Month: November 2010

If only healthcare was as easy as getting a manicure…

During the Thanksgiving holiday, I had the opportunity to get my nails done.  As I visited the nail salon, I could not help thinking how easy it was to walk into a new city and find a place to get your nails done.  While I knew of this place primarily through word of mouth, it was also highly recommended on Yelp. As one Yelper writes, My favorite thing about this place should be the amazing decor and time and attention each nail tech puts into his/her work, but it’s actually the owners that make it great. I love seeing them each time I walk through the door. I tend to arrive right before they close, and they never turn me away, or hurry the service along.”   Here are a few things that I noticed that healthcare could learn from.

  • Customer-oriented– As soon as I walked in, I was offered my choice of beverages and asked to pick a color which there were many to choose from. 
  • Access to a technician – As soon as I was done picking my color, my nail technician was ready for me – no wait!  There were over 40 seats and almost all of them seemed filled on this busy Wednesday before a holiday.  This place was not a small shop but a large well oiled machine.   
  • Certification prominently displayed – All the nail technicians certificates were on the wall and actually their state certification number was listed as part of their badge.  For one nail technician who forgot her badge that day (or maybe it wasn’t made yet?), she wore a paper name tag with her number on it.  It definitely provided me with some reassurance that these were trained professionals.
  • Teamwork – The first step in getting my nails done was a lotion and heat treatment which was applied first by one technician.  After that was done, the nail technician sat down and asked me whether I how short I wanted them and I responded with ‘short.’  
  • Benefits of a large employer – I got in a conversation with my nail technician and found out that she had been working there for six years.  In fact, this nail salon was a chain of 12 nail salons all over the country primarily associated with malls.  While she did previously own her own nail salon, switching over to be an employee at the large nail salon meant that she could focus her attention on doing nails and did not have the hassle of running her own business. The benefits were good and she also had flexible hours so that she had the resources and time to care for her sick grandmother.
  • Focus on perfection – Before she applied the nail polish I selected, she confirmed that this was the nail polish that I indeed wanted.  Before she applied the coat, I went ahead and paid as to not ruin my nails.  After my nails were done, my technician walked me over to the nail dryer and brought my shoes and purse so that I would not have to ruin my freshly glazed nails. 
  • Open to feedback – While at the nail dryer, there was a comment card for feedback that you could turn in to reflect on your experience.   
  • Affordable – With all this great service, I was expecting to pay a pretty penny and was pleased that it was only 12 dollars!

Alas, if only healthcare was this simple.  Getting your nails done is also a splurge or luxury and certainly not an essential health benefit.  After all, there are not ‘emergency’ nail salons open 24 hours for nail emergencies that will take anyone no matter how poor or ungroomed they are.  Moreover, the nail technician did not need to take a detailed medical history, reconcile my medications, review my preventive care, and perform a thorough physical exam, and complete additional paperwork to ensure proper payment.  Of course, what’s interesting is that it’s certainly not out of the realm of the possible.  A recent study (aptly named the BARBER-1 trial) showed that men who receive preventive care at the barber shop had lower blood pressure.  The promise of health benefits during barbershop visits has been the impetus for longstanding programs like our own community’s Project Brotherhood.  I doubt we’ll be mixing pap smears and nail salons anytime soon, but it is a place where health screenings have been performed with referral to medical providers.  After all, nails are the window to the certain health diseases and no mention of healthcare and nails would be complete without a run down of some of the famous ones. 

 –Vineet Arora, MD


Is Medical Education Oppressive? Expert Failure, Social Media & Other Lessons from AAMC 2010

I spent the majority of last week at the Association of American Medical Colleges.  This was my first time attending the majority of the meeting and it did not disappoint.  While there is lore that some authors are not good speakers, this was definitely not the case with Malcolm Gladwell. Using vignettes ranging from the Civil War to the downfall of Bears Stern and recent financial crisis, he eloquently described what happens when ‘experts’ fail.  Experts fail due to miscalibration, not incompetence.  Miscalibration results from overconfidence when one perceives they have perfect information.  This is certainly true in medicine, in which overconfidence can lead to diagnostic error through early closure.  

While I was still mulling over expert failure, I attended a very interesting session titled “Flexner, Freedom, and the Way Forward” delivered by Steve Kanter, editor of Academic Medicine and Dean of the University of Pittsburgh. Drawing from the educational pedagogy of Brazilian Paulo Freire, he articulated the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity to one that promotes intellectual inquiry, the freedom to explore ideas, and imagination.  Unfortunately, the current “deficit” model focuses on students as the major problem, as opposed to environment or instructional practices, and is characterized by the famous “P=MD” promulgated in medical schools today. The increasing emphasis on student unprofessionalism, with little attention on altering the environment or examining the role models – positive or negative- that students interact with is another example of the deficit model. 

So, how do we move to a generative model, which encourages more imagination, creativity, and freedom?  Interestingly, one of Kanter’s answers was through the cultivation of scholarly projects, something that he has championed at the University of Pittsburgh.  This was particularly interesting given the explosive growth in schools that now offer scholarly concentrations, including our own.   During an early morning breakfast meeting of schools with ‘scholarly concentrations’,  I wondered if we would reach a Gladwell ‘a tipping point’ where medical school ‘majors’ would become commonplace or whether these would remain a niche for select schools.   

In addition to thinking about how to move forward, it’s also important to think about how we ended up with this model if it is not desirable?  Is it possible that expert medical educators failed to recognize the importance of critical thinking?  Well, a more plausible explanation is conformity is actually desirable.  After all, few patients are looking for ‘creative imaginative doctors’ (often synonymous with quackery).  Instead, doctors are rewarded for ‘standard of care’ and following ‘evidence-based standards.’  Although creativity and imagination are not rewarded in medical practice, it is certainly needed in medical education.  On this centennial of the Flexner report, there were plenty of reminders at AAMC that we still have the same problems that plagued medical educators 100 years ago.  Reasons for lack of progress in this area include inertia, lack of funding, and the perverse incentives academic health centers that detract from the teaching mission. 

But, this begs the question, is medical education ready for creativity and freedom?   Interestingly, while the “mHealth” or mobile health summit was showcasing the latest technological innovations and advances just down the road in DC, AAMC sessions on social media and medical education focused on the fears associated with increasing use of social media among medical trainees.  When full-scale institutional bans were mentioned, students highlighted how this may inadvertently result in a backlash, popularizing these technologies or the creation of an underground.  In the words of one student (per @MotherInMedicine) “You trust us to care for patients, but not to post on Facebook.” Interestingly, medical educators weren’t the only group thinking about social media and professionalism.  At the same time, the AMA issued its new guidelines for social media, aimed at helping physicians cultivate a positive professional online presence without jeopardizing the doctor-patient relationship.  While social media use in medical education continues to be debated, the meeting was a powerful reminder that we need to consider the future practice of medicine in training the physicians of tomorrow.  While we cannot ‘see’ exactly what the future holds, ignoring it entirely would certainly be oppressive and an expert failure.

–Vineet Arora, MD

Healthcare Horrors: Needles, Medical Studentitis & Other Medical Phobias

Every Halloween, I take note of some of the most infamous Doctor costumes, ranging from the mad scientist who created Frankenstein to Dr. Jekyll and Mr. Hyde.  Even if you don’t dress up as a doctor, there’s enough medical paraphernalia that contributes to costumes including all that medical gauze for the perfect mummy costume, the skeleton head for your porch, or the fake blood for the perfect vampire or zombie.  This does beg the question, what is it about doctors and healthcare that is scary?  As it turns out, fear of doctors and healthcare is very common.  Here is a short rundown of the more common healthcare-associated phobias.

  • Iatrophobia is a fear of doctors.  Interestingly, these phobias are actually types of social phobias in which the afflicted is afraid of interacting with the doctor, discussing their personal illness, or being examined.  Some suggest that ‘white coat syndrome’ or higher blood pressure in the doctor’s office is part of this syndrome.  
  • Dentophobia is the fear of dental care or dental procedures.  Unlike iatrophobia, this is quite common and some sources cite estimates as high as 75% of Americans suffer from some form of ‘dental fear’. Some suggest this is actually a variant of post-traumatic stress disorder due to the pain associated with a prior dental procedure.  Not surprisingly, the dentist’s professional demeanor is also important.  Anyone scared of Willy Wonka’s dentist dad in Tim Burton’s Charlie and the Chocolate factory?
  • Nosocomephobia is fear of going to the hospital, which is either related to fear of death or could also be related to fear of contracting illness or disease (germophobia initially described in JAMA in 1910) and may be a variation on obsessive-compulsive disorder. Of course, it is important to distinguish this pathological fear from normal concern since hospitals are reservoirs for germs and disease and hospital associated infections are on the rise
  • Pharmacophobia is the fear of taking medicine, which is often related to fear of rare side effects due to a medication.  This can sometimes manifest itself as medication ‘noncompliance’, which doctors often assume patients are intentionally not following directions.  It is also often associated with prior adverse drug events.  Perhaps the best known pharmacophobia is currently manifest as the fear of vaccines in which it is not the fear of the needle (see below) but the fear the risks of vaccination like autism or that the flu shot causes the flu.
  • Needle phobia is a very common phobia.  Some estimates say at least 10% of Americans are trypanophobic, and are likely to faint during a needle stick.  This may even be an underestimate since those with needle phobia are not likely to seek medical care.  This is a very serious phobia since needle phobia is characterized by very low blood pressure and shock when presented with needles, and there have been reports of patient deaths.  Unfortunately, people with needle phobia often avoid recommended vaccinations and blood tests, placing them at higher risk of illness.
  • Nosophobia is the fear of contracting disease.  Perhaps the most classic example of this occurs in medical students (typically in their second year) who believe they or others around them are suffering from the symptoms of the diseases they study.  Medicalstudentitis was reported as early as 1964, and it is still alive and well.  One study estimated 80% of students suffered from this and a Facebook support group even claims 1000 members.  Nosophobia can also manifest itself in patients who spend a lot of time online searching for causes of their symptoms.  Cyberchondria is a type of nosophobia the unfounded concern that common symptoms are harbingers of serious disease due to online searching.

While these phobias may sound harmless, exaggerated or silly, it is actually important to identify people with these phobias and help them seek professional treatment early.  Patients with healthcare phobias are likely to avoid seeking care for actual symptoms which places them at higher risk of morbidity and mortality.  Now, that’s a scary thought!

–Vineet Arora, MD