Apparently I Have An Opinion On Health Care Too!

If you've turned on your TV, glanced at a newspaper, or checked your Facebook in the past 24 hours, you are probably aware of the US Supreme Court ruling on the PPACA (the healthcare reform signed into law back in March 2010). If you're interested in the specifics, you need only google "PPACA" or something of the sort, and you will be inundated with results about what the law entails. In super brief form, it adds several provisions designed to make sure everyone has access to healthcare, as well as means to fund these provisions. One method of funding comes from the "Individual Mandate" (IM), which requires individuals to obtain health insurance or pay a fine/penalty/tax (realistically what it's called doesn't matter because the function is the same in each case). More people buying insurance should increase competition in the market and bring down prices because those that use healthcare infrequently can help subsidize those who use it more often. The Supreme Court case was about this mandate, ultimately deciding it was constitutional under Congress's power to tax. Without the IM, the ACA would face challenges on how to fund the rest of its measures, and that would not be good.

So, why is everyone making so much noise about this law? Good question; one that has many answers. First, people are upset because they feel like they shouldn't be obligated to buy health insurance. Understandable, except for the fact that, at some point, every person will use the healthcare system. This is analogous to car insurance: if you drive a car, you are required (in nearly all states) to have insurance. That way, if someone attempts to occupy your location in space and time, you can be sure to be reimbursed for the energy the imparted into your rear bumper. If you are caught without insurance, you face a fine (sound familiar?). "But Liam," you say, "People who don't drive don't need insurance. I don't get sick, so I shouldn't need health insurance!" Unfortunately, not quite, because by virtue of being born as a human being (welcome to the club, 7 billion strong!), you have entered the healthcare market. You may never get in an accident, but you still must have insurance to cover damages. Similarly, you may never get sick, but you must have insurance to pay for services if you do. Essentially, this is designed to work like Social Security, where the old (sick) are supported by the young (healthy). Everyone becomes old at some point, so it is reasonable to collect money from everyone.

Interestingly enough, people seem to favor the provisions in the ACA, such as eliminating pre-existing conditions, but are against the IM and the law as a whole. This sort of amounts to, "we like the benefits, just not the part where we have to pay for it." While an unpleasant realization, there is no avoiding it. Healthcare is really expensive, and it shows no signs of getting cheaper spontaneously. Resources are limited, and if we don't allocate them responsibly, everyone gets screwed. The real trick is figuring out how to cut costs and manage resources while still getting quality healthcare. Originally, the focus was on waste and inefficiency in administrative and clinical settings. EHRs, streamlined billing, new payment models, and evidenced-based medicine can save money by preventing treatments and procedures that have no benefit as well as minimizing overhead costs. However, new estimates suggest that fixing 'waste' won't make up for the increasing expenditures. This doesn't mean we'll ignore all those savings; we just need to make additional changes. 

Additional cuts will come from limiting some services. We will have to start saying no to some procedures and devices in some patients. Expensive imaging studies or surgical procedures may be foregone in favor of clinical diagnoses and alternative therapies. In addition, the new focus will be on preventing chronic diseases rather than attempting to manage existing ones. For example, look at diabetes and heart disease (co-morbidities in many cases too). Diabetes alone was estimated by the ADA to cost us $174 billion (in 2007). Heart disease (which includes HTN, CAD, CVA, and CHF) was estimated to cost us $272 billion (in 2010). Both diseases are highly preventable with lifestyle modifications and supportive drug therapy if necessary.

I suppose my overall point, and I'm not alone in this, is that healthcare reform is necessary and will occur no matter what goes on in government. I think that having the PPACA and IM is an important step in the right direction, but it is only the beginning. Buckle up, because there's a long, tough road ahead.

Edit
Ran across this article just now. Should help clear up some misconceptions and disinformation.
http://www.usatoday.com/news/politics/story/2012-06-29/fact-check-court-health/55927118/1

Citations

Diabetes stats: http://www.diabetes.org/diabetes-basics/diabetes-statistics/

CVD stats: http://www.theheart.org/article/1176761.do

Bloche MG. Beyond the “R Word”? Medicine's new frugality. N Engl J Med. 2012;366:1951-1953.

Blumenthal D. Performance improvement in health care — Seizing the moment. N Engl J Med. 2012;366:1953-1955.

Brody H. From an ethics of rationing to an ethics of waste avoidance. N Engl J Med. 2012;366:1949-1951.

Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366:973-977.

Song Z, Landon BE. Controlling health care spending — The Massachusetts experiment. N Engl J Med. 2012;366:1560-1561.

Know the Difference: Allergy vs Adverse Reaction

A common question, asked at least once at every assessment. It is an important question because it is the difference between taking a drug and getting better, or say, going into anaphylactic shock. Typically, we try to avoid the latter.

However, the responses I've heard to this question indicate to me that there is a crucial misunderstanding about what an allergy is. On several occasions I've heard people say they are allergic to a drug, and when asked what reaction occurred, they respond with nausea or something of the sort. Of course, nausea can be a symptom of an allergic reaction, particularly in anaphylaxis. Usually though, nausea is a side effect of a medication, which is separate from an allergy. Now, time for some science and jargon!

An allergic reaction (Type I Hypersensitivity for those of you so inclined) occurs when IgE, a type of immunoglobulin (antibody), interacts with an allergen. IgE bound to the allergen can then bind to receptors on mast cells, basophils, and eosinophils to stimulate an allergic reaction. Mast cells in particular release large quantities of histamine (along with cytokines and other chemicals), which causes vasodilation as part of the inflammatory response. When vasodilation of the blood vessels in the skin occurs, the affected area will turn redder in color (also know as rubor). Other inflammatory agents like leukotrienes, cytokines, and prostaglandins contribute to the inflammatory response, causing further vasodilation, pain, and broncoconstriction. Usually the allergic reaction is limited to the immediate area where the allergen made contact. Anaphylaxis is a severe, systemic allergic response, involving broncoconstriction and global vasodilation, which leads to difficulty breathing and shock. Anaphylaxis is a life-threatening emergency, but is treatable with prompt intervention. The allergic response to a drug may occur in several different ways (Type I, II, or III), and the signs and symptoms will vary depending on the mechanism and severity. Rash and itchiness are the most common presentations of a drug allergy.

The reason allergic reactions should not be confused with side effects is because of the outcome. An allergic reaction to a drug can be very dangerous, so it is important to avoid it by using alternative medications. Side effects are often unpleasant, but rarely immediately life-threatening. For instance, the flushing that occurs when taking niacin is not an immune hypersensitivity reaction, even though it appears as one. Opioids like hydrocodone or oxycodone may cause nausea, but not due to an allergic response. Additionally, almost all medications have side effects, so it is harder to pick and choose in that case. This is why healthcare workers ask for the reaction associated with an allergy; they are trying to distinguish a true allergy from an unpleasant side effect.

I have two points, one for healthcare professionals and one for the general public. First, if you are asking a patient about any drug allergies, be sure to ask for the type of reaction that occurs. It is reasonable that the average individual may not know the difference between a side affect and allergy, but the RN/MD/DO/PA/NP needs to know whether there are any contraindications to particular medications. Second, if you are telling a healthcare worker about an adverse drug reaction, be sure to mention what happens when you take it. Additionally, if you are unsure about whether or not you are allergic to a medication, be sure to ask (and write down the response for that matter).

Sources

1. Drug allergies. PubMed Health. 2010. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001822/. Accessed June 21, 2012.

2. Levinson W. Chapter 65. Hypersensitivity (Allergy). In: Levinson W, ed. Review of Medical Microbiology and Immunology. 11th ed. New York: McGraw-Hill; 2010. http://www.accessmedicine.com/content.aspx?aID=6459867. Accessed June 21, 2012.

3. Papaliodis D, Boucher W, Kempuraj D, Michaelian M, Wolfberg A, House M, Theoharide TC. Niacin-induced "flush" involves release of prostaglandin D2 from mast cells and serotonin from platelets: Evidence from human cells in vitro and an animal model. J Pharmacol Exp Ther. 2008;327:665-672.

In the Hospital: The Good, the Bad, and the Ugly

Ask any healthcare worker if they have interesting stories from their job, and you will be bountifully rewarded. This is especially true if said person works in an emergency department or hospital. The main reason for this effect is relatively simple: the more people you interact with, the crazier the world seems. The ED is a melting pot, with people of all demographics (though predominantly low SES) represented. Bringing such a diverse group together tends to give you interesting results.

The Ugly
ED stands for "Emergency Department," but it could also just as easily stand for "Elected to Display." What I mean by this is, people often have no shame in showing you exactly what ails them. As a volunteer, one of my jobs was to help people fill out a form so they could be triaged. We had several signs pointing to the forms, indicating they should be filled out first, but people often walked up to the window anyways. The conversation usually goes like this:

Me: Can I help you?
Patient: I need to be seen. I have this huge rash (reaches for shirt).
Me: (Quickly) Ok, I need y...
Patient: (Pulls up shirt revealing a large rash, fully in view of everyone in the room.)
Me: (To myself) Thanks for that.
Me: Ok, please fill out that form for me and we'll get you looked at. Sigh...

The probability of me being shown an ailment is proportional to how bad/disgusting it looks. If blood is involved, the chance jumps to 100%. Traumatic wounds need to be checked of course, so I don't fault people for that. It's the absurdity that gets me. You would not say, show your bulging abscess at a dinner party as part of your introduction (if it comes up in conversation, well, that's fair game). But in an ED, you'll walk up, lift your shirt triumphantly, and share with myself and others your pathological achievement.

The other common presentation is the "waited too long" patient. A couple of instances stand out in my mind. One was a woman who was extremely lethargic. She could barely even speak or hold her posture while sitting. A history revealed that she had hypothyroidism and had either run out of medication or just didn't take it for a while. Without treatment, she surely would have fallen into a myxedema coma. I remember the nurse blatantly scolding the woman and her family for not coming in sooner. The other case involved an older man who may well have set a hospital record for highest temperature in a living person. He arrived (astoundingly) by personal vehicle, driven by his daughter. He was a bigger guy, so I called the paramedic to help get him out of the van. He gave me a ribbing for not doing it myself. After a few minutes, he came back in sweating and out of breath with the patient slumped over unconscious in a wheelchair. "He was complete dead weight" the medic said (I should have gone out to help him, which I apologized for afterwards). I don't know how in hell his family got him into the car. The nurse took his temperature, which read 106.7 F (41.5 C). For those of you wondering, this is borderline "incompatible with life." The nurse wasn't even sure if the thermometer would be able to read that high. I'm fairly certain he was septic, although I think he ended up surviving. The ED really alternates between the mundane and the unbelievable.

The Bad
I'll end on good so as not to leave you feeling (too) depressed. Unfortunately, the ED is not generally a happy place. It is visited out of necessity rather than desire, which makes it ripe for unpleasantness. When you add pain/nausea/malaise/uncertainty with long, seemingly arbitrary waiting times, things can get really, really unpleasant. The worst cases occur when someone gets to "cut in line." Triage works like this: the nurse takes your vital signs and a brief history. He/She makes any quick assessments necessary, like a vision test or brief neuro exam, along with a self-reported level of pain. This is all summed up by a triage score 1-5, 1 indicating immediate life-threatening condition (like cardiac arrest) and 5 indicating minor condition with no necessary procedures (like a cold). The severity of the condition dictates who sees the doctor first. Things possibly affecting the heart (chest pain) or lungs (dyspnea) are the more common sources of line-cutting. On certain occasions, it's very obvious someone needs to go back right away (serious laceration, head trauma, altered mental status, etc) for instance, like the man who seized while being triaged. These types of problems draw few objections from the waiting room. Most times it is less obvious why someone goes back first though. One day in particular, I had a women who was fairly sick, with nausea and vomiting (n/v). However, her vitals were essentially normal, with perhaps a mild fever and and tachycardia due to the nausea. Unfortunately for her, several ambulances showed up, and we were already full. Additionally, a few other walk-ins had deviations in vital signs like hypotension, which needed to be worked up. She waited for at least three hours before she had enough. I tried to explain to her why other people went back first, but I wasn't getting through. I think she ended up leaving to go to another hospital (where she will probably wait just as long again).
On my final day, a woman showed up, depressed and on the verge of tears. She was looking for her son, who had gone missing the night before. His car was deserted, and his wallet was left behind, suspicious for foul play. But he wasn't at our hospital, and there was nothing I could do. I told the woman he wasn't at our hospital, but I would look out for the name. She then asked me what she should do. I told her to contact the police (which was her best option). She said okay, and thanked me sadly before leaving. It is a difficult thing in medicine, to want to help others but accept that sometimes, there just isn't anything you can do.

Another part of the ED is that bad news often arrives unexpectedly. People go from alive to dead without any warning or preparation. I've seen a few people coded, and not one of them survived. Listening as the doctors break the bad news is not something you easily forget. I arrived a couple times to deceased children, which is about the worst. I've seen several repeat patients, one of whom always arrives by ambulance, always complains of dyspnea, and then immediately proceeds to go outside and smoke a cigarette. Patients are often obese, some are drug seekers, some malingering for disability or other reasons. And many lack the capacity to understand how medicine and the ED works. They struggle with their own problems, and fail to appreciate the perspectives of the people trying to help them. I've seen people arrive intoxicated or high on drugs, sometimes dangerously so. Patients are combative or abusive to the staff, especially the behavioral or law enforcement ones. And the worst part of all is that so many of these people will return with the same problems, lacking the money or reinforcement they need to change. To see the human condition so exposed, so gritty, it can turn even the most optimistic people cynical.

The Good
Like most jobs that deal with the seedy side of life, you survive for the few good things. Occasionally, you will get a patient who is helpful and courteous, and it makes all the difference. Elderly people tend to be better mannered and more likely to wait patiently, but that's not always the case. The clinical and support staff can also make a big difference. Some people are naturally easy going and funny while others crumple under stress. There was one nurse in particular that I remember, because initially I think she didn't like me. When you start volunteering, you're basically a massive tool because you don't know anyone, you don't know where anything is, and you don't know how things run. As Samuel Shem puts it in the House of God, "Show me a [medical student] that only triples my work and I will kiss his feet." Such was the case with this nurse. But after spending time in triage with her, she eventually considered me a colleague/friend. If you establish yourself as a competent, trustworthy person, you'll make friends easily.
Getting to know the patients also helps. Towards the end of my volunteering career, I started spending more time talking to people. I wish I had done this sooner, because it gives you new perspectives. One man I talked to lived in NYC with his girlfriend until they broke up. He moved to a small town in Arizona, but left because of a drug problem (in the town, not necessarily himself). Another man I talked to was younger than me and had just been released from jail just a few days ago. He suffered from substance abuse and was probably in withdrawal. I chatted with him in the waiting room, and then I checked up on him once he was in a room. He was very grateful that I had spoke with him. The epitome of grateful patients occurred when a woman walked in with questions about medications for a surgery she had a few days ago (yes, she showed me the scar). I didn't want to make her wait in the ED, so I talked to the unit clerk, who managed to contact the surgeon. He said she didn't need any prescriptions for antibiotics or pain pills. I walked back out to the waiting room, expecting to hear objections raised. When I relayed the message however, she smiled and thanked me. She didn't want to take anything in the first place!

Most of my memories from the hospital are snapshots, brief clips that struck me as poignant or odd. Most are relatively neutral, but several fall under the Bad category and even fewer into Good. I learned a lot from my two and a half years at the hospital. Most importantly, I learned that communication is everything. It can mean the difference between making friends or creating enemies; the difference between gaining patient's trust or losing all credibility. What you say can make just as big an impact as what you do, medical or otherwise. When you understand a patient's perspective, it allows you to better help him or her. Medicine is all about the good, the bad, and the ugly. You just never know what your next patient is going to show you.

Of Schools and Secondaries

Welcome back! This is the second installment of "Liam's Somewhat Handy Guide to Applying to Medical School," and it's going to be a good one. In the first installment, we covered the Primary Application, introduced a couple tips, and tried to keep stress to a reasonable level. In this post, I'll be covering a short bit about how to decide to which schools to apply, and what the secondary applications entail (spoiler warning: money, essays, and waiting). So, let's get started.

Now, some of you might be thinking, "Liam, why did you choose to mention the schools here instead of in your post on the primary application?" A very valid question, and one I will politely choose to ignore. With that out of the way, let's talk about schools. There are 137 accredited U.S. medical schools and 17 Canadian medical schools recognized by the AAMC. The number of schools you can apply to through AMCAS differs slightly, because most Texas schools use a separate application service (TMDSAS) and some schools have multiple campuses (the University of Arizona has two campuses currently, although they're working on separate accreditation). In any case, you have about 125 choices if you plan to stay in the 50 states, and I would plan on choosing around 15-20. Why? Because of our arch nemesis, probability. Medical schools tend to follow the rule of 10%, where 10% of applicants receive an interview, and 10% of interviewees receive an acceptance (in reality, the probability of being selected after an interview is a little higher, around 15-20%, but the Rule of 10% sounds nicer). What this means is that around 1-2% of applicants to any given school actually matriculate in the fall. Now, before you reach for that bottle of whiskey, Tip #5 says "Don't Panic!" and you should strongly consider this one. Sure, the odds aren't great (still more likely than winning the lottery though). But that's why you're here looking up tips for how to improve those odds. Applying to several schools will help your chances, but you also need to make each choice count. 100 crappy applications won't beat 1 good one. Even if you're Johnny Awesomesauce, the Super Applicant.

So, now that you're completely discouraged, let's focus on how to choose specific schools. The first step is to find a copy of the MSAR®. This is your application bible. It has information on each school, including stats like average GPA and MCAT, and it can help you quickly eliminate schools that don't fit your profile. If you're as neurotic as I am, you might even enter this information into a spreadsheet to compare schools faster. I even computed Z scores for GPA and MCAT, and then averaged those to figure out how schools compared to my stats (borderline unhealthy behavior in retrospect). In any case, it'll help you eliminate schools that don't take very many OOS (out-of-state) applicants or ones where you are outside the range they usually accept. That way you don't waste time on money on an application that is doomed from the start.

The actual distribution of the 15-20 depends on you. For the love of all things holy, apply to your state school. It's almost always less expensive, and sometimes you will get some favoritism. Even if you don't intend to go there, include it. The rest of your schools should include some safety and reach choices, but make sure all your choices are places you can see yourself going to. Also, as a little note, there is a small area bias for residency locations (allegedly). What I mean is that applicants to residencies in the northeast may fare slightly better if they went to the school in the northeast. I suspect this is mostly due to familiarity and connections you develop within your area, so don't stress about this too much.

Now, this may come as a surprise to you, but medical school is basically the same everywhere. Each school has its own take on the curriculum and clinical sites, and some schools may be more focused into areas like primary care or research than others, but for the most part, they're all pretty equal. After all, an MD is an MD (it's your residency that really matters, but that comes later). My point is, don't think you have to go to a Harvard or Yale just because it's a good school. Go somewhere where you can enjoy yourself, develop new experiences, and make the most of your education. You're going to be stuck there for at least 4 years, so you damn well better choose a place where you can be happy. And, since we haven't introduced a new tip in a while, here's one now:

Tip #7: Be passionate.


Really, this should extend in to all aspects of your life. If you don't find yourself passionate or excited about the school, it's probably not the one for you (hint, you can substitute person for school to apply this to relationships too). People generally do better work when they are happy and motivated (or at least they don't mind the work as much), so it makes sense to maximize your chances of being in a positive frame of mind.

Secondaries
I've just gone on and on and on about choosing a school, and I've only barely mentioned the secondary application. There's a reason for this (Spoiler alert!). The secondary is really just a couple more essays, on average, I would guess about three, with a ludicrous fee. One essay is usually a "Why do you want to go here?" type, which is fairly self-explanatory. Look up information about the school, and talk about how it matches your experiences and goals. Check, one down. Another essay I encountered frequently asked, "How would you contribute to the diversity of the student body?" (ie what makes you unique?). This one can be tricky. It is really up to you to decide what aspect of your personality and history you focus on. If you're really struggling like I was, ask your friends and family for help. Sometimes you can overlook an event or behavior that's worth talking about. Those two are the ones that appear frequently. Keep in mind secondaries are pretty heterogeneous. Some had no essays (awesome, except for the money part) and a couple had 7+ essays (rarely, thank god). SDN has school-specific threads for the current cycle and previous one, so you can often check past threads to see how many and what type of questions the last group had.

Otherwise, there's not much to it. This is where the long waits come in. Most schools send secondaries to everyone, so the earliest you receive yours is usually based on when they received your primary. When you do get it, try to fill it out in a reasonable amount of time. That way, if you're filling out multiple secondaries, you don't get too bogged down. I would also recommend having all secondaries submitted and complete (LORs received) by the end of August. Interviews start around September, and you want to give yourself as much time as possible to be selected. After you submit your secondary, try not to obsess over it. The wait will be long and stressful, but if you keep checking SDN to see who is getting interviews, it will be that much longer and more stressful. But that's it. And not only that, most of the hard work is done! You still have the interview, but your chances greatly improve if you can get that invitation. So, put away the Tums for now and go enjoy your summer. If you have to wait, may as well make the most of it!

Behavior: It's What You Do!

As far as undergraduate majors go, psychology is typically one of the more popular ones. This occurs for a variety of reasons, but I suspect the relatively easy course material plays the dominant role. Psychology has the sophisticated appearance of a science without all that pesky scientific rigor and prerequisite chemistry and biology work (not actually true). The theories and concepts put forth by people like Descartes and Freud sound very scientific and appear to explain why people act as they do. Unfortunately, Freud's theories suffer from the problem of being completely un-testable, which just doesn't fly with those who practice the scientific method. Additionally, his data came primarily from case studies, which are great for identifying problems and events that need explaining, but cannot be used as compelling empirical evidence. Despite this, pop psychology is immensely, um, popular because it uses cool words like transference and cognition and describes events we can relate to. But those are problems for another day. Instead, I am going to introduce behavior and how I was trained to view psychology from a behavioral perspective.

Behavior can be defined in several ways. So far, the most useful definition comes from a functional standpoint: A behavior is an action that solves an adaptive problem. An adaptive problem is a fancy term for some event that affects your fitness (reproductive success). For instance, say you are out for a nice evening stroll through the park. It is a pleasant night, and although you are annoyed that Tom didn't fax his request for additional copy paper before leaving for the day, you are ultimately in a good mood. As you pass by the rock formation shaped in the uncanny likeness of John Belushi, you encounter a very aggressive-looking lion. The presence of the lion (called the context, more on that later) presents you with an adaptive problem: Your fitness will decrease substantially if the lion is allowed to solve his adaptive problem (to my knowledge, there are no cases of successful reproduction when one partner is deceased. The internet may suggest otherwise). In any case, your response to the lion is a behavior. It might consist of fighting the lion, running away from the lion, bargaining with your choice of higher power, or attempting to persuade the lion that you are not a suitable source of food (what you end up doing depends on your behavioral and evolutionary history, but again, more on this later). What matters is that you were presented with a problem that would affect your fitness, and you responded in a manner to address that problem. Even mundane activities such as driving to work, checking your mail, and watching TV can be called adaptive problems, because they affect your ability to acquire/distribute resources or attract a mate. Behavior is everywhere, and you are doing it all the time.

(As a clarification, behavior is specifically what you do, never what you are not doing. Avoiding your homework is not a behavior because it fails the so called "dead-man test." If a dead person can do it, it isn't behavior) (Malott & Suarez, 2004)

There is also a special type of behavior that describes the transfer of information (essentially cues) between individuals. We, unimaginatively perhaps, call this type of behavior verbal behavior. Your speech and non-verbal communication is considered behavior because again, it solves adaptive problems (and involves a verbal episode, which is the exchange of discriminative stimuli). You might say, "Honey, please pass the salt" or "Did I tell you about the time I was attacked by a lion?" to initiate the verbal episode. The other person will respond, either continuing or concluding the episode. Verbal behavior also includes nonverbal actions like facial expressions, body language, sign language, and even ordinary signs, like those you might see on the road or warning you to wear a hard hat. Remember, if you do it, it is behavior (pending passing the dead man test).

Behavioral psychologists are usually less interested in the behavior itself, and more interested in the adaptive problems it may solve. Often times it is unclear what adaptive function a behavior serves, as in schizophrenia or depression. Sometimes the adaptive function is diminished over time or disappears entirely, but the behavior continues anyways, such as using eating utensils or consuming high-caloric foods. Luckily, the very principles that lead behavior astray can also help fix it.

Behaviorism is not a complicated subject. Many of the concepts and principles are intuitive and similar to concepts in other sciences (especially with respect to evolutionary theory). The core philosophy of behaviorism though, drastically contrasts the popular, dualistic notions of psychology, and it can be profoundly difficult to unlearn those notions. I promise however, that once you start seeing the world through behavior-colored lenses, it becomes much easier to identify problems and institute actions to fix them. After all, behavior is what you do. What could be simpler than that?


My information comes from my behavioral psych professor and these two books (both available on Amazon). If you're looking for much more detail on behaviorism and behavior, give these a read:
1. Principles of Behavior by Richard Malott and Elizabeth Suarez.
2. Understanding Behaviorism: Behavior, Culture, and Evolution by William Baum.

In the Hospital, Day 1

One hot summer afternoon, I walked into the emergency department (ED) at a local hospital for the first time. I was nervous about my new position because at no point did I receive any substantial training. I was shown places where important items were present and should be, as well as places where important items weren't but should have been. My function was to remedy the situation so that all the places fell under the first category (this was very rarely achieved in full). I was also more or less in charge of the waiting room, which meant I would be the first person patients and visitors would address with their questions and comments. At first this seemed problematic, given the absence of training and a lack of knowledge on hospital procedures. But it quickly became clear that only a few phrases would be necessary, most of which include the words "wait" and "soon" in some configuration.

It was a small waiting room, with enough chairs for approximately twenty-five people. The triage area, nicknamed The Fishbowl, overlooked the room from the corner. The Fishbowl owed its nickname to the plexiglass windows that closed it off from the waiting room (more importantly, the people in the waiting room). Thankfully, it was not too busy, which I considered a good omen. I swiped my badge, and proceeded through the double doors that led to the rest of the hospital and the ED. There I met Roger (not his real name), the volunteer who offered to lend for my first day. His first two pieces of advice immediately contradicted the little training I was given. First, he recommended that I avoid doing "Rounds" on the people waiting. This tended to disturb the fragile equilibrium between people asking me questions and people becoming frustrated with my "wait" and "soon" responses. Once a patient views you as a foe, your job becomes infinitely more difficult and miserable, and so we decided it was best to let sleeping dogs lie (especially the people actually sleeping). Second, he recommended that I stay inside the Fishbowl. This allowed me to watch over the room and get to know the triage nurse while further discouraging questions. And so we set off, thwarting attempts to bother the nurse, helping family members find a relative, and keeping individuals contently (quietly) waiting.

Before my volunteer savior left me to manage alone, a patient arrived by EMS suffering from seizures (unknown to Roger and I). One woman was particularly hysterical, pacing back and forth, barely able to form complete sentences. She pleaded with us to let us see the patient, but he wasn't settled in yet (IVs, meds, exam, etc). At first we didn't even know who she was talking about, and before we could get any information from her, she hurried outside to make a phone call. Roger shrugged, and we went back to work. Later, I recall walking by his bed as he began seizing again. Had it not been my first day, I would have paused briefly to see how they were managing him. Eventually, the woman was let back to see him, although she was somewhat of a thorn in the side of the staff.

The rest of the evening was less eventful, but busier (which tends to be both a good thing and a bad thing). As I was leaving (an hour after my shift was supposed to end), the triage nurse, recognizing that it was my first day, gave me some advice (which I would not heed nor fully appreciate until much later). He told me, "don't forget to have fun." It's easy to spend all your time volunteering or studying or focusing so much on your goals that you forget to take a breather. I left that night tired but excited. This was my first step into the world of medicine, and it was sure to be interesting.

Applying to Medical School, the Primary

May is here again, which heralds the beginning of the 2013 admissions application cycle. Thousands of pre-medical students will begin filling out their AMCAS applications (the primary application), inputting a long list of information that seems slightly redundant. However, this should not discourage a pre-med, because by this time, hoop-jumping and tedious activities should be well practiced. Assuming you are a pre-med, let's go over some of the stuff you will need for the primary. (Note: These are my recommendations and experiences with the application. Your experience will differ. Take my advice with a healthy degree of skepticism and maybe an antacid).

Also note: This is a longer post. Use the search function to find what you're looking for, although I'd love it if you read the entire thing. I wrote all this stuff for a reason you know...

We start at the AMCAS application page. AMCAS is an acronym that is entirely unimportant; just think of it as the primary application, where grades, letters of recommendation, your relevant experiences, and the personal statement go. Eventually you will associate it with frustration, anxiety, and a vague sense of abdominal discomfort, but that comes later. Currently on the front page is a 20 minute video about the application. I suggest you watch it. Better yet, read the manual too. (A stretch I know, but suck it up. You're in for a lot of reading in medical school anyways). In fact, let's do that right now. Grab a snack, close out of Facebook, and give the video a go.



... Finished? Fantastic! That was a lot of material, and you may feel that mild abdominal discomfort developing already. Congratulations, you're ahead of the game! But like Douglas Adams said, "Don't panic." As with any large project, if you tackle it systematically, everything will turn out okay.

Coursework
As part of the application, you will have to input your coursework. This includes every class you've ever taken at a college, including community college and college credits you may have earned during high school. You will also need transcripts from each school you've attended. When you enter in your courses, you want to match the transcript as closely as possible, down to the course name and code. The manual has a couple special cases for certain classes, like combined lecture/lab classes. It is also okay to specify which semester a class is if it isn't explicit in the name (for example, if the name of organic chemistry is the same for both semesters, you can add a I and II or 1 and 2 to indicate first and second semester). Double and triple check that you entered everything correctly before you submit, as inconsistencies may hold up your application.

The rest of the application is not very complicated; there just happens to be a lot to fill out. That being said, here are the first two tips:

Tip #1: Use common sense. If you are completely unsure, ask for help.
Tip #2 : Be honest. Be yourself.

These tips extend through the entire application process really. The application is not trying to trick you. In fact, this application will be the predominant way the Adcoms (and possibly the interviewer) will get to know you. On one interview, I actually sat down with my interviewer as she went through my primary application bit by bit. So be reasonable. Answer questions as you would answer to a friend. Be completely honest, because you may end up being asked questions about your essays or personal statement.

Work/Activities
The work/activities part is where you enter information about the things you've done during college. This section and the personal statement are really the only ways the Adcoms will be able to get to know you as an individual, so do not skimp. That being said, you don't have much room, so you'll have to be concise as well. This leads into my next tip:

Tip #3: Don't sell yourself short!

You are applying to medical school. Just think about that for a second. That's pretty awesome. You've worked your ass off throughout undergraduate just to get to this moment. Sure, there's someone who set up clinics in Africa while rescuing infants from a burning building and scoring a 52Y on the MCAT. There's someone who somehow cured AIDS, cancer, and eczema with a single discovery. Don't focus on that. They're probably really boring anyways. Adcoms want people who are enthusiastic and genuine. Don't try to be something you aren't, but be proud of the things you've accomplished and what you think is important. Plus, you'll write better about things you naturally find interesting.

Personal Statement
The personal statement is similar in that regard, except it is longer and more like a story. Do not simply restate your activities. You want to demonstrate how your experiences and personality make you an excellent candidate. I took a couple of experiences I found most profound, and used them to tell a story about how they shaped my perception of medicine and the kind of doctor I wanted to be. My theme was fun; medicine is serious business but there's no reason why it can't be fun as well. So try to enjoy writing your personal statement. Imagine that J.K. Rowling wanted to write a book using you as the main character. Be memorable (in a good way. Spelling and grammar mistakes or completely inappropriate material may be 'memorable', but will probably hurt your chances). I suggest you have several people look it over too. Find an English major (better yet, creative writing) and ask him/her to make suggestions. They will be flattered that you need their skills.

Letters, schools, and miscellaneous stuff
We'll start with a tip:

Tip #4: Read everything thoroughly.


Make sure you read the instructions, questions, responses, everything completely. I'm serious. You can't change most of the application after you submit it. You'll kick yourself if you missed the "not" in a question, or used one school's essay for another one and forgot to change the names (not me thank god, but I heard stories). Minor mistakes can usually be clarified with individual schools (I messed up a course code so it looked like I listed the same course twice). For LoRs, make sure you check each school's requirements. Some cap how many they'll accept (min and max), and most specify from whom the letters should come.

Tip #5: Don't panic!


I'm saying this twice for a reason. Applying to medical school has a way of giving people ulcers (and emptying their wallets). You've spent years getting to this point. You've shadowed, volunteered, studied, tested, and worked far more hours than you've slept. Now you have to summarize those years in just a couple paragraphs, pay an absurd amount of money, and wait. Then, secondaries will come back, meaning more writing and more money. This is followed by a lot more waiting. You'll go interview, where everyone else seems to be more qualified and experienced. Then you wait some more. Eventually, mail will start arriving. Waiting and lists, two hallmarks of the application process, will be combined into one nebulous and depressing package. Rejections will test your resolve and patience. But, stay with me here, But, you'll check your email and see "Congratulations" in the heading, and promptly spend the remainder of the day getting absolutely smashed. And at no point should you panic. Mistakes can be fixed with a polite email. Your friends and other applicants can commiserate together. Even in a worst case scenario, there will be another application cycle coming around. There are many paths to medical school, and no one is best. So, don't panic. In the end, the people who get into medical school are not necessarily the ones with the highest grades or longest resume. The people who are accepted are the ones who are the most persistent and confident that they would make great doctors.