Zahav

We went to Zahav last night for restaurant week. It's supposed to be a modern Israeli restaurant, and it was spectacular. A nice treat on a non-call and non-post-call night. Sometimes restaurant week is hit or miss because some restaurants become overloaded with customers and they're not used to - so the service goes downhill as well as the food. I think the really good restaurants though, ones that are often busy all the time and are used to the customer load, do just as well during restaurant week as they do during other times.

Last night, they started us off with some pickles and olives, and then brought some large trays of amazing hummus with this homemade bread called laffa that reminded me of naan. Then they brought an appetizer of 8 different vegetables/salads prepared different ways: pickled turnips, beets, carrots in a peppery marinade, cucumbers, a pepper pesto, eggplant, and a couple other things I can't remember off the top of my head. They were all excellent - the beets were my favorite, as well as the table's favorite.

Then we each got to choose two appetizers and an entree. As you can imagine, there was a lot of sharing. I personally ordered the fried cauliflower (one of their specialties) and mini stuffed peppers. The fried cauliflower was soooo good. Pete got bulgar wheat stuffed with ground lamb (sort of like an empanada) and chopped liver. It was probably the best chopped liver I've ever had. From other people at the table, I also tried the fried sheep's milk cheese, which was amazingly tasty and rich, and also these leek and mint fritters, which were mild, but I thought really really good and creamy.

For entrees, we all got similar items. I got a ground beef and lamb entree (the "bulgarian) while Pete got a ground beef and lamb sausage ("Monsieur Merguez"), which was very very tasty, with good spiciness and texture. Then for dessert we shared a cashew baklava with white chocolate argan ice cream and a "konafi" which looked a little bit like sugar and chocolate deep fried noodles, topped with ice cream.

I think I'm still full. :)

Interviewing

It's coming to the end of the interviewing season, thank goodness. :) For the last couple of months, with a break for the holidays, Pennsylvania hospital has been interviewing candidates for next year's intern class on Wednesdays, Thursdays and Fridays, about 10-20 4th year medical school candidates each day. It's somewhat interesting to see how a program recruits good candidates.

Of course, the program reputation speaks for itself - either for good or for bad. Word of mouth goes a long way, and during the day, they give the candidates ample opportunity to speak to current residents and interns and ask them questions. I, for one, believe in being completely honest about everything, even if that puts the program in a bad light. Of course, I tend to look at things more positively than others, I think, so I may be putting a good spin on things unintentionally. I think it's a bad sign when a program doesn't give you time to spend with current residents and interns - what are they afraid of?

More interesting to me are the little things that candidates care about that draw them to or away from a program. #1 thing is the food. I can't tell you how many times the subject of food or how well candidates have been treated during the interview comes up or plays a role in their decisions. Logically, this should have nothing to do with someone's decision to join a program, or how good the program is, but if crappy food is served during the interview, candidates notice! It's worth noting that on the days that preliminary candidates come to interview (these candidates are internship candidates that, instead of staying in an internal medicine residency for 3 years, are in the program for one year and then go on to a specialty like radiology or opthalmology), the food is much better because good preliminary candidates are thought of as much more competitive and more difficult to draw to your program.

Other little things include paying for parking, taking you out that night with other residents, etc. If a program goes so far as to pay for other things, like hotel costs or travel costs, that's even more impressive to candidates. I think for most people this plays out during residency too - in the end, many people are concerned not just with the training they receive during residency, but their quality of life during residency which includes all these "little things."

Our litiginous society

I've known for a long time that there's a problem with the medical legal system in this country that needs to be fixed. However, I recently heard this story that rams home the point.

There was a patient who had multiple medical problems and normally is seen by doctors at the hospital medical clinic. Due to various reasons, usually the clinic is used by patients who have little insurance or bad insurance, and so they cater to many of the inner city population. The doctors rotate there as well, so continuity of care is not always the best, and the patients don't often follow up with their appointments. The clinic is often also abused, with people walking in constantly without appointments and expecting to have 10 different medical complaints addressed in a single visit.

At any rate, for reasons I won't go into, this patient had to be anticoagulated - that is, her blood had to be kept thin with medications so that she would not develop a clot. Clearly a clot can be a very bad thing - it can travel to the heart and cause a heart attack, it can go to the brain and cause a stroke, it can go to the lungs and cause a pulmonary embolism or a "lung attack". So it's important that her blood is kept thin so that the clot doesn't get any bigger and perhaps would even dissolve away eventually. However, as with any other medications, there are risks. The particular medication you use as an outpatient (coumadin) needs to be monitored closely. The levels are usually tested every 1-2 weeks at an outpatient laboratory or clinic, and if your blood is too thin, there is certainly a risk of bleeding. This can be very serious as well, causing yet another type of stroke, or patients can lose so much blood that they become very sick or die. So monitoring the level of coumadin in your blood every once in a while is very important until you reach a good regimen that keeps you consistently at the right blood thinness.

This woman had been admitted to the hospital several times in the last several months for unrelated issues, and each time, her coumadin level was not right. Sometimes her blood was too thin, and sometimes it was not thin enough. They would always get it just right before sending her home and tell her to follow up at the hospital clinic to get it checked out a week or two later. Sometimes she did this, sometimes she didn't. Finally, one particular instance, she was supposed to be seen at the clinic and missed her appointment. Two weeks later, she was admitted to the hospital where her blood was much much too thin, she started bleeding, and bled so much that she ended up dying.

Her relatives are now suing everyone that has ever been involved in her care, including a cardiologist who saw her only once during one of her hospital stays, an excellent medicine attending who saw her once at the clinic 2 years ago, and doctors from other hospitals as well who have been involved. Even though there has been no wrong-doing on anybody's part at all, and their lawyers agree they could win this case, pretty much everyone involved (and their insurance companies) has finally decided to settle out of court and pay instead of fighting this because it would be much cheaper. Just as an example, it would cost them $2 million to fight this battle in court after all the lawyer fees, etc whereas settling out of court they pay the family $200,000. Easy money for the family.

The only point someone brought up is that when the patient missed her appointment, nobody called her to ask her to come in or to reschedule. But is that our responsibility? Patients get a reminder call, and when they don't come in, I don't necessarily think it's the health system's responsibility to beg them to come in. At some point, you have to ask the patients to take responsibility for their own health care and participate.

This story exemplifies one of the reasons why health care costs so much for everyone. The $200,000+ that the family won (which doesn't even include the doctors' time, paperwork, other court fees) is basically being paid by all the other health care users out there. There needs to be some sort of reform within the medical-legal system. I don't have any great ideas, but something needs to be done.