Healthcare Napkins

[Via SlideShare.net]
Healthcare Napkins All

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Pay For Performance

This is why it will not work in healthcare. I rest my case.

[Video Below]

Homeopathy doesn't work? No Duh.

Just a few posts ago I talked about how I think that some alternative medicine may need to be investigated to see if it truly does have an effect. And if so, how does it work? We may be able to learn something from these different types of 'healing.'

But if there is one alternative medicine that's pretty much be debunked from every angle, it's homeopathic medicine. The problem is that official political people and organizations don't like to take a strong stance against things. Well, the WHO has broken the mold (a little).

They state that homeopathic remedies are not recommended for the use against HIV, TB, malaria, influenza, and infant diarrhea. And that they have found no evidence to date that has suggested that it provides any kind of benefit for these aliments.

It's not exactly saying that homeopathy is bull crap, but its a great start. By officially declaring which of these alternative medicines are quackery, and which ones may provide some kind of benefit is the first step to sorting out what works and what doesn't.

For more on this topic and the general quackery of homeopathy please visit the NeuroLogica Blog.

[Via NeuroLogica]

Myths and falsehoods about health care reform

Interesting blog post at MediaMatters.org

Anyone interested in the current healthcare debate should give this a good read over.

MYTH 1: There is no health care crisis

CLAIM: The health care system currently works fine, and only a purportedly small number of uninsured people would benefit from reform.

RUSH LIMBAUGH: "There really isn't a crisis in health care in this country. The crisis in health care that -- if you wanna say, that does exist -- is the fear that a major illness or catastrophe could wipe you out, which isn't gonna change. In fact, the odds of you being wiped out by a catastrophe or accident once the government gets started running this stuff is greater than if the private sector -- but day-to-day, there's no health care crisis in this country. You can get it. So, it isn't about health care, per se. This is just about gaining control, taking money, and controlling people's lives, and wiping out Republicans -- a nice cherry on top." [Premiere Radio Networks' The Rush Limbaugh Show, 6/18/09]
STEVE DOOCY: "Currently, 90 percent of all Americans have got some sort of health care coverage, which means they are effectively blowing up the system for 5 percent. Now, the 5 percent, you gotta worry about them -- you gotta worry about everybody who doesn't have it. But is it worth all of this for 5 percent?" [Fox News' Fox & Friends, 7/30/09]
REALITY: Roughly 25 million Americans were underinsured in 2007. According to Cathy Schoen, senior vice president of The Commonwealth Fund, "From 2003 to 2007, the number of adults who were insured all year but were underinsured increased by 60 percent. Based on those who incur high out-of-pocket costs relative to their income not counting premiums despite having coverage all year, an estimated 25 million adults under age 65 were underinsured in 2007." [Testimony from Schoen before the Senate Health, Education, Labor and Pensions Committee, 2/24/09]

The underinsured do not receive adequate care and face financial hardship. Schoen explained that the "experiences" of the underinsured were "similar" to those of the uninsured, noting that "over half of the underinsured and two thirds of the uninsured went without recommended treatment, follow-up care, medications or did not see a doctor when sick. Half of both groups faced financial stress, including medical debt." [Schoen testimony, 2/24/09]

Insurance companies currently rescind policies when their insured customers need treatment. Insurance companies restrict or deny coverage by rescinding health insurance policies on the grounds that customers had undisclosed pre-existing conditions. On June 16, a House Energy and Commerce subcommittee held a hearing exploring this practice, with the goal of examining "the practice of 'post-claims underwriting,' which occurs when insurance companies cancel individual health insurance policies after providers submit claims for medical services rendered." The committee also released a memorandum finding that three major American insurance companies rescinded 19,776 policies for over $300 million in savings over five years and that even that number "significantly undercounts the total number of rescissions" by the companies.

Currently, insurance companies deny coverage based on pre-existing conditions. CNN senior medical correspondent Elizabeth Cohen wrote in a May 14 CNN.com article, "According to the Kaiser Family Foundation, 21 percent of people who apply for health insurance on their own get turned down, charged a higher price or offered a plan that excludes coverage for their pre-existing condition. ... The health insurance industry doesn't deny that people are rejected or charged higher premiums because of pre-existing conditions."

Synchronized Bicycling - WOW

[Video Above]

Sweet Poster

Via Brownstoner

Do I possess the surgeon personality?

Yesterday, our class learned and practiced how to correctly 'scrub' for surgery. During this little lab activity, we were all gowned up and washing our hands when a couple of classmates asked if I was going to be a surgeon.

I said I didn't really know yet, although I did find surgery pretty fascinating. With that they told me that they thought I would make a good surgeon. due to the fact that I always seemed calm and collected, but at the same time confident enough to tell people what to do. I told my classmates that the act I'm pulling has them fooled, and I continued on with the lab. But it got me thinking, what is the surgical personality and do I have it?

The stereotypical surgical personality is said to be "decisive, well organised, practical, hard working, but also cantankerous, dominant, arrogant, hostile, impersonal, egocentric, and a poor communicator."

I think that I am decisive, organized, practical, and hard working. But am I cantankerous, arrogant, hostile, impersonal and egocentric? I hope not. I can admit that my communication probably needs work. I think I'll give my self the benefit of the doubt, and rate my communication and 'average' instead of 'poor'.

So there it is, I am half the surgical personality according to the stereotype (well in my eyes, maybe everyone else thinks I am hostile and egocentric and thus fit the stereotype perfectly).

I've met a few surgeons, and it sure doesn't seem like they all fit the stereotype. Does every surgeon have this personality or is it a few bad apples setting up the reputation for the profession?

I personally think that some of this mean surgeon reputation may come from the residency training. A tired, overworked resident may snap at a surgical tech or nurse and then they are just another hostile surgeon. It could be that some of these bad habits that are picked up in residency stay with attendings, and then this stereotype gets perpetuated.

It has been argued that the military-like leadership of a surgeon must exist in order for an OR to run (Thomas The Surgical Personality: Fact or Fiction). In today's ORs this strategy for operating is actually counter-productive, and may lead to more mistakes. Many studies have shown that the surgical personality really can't be measured or pinned down, because maybe it doesn't really exists. Some other studies conclude that the surgical personality does exist but it's not to the extreme that the stereotype plays it out to be. They conclude that novelty seeking, competitive, reward dependent, extroverted-thinking types, who score high in activity traits, self discipline, and achievement, while scoring low in compliance and vulnerability tend to be surgical types (note that many of these studies concluded this data, but not to a significant difference from the general population).

Obviously a stereotype is just a stereotype and not everyone is going to fit it. Surgeons out there can be personable and nice, just like they can be mean and hostile. Do I have the surgical personality? Maybe, but one could argue that many medical students fit that hard working & competitive mold or we wouldn't have gotten into medical school. Will my 'surgical personality' push me towards a career in surgery? Only time will tell.

For more about the surgical personality:

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=287537&blobtype=pdf

http://www.webmm.ahrq.gov/case.aspx?caseID=122

http://www.apds.org/APDS2001n/APDS%20Panel%20Talk_files/v3_document.htm

http://answers.google.com/answers/threadview/id/394287.html

http://www.cancerlynx.com/surgeon.html

France: 'Best' Health Care?

This video dodged the issue of the dreaded wait times and the regular clinics. Also, physicians make a whole lot less money, but I'm interested to hear about how much medical school costs in France. Even the number one system in the world has it's problems. With a $13 billion dollar deficit, it won't be long before France is looking at a healthcare over haul of their own. Point being, if we stick with the system we have now, or we switch to something universal our problems are going to continue.

ObamaCare Yay Or Nay? The Truth About Canada!

I'd like to see how a follow up video on the US healthcare system would look.

Comparisons

Dr. Silverman reminds us, that statistics aren't always what they seem. Remember to question what you read in the news, because a lot of times you don't have the whole story. Even politicians who are trying to convince us, don't have the whole story.

Is America's healthcare system really that horrible? Maybe not.

Is it fair to compare American health care with systems in Europe or Canada?
AUGUST 18, 2009
by Ralph Silverman, MD, FACS, FASCRS

I am tired of the comparisons people make between health care in the United States and other countries. For instance, there are those who think that we should have universal health care because some European countries and Canada do.

It is true that those countries do have universal health care, but is it a fair comparison?

Who does Canada rely on to defend its borders? When the Germans invaded France in World War II who stormed the beaches at Normandy? The point is, these countries rely on the United States for security when peace is compromised. America allocates trillions of dollars to defend both itself and the rest of the world. No other country does this. That money could easily be used for universal health care.

Furthermore, President Obama has consistently said that health care costs are rising and we aren’t any healthier. The White House uses statistics that demonstrate that, in the U.S., childhood disease is more rampant than in European countries, and that people die earlier Stateside. They ask the question, “Why are we not healthier than other countries when we spend more on health care?”


The answer may lie with American patients, who are more obese than patients in other countries. We eat a diet high in fat and carbohydrate content. As a population, we smoke like there’s no tomorrow. We drive everywhere we go and don’t get any exercise. Instead of exercising to control our blood pressure or diabetes, we sit on the couch and take a pill. We eat ice cream and cake, and then take some insulin to bring down our sugar levels.

Consider Asia. People there eat mainly rice and fish and walk everywhere they go. Smoking is a problem there, but it is worse in the United States. How many 300 pound Asian men and women do you see walking into Burger King in Tokyo? The same is true in France. And guess what? People in these countries are healthier than we are. It’s not surprising.

If anything, the United States should give itself a pat on the back. We have managed to treat our bodies like trash, and yet, the length of life is comparable to other countries that live a much healthier lifestyle. Just imagine if we kept health care at the same level and we, as a population, decided to really change our way of life for the healthier.

The White House and the rest of the government need to make fairer comparisons when contrasting our health care system with those of other countries.

After doing so, perhaps things may not be as bad as they appear.

Ralph Silverman is a colorectal surgeon who blogs at The Colon Doctor.

Bowtie Comeback

The bowtie is coming back. If you want to be part of a revolution, now is the time. Just ask these two dudes.

If my name was Dr. Stampe, I'd be very scared of being terribly out-dressed tomorrow.

My Sincerest Condolences

To the family of the two who died near Tea, SD today. My sincerest condolences go out to you.

The aviation community is saddened and hurt by the loss of these two individuals.

May the flying in heaven be infinitely better than it is down here. May they rest in peace.

Requiescat In Pace

The Alternative Medicine Divide

As I continue on with Dr. Ramachandran's book, Phantoms in the Brain, really gain a new appreciation for the brain and the mind body connection. I already had a huge interest in the world of the brain, and this book is just feeding into a growing obsession. Dr. Ramachandran if you ever stumble onto this blog, please get a hold of me, I would love to do some research with you!

I honestly have always been a hater of alternative medicines. In fact, I am a huge fan of Dr. Barrett, the man who started Quackwatch. Later in the book, Dr. Ramachandran brings up an interesting point. The mind-body interaction is a crazy thing, something that we don't fully understand. And although it is easy to dismiss alternative medicine practices as quackery, maybe there is something to some of them. Just because we don't know how it works doesn't mean we should completely dismiss it. We are the scientists, we should be testing it. Is it possible to hypnotize patients and cure their warts? What causes pseduocyesis? Can we classically condition the immune system just using our brains?

I hope to see more research about 'alternative medicine' to see if mind-body medicine is something that should be pursued instead of just dismissed.

**Side note: please don't confuse this post with me advising people to seek alternative medicine. A lot of it is obvious quackery (please visit Quackwatch for details).

NRMP Charting Data 2009

If you're anything like me, you are constantly wondering about medical specialty choice. Am a surgeon or a medical physician? Do I like the mental challenge of a good puzzle? Or do I love the medical procedures? Am I a bigger fan of long-term patient relationships, or do I like to deal with acute problems?

Even if I had these questions answered and knew exactly what specialty I wanted to pursue, I would still wonder if I was competitive enough to match into that specialty. That's where the NRMP comes in. The wonderful people who run the match, also known as the National Resident Matching Program, run these great statistics on all of the specialties that are offered in their match. It really helps spell out what kind of Step 1 score you should go for, how competitive each specialty is to get into, and what other qualifiers these matched/unmatched students may have had in common (AOA, PhD, research).

So, check out the NRMP Data for 2009.

Kevin MD - There are other reasons too.

Kevin MD comes out with a post today called Medical students want to become primary care doctors, until reality hits.

That reality involves staggering medical school debt, where numbers show that 40 percent of students graduate with debt in excess of $140,000.

And it’s not all about the money. Combined with the fact that theburnout rate is higher in primary care, along with the onerous paperwork and bureaucracy requirements, it’s no wonder why students are avoiding primary care.

A paltry increase in pay isn’t going to stem the medical student tide towards specialty practice.

And to those who suggest that mid-level providers can help with the shortage of primary care doctors, think again. They are not immune to the same economic incentives, and indeed, we’re seeing physician assistants and nurse practitioners gravitate specialists’ offices as well.

But this isn't all Kevin MD. As a current medical student following primary care physicians I can say with certainty that many other unmeasurable reasons make the top of my list on why I might dodge primary care too.

The truth is that raw primary care is sexy. The know-it-all doctor who can do anything steps in and solves almost any problem thrown at him/her. They are the diagnostic master and have a few procedural tricks up their sleeves as well. They are seeing patients of all ages, all races, all extremes, all levels of sickness. But we come to realize very fast that if you don't plan on practicing on the edge of Alaska, or being with Doctors Without Borders for the rest of your life, the primary care career will quickly turn into adjusting med lists, trying to explain why the patient DOESN'T need antibiotics (even though you know they are just going to go to the next doc and try to get the script), and trying to explain to every patient that they really need to diet, exercise, and quit smoking.

Also, the primary care doctor has lost a lot of respect in the clinical arena. The hospitals and clinics regularly tell the primary care doctors how they will practice, what software they will use, and taking the autonomy out of their practices. Yet, specialist and surgeons seem to have individuals dedicated to making sure that the physician is happy with this arrangement or that new machine.

Lastly, primary care just seems the most restricted and thankless. We went into medicine to help those in need, and it just doesn't seem like that's what they do. I can't really put it into words. Maybe I can explain it with an example.

My brother asked me the other day now that I'm so obsessed with flying, if I won the lottery ($200 million) would I stop going to medical school?

That question really caught me off guard. So I thought about it for a few minutes, and lots of different scenarios went through my mind at light speed. Then I settled I want I thought I would seriously do if I had won $200 million.

I would finish medical school, concentrating on either family practice or general surgery (either with a rural emphasis). I would also work on my pilot's license and increase my ratings to fly a little bigger planes. Then I would go around similar to Doctors Without Borders, to third world countries and practice medicine. I would be a real doctor, out there saving the world one person at a time. I would hop from country to country and give medical care. It would be amazing. Helping people who are really poor and in real need, without the worry of crazy amounts of paper work, law suits, or the business side of medicine. Just the patient and the doctor. That's what real primary care is about.

Censoring Yourself

Social media like FB and Twitter are awesome and can be great promotion tools and a way to keep in contact with friends.

It can also be a way to vent. But if you are venting on FB, be sure you're censoring yourself a little.

[Via The Next Web.com]

Cost of the Private Pilots License

Well my final bill came in from Quest Aviation. Now, as promised I can post what it cost me down to the cent for my private pilots license for all of you interested wanna-be pilots. As you'll recall from my earlier post "Intro To Private Pilot" I summed up what it cost to get started, and I'll be using those numbers in my grand total for the expenses of a license.

First off what did Quest Aviation estimate it would cost to get the license?

40 Hours of Cessna 172 Rental = $4720

20 Hours of Instructor Time = $800

Training Materials = $330

FAA Written Exam = $100

FAA Practical Test = $300

Grand Total: $6250

Keep in mind, in this estimate they do not include the cost of a medical physical which is required to fly solo. So did it actually cost that much? Here are my figures:

Discovery Flight = $92.56
Book Kit (King's School Kit) = $344.75
Third Class Medical Physical = $148.00

Instructor Time & Plane Rental (In both Cessna 150 and 172-S models) = $5301.27

Sectional Map (For cross-country flying) = $9.25

David Clark Headset (Optional - but I couldn't help myself) = $325.00

Oral Exam Guide = $12.95

FAA Written = $100.00

Huron Landing Fee (Those jerks) = $10.60

FAA Check Ride Fee = $320.00

MY GRAND TOTAL: $6664.38

Was it worth it? Totally.

Fight back against health insurance lies

[Video Above]

This video makes me a little sick that this guy makes that much money, through a business that shouldn't even exist. Whether you're on the single-payer side, or the free market junkie, everyone can agree that the health insurance companies are ripping us off. Something should be done about it.

Interesting Medical Fact of the Day

I can already tell that Pathology is going to be an extremely interesting class. Studying disease is one of the main reasons I went to medical school. The human body and disease speaks to me. So without further adieu, the medical fact of the day.

Studies in model organisms, from yeast to mammals, have shown that the most effective way of prolonging life span is calorie restriction. How this works is still not established, but the effect of calorie restriction on longevity appears to be mediated by a family of proteins call sirtuins.

-- Pathologic Basis of Disease 8th ed. Robbins and Cotran

Nurse Practitioners' Role in Expanding Healthcare

How about we break down this article in the TIME.

As the House and Senate prepare to embark on their summer recess without having passed any health-care-reform bills, President Obama's dreams of radically restructuring the system have, at least for now, bumped up against the reality of Washington politics. But even if Congress manages to overcome the many obstacles and pass some kind of meaningful reform this fall, the goal of covering some 50 million currently uninsured Americans will encounter a whole new range of hurdles. Chief among them is that there almost certainly won't be enough doctors to care for that many new patients.

This is completely true and a worry among many physicians. We can see that in Massachusetts (the state that the healthcare reform will probably be modeled after) there are huge physician shortages especially in primary care.

Even without reform, experts on the health-care labor force estimate there is currently a 30% shortage in the ranks of primary-care physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, with the rest choosing more lucrative specialties. That could pose problems if a national health-care bill is enacted. After Massachusetts enacted mandates for universal health insurance in 2006, those with new coverage quickly overwhelmed the state's supply of primary-care doctors, driving up the time patients must wait to get routine appointments. It stands to reason that primary-care doctors could be similarly overwhelmed on a national scale.

Again, this statement makes sense. There is a shortage of doctors, and the healthcare reform that was enacted in Massachusetts actually made matters worse. So what should be done about this impending doom?

But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat patients and diagnose ailments as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services.

Ah, and there lies the problem. If there's a lawyer shortage do we say we should hire more paralegals? If there is an accounting shortage would we hire more accounting assistants? If there is a physician shortage shouldn't we figure out a way to get more physicians? That makes the most logical sense to me. Also, it sure is easier to charge a nurse practitioner less money when they don't share the same responsibility in a clinical and a legal (torts & malpractice) sense as physicians.

The nurse-practitioner profession was created in 1965, the same year as the invention of Medicare, which dramatically increased the need for primary-care providers. Yet while nurse practitioners can be valuable assets in the context of health reform, they have also created a conflict with doctors, many of whom are not keen on being supplanted by providers with far less training; doctors in some cases have lobbied to restrict the services of nurse practitioners. "In some situations, it can be a turf battle," acknowledges Rebecca Patton, president of the American Nursing Association.

Why would physicians "not [be] keen" with people who are not trained to the same extent and in the same manner, doing the exact same work as physicians? Has Rebecca Patton ever thought that maybe doctors care about the best interest of the patient verses the so called "turf"? What really amazes me is that many if not most physicians realize that mid-level providers are smart, competent, and are an asset to the medical community. Yet, they almost all agree that mid-levels are not qualified to practice as independent providers. 'Darn those evil turf protecting doctors for trying to care about their patients.' Sometimes these 'nurse practitioners can save the healthcare crisis' articles make it sound like every physician went to medical school to make money and horde it away from nurses.

In addition to providing many of the same services less expensively, nurse practitioners offer something else that makes them darlings to health reformers: a focus on patient-centered care and preventive medicine. "We seem to be health care's best-kept secret," says Jan Powers, health-policy director for the Academy of Nurse Practitioners. Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling. "In the United States, we are so physician-centric in our health system," says Patton. "But it should be about wellness and prevention, not about procedures and disease management."

Since when did doctors not focus on patients or preventive medicine? I'm sorry NPs but this paragraph is a bunch of baloney. Yes it's true NPs have less medical education, but where does this 'far more training in less measurable skills like bedside manner and counseling' come from? I can tell you that being a medical student, we talk about the soft-side of medicine (ie: bedside manner, counseling, patient feelings, confidentiality, confiding in the patient, trust, etc) almost as much as we study pathology, microbiology, anatomy, biochemistry, and the like.

But you are right about one thing, healthcare shouldn't be all about the procedures. Disease management though, that's kinda the whole point of healthcare and medicine (but what do I know I'm only a medical student and you're the president of the ANA). So, would replacing the whole medical field with NPs make healthcare all about prevention and wellness? No. Because the payment system isn't setup for wellness and prevention. That's why physicians are not making it their number one priority. When did the whole population of NPs become so high and mighty that if they replaced every physician they would not fall into the same pitfalls?

President Obama told the American Medical Association in May that the government should do "more to reward medical students who choose a career as a primary-care physician and who choose to work in underserved areas instead of a more lucrative path." As part of health reform, the Administration wants more money for the National Health Service Corps, which offers loan forgiveness to primary-care providers — including nurse practitioners as well as doctors — who agree to work in rural and remote areas. But even if these measures encourage more medical students to pursue careers in general practice, it will take years to have a real impact. Nurse practitioners, on the other hand, require fewer years of training and can therefore bump up their ranks faster.

True, it will take years for changes to be seen and more primary care physicians to be available. Quality training takes TIME. NPs can supplement and assist, but they are not a replacement. Let me make my point by using an example. Do you want someone like Sullenberger to be flying your plane, or some guy who took night classes at tech school? Sure the guy who went to tech school thinks he can fly just as good as anyone else, but do you really believe him?

In the recently released House health-reform bill, nurse practitioners (and physicians' assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can work only under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.

All-in-all I think this story screams NPs wanna-be physicians. Again, I am well aware of how much of a huge impact PAs and NPs make in the healthcare world. They are extremely important in assisting physicians with the day-to-day grind of medicine. Yet, to come out and say 'we are just as good, and probably better than doctors' makes the whole profession sound naive, ignorant, and just plain stupid. The fact that the leaders of the NP profession do not have the insight and self reflection to realize that they do not have the same amount of training or kind of training that physicians have and claim to be better makes me worry about the future of the patients.

On the other side of this, are physicians better than NPs or PAs? I don't think that either. That's like saying a cardiologist is better than a neurologist. The jobs are different, and the training is different, because there is a different end goal in mind. Physicians are trained to understand the underlying and complex physiology, to think through difficult and complicated diseases and patients. Is every physician practicing in a way that involves complex and involved thought? Hardly. What I am trying to say is the base-line or the average of physicians and the way they are trained is different and more involved than that of the average NP or PA. At this point in my medical career any second year PA student could out diagnosis and probably out treat any second year medical student in any disease process. But do they understand the complex mechanism by which that disease process harms and destroys the body? Do they fully comprehend the receptors and mechanisms by which the drugs work? Will they be able to recognize the subtle differences in symptoms and pathology between similar looking but very different diseases? I don't know, but in my opinion I think the medical student will come out on top for those.

So in conclusion, mid-levels are an extremely important asset for the future of medicine, but they are not the saviors or replacement physicians for the healthcare crisis.

Class of 2013

Congratulations all of you medical students of the class of 2013 on getting into medical school. Now that you have your white coats, let the fun begin!

Starting Tomorrow

Well it's official, the last day of summer is upon us. Classes begin tomorrow, and I will start my 2nd year of medical school. Looking back at my last scheduled summer of my educational career, I have to say I am happy with it. I feel rested yet not like I didn't get anything done. I feel productive, yet I don't feel burned out. With a private pilot's license, Avera Clinical First Steps, Scholarship Pathways, two physician shadowing experiences, and a good amount of time spent with friends an family all behind me, I have to say bring on the 2nd year!