Medical School- Clinical years: Realizing medicine was not focused on health improvement

On May 18, 2010, in health care, incentives/ metrics, vitality, by Vijay Goel, M.D.
Pediatric polysomnography
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This is post 3 in a series highlighting my journey from physician to consultant to entrepreneur

I write this in a period of reflection — when I try to figure out what’s next for me as I reflect on my career to date.  My calling is the fixing of our broken health system.  However, as but one individual, how to do so in a way that allows me to build something of immediate value while taking care of my family is a complex challenge.  My goal is writing this is to help highlight my somewhat strange career path, as I’ve been contacted by a number of physicians at all stages of their careers.

While applying for medical school, my goal was to be a preventive medicine pediatrician: I wanted to keep kids healthy and make sure they never got sick.  This perspective, even in interviews for medical school, got me in trouble…great doctors were supposed to be tremendous diagnosticians with ability to memorize vast facts and prescription/ procedure options.  I never really understood why…for me the challenge was in understanding how to change basic behaviors early…so the bread and butter things that impacted the majority of people either occurred later or never.  I questioned the impact of the things we spent 80% of our time on…and needless to say it didn’t make me popular in an environment where people were conditioned to jump through professional hoop after professional hoop.

It all crystallized for me in a few places:

  1. I had a pediatric orthopedic surgery rotation with a bunch of “SCFE” kids.  SCFE stands for Slipped Capital Femoral Epiphysis.  Basically, these kids were so fat (and they were a bit more than “husky”, that their growth plates attaching the ball (in socket) part of the hip bone with the leg part of the hip bones cracked…and needed to be pinned to keep the kid’s leg in place.  What I saw was extraordinary technology to get the leg pinned and some followup with rehab.  What I didn’t see was any effort to get the kid’s weight under control (it is horrifying to see that a 12 year old is on the verge of type II diabetes)…although they did note they would put them on insulin if they tipped into diabetes.  I was pretty disgusted with how doctors were trained to view the world.
  2. I had a 5 yr old 110 pound girl (and no, that’s not a typo) on an ENT rotation in for a tonsillectomy to clear airway so she could breathe.  The ENT was executed beautifully.  The child’s health?  That was someone else’s concern…surgeons must move on to their next case once a patient comes off the table.  When I bothered to try and figure out in my busted Spanish what was going on, it all made sense.  The child was 110 pounds and had no teeth because her parents thought soda was better for her than water.  This was the moment I decided I didn’t want to practice in a system that defines success in a way where the patient may not have survived.
  3. I came across the book “Demanding Medical Excellence” by Michael Millensen.  This was my first concrete exposure to the inanity of a health system where better results (on a cost-plus basis) often equate to a bankrupt organization.  The need to change business models in health to reward EFFECTIVENESS vs. EXPENSIVE ACTION dawned and me…and has become the cause to which I’ve dedicated my career.

Late in my 3rd year, I decided not to apply to residency.  It came with much heartache and second-guessing at the time, but while doors closed others have opened that have led to a passionate-filled and interesting start to my career…

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Pre-clinical Medical School: Memorizing facts at the beginning of the internet era of medicine

On May 3, 2010, in health care, life, science, by Vijay Goel, M.D.
A statue of Asclepius. The Glypotek, Copenhagen.
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This is post 2 in a series highlighting my journey from physician to consultant to entrepreneur

I write this in a period of reflection — when I try to figure out what’s next for me as I reflect on my career to date.  My calling is the fixing of our broken health system.  However, as but one individual, how to do so in a way that allows me to build something of immediate value while taking care of my family is a complex challenge.  My goal is writing this is to help highlight my somewhat strange career path, as I’ve been contacted by a number of physicians at all stages of their careers.

Having been admitted to medical school, I now was immersed deep into the more academic curriculum of the first two years.  I have to admit I was tremendously disappointed.

Don’t get me wrong, I loved the clinical piece of medicine.  Interacting with patients (even in our limited pre-clinical years) was an amazing process.  Donning the white coat opened up a whole new world of access into the deepest, most intimate details of a person’s life.  The tradeoff was the dimming of your own empathetic humanity…the role required that those deep details be used to drive medical diagnoses and services and a filter of “doctor” screen all normal human impulses and reactions.  This perspective would truly change my life and enforce the importance of time in generating enough of a rapport and relationship to really be able to help someone.

The academic/ science side was a different story.  What I thought would be an experience that built upon the dynamic understanding of physiology combined with how to achieve great results in real patients in the health system…instead was a flood of didactic memorization based on the deep (and largely irrelevant) details of our professors’ research.  There seemed to be a great focus on breadth in detail…providing a slurry of facts and figures without the focus on building a high-level framework that would serve as our foundation in medicine.  In an era where most of these details were available on my palm pilot, when they were relevant to anything I was doing, I found incredibly frustrating and largely a waste of time.  Where I wanted discussion and debate, I found a premium placed on memorizing what my elders told me…and substantial challenges at the points where I thought that the literature pointed to plausible alternatives to what I heard in class (e.g., my early suspicions that “mature” tissues like nerves and muscles could regenerate based on satellite cells and latent stem cells).  My love for science and probing mind had become a liability in the two year sprint through the basic sciences…and how I was frustrated by the intellectual challenges of science turning into brute memorization of things I didn’t quite believe.

What had happened was that the explosion of science had translated into a desire to cover all of life sciences, rather than to focus on the skills and evaluation frameworks that would ensure that we were lifelong scholars we could evaluate all of that research relevant to our patients.  As a happenstance of fate, our class of supposedly 150 at USC School of Medicine had somehow accepted our admits in a way well outside the bell curve.  We ended up with 180+ in our class, 2/3 men.  This meant that our lectures had to be videotaped and broadcast into a satellite room.  This provided me the opportunity to study instead of waste my time in class, read the textbooks and literature and go deep in areas of interest, while still being able to review lectures that I wanted to play back.  I became a virtual student…and memorized enough of what I was told to pass my pass/fail first couple of years.

What did I do with that extra time?  I focused on a few things…I spent a fair bit of time volunteering in the emergency room and I pursued a deeper understanding of how health care worked…not the scientific part but the people part.  This would be the element that would change my life and move me away from my initial calling in prevention-oriented pediatrics…but that will come in the next installment…

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What I learned in medicine

On October 8, 2007, in Uncategorized, by Vijay Goel, M.D.

The pursuit of medicine and helping people attain health is a noble one, and I learned many valuable lessons on my way to the M.D.

I can’t really put into words how amazing it is that idealistic young people decide to sacrifice their early careers to hard work, low pay, terrible working conditions, and a largely outdated teaching model in hopes of someday making a difference in the lives of their fellow humans as they don the white coat.

I also can’t tell you how disappointing it is to see the system take these young idealists and have them use the poor as their “teaching cases” (the rich ones are not to be touched by mere students) on their way to building skills, saddle them with a lifetime’s supply of debt, and then prevent them (through reimbursement) from practicing the human-focused medicine that most people originally entered the field to perform.

Going through all that, however, it was a privilege to wear the white coat and it still carries with it an aura of trust and advocacy that gave me an extraordinary access to look into people’s bodies and their lives. The analytic and financial rigor I picked up in business will always be balanced by the emotion and drive of human life– whether in seeing the smile of a child who had been in pain, the tears of the family of a life lost, the confusion of someone whose life has just changed, the self-doubt in looking back on a lost case, or the cessation of the pulses in a beating heart as a life extinguished in my hands.

The biggest thing I’ll take with me is that life is extremely random and unpredictable– and for those who make it through to an old age there really is only a few things that really matter at the end of this life. I had the honor of being close to the last moments of several individuals– and to see what family and friends and a life that had personal meaning meant to those individuals. On the flip side, I also saw how fragile our existence is– and how precious every moment can be when it may be near your last.

This really put career, and family, and risk into perspective for me–Am I living a life today, that I can take pride in if it ends tomorrow or fifty years hence? When I look back, will I have done what I can to make a living for my family and leave the world a better place?

In those more simple terms, it seemed easy to turn into the one lone individual at my school looking to change the system from sick-care to a more healthy one. It made job security by going through residency pale in comparison to a chance to really change the world and make a difference– by building new ways of approaching health and healthcare.

And when you go looking, you’re likely to find something– I stumbled across McKinsey while looking for B-schools and had an amazing experience there. I’m now stumbling through the entrepreneurial internet space and trying to build my first company there. This has already been an amazing journey, and I’m looking to share with you the next chapter as it unfolds.

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Leaving medicine for business

On October 5, 2007, in Uncategorized, by Vijay Goel, M.D.

My dream for most of the early part of my life was to be a doctor. While playing football in high school, I thought it would be really neat to be a sports doc and an orthopedic surgery spot at a place like Kerlan Jobe seemed a dream.

As I developed a bit more of life in college, I realized that shaping the lives and experiences of young people really was my calling– I spent time as a SAT tutor, athletic tutor, teaching assistant and spent my free time volunteering at camps for kids who had faced significant challenges– mainly at Camp Ronald McDonald for Good Times, but a little at Unicamp, Diabetes camp, and a heart camp. It was here I realized a few things: how much I got back from giving just a little, and how much I was driven by activities that taught and created sustainable change, not just a break or short-term intervention.

My college pursuits taught me well. I was more a physiologist and psychologist than a M.D.– I saw the provision of health services as a system and it wasn’t just enough to try hard and do my best.

I was going to follow my passions and become a pediatrician and help start young people off on the right foot– until I started doing my electives in pediatrics. I had a few rounds of SCFE kids (a slipped capital femoral epiphysis occurs often when a child is so fat that their weight causes the growth plate in their hip to fracture) and one tonsil removal that broke my heart– she was 5 years old, 110 pounds, and getting her tonsils out to clear more room in her airway so she could breathe. It turns out in getting her history that her parents thought Coke was better for her than water— so thats all they gave her.

Seeing a system where my patients would be broken far before they came to me– and far too in need of many services for me to make a dent with a 15 minute office visit. I decided I had to find out why medicine was this way– and how changing the business model to focus on prevention would actually work.

Financial considerations were also a factor– I considered why I would take my $200K in med school loans, work slave wages for another 3 years, and then hope to get a spot making $90K to start, when friends of mine that had gone off to banks or business were already making more than that today. I found it ironic that my friends going off to residency were paying to take their interviews for $40K a year jobs, while I had the same degree and training and was getting paid to go out to interview with business firms for 6 figure jobs.

I decided that management consulting would be the best option for me and looked at firms like McKinsey and BCG, who were receptive to MDs coming out of school. McKinsey had the best training for non-MBAs, a 3 week training course called Mini-MBA.

I’ve since found that others have taken many different routes (and that there are a number of folks that have linked together through the Doctors Dropout Club that have gone to investment banks, pharmaceutical industry, not-for-profits, research and think tanks, equity research, and specialty information companies (Gerson Lehrman is a favorite).

Its been a path that suited me well. While my colleagues were learning much more tactical things about how the human body works and how to stick people with things, I did a residency in learning how the health system works– why things function as they do, and where there are opportunities to change it for the better.

As I’ve left McKinsey to create new avenues to deliver quality health information, services, and products to consumers, I take with me the beliefs I had as a young medical student– that the doctor patient relationship is paramount to good care, that patients have every right to find a provider that will treat them the way they think is best for their health, and that innovative providers deserve to be paid for superior service.

For those medical students, residents, or physicians that stumble across this in their search for something else, please feel free to reach out– I’d be happy to help you think through your options.

Addendum– Dr. Reece has a great article on why managed care will lead to a primary care physician shortage

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