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guidewire: 外科FELLOW毕业,找工的一点体会(及讨论)
作者:USMedEdu
发表时间:2010-01-18
更新时间:2010-01-18
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发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 15:55:15 2010, 美东)

找工的一点体会

虽然各个科有差别, 但作为CMG来说还是有共性的。 网上关于这方面的讨论很少,我
在此抛砖引玉。

首先说一下工作有几种:private (solo, single specialty group, multispecialty
group, and for the multispecialty group, some of them have partnership
tract, some just employed position), hospital employed and pure academic.


一般来讲, private earns more than academic. 但是 private 会很忙, 很多活要
自己干, 因为要雇人帮你的话就要自掏腰包了。 而academic 会有很多的人打下手,
还有搞科研的条件, 有事业上升的空间。 所以要什么样的工作,是仁者见仁,智者见
智了。

从CMG自身的条件来讲, 作private的竞争力要比AMG差。因为primary care要病人
选你, specialist 要pcp's referral. CMG 很难与AMG 争病人,尤其刚开始的几
年。这是我的感觉,找工时, 我最重要的问题是, 病人从那里来, 是他们来找我,
还是我要到社区里去找? 有没有竞争对手? 没有病人, 什么都是空的。但是hospital
employed and pure academic 工作, 就不要担心那么多。病源是有保证的。

从地方来讲, 大城市要热闹,交通方便, 中餐多, 等等, 就不多说了。 训练时间
是有限的,再长不过5-10年。而工作则是要作呆一辈子的打算,勤换工作对个人是不利
的。因为每到一个新的地方,都要从新开始。不过,这个也是很个人的决定。


好, 那如何找理想的工作哪?

首先要早作决定,早准备。俗话说,苯鸟先飞。作为CMG, 与AMG比,有先天不足,那
就早作准备,后天补上。 我认为, 能作fellowship 就作, 因为愈往上走,竞争对手
愈少。当然,也不是一概而论。有个朋友作了麻醉,又作疼痛专科。后来工作只做麻醉
,他认为那一年就浪费了。

其次,如果要作fellowship, 不但要看兴趣, 还要看就业前景。像有的专业,基
本上毕业即失业, 最好不要去浪费时间。选fellowship, 要选能达到的最好的,
这对日后找工很重要。而且, 如果要找academic 工, fellowship时要多写文章,会
对申请有利。

时间上来说,提前一年找比较合适。 太早了, 上一级也在找, 雇主当然不愿等你一
年。7月开始联系, 8,9 月雇主开始纷纷出动了。9,10,11 月面试, 12月,1月大
部分人就作决定了。因为办执照什么的,要花时间。

找工的资源:
1, 本单位, 会有很多的雇主和训练单位联系, 你可以看他们的flyer, 选合适的。
有很多时候, attending's 熟人会问他们要人。 但他们推荐的, 未必是你最想要的


2, www.practicelink.com 这是一个很好的网址, 所有美国医院的召人(hospital
employed position)都在上面。有很多时候他们也会为在他们医院的大的private
group 找人。
3。本专业的杂志。
4。 本专业会议, 通过社交。
5。recruiter. 有人说, 他们手里没有好工作, 因为好工作用不着他们,就找到
人了。 其实有时候, 也有挺好的工作。 但要小心他们。 因为他们是靠佣金生活
的。 把你卖出去是第一位的, 所以他们的利益是与你的不一致的。 他们会把一方面
把雇主说的天花乱坠, 一方面说雇主多么喜欢你, 你是他们的唯一等等。把你拖住,
使你不再想找别家。 如果不成, 会耽误好多时间和机会。

面谈: 一半单位会给你买机票,一半会让你先买,回头在付你钱。 开销都是有对
方付。 我觉得, 要多看几家, 才能知道什么最适合你。 首次面谈不要谈钱, 要到
二次面谈后,对方要给工作了, 才会告诉你。

总之, 要早作准备, 住院和专科训练时努力工作, 因为reference 很重要。 要
货比三家, You have been working so hard, deserve a good place to live and
work. good luck.

there is also a book worth to read, call the ultimate guide to finding the
right job after residency. by koushik k. shaw. ISBN 0-07-146113-2. a lot of
people recommend it,I read part of it. found useful.

关于不同科, 再说两句。 与我同一个住院毕业的朋友, 也是IMG. 选择了肛肠科。
当时肛肠也很热, 而且只有一年。 但是出来找工作时就很难。 而且他又坚持在大城
市, 最后只好自己开业, 半年了, 挣的还不够支付overhead



※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 99.161.]


发信人: ericusa (eric), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 16:51:09 2010, 美东)

For primary care hospitalist is a good choice, and no worry about patient
base. Many private groups may provide income guarantee, for example, for the
first two to three years. After that you will need to have a large patient
base to generate enough revenue thus income. For each primary care doctor
the patient base should be at least 2000+.
--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 67.53.]


发信人: yams (麦地阳光), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 17:27:09 2010, 美东)

但我也听说hospitalist不是那么容易的,一个shift要管很多很多病人。当然不同医院
不同地区可能不一样。内科的话,有的病人很复杂,一天看几十个住院病人很有疲于奔
命的感觉,并不是提供quality patient care. 会比较frustrated. 收入是有保障的,
但是成就感,生活质量就很难说。
以前我也觉得7天上班,7天休息好象很不错,不过事实好像并非如此。

发信人: againstwind (逆风而行), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 17:25:59 2010, 美东)

看到导线兄的这句话,颇有感触啊。

我们科里几个本科的孩子很起劲地跑来给主治做临床实验干点活儿,为了就是将来申请
医学院可有闪光点。
住院医生也老想着要参加点什么试验,好在文章上缀个名字,有利于申请fellow.
fellow为了毕业找工作,也要写文章。
结果老板们的idea层出不穷,而且总有大大小小的壮丁么给他们去实现,然后他们再成
长为下一代的老板,继续培养壮丁,circle of academic life, hehehehe
--

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 140.254.]


发信人: againstwind (逆风而行), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 17:38:48 2010, 美东)

yeah, yams is right, don't be too optimistic about hospitalists. in my class
, half of us persued fellowship and half of us went for hospitalists, in FL
, TX and midwest. from what i hard, hospitalists are very busy and
stressful jobs, cover large amount of patients each shift. and lots of
hospitals require them cover ICU at night too.
if you consider yourself very efficient, won't spend too much time tangling
in details, can confidently rounding on 25 patients and do admissions at the
same time, you might be the right person, but i see some residents are
really not that style, and they end up sufferring very badly.
pay is good, but i can't imagine myself doing this when i am 40,50,or 60
years old.


发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 17:41:20 2010, 美东)

一个与我同年进住院医的朋友, 去的是内科。 我作4年级时他毕业了留在医院作
hosiptalist.收入不错, 15,6 万, 但每次看到我就摇头, 说宁愿还是住院医。 给
我看他的census, 100 多病人。 怎么看得过来, 所以就要consult everybody, ask
other people to see patient for him. 我现在看到一个趋势, 就是很好的大医院开
始雇愈来愈多的FMG 去做 hosptialist, 可能是有办法的人都不做这个了巴。


good thing about multispecailty group is you can get patient referal from
your partner(PCPs) within the group, the bad news is, you have to share the
profit!, so for pcps it is better to join multispecialty group, but for
subspecialist, single group is better as long as you have a steady patient
source.
but some multispecialty group also owns facilities, like surgi-center, MRI/
CTs etc, they supplement income too. so it is hard to say absoltely which
one is good or bad. when they give you offer, not only care who much you get
initially, but more importantly, the potential, ie, how much other people
in the group make after several years, so you will have a rough idea how you
will do in the future.
【 在 againstwind (逆风而行) 的大作中提到: 】
: Hey guidewire,
: can you talk little more about the difference between single vs.
: multispecialty group? what's the pros and cons for them?
: :private (solo, single specialty group, multispecialty


发信人: againstwind (逆风而行), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 18:02:40 2010, 美东)

thank you so much. i learned a lot from this thread! will definitely pay
attention to what you said during my job seeking.

endo is more like PCP, not making as much as cards/GI/pulm or nem/onc, i
think most time they actually have to share profits with endo. when i was
doing my resdiency, couple of endocrinologists quit and opened their own
practice because cards/GI were giving them hard time because of the profit
sharing. endo see lots patients in clinic but do not have lots prodedures,
that limited their profit. we have to do thyroid ultrasound/biopsy and read
DEXA to compensate the income.


发信人: feelfeel (ff), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 20:43:30 2010, 美东)

而且hospitalist,很多地方只有晚上的shift available. 确实辛苦。忙起来一个晚上
收15-16个病人。要折腾到第二天中午才弄完。晚上7点再来上班。

yams, 难得看你上来:)我在clinic and ward遇到一些psych pt。Some of them are
very intelligent, even charming. 我现在的team,另外的intern是psych intern。
Whenever I have psych pts, I always ask her to go with me. It is so
interesting to see how psych docs approch those pts.


发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 21:40:22 2010, 美东)

the point I am trying to make is when apply for fellowship, don't just look
at this step, you should look one step further. where are you going after
that, cause fellowship is relatively short. like in surgery field, most
people likes surgi-onc, which you do the biggest of general cases, like
whipple, but the fact is if you want to do big case cases, the only options
is going to the big academic center, if not, you have to do alot of general
surgery cases to supplement your income, and pay is not that good. I meet a
CMG did colorectal fellowship, when looking for job, found really had
difficulty to find one and pay is not that good, he told me that he
regretted his decision.

if you are private, you bill the insurance, if you work for the hospital,
the hospital bills the insurance. doesn't matter if you are pcp or
specialist. how much does the insurance company pay for each specialty
depends on the medicare, which is actually controlled by congress, the rest
of insurance company will follow medicare payment. and most recent trend is
cut on the payment for specialist like radiology and cardiology and give
more money to pcps.

发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 22:05:57 2010, 美东)

you need to write paper to get promotion, but for funding, I don't think
there is a hug pressure, because most of the physician dose not have funding
, they do clinical work. during interview, I asked a young faculty about
paper, he said no body pushed him to write anything for 3 years. but he told
me, "it kills me to see the guy in private practice next door do the same
work but earns much more than I do".
【 在 acne (麦地米虫) 的大作中提到: 】
: 您说academia到底是好还是不好呢?杂事有resident管,是挺省心的,可是还要写
: paper,拉funding。
【 在 usatravel (usatravel) 的大作中提到: 】
: Thanks a lot!! Best Luck to you.
: "如果要作fellowship, 不但要看兴趣, 还要看就业前景" .
: Where can I get info. about 就业前景?
: multispecialty



发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sat Jan 16 22:30:39 2010, 美东)

I don't know about other specialty, but for academic surgeons, they do
operate a lot, some of them are also big, complex cases. although they get
help from residents/fellows to do their floor work, they have to do the
surgeries by themself, at least be there. and surgeons actually bills by
their procedures, so when they see other private guys do the same amount of
work but earns more, they feels undercompensated. but I guess they never
think about their pain of floor work and calls are taken care by the fellows
/resdients
【 在 acne (麦地米虫) 的大作中提到: 】
: academia工作量怎么能private practice和比。private practice那边大部分事情都得
: 亲力亲为。我们这里floor attending晚上根本不会有住院call,private practice能
: 做到这一点吗?

发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sun Jan 17 14:12:28 2010, 美东)

that is called hybrid program, you work with private group, and the hospital
has residence, but ask you to be on the teaching stuff. so you can have a
lot of help for free. but you need to teach on the other hand, this means
give leture, help with journal club, and in surgery, let the resident to
operate. this may take you some time, and slow you down some time, but you
get free help to take care of your scut, and have an buffer for call. it is
well worth it. it is a selling point for a lot of hospitals that they have a
residency.
【 在 kobejordan (baobao) 的大作中提到: 】
: 天真的想想有没有私人GROUP开业和教学医院结合的呢?

发信人: USMedEdu (US_CMGs), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sun Jan 17 20:43:08 2010, 美东)

其实,找什么样的位置,跟当年找住院很有点类似:你到底想要什么?你自己得先搞
清楚这个问题,才可能找到相对称心如意的工作。当然,在JOB市场不好时你想清楚
了,也未必能找到你想的。那只能按最接近你的理想的目标找了。

病理其实跟内外科差不多想挣大钱那去PRIVATE掉或诊断公司,想学术,则去大学。

基本是鱼和熊掌不可兼得。但一般而言,对于CMG,我觉得先到ACADEMIC待续-5年再
跳槽到PRIVATE比较安全和理想一些。那时,你不是找而是挑你的BARGIN哥POWER 就
大得多。

即使ACADEMIC,一般也有3种途径:纯临床CLINICAL TRIAL,TENURE TRACK,和/或
介于其间的一种。泰牛之道一般而言,比较STRESS,要文章和FUNDING。临床的只要
搞好临床就行了。写些小文章锦上添花利于快升。象UC就有介于二者之间的CLINICAL
SCIENTIST,往往是以50%:50%的临床和科研,但对于文章和FUNDING没有泰牛那样
苛刻要求。这个路也可以走到泰牛--如果你确实能干和运气贼好。
--


发信人: guidewire (guidewire), 信区: MedicalCareer
标 题: Re: 找工的一点体会
发信站: BBS 未名空间站 (Sun Jan 17 21:01:10 2010, 美东)

totally agree. for surgery, academic institution you can really do big cases
and some of them give you chance to help you for research if you want. and
operative skill really build up fast. majority of small private surgical
practice does not do good big complex cases due to lack of support, like in
the cards,renal, critical care and endo etc. and over years, your ability
regresses. the only thing is if you want to jump ship to private after
several years, you have to restart, no body will give you a partnership
immediately, it takes 2 years for the patients to build up.The practice I
have now is big private group within a large hospital, doing comparable
complex cases as academic, so it is like one step to the final destination.
if I could not find this one, I am for sure will accept an academic offer
maybe change after several years.

在 USMedEdu (US_CMGs) 的大作中提到: 】
: 其实,找什么样的位置,跟当年找住院很有点类似:你到底想要什么?你自己得先搞
: 清楚这个问题,才可能找到相对称心如意的工作。当然,在JOB市场不好时你想清楚
: 了,也未必能找到你想的。那只能按最接近你的理想的目标找了。

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共有1条评论
1   [USMcdEdu 于 2011-02-07 20:58:29 提到] [FROM: 199.]
发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
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