Friday, August 13, 2010

My Teachers From Near and Far

I've just finished week 3 of pediatrics, and I must say that I am enjoying it a lot more than I expected. Our attending, Dr. J, is just fantastic. When I came into the rotation, the outbound medical students warned me that he was a person to be feared on his "bad days", and often was short with them, etc. On my first day of the rotation, he sharply rapped his hand on the cart of patient charts when his student yet again failed to present the patient's clinical progress and physical exam in the correct progression. Rounds with him are tough, because he expects us all to be thorough with our patient interviews and exams, but you always come out of it feeling as though you have learned more. In my weeks with him, he has been not only professional, but extraordinarily kind and gentle with his patients and their families. It always seems as though he has seen everything, almost as if he can divine diagnoses. He knows exactly what's going on with each patient, and which are good cases to see, and which complications should be anticipated. Furthermore, it's effortless for him to spout key information while guiding everyone into doing the work exactly as he wants it done.

Notably, Dr. J is foreign-born and trained. He speaks with a strong accent, has a difficult to pronounce name, and can be unorthodox in his manner of interaction with people. He is not alone in these features - I have had many foreign-born attending physicians who were brilliant, unparalleled in their clinical skills and breadth of knowledge base, but perhaps also have certain features that could make any patient who isn't "in the know" be wary.

Pauline Chen wrote a piece this week on this same issue, discussing the unfortunate nature of this situation. In the United States, there are typically more residency spots per year than there are American graduates to fill them. Usually, those spots will either go empty, or are filled by graduates from foreign medical schools. These graduates, for lack of a better categorization, are typically Americans who attended school abroad (most often in the Caribbean), or foreign-born doctors who attended school in other parts of the world (India, China, Europe, Africa, Central and South America). The second group, simply by originating from countries where academic competition is far more rigorous than in the US, tend to be the cream of the crop for those nations intellectually, and score better on medical exams than even our own medical students and residents do. Having trained abroad, they often have seen a far greater volume of cases than we get to, and are drilled much more heavily on traditional subjects like physiology and pathophysiology than we are. Also, since they may not have had as immediate access to imaging and laboratory studies as we do, their clinical diagnostic skills are often superior. They represent a unique opportunity for American medical students and residents to learn, because we may go our whole residency never seeing a real case of measles or malaria, and those classically tested subjects were most likely bread and butter to them on clinical rotations.

However, I have certainly seen more than a few foreign-trained doctors with a total lack of understanding for the culturally and socially specific needs of the American patient. On my first day of 3rd year internal medicine, there were several new residents in the program who had no earthly idea of which illegal drugs had which commonly used nicknames, and what the various routes of administration were. Nor did they care to ask, because they were too focused on the more immediate, tangible medical issues at hand. I later rotated with an Indian-run suburban family practice group that almost never suggested Gardasil for their pre-teen female patients, and barely discussed it even if prompted. Their reasoning was that good Indian girls don't have sex when they go to college, and it wasn't a conversation that needed to be had, even if just to ensure that those girls didn't become sexually active. (Having attended an American college in a large city, I can emphatically state that Indian girls DO IN FACT have sex in high school and college, they just don't tell their parents.) Discussions regarding psychosocial issues behind dangerous behavior patterns nearly never take place, even while the pediatric and obstetric-gynecologic communities are pushing for increased openness. But again, this is no hard and fast rule - Dr. J and several others I have met all fully investigate these issues, and are sometimes even more skilled than the average psychiatrist in teasing them out.

Pauline Chen brings up one more objective method of evaluating a doctor's abilities, better than the name of the med school a doctor graduated from, or where he or she did her residency, or what the scores were on all the exams. She points to the board certification, which is the designation of a physician who has demonstrated mastery in his or her specialty, as deemed by the Board of that specialty. Usually this involves a written exam, and often an oral exam as well. It is a rigorous process which is completed after completion of residency and/or fellowship training, and re-certification has to be done every 7 to 10 years (depending on the field). It is a super expensive exam to take, and if you're the only doctor for miles, it doesn't have much value because people will come to you anyways. So while not being board-certified doesn't indicate lack of competence, having it does allow some degree of assurance of knowledge and skill in the specialty.

The problem with board certification is that virtually nobody in the general population even knows what the heck it is. Even amongst people who have some connection to the medical world, like family that has seen you through the process or people working in the field, it is very easy to confuse the MCATs (med school admission test), the Step 1 Boards (at the end of 2nd year of med school, testing book knowledge), the Shelf Exams (following each 3rd year core clinical rotation), the Step 2 Boards (during 4th year of med school, testing book and clinical knowledge), the Step 3 Boards (during first 2 years of residency, testing clinical knowledge), the in-service exams (yearly testing during residency, for your specific specialty) and the Board Certification exam. Oh, and state licensing, which is when you register with your state as a physician and they license you to practice, and you can now write prescriptions without having another doctor co-sign with you. When a friend seeking a primary doc decided he wanted a board-certified internist, he still had no idea of how to search for such people in his area, and then figure out if they took his insurance or not.

So, I suppose the point of all of this is just to say that there is no 1-click way of knowing which doctors are competent for your needs. Do you research to narrow it down to a few people that fit your needs, then try each person out. Sometimes, it's hit or miss. But the foreign-trained physician gems are there, and far more of them exist than we give credit for.

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