due to an "anti-pharm" movement from within the profession).

But before I get into physicians salaries, let's talk about what it costs to go to medical school. For OHSU, yearly tuition runs about $36,000, and most students take an additional $14,000 per year for living expenses. So that's $50,000 per year, for four years, leaving one with a balance of $200,000 for just medical school. If you have any undergraduate loans already accumulated, that is just added onto the top. According to the American Medical Association, in 2008, the average medical student in the US graduates with $154,000 of debt, and 80% of graduates have debt over $100,000.

There are a few issues that come up in the process of even getting the student loans. First, there is a minimum of amount that the government will guarantee to loan a student that does not have the money to pay. This is determined yearly by filling out a form, where you list how much money you made (if any), and if you are still supported by your parents, how much money they made in the previous year as well. This allows the government to determine who should get the loans, which have a pretty decent interest rate of about 6%. These government loans however, do not cover up to the $50,000 needed for a year of medical school. I'm not sure of the exact amount, but at least $15,000 has to come from private lenders, and for this you have to have good credit. If you happen to have bad credit, too much debt, or don't have anyone else to cosign for you to get the additional funds, too bad....no med school for you. Or you could always give up four years of freedom after residency by joining the armed forces, which two of my classmates did do, just so that they could pay for medical school.

So once you have secured the $50,000 you might think you are in the clear, that all will be just fine financially for the next four years. Not so. There are many other expenses that come up during medical school that are not accounted for in the financial aid packages. First, the cost of books. Yes there is some money in the student "budget" to allocate for books, but this amount definitely does not cover the cost of getting the long list of new edition books that are either required or recommended for each class. For this reason, many students either 1. don't get any books at all, and just use the syllabus to study from, 2. buy older used editions from upper classmates that are full of highlighting, 3. use their grocery money to buy books.

You see, the additional $14,000 per year is not a lot of money to live off of....because with that you have to pay for rent, car expenses, utilities, groceries, not too mention the balances of medical expenses you may have. Yes, there is a health care plan that comes with the tuition, but it is a deductible plan, where the student/patient has to pay out of pocket....all from that just over $1,000 per month that is left over after tuition is paid. Fortunately for me, I have a husband with a job that can support me while in medical school. And for anyone who happens to be a non-traditional student with children, you have to support your family on that measly monthly amount, leading again to a lack of diversity amongst our physicians.

In addition to books, there are A LOT of expense associated with the licensing process in becoming a doctor. You have to register for the board exams you are required to take during medical school (step one costs $480, step 2 costs $1,500, plus a plane ticket to fly to LA to take the practical board exam). Then in order to even pass the exams, you need to buy practice test question banks (step one costs $350 for 3000 questions, step 2 costs $500 for 3300 questions),not to mention the high yield exam books that are needed for review, because no student has the time to use the books we had to buy for our individual classes. You need the more succinct bullet type review books, a condensation of all we learned in the first two years.

Then there is the expense of applying to residency. Just like the expenses associated with applying to medical school, there is a flat fee for the first 10 programs that you apply to, with an addition amount added for each program above 10. The baseline cost for the online application is only $65 (phew!) with an additional $8 or $15 or $25 per program depending on how high you go. I heard of a current 4th year student that applied to 127 programs.....that comes to about $2,700!! Of course most students don't apply to that many programs....I think the average is around 15 - 20.

In addition to books, exams, and application expenses there is the HUGE expense of flying all over the country for residency interviews. If you are fortunate enough to go to medical school on the east coast, your expenses will be less because you can drive to many places that you need to interview. For us here in OR, we are not so lucky, as most places are far enough away that a plane flight is necessary, as well as a hotel stay. Now, you might think, people fly across the country all the time for job interviews, what's the big deal? It's the number that matters. Just like applying to medical school, you have to anticipate a certain amount of attrition at each level of the process.

It is recommended that you "rank" at least 10 residency programs. That means that you have interviewed at those ten places and liked what you learned about their programs. But each place only has a certain number of positions open for interviews, and not every interested student gets to interview. So, you have to apply to many many more than you will even get an invite to, in order to make sure that you can rank at least 10 programs in the end. So, that usually means you should apply to 20-30 programs, hope to get invited to at least 20 interviews, and actually attend about 15, in order to eventually put down your list of top ten.

So that means flying to 15 different programs, each of which will give you the limited months and days with openings. Fortunately, many programs will try to accommodate you if you know that you will be in the Chicago area for one interview for example, by interviewing you when you are in town. I don't know yet how much this process will cost, but I have heard estimates around $5,000 depending on how many programs you interview at, and how spread apart the programs are. I have heard that you can take out an additional loan for these expenses, but that the interest rates are high. Go figure.

I am not complaining about all the expenses involved....only trying to clarify it for those who are not aware of what it costs for a student to go to medical school these days. I will finish with around $250,000 in debt, and that's debt that used to be put off until after residency, with no accruing interest. Recently this has changed, in that the loans have to be paid during residency.

So what's the big deal when physicians make so much money right? It's true that doctors do make a very good living, but certainly nothing in comparison to corporate CEOs - the real money is in business. The top doctors (neurosurgeons) can make up to $800,000 or more, but there are very few of those. Most family practice doctors make between $128,000 and $200,000, so no wonder why many students are staying away from primary care because they are wondering how they are going to pay off their debt, have a family, buy a home and dependable car, and live the American dream. I wish that I could have given that patient that asked me if I was going to be rich all this information. Maybe then she would know that going into medicine these days is not about the money, it can't be. It's about doing what you love, taking care of others, and making those darn student loan monthly payments. Cheers!