Best Articles 2011

8/2/2019 Best Articles 2011

1/57

Emergency Medicine: The Good, the Bad, and

the Ugly

Mark Reiter, MD

Posted: 09/30/2011

Emergency medicine (EM) is a fast-paced, team-oriented specialty where you can have atremendous impact on your patients. Emergency physicians are experts on diagnosing andmanaging the acute, undifferentiated patient.

The landscape of the EM workforce has changed tremendously. Only a few decades ago, most USemergency departments (EDs) were staffed by physicians with no EM training. Many of these

early physicians had little interest or expertise in EM.

EM residency training began in the 1970s, and the American Board of Emergency Medicine wasrecognized in 1979. Dramatic growth in EM residency programs boosted the number of EMspecialists now staffing EDs throughout the country; about 70% of emergency physicians are EMtrained, according to a 2008 study.[1] In addition, the study shows nearly all (98%) emergencyphysicians who graduated within the past 5 years are EM trained.

Before you opt for a career in EM, it helps to understand its many advantages, such as the ability towork flexible schedules and see a variety of cases, as well as its challenges. Here are some prosand cons you might consider.

Advantages

Feeling like a "real" doctor. Emergency physicians are trained to handle virtually anyemergency. Although many patients require additional care (for example, surgery), the emergencyphysician has the tools needed to begin the management of any acute medical condition or injury.You will manage sick patients every day and have a major impact on their lives. You will have theopportunity to perform many procedures, both routine and life-saving.

Making the diagnosis. EDs have become the diagnostic centers for the healthcare system. Patientscome to the ED to find out what is wrong, and we can often make a diagnosis during the ED visit

that could take weeks or longer in an outpatient setting.

Variety. Emergency physicians see a tremendous variety of patients, including babies and elderlypatients, the critically ill and the worried well, pregnant patients, psychiatric patients, and peoplefrom every walk of life. Emergency physicians manage patients with all types of medical andsurgical illnesses and injuries. Within a few hours of a shift, you may reduce a shoulderdislocation, manage a cardiac arrest, evaluate a suicidal teenager, place a chest tube for a tension

8/2/2019 Best Articles 2011

2/57

pneumothorax, manage a multiple trauma moving vehicle collision, and evaluate a 3-year-old anda 90-year-old for abdominal pain.

Flexible schedule. Emergency physicians typically work 8-12 hours at a time, at all hours. Due tothe intense nature of EM, emergency physicians work between 1500 and 2000 hours per year.

Most EM practices do not have on-call time. This allows emergency physicians to have time off,often during the weekdays, to pursue outside interests. Many emergency physicians work part-timeor take extended vacations, and it is not uncommon for an emergency physician to devote time toother professional pursuits such as administration, leadership, research, education, orentrepreneurship.

Chance to build teamwork and relationships. Emergency physicians work closely withemergency nurses and ancillary staff, other emergency physicians, the medical staff, and manyother members of the healthcare team. A successful ED has excellent interpersonal staffrelationships and works well as a team.

Compensation. A greater proportion of emergency physicians (65%) -- compared with 53% ofphysicians overall -- feel they are fairly compensated.[2] Emergency physicians typically work moreintensely for fewer total hours compared with other physicians and enjoy above-averagecompensation per hour.

Challenges

Stress level. Emergency physicians work very hard, often managing many critical patients at onetime. Some patients will die in front of you. You will see patients who are victims of child abuse,rape, or other terrible situations. Litigation stress is common: emergency physicians are the fifthmost likely to be sued compared with other specialists.[3] It is widely speculated that emergency

physicians have high rates of "burnout" and shorter effective careers than other physicians.However, according to the 2008 AMA Physician Masterfile, the emergency physician attrition rate(including death) is only 1.7% per year, lower than the 2%-3% average of other specialties. [4,5]

Difficult patients. Emergency physicians handle more "difficult" patients than most otherspecialties. Our patients and their families are typically under strain from their acute medicalconditions. Sometimes they will treat the emergency physician, who they typically have never metbefore, inappropriately. Many of our patients are intoxicated or have serious psychiatric problems.Some of our patients are homeless, prisoners, or have been released from every medical practice intown due to inappropriate behavior. Violent, out-of-control patients often threaten and sometimeseven assault members of the healthcare team. As the "safety net," the ED sees everyone who

comes through the door, no matter how they have treated us in the past.

Difficult physicians. Unfortunately, emergency physicians are sometimes mistreated by theirphysician colleagues. EM is a 24/7 operation, and many of our patients require hospital admissionor consultation. We deal with uninsured or underinsured patients, some of whom have complicatedmedical or social situations. In response, emergency physicians are sometimes treated poorly bytheir physician colleagues, who may be upset about being contacted during off-hours to helpmanage a patient that they might not otherwise take into their practice.

8/2/2019 Best Articles 2011

3/57

Practice settings. Less than 33% of emergency physicians work in private groups. The majority ofemergency physicians either work directly for the hospital as an employee or work for a national orregional practice management/staffing company. Emergency physicians in these practice settingsmay have less autonomy, earn less compensation, and have fewer practice rights (because of lackof due process or restrictive covenants).

Crowding. ED patient volumes continue to rise each year. The National Hospital AmbulatoryMedical Care Survey estimates that ED visits have grown from 94.9 million in 1997 to 123.8million in 2008.[6,7] This 30% increase is about double what we might expect from populationgrowth. Instead, EDs are becoming more crowded as a result of an aging population, higher acuity,more regulation, and more available advanced testing. In addition, hospital inpatient capacitycontinues to decrease, which ups the number of inpatients in the ED. In many EDs, patients wait along time and are seen in hallway stretchers during peak times.

Inconvenient schedules. Although many emergency physicians enjoy flexible schedules, they dotend to work many evening and night shifts, as the ED is a 24/7 operation with highest volumes in

the evening. Many emergency physicians, especially as they get older, find it difficult to work latehours and often frequently change shift times. In addition, the ED must be staffed on weekends andholidays, so we often miss family and social activities due to work responsibilities.

Lack of continuity in patient care. Although this is a common concern among medical studentsconsidering EM, few practicing emergency physicians consider this to be a significant drawback.The emergency physician can always follow up on a patient on their own, and our sickest patientstend to make many return visits to the ED.

References

1. Ginde AA, Sullivan AF, Camargo CA Jr. National study of the emergency physicianworkforce, 2008. Ann Emerg Med. 2009;54:349-359.Abstract2. Medscape Emergency Medicine Compensation Report: 2011 Results.

http://www.medscape.com/features/slideshow/compensation/2011/emergencymedicineAccessed September 26, 2011.

3. Kane CK. Medical Liability Claim Frequency (AMA Center for Economics). August 2010.4. American Medical Association. FREIDA Online. Available athttps://freida.ama-

assn.org/Freida/user/specStatisticsSearch.do?method=viewDetail&spcCd=110&pageNumber=2 Accessed September 26, 2011.

5. Ginde AA, Sullivan AF, Camargo CA Jr. Attrition from emergency medicine clinicalpractice in the United States. Ann Emerg Med. 2010;56:166-171.Abstract

6. 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS).http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdfAccessedSeptember 26, 2011.

7. Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of USemergency department visits, 1997-2007. JAMA. 2010;304:664-670.Abstract

8/2/2019 Best Articles 2011

4/57

How Can I Get Enough Sleep During Med

School?

Graham Walker, MD

Posted: 04/04/2011

Question:

Sometimes I can't sleep, and other times I'm afraid to sleep because of the amount of work that Ihave to do. How do I fit in quality sleep during medical school?

Response from Graham Walker, MDResident, Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York,

NY

Sleeping well -- or at least enough -- is a challenge for medical students and even for physicianslong after they've finished a grueling residency. If it's not the long hours, it's a late call in themiddle of the night or the tossing and turning while you worry about a patient you saw on theprevious day. At the same time, notsleeping well sets you up for a rotten next day filled with brainfog and the mistitration of caffeine. One of the most frustrating things is knowing that you need tosleep but feeling wide awake. What are we to do?

Ask any sleep specialist and they'll tell you that it all begins with good "sleep hygiene." That termrefers to the behavioral and environmental factors that precede sleep and that may interfere withsleep. To improve your sleep hygiene:

Avoid stimulants and depressants starting 6 hours before your bedtime (some would evensay after noon). The goal is to prime your body to be appropriately tired at just the righttime.

Don't take naps. As great as they feel, they're going to mess up your sleep cycle. Don't study or do anything else in bed besides sleep. This helps train your body so that

your bed is the place where you sleep, and getting in bed means "time to get sleepy."

Dark, quiet, and cool conditions are most conducive to falling and staying asleep.

You can find more recommendations at the University of Maryland'sSleep Disorders CenterWebsite.

So that's how to fall asleep, but how can you fit it into the demanding lifestyle of a medicalstudent?

8/2/2019 Best Articles 2011

5/57

Like everything, it's all about balance. When you hear people talking about having a balanced life(social life, academic life, work life, family life), they never mention their sleep lives. You get 24hours in a day to do with as you please, but sleep affects your ability and motivation to do whatyou want in other parts of the day. Sure, you can be the all-star in rotations and studying and stillhave a social life, but if you're sleeping 1 hour a night you will fall asleep in lectures, overdose on

coffee, and feel cranky all day long. Making sleep a priority is vital to performing wellin life.(Think of it this way: If you're getting a good night's sleep, you'll be energized the next day andless sluggish. You could potentially get more done because you're efficient.)

When it's late and I'm studying, I try to recognize my own limitations and the law of diminishingreturns: You can only cram so much into your head in one evening. The later it gets, the less ableyou are to concentrate, analyze, and store the information that you so desperately want. Do youever find yourself staring at a page trying to read but finding your mind constantly wandering?Alert! Alert! It's tired! Sleep helps you consolidate and lock in facts that you've been learning allday. If you don't sleep, what's the point of all that studying?

That said, even the most dedicated people have times when they simply have to cram. Try thismethod next time: Study until you start to recognize those diminishing returns, and then throwdown a bookmark and go to sleep. Set your alarm for a couple of hours earlier than when you'dnormally get up. You'll be surprised how much easier it is to study at 4:00 AM with some sleepunder your belt than it is to wade through information at the end of a long day.

Finding the right way to sleep -- and knowing what your own body needs -- is absolutely critical toyour success as a physician. Experiment with different approaches, and once you find what worksfor you, commit to it. You will be happier, healthier, and better able to cram that last bit ofknowledge into your head to do your best in medical school, residency, and your career.

Now if you'll excuse me, it's time for a nap.

Medscape Med Students 2011 WebMD, LLC

8/2/2019 Best Articles 2011

6/57

Tips for Surviving Medical School

Farook W. Taha; Adeleke T. Adesina

Posted: 02/04/2011

Remember when you were a premedical student in college? It seems like a century ago for many ofus who have just completed the first year of medical school. It feels that way because our liveshave changed dramatically. Normal life seems to have vanished, and suddenly, 24 hours in a dayare not enough to get through the enormous volumes of information that we are expected to learnfor every exam. It seems virtually impossible. We barely have time to eat or sleep.

Medical school is not the end of the world. Take it from us, 2 students who have been there, whenwe say that medical school is what you make of it. Do not let medicine define you; instead, youshould tailor medicine to your lifestyle. Otherwise, you might become overwhelmed by the

demands of your new life and lose the sense of why you chose medicine in the first place.

How do you survive medical school? From the beginning, time management must be a majorpriority. If you can manage your time successfully, you can still enjoy your life to a certain extent.Studying in med school is not the same as it was in college; this is a new world where you have toexplore different techniques and find what works best for you. In medical school, it is all aboutstudying smart, not studying hard. If you don't know this at the beginning, you will learn it the hardway.

Studying medicine is a long process and demands a great amount of discipline and sacrifice. Butthe reward is priceless. We hope that you chose medicine for the amazing field it is: the rich

opportunities it provides for helping humans and the avenues it opens for making a difference inthe world. The following are some of the most common pieces of advice we have collected:

1. Take care of yourself. You may face long-term negative consequences to your health if youadopt negative behaviors. Do not deprive yourself of healthy, fresh food. Do not ruin yourhealth by eating fast food and avoiding exercise. Do not pull all-nighters and deprive yourbody and brain of sleep; the consequences are too severe for what may be only 15 minutesof productive studying. Your brain needs fresh food, water, fruits, and vegetables. Yourbody needs exercise and sleep.

2. Do not compete with your classmates or compare your grades with others. We all had to becompetitive to get into medical school. But once you are accepted, it becomes a level

playing field. Although many students still compete with their classmates, it will not makethem better physicians. Getting a 95% on your pathology exam does not mean you will bea great pathologist or clinician. As soon as you walk out of your first exam, look around,and you will see people obsessing about what the right answer was for Question 13. It iseasy to spot them. They will come to you and ask you if you put "C" for Question 84.Seriously! Avoid everyone after the exam, and make friends with those who share yourphilosophy.

8/2/2019 Best Articles 2011

7/57

3. Answer practice questions while you study. "Studying my notes 10 times is probably thebest way to prepare for exams." Wrong! The only way to test your learning is to do practicequestions. For example, after studying your Board Review Series physiology textbook,make sure you complete the questions at the end of each chapter. This will help solidify theconcepts you just read. Studying the same thing repeatedly does not make you smarter, but

getting a question wrong will teach you quite a bit. Professional educators will tell you thatit is statistically proven that students who do more questions perform better on boards, andthat the only time you should go back to the big books is when you consistently missquestions on a certain topic and the answer explanations are insufficient.

4. Learn the big picture. You will likely start your first day in school delving intobiochemistry, anatomy, physiology, or histology. From the start, instructors talk aboutcolumnar cells, impulse transmission, and glycolysis in fine detail. The next day, you arelearning about brachial plexus and cardiac output. This is an enormous amount ofinformation overload and students are often not prepared. As you memorize, learn the bigpicture

5. Study with groups. "I am going to study on my own because I don't need anyone's help."

Wrong! Medicine is all about teamwork and sharing information. You have to be able tocooperate with others. Even when you apply for residency, it is important to keep thisconcept in mind. The moment the residency directors feel you will not be a good teamplayer or that you might have "issues" with your colleagues, your application goes in theshredder. Find a small group of people who share the same healthy habits as you, meaningthey like to exercise, they do not like to discuss grades, and they have a positive attitude.Once you find the right group, arrange to meet weekly for several hours to ask each otherquestions about concepts you do not understand. Even better, ask each other questions onlittle details you think your friends might have understood. Arrange for a review sessionthe night before the exam for last-minute tweaking of your knowledge.

6. Take time to engage in stress-relieving activities. Everyone in your class is facing thesame amount of stress, some people more than others. You might notice some studentswalk around with a frown, whereas others wear huge smiles. How is that possible if theyare all facing the same pressure? Again, it is time management. If you have extra time, youare able to reduce stress. Spend time with friends, or do something on your own that makesyou feel better. Activities like exercise, yoga, listening to calm music, talking to yourparents or praying -- there is something out there that makes you feel better. Find it and doit. Do not let the stress affect your studies, relationships and, most importantly, health.

Finally, and we cannot emphasize this enough, remember that we are joining a great profession. Bepassionate about what you are learning! Medicine is a treasure and an art. As Henri Amiel said,"To me, the ideal doctor would be a man endowed with profound knowledge of life and of thesoul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by hismere presence."

Editor's note: This was adapted from a book manuscript in the publication process,How toPrepare for the Medical Boards Secrets for Success on USMLE Step 1 & COMLEX Level 1, byAdeleke T. Adesina and Farook W. Taha.

8/2/2019 Best Articles 2011

8/57

Could a Facebook Page Get Me in Trouble?

Megan L. Fix, MD

Posted: 05/06/2011

Question:

Like many of my friends, I enjoy using Facebook, Twitter, and YouTube. How can I keep myonline presence professional and in accord with patient privacy rules?

Response from Megan L. Fix, MDAssociate Residency Director, Emergency Medicine, University of Utah, Salt LakeCity

Facebook, Twitter, and other social networking Websites are fun, and your online identity can beinformative to future employers, patients, or colleagues. But involvement in social media can alsoget you into trouble if you aren't careful. Here are some suggestions for safeguarding hospital andpatient privacy and your perceived professionalism online, both as a student applying for residencyand as a medical professional.

Hospital and Patient Privacy

Privacy is paramount to good patient care. At some point in your medical training, you will learnabout the Health Insurance Portability and Accountability Act (HIPAA), which prohibits you fromgiving out "individually identifiable health information without it being medically necessary --and without the patient's permission.[1,2] Let's pretend you are a patient who has a rash in avulnerable area. You go see a physician and get treated, and that's the end of it, right? Well, itshould be, but I have heard stories of providers posting pictures of rashes, fractures, and accidentson Facebook without the patient's permission. This is a violation of HIPAA, and in many of thesecases, the provider was fired. Your safest bet is to neverpost anything online that is directly relatedto a specific patient.

Unfortunately, unsanctioned posting is common among medical students. About 60% of US

medical school deans report that their students have posted unprofessional content online, and 13%of those deans also report that their students have violated patient confidentiality, according to a2009 study inJAMA.[3] These violations are grounds for expulsion.

If you have questions about what is acceptable to post, read your school's social media policy. Ifyour school does not have a rule -- only about 10% of US medical schools have guidelinesexplicitly mentioning social media[4] -- I suggest that you work with your dean and a focus group tocreate one. (It would be a great addition to your medical school and to your future residency

8/2/2019 Best Articles 2011

9/57

8/2/2019 Best Articles 2011

10/57

1. Health Insurance Portability and Accountability Act of 1996. 45 CFR. 160.103. 2002.2. DHHS. Understanding Health Information Privacy. Available at:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html Accessed April 25, 2011.3. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content

by medical students. JAMA. 2009;302:1309-1315. Abstract

4. Kind T, Genrich G, Sodh A, Chretien KC. Social media policies at US medical Schools.Medical Education Online. 2010;15:5324.5. Wynn P. Brave new world of social media: Social networking is transforming the way

medical students communicate with one another, but is online content meeting professionalstandards? The New Physician. 2010 Jan-Feb;59(1).

Medscape Med Students 2011 WebMD, LLC

Overcompetitive Students

8/2/2019 Best Articles 2011

11/57

Anna Mead-Robson

Posted: 04/12/2011; Stud BMJ 2011 BMJ Publishing Group

Introduction

Most medical students are well accustomed to competition. During bedside teaching, it's almostinevitable that one keen student will blurt out the answers to questions directed at others. But whathappens when friendly competition turns nasty?

"Gunners"

With far fewer residency places than eligible graduates,[1] medical students in the US areaccustomed to competition. There, pathologically competitive medical students are referred to as"gunners."

"As a medical student, you will almost certainly encounter a gunner classmate at some point," saysSara Cohen, a rehabilitation physician in Massachusetts. "Some people use the term to refer tostudents who study much more than average and are especially concerned with grades. The termcan also be used to refer to medical students who exhibit behaviour that is either borderlineunethical or even blatant cheating."

Typical gunner behaviours, she says, include hoarding study materials, ripping key pages out oflibrary books, dominating tutorials, and making comments in front of tutors that are meant to makethe gunner look smarter than their peers.

"Unfortunately, gunner behaviour often escalates during the clinical years because grades are

largely based on evaluations from the doctors observing you. A gunner may try to be the firstperson at work every day and the last to leave. He or she may try to leap in and do every availableprocedure or surgery, even on a patient who belongs to another student."

Sound familiar? A recent unpublished survey of students at a London teaching hospital foundBritish medical students to be just as competitive as their US counterparts. Students reportedstealing other people's memory sticks just before presentations, not informing peers about teachingsessions, and advising staff falsely that other students had behaved inappropriately on wards, orhad not contributed to coursework. Furthermore, some medical students claimed they would bewilling to mislead other students about exam content if they had the chance.

"Last year a friend of mine told me that an OSCE [Objective structured clinical education] I wasabout to take was really hard," says a fourth year medical student at St George's, University ofLondon, who did not want to be named. "We had been studying together for some time, and hetold me that nothing we had revised would come up. I became terrified and went into that examsweating and shaking. But it turned out he was lyingit was a very straightforward series ofstations that we were both well prepared for. I am quite sure he deliberately tried to scare me sothat I would perform badly compared to him. The sad truth is that I might have done the same had I

8/2/2019 Best Articles 2011

12/57

taken the OSCE before him. I don't think there's anyone you can trust at medical school when itcomes to exams. Even your best friend might be willing to lead you astray."

Obsessive Personalities

What leads some medical students to such extreme measures? "Competitive behaviour has a rangeof drivers," says Phillip Hodson, fellow of the British Association of Counsellors andPsychotherapists, "firstly the personality of the student, but equally important is the system theyare working in, which includes their family background as well as medical schools themselves."

Some students, he says, have an obsessive personality that predisposes them to competitivebehaviour. "These students have a narrow mindset that says that the most important thing in theworld is to succeed. Their number one focus might be to get a certain exam grade, or to get a job ata certain hospital. Students from successful families may be particularly afraid of failure. Theworst case scenario would be a student whose parents were both successful medical professors.That's an awful lot to live up to."

Working within a competitive environment is highly stressful, says Phillip, particularly for medicalstudents who are desperate to succeed, but also for those affected by their peers' aggressivebehaviour. "Stress isn't always a bad thing," he says. "Humans need a degree of stress in order toperform, but beyond a certain point it can impair function, and ultimately it causes burn out. Alllife needs balance. If all you do is study then you're not really going to have a lifeand you'reprobably not going to be a great doctor."

As competition to get into medical school in the UK is high, medical students may be particularlyprone to obsessing about their performance, particularly when placed in an environment full ofother academically successful students. "Not wishing to blow my own trumpet, and those of my

peers, but medical students are some of the brightest in the country," says Joshua Harvey, a thirdyear medical student at Oxford University. "Personally I found it a hard transition to go from aschool where I was not really challenged by my work or peers to a place where it seems everyoneis smarter than me. I have noticed that I am now much more concerned how I have performed inrelation to the class. Feeling like I have done my best is no longer enough."

The Hidden Curriculum

Medical schools themselves may fuel competition through the "hidden curriculum," a set ofcultural and organisational influences that can affect medical students' attitudes and behaviour overtime. Students exposed to the hidden curriculum come to accept hierarchy, which is often learnt

through teaching involving humiliation. In one study of medical students' perceptions, half theparticipants reported that competition, not cooperation, was the defining characteristic of medicine,a view that was more common among clinical students. In addition, more than a third of studentsreported a desire to impress senior staff in the hope of gaining prestigious jobs after graduation.[2]

Ross Kirkbride, a foundation year 1 doctor in Bristol, feels that his medical school promptedcompetitive behaviour among students by encouraging them to think about their future careersearly on. "Unfortunately, my medical school banged on about how we should make our CV better,

8/2/2019 Best Articles 2011

13/57

8/2/2019 Best Articles 2011

14/57

"Medical schools are already concerned about the impact that intense competition can have," sheadded. "Clearly competition can affect mental health, and there have been tragic cases of medicalstudents becoming very unwell through worrying that they are not as good as their peers."

Despite the General Medical Council's requirement for medical students to learn to respect their

colleagues and make the care of the patient their first concern,[4]

it is likely that some medicalstudents will occasionally overlook these duties in order to succeed. So what is the best way tocope with fellow students whose competitive behaviour gets out of hand? "The best thing you cando is try to ignore the gunner's behaviour and do the best job you can on your own patients," saysDr Cohen. "Keep in mind that all consultants were once medical students, and they're often able torecognise gunner behaviour. Although the gunner may impress some doctors, others will be turnedoff by attempts at showing off. You may be gratified to discover that your seniors dislike thegunner as much as you do."

References

1. Zarsadias P. Not enough jobs. Student BMJ 2010;18:c6314.2. Lempp S, Seale C. The hidden curriculum in undergraduate medical education:qualitative study of medical students' perceptions of teaching. BMJ2004;329:770-3.

3. Dyrbye L, Thomas M, Shanafelt T. Medical student distress: causes,consequences and proposed solutions. Mayo Clinic Proceedings 2005;80:1613-22.

4. General Medical Council. Tomorrow's Doctors. London. GMC, 2009. www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp.

Competing interestsNone declared.

Provenance and peer reviewCommissioned, not externally peer reviewed.

Stud BMJ 2011 BMJ Publishing Group

New Rules for Resident Hours Called

Inadequate

8/2/2019 Best Articles 2011

15/57

Robert Lowes

June 29, 2011 First-year residents must pull shifts no longer than 16 hours straight, thanks tonew work standards that take effect on July 1, but a group of patient safety advocates says moremust be done to protect all residents from sleep deprivation, fatigue, and the medical errors that

often follow.

In an articlepublished last weekin the online journalNature and Science of Sleep, these patientsafety advocates write that the new standardsissued by the Accreditation Council for GraduateMedical Education (ACGME) "stop considerably short" of guidelines issued by the Institute ofMedicine (IOM), which they endorse. An IOM reportpublished online in 2008, titled "ResidentDuty Hours: Enhancing Sleep, Supervision, and Safety," recommended that the maximum shift forany resident be 12 to 16 hours.

As it stands, beyond their first year, residents can be scheduled for up to 24 straight hours, and theycan stay on an additional 4 hours for the sake of a proper patient hand-off, according to the

ACGME standards taking effect July 1. Under the previous ACGME standards, 24 hours was themaximum shift for all residents, and 6 hours was the most they could tack on.

The authors of the article inNature and Science of Sleep wanted more change than that.

"The current system amounts to an abuse of patient trust," said coauthor Lucian Leape, MD, anadjunct professor of health policy at the Harvard School of Public Health in Boston,Massachusetts, in a press release accompanying the article. "Few people enter a hospital expectingthat their care and safety are in the hands of someone who has been working a double-shift or morewith no sleep. If they knew, and had a choice, the overwhelming majority would demand anotherdoctor or leave."

Dr. Leape helped convene a group of 26 "stakeholders" in the issue of patient-safety, includingmedical educators, hospital administrators, and sleep scientists, for a 2-day conference last year onhow to implement the 2008 IOM report on resident hours. The article inNature and Science ofSleep presents their final recommendations.

Experience "Does Not Overcome the Need for Sleep"

The ACGME and IOM appear to disagree on the connection between fatigue and medical errorscommitted by residents. The ACGME has stated that there are "limited data" on the subject,whereas the IOM asserts that there is enough evidence to justify its more stringent reforms.

According to the ACGME, shorter shifts are warranted for first-year residents, whom it calls theleast experienced and most vulnerable physicians in training. In their case, "fatigue has aninfluence on the frequency of errors," the accrediting organization once stated. However, beyondyear 1, longer shifts are appropriate because residents must be prepared to "practice medicineoutside the learning environment where they will be unsupervised, must think independently, andoften must function at their top abilities when fatigued."

8/2/2019 Best Articles 2011

16/57

Charles Czeisler, MD, PhD, another coauthor of theNature and Science of Sleep article, countersthat a resident's experience "does not overcome the need for sleep."

"There is no justification for maintaining unsafe work hours, other than that they're a good deal forhospitals," said Dr. Czeisler, chief of the Division of Sleep Medicine at Brigham and Women's

Hospital in Boston, in the press release. "But they endanger patients, and they even endangerresidents."

Other recommendations from Dr. Czeisler and his fellow patient safety advocates include:

requiring attending physicians to supervise all hospital admissions, requiring in-house supervision of all critical care services performed by residents, eliminating noneducational and nonessential work from resident duties, making adherence to IOM recommendations on work hours a condition of receiving

Medicare funds for residency training, providing transportation for any resident who says he or she is too tired to drive home

safely, and training residents and attending physicians on standardized ways to effectively hand-off

patients.

Shortening shifts, providing more supervision, and reforming residency training in other ways willrequire hospitals to hire more personnel. However, the quality improvement that ensues (eg, fewerpreventable errors, shorter hospital stays, smarter discharges) will yield savings that help offsethigher staffing costs, according to the authors.

Nat Sci Sleep. 2011;3:47-85. Full text

Medscape Medical News 2011 WebMD, LLCSend comments and news tips to [email protected].

The Forsaken Specialty: Why Do DoctorsLook Down on Psychiatry?

Zo Cruse

Posted: 03/31/2011; Stud BMJ 2010 BMJ Publishing Group

8/2/2019 Best Articles 2011

17/57

Abstract and Introduction

Introduction

As a medical student I found that most other students thought that psychiatry was not a true

professionthe consultants sit and sip tea, talk nonsense, and nobody ever seems to gets better.No blood test confirms what is wrong. No imaging shows the diagnosis. Simply put, ward roundsthat consist of sitting in a room and chatting just didn't seem like "real medicine" to most of mypeers. Psychiatric patients were people to be mocked, feared ("you were left alone with them?"), orignored. Revision for objective structured clinical exams and written papers was left to the lastminute because it was "only psych."

I don't know why I thought this would be different when I qualified. Perhaps the "doctor" titlewould equate to being surrounded by those who understand, appreciate, and respect psychiatry?Goes to show that a label does not define how you act.

Throughout medical school I was taught to be impartial and non-judgmental, and I swore to upholdthe Hippocratic oath and "do no harm or injustice" to patients, either verbally or physically. [1] I amsure the doctor who rolled his eyes, saying "nutter" under his breath when a patient who hadoverdosed on paracetamol came in had taken the same oath as me. I've heard qualified doctorsshare a joke about a "schizo" patient, giggling and clutching their sides laughing.

Needless to say I have never sat and shared a joke about a patient receiving palliative care, so whythe difference?

Anyone who has experienced similar scenarios must realise that stigma, fear, and discriminationstand between us and our duty of care.[2] Why the view that psychiatry is the bottom of the pile? A

career only fit for the students who just scraped through medical school? Odd, when you considerthat one in four British adults will have at least one diagnosable mental health problem in any oneyear and that suicide remains the most common cause of death in men under the age of 35. [3 4] Thestigma surrounding mental health and those who work within the specialty seems to be cementedin many minds.

Perhaps I am too sensitive and defensive. I have lived with mental health issues since I was a child,and have experienced them both first hand and in my daily environment. I am not unique or alonein having these experiences and am by no means a martyr, but there is nothing quite like seeing aparent lying intubated on the intensive care unit after they have hanged themselves to get you totake mental health seriously.

Stigmatised Within Their Own Profession

So why is mental health and psychiatry viewed the way it is?

A recent press release by the Royal College of Psychiatrists showed that only a quarter of medicalstudents thought that a career in psychiatry was appealing, with most believing it was not seen as a

8/2/2019 Best Articles 2011

18/57

prestigious career by either the public or by other doctors. Surgery was viewed as the most wellrespected profession.[5]

A separate piece of research showed the effect of this stigma on doctors' career choices.Researchers asked 51 psychiatrists and 50 non-psychiatrists about their opinions of different

medical specialties; 57% of the psychiatrists felt their own specialty was the least respected. Manysaid they felt stigmatised within their own profession. Forty one per cent thought their advice wasnot valued by non-psychiatric colleagues, and 55% felt there was a stigma attached to beingassociated with mental illness.[5]

An article in theJournal of Psychosocial Nursing and Mental Health Services describes threetypes of stigma: public stigma (what people with mental health problems believe the public thinkof them), self-stigma (how these people view themselves), and label avoidance (which ultimatelysuggests that people with mental health disorders avoid accepting their diagnosis for fear of othersdiscriminating against them). Although self-stigma and label avoidance are more directed towardspeople with mental illness, public stigma is a phenomenon that we as doctors and students are

clearly affected and shaped by. The article stresses that challenging public stigma is "essential inhelping individuals accomplish recovery-related goals" and that stigma can be addressed throughprotest and education.[6]

Laugh at Someone Who is Suffering

Cinematic stereotypes of mental health workers have probably deepened public stigma. RobinWilliams is the all hugging, loving, overly involved therapist in Good Will Hunting; Dr FrasierCrane is the comical, hopeless radio psychiatrist; and the infamous, evil Dr Hannibal Lecter simplyate his patients. Rarely portrayed as using scientific methods and drugs, these versions do notmirror professionals that I have met. Depictions of people with mental illness are no better in

cinema. Jim Carrey inMe, Myself and Irene encourages us to laugh at someone with "advanceddelusionary schizophrenia with narcissistic rage,"[7] and the recent film Shutter Islandseestraumatised and paranoid Leonardo DiCaprio violently murder his wife. Even the television dramaCrash, a series about newly qualified junior doctors, shows a man with schizophrenia murder theleading character in an unprovoked attack. No wonder 36% of us think people with mental healthproblems are prone to violence.[8]

David Healy, consultant psychiatrist and professor of psychiatry at Cardiff University, suggeststhat it may not be that stigma is attached to the mental health issue itself, but that mental healthdisorders are so challenging to treat. "Surgeons win, we lose," he told me, "the stigma is notbecause it is mental health, but that we are not overly good at treating it." This clearly has weight;

surgeons can successfully remove a lump or resect a bowel and give a reasonable guarantee of acure. Psychiatrists cannot do the same.

Some steps have been made toward public education and destigmatisation of mental health. TheRoyal College of Psychiatrists' Changing Minds campaign produced a two minute film called 1 in4 that emphasises that anyone can have mental illness. It says, "1 in 4 could be your brother, yoursister. Could be your wife, your girlfriend 1 in 4 could be your daughter 1 in 4 could be me it could be YOU."[9]

8/2/2019 Best Articles 2011

19/57

Campaign group Time to Change works in the United Kingdom to challenge the misconceptionthat people with schizophrenia are often violent. In April they launched a film called Schizo. Itbegins like a horror film, with grainy images and flashing lights, and words such as "terrifying,""chilling," and "he is among us" fill the screen. Then it cuts to a middle aged man called Stuart,who is making a cup of tea in his kitchen with his wife. He describes his struggle with the stigma

attached to his diagnosis of schizophrenia. It is a powerful video and hopefully one that will helpchallenge public opinion and work towards alleviating the fear that surrounds mental illnesses suchas schizophrenia.

Exposed to Public Stigma

I am not suggesting that all students and doctors behave badly towards patients with mental healthissues, or that all medics dismiss psychiatry as a specialty. They don't. But we are all exposed tothe stigma of mental health, and affected by it. Many people believe that more needs to be done toimprove psychiatry's reputation. Professor Healy is concerned that medical placements are sofocused on passing exams that much of the mystery and finesse of psychiatry is lost. "The fun is

taken out," he says.

He calls on medical schools to expose their students to neuroscience, to teach about the theories onthe difference between the brain and the mind, and to show how fascinating it is to never have twopatients who are the same.

It might not require quite as much investment from already overstretched education budgets,however. A Scottish study, presented at the International Congress of the Royal College ofPsychiatrists in Edinburgh, showed that students who completed a short placement in psychiatryended up viewing the specialty far more positively. Before their placement, just 25% of studentsbelieved that psychiatry was an appealing career, but after a four week placement in the specialty,

this number jumped from 25% to 70%.

[5]

Perhaps, as James Strain writes in theNew EnglandJournal of Medicine, "destigmatisation requires demystification," and simply allowing students tohave short yet broad placements in psychiatry will go a long way to improving the situation. [10]

Stigma has reduced throughout timethankfully we no longer think that psychotic traits aresupernatural in their originbut there is still a long way to go. When people with mental illnessare asked to name the greatest obstacle to recovery, by far the most common answer isdiscrimination and stigma.[9] Stigma is a prejudice, based on stereotypes, leading to discrimination.[11] As medical students and doctors we have sworn to treat without prejudice, judgment, or bias.We need to stop stigma before stigma stops us, be it in our job or even accepting that we may endup being the "1 in 4." Challenging attitudes is going to be difficult, but if we keep an open mind

and appreciate the intricacies and mystery surrounding mental illness, and acknowledge that acondition that has no cure is not one to be feared, then maybe we can make a change.

"Assent and you're sane; demur, you're straightway dangerous, and handled with a chain."[12]

References

8/2/2019 Best Articles 2011

20/57

1. National Library of Medicine. Hippocratic oath. Translated by Michael North.2002. www.nlm.nih.gov/hmd/greek/greek_oath.html.

2. Crisp A. Every family in the land: understanding prejudice and discriminationagainst people with mental illness. Royal Society of Medicine Press, 2004.

3. Office for National Statistics. Psychiatric morbidity report. ONS, 2001.4. Department of Health. The national service framework for mental healthfive

years on. DH, 2005.5. Royal College of Psychiatrists. Short placements could switch medical students

on to psychiatry. Press release, 21 June 2010.6. Corrigan PW, Wassel A. Understanding and influencing the stigma of mental

illness.J Psychosoc Nurs Ment Health Serv2008;46:428.7. Frontier Psychiatrist. Psychiatry at the movies.

http://frontierpsychiatrist.co.uk/psychiatry-at-the-movies.8. National Mental Health Development Unit. Stigma and discrimination in mental

health. Factfile 6: 4. www.nmhdu.org.uk/silo/files/nmhdu-factfile-6.pdf.9. Royal College of Psychiatrists. Changing Minds campaign. DVDs: Stigma. 2010.

www.rcpsych.ac.uk/default.aspx?page=1648.10.Strain J. Book reviewstigma and mental illness. N Engl J Med 1993;328:1133.

11.Royal College of Psychiatrists. Let wisdom guide: discrimination and stigma.2008.www.rcpsych.ac.uk/campaigns/fairdeal/whatisfairdeal/discriminationstigma.aspx.

12.Dickinson E. The poetry of Emily Dickinson. Complete poems of 1924. Little,Brown, 1924.

Competing interestsNone declared.

Provenance and peer review

Not commissioned; not externally peer reviewed.

Stud BMJ 2010 BMJ Publishing Group

Personal Life, Professional Life: Drawing the

Line

Sarah L. Averill

Posted: 05/15/2009

8/2/2019 Best Articles 2011

21/57

"Any time now, he told me, I could die in my sleep, painlessly. It's not like other cancers." Mymother is explaining what the neuro-oncologist told her today. She looks strangely radiant standingin the bright lights of my kitchen, wearing a spring green sweater, the color of her Irish eyes. Herhair has grown back, thicker and a more stately silver than the red color she dyed it before thediagnosis a year ago. She is thin now but does not look sick; rather, she looks more like the figure

she struck in her wedding photo beside my father at the Golden Gate Bridge in San Francisco,petite and wiry, a glint of fire in her eyes.

I am engrossed in her description of the visit to this new doctor who, to her amazement, did acomplete physical exam for the first time since she was told that she had a brain tumor. "Heactually felt for lymph nodes in my neck and in my armpits," she said. "No one does thatanymore!"

She laughs, then laments how things have changed since she went to medical school more than 30years ago. She could always draw me into her stories; it was the Irish in her, the touch of Blarneystone that gave her the power to captivate. Last week, I was listening so intently that I let the

cookies I was making for her burn, and I had to put them out in the snow to smoke. She was thatkind of storyteller -- still is, but now she could die any day, or so her doctor told her today.

I am standing there looking at her sweater: It is the color of the first green leaves on the poplars inearly spring, the color of hillsides in April, and she is going to die -- very soon maybe, tonightmaybe. I am waiting for my throat to tighten, for the tears to fall, but they do not come. So manytimes this year they have caught me off guard. I have had to bite my lip at the bedside of patients inthe hospital where I am a third-year medical student. I have stood in the back of the room whilerounding on patients who have the same diagnosis as my mother and have fought back tears, tryingto blend into the cloud of white-coated residents, medical students, and attendings.

At the beginning of the year, I struggled with how I might handle my mother being admitted to thesame hospital where I was training to become a physician. Who should I tell that she was sick?When should or could I take time off? How much should I tell my course directors and attendings?For the first half of the academic year, I followed the advice of my advisory dean and spoke witheach clerkship director, letting them know my situation, telling them that I might need to take timeoff on short notice. I was already balancing family and school, with 2 young children at home anda husband who wanted more time than I could give, and now this.

I was pleased to find that my course directors were eager to help and that they supported mydecision to continue my education. Halfway through my medicine rotation, however, I learned thatI was being criticized for being too focused on my family and on going home at the end of shifts.The criticism was being lodged by anonymous residents who were supervising me, potentially thesame residents who had been kind when I told them of my mother's glioblastoma and who had toldme to please let them know if I needed to leave early, anytime.

I had a predictable medical student response: paranoia, a sense of betrayal, a vague worry that Imight fail the clerkship, or worse, end up with a bad narrative in my final evaluation, precludingme from getting into the residency of my choice. I worried, too, that I might not be getting as muchexperience as my peers because I was placed on teams with fewer patients. Again, I wondered

8/2/2019 Best Articles 2011

22/57

whether I should take time off, even though I had already taken off 5 weeks in the summer tospend with my mother and my kids.

I began to feel that my performance and attitude at work were being interpreted in light of mypersonal life. Perhaps it was not serving my best interest to communicate so freely. I was open to

criticism on anything that might jeopardize my training or my role in patient care, but I did notwant preferential treatment. After some reflection, I decided to start the new semester withouttelling my clerkship directors the details of my situation, well aware that my mother was evercloser to dying.

Since then, it has been a relief to work with colleagues who don't know about my personalsituation. In fact, I have gradually learned a lesson that would have taken longer to learn in othercontexts: Death and illness are part of the texture of life, much like marriage, the birth of a child,divorce, and other challenges of life. Watching patients and their families shoulder the burden ofillness, along with my fellow students, residents, and senior attendings, has helped me view mypersonal burden in a broader context. I now know that I must be the judge of what I need to do for

my mother and when I need to do it in order to live with myself for the rest of my life.

Ultimately, this is the same challenge that others face in managing their marriages, theirrelationships with their children, and their life's ambitions, while still attending to their patients'needs and their own educational requirements in a profession with vast demands. Medical studentsand physicians have complex lives and complex responsibilities, including a responsibility to beself-aware as well as being open to feedback from patients and colleagues.

At the same time, I think we have a right to privacy, a right to limit the extent to which personalinformation colors professional evaluations and educational opportunities. I thought that informingmy supervisors would make me appear mature and forward-thinking, should the need arise for a

sudden leave of absence. But in following that course, I felt that I lost what little control I had overmy evaluations as a medical student. Reclaiming the privacy of my experience in dealing with mymother's illness, placing it squarely back in the realm of my family and my personal life, gave me asense of control. Whatever feedback I get, good or bad, will be based purely on my performance. Ifmy supervisors raise concerns about my work or my studies, there will be time enough todetermine whether I need to take time off or request accommodation.

In the meantime, the snow has melted and the moon is full. My mother has lived to see spring andmake the world green once more. I've got a new copy of the 1971 John Prine album that mymother bought on 8-track when we were toddlers and played until it wore out. I still remember allof the songs and so does she. She's riding shotgun to me tonight, wrapped in a Navaho-patternblanket. She looks like a nomad. She always was a driving fool. Tonight we are singing, enjoyingevery inch of the sky, every mile of the road.

Medscape Med Students 2009 Medscape, LLC

8/2/2019 Best Articles 2011

23/57

Twelve Steps for Choosing a Specialty

Anne Vinsel, MS, MFA

Posted: 09/02/2009

Question

I need to declare a medical specialty before long, but I have so many conflicting feelings andthoughts about various clinical areas. How can I make the right choice?

8/2/2019 Best Articles 2011

24/57

Response from Anne Vinsel, MS, MFAProject Administrator, Graduate Medical Education, University of Utah MedicalCenter, Salt Lake City, Utah

It's time for fourth year students to get serious about choosing their specialty area. Some of you arelucky, and everything lines up: you know which clinical area interests you most, your board scoresand grades/letters are all in the correct range, and you have helpful professors on your side. Foryou, it's just a matter of doing the paperwork on time. You can stop reading here.

But I know there are many others of you out there who aren't sure what specialty to choose. Or,you're torn between 2 or 3 specialties. Or you know what you don't want but aren't sure what youdo want. Or you know what you want, but aren't sure if your qualifications are strong enough.Read on!

If you're stuck, here's a decision tree to follow:

1. Find or make a list of all the specialties available directly after medical school (ie, skipfellowships).

2. Cross off the ones you definitely don't want. You don't need a string of reasons beyond thefact that you simply can't see yourself doing it long term.

3. Perform a Google search with the phrase "choosing a medical specialty." When I tried it,I got about 89,800,000 entries. Set a timer for no more than 1 hour and browse through thefirst several pages. Take some of the "what specialty are you?" quizzes. If nothing else,they will give you some ideas and possibly make you think about specialties you haven't

explored. You can safely avoid making an exact ranking of specialties at this point. Just seewhich specialties you seem to be most suited to and which you should rule out.

4. Now, list several specialties you can see yourself doing long term, no more than 6.5. Research those specialties in your institution. Go to the departments and make friends with

the residency program coordinators. If you haven't already done so and haven't rotated inthe program, arrange to shadow a faculty member for a day. Talk with 1 or 2 residents andcheck out the pros and cons of the specialty. Finally, ask the program coordinator if yourboard scores would be in a competitive range. Most program coordinators won't share theirboard score cut-off, but they likely would tell you if your scores are within range.

6. Narrow your list to 2 or 3 specialties. Now, and only now, talk with family and friends.Tell them you're thinking of these specialties, and get their opinions. Listen hard, and get

them to articulate the basis for their opinions.7. Delete any reasons related to job shortages or oversupply of physicians in a specialty. You

don't need 200 jobs, you only need 1, and you should be prepared to relocate somewhereless attractive if you choose a specialty that's overcrowded or not in much demand. Plus,demand can change by the time you finish training.

8. Delete any reasons related to lifestyle or money, unless those concerns come from yoursignificant other.

9. Delete heritage reasons ("Your father is a surgeon; you should be one, too").

8/2/2019 Best Articles 2011

25/57

10. Now, write down your own pros and cons, independent of all the advice and aptitudetesting and board scores. Be honest here. If your priorities are lifestyle, having childrenduring residency, income, opportunities for foreign travel, or avoiding roughcircumstances, then rank them appropriately. What fascinates you, what could you bepassionate about? Don't be at all logical here.

11. But do be logical in this next step. And brutally honest with yourself: Did you barely passthe boards? Internal medicine might not be for you, even if you really enjoy outpatientmedicine. Do you tend to avoid or dislike patient contact? Don't consider family medicineor pediatrics. Do you have high board scores, want a benign lifestyle, but aren't veryvisual? Don't pick radiology.

12. If you follow all these steps, combining thoughtful reflection on what makes you happywith an objective look at your strengths and weaknesses, one option should start singingout louder than the others. And that's your specialty.

Note that you should take other people's views of your strengths and weaknesses into account, butnot necessarily follow their advice. Spouses are a special case because you are making a joint life

together. Still, the final decision should be yours, informed by some actual data that help youdetermine "the best fit" between you and your specialty-to-be.

You can do this in a week; don't procrastinate and don't make the problem bigger than it is. If youchoose a specialty that turns out to be a bad fit, you can still change after the first year.

Be practical, but don't limit yourself. I know a physician who started medical school at age 38, onewho had to take the boards several times, one who barely passed one of her steps by 1 point, andanother who doesn't like patient care. The first one is now practicing radiology in a large privateclinic, the second is a fellow in a high-risk obstetric anesthesia program at a very prestigiousacademic medical center after switching from surgery because of physical limitations, the third is a

fellow in a neonatal intensive care unit after completing a successful pediatrics residency, and thelast is working for a large drug company doing information technology, his real love.

Even if you are "nonstandard," you can find a specialty you will love and which will value you.Good luck!

Medscape Med Students 2009 Medscape, LLC

8/2/2019 Best Articles 2011

26/57

Young Doctors: Saddled With Debt and a

Deflated 401(k)? Here's Help

Dennis G. Murray

Posted: 08/27/2009

Introduction

They say misery loves company, but who needs this sort of grief: whopping medical school loans,a crushing mortgage coupled with the real estate downturn, and credit card balances that won't goaway?

8/2/2019 Best Articles 2011

27/57

And it is all made worse by last fall's financial crisis. If you had a stock-heavy portfolio, you'veprobably seen the balance of your 401(k) and other retirement plans drop by 30% to 40% in thepast 12 months.

"Younger doctors are coming out of residency with much greater student loans than their

predecessors did," says Todd Bramson, CFP, financial planner and senior partner with NorthStarFinancial, Madison, Wisconsin. "Younger doctors' income is lower and, until recently, the cost ofhousing was higher."

For young doctors, getting out of debt and saving for retirement is crucial, especially in these tougheconomic times. Financial planners describe ways to manage your debt while still replenishingyour retirement plan.

Six-Figure Debts Are the Norm

The biggest obstacle to saving and investing is debt. Excluding people who say they have no major

credit cards, or only a low-balance gas or store card, the average amount of credit card debt perhousehold is $9659, according to a 2007 online survey released by CardTrak.com.

Moreover, while 64% of those surveyed said they had credit card balances under $10,000, some13% reported carrying more than $25,000. The typical household pays an average of $1500 a yearin interest alone, CardTrak says.

But for many young doctors, credit card debt is small potatoes next to medical school andmortgage debt. According to 2008 data from the Association of American Medical Colleges, thetypical graduate is carrying a debt load of $141,751. Add on another 6 figures of mortgage debt,and it's easy to see how that paycheck gets gobbled up quickly and how the allure of credit cards is

so strong.

Still, there's a different between "good" debt and "bad" debt. "Bad debt includes credit cardbalances and depreciating assets like cars and boats -- anything that's not an appreciating asset orthat is used to finance a lifestyle that's higher than it should be," says Bramson. "You want to payoff bad debt as soon as possible."

"Good debt helps you increase your long-term net worth and security," he says. "Real estate, yourhome, rental property, student loans, a loan for your business, or an investment in your practice ora surgery center are investments in your future. Hopefully the interest on your payment will be lessthan the profit you will receive on the investment itself."

Different Strategies to Pay Down Debt

Philosophies of life differ, and so do philosophies and strategies for tackling debt. Bramsonsuggests thinking of debt management from a quantitative and a qualitative standpoint. Each hasits advantages.

8/2/2019 Best Articles 2011

28/57

Quantitative: Rank your debts from the highest interest rate to the lowest interest rate and paythem off in that order.

As much as you hate debt, a majority of student loans are under 5% and are probably among thelowest rates you'll ever get. "At that low rate, maybe you don't have to aggressively pay them off,"

says Bramson. "The cash you'd use to pay them off could be better used on other investmentopportunities.

"However, if your money's sitting idly in a money market account getting 1% or 2% interest,you're not getting much benefit from it, so you may as well use it to pay down the debt.

"If your loans have rates that are 7% or higher, aggressively try to pay them off because it's likegetting a 7% return on your money with no risk," says Bramson.

Qualitative: Rank debts from the lowest to the highest balance and pay them off in that order.Tackle the lowest balances first, regardless of interest rate. "If you only have 3 or 4 payments left,

even on a low interest loan, it's an emotionally great feeling to wipe it out and be done with it,"says Bramson. Also, freeing up that cash flow enables you to double up on payments to other debt.

While you can choose your strategy for paying off overall debt, credit card debt should be paid offin a particular way. "First pay off the card with the highest interest rate, regardless of the balance,"recommends Robert M. Doran, president of Infinity Wealth Management in Wantage, New Jersey."Then work on the one with the second-highest interest rate, again, ignoring the balance."

Finding Ways to Reduce Loans

To wipe out that high-interest debt entirely, he says, consider taking a low-interest home-equity

loan (assuming your house is worth more than you owe on it) to pay off the cards and consolidateyour other bad debts (car loans, etc.). This strategy is akin to robbing Peter to pay Paul, butdepending on the size of your debts, you could wind up saving a few hundred dollars a month ininterest and get a tax break to boot.

Where to look? To borrow a line from The Wizard of Oz, there's no place like home. If you haven'tlooked into refinancing your mortgage or restructuring it -- from, say, a variable-rate loan to onethat has a fixed rate -- now's the time, as fixed rates are at historic lows. Even a reduction of onepercentage point can free up hundreds of dollars a month to direct toward your credit cardbalances. And a fixed rate lets you lock in a monthly principal payment that will never fluctuate,something that will help you better manage your finances.

Trading down to a smaller home is another option that will put more cash in your hands, plus you'llsave on utilities, insurance, and taxes. But think this one through before you put your house on themarket. Selling could prove to be counterproductive if your home is worth less than what you paidfor it or you anticipate needing the space, whether for a growing family or to care for an elderlyrelative.

8/2/2019 Best Articles 2011

29/57

You may hear about "debt consolidation loans" tied to the equity in your house, which you can useto bundle your debts, good and bad, including your school loans. It sounds like a good strategy, butit assumes that the rate on the consolidated loan is less than those on your student loans. Moreimportantly, it assumes that you have enough equity in your home to make a significant dent in theeducation debt. Actually, many young doctors haven't built up enough equity to cover more than

their high-interest credit card debt and auto loans.

You probably can rustle up cash in ways you haven't imagined. There are the obvious tactics liketrading down to a less-expensive vehicle or shopping around for cheaper insurance, but alsoconsider some simple steps, such as dropping premium TV channels.

By concentrating on saving on big-ticket items, or eliminating some lesser ones, you can helpincrease the amount of money you have available. "If you're used to taking 3 vacations a year, cutback to 2, or pick a cheaper destination, like San Diego instead of Paris," says Larissa Grantham, afinancial planner with Stepp & Rothwell in Overland Park, Kansas. "Likewise, if you're thinking ofremodeling the kitchen, maybe it can wait awhile."Insurance is usually a big-ticket item, but be

cautious about cutting down on coverage to save money. Review your policies every year and don'tcarry more insurance than you really need. If you have a serious illness or an accident, insufficientcoverage can leave you in worse financial shape.

If you've tried everything to rein in your debt and nothing seems to be working, consider calling aprofessional debt counselor. A professional can perform an unbiased assessment of your spendingand suggest ways to get it back on track.

To avoid some of the unqualified companies in the debt counseling industry, start with theNational Foundation for Credit Counseling (http://www.nfcc.org; 800-388-2227), a network ofnonprofit counseling agencies that provide free or low-cost confidential services. As a further

safeguard, check the recommended company with your state's attorney general; for a completelisting, go to http://www.naag.org/sttorneys_general.php.

Take the Time to Make a Budget

If you don't have a budget, now's the time to draft one, dividing it up into "essentials" and"nonessentials." The ability to put on paper what you spend each month may help you reconsiderwhat's really necessary and what's a bit on the frivolous side.

"In my experience," says Doran, "the people who have a budget when cash flow is tight are theones who are much more disciplined and focused on current expenses and saving for retirement.

Professionals with high incomes or a high net worth often neglect budgeting, but it's important foreveryone to be accountable for their spending."

Financial planner Bill Cleveland agrees. "Just because you make a lot of money doesn't meanyou'll necessarily be prudent in spending it," says Cleveland, a principal with Augusta, Georgia-based Preston & Cleveland Wealth Management.

8/2/2019 Best Articles 2011

30/57

"I've seen surgeons who make $500,000 a year spend $600,000. If you don't have the time ormotivation to draw up a budget, a good CPA or financial advisor can help prioritize your debts, de-leverage, and get you back on the right track."

A well-crafted budget devotes at least 10% to 15% of your income to savings, the bulk of which

should be stashed away for retirement. While that may sound impossible to you at this stage inyour life, it's definitely something to shoot for.

"This goal has a dual purpose," Cleveland explains. "It allows you to save for retirement plus givesyou a cushion to absorb the unexpected expenses and setbacks that come with life. The rest of yourbudget should base your expenses on your 'worst' year of salary, not your best, to help you livewithin your means."

Continue to Invest for the Future

The more you delay saving for retirement, the harder it'll be later on to provide for a desirable

future lifestyle.

While it's certainly possible that we'll suffer another steep market downturn, sitting on the sidelinescarries its own huge risk because of inflation. While in this economy it sounds great to earn a fewpercentage points a year in a savings account ("Hey, I'm not losinganything!"), those generallypaltry returns won't stand a chance of keeping pace when inflation rears its ugly head again.

"In some cases, when you combine the inflation rate with the taxes on the gains, you're going tohave negative returns in terms of purchasing power," warns Bill Cleveland. "That's not going totake you through a retirement that may be as long as 20 or 30 years."

Fund your 401(k) or SEP IRA first, either of which gives you a tax break, then move on to a RothIRA if you have extra money and meet the income requirements to participate. If you work for anorganization that matches your contributions, put away enough to get the match.

"That's free money," says Larissa Grantham. "Even putting away 5% a year is something, becauseof the power of compounding." Stocks are battered right now, and most financial planners will tellyou that this equates to a true buying opportunity. According to a recent article posted onCNNMoney.com, stocks have outperformed bonds over 10-year stretches roughly 80% of the time,which means that young doctors should still own equities.

Despite the recent meltdown, it's unwise to shift a large chunk of assets out of equities and into

safer investment harbors, say many financial planners.

"We went through a tough cycle, no question, but the numbers you're looking at on yourstatements today are not going to be the numbers 20 years from now," says Doran. "This currentmarket is a gift in terms of stock valuations, and wouldn't you rather buy when prices are low,especially for your long-term investments?"

8/2/2019 Best Articles 2011

31/57

Whatever you do, don't try to make up for last fall's debacle by getting too aggressive with yourportfolio. "Good, solid, disciplined investing -- the kind that earns 7% or 8% a year -- is boring,"Cleveland admits. "But you'll double your money every 10 years with average annual returns in theneighborhood of 7%." He says the key is to stay invested, not flit in and out of the market duringits peaks and troughs or chase hot stock picks.

Medscape Business of Medicine 2009 Medscape, LLC

Young Doctors: Saddled With Debt and a

Deflated 401(k)? Here's Help

Dennis G. Murray

Posted: 08/27/2009

Introduction

They say misery loves company, but who needs this sort of grief: whopping medical school loans,a crushing mortgage coupled with the real estate downturn, and credit card balances that won't goaway?

8/2/2019 Best Articles 2011

32/57

And it is all made worse by last fall's financial crisis. If you had a stock-heavy portfolio, you'veprobably seen the balance of your 401(k) and other retirement plans drop by 30% to 40% in thepast 12 months.

"Younger doctors are coming out of residency with much greater student loans than their

predecessors did," says Todd Bramson, CFP, financial planner and senior partner with NorthStarFinancial, Madison, Wisconsin. "Younger doctors' income is lower and, until recently, the cost ofhousing was higher."

For young doctors, getting out of debt and saving for retirement is crucial, especially in these tougheconomic times. Financial planners describe ways to manage your debt while still replenishingyour retirement plan.

Six-Figure Debts Are the Norm

The biggest obstacle to saving and investing is debt. Excluding people who say they have no major

credit cards, or only a low-balance gas or store card, the average amount of credit card debt perhousehold is $9659, according to a 2007 online survey released by CardTrak.com.

Moreover, while 64% of those surveyed said they had credit card balances under $10,000, some13% reported carrying more than $25,000. The typical household pays an average of $1500 a yearin interest alone, CardTrak says.

But for many young doctors, credit card debt is small potatoes next to medical school andmortgage debt. According to 2008 data from the Association of American Medical Colleges, thetypical graduate is carrying a debt load of $141,751. Add on another 6 figures of mortgage debt,and it's easy to see how that paycheck gets gobbled up quickly and how the allure of credit cards is

so strong.

Still, there's a different between "good" debt and "bad" debt. "Bad debt includes credit cardbalances and depreciating assets like cars and boats -- anything that's not an appreciating asset orthat is used to finance a lifestyle that's higher than it should be," says Bramson. "You want to payoff bad debt as soon as possible."

"Good debt helps you increase your long-term net worth and security," he says. "Real estate, yourhome, rental property, student loans, a loan for your business, or an investment in your practice ora surgery center are investments in your future. Hopefully the interest on your payment will be lessthan the profit you will receive on the investment itself."

Different Strategies to Pay Down Debt

Philosophies of life differ, and so do philosophies and strategies for tackling debt. Bramsonsuggests thinking of debt management from a quantitative and a qualitative standpoint. Each hasits advantages.

8/2/2019 Best Articles 2011

33/57

Quantitative: Rank your debts from the highest interest rate to the lowest interest rate and paythem off in that order.

As much as you hate debt, a majority of student loans are under 5% and are probably among thelowest rates you'll ever get. "At that low rate, maybe you don't have to aggressively pay them off,"

says Bramson. "The cash you'd use to pay them off could be better used on other investmentopportunities.

"However, if your money's sitting idly in a money market account getting 1% or 2% interest,you're not getting much benefit from it, so you may as well use it to pay down the debt.

"If your loans have rates that are 7% or higher, aggressively try to pay them off because it's likegetting a 7% return on your money with no risk," says Bramson.

Qualitative: Rank debts from the lowest to the highest balance and pay them off in that order.Tackle the lowest balances first, regardless of interest rate. "If you only have 3 or 4 payments left,

even on a low interest loan, it's an emotionally great feeling to wipe it out and be done with it,"says Bramson. Also, freeing up that cash flow enables you to double up on payments to other debt.

While you can choose your strategy for paying off overall debt, credit card debt should be paid offin a particular way. "First pay off the card with the highest interest rate, regardless of the balance,"recommends Robert M. Doran, president of Infinity Wealth Management in Wantage, New Jersey."Then work on the one with the second-highest interest rate, again, ignoring the balance."

Finding Ways to Reduce Loans

To wipe out that high-interest debt entirely, he says, consider taking a low-interest home-equity

loan (assuming your house is worth more than you owe on it) to pay off the cards and consolidateyour other bad debts (car loans, etc.). This strategy is akin to robbing Peter to pay Paul, butdepending on the size of your debts, you could wind up saving a few hundred dollars a month ininterest and get a tax break to boot.

Where to look? To borrow a line from The Wizard of Oz, there's no place like home. If you haven'tlooked into refinancing your mortgage or restructuring it -- from, say, a variable-rate loan to onethat has a fixed rate -- now's the time, as fixed rates are at historic lows. Even a reduction of onepercentage point can free up hundreds of dollars a month to direct toward your credit cardbalances. And a fixed rate lets you lock in a monthly principal payment that will never fluctuate,something that will help you better manage your finances.

Trading down to a smaller home is another option that will put more cash in your hands, plus you'llsave on utilities, insurance, and taxes. But think this one through before you put your house on themarket. Selling could prove to be counterproductive if your home is worth less than what you paidfor it or you anticipate needing the space, whether for a growing family or to care for an elderlyrelative.

8/2/2019 Best Articles 2011

34/57

You may hear about "debt consolidation loans" tied to the equity in your house, which you can useto bundle your debts, good and bad, including your school loans. It sounds like a good strategy, butit assumes that the rate on the consolidated loan is less than those on your student loans. Moreimportantly, it assumes that you have enough equity in your home to make a significant dent in theeducation debt. Actually, many young doctors haven't built up enough equity to cover more than

their high-interest credit card debt and auto loans.

You probably can rustle up cash in ways you haven't imagined. There are the obvious tactics liketrading down to a less-expensive vehicle or shopping around for cheaper insurance, but alsoconsider some simple steps, such as dropping premium TV channels.

By concentrating on saving on big-ticket items, or eliminating some lesser ones, you can helpincrease the amount of money you have available. "If you're used to taking 3 vacations a year, cutback to 2, or pick a cheaper destination, like San Diego instead of Paris," says Larissa Grantham, afinancial planner with Stepp & Rothwell in Overland Park, Kansas. "Likewise, if you're thinking ofremodeling the kitchen, maybe it can wait awhile."Insurance is usually a big-ticket item, but be

cautious about cutting down on coverage to save money. Review your policies every year and don'tcarry more insurance than you really need. If you have a serious illness or an accident, insufficientcoverage can leave you in worse financial shape.

If you've tried everything to rein in your debt and nothing seems to be working, consider calling aprofessional debt counselor. A professional can perform an unbiased assessment of your spendingand suggest ways to get it back on track.

To avoid some of the unqualified companies in the debt counseling industry, start with theNational Foundation for Credit Counseling (http://www.nfcc.org; 800-388-2227), a network ofnonprofit counseling agencies that provide free or low-cost confidential services. As a further

safeguard, check the recommended company with your state's attorney general; for a completelisting, go to http://www.naag.org/sttorneys_general.php.

Take the Time to Make a Budget

If you don't have a budget, now's the time to draft one, dividing it up into "essentials" and"nonessentials." The ability to put on paper what you spend each month may help you reconsiderwhat's really necessary and what's a bit on the frivolous side.

"In my experience," says Doran, "the people who have a budget when cash flow is tight are theones who are much more disciplined and focused on current expenses and saving for retirement.

Professionals with high incomes or a high net worth often neglect budgeting, but it's important foreveryone to be accountable for their spending."

Financial planner Bill Cleveland agrees. "Just because you make a lot of money doesn't meanyou'll necessarily be prudent in spending it," says Cleveland, a principal with Augusta, Georgia-based Preston & Cleveland Wealth Management.

8/2/2019 Best Articles 2011

35/57

"I've seen surgeons who make $500,000 a year spend $600,000. If you don't have the time ormotivation to draw up a budget, a good CPA or financial advisor can help prioritize your debts, de-leverage, and get you back on the right track."

A well-crafted budget devotes at least 10% to 15% of your income to savings, the bulk of which

should be stashed away for retirement. While that may sound impossible to you at this stage inyour life, it's definitely something to shoot for.

"This goal has a dual purpose," Cleveland explains. "It allows you to save for retirement plus givesyou a cushion to absorb the unexpected expenses and setbacks that come with life. The rest of yourbudget should base your expenses on your 'worst' year of salary, not your best, to help you livewithin your means."

Continue to Invest for the Future

The more you delay saving for retirement, the harder it'll be later on to provide for a desirable

future lifestyle.

While it's certainly possible that we'll suffer another steep market downturn, sitting on the sidelinescarries its own huge risk because of inflation. While in this economy it sounds great to earn a fewpercentage points a year in a savings account ("Hey, I'm not losinganything!"), those generallypaltry returns won't stand a chance of keeping pace when inflation rears its ugly head again.

"In some cases, when you combine the inflation rate with the taxes on the gains, you're going tohave negative returns in terms of purchasing power," warns Bill Cleveland. "That's not going totake you through a retirement that may be as long as 20 or 30 years."

Fund your 401(k) or SEP IRA first, either of which gives you a tax break, then move on to a RothIRA if you have extra money and meet the income requirements to participate. If you work for anorganization that matches your contributions, put away enough to get the match.

"That's free money," says Larissa Grantham. "Even putting away 5% a year is something, becauseof the power of compounding." Stocks are battered right now, and most financial planners will tellyou that this equates to a true buying opportunity. According to a recent article posted onCNNMoney.com, stocks have outperformed bonds over 10-year stretches roughly 80% of the time,which means that young doctors should still own equities.

Despite the recent meltdown, it's unwise to shift a large chunk of assets out of equities and into

safer investment harbors, say many financial planners.

"We went through a tough cycle, no question, but the numbers you're looking at on yourstatements today are not going to be the numbers 20 years from now," says Doran. "This currentmarket is a gift in terms of stock valuations, and wouldn't you rather buy when prices are low,especially for your long-term investments?"

8/2/2019 Best Articles 2011

36/57

Whatever you do, don't try to make up for last fall's debacle by getting too aggressive with yourportfolio. "Good, solid, disciplined investing -- the kind that earns 7% or 8% a year -- is boring,"Cleveland admits. "But you'll double yo