“Free Tuition” Isn’t a Primary Care Pipeline

This week, there were two types of discussions on my social media feeds: non-medical friends fascinated by New York University’s announcement of free tuition for all its medical students, and medical friends frustrated that their own schools weren’t so generous (gee, thanks, Vanderbilt!)

To be clear, it’s an impressive and laudable feat to cover tuition—at present, around $55,000 per year—for about 450 students in perpetuity. By the Association of American Medical Colleges’ numbers, 75% of the Class of 2017 graduated with education debt; on average, over $190,000 per student, between eight years of undergraduate and medical studies. NYU raised $600 million in donations to ensure that its graduates don’t have such financial considerations hanging over their early-career decisions.

NYU’s stated rationale here is twofold: to reduce the cost barriers that would prevent some students from pursuing careers in medicine, and to encourage students to choose less-lucrative specialties like primary care. “I don’t want people moving away from what they’re passionate about because of their fear of the money,” said Rafael Rivera, NYU’s Associate Dean for Admissions and Financial Aid.

I think those are pressing problems for medical education, and I applaud NYU for putting forth a bold, ambitious solution. I just don’t think it’s the best fix for either issue.

Free tuition is a definite game-changer for students from less-affluent backgrounds that otherwise might not have been able to afford medical education. As a society, we need these people to become doctors. They’re more likely to return to the communities and populations they’re from to practice. Moreover, seeing as there’s a wealth of literature on the implicit biases that shape our care of women, minorities, and socioeconomically disadvantaged patients, medicine could certainly benefit from the added diversity of represented backgrounds and viewpoints among its ranks.

That being said, NYU students will still have to take on $27-29,000 per year in costs of living and other expenses, which may continue to deter some of those cost-prohibited prospective physicians.

It’s also not clear how this improves access over less costly initiatives, like Columbia’s $250 million plan to eliminate medical student loans. From my own medical school experiences, many of my classmates (though certainly not all) came from well-off backgrounds. I’d estimate at least 30% were themselves children of doctors, myself included. Can’t a university like NYU find a better use for the extra $350 million its plan will take over Columbia’s than to give aid to some students like me who, ultimately, would likely be able to become doctors and attain well-off lifestyles without it? Its education or social work students, for whom a six-figure income at their ten-year reunion is less assured, probably have some ideas.

Free tuition is a start to medical education’s access problem. A real solution, though, needs to consider the myriad ways low-income students are shut out from medicine—like limited early exposure, fewer test-prep resources, and less resume-building opportunities, to name a few—and act broadly to make a substantial impact.

If free tuition is a suboptimal solution for improving access, it’s even worse for solving the shortage of primary care physicians.

A $220,000 four-year tuition relief makes primary care specialties more feasible for altruistic students who are deterred from lower-paying fields by the prospect of loan repayments. It doesn’t, by any measure, make such careers more financially attractive in the U.S.’ current payment structure, in which doctors are paid for doing things, and paid even more for invasive or interventional things than for time spent talking to people or thinking through complex diagnoses.

According to Doximity, the average Manhattan general pediatrician makes $181,000; for family physicians and internists, it’s $205,000 and $207,000, respectively. When an NYU medical student chooses primary care, they choose to forgo the salary of an orthopedic surgeon ($458,000), radiologist ($384,000), or cardiologist ($391,000) out of an intellectual interest or sense of social duty in preventive care or population health management. Against a lifetime of thirty to forty years’ worth of accumulated earnings, the cost of a medical degree—even considering the interest on loans a student might otherwise take—is a drop in the bucket.

Don’t get me wrong: primary care is muchmuch more important than the salary comparison suggests. It’s just not any better a financial decision with a free medical education than without it.

To add an even more cynical perspective, as NYU’s application pool undoubtedly draws even more competitive, talented applicants, it wouldn’t be surprising to see its match list tip even more toward selective specialties like derm., IR, ortho., or ENT.

So, if medical schools really want to cultivate primary care doctors, they can introduce tracks for primary care-specific training and exposure, like the ones at Duke and Johns Hopkins. They can offer accelerated training programs for primary care, as Mercer and Texas Tech do. If they go the scholarship route, like NYU, they can borrow from UC Riverside‘s playbook: it covers tuition, but only if the students stay and practice in underserved Inland Southern California.

What NYU and its donors have done is an incredible gift for its future graduates, one which will surely have an impact on its students’ bank accounts—not to mention, its upcoming years’ U.S. News rankings. It’s every bit as generous and impressive as it seems. It’s not, though, the moonshot strategy for improving access to medical education or promoting careers in primary care that some, like The Atlantic, NPR, or Fox News, suggest.

P.S.: If you’re from NYU Med and reading this, I’m totally not related to any other Utrankars you might see an application from in the next few years.

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What matters in a medical school?

As a fourth-year medical student, I’m no stranger to admissions processes; I’ve been through two, am currently in one, and have at least one more ahead. At each stage, one of the most challenging elements of finding and selecting a ‘best fit’ institution is knowing, in advance, what really matters in a training program. You have an important decision before you—a four-year investment, which will provide the foundations upon which you’ll care for tens of thousands of patients—but, if you’re like me, an unclear sense of the essential factors that ought to shape that decision. What am I really looking for in a prospective institution?

I write about this now because, going through residency interviews, it’s currently all I think about. Every 15 minutes, I’m asked, “So, what questions do you have for me?” I dine with residents, interview with faculty, and tour hospitals, all to address the nebulous question of which program is optimally suitable to launch my career. My co-interviewees and I ask all sorts of queries, with widely varying degrees of significance to the training experience.

  • What is the didactics curriculum like?
  • How is your call schedule structured?
  • Where do residents live in relation to the hospital?
  • How many livers do you do each year?
  • Are there moonlighting opportunities?
  • What’s the free food situation?

It feels clumsy, murky, and at times even silly; am I really going to weigh the ‘food situation’ in my residency decision? How ‘mission-critical’ are strong didactics, case volumes, or moonlighting opportunities, really? While I can’t speak to any of those questions at present, I’ll offer my perspectives on the process on which I now do feel somewhat better equipped to advise: what matters when selecting a medical school.

Does the institution’s mission statement match yours?

A mission statement is more than boilerplate text. It outlines what the institution values and aspires to—and by extension, the role they envision for you as a future physician. My medical school, for instance, defines itself as a regional referral center for complex cases, as well as a hub for leadership, innovation, and scholarship in subspecialty care. The faculty it recruits, the programs it invests in, and the curriculum it instills all reflect those objectives. For the aspiring physician-scientist or sub-subspecialist, it’s a strong fit. For those with professional interests in ‘country doc’ or ‘safety net’ medicine, perhaps less so.

Does the curriculum align with your learning habits?

By now, you likely have a sense of how you learn and study best, so find a school where the educational activities mirror those preferences. If you like to study in groups, favor discussion-based courses, or retain content better when you can situate it in an experiential framework, look for schools that emphasize active learning over traditional lecture. If you’re unable to self-structure your time productively, maybe a school that requires attendance is best for you. The more honest you can be with yourself here, the better your chances of selecting a setting where you’ll succeed academically.

How flexible or adaptable is the curriculum to meet your goals?

Academic interests evolve, almost inevitably. Therefore, even if you’re certain a future in pediatric cardiothoracic surgery awaits, pick a curriculum that affords you the flexibility to pivot if you discover a late latent passion for, say, family medicine or geriatrics. At my medical school, for instance, the third and fourth years are almost entirely elective-driven, which gives students the flexibility to choose their own adventure and adapt as their goals shift.

Even if you’re set on your path, flexibility matters a lot. Medicine offers infinite opportunities to customize your career. In addition to the myriad specialty and subspecialty routes available, physicians can be scientists, entrepreneurs, technologists, administrators, policymakers, activists, educators, ethicists, creatives, and much more. While there are some competencies which are foundational for all physicians, your classmates paths may look profoundly different from yours, and the best curriculum is one that provides the time and resources to train you for the particular career you want.

Is there a formal, student-engaged process to elicit and implement learner feedback?

No medical school is perfect, but the best ones are committed to the idea of rapid-cycle, feedback-driven improvement. When considering a school, ask students and faculty for examples of changes in response to student-voiced needs or interests. Ask how often students have face time with educators and administrators, and what mechanisms exist for students to relay feedback—or even better, to shape administrative decisions in collaboration with deans and leaders. Of course, every school will think it achieves this objective exceptionally well, so seek input from multiple perspectives and ask for particular examples.

Is it an environment where, when you’re not in the classroom, at the library, or on the wards, you’ll be happy?

There’s a lot of down-time in medical school. While it might not feel that way the week before a block exam or during a surgery rotation, medical school (usually) won’t be your life. You will have time to pursue hobbies, hang out with loved ones, explore your surroundings, and have fun .. so make sure your environment is conducive to it. If you’re someone who draws heavily upon support from family, going somewhere distant might not be worth it. If you’re ‘single and searching,’ a small town may not be your scene. Academics matter, but four years is a long time to “grin and bear it.” Pick a place where you’ll find happiness as you define it, and where you can be the person you want to be.

But wait! What about the U.S. News and World Report rankings?

Frequently—looking at you, Indian dinner parties and Student Doctor Network forums—pre-meds wonder how much weight to ascribe to rankings when selecting a school. The unpleasant answer is: they sort of matter, but they sort of don’t.

Reputation, in itself, isn’t terribly important. But those ‘name-brand’ schools are also the tertiary or quaternary care centers where you’ll see the most complex cases, where you’ll build connections with mentors that are leaders in their respective fields, where you’ll reap the educational and scholarly resources that come with a major research institution and a generous endowment. Those opportunities aren’t necessarily exclusive to “elite” institutions, but they might come easier at some places than others. Therefore, my standard advice is this: don’t focus on the rank number, but look for the benefits and advantages that come with it.

That’s a lot to think about, so I’ll close with some words of comfort: I’ve worked under many incredibly bright and gifted residents at Vanderbilt, enough to know that it’s nearly impossible to distinguish from observing someone’s clinical skills whether he/she went to Harvard Med or State U. If you’re smart enough to get accepted to medical school and build upon that inherent intelligence with diligent effort, you can go anywhere from anywhere. When the process feels daunting, think back on that, and you’ll get through just fine.

Medical students and physicians: what do you now feel is important in a medical school that you would advise prospective students to consider?

 

“Wow, you don’t have an accent at all!”

From Charlottesville to NFL stadiums, conversations and controversies surrounding race relations have seldom felt more heated. These events challenge each of us to consider how racial issues intersect with our daily lives, as OHSU emergency physician Esther Choo notably did in a now-viral tweetstorm about patients refusing care from providers of color.

The reverberations of these seismic disruptions in our social consciousness have, naturally, stirred discussions in our medical school’s classrooms and clinics: how we’ve felt impacted, how our patients have been affected, and how we can root out structurally-ingrained racism in our local environments. And while I can’t claim to understand or have experienced the unique challenges my black or Latino colleagues encounter, these conversations have raised common threads of reflection among my Asian-American peers about the micro-aggressions we navigate while learning medicine in the ‘buckle of the Bible Belt.’

Thankfully, the experience of being verbally confronted or having my services refused on the basis of race isn’t something I’ve had to handle—for such overt hostility, the New England Journal of Medicine has an excellent primer on “Dealing with Racist Patients.” Instead, my brushes with “lowercase-r” racism have been much more subtle, and often unintentional.

“I know a Dr. Patel; he lives in North Carolina? Do you know him?”

Funny; I know a Joe Smith in Edison, New Jersey. Do you know him?

“Where are you from?”

New Jersey.

“No, where are you really from?”

I promise, I am really really from New Jersey.

“Where are your parents or grandparents from?

[Groan.]

“Wow, you don’t have an accent at all, and your English is great!”

Well, I scored 5’s on my AP English exams and an 800 on my SAT verbal, so I’d say I’m pretty decent at English, yes.

“You moved here when you were two months old? That means you’re almost one of us!”

Thank you for letting me know that, though I’ve spent 99.3% of my life here, completed 20 years of schooling here, renounced my Indian citizenship for a U.S. one, and consider myself as deeply immersed in your sports, music, and pop culture as anyone else, that you still think of me as less entitled to the privilege of being “American” than you are.

If you’re not convinced, Buzzfeed has some delightful examples, too.

I came to Tennessee (which is 1.8% Asian) from a university ranked #1 for race-class interaction, and before that, a minority-majority hometown where our high school cafeteria resembled the United Nations. It felt entirely foreign, then, to transition to a setting where most of my patients not only didn’t look like me, but had often lived for decades in rural communities where everyone looked the same, sounded the same, prayed the same, and voted the same. It was a rare experience to feel hyper-aware that I was different, which was only heightened by my patients’ comments and curiosity questions. These bigots, these ignorant rednecks, these deplorables, I fumed internally.

With time, though, as I grew to better understand my patients, my exasperation softened to empathy. Through brief interactions at the bedside, I came to see my patients’ “political incorrectness” not as ill-intent, but inexperience. If you live in McMinnville, Tennessee, you might believe that most towns, like yours, have only one South Asian family, and intuit that these dispersed Desis find and know each other. You might only know of South Asian culture through the pop culture vignettes of Simpsons or Slumdog, so that when you encounter an Indian American medical student, your conversational instinct is to ask about accents, bindis (“dots”), the caste system, or arranged marriages. Maybe that is bias or racism, but it’s a curious naivete that’s infinitely harder to hate or look down upon than a tiki-torch mob.

Acknowledging that naivete, I no longer get frustrated or angry. Instead, I teach.

“I know a Dr. Patel; he lives in North Carolina? Do you know him?”

“No, I don’t. There are 4 million Indian Americans across the U.S., so it’s hard for all of us to keep in touch! “Patel” is also as common a last name among Indians as “Smith,” “Jones,” or “Johnson” are here. It’s like asking if you know my neighbor back in New Jersey just because he has the same last name; I’m guessing you probably haven’t met!”

“Where are you from?”

“I’m originally from New Jersey, where my family still lives.”

“No, where are you really from?”

“Well, I was born in India, but moved here when I was two months old. I’ve completed all my schooling here, gone to college here, and consider myself culturally American with Indian roots. Most people tend not to remember much from the first two months of their life, so practically, my life here is all I’ve lived and known!”

Likewise, acknowledging my limited insight into the lived experiences of the South, I learn. I ask my patients what it’s like to live in rural Tennessee or the ‘urban underserved’ areas of Nashville. I ask about the factors that promote or impair physical and mental wellbeing in their communities. I ask about their beliefs, values, and goals, realizing that their social contexts might frame these perceptions to be drastically different than my own precepts or presumptions. As I realize that I understand their lives and backgrounds as little as they do mine, it becomes harder to cast judgments or throw stones.

Of course, not everyone’s experiences might be as benign as I’ve been fortunate to have, or as amenable to resolution with casual conversation and cross-teaching. Medicine has much self-reflection and work to do regarding racial disparities—certainly, among others—in our physicians’ demographic composition, in our patients’ health outcomes, and in our interpersonal interactions in clinical practice. That’s a much larger matter, and I’ll table it for a more seasoned expert’s commentary.

But, for immigrant medical students and physicians, I offer this advice: the next time you encounter an off-putting or politically-incorrect remark, consider where it’s coming from, and the contexts and experiences which frame that person’s viewpoint. Consider the positive impact you might offer by deferring confrontation for education. And most critically, consider your own biases or presuppositions before judging or critiquing someone for theirs. Shared understanding isn’t always the solution, but it’s often a worthwhile start. Give it a try; I promise your patient interactions (and cortisol levels) will be all the more better for it.

Why professional societies are worth it

As someone who’s all too familiar with the ‘student loan life,’ there are few things I’d recommend as essential buys besides UWorld, ramen noodles, and Keurig cups. One that’s often overlooked by medical students, though, is membership in the professional society for your future specialty.

Cue the collective groan. I know, and I get it: why pay an annual subscription fee to join a club, add a line on your CV, and pay your respects to “the guild?” At first, I felt similarly skeptical. As a digital native, I was confident that I didn’t need my professional society. I had a blog. I had a Twitter account and LinkedIn profile. I could advocate for myself, and network for myself.

Since then, as I’ve furthered my interest in anesthesiology and advanced my involvement in the specialty, I’ve come to see the value that a $10 American Society of Anesthesiologists (ASA) student membership provides. Here, I’ve outlined a few of the high-yield benefits of the ASA Medical Student Component—and, I should add, even if you’re not a gas-passer in the making, these same benefits likely extend to the society for whichever specialty’s caught your heart.

Know what’s happening in the field, and where it’s headed. Through the ASA, I receive a complimentary print subscription to Anesthesiology, its peer-reviewed journal; the ASA Monitor, its monthly magazine; and ASAP, the weekly email newsletter. As an outsider looking in, these publications provide an introduction the ‘hot topics’ in anesthesia research and practice and an overview of educational content that’s likely to be useful on your anesthesia rotation (and not to mention, future training). Not all of it applies to learners, so feel free to gloss over the articles on practice management or billing code jargonology, but you’ll pick up enough to show attendings that you’ve done your homework, and to show interviewers that you know what you’re getting into.

Learn, do, and network at the Annual Meeting—for freeThe ASA and other specialty societies know that their students are their future, and they invest in our growth (and theirs!) by waiving students’ registration fees for the ANESTHESIOLOGY Annual Meeting. This conference is a ‘must-do’ for the future anesthesiologist, without question. It’s an opportunity to learn what’s new in anesthesia through presentations and panel discussions, practice procedures in hands-on skills workshops, and network with residency programs (and future employers!) And again, it’s all for free—which, right behind “go home” and “do you want to do this procedure?” are a medical student’s favorite words.

Support the people who are fighting for your future. In medical school, it’s sometimes easy to be complacent about advocacy, policy, and the landscape of physician practice; after all, life after residency seems so far away that we’re rarely looking beyond the next shelf exam. Even if you’re not looking ahead to the future, your professional society is. That’s why, in the last year, the ASA has been looking out for anesthesiologists and their patients and advocating for physician-led anesthesia care—and for evidence of that, look no further than the Safe VA Care initiative. And these are challenges facing every specialty: family medicine, internal medicine, pediatrics, psychiatry, radiology, you name it. Even if you view your membership as solely an investment in the safety of patients and the relevance of your future profession, it’s well worth it. And of course, if you want to go the extra mile, there are advocacy opportunities and leadership positions available.

When you think about what it costs to become a physician today—medical school tuition, supplies for clinical rotations, test prep resources, residency application and interview travel fees, and much more—a $10 annual membership to the American Society of Anesthesiologists (or your specialty’s professional society), with all it affords, is easily the right decision. If it does present a financial challenge for you, don’t worry; your medical school’s student affairs office, your school’s anesthesiology department, or your state’s anesthesiology society can likely lend a hand. Whatever the case, don’t overlook the chance to tap into this valuable resource and the education, professional development, and advocacy advantages that come with it.

Bottom line: prospective members, join the ASA, or your professional society, ASAp (#badpuns, I’ll admit). For current members: what additional benefits or perks have you gotten from your involvement in your professional societies? Leave a comment to weigh in!

Disclaimer: I am a medical student member of the American Society of Anesthesiologists and a member of the ASA Medical Student Component Governing Council. This blog post is not on behalf of the ASA, nor has it been authorized or supported by the ASA (or any other organization) in any capacity; it represents my views, and my own advice for my fellow future anesthesiologists, alone. [In short, I speak for myself, because I’m fairly certain nobody wants me to speak for them anyway!]

Chugging Along

It’s the morning after Election Day, and the world still has a sort of surreal quality to it.

I awoke this morning with a sense of fear. Fear for my own safety, and the safety of my loved ones who fall beyond ‘standard’ templates of race, faith, nationality, gender, or sexuality. Fear for the stability of public discourse and debate in the coming days and weeks. Fear for the legacy of the last 8 years—and the last 240 years, really—which today seems more vulnerable than ever.

Somehow, I got out of bed, took a shower, got dressed for school, packed a lunch, and drove to school, all the while feeling anxious to discover what a “Great Again” America would look and feel like.

And then I reached the hospital. Here, it doesn’t feel like the morning after Election Day; it’s Wednesday, November 9th, and just that. Doctors are taking care of patients. Residents are scurrying about, completing their usual errands. Patients are being seen, heard, and cared for, just like any other day.

One of medicine’s most beautiful qualities is that, whatever the turbulence beyond the hospital, the essence of the patient-provider interaction and the bedside encounter remains a familiar constant. Today, my fellow healthcare providers will head to work carrying the weights of their emotions and thoughts, but once we walk into that exam room, nothing else will seem relevant but the needs of the patient before us. Even if that patient is wearing a “Make America Great Again” cap, and even if he holds an ideology that considers my kind an outsider or a threat, we’ll look beyond that. We’ll resist the temptation to see a ‘deplorable,’ and challenge ourselves to see someone who needs our guidance, compassion, and care. A patient—nothing less, nothing more.

That’s not to suggest at all that medicine occurs in a vacuum. As physicians and physicians-in-training, we now face an uncertain future that could well profoundly affect the way we practice. Our patients will face renewed challenges to receiving accessible, affordable, equitable health services. The health and wellbeing of marginalized populations, such as women and LGBT individuals, will be more vulnerable to the whims of partisan policy than ever before. Gun violence will, once again, fail to receive its due recognition as a public health emergency.

These are important matters, and as educated experts who navigate these issues in the trenches each day, our voices will be critically important to these conversations. We cannot let our commitments to advancing the health of populations waver in the face of adversity. The path forward will be harder, and so our convictions must be even stronger. That conversation begins tomorrow.

But today, when it seems like the rest of the world is standing still, and when it feels like a future with a President Trump is too painful to even imagine, I take comfort in the assurance that ours is a profession that, despite our emotions and adversities, keeps chugging along, changing the world one patient at a time.

When Breath Becomes Air

As I write this, I’m wiping away the tears in my eyes stirred by Dr. Paul Kalanithi’s When Breath Becomes Air. Richly reflective and powerfully evocative, it’s the touching narrative of a doctor’s attempts to confront death—as a student of literature, as a neurosurgeon, and as a patient—and, through the lens of terminal illness, examine how dying gives meaning to living.

With When Breath Becomes Air, Dr. Kalanithi allows us to, in his words, “Get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here … sooner or later I’ll be back here in my own shoes.'” It’s a walk that resonates particularly strongly for me as a fledgling physician.

As he reflects on his medical training, Dr. Kalanithi looks back with the perspectives of both patient and provider to offer valuable insights on what it means to be a physician: someone who translates statistics and survival curves into a patient-oriented language of values, identities, and capabilities; someone who is relentless in the pursuit of operative excellence, but understands that a surgeon is more than an expert technician; someone who aspires to perfection, but ultimately accepts his fallibility.

For any avid reader of medical non-fiction, these reflections will sound familiar, the stuff of Better and Being Mortal. And yet, When Breath Becomes Air feels different, because it explores medicine’s virtues, values, and flaws from the perspective of a patient, someone who is both an insider and outsider to medicine. As Dr. Kalanithi writes, “As a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know.” His perspectives on what makes a good doctor are informed by an intimate understanding of what patients feel, what patients think, and what patients want that most of us, as providers, can only infer and intuit from our interactions with illness in the third person.

At its heart, When Breath Becomes Air is about more than how we ought to provide care; it’s a contemplation of how we ought to live. The life of a physician-in-training often feels like a life of anticipation, of potential, of surviving the present to reach the rewards of the future. We spend a third of our lives studying, sacrificing sleep, accumulating loans, and watching our friends build lives that are less exhaustive and more lucrative, all of which we accept for the eventual promise of a career that offers an unparalleled balance of intellectual engagement, moral fulfillment, and socioeconomic comfort.

I ask myself, then: if faced with a terminal illness tomorrow, would I feel that I’d achieved anything more in 23 years besides a pursuit of a life still yet to come? For Dr. Kalanithi, the prospect of dying gives the present an immensely deeper significance, a more imminent urgency. As I read his detailed recollection of his last day as a physician, a heartfelt recall of each interaction, each sensation, each incision, I felt uncomfortably reminded of what I’ve seen and done over the last week, and how it felt so unremarkably routine. I’d been present, but I hadn’t been truly present.

Reading When Breath Becomes Air, I felt called to attention, awoken from autopilot to embrace the quiet miracles and subtle wonders that transpire around us each day in the hospital. If we practiced medicine each day as if it were our last, what might that look like? What could it do for our connections with patients, for our interactions with our colleagues, for our thirst for meaning and fulfillment in our daily lives? This, I think, is Dr. Kalanithi’s strongest parting advice for us. And as cliche as “live as each day is the last” sounds, that we so rarely do it makes it advice worth hearing.

When Breath Becomes Air is an easy read that raises difficult questions, a short book that invites lengthy pauses for thought. Whether you’re in medicine or not, you’ll invariably someday find yourself pondering the matter of mortality and the meaning it imparts to the closing days of life—and therefore, you’ll invariably find this book to be both moving and meaningful.

Thanks, Dr. Kalanithi.

This Just In: Patients Can Use the Internet Now.

Sometimes, the future arrives so swiftly that we don’t even notice the subtle revolutions unfolding before our eyes.

For years, the notion of patients searching for health information online was anathema to physicians. The slightest mention of patients as engaged consumers of health information would cue a noxious reflex from most providers, fueled, no doubt, by stereotypes of patients like these:

Screen Shot 2015-10-09 at 20.18.23

As recently as 2013, when I interviewed for medical school, stated interests and curiosities in healthcare social media, e-health, and participatory medicine were best, bold propositions, and at worst, toxic taboos.

“Do me a favor,” one dean of admissions quipped, “When you’re a third-year on clerkships, you’ll meet the man who’s been convinced by a WebMD search that his toe pain is diagnostic for brain cancer. Spend 15 minutes with that guy, then come find me and let me know if you’re still an optimist about online resources as tools for patient empowerment and engagement.”

Fast forward to 2015, where I’m now a clinical-phase student on an outpatient pediatrics rotation, and I finally have an answer for that dean–though it’s probably not the one he expected. I’m still an optimist in the power of online communities and digital content to equip patients with the information they need to engage in their clinical-decision making, as equals, with their providers.

Actually, after the conversations and clinical interactions I’ve witnessed these past weeks on pediatrics, that optimism has never held more firm.

Figure 1. An adolescent seen one week earlier for an acute infection and prescribed antibiotics returns with unresolved infection. The physician makes a diagnosis of antibiotic treatment failure. As she studies the literature for an appropriate second-line treatment, the patient’s mother does a Google search on her phone–and suggests a finding of her own. The physician reviews it, confirms it, prescribes it. Snap.

Figure 2. A child who is seen frequently for recurrent febrile illnesses presents for a well-child visit. The child’s parent mentions having searched online and identified a periodic fever syndrome consistent with the child’s clinical history. The parent shares printouts of relevant patient education materials, academic review articles, and diagnostic manuals with the physician. The physician agrees with the parent’s impression, and makes the diagnosis. Snap, crackle.

Figure 3. A neonate with a congenital condition arrives for a new-patient evaluation. The patient’s mother admits she selected this physician based upon reviews and recommendations from a local online patient community for disease-specific support. At the visit’s conclusion, the mother impresses the physician when she suggests a prescription for ondansetron–a tip she found through, yes, an online patient community. Snap, crackle, and pop.

As a health technologies optimist and medical futurist, it’s evident I’ve been so focused looking ahead to the future that I’ve missed the simple reality: in subtle ways, it’s already arrived.

We used to see e-health as synonymous with WebMD, the digital quack doc where all differential diagnoses lead to cancer. We used to think too much information would break the patient, break the doctor-patient relationship, or worst of all, break the monopoly on expertise that gave our profession relevance. We were, clearly, misguided.

The patient’s access to communities and open-access platforms for online health information is breaking healthcare–but not as doctors once thought it would. Instead, it’s breaking hierarchies, allowing patients to contribute to differentials and suggest treatments as engaged participants on their care team. It’s breaking barriers, connecting patients to insights and innovations previously sealed beyond paywalls and subscriptions. And it’s breaking the metaphorical walls of isolation, bringing patients in touch with others who understand the experience of living with illness and navigating a complex health system.

And every evening, as I drive home from another day in medical school, I’m inspired by the resilience of children, the resourcefulness of their caregivers, and the realization that I’m blessed to be entering medicine at a time of profound transformation, revolution, and creative destruction.