language for some IMGs

[iatm]

Has anyone had experiences with IMGs who are not native English speakers and who were educated in foreign languages?

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[Winged Scapula]

Originally posted by iatm
Has anyone had experiences with IMGs who are not native English speakers and who were educated in foreign languages?

Plenty; I've met many residents and attendings over the years who are foreign nationals. What are you interested in knowing?

 

[iatm]

What specialities are most of them in? Does it take more effort than otheres to earn patients' trust?

 

[Winged Scapula]

Originally posted by iatm
What specialities are most of them in? Does it take more effort than otheres to earn patients' trust?

In my experience, most IMGs were to be found in IM and its specialties, although there are a fair number in Psych and Anesth as well.

It should come as no suprise to anyone that the US is ethnocentric (or even racist) and that *some* IMGs with foreign accents *might* experience *some* difficulties with *some* patients/co-workers. I do not believe that it takes more effort *across the board* to gain patient's trust simply because one is an IMG with an obvious foreign accent.

Most of us distrust the unfamiliar - but with time and obvious concern and good care on the part of the physician, this can usually be overcome.

 

[stoic]

One of the MD's I've spent a good deal of time shadowing is a Polish native who attended medical school in Poland (taught in polish) before coming to the US. He's an IM guy and I had a had a chance to talk with a few of his patients while he ran to get some test results. One particular incident sticks out in my mind. A middle aged woman, about 55, was in the office for a general visit. While Dr. Slomka had stepped out, she mentioned that when first she starting coming to this MD, she didn't know what to think. She was nevous because Dr. Slomka did medical school in Poland and because at that time his English was not perfect. She went on to comment on that since then he has become her favorite and most trusted physician off all time and that she had learned to enjoy his accent! Hope that ancetdote helps.

Dave

 

[carddr]

Addressing the subject of patient's distrust: two doctors in the room having a discussion in their foreign language together, what is the patient to think. Naturally they assume you are talking ABOUT them and tend to assume the worst case scenario, even after a proper explanation is offered they tend to have veiled doubts and may require further assurance from someone who does speak english. Have had this experience, as they address only their inquiries to me, the only one speaking english. So I would suggest this practice be very limited. However if the patient speaks the language, go ahead have a field day. Just make sure you write english on the charts.
As for specialities: I'm in surgery and I swear I'm in a international practice, hardly anyone is from America, but we all speak excellent english. I actually speak Tagalog and even the filiinpos give me a hard time...

 

[Apollyon]

When I was a med student, doing my peds Sub-I, there was a pedi patient whose mother spoke only Urdu. The junior and senior residents both spoke Urdu, and did so with the mother, but spoke English while we were discussing the case, so that I wouldn't be left out.

It's just bad form to speak in another language in front of a person who doesn't understand. If you explain this first to the patient, it's all good. The relationship between the doc and the patient is the glue that says either, "It's all good", or, "This doc is a tool!".

 

[pitman]

I realize this thread is about accents and foreign languages, but here's my tangent..

I've had several European and S. African general practictioners, and have worked with a bunch of other European IMGs. I've found them to have far more breadth and common sense and less reliance on expensive diagnostic equipment than most the American-trained doctors I've known...when was the last time you knew an American GP (under the age of 50) who could diagnose a heart murmur with a stethoscope, a kidney stone without MRI, or who knows when better to up a dose of (the non-toxic) penicillin rather than to jump on the latest exotic (patented, resistance-creating, kidney and/or liver-damaging) antibiotic?

Yeah, that old saw, and probably addressed all over this board. I guess my point is only that those who care or are knowledgeable about good *medicine* won't give a hoot about an accent or less-than perfect English proficiency (so long as there isn't the rude side-show of foreign banter around the patient, as stated above).

Not that I'm totally pro-IMG -- after spending time in mainland China, I would never trust a doctor formally trained there, accent or not.

-pitman

 

[carddr]

We all have our war stories, but generally I agree with you, however I included Asian trained docs as well. Totally convinced US medical schools on the whole have some real gaps in their approach to the teaching and training of their MDs'. You get lots more hands-on in even say third-world countries. (although the absolute worst MD in my program is from I----and has lots to learn in so called"bedside" manners and makes tons of mistakes, which he tends to blame on others). But I really admire those confident, assured foreign trained docs who know their stuffl. Heck, I'll pick anyone's brain at this point in my training. Loving every minute!!!

 

[pitman]

Originally posted by carddr
You get lots more hands-on in even say third-world countries.

Indeed, I'd add that locum tenentes in 3rd World countries in *particular* get the better hands-on, and every general practitioner IMHO should seriously consider doing such work at least to complement their formal training.

And future American IMGs would do well to factor such a potential training difference in when considering an int'l school. Nothing against the Carib schools, but students go there more for getting back to standard US medicine, and thus get standard US training, whereas some of the difference in training at other foreign schools can be seen as an advantage rather than the hindrance that some posters in this forum like to gripe about.

Go to a foreign school to learn American med? This is often (but not necessarily) done out of weakness. Go to a foreign school or similarly, try locum tenens, to be a better complemented doctor? This is a philosophy of strength.

-pitman

 

[carddr]

I have to laugh at these comparisons, US versus foreign medical schools...the textbooks are the same in most cases, only a heck of a lot cheaper in say the Philippines, science, like anatomy doesn't change, da bones, musles, respiratory, blood etc,etc.,etc., are the same. You're not studying the weather here. However there are some distinct differences in the area of diagnosis, treatment,drugs/medications,equipment(like AC),the latest technology, exposure to testing data, and others. Point being, medicine is medicine, here or there. All comes down to Step I,II, and III, plus for foreign graduates,CSA, English test, traveling, visas, green cards, separations, and so much more.

It's a long haul and failure is not an option.

 

[pitman]

Originally posted by carddr
I have to laugh at these comparisons, US versus foreign medical schools...the textbooks are the same in most cases, only a heck of a lot cheaper in say the Philippines, science, like anatomy doesn't change, da bones, musles, respiratory, blood etc,etc.,etc., are the same. You're not studying the weather here. However there are some distinct differences in the area of diagnosis, treatment,drugs/medications,equipment(like AC),the latest technology, exposure to testing data, and others. Point being, medicine is medicine, here or there. All comes down to Step I,II, and III, plus for foreign graduates,CSA, English test, traveling, visas, green cards, separations, and so much more.

I'd have to disagree with you a bit there, carddr, and it sounds like you're backtracking a bit from your earlier post(?). Yes, the basic sciences are the basic sciences, wherever you take them. And yes, to practice US medicine, the sine qua non is passing some exams to get US residency...and then you become *a* *US* doctor. But my issue is "what kind of doctor?", because it is not the case that "medicine is medicine" -- different schools or programs teach in different ways, with different philosophies, different exposures, and have students/mentors who expose each other with different backgrounds, skills and philosophies. Any moderately intelligent American can get a med degree and pass the exams and gain *some* US residency, but alas, many doctors are nut-jobs, incompetents, or automatons, myopic and/or improperly trained. If one argues that such problems are with the *individual* rather than with a particular school, program, or system, then my response (as a behaviorist) is that people are shaped by (learn from) their environment, from their experiences, from what/whom they perceive to be authorities, from the system...

I don't think foreign schools are SUPERIOR to US schools, nor vice versa, rather I think that the differences in approach and/or opportunities (such as the exposure to hands-on, or a different, any culture) in "other" programs, or in later training, are factors that should not be *dismissed* or belittled (as many seem to do), and anyone in medicine (indeed, anyone at all) who is a "lover of wisdom", and not just a technician, should expose himself to as many different experiences as possible to become a better practitioner. Else he is just a sheep, or maybe worse, a dilettante.

-pitman

 

[carddr]

Think we are saying the same thing here. A nut is a nut no matter what program/profession/mediccal school/country, they are in. Take John Nash, now there's a man with limited life experience who sees/saw the world totally different, and man did he contribute to the academic world, some people operate(no pun intended) on a different level than others. Therein lies the intrigue.
That said when I am the PD if that nut lacks the proper operating skills he's outta there, however if he's a great surgeon and somewhat anti-social so be it. He's on my team.
Bottom line, you better know your stuff in the operating room, mistakes here are too costly, and simply won't be tolerated, faking it in the operating room is rarely forgotten and I might add recognized readily.
Maybe I'm really addessing those students who study just for taking THE test and think they can get by. Yes, you can graduate, bottom of the class or the top, that decision is up to you, either way you had better know what matters, there are no Fs' in the OR.

 

[pitman]

ok, sorry about that, you threw me off with your previous post -- sounded like you were saying that nothing really matters in med education except passing the exams and getting residency.

For those who actually do hold that opinion, I think they've got their head on backwards and I'd personally like to dissuade them from becoming a physician.

-pitman

 

[NewDragon]

Originally posted by pitman

Not that I'm totally pro-IMG -- after spending time in mainland China, I would never trust a doctor formally trained there, accent or not.

-pitman

You are so wrong. Are you saying that all those doctors in China are not good? How many have you met? You can not generalize the whole doctor population in China just because you have met a few bad ones.

 

[carddr]

Pitman: elaborate on opinion of trained doctor from China, why the negative opinion?

 

[iatm]

But once FMGs finish their US residencies, wouldn't they be considered US trained? Or they would be still labeled as made in India, Parkistan, Syria, China...?

 

[Winged Scapula]

Originally posted by iatm
But once FMGs finish their US residencies, wouldn't they be considered US trained? Or they would be still labeled as made in India, Parkistan, Syria, China...?

Well, that's the inanity of it all. While WE realize that the training on how to be a physician comes during residency (not medical school), IMHO the general public does not. Or the assume that a physician with an accent was trained abroad, not here in the good ol' US of A.

However, the bias against IMGs within the medical community generally ends once you've completed your training (especially if done in the US) - although there may always be some left, which can often be traced to racism rather than US ethnocentrism.

 

[pitman]

Originally posted by NewDragon
You are so wrong. Are you saying that all those doctors in China are not good? How many have you met? You can not generalize the whole doctor population in China just because you have met a few bad ones.

No, I'm not saying that all doctors trained in China are not good.

First, I should not have said I "would never" trust such doctors, but that I "do not" (similarly strong but indicative only of present attitude, rather than any potential future one) -- I was writing a bit casually, and should not have. However, keeping "never" would still not imply that I indict all Chinese-trained doctors (although you phrase your counter-argument in the form of questions, your conclusion is still, "You are so wrong" -- about what exactly?).

Second, my attitude (without my expecting others to hold it) arises from probability -- not trusting such doctors because of the (perceived) probability that they are not adequate, which is quite different. I readily acknowledge that I don't know all the approximately 2 million physicians trained there. As with most beliefs, this one is inductive and therefore should not be considered stereotypical (i.e., an indictment of all). Again, even if "never" were to remain in my resulting opinion, are you claiming that any empirical evidence I might have is (factually) wrong, or my particular response to it is (morally or logically) "wrong"?

Third, my evidece arises from time I spent in Shanghai, where my mother also teaches clinical med to Chinese doctors, and where her husband teaches graduate students. The three of us (myself and two others whose opinions I value) have independently found that doctors, among others, trained in China are exceptionally bad at problem-solving, i.e., at diagnosing. Further, the texts the doctors used in a variety of schools were typically translated from English, yet watered down to omit most of the problem solving + analysis which I'd claim is the real knowledge, often leaving behind mere lists of symptoms and treatments. One (bad texts) does not necessarily *cause* the other (similar practitioner behavior), but both were found to be true in our experiences.

Now, there certainly are Chinese doctors trained in China who practice, and maybe Chinese schools that train, very differently, but given that China is very much a top-down society (e.g., so much is dictated by the Party), and given that the Revolution did a very effective job of weeding out independent/creative thinkers, I hold my opinion based on applying probability to my admittedly limited (small sample of) data. Note however that I referred only to the mainland, excluding Hong Kong, since I acknowledge that MUCH is different (still) in that former colony.

Please note that while I may entertain debating the nature of (empirical) beliefs, I'm not going to get into a debate about Chinese medicine (allopathic or traditional) or spend time countering anecdotes, although certainly I'd read any offered to gain more insight. My blurb merely reflected my personal opinion, which might change if I were to be exposed to the contrary.

Apologies if I offended anyone here, there are always outliers

-pitman

 

[pitman]

Originally posted by Kimberli Cox
While WE realize that the training on how to be a physician comes during residency (not medical school), IMHO the general public does not.

Except one leads to the other, as with other "life" experiences, and (bad) habits are born easily while die hard ("we behave as we have tended to behave" - Skinner).

-pitman

 

[Stephen Ewen]

Originally posted by pitman
I don't think foreign schools are SUPERIOR to US schools,

I have to make a point for thought here.

Many think it is plain crazy to cram medical school into four years, lest anatomy into one semester. They would also wonder at statements concerning how residency is when you REALLY learn material, rather than impove and focus it.

 

[pitman]

Stephen -- apologies, but for the life of me I can't figure out what you're saying above and don't see how it relates to my quote, and I certainly wouldn't want to presume...could you re-phrase/elaborate on this?

Thanks!

-pitman

 

[Stephen Ewen]

Oh, no problem. I am just saying that some foreign schools extend (actual) med school over longer than four years, and that some folks, myself included, think that it is a SUPERIOR way of being medically educated.

 

[pitman]

gotcha. I think that preference is analogous to one I have: people should (in general) take longer to decide on their profession, and should spend significant time doing *something* outside of college, something maybe even just tangentially related to medicine, before committing to med school. Then the sum-total of relevant pre-residency experience will (potentially, in faith) be more than 4 years.

But if I were fascist, I'd require cultural retraining, forced 3rd World servitude, courses in logic, probability+stats and epistemological/moral philosophy, and extend the formal process a few years. In my image, of course. Alas, all we can do is hope students do what we think is relevant, on their own .

-pitman

 

[Stephen Ewen]

Gocha too, and I agree, especially as relates to requiring a rigorous program in probability+stats if I were of the mentioned icky sort.

 

[Thewonderer]

Originally posted by pitman
I've had several European and S. African general practictioners, and have worked with a bunch of other European IMGs. I've found them to have far more breadth and common sense and less reliance on expensive diagnostic equipment than most the American-trained doctors I've known...when was the last time you knew an American GP (under the age of 50) who could diagnose a heart murmur with a stethoscope, a kidney stone without MRI, or who knows when better to up a dose of (the non-toxic) penicillin rather than to jump on the latest exotic (patented, resistance-creating, kidney and/or liver-damaging) antibiotic?

1) Hearing a heart murmur and says that you have heard it, is not that hard. But what is the point of saying the pt has a systolic murmur? It means nothing because it could have a number of different underlying pathologies. Furthermore, the loudness of murmur is not correlated to, say, how bad the pressure gradient is across the atrial valve. Therefore, for the sake of the patient's health and further management, you need to get an ECHO, whether you are in the US or in the UK. If you do not get an ECHO, then you are doing a disservice to your patient (on the other hand, S3 is pretty benign).

2) You can diagnose kidney stone with plain film if pt has had a hx of calcium stone. Otherwise, the standard protocol is to get a spiral CT, not MRI.

3) Regarding antibiotics use, that is up for debate. The bugs in the US hospital are differen than the bugs at, say, Kenya due to past abx exposure (hey if people cannot afford abx in Kenya, then for the most part, there is no resistance!). Even the bugs at say Hopkins is different than the bugs at Columbia-Presbyterian. There are a lot of things to consider when choosing an abx. In the US, most people follow Sanford's Guide and it is evidence-based medicine. So if you follow the guide, there should not be an abuse of abx.

Lastly, since you keep on saying how great foreign training is, an ID fellow I talked to last year did a month of electives at Radcliffe Hospital affiliated with Oxford. And he just COULD NOT BELIEVE that he had such a hard time asking students over there to pre-round on their patients! In fact, those students never did and just shadowed the team on the round and disappeared soon after finish rounding.

In many countries, they might have 3 years of clinical exposure in med school, but 2 of those 3 years are spent shadowing docs and as a result, they do not learn much since they do not take ANY responsiblities for their patients. Can you imagine how boring it is to shadow docs for two years? By contrast, in the US, once you are on the ward, you are expected to hit the ground running and much is demanded from you. It is NOT easy to be a med student and a resident in the US. And if you have lived in other countries, you will know that Americans are more serious toward their higher education and learning than people at many many other countries (dude, in UK, those D.Phil or PhD students spent hours drinking tea or doing other things in the afternoon and I rarely saw them in the lab before 9am) . There is a reason why people want to come to the US for residencies and it is because they work you like a dog and expect you to learn.

It is easy to criticize the use of technology. but the bottomline is that it is all about achieving the best sensitivity and specificity for your pts. Physical exam will never, ever approach the sensitivity and specificity these expensive tests buy you. The question is that, is it cost-effective? For one, cost-effectiveness is a nebulous concept that is difficult to test. So you save one more patient's life with a $700 test as opposed to a $25 physical exam but how much productivity do you get from that patient for the next 30 years of his life? How the heck do you measure that and its impact on the society? Lastly, expensive test equipment saves lives, as mentioned above in increases in sensitivity. To the family member of the patient you save, they do not give sh#t how much money that test cost. That's real medicine. You save lives and sometimes at the expense of increase health care cost. There is always the possiblity of you missing something and if you can live with that guilt and rely solely on your physical exam skills, then the more power to you.

 

[pitman]

Originally posted by Thewonderer
1) Hearing a heart murmur and says that you have heard it, is not that hard. But what is the point of saying the pt has a systolic murmur? It means nothing because it could have a number of different underlying pathologies. Furthermore, the loudness of murmur is not correlated to, say, how bad the pressure gradient is across the atrial valve. Therefore, for the sake of the pt's health and further management, you need to get an ECHO, whether you are in the US or in the UK. If you do not get an ECHO, then you are doing a disservice to your patient (on the other hand, S3 is pretty benign).

I'm doubting you know very good older docs. Ask one who's been listening to murmurs for, say 30-40 years (indicative of when trained, not of how long it takes to be good). It's an issue of triage, of knowing *when* to take the next step. But most younger docs I know cannot hear slight murmurs & scoff at the suggestion that someone can, while older ones can. Glad to hear you think it's not hard, but if you had my bro as a pt, I'd bet you'd miss it.

2) You can diagnose kidney stone with plain film if pt has had a hx of calcium stone. Otherwise, the standard protocol is to get a spiral CT, not MRI.

1) as 80% are Ca-based, do plain film 1st, save $1000. And if +, you'd know it's Ca! But tell this to an ER and see what answer/excuse you get (all the while with pain=10 + morphine drip awaiting "confirmation"). Also requires a radiologist who's willing.

2) you can also do an ultrasound (like for my 1st stone, at NYU Downtown), but apparently only former-Soviet techs are good enough at this art to detect them, WITHIN the kidney (goes to my point -- lost hands-on skills in US). Can also do urine (for blood), not as definitive, but will serve to corroborate pt claim (e.g., to speed approval for morphine).

3) Tell this to the ER that gave me an MRI (for my 2nd stone).

I could just as easily said "CT" rather than MRI -- the "standard protocol" is just as silly. Why do you suppose I have a beef with so many docs today? b.c. they're being taught such protocols rather than how to be proficient at inexpensive alternatives or first-lines. Why do you suppose I'm giving the examples that I am? b.c they are commonly not questioned by US doctors, b.c. they are written in a guide.

3) Regarding antibiotics use, that is up for debate. The bugs in the US hospital are differen than the bugs at, say, Kenya due to past abx exposure (hey if people cannot afford abx in Kenya, then for the most part, there is no resistance!). Even the bugs at say Hopkins is different than the bugs at Columbia-Presbyterian. There are a lot of things to consider when choosing an abx. In the US, most people follow Sanford's Guide and it is evidence-based medicine. So if you follow the guide, there should not be an abuse of abx.

We rely much on what we perceive to be authority. But docs/systems must decide what authority(ies) to listen to, why, and how to question them.

When docs don't even consider pen./amox. to treat simple strept or ear infections, or don't even REALIZE that no matter what guide claims should be the top pen. dose, that you just can't OD on the stuff, and higher doses do often do the job when 250 or 500 doesn't, or for whatever other reason (free samples, buying into pharm. propaganda, limited exposure to alternatives, etc.), as soooo many don't, they're adding to the problems of resistance and increased health care cost.

Haiti is now starting to have a problem with resistant TB, not because of overuse of exotic antibiotics (virtually no one can afford more than the basics), but because of resistant TB from abroad. Now they're all screwed. I.e., effects of US practice are not isolated to US.

Lastly, since you keep on saying how great foreign training is, an ID fellow I talked to last year did a month of electives at Radcliffe Hospital affiliated with Oxford. And he just COULD NOT BELIEVE that he had such a hard time asking students over there to pre-round on their patients! In fact, those students never did and just shadowed the team on the round and disappeared soon after finish rounding.

I never said that foreign training was "great" (in general or specific to a locale), in fact have claimed that neither US nor foreign training is "better", and have been criticizing those who don't see the added benefit of variety of training (e.g., as a consideration when deciding on a school or on locum tenens, in order to see not just *what* but *why* the alternatives, to what effect, a bigger cultural/holistic awareness, etc.).

Not sure why you chose a sample of 1 to make your point -- I'd have to not only claim that all foreign training was "great", but also that all foreign trained docs were "great".

In many countries, they might have 3 years of clinical exposure in med school, but 2 of those 3 years are spent shadowing docs and as a result, they do not learn much since they do not take ANY responsiblities for their patients. Can you imagine how boring it is to shadow docs for two years?

Some schools yes, others no. Not sure of your point here. Are you saying that all US schools are best, all US protocols inherently better? To see potential benefits of going abroad for some part of formal and/or informal training (4yr, just electives, locum tenens, etc.), one'd still have to be conscientious enough to go somewhere that *complements* what's learned here. Either way, either place, there's indoctrination and other unsavory practices to weed out...thus my point.

By contrast, in the US, once you are on the ward, you are expected to hit the ground running and much is demanded from you. It is NOT easy to be a med student and a resident in the US. And if you have lived in other countries, you will know that Americans are more serious toward their higher education and learning than people at many many other countries (dude, in UK, those D.Phil or PhD students spent hours drinking tea or doing other things in the afternoon and I rarely saw them in the lab before 9am) . There is a reason why people want to come to the US for residencies and it is because they work you like a dog and expect you to learn.

Sorry these were your experiences, and I feel sorry that you generally view Americans as more serious. I too have anecdotes, about incompetent/non-serious (American) doctors, and have lived/volunteered in other countries. But seriousness does not pre-empt indoctrination nor limited exposure. Nor was there an argument that a non-serious American going abroad (for breadth??) will suddenly become serious (subtle point here).

Docs come to the US for residencies for a number of other reasons:
1) US practice ($)
2) US standard of living
3) relative freedom
4) for better or for worse, for whatever reasons, b.c. US training is valued in other countries (assuming the doc returns home).

It is easy to criticize the use of technology. but the bottomline is that it is all about achieving the best sensitivity and specificity for your pts. Physical exam will never, ever approach the sensitivity and specificity these expensive tests buy you. The question is that, is it cost-effective? For one, cost-effectiveness is a nebulous concept that is difficult to test. So you save one more patient's life with a $700 test as opposed to a $25 physical exam but how much productivity do you get from that patient for the next 30 years of his life? How the heck do you measure that and its impact on the society? Lastly, expensive test equipment saves lives, as mentioned above in increases in sensitivity. To the family member of the patient you save, they do not give sh#t how much money that test cost. That's real medicine. You save lives and sometimes at the expense of increase health care cost. There is always the possiblity of you missing something and if you can live with that guilt and rely solely on your physical exam skills, then the more power to you.

I haven't criticized the mere use of technology, but rather the absolute dependence on it because US-trained docs aren't taught *when* it should be used. *If* something can be diagnosed/ruled out using a $200 test (ultrasound, steth.), then such triage will save time and $.

But it can't, can it -- I readily acknowledge that the vast majority of current docs should (er, "must") use such procs, precisely because they don't know how/when *not* to use them! I'm not calling to abandon high tech (I'm a biomed engineer), not saying that high tech doesn't save lives when used, but rather that docs are no longer trained in the US to be very good at, e.g., triage, which requires a better knowledge of hands-on.

Your point here about $ is not as simple as you seem to make it sound. First, reductio ad absurdum, 99% of the US budget should be spent on health care if it means "more accurate/sensitive" -- as you effectively said, "for how much productivity?", and as I add, "for what expected benefit?". Second, less *reliance* doesn't mean don't use. Third, even if increasing costs of health insurance didn't come back to the patient(!), there are many who don't have insurance, and even some, just a few, who do know that a $200 test is sufficient (and faster) and do not want the $2k gratuitous MRI or CT, "just in case your kidney stone is some rare form of cancer", or know that $10 worth of penicillin will likely cure their strept better than $50-$100 of an exotic, less-tested antibiotic that may also be used as a last resort for resistant TB...But you're right, there will always be those who will insist that CBA cannot apply to med, and on buying anti-biotic soap, because hell, `I'm #1, and why should *I* take that risk of getting flesh-eating bacteria?`

-pitman

 

[pitman]

Thewonderer -- I do see your point of correcting "MRI" with "CT", since although I got an MRI, my question should have been, "...who could diagnose...a kidney stone without CT?". The problem I have is still the dependence on the expensive test.

 

[Thewonderer]

I can see why u are upset that some docs try to order a bunch of labs and tests. A lot of times, they try to cover their butts from lawsuits. If there is a tort reform, I can reassure you that many expensive tests would not have been ordered.

I am curious where you got an MRI for a kidney stone. That's way too excessive. How the heck do you have tumor when you are so young and have a hx of kidney stone? Which hospital is that?

However, I sense that you prefer docs doing medicine from their "past experiences." What is exactly what the US is moving away from because of the concept of evidence-based medicine. Docs have been doing stuff they "think" have worked and kept on doing but they do not realize that the intervention could be causing a placebo effect. Therefore, people are now moving toward ordering tests and doing interventions according to the studies that have been published and not based on their past "personal" experience. That's why there are guidelines. Guidelines lead to more accurate care, not the other way around. Some people could of course follow a part of the guidelines and order, say, CT for everyone but forgot that pt with a hx of Ca stones only need plain film. But that's the fault of the clinician, not the guidelines. Sanford's guide is good, not bad. Relying mostly on your past clinical experience might actually be bad for patient care. Granted, not every area is covered by evidence-based medicine (after all, NOT everything has been researched thoroughly), but you should incorporate EBM into as much of your practice as you can.

What you said regarding cost-effectiveness is what I said. You cannot measure it. It is hard to measure. People can cry that something is not cost-effective all they want, but it is not clear-cut. Just as long as there are tests out there, somebody is going to order it, even under unnecessary circumstances.

 

[macrosky]

As I know, Chinese doctors assume even more responsibilities during their residency training because residency program there is seemed as a formal job instead of just a training process. The residency "job" push the doctors to solve the problem independently. So most Chinese doctors are very good at diagnosing and treating patients. Furthermore, a Chinese doctor usually have chance to treat many patients. Since the medicine-practicing is largely a experience-accumulating process, we could assume that a doctor has experience to treat 100 patients is better than a doctor only treat 50 patients.

 

[pitman]

Thewonderer -- as stated above, my issue is not with evidence-based medicine (EBM -- really, just good old-fashioned science with a fancy new title) in theory, which does actually incorporate what I've referred to (not "personal [subjective] experience" per se; and much of what cannot be encapsulated by the simple `placebo effect' argument -- e.g., whether a phys. exam can diagnose a murmur, or whether penicillin > 500mg in the face of Sanford's should be tried on a suspected resistant strain of s. pneumoniae).

My issue, or the one that has been narrowed down onto here, is the dependence, indeed a commonly blind dependence, on limited exposure/sources (on EBM in practice if you will). If status quo exposure is typically limited to a slice of US patients in a slice of the US, using current US protocols (selectively distilled from the science) as dogma rather than as the guides -- taken in the literal sense -- they were intended to be, then this serves only to create an over-generalized and over-simplified common denominator in practice, which certainly helps to protect the industry, but which can in fact be the "bad".

Therefore my attitude has been that it does good for individual doctors to increase their exposure, by seeing more, in other countries, in other cultures, etc., so that there is a greater depth of understanding, of the reasoning, of the "why's" and "when nots", w/ a better practical knowledge, and not a capitulation to what should *return* to being mere *guides* and *references*.

In the following posts, I'll explain more formally (er, metaphysically) my issues with EBM-based protocols in practice.

To show my appreciation of EBM (science), I'll start with a slice of the issue as seen by the authors of a peer-reviewed industry article:

Charles R. Bonapace, Pharm.D., Roger L. White, Pharm.D., Lawrence V. Friedrich, Pharm.D., and John A. Bosso, Pharm.D. (2002). Differences in antimicrobial drug exposures in patients with various degrees of renal function based on recommendations from dosing references. Pharmacotherapy 22(9):1097-1104.

The range of doses and/or dosing intervals commonly recommended in references is likely to cause confusion among prescribers. Whereas patient-specific variables must be taken into account when choosing a dosage regimen (site and severity of infection, altered apparent volume of distribution, organism's MIC), selection of a recommended regimen from a reference may result in either suboptimal therapeutic effect or unnecessary drug exposure in patients with renal impairment.

-pitman

 

[pitman]

Sorry about not posting my "treatise" yet , but it requires more organized thought than is possible now as I plan for an interview trip to Australia. More on this in a couple of weeks...

-pitman