Yesterday was Christmas and six days since I last had to focus on anatomy - yet, I find myself thinking about it constantly. One relative showed me his ventral hernia - where his intestines poke through his abdominal muscles, which were cut and never healed from a previous operation, so that you can feel the intestines right under his skin. And I think of all the ways a hernia can be defined: direct, indirect, complete, incomplete.
Another relative talked to me about her struggle with the side effects of her antidepressant medication (weight gain, high blood pressure, nausea) and how she was weighing them against the symptoms of her depression. I think of what I'm learning about how your stomach has even more receptors for seretonin than your brain.
A friend pointed to the part of her knee that hurts her when she runs and even though I don't know anything about pathology yet, I could tell her that it was her patellar tendon and it was an extension of the muscle that runs down the front of her leg and makes up her quadriceps.
I explained the differences between the different types of tonsils and how you only call your pharyngeal tonsils adenoids if they're inflamed. I talked to my sister about how mono works and why they would be so worried about ones spleen bursting.
I find myself having moments where I just sit still and feel so lucky that everything in my body is somehow managing to work correctly.
December 26, 2009
December 10, 2009
An Afternoon in the ER
A few weeks ago I shadowed an incredible physician in the ER for an afternoon. I had planned on going for a few hours after class and ended up staying for half of a shift (= 6 hours) because it was fascinating.
For background, I had actually never thought about becoming an ER physician until I started interviewing for medical school. I had been of the opinion that I would be personally frustrated by stabilizing and not treating patients. However my interview at the medical school I currently attend was with an ER physician and I just loved hearing him talk about his work. The biggest thing that struck me was that he said, I am the very last type of physician who says, I will try to help no matter what; no matter who you are, what you have (or don't), if you have insurance, if you speak english, if you live here or are just visiting - I will try to help. And while I think that speaks to the flaws of our medical system, it's also true.
So I arrive in the ER around 2 pm with my stethoscope and lots of questions. Over the course of the time we saw so many patients that there isn't space to recount them all, so I'll just pick two.
The first was a man who came in an ambulance having grand mal seizures and potentially a heart attack. It was the first case where I got to see the ER respond. It was almost like a dance; the physician I shadowed prepared to create an airway down this man's throat, the nurses set up all sorts of medication stations, the charge nurse (the head nurse) coordinated with the paramedics so that when they arrived, they knew exactly which room to come into and what to expect. They cut off his clothes, hooked him up to monitors for his heart, breathing, and blood pressure. Then the physician started talking to him, in between seizures, to check to see if he could be responsive. He grabbed her hand and dug his nails in hard. They got him hooked up to oxygen, made sure there was nothing for him to hit, and started to give him medications to help break his seizure.
The second was an older man who came in with his brother. He was incredibly thin and pale and his brother was scared because he had not wanted to get out of bed that morning or eat anything. The physician I was shadowing asked them about their history and found out that the patient was terminally ill and had spoken with a hospice care worker with whom he (and his brother) had decided that he would be comfortable at home. His brother, it seemed, was rethinking that decision as the patient was getting closer and closer to actually dying. The physician explained what hospice care was and asked the patient if he still wanted to do that. The patient said yes, but his brother begged the physician to admit him to the hospital.
I left the ER, finally, because I had to head to another meeting (and study the rest of the evening) but after being so privileged to be a part of those intimate moments my head was buzzing and I felt like I was floating. I'll be back for sure.
For background, I had actually never thought about becoming an ER physician until I started interviewing for medical school. I had been of the opinion that I would be personally frustrated by stabilizing and not treating patients. However my interview at the medical school I currently attend was with an ER physician and I just loved hearing him talk about his work. The biggest thing that struck me was that he said, I am the very last type of physician who says, I will try to help no matter what; no matter who you are, what you have (or don't), if you have insurance, if you speak english, if you live here or are just visiting - I will try to help. And while I think that speaks to the flaws of our medical system, it's also true.
So I arrive in the ER around 2 pm with my stethoscope and lots of questions. Over the course of the time we saw so many patients that there isn't space to recount them all, so I'll just pick two.
The first was a man who came in an ambulance having grand mal seizures and potentially a heart attack. It was the first case where I got to see the ER respond. It was almost like a dance; the physician I shadowed prepared to create an airway down this man's throat, the nurses set up all sorts of medication stations, the charge nurse (the head nurse) coordinated with the paramedics so that when they arrived, they knew exactly which room to come into and what to expect. They cut off his clothes, hooked him up to monitors for his heart, breathing, and blood pressure. Then the physician started talking to him, in between seizures, to check to see if he could be responsive. He grabbed her hand and dug his nails in hard. They got him hooked up to oxygen, made sure there was nothing for him to hit, and started to give him medications to help break his seizure.
The second was an older man who came in with his brother. He was incredibly thin and pale and his brother was scared because he had not wanted to get out of bed that morning or eat anything. The physician I was shadowing asked them about their history and found out that the patient was terminally ill and had spoken with a hospice care worker with whom he (and his brother) had decided that he would be comfortable at home. His brother, it seemed, was rethinking that decision as the patient was getting closer and closer to actually dying. The physician explained what hospice care was and asked the patient if he still wanted to do that. The patient said yes, but his brother begged the physician to admit him to the hospital.
I left the ER, finally, because I had to head to another meeting (and study the rest of the evening) but after being so privileged to be a part of those intimate moments my head was buzzing and I felt like I was floating. I'll be back for sure.
November 12, 2009
Womens Choice v. Health Care for All
I was shocked to read in a NYT article today that the new health care reform bill proposed by the US Senate includes language stating that the federal health plan would not cover abortion services - AND that if a woman has the federal health plan, she cannot also purchase insurance that would cover it. In an incredibly articulate article, Kate Michaelman (former president of NARAL) and Francis Kissling (former president of Catholics for Choice) lay out how these choices are being put on the back burner for another day's fight instead of being seen as intimately connected to health care.
Read more here.
Read more here.
November 7, 2009
Your Brain on Football (er...collisions)
My only real source of consistent news these days - outside of medical school and word-of-mouth from friends and family - is the New Yorker magazine. When I began medical school I decided 2 things: 1) I wanted some sort of news source that would be shorter articles, entertaining, current, and involved in many spheres of life besides medicine 2) the new yorker had a big recession-style sale on subscriptions (and they threw in a free umbrella).
One story that particularly struck me recently was a report by Malcolm Gladwell on the impact of football (and boxing) on the brain. Gladwell talks with Dr. Ann McKee who runs the research program at the VA in Boston looking at brains of sports players found strange brain patterns in autopsies of football players (specifically linemen) and boxers. The patterns include scarring on the front and back of the brain - where it's been hit against the skull) as well as tissue blockage patterns that are more severe than she has seen in the brains of people who had Alzheimer's.
He also talks to researchers at UNC who have figured out how to put sensors in the football helmets of the players that record the force of each hit they take. The force is measured in how many times the force of gravity it is (e.g. 76g = 76 times the force of gravity). These guys - who are not even professional football players - were regularly taking 60g, 70g hits - in practice and in games. The researchers said it has been incredibly revealing because concussions often occur after a much smaller hit (23g, for example) even though the 70g hit the guy took in practice earlier that week didn't knock him out. It has led them to conclude that concussions do cumulative damage.
Gladwell talks briefly with the Chairman of the NFL about possible fixes to what seems to be proof that football, specifically the lineman position, is severely hurting people's brains. The thing is, the chairman says, football's not going anywhere, and as long as people love it, boys will grow up wanting to play it. We've thought about limiting professional careers to <6 years, but that's really just when a player starts to get valuable. So it's tough.
I'm not sure if there is solution to this - but I know that if I have sons (or daughters), I'm definitely not supporting any dreams of being a center.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"some people think football is a matter of life or death. I assure you it's more serious than that." - Bill Shankley (*he was talking about the other football)
One story that particularly struck me recently was a report by Malcolm Gladwell on the impact of football (and boxing) on the brain. Gladwell talks with Dr. Ann McKee who runs the research program at the VA in Boston looking at brains of sports players found strange brain patterns in autopsies of football players (specifically linemen) and boxers. The patterns include scarring on the front and back of the brain - where it's been hit against the skull) as well as tissue blockage patterns that are more severe than she has seen in the brains of people who had Alzheimer's.
He also talks to researchers at UNC who have figured out how to put sensors in the football helmets of the players that record the force of each hit they take. The force is measured in how many times the force of gravity it is (e.g. 76g = 76 times the force of gravity). These guys - who are not even professional football players - were regularly taking 60g, 70g hits - in practice and in games. The researchers said it has been incredibly revealing because concussions often occur after a much smaller hit (23g, for example) even though the 70g hit the guy took in practice earlier that week didn't knock him out. It has led them to conclude that concussions do cumulative damage.
Gladwell talks briefly with the Chairman of the NFL about possible fixes to what seems to be proof that football, specifically the lineman position, is severely hurting people's brains. The thing is, the chairman says, football's not going anywhere, and as long as people love it, boys will grow up wanting to play it. We've thought about limiting professional careers to <6 years, but that's really just when a player starts to get valuable. So it's tough.
I'm not sure if there is solution to this - but I know that if I have sons (or daughters), I'm definitely not supporting any dreams of being a center.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"some people think football is a matter of life or death. I assure you it's more serious than that." - Bill Shankley (*he was talking about the other football)
October 11, 2009
gray's anatomy for real
What is up with the cadaver dissection in medical school?
Since the last time I wrote (which now I realize is a while ago) I have started our anatomy/histology/imaging/doctoring skills block - which is to say that I am dissecting a cadaver daily as well as practicing doctoring skills (right now skeletal screening exam, apparently sometime soon, prostate screening exam!), learning how to read radiology tests (at a pre-novice level), and understand what slides of cells are telling me about the health of tissue.
I have been wanting to write about our cadaver dissection but am still not sure how I feel about it. I had such mixed feelings going into it and I'm not sure if they've changed all that much since starting. Dissecting a cadaver seems like the keystone experience for medical school - it teaches you to objectify the human body into parts, it forces you to confront your own mortality, and teaches you things you could never learn about the human body in a live being.
The cadaver I've been assigned to for the first month (of 3) died at the age of 54 from pancreatic cancer. He's only a year older than my own father and doesn't look sickly or anything. Oh, except that he's dead. I think that his young age has made it more strange for me - because he doesn't look old and shriveled and like maybe he lived a long life and this truly is resting. He looks like any man I could see talking with his buddies on the side of his son's football game, drinking a beer and having a hot dog.
Except that he's dead.
And I'm dissecting his body.
And the thing is - it's probably the coolest thing I've ever done. This past week, we dissected the entire arm - so I can tell you what all those veins and nerves are in your hands - what muscle you use to open a refrigerator or hold a lover's hand; I know why only your pinky and your ring finger go numb when you hit your funny bone; I know the name of your funny bone. This means that over half of the time, I'm in complete awe of the awesomeness that is the human body. For example, our circulatory system has set up a split in your brachial artery (big artery that supplies blood to most of your arm) around your elbow - on both sides - so that you can bend your elbow (to hold a baby, to do a biceps curl) and still get blood flow to your hands.
Perhaps my mixed feelings can be represented by a moment that happened a few weeks ago when we were removing a part of our cadavers spine:
For those of you who have not ever chiseled a spine (and I hope that's all of you) - your spine is really hard. my group had to take two minute turns because it was harder than constructing my bed. As I passed on the chisel and hammer to the next person, I realized I was standing next to our cadaver and rubbing his (still skin-encased, so somewhat normal looking) arm, trying to be soothing - as I watched my lab partners chisel his spine. It was the strangest moment and I'm still not sure what to take from it.
We've been able to talk a lot about how we're feeling about all of it - and what I keep coming up with is that the best way I can honor this incredible gift is to learn as much as I possibly can from this experience.
Since the last time I wrote (which now I realize is a while ago) I have started our anatomy/histology/imaging/doctoring skills block - which is to say that I am dissecting a cadaver daily as well as practicing doctoring skills (right now skeletal screening exam, apparently sometime soon, prostate screening exam!), learning how to read radiology tests (at a pre-novice level), and understand what slides of cells are telling me about the health of tissue.
I have been wanting to write about our cadaver dissection but am still not sure how I feel about it. I had such mixed feelings going into it and I'm not sure if they've changed all that much since starting. Dissecting a cadaver seems like the keystone experience for medical school - it teaches you to objectify the human body into parts, it forces you to confront your own mortality, and teaches you things you could never learn about the human body in a live being.
The cadaver I've been assigned to for the first month (of 3) died at the age of 54 from pancreatic cancer. He's only a year older than my own father and doesn't look sickly or anything. Oh, except that he's dead. I think that his young age has made it more strange for me - because he doesn't look old and shriveled and like maybe he lived a long life and this truly is resting. He looks like any man I could see talking with his buddies on the side of his son's football game, drinking a beer and having a hot dog.
Except that he's dead.
And I'm dissecting his body.
And the thing is - it's probably the coolest thing I've ever done. This past week, we dissected the entire arm - so I can tell you what all those veins and nerves are in your hands - what muscle you use to open a refrigerator or hold a lover's hand; I know why only your pinky and your ring finger go numb when you hit your funny bone; I know the name of your funny bone. This means that over half of the time, I'm in complete awe of the awesomeness that is the human body. For example, our circulatory system has set up a split in your brachial artery (big artery that supplies blood to most of your arm) around your elbow - on both sides - so that you can bend your elbow (to hold a baby, to do a biceps curl) and still get blood flow to your hands.
Perhaps my mixed feelings can be represented by a moment that happened a few weeks ago when we were removing a part of our cadavers spine:
For those of you who have not ever chiseled a spine (and I hope that's all of you) - your spine is really hard. my group had to take two minute turns because it was harder than constructing my bed. As I passed on the chisel and hammer to the next person, I realized I was standing next to our cadaver and rubbing his (still skin-encased, so somewhat normal looking) arm, trying to be soothing - as I watched my lab partners chisel his spine. It was the strangest moment and I'm still not sure what to take from it.
We've been able to talk a lot about how we're feeling about all of it - and what I keep coming up with is that the best way I can honor this incredible gift is to learn as much as I possibly can from this experience.
September 23, 2009
Health Reform Update: Baucus releases the new bill!
2 Quick Updates,
First, on Health Care Reform:
Senator Baucus just released the new bill with more than 500 amendments (including all of the ones offered by Senator Snow, potentially the only Republican who will vote for it). The bill purportedly includes an amendment to cut the fine for not having health insurance, and increases the threshold for taxation of high cost insurance plans (tax to insurer, not person). These changes were made to try to increase affordability for low- and middle income people. The mandate still stands and is unlikely (and hopefully) not something that the Committee will budge on. Like Speaker Pelosi has (and many others have) said, we need to make sure everyone is included so that the risk is dispersed among all of us.
Read more at the NPR Health Blog and from the Wall Street Journal article.
Thoughts on health reform that have come up in recent conversations (and aren't really being addressed by this bill...yet):
- should people with expensive-to-treat illnesses have to pay more for health insurance (e.g. someone with cystic fibrosis or type 2 diabetes, who is much more likely to use the services of a hospital)
-Does it make a difference if the illness is hereditary, accidental, or behavior-related? (Type 2 diabetes from obesity v. type 1 diabetes, which is hereditary; or cystic fibrosis, which is inherited, versus cancers from smoking?)
-Should we be able to tax behaviors, such as drinking pop (aka soda, if you're not from the midwest), smoking, alcohol, even fast food - to pay for health care to try to compensate for these costs?
-For the economists out there: would they ever actually compensate for the costs of these behaviors to the health care system?
Second update on med students and lack of professionalism:
We physicians-in-training are not doing a great job of assuring our future patients that we are worth trusting. JAMA just released a paper citing a huge lack of online decorum by medical students. This may seem like nothing compared with the very public trial earlier in the year for a second year medical student at BU who was arrested for murders of women who he met on Craigslist (read more on Boston Globe website)
We had a lot of lectures during orientation and our first block about professionalism - and while many of the topics discussed could seem minor compared to the vast amount of scientific knowledge we're trying to learn - I think it may be the most important.
One of our greatest professors here said that his friend's father was a physician and every time he would leave the house, he would put on a tie. He said that there was always a chance he would run into a previous patient, a current patient, or a future patient - and he wanted them to know that there doctor took his profession seriously. I clearly won't be wearing a tie every time I leave my house (in fact, I'm just embracing wearing jeans again), I do think that you are allowed to have higher expectations for someone to whom you are telling your most intimate life details, who you are letting examine your naked body, and who you are trusting to help you make the best decisions you can about your health.
That said, medical school is quite hard - and incredibly time consuming. The commitment that the path to medicine requires is near total and by embarking on it, you are choosing to have less free time for people and fun - which is not to excuse these students but to provide a framework for understanding the need for a comedic release. But no one tells you medical school will be easy - if anything, they tell you it will be the hardest thing you have done yet. As medical students and future physicians, we really have to consider that even though it may be an arduous path, if we want our patients to trust us, if we want society to continue to hold doctors on such high moral ground, we have to honor this profession, tie or no tie.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.”
-Michaelangelo
First, on Health Care Reform:
Senator Baucus just released the new bill with more than 500 amendments (including all of the ones offered by Senator Snow, potentially the only Republican who will vote for it). The bill purportedly includes an amendment to cut the fine for not having health insurance, and increases the threshold for taxation of high cost insurance plans (tax to insurer, not person). These changes were made to try to increase affordability for low- and middle income people. The mandate still stands and is unlikely (and hopefully) not something that the Committee will budge on. Like Speaker Pelosi has (and many others have) said, we need to make sure everyone is included so that the risk is dispersed among all of us.
Read more at the NPR Health Blog and from the Wall Street Journal article.
Thoughts on health reform that have come up in recent conversations (and aren't really being addressed by this bill...yet):
- should people with expensive-to-treat illnesses have to pay more for health insurance (e.g. someone with cystic fibrosis or type 2 diabetes, who is much more likely to use the services of a hospital)
-Does it make a difference if the illness is hereditary, accidental, or behavior-related? (Type 2 diabetes from obesity v. type 1 diabetes, which is hereditary; or cystic fibrosis, which is inherited, versus cancers from smoking?)
-Should we be able to tax behaviors, such as drinking pop (aka soda, if you're not from the midwest), smoking, alcohol, even fast food - to pay for health care to try to compensate for these costs?
-For the economists out there: would they ever actually compensate for the costs of these behaviors to the health care system?
Second update on med students and lack of professionalism:
We physicians-in-training are not doing a great job of assuring our future patients that we are worth trusting. JAMA just released a paper citing a huge lack of online decorum by medical students. This may seem like nothing compared with the very public trial earlier in the year for a second year medical student at BU who was arrested for murders of women who he met on Craigslist (read more on Boston Globe website)
We had a lot of lectures during orientation and our first block about professionalism - and while many of the topics discussed could seem minor compared to the vast amount of scientific knowledge we're trying to learn - I think it may be the most important.
One of our greatest professors here said that his friend's father was a physician and every time he would leave the house, he would put on a tie. He said that there was always a chance he would run into a previous patient, a current patient, or a future patient - and he wanted them to know that there doctor took his profession seriously. I clearly won't be wearing a tie every time I leave my house (in fact, I'm just embracing wearing jeans again), I do think that you are allowed to have higher expectations for someone to whom you are telling your most intimate life details, who you are letting examine your naked body, and who you are trusting to help you make the best decisions you can about your health.
That said, medical school is quite hard - and incredibly time consuming. The commitment that the path to medicine requires is near total and by embarking on it, you are choosing to have less free time for people and fun - which is not to excuse these students but to provide a framework for understanding the need for a comedic release. But no one tells you medical school will be easy - if anything, they tell you it will be the hardest thing you have done yet. As medical students and future physicians, we really have to consider that even though it may be an arduous path, if we want our patients to trust us, if we want society to continue to hold doctors on such high moral ground, we have to honor this profession, tie or no tie.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.”
-Michaelangelo
September 16, 2009
infections and wrinkles
random thing I learned today (and maybe this is more common knowledge than I thought):
botulism, like the bacteria you're worried about getting from your canned goods that aren't acidic enough, is caused by a bacteria called Clostridium botulinum. But that's not the exciting part - how the bacteria works is by infecting your neuro-muscular junctions (the parts of your body where nerves connect to muscle to stimulate them to flex). When it infects these junctions, it inhibits the release of a neurotransmitter, called Acetylcholinase (it's like, THE neurotransmitter). This prevents any signaling from the neurotransmitter to the muscle, so the muscle cannot be enervated - or flex.
Horrible infection that causes breathing problems and often requires hospitalization with insertion of all sorts of breathing machines, feeding tubes, etc. If you suspect you have Botulism - call your doctor or go to the ER - type stuff. Treatment is with an antitoxin that kills the bacteria and reverses the symptoms.
BUT! (this is the crazy part) the bacteria are exactly what are used in Botox - like the thing you inject into your forehead to prevent wrinkles. In fact, Bo-tox stands for "botulism toxin". Apparently all over the US and world people are injecting toxic bacteria that inhibit neuromuscular junctions INTO THEIR FACES to prevent their facial muscles from flexing into positions that could cause them wrinkles. This explains why the risks of Botox include that you may hit a neuromuscular junction that matters - and get a droopy eye or something. Lucky for people interested in Botox, the effects don't last very long at the concentration given. So if you get a droopy eye it will only be for about four to six months. WHAT?!?!
I guess I haven't thought much about reducing the signs of aging. I've had a wrinkle on my forehead since I started reading, and I kinda dig it. But maybe I'll feel differently in a few decades...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I wonder if I can grow fangs when my baby teeth fall out"
-Bill Waterson in Calvin and Hobbes
botulism, like the bacteria you're worried about getting from your canned goods that aren't acidic enough, is caused by a bacteria called Clostridium botulinum. But that's not the exciting part - how the bacteria works is by infecting your neuro-muscular junctions (the parts of your body where nerves connect to muscle to stimulate them to flex). When it infects these junctions, it inhibits the release of a neurotransmitter, called Acetylcholinase (it's like, THE neurotransmitter). This prevents any signaling from the neurotransmitter to the muscle, so the muscle cannot be enervated - or flex.
Horrible infection that causes breathing problems and often requires hospitalization with insertion of all sorts of breathing machines, feeding tubes, etc. If you suspect you have Botulism - call your doctor or go to the ER - type stuff. Treatment is with an antitoxin that kills the bacteria and reverses the symptoms.
BUT! (this is the crazy part) the bacteria are exactly what are used in Botox - like the thing you inject into your forehead to prevent wrinkles. In fact, Bo-tox stands for "botulism toxin". Apparently all over the US and world people are injecting toxic bacteria that inhibit neuromuscular junctions INTO THEIR FACES to prevent their facial muscles from flexing into positions that could cause them wrinkles. This explains why the risks of Botox include that you may hit a neuromuscular junction that matters - and get a droopy eye or something. Lucky for people interested in Botox, the effects don't last very long at the concentration given. So if you get a droopy eye it will only be for about four to six months. WHAT?!?!
I guess I haven't thought much about reducing the signs of aging. I've had a wrinkle on my forehead since I started reading, and I kinda dig it. But maybe I'll feel differently in a few decades...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I wonder if I can grow fangs when my baby teeth fall out"
-Bill Waterson in Calvin and Hobbes
September 11, 2009
The Evolutionary Advantage of Microbes
Right now we're working on the fastest biochem review in the history of the world. Okay, so maybe not in the history of the world, but definitely in my world. As a class, I think although we have times of being really frustrated, we're all nerdy enough that learning about bacteria, viruses, and protein misfolding is really really cool. One of our professors who has been teaching us about different types of pathogens answered a question posed by a classmate the other day, about WHY something happened with: "Instead of asking "Why" in science, which is very hard to answer - ask "What is the evolutionary advantage of this..." and I just totally dug it.
Antibacterial medication is now super common because we discovered (totally by accident - see: Alexander Fleming and look under "accidental discovery")that because bacteria had been competing amongst themselves for food, space, and other supplies, they (and plants and fungi) had developed nasty ways of getting rid of each other. But then evolution skipped right past super helpful to somewhat harmful - this getting rid of each other resulted in the selection of bacteria who were resistant to some of these defenses, thereby introducing resistance to antibacterials. It's not that bacteria are super smart...at all. It's just that there are so many of them, that they can naturally select for THE MOST ADVANTAGEOUS traits - even if there's only a one in a million chance of a certain gene being incorporated in a certain place, because there are probably one million bacteria on my body right now (and yours).
While I still am anxiously awaiting our anatomy labs - learning about pathogens and how they evade even our best scientific knowledge is pretty fascinating.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“I have been trying to point out that in our lives chance may have an astonishing influence and, if I may offer advice to the young laboratory worker, it would be this - never to neglect an extraordinary appearance or happening.”
-Alexander Fleming
Antibacterial medication is now super common because we discovered (totally by accident - see: Alexander Fleming and look under "accidental discovery")that because bacteria had been competing amongst themselves for food, space, and other supplies, they (and plants and fungi) had developed nasty ways of getting rid of each other. But then evolution skipped right past super helpful to somewhat harmful - this getting rid of each other resulted in the selection of bacteria who were resistant to some of these defenses, thereby introducing resistance to antibacterials. It's not that bacteria are super smart...at all. It's just that there are so many of them, that they can naturally select for THE MOST ADVANTAGEOUS traits - even if there's only a one in a million chance of a certain gene being incorporated in a certain place, because there are probably one million bacteria on my body right now (and yours).
While I still am anxiously awaiting our anatomy labs - learning about pathogens and how they evade even our best scientific knowledge is pretty fascinating.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“I have been trying to point out that in our lives chance may have an astonishing influence and, if I may offer advice to the young laboratory worker, it would be this - never to neglect an extraordinary appearance or happening.”
-Alexander Fleming
August 26, 2009
What happens when a physician is addicted?
today we talked all about physicians who are addicted to different substances. We're learning about ethics, study design, public health and genetics - so we first read a few papers about an outbreak of a hospital infection in a surgical ICU that was most likely caused by one of the employees tampering with the fentanyl (a type of synthetic opiod) of patients who were acutely ill post-surgery in order to take some and use it. So we got to learn about how you study outbreaks (infection all over the surgical ICU), talk about how you deal with infection (public health), about whether we hold physicians to a different standard when it comes to drug abuse - and if so, why? (ethics), and then about addiction as an illness (genetics).
So suffice it to say, my mind is spinning. I also have my first exam on Friday (eek) so I'm trying to transform myself into a studying machine. I still feel pretty human so far, but here's hoping.
So what we should do for physicians who are addicts? Do we treat them differently than anyone else? In class, we read an excerpt from Abraham Verghese (a physician/writer)'s book, The Tennis Partner, which talks about him playing tennis with a fellow physician and the relationship that forms between them. Dr. Verghese ends up confiding in his tennis partner about his failing marriage, and his tennis partner confides in him all about his addiction to cocaine. Ultimately, the tennis partner gets addicted to perscription drugs and Dr. Verghese has to decide wha the best form of intervention is.
He thinks along the lines of: a physician is worth so much to society that we shouldn't put him in jail; plus rates of recovery from addiction are much higher in physicians than in other professions - potentially because they have more to lose by not recovering. He also thinks: this guy can't be treating patients when he needs to be a patient himself.
Thoughts? Here's a link to an interview with a doctor who treats addicted physicians for more background: http://www.physiciansnews.com/spotlight/397wp.html
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"just because you got the monkey off your back doesn't mean the circus has left town"
-George Carlin (about addiction)
So suffice it to say, my mind is spinning. I also have my first exam on Friday (eek) so I'm trying to transform myself into a studying machine. I still feel pretty human so far, but here's hoping.
So what we should do for physicians who are addicts? Do we treat them differently than anyone else? In class, we read an excerpt from Abraham Verghese (a physician/writer)'s book, The Tennis Partner, which talks about him playing tennis with a fellow physician and the relationship that forms between them. Dr. Verghese ends up confiding in his tennis partner about his failing marriage, and his tennis partner confides in him all about his addiction to cocaine. Ultimately, the tennis partner gets addicted to perscription drugs and Dr. Verghese has to decide wha the best form of intervention is.
He thinks along the lines of: a physician is worth so much to society that we shouldn't put him in jail; plus rates of recovery from addiction are much higher in physicians than in other professions - potentially because they have more to lose by not recovering. He also thinks: this guy can't be treating patients when he needs to be a patient himself.
Thoughts? Here's a link to an interview with a doctor who treats addicted physicians for more background: http://www.physiciansnews.com/spotlight/397wp.html
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"just because you got the monkey off your back doesn't mean the circus has left town"
-George Carlin (about addiction)
August 25, 2009
Health Care Reform: Simplify
There are two major questions to health care reform:
1) How do we reform how we pay for health care? The goal of this reform is to make health care affordable for patients, to make sure health care workers are getting reimbursed fairly, and to figure out a way for our government to help subsidize this type of system without increasing our national debt too much.
2) How do we reform how we provide health care? The goal of this is to make health care better. This means putting best practices into effect so that patients everywhere can benefit from them. It means
But like any good market system, systems reform is inextricably tied to financial reform - and a good health care reform plan must address both.
I would like to draw attention to two articles, each focusing on one of these questions while simultaneously showing that the two questions are inter-related and any real reform must take into account.
First, a column in the New York Times Economix Blog by Princeton Economist Uwe Reinhart. Professor Reinhart divides the reforms proposed into those aimed at the supply side (health care provision) and those for the demand side - because yes, he's an ecomonist. He argues for the increased use of electronic medical records and other measures to increase efficiency, but his focus is on how to create the pool of people who will be insured. He says that a good system must include everyone, regardless of their health condition and whether they want to opt into health insurance - so a mandate for insurance companies to accept everyone and a mandate that everyone purchase at least basic insurance. He also admits that even the most basic insurance may not be affordable for many families (especially in the current economy) and that subsidies must be made available - assuring that everyone is in the insurance pool.
The second article is by one of my favorite physician/writers, Atul Gawande in the New Yorker. Dr. Gawande examines the differences between some areas of the country where health care costs are absurd versus areas of the country where they are virtually under control - and finds that in the areas where we spend more money, care is actually worse. The themes in the places where patients receive incredible care AND health care spending is under control seem to have in common several key characteristics including: doctors worked more as a team than as separate entities, there was more of a divide between physicians and expensive procedures (as in, they didn't own the machines that did the scans), agreements about charging similar fees regardless of insurance (so there's no incentive to see the patient with private health insurance over the person with medicaid), and many hospital-wide electronic medical records.
These articles are encouraging in that, from an economics perspective and a practical perspective, they break down health reform from confusing seemingly impossible ideas to concrete - dare I say, logical? - policies that we can and should implement.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes." -Atul Gawande, MD MPH in the new yorker article referenced above
August 24, 2009
Atul Gawande's Five Rules of Medicine
Now I'm over a week into medical school - which sounds so short, I'm sure - but when I think of all the things that have entered my consciousness and been mulled over in my mind as I talk with friends and family, as I go on runs by the lake, and even while I sleep - it seems like a whole lot.
It's such a different experience to be in class learning only about things that are directly applicable (or could be) to what you will be doing for the rest of your life. And more importantly, perhaps, they're things you will be expected to know - by your colleagues, patients, and the world. It's enough to make me feel like studying all the time isn't too much.
They say that after four years of medical school, students change their reasons for becoming a doctor, change their ideas of what is required of a physician, and try to figure out ways to avoid patient contact, when that's why they went to medical school in the first place. I am pledging that I will do everything I can to remind myself of why I want to join the ranks of this honorable profession - through sleepless months and difficult patients. My reasons for becoming a doctor are because I think it is the best role in which I can serve society - and I never want to forget that.
Atul Gawande, MD MPH, one of my favorite doctor/writers (Che Guavera is another, read Motorcycle Diaries if you ever get the chance), has 5 rules he recommends to new medical students, and by which I am trying to live as a I go through the beginnings of this process:
1) ask an unscripted question (he attributes this to the writer Paul Auster)
2) don't whine
3) count something
4) write something
5) change.
Surely we can all try to do that.
A link to the full text of the graduation speech here.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary sprit with a breadth of charity that raises you far above the petty jealousies of life.
-William Osler, MD
It's such a different experience to be in class learning only about things that are directly applicable (or could be) to what you will be doing for the rest of your life. And more importantly, perhaps, they're things you will be expected to know - by your colleagues, patients, and the world. It's enough to make me feel like studying all the time isn't too much.
They say that after four years of medical school, students change their reasons for becoming a doctor, change their ideas of what is required of a physician, and try to figure out ways to avoid patient contact, when that's why they went to medical school in the first place. I am pledging that I will do everything I can to remind myself of why I want to join the ranks of this honorable profession - through sleepless months and difficult patients. My reasons for becoming a doctor are because I think it is the best role in which I can serve society - and I never want to forget that.
Atul Gawande, MD MPH, one of my favorite doctor/writers (Che Guavera is another, read Motorcycle Diaries if you ever get the chance), has 5 rules he recommends to new medical students, and by which I am trying to live as a I go through the beginnings of this process:
1) ask an unscripted question (he attributes this to the writer Paul Auster)
2) don't whine
3) count something
4) write something
5) change.
Surely we can all try to do that.
A link to the full text of the graduation speech here.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary sprit with a breadth of charity that raises you far above the petty jealousies of life.
-William Osler, MD
August 20, 2009
Right to Refuse
We've been talking a lot about death and life this week - I know, the first week of medical school and we literally just dive right into the deep stuff - but it's made me think a lot about what the right to die means, and what it means for me.
So in this country, we have not a right to die, but a right to refuse life-saving treatment. There have been several court cases guarenteeing consenting adults' right to refuse life saving treatment. In two states, Washington and Oregan, it is legal for physicians to prescribe a lethal dose of a medication to terminally ill patients, but those patients have to take the medication orally themselves.
As part of this class, we had to fill out our own advanced directives or "living wills". At first I was a bit petrified to do this and even though I'm in medical school, I'm not so interested in thinking about death, especially my own. But this class made me realize that that fear - of mortality of our patients and especially our own - can result in physicians avoiding taking care of patients completely when they are close to dying or not telling patients the whole truth about the progression of their illness. I feel that becoming comfortable with the concept of good deaths and bad deaths is something that is very important for physicians-in-training - and knowing how to make sure the decisions of the patient are being secured is the first step. Additionally, giving a patient all the information s/he wants about her/his own health care is something I feel really strongly about - there are very few reasons other people should know things about your body that you are not allowed to know.
I ended up filling out my advanced directive and talking about it with my family and friends - I realized that if someone I love does have to make really hard decisions about how to care for me if I am incapacitated, I want them to know that they are making the decisions I would want them to make. There's enough that's hard about losing someone you love, guilt about making them comfortable should not be part of it.
For more info on advanced directive terminology and to learn how to write your own:
The American Academy of Family Physicians info sheet
A Great Wall Street Journal Health Blog Article on AD:
http://blogs.wsj.com/health/2009/08/18/living-wills-and-other-advance-directives-a-primer/
For more info on palliative care (which is different from hospice care) see a recent New York Times Article on Palliative Care
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“I would like a doctor who is not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul…I want a metaphysical [person] to keep me company. To get to my body, my doctor has to get to my character. He has to go through my soul”
– Anatole Broyard in Intoxicated by My Illness
So in this country, we have not a right to die, but a right to refuse life-saving treatment. There have been several court cases guarenteeing consenting adults' right to refuse life saving treatment. In two states, Washington and Oregan, it is legal for physicians to prescribe a lethal dose of a medication to terminally ill patients, but those patients have to take the medication orally themselves.
As part of this class, we had to fill out our own advanced directives or "living wills". At first I was a bit petrified to do this and even though I'm in medical school, I'm not so interested in thinking about death, especially my own. But this class made me realize that that fear - of mortality of our patients and especially our own - can result in physicians avoiding taking care of patients completely when they are close to dying or not telling patients the whole truth about the progression of their illness. I feel that becoming comfortable with the concept of good deaths and bad deaths is something that is very important for physicians-in-training - and knowing how to make sure the decisions of the patient are being secured is the first step. Additionally, giving a patient all the information s/he wants about her/his own health care is something I feel really strongly about - there are very few reasons other people should know things about your body that you are not allowed to know.
I ended up filling out my advanced directive and talking about it with my family and friends - I realized that if someone I love does have to make really hard decisions about how to care for me if I am incapacitated, I want them to know that they are making the decisions I would want them to make. There's enough that's hard about losing someone you love, guilt about making them comfortable should not be part of it.
For more info on advanced directive terminology and to learn how to write your own:
The American Academy of Family Physicians info sheet
A Great Wall Street Journal Health Blog Article on AD:
http://blogs.wsj.com/health/2009/08/18/living-wills-and-other-advance-directives-a-primer/
For more info on palliative care (which is different from hospice care) see a recent New York Times Article on Palliative Care
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“I would like a doctor who is not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul…I want a metaphysical [person] to keep me company. To get to my body, my doctor has to get to my character. He has to go through my soul”
– Anatole Broyard in Intoxicated by My Illness
August 19, 2009
health reform takes front page and ethics case #1
everything is moving so quickly that it's hard to keep track of everything.
this week our lectures have run the gammit from statistics to evaluating resources to genetics to public health to ethics; but I guess those are the major themes of this block, so it makes sense.
Two things:
1) Obama wrote an op-ed about health care reform in the NYT and a bunch of different people responded, including FOX News, Steven Colbert, and Gail Collins.
2) our ethics case tomorrow is on a pretty debated topic known as "The Ashley Treatment" The case involves treatment decisions for a young girl (I think she's about 7 at the time of the decision) who is severely neurologically and developmentally impaired. Doctors have diagnosed her “static encephalopathy of unknown etiology”, meaning "an insult to the brain of unknown origin or cause" (encephalopathy of unknown origin) that will not improve (static). From her parent's blog (http://ashleytreatment.spaces.live.com/blog), her abilities are extremely limited "Now nine years old, Ashley cannot keep her head up, roll or change her sleeping position, hold a toy, or sit up by herself, let alone walk or talk. She is tube fed and depends on her caregivers in every way. We call her our Pillow Angel since she is so sweet and stays right where we place her—usually on a pillow."
After she showed very preliminary signs of pubertal development, her parents took her to see an endocrinologist and eventually came up with a treatment plan that involved a hysterectomy (without oophorectomy, or ovarian removal), removal of her breast buds, and an appendectomy, followed by high dose estrogen treatment. The goal of this treatment was to attenuate her growth. Her parents requested this treatment because they determined that it would most maintain Ashley's quality of life because it would allow them to continue to care for her (not institutionalize her), move her easily (thus including her, preventing bed sores, increasing circulation), and prevent any unncessary pain (menstrual cramping, unintended pregnancy, appendicitis) that she would not be able to communicate to them.
Concerns include the unknowns about this risk/benefit analysis including: very little is known about the consequences of stunting growth on women with developmental and neurological impairment; there are serious risks with high risk estrogen treatment, some of which - like blood clots in the leg - are increased in people who do not move; how do we know that this treatment is increasing Ashley's happiness and not stunting it in some way (can we assess this confidently?); how do we know that her condition will not improve with age or with continued treatment as an infant?
After consultation with the ethics board at the hospital, Ashley's doctors went ahead with the surgery and hormone treatment. She's now about 10 years old and no major complications have been reported. We're discussing issues of consent and assent tomorrow and I am eager to see what people think of this case. If you look on the defense and explanation from Ashley's parents on their blog: http://ashleytreatment.spaces.live.com/blog/cns!E25811FD0AF7C45C!1837.entry
as well as statements from the disability law project, ethics committees and numerous physicians - it gets complicated. More on what we discuss later.
this week our lectures have run the gammit from statistics to evaluating resources to genetics to public health to ethics; but I guess those are the major themes of this block, so it makes sense.
Two things:
1) Obama wrote an op-ed about health care reform in the NYT and a bunch of different people responded, including FOX News, Steven Colbert, and Gail Collins.
2) our ethics case tomorrow is on a pretty debated topic known as "The Ashley Treatment" The case involves treatment decisions for a young girl (I think she's about 7 at the time of the decision) who is severely neurologically and developmentally impaired. Doctors have diagnosed her “static encephalopathy of unknown etiology”, meaning "an insult to the brain of unknown origin or cause" (encephalopathy of unknown origin) that will not improve (static). From her parent's blog (http://ashleytreatment.spaces.live.com/blog), her abilities are extremely limited "Now nine years old, Ashley cannot keep her head up, roll or change her sleeping position, hold a toy, or sit up by herself, let alone walk or talk. She is tube fed and depends on her caregivers in every way. We call her our Pillow Angel since she is so sweet and stays right where we place her—usually on a pillow."
After she showed very preliminary signs of pubertal development, her parents took her to see an endocrinologist and eventually came up with a treatment plan that involved a hysterectomy (without oophorectomy, or ovarian removal), removal of her breast buds, and an appendectomy, followed by high dose estrogen treatment. The goal of this treatment was to attenuate her growth. Her parents requested this treatment because they determined that it would most maintain Ashley's quality of life because it would allow them to continue to care for her (not institutionalize her), move her easily (thus including her, preventing bed sores, increasing circulation), and prevent any unncessary pain (menstrual cramping, unintended pregnancy, appendicitis) that she would not be able to communicate to them.
Concerns include the unknowns about this risk/benefit analysis including: very little is known about the consequences of stunting growth on women with developmental and neurological impairment; there are serious risks with high risk estrogen treatment, some of which - like blood clots in the leg - are increased in people who do not move; how do we know that this treatment is increasing Ashley's happiness and not stunting it in some way (can we assess this confidently?); how do we know that her condition will not improve with age or with continued treatment as an infant?
After consultation with the ethics board at the hospital, Ashley's doctors went ahead with the surgery and hormone treatment. She's now about 10 years old and no major complications have been reported. We're discussing issues of consent and assent tomorrow and I am eager to see what people think of this case. If you look on the defense and explanation from Ashley's parents on their blog: http://ashleytreatment.spaces.live.com/blog/cns!E25811FD0AF7C45C!1837.entry
as well as statements from the disability law project, ethics committees and numerous physicians - it gets complicated. More on what we discuss later.
August 11, 2009
the master secret keeper
Today we talked a lot about professionalism and leadership - and actually already had an assignment about what people want in a doctor (and how that may be different if they have a terminal cancer, a chronic disease, or an ear ache). One thing that caught me today in the lectures was the distinguishing of a profession from a job - and what it means to call medicine "a calling". The professor said the distinction was that a profession is an integration of who are you are with what you do, versus just something you do because it pays the bills and is pretty painless (a job).
I wonder if it also works the other way: an integration of what you do with who you are.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"don't squander your love"
-Luis Alberto Urrea
I wonder if it also works the other way: an integration of what you do with who you are.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"don't squander your love"
-Luis Alberto Urrea
August 10, 2009
what the hell is water? (first day of medical school)
question: what about yourself, your life, do you assume to be true, that could be entirely and completely WRONG?
the answer is complicated (mostly because I don't know yet), but the question is a result of today being my first day of medical school. After the requisite intros to the school and the curriculum, we were introduced to our first course with a quote from a speech by David Foster Wallace, where he talks about how two new fish are swimming along in the ocean when a big fish swims by and says "morning boys, how's the water?" after he swims away, the new fish turn to each other and say "what the hell is water?"
our professor today (and David Foster Wallace originally) said this to demonstrate the importance of knowing the environment (and assumptions) we make based on the experiences we have had; and what we don't question because of it. the class is designed to make us question specifically this - what we think to be true - about ourselves, about medicine, about our patients - that just might not be.
It has made me think about the aspects of myself of which I am not yet aware. I looked up DFW's whole commencement speech at Kenyon because I was so curious how he elaborated. The theme of his speech is why learning how to think (i.e. what a liberal arts education teaches you) actually is really important. In the speech, he says, "...learning how to think really means learning how to exercise some control over how and what you think. It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience." I try to extract meaning from most experiences, but I am trying to think about the types of meaning I try to extract - truths about the people in the experience, truths about the places and relationships present, and maybe even bigger truths about the world, but perhaps too rarely to I try to extract meaning for truths about me. More on this later, because I want to think more (and tomorrow, in class, learn more) about how one does this.
In the meantime: Do you think you examine this in your own experiences? What are the tools or guidance you use to help you do this?
The instructor also introduced science as a philosophy based on "unrestrained curiosity" - unrestrained by assumptions of what is or is not true. Because in science, you can - and are encouraged to - test everything. He called it an open-minded skeptism of everything; taking it all in as something that might be true, but has not proved to be - YET. I dig it. I think this is perhaps why science is my favorite religious philosophy (if it could fit into that category...can it?)
On another note, my big sib (and guide through medical school) told me today that he has realized that he has to be a specialist. When I asked him why - he said that he's just not smart enough, doesn't have the mind capacity to understand as many systems as thoroughly as you have to in order to be an effective internist (same thing as a PCP). Later, I talked with a guy who is taking a year off between his 3rd and 4th year to work in a pathology lab. This means that he's getting paid to dissect bodies and tissue to figure out what went wrong. I asked him why he would ever want to do that for a whole year (or what I really said was: oh. that's cool. do you want to be a pathologist?), to which he responded that in his experience, the pathologists knew the most - and because he wants to be an internist, he has to know as much as he can. I love that primary care physicians are regarded with such a high degree of respect here. I guess I knew that would happen coming here, but I think I pictured it more like all these people who still acknowledged specialists were smarter, but knew that internists were more important. But now I am wondering why I ever believed specialized knowledge made you smarter. The more I think about it, it's just a different kind of thinking: do you want to have to hear the story and put the pieces together, knowing you'll never - or rarely - have them all under control, or do you want to be called upon to perform a set of skills that you have, for all intensive purposes, mastered? I'm going to keep asking myself that question - but I lean towards the former right now.
~~~~~~~~~~~~~~~~~~~~~~~
"It seems important to find ways of reminding ourselves that most "familiarity" is meditated and delusive."
-David Foster Wallace
"Try to learn to let what is unfair teach you."
-David Foster Wallace (Infinite Jest: A Novel)
the answer is complicated (mostly because I don't know yet), but the question is a result of today being my first day of medical school. After the requisite intros to the school and the curriculum, we were introduced to our first course with a quote from a speech by David Foster Wallace, where he talks about how two new fish are swimming along in the ocean when a big fish swims by and says "morning boys, how's the water?" after he swims away, the new fish turn to each other and say "what the hell is water?"
our professor today (and David Foster Wallace originally) said this to demonstrate the importance of knowing the environment (and assumptions) we make based on the experiences we have had; and what we don't question because of it. the class is designed to make us question specifically this - what we think to be true - about ourselves, about medicine, about our patients - that just might not be.
It has made me think about the aspects of myself of which I am not yet aware. I looked up DFW's whole commencement speech at Kenyon because I was so curious how he elaborated. The theme of his speech is why learning how to think (i.e. what a liberal arts education teaches you) actually is really important. In the speech, he says, "...learning how to think really means learning how to exercise some control over how and what you think. It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience." I try to extract meaning from most experiences, but I am trying to think about the types of meaning I try to extract - truths about the people in the experience, truths about the places and relationships present, and maybe even bigger truths about the world, but perhaps too rarely to I try to extract meaning for truths about me. More on this later, because I want to think more (and tomorrow, in class, learn more) about how one does this.
In the meantime: Do you think you examine this in your own experiences? What are the tools or guidance you use to help you do this?
The instructor also introduced science as a philosophy based on "unrestrained curiosity" - unrestrained by assumptions of what is or is not true. Because in science, you can - and are encouraged to - test everything. He called it an open-minded skeptism of everything; taking it all in as something that might be true, but has not proved to be - YET. I dig it. I think this is perhaps why science is my favorite religious philosophy (if it could fit into that category...can it?)
On another note, my big sib (and guide through medical school) told me today that he has realized that he has to be a specialist. When I asked him why - he said that he's just not smart enough, doesn't have the mind capacity to understand as many systems as thoroughly as you have to in order to be an effective internist (same thing as a PCP). Later, I talked with a guy who is taking a year off between his 3rd and 4th year to work in a pathology lab. This means that he's getting paid to dissect bodies and tissue to figure out what went wrong. I asked him why he would ever want to do that for a whole year (or what I really said was: oh. that's cool. do you want to be a pathologist?), to which he responded that in his experience, the pathologists knew the most - and because he wants to be an internist, he has to know as much as he can. I love that primary care physicians are regarded with such a high degree of respect here. I guess I knew that would happen coming here, but I think I pictured it more like all these people who still acknowledged specialists were smarter, but knew that internists were more important. But now I am wondering why I ever believed specialized knowledge made you smarter. The more I think about it, it's just a different kind of thinking: do you want to have to hear the story and put the pieces together, knowing you'll never - or rarely - have them all under control, or do you want to be called upon to perform a set of skills that you have, for all intensive purposes, mastered? I'm going to keep asking myself that question - but I lean towards the former right now.
~~~~~~~~~~~~~~~~~~~~~~~
"It seems important to find ways of reminding ourselves that most "familiarity" is meditated and delusive."
-David Foster Wallace
"Try to learn to let what is unfair teach you."
-David Foster Wallace (Infinite Jest: A Novel)
August 9, 2009
morality and markets
question: are there some things money can't - or shouldn't - be able to buy? or, in other words, are there some things that the market should not regulate?
an answer this time comes from the aspen ideas festival, a program put on by the aspen ideas institute where great minds from all over the world come to discuss the most meaningful questions in contemporary (american) life. one lecture by Michael Sandel, a professor of government who teaches a famous class called "Justice", discusses how markets should (or should not) be used to address questions with moral undertones including:
1. surrogacy: should there be any additional regulations? If a woman consents to carry the child of another couple, provided that the couple pays her a hefty amount of money, is this just the market working in everyone's favor? The woman gets a huge amount of money, which if she is a woman in India, where surrogacy for american parents is popular because it is less expensive, could be more than she could make in fifteen years. The couple gets the child they've always wanted.
*possible objections:
a) Is this sliding on a slippery slope towards creating virtual factories of uteri from desperate women - for whom the potential paycheck is so important that they will go through nine months of creating a life to which they will hold no claim?
b) How can we (and who is we?) be sure that these women are consenting, and are not being coerced in some way or another into this type of work? Especially in situations in which economic disparity is so great, questioning whether there is coercion is incredibly important.
2. paying children to read: in some school districts, children are being paid for every book they finish and/or for every test on which they score well. Dr. Sandel posits that although this might increase the amount of reading these children do in the short run, it teaches them to regard the reward from reading as monetary, and they may therefore be less likely to read if there is no direct monetary gain. One example he cites is a study conducted by economists in Israel on daycare centers. In a group of daycare centers, some parents were late to pick up their children. This was of course disruptive as a teacher had to stay late, the children were fussy, etc. So the economists decided in half of the daycare centers to implement a fine for picking one's child up late, expecting that this would provide added incentive for parents to be on time. However, the exact opposite occurred: more parents began picking their children up late. Dr. Sandel states that the late fine acted as a fee, replacing not supplementing the moral obligation parents felt to their children or the teachers to be on time.
this has huge implications on new ideas in circulation right now using markets to regulate systems that deal with moral situations. One example is cap and trade for emissions - if we allow people to pay for excess emissions, will it replace instead of supplement, the moral obligation to produce fewer emissions, with the end result of increasing emissions guilt-free?
There are also questions involving new health care regulations - if we allow people to elect not to pay for health insurance and simply pay a fine instead, will people then take advantage of emergency rooms and government funding (medicaid, etc) without feeling any moral obligation to contribute?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Every economic decision has a moral consequence."
-Pope Benedict XVI
an answer this time comes from the aspen ideas festival, a program put on by the aspen ideas institute where great minds from all over the world come to discuss the most meaningful questions in contemporary (american) life. one lecture by Michael Sandel, a professor of government who teaches a famous class called "Justice", discusses how markets should (or should not) be used to address questions with moral undertones including:
1. surrogacy: should there be any additional regulations? If a woman consents to carry the child of another couple, provided that the couple pays her a hefty amount of money, is this just the market working in everyone's favor? The woman gets a huge amount of money, which if she is a woman in India, where surrogacy for american parents is popular because it is less expensive, could be more than she could make in fifteen years. The couple gets the child they've always wanted.
*possible objections:
a) Is this sliding on a slippery slope towards creating virtual factories of uteri from desperate women - for whom the potential paycheck is so important that they will go through nine months of creating a life to which they will hold no claim?
b) How can we (and who is we?) be sure that these women are consenting, and are not being coerced in some way or another into this type of work? Especially in situations in which economic disparity is so great, questioning whether there is coercion is incredibly important.
2. paying children to read: in some school districts, children are being paid for every book they finish and/or for every test on which they score well. Dr. Sandel posits that although this might increase the amount of reading these children do in the short run, it teaches them to regard the reward from reading as monetary, and they may therefore be less likely to read if there is no direct monetary gain. One example he cites is a study conducted by economists in Israel on daycare centers. In a group of daycare centers, some parents were late to pick up their children. This was of course disruptive as a teacher had to stay late, the children were fussy, etc. So the economists decided in half of the daycare centers to implement a fine for picking one's child up late, expecting that this would provide added incentive for parents to be on time. However, the exact opposite occurred: more parents began picking their children up late. Dr. Sandel states that the late fine acted as a fee, replacing not supplementing the moral obligation parents felt to their children or the teachers to be on time.
this has huge implications on new ideas in circulation right now using markets to regulate systems that deal with moral situations. One example is cap and trade for emissions - if we allow people to pay for excess emissions, will it replace instead of supplement, the moral obligation to produce fewer emissions, with the end result of increasing emissions guilt-free?
There are also questions involving new health care regulations - if we allow people to elect not to pay for health insurance and simply pay a fine instead, will people then take advantage of emergency rooms and government funding (medicaid, etc) without feeling any moral obligation to contribute?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Every economic decision has a moral consequence."
-Pope Benedict XVI
August 7, 2009
how to cure sick hospitals
Question: How can we use the lessons from the private sector to improve care for everyone?
An answer from an article in the Wall Street Journal today says that it may be more straightforward than we think. Dr. Abraham Verghese, a physician and professor at Standford Medical School, reflects on a recent trip back to a public hospital in El Paso, Texas, now called University Medical Center,where he worked after medical school. Then, the hospital was backed by a falling tax base, had a huge population of people who were not necessarily legal immigrants (El Paso is right next to Mexico) and therefore did not qualify for any medicaid, and was largely unable to handle the myriad problems of its patient population. Now, after the arrival of a new CEO in 2004 (James Valenti) the hospital is thriving, the atmosphere is positive, and they've actually cut costs. Mr. Valenti says he did it by imposing a private model on the public hospital. He created a physician advisory panel, so the physicians feel more involved in decision-making, he has renegotiated contracts with insurance companies, and streamlined costs (e.g. instead of ten different knee prosthetics, the hospital offers one at a very reduced price). The Dean of Texas Tech Medical School, the medical school affiliated with the hospital, said of the changes Mr. Valenti has made, "care was not rationed so much as a rational approach made to giving care."
Dr. Verghese ends the article with a prescription for improving care given in hospitals without raising costs: "Just as much of the funding gap for Medicare could be plugged by cutting out waste and fraud, sick public hospitals —and so many of them are sick-- do not always need infusions of money to be fixed. Instead they need discipline, accountability, and progressive politicians and hospital boards whose actions are made very public and who are held accountable."
I like the sound of it.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I want to stand as close to the edge as I can without going over.
Out on the edge you see all kinds of things you can't see from the center."
-Kurt Vonnegut
An answer from an article in the Wall Street Journal today says that it may be more straightforward than we think. Dr. Abraham Verghese, a physician and professor at Standford Medical School, reflects on a recent trip back to a public hospital in El Paso, Texas, now called University Medical Center,where he worked after medical school. Then, the hospital was backed by a falling tax base, had a huge population of people who were not necessarily legal immigrants (El Paso is right next to Mexico) and therefore did not qualify for any medicaid, and was largely unable to handle the myriad problems of its patient population. Now, after the arrival of a new CEO in 2004 (James Valenti) the hospital is thriving, the atmosphere is positive, and they've actually cut costs. Mr. Valenti says he did it by imposing a private model on the public hospital. He created a physician advisory panel, so the physicians feel more involved in decision-making, he has renegotiated contracts with insurance companies, and streamlined costs (e.g. instead of ten different knee prosthetics, the hospital offers one at a very reduced price). The Dean of Texas Tech Medical School, the medical school affiliated with the hospital, said of the changes Mr. Valenti has made, "care was not rationed so much as a rational approach made to giving care."
Dr. Verghese ends the article with a prescription for improving care given in hospitals without raising costs: "Just as much of the funding gap for Medicare could be plugged by cutting out waste and fraud, sick public hospitals —and so many of them are sick-- do not always need infusions of money to be fixed. Instead they need discipline, accountability, and progressive politicians and hospital boards whose actions are made very public and who are held accountable."
I like the sound of it.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"I want to stand as close to the edge as I can without going over.
Out on the edge you see all kinds of things you can't see from the center."
-Kurt Vonnegut
August 6, 2009
the power of storytelling in medicine
My beach book this summer was The Hakawati (which means storyteller, in arabic) by Rabih Alameddine which is a story of the power of storytelling. Since I am also about to begin medical school, a friend suggested that before the summer is over, I also read How Doctors Think by Jerome Groopman, MD, a book about the power of listening to storytelling - in medicine. The two books are on such vastly different topics, but begin with the same instruction: Listen.
My question for this post is: what is the most powerful tool in all of medicine?
The answer, according to Dr. Groopman and others (Mr. Alameddine would probably agree) is the ability to fully listen. While this is not included in my personal essay about why I want to become and think I can become a truly effective physician - I think the fact that I love, and have always loved, to know people's stories, contributes to my fascination with medicine. In how many other professions do you get to know the intimate details of people's lives - their fears and hopes, their family structure, that they lay awake at night and can't fall asleep? I think maybe just writers and doctors - perhaps that's why there's so much overlap...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Ask an unscripted question" -Atul Gawande, MD in a speech to Harvard Medical School students telling them about his five rules of medicine (this is the first)
My question for this post is: what is the most powerful tool in all of medicine?
The answer, according to Dr. Groopman and others (Mr. Alameddine would probably agree) is the ability to fully listen. While this is not included in my personal essay about why I want to become and think I can become a truly effective physician - I think the fact that I love, and have always loved, to know people's stories, contributes to my fascination with medicine. In how many other professions do you get to know the intimate details of people's lives - their fears and hopes, their family structure, that they lay awake at night and can't fall asleep? I think maybe just writers and doctors - perhaps that's why there's so much overlap...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Ask an unscripted question" -Atul Gawande, MD in a speech to Harvard Medical School students telling them about his five rules of medicine (this is the first)
August 5, 2009
in a farmhouse down the road
Question: In what situations do you find yourself truly happy?
an answer: The best, yet perhaps least striking, moments in my life have been by and large sitting around a table with delicious food and enthralling conversation.
Last night, my new room mate and I went to dinner at an old farmhouse just outside of town, where a couple she knows is staying in exchange for doing construction on the house. We ate delicious salad and sandwiches - with ingredients straight from their luscious leafy garden!
Conversation topics included:
*puffin preservation; apparently because puffins are endangered because (stay with me on this) gulls are flourishing because of all the trash in the ocean, and these new, expanded populations of gulls take over tern environments on islands. Puffins and terns live together - and no one quite gets it, but apparently the puffins don't like to live without the terns, because when the terns leave (because the gulls are taking over their nests), the puffins leave. Check out http://www.projectpuffin.org/ for more info.
*the mindset of a surgeon (both an animal surgeon and a people surgeon)
*the different ways men and women perceive facial cues; apparently women - and even newborn baby girls - are WAY better at correctly identifying non-verbal cues and even mimic the facial expressions of someone in order to be more fully empathetic.
*how much more sense it makes to carry large, heavy things on your head than on your back.
I'm so excited to be here.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In pursuit of answers I traveled with people of differing dispositions."
-Barry Lopez in Arctic Dreams
an answer: The best, yet perhaps least striking, moments in my life have been by and large sitting around a table with delicious food and enthralling conversation.
Last night, my new room mate and I went to dinner at an old farmhouse just outside of town, where a couple she knows is staying in exchange for doing construction on the house. We ate delicious salad and sandwiches - with ingredients straight from their luscious leafy garden!
Conversation topics included:
*puffin preservation; apparently because puffins are endangered because (stay with me on this) gulls are flourishing because of all the trash in the ocean, and these new, expanded populations of gulls take over tern environments on islands. Puffins and terns live together - and no one quite gets it, but apparently the puffins don't like to live without the terns, because when the terns leave (because the gulls are taking over their nests), the puffins leave. Check out http://www.projectpuffin.org/ for more info.
*the mindset of a surgeon (both an animal surgeon and a people surgeon)
*the different ways men and women perceive facial cues; apparently women - and even newborn baby girls - are WAY better at correctly identifying non-verbal cues and even mimic the facial expressions of someone in order to be more fully empathetic.
*how much more sense it makes to carry large, heavy things on your head than on your back.
I'm so excited to be here.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In pursuit of answers I traveled with people of differing dispositions."
-Barry Lopez in Arctic Dreams
August 2, 2009
Keep your Government Hands off my Medicare (?!!?)
Question: Should the government be involved in health insurance?
Answer: It already is.
In the Sunday Times (of the NYT), Krugman describes an all too familiar situation of a man in a town hall meeting in South Carolina with a representative there who said "Keep your government hands off my medicare!" To which, the Representative, tried to explain that Medicare already is a government program (and thank goodness it is, because no insurance companies right now want to cover the care of all the older Americans who have the highest incidences of so many chronic illnesses).
Read the whole article on the NYT website.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"give yourself permission to begin from here"
-Oriah, the Invitation
Answer: It already is.
In the Sunday Times (of the NYT), Krugman describes an all too familiar situation of a man in a town hall meeting in South Carolina with a representative there who said "Keep your government hands off my medicare!" To which, the Representative, tried to explain that Medicare already is a government program (and thank goodness it is, because no insurance companies right now want to cover the care of all the older Americans who have the highest incidences of so many chronic illnesses).
Read the whole article on the NYT website.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"give yourself permission to begin from here"
-Oriah, the Invitation
July 30, 2009
Long Live the Flying Leap!
Question: How are we supposed to make something of ourselves in a world that seems incredibly un-inviting of new employees?
As an answer to this one, I give you an excerpt from the commencement speech at Wesleyan University this past May, by the always inspiring author, Anna Quindlen. She talks about how even though this may be the most intimidating world to try to make something of ourselves in, perhaps it is the first time in a while where we really get to redefine what "make something of yourself" really means - and that's a good thing. In her words:
We are supposed to apologize to you because it seems that that is no longer how things work, that you will not inherit the SUV, the McMansion, the corner office really ought to mean that you will not do better than we did. But I suggest that maybe this is a moment to consider what “doing better” means.
If you become the first generation of Americans who genuinely see race and ethnicity as attributes, not stereotypes, will you not have done better than we did?
If you become the first generation of Americans with the clear understanding that gay men and lesbians are entitled to be full citizens of this nation, will you not have done better than we did?
If you become the first generation of Americans who accord women full equality instead of grudging acceptance, will you not have done better than we did?
And on a more personal level, if you become the generation that ditches the 80 hour work week and returns to a sane investment in your professional lives, if you become the first generation in which young women no longer agonize over how to balance work and family and young men stop thinking they will balance work and family by getting married, won’t you have done better than we did?
Believe me when I say that we have made a grave error in thinking doing better is merely mathematical, a matter of the number at the bottom of your tax returns. At the end of their lives people assess them, not in terms of their income but in terms of their spirit, and I beg you to do the same from the beginning even if we who came before often failed to do so.
Frankly, I already think of your generation as better than my own as a group. You’re more tolerant, more creative, less hidebound and uptight. You’ve done more community service than any other generation in the history of this country. It is no accident that as all of you finally became old enough to vote we finally became brave enough to have an election process in which Americans were really engaged.
And all this despite the fact that you’ve been bombarded by a culture that sends you so many confusing messages. Let’s see, you’re supposed to live clean, to drink Bud, to be Zen, to work tirelessly, to have sex without guilt but seek enduring love. And maybe because of that you have had to figure out for yourself what matters in a way past generations, with their bright lines of behavior, did not. In the first full sentences she ever uttered, Maggie Simpson took the pacifier out of her mouth and spoke of herself in the voice of all of you, “She did not live to earn approval stickers. She lived for herself.”
You’re the children of the new technology and the new tolerance, of gigabytes and gay marriage, the first generation of Americans who assume the secretary of state will be female, and the huggiest group of people who have ever lived. You are totally qualified to be and create the next great new thing.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
To see the entire text visit the wesleyan website here.
"Long live the flying leap!"
-Anna Quindlen
As an answer to this one, I give you an excerpt from the commencement speech at Wesleyan University this past May, by the always inspiring author, Anna Quindlen. She talks about how even though this may be the most intimidating world to try to make something of ourselves in, perhaps it is the first time in a while where we really get to redefine what "make something of yourself" really means - and that's a good thing. In her words:
We are supposed to apologize to you because it seems that that is no longer how things work, that you will not inherit the SUV, the McMansion, the corner office really ought to mean that you will not do better than we did. But I suggest that maybe this is a moment to consider what “doing better” means.
If you become the first generation of Americans who genuinely see race and ethnicity as attributes, not stereotypes, will you not have done better than we did?
If you become the first generation of Americans with the clear understanding that gay men and lesbians are entitled to be full citizens of this nation, will you not have done better than we did?
If you become the first generation of Americans who accord women full equality instead of grudging acceptance, will you not have done better than we did?
And on a more personal level, if you become the generation that ditches the 80 hour work week and returns to a sane investment in your professional lives, if you become the first generation in which young women no longer agonize over how to balance work and family and young men stop thinking they will balance work and family by getting married, won’t you have done better than we did?
Believe me when I say that we have made a grave error in thinking doing better is merely mathematical, a matter of the number at the bottom of your tax returns. At the end of their lives people assess them, not in terms of their income but in terms of their spirit, and I beg you to do the same from the beginning even if we who came before often failed to do so.
Frankly, I already think of your generation as better than my own as a group. You’re more tolerant, more creative, less hidebound and uptight. You’ve done more community service than any other generation in the history of this country. It is no accident that as all of you finally became old enough to vote we finally became brave enough to have an election process in which Americans were really engaged.
And all this despite the fact that you’ve been bombarded by a culture that sends you so many confusing messages. Let’s see, you’re supposed to live clean, to drink Bud, to be Zen, to work tirelessly, to have sex without guilt but seek enduring love. And maybe because of that you have had to figure out for yourself what matters in a way past generations, with their bright lines of behavior, did not. In the first full sentences she ever uttered, Maggie Simpson took the pacifier out of her mouth and spoke of herself in the voice of all of you, “She did not live to earn approval stickers. She lived for herself.”
You’re the children of the new technology and the new tolerance, of gigabytes and gay marriage, the first generation of Americans who assume the secretary of state will be female, and the huggiest group of people who have ever lived. You are totally qualified to be and create the next great new thing.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
To see the entire text visit the wesleyan website here.
"Long live the flying leap!"
-Anna Quindlen
July 29, 2009
Health Care Reform: Changing Physician Incentives
Question: How do we incent health care providers (specifically physicians, because they are the ones in control of care) to provide the best care, not just the most expensive?
This answer comes from a few sources, as everyone seems to be talking about health care reform!
In a new article in the NewYorker, Hertzberg breaks down why we're having such a hard time with health care reform:
"Americans, polling shows, have long been as receptive as Europeans to the principle of universal health care. Six times since 1948, we have elected Presidents committed, at least on paper, to that principle."
He goes on to say that most everyone believes that health care should be a human right, not a commodity - meaning that because you are part of a society and pay taxes to a government, you should be entitled to health care. However, he also says that pretty much everyone believes that a drastic change (say, to a system funded entirely by taxes that treats everyone based on their health care needs, not how much they pay) is not feasible.
I agree with Obama's initial health care reform principles (see them on healthcarereform.gov) and think the basic idea is to (in a way that will not increase debt) cover everyone for the services and procedures that are necessary and feasible, make sure coverage stays with people no matter what their job is or where they move, and in the process, make health care better.
After creating a system where everyone is covered, the immense administration costs for all the people and paperwork to make sure everyone gets reimbursed can stop being the focus, and people who work in health care can focus on what they have be trained to do, as clinicians, scientists, and care givers: provide great care and continue to figure out ways to make it better.
The way reimbursement works right now does not reward or incent prevention of illness, lifestyle changes (instead of invasive measures), or helping patients navigate through a system that is hard to navigate even when you're not sick. One of the systemic changes that has been proposed is to pay physicians set salaries, potentially with extra bonuses for good patient results. This means that no matter how many procedures a physician orders or how many patients s/he sees, s/he takes home the same salary. In places like the Cleveland Clinic, the Mayo Clinic, and a smaller hospital called Basset where this has been implemented, costs have decreased considerably and the level of care remains some of the best in the country (though I'm not sure what the standards used for that are).
The complaints with this have mainly been along the lines of:
1) physicians wouldn't make as much money, and it takes away from the entrepreneurial side of the professions (says the AMA, some physicians).
2) the model is not replicable. Places like the Cleveland Clinic and the Mayo Clinic receive a lot of federal money for teaching their interns and residents, who perform a significant proportion of the work for a very minimal cost.
Lots to think about - more soon.
To hear more perspectives on the role of physician payment in health care reform, see the following links in the NYT blogs: (thank you NYT!)
*the Well Blog's take (the original article with more details about Cleveland Clinic, Bassett, and The Mayo Clinic deals)
*roomfordebate Blog (perspectives from many people in the field about how doctors are taught to order up more procedures, because they, not coordination of care or explaining things thoroughly so to prevent future hospital trips, are rewarded by our current system)
*economix Blog (discusses what would be the "just" pay for physicians, in economics terms)
~~~~~~~~~~~~~
“It is a model that has taken the pursuit of medicine from a profession — a calling — to a business,” -President Obama in a speech about health care reform
This answer comes from a few sources, as everyone seems to be talking about health care reform!
In a new article in the NewYorker, Hertzberg breaks down why we're having such a hard time with health care reform:
"Americans, polling shows, have long been as receptive as Europeans to the principle of universal health care. Six times since 1948, we have elected Presidents committed, at least on paper, to that principle."
He goes on to say that most everyone believes that health care should be a human right, not a commodity - meaning that because you are part of a society and pay taxes to a government, you should be entitled to health care. However, he also says that pretty much everyone believes that a drastic change (say, to a system funded entirely by taxes that treats everyone based on their health care needs, not how much they pay) is not feasible.
I agree with Obama's initial health care reform principles (see them on healthcarereform.gov) and think the basic idea is to (in a way that will not increase debt) cover everyone for the services and procedures that are necessary and feasible, make sure coverage stays with people no matter what their job is or where they move, and in the process, make health care better.
After creating a system where everyone is covered, the immense administration costs for all the people and paperwork to make sure everyone gets reimbursed can stop being the focus, and people who work in health care can focus on what they have be trained to do, as clinicians, scientists, and care givers: provide great care and continue to figure out ways to make it better.
The way reimbursement works right now does not reward or incent prevention of illness, lifestyle changes (instead of invasive measures), or helping patients navigate through a system that is hard to navigate even when you're not sick. One of the systemic changes that has been proposed is to pay physicians set salaries, potentially with extra bonuses for good patient results. This means that no matter how many procedures a physician orders or how many patients s/he sees, s/he takes home the same salary. In places like the Cleveland Clinic, the Mayo Clinic, and a smaller hospital called Basset where this has been implemented, costs have decreased considerably and the level of care remains some of the best in the country (though I'm not sure what the standards used for that are).
The complaints with this have mainly been along the lines of:
1) physicians wouldn't make as much money, and it takes away from the entrepreneurial side of the professions (says the AMA, some physicians).
2) the model is not replicable. Places like the Cleveland Clinic and the Mayo Clinic receive a lot of federal money for teaching their interns and residents, who perform a significant proportion of the work for a very minimal cost.
Lots to think about - more soon.
To hear more perspectives on the role of physician payment in health care reform, see the following links in the NYT blogs: (thank you NYT!)
*the Well Blog's take (the original article with more details about Cleveland Clinic, Bassett, and The Mayo Clinic deals)
*roomfordebate Blog (perspectives from many people in the field about how doctors are taught to order up more procedures, because they, not coordination of care or explaining things thoroughly so to prevent future hospital trips, are rewarded by our current system)
*economix Blog (discusses what would be the "just" pay for physicians, in economics terms)
~~~~~~~~~~~~~
“It is a model that has taken the pursuit of medicine from a profession — a calling — to a business,” -President Obama in a speech about health care reform
July 27, 2009
Recipe for Ethiopian Fosolia/Lebanese Loubeih Bi' Zeit
Question: What is that delicious ethiopian food I just ate tonight and how can I make it myself at home?
This answer comes from a brilliant recipe I found on another blog about vegan cooking for a cross between ethiopian fosolia and lebanese loubieh bi'zeit:
ingredients:
5 cups stringbeans, cut in half and ends removed
2 normal-large onions, diced
2 cloves garlic, diced
half a bag of baby carrots
16-oz can stewed tomatoes, crushed (squish in your fists)
olive oil
1 cup white wine sweetened with agave (to approximate tej, ethiopian honey wine - don't use anything too dry)
1-2 tsp salt
berbere to taste (2 tbsp or 3tbsp if you like it really hot)
cook your garlic and onions in oil over medium heat until the onions are translucent; then add your stringbeans. get them coated in oil and saute until they turn bright green, and add the rest of your ingredients (start out with a teaspoon of berbere, add more as you go). bring the mixture up to a boil, and basically, let it stew and reduce. if you boil off the liquid before the carrots and string beans are nice and soft, add extra wine or water; if it starts to burn, add a little more oil. it takes a LONG time to cook down, but requires pretty much no monitoring, so this is a good one to put on the stove right when you get home, and then read a book/play with your dog/do your dishes/drink the rest of that tej.
the mixture is done when the liquid is pretty much gone, the onions and tomatoes are undetectable in a sort of red sauce, the green beans are soft and way way smaller than they were, and the carrots can be cut with a spoon. it looks like nothing on earth, but tastes SO good, with a hint of caramel from the tomatoes, carrots, and agave. i recommend eating it with crusty bread.
This answer comes from a brilliant recipe I found on another blog about vegan cooking for a cross between ethiopian fosolia and lebanese loubieh bi'zeit:
ingredients:
5 cups stringbeans, cut in half and ends removed
2 normal-large onions, diced
2 cloves garlic, diced
half a bag of baby carrots
16-oz can stewed tomatoes, crushed (squish in your fists)
olive oil
1 cup white wine sweetened with agave (to approximate tej, ethiopian honey wine - don't use anything too dry)
1-2 tsp salt
berbere to taste (2 tbsp or 3tbsp if you like it really hot)
cook your garlic and onions in oil over medium heat until the onions are translucent; then add your stringbeans. get them coated in oil and saute until they turn bright green, and add the rest of your ingredients (start out with a teaspoon of berbere, add more as you go). bring the mixture up to a boil, and basically, let it stew and reduce. if you boil off the liquid before the carrots and string beans are nice and soft, add extra wine or water; if it starts to burn, add a little more oil. it takes a LONG time to cook down, but requires pretty much no monitoring, so this is a good one to put on the stove right when you get home, and then read a book/play with your dog/do your dishes/drink the rest of that tej.
the mixture is done when the liquid is pretty much gone, the onions and tomatoes are undetectable in a sort of red sauce, the green beans are soft and way way smaller than they were, and the carrots can be cut with a spoon. it looks like nothing on earth, but tastes SO good, with a hint of caramel from the tomatoes, carrots, and agave. i recommend eating it with crusty bread.
July 21, 2009
the price for a year of life
I think that extending a life by one year is worth $________.
This is the question Peter Singer, professor of bioethics well known for his utilitarian views, wants us to add to the debate on health care reform. In a recent op-ed in the New York Times he argues that we should not shy away from incorporating a structured rationing of health care because we ALREADY ration health care - just not in a good way. He argues that our current form of rationalization is based on who (or whose employer) can afford to pay for insurance (or for good insurance) whereas the type of rationing he would like to see is in the form of deciding what treatments and procedures are or aren't worth the cost (and therefore should or should not be covered by insurance plans). While I am certainly not a strict utilitarian (I'm not sure there are any physicians or people studying to be physicians who really can be, but I'll save that argument for another post) and often do not agree with the extent to which Singer applies this philosophy, in this case I think he is absolutely right.
The current debate about health care reform, and really, any debate about health care reform, has to include 3 phases: 1) figure out how to get everyone covered and what that coverage will mean, 2) figure out how to pay for it, and 3) make it better.
The ideas circulating around congress assume the first part (that everyone should be covered) without changing too much from the current system in terms of how), which is what Singer questions in his op-ed; not that we should not cover everyone but to the extent to which we all need to be covered. Congress is mostly focusing on the 2nd part: of how to pay for a system that will include an additional 50 million people, many of whom were not insured because they were considered too ill to be insurable by companies providing insurance. This is critical because without figuring out how to pay for it, no plan can go into effect.
While the first two parts are fascinating and I will be writing more about perspectives in both - I'm most interested in the third part: how to make it better, because I think it could make both the first and second parts easier. Implementing a system that effectively creates positive changes in people's health will alter A) how we cover people and B) how much it costs us to do it. It affects the first because if you make health care more effective, there will be fewer people in the high risk category whose care the rest of us will have to supplement in our premiums. Better practices affects how much it costs because often the most effective medical procedures (e.g. regular check-ups and screenings, early treatment, asking questions, active listening) are the least costly.
An excellent example is the cost effectiveness of mamography, or breast cancer screening. In an article publishes in the Journal of the National Cancer Institute in 2006...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
“The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
-President Barack Obama
This is the question Peter Singer, professor of bioethics well known for his utilitarian views, wants us to add to the debate on health care reform. In a recent op-ed in the New York Times he argues that we should not shy away from incorporating a structured rationing of health care because we ALREADY ration health care - just not in a good way. He argues that our current form of rationalization is based on who (or whose employer) can afford to pay for insurance (or for good insurance) whereas the type of rationing he would like to see is in the form of deciding what treatments and procedures are or aren't worth the cost (and therefore should or should not be covered by insurance plans). While I am certainly not a strict utilitarian (I'm not sure there are any physicians or people studying to be physicians who really can be, but I'll save that argument for another post) and often do not agree with the extent to which Singer applies this philosophy, in this case I think he is absolutely right.
The current debate about health care reform, and really, any debate about health care reform, has to include 3 phases: 1) figure out how to get everyone covered and what that coverage will mean, 2) figure out how to pay for it, and 3) make it better.
The ideas circulating around congress assume the first part (that everyone should be covered) without changing too much from the current system in terms of how), which is what Singer questions in his op-ed; not that we should not cover everyone but to the extent to which we all need to be covered. Congress is mostly focusing on the 2nd part: of how to pay for a system that will include an additional 50 million people, many of whom were not insured because they were considered too ill to be insurable by companies providing insurance. This is critical because without figuring out how to pay for it, no plan can go into effect.
While the first two parts are fascinating and I will be writing more about perspectives in both - I'm most interested in the third part: how to make it better, because I think it could make both the first and second parts easier. Implementing a system that effectively creates positive changes in people's health will alter A) how we cover people and B) how much it costs us to do it. It affects the first because if you make health care more effective, there will be fewer people in the high risk category whose care the rest of us will have to supplement in our premiums. Better practices affects how much it costs because often the most effective medical procedures (e.g. regular check-ups and screenings, early treatment, asking questions, active listening) are the least costly.
An excellent example is the cost effectiveness of mamography, or breast cancer screening. In an article publishes in the Journal of the National Cancer Institute in 2006...
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“The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
-President Barack Obama
July 20, 2009
metrosexual package
Question: What is the best description of a public figure you have heard or read lately?
this brilliant answer was sent from a friend: (I love it)
From Mark Leibovich's Times Magazine article on the gubernatorial race in California, a fantastic quote about Gavin Newsom:
"There is indeed about Newsom something of that quintessential California type, the overgrown and hyperactive child. Immensely gifted but flawed, he is a jumble of self-regard, self-confidence and self-immolation — potential greatness and a potential train wreck in the same metrosexual package."
http://www.nytimes.com/2009/07/05/magazine/05California-t.html
this brilliant answer was sent from a friend: (I love it)
From Mark Leibovich's Times Magazine article on the gubernatorial race in California, a fantastic quote about Gavin Newsom:
"There is indeed about Newsom something of that quintessential California type, the overgrown and hyperactive child. Immensely gifted but flawed, he is a jumble of self-regard, self-confidence and self-immolation — potential greatness and a potential train wreck in the same metrosexual package."
http://www.nytimes.com/2009/
May 20, 2009
Loosening the moorings of the soul
Question: How do we adjust our lives in a world that requires us to be in so many more places?
Answer inspired by a novel by Salman Rushdie, called the Enchantress of Florence:
"In a small wooden box concealed behind a sliding panel...[he] kept a collection of beloved 'objects of virtue', beautiful little pieces without which a man who traveled constantly might lose his bearings, for too much travel....too much strangeness and novelty, could loosen the moorings of the soul"
-Salman Rushdie, The Enchantress of Florence
The quote made me think of how any travel, especially international travel, wears on your soul after a while. Perhaps you need more "objects of virtue" to remind you of everything that keeps you grounded. I just started this book (The Enchantress of Florence) last night and am already disliking Rushdie and loving his writing; it's strange to try to separate the two. I wonder how often we do this with people: separate the acts from the person or the intentions from the acts - and where that takes the discussion of right and wrong/good and bad.
As the people I love travel everywhere from Seoul and Panama to the Arizona desert and the inner city of Baltimore, I think of how "objects of virtue" have been sacred since the beginning of time - reminders of people and places we have been (and might return). And perhaps this "loosening of the moorings", as Rushdie so beautifully puts it, can be a good thing if the end result is that it creates space for new thoughts to pour in.
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"The king was not content with being. He was striving to become"
-Salman Rushdie, The Enchantress of Florence
Answer inspired by a novel by Salman Rushdie, called the Enchantress of Florence:
"In a small wooden box concealed behind a sliding panel...[he] kept a collection of beloved 'objects of virtue', beautiful little pieces without which a man who traveled constantly might lose his bearings, for too much travel....too much strangeness and novelty, could loosen the moorings of the soul"
-Salman Rushdie, The Enchantress of Florence
The quote made me think of how any travel, especially international travel, wears on your soul after a while. Perhaps you need more "objects of virtue" to remind you of everything that keeps you grounded. I just started this book (The Enchantress of Florence) last night and am already disliking Rushdie and loving his writing; it's strange to try to separate the two. I wonder how often we do this with people: separate the acts from the person or the intentions from the acts - and where that takes the discussion of right and wrong/good and bad.
As the people I love travel everywhere from Seoul and Panama to the Arizona desert and the inner city of Baltimore, I think of how "objects of virtue" have been sacred since the beginning of time - reminders of people and places we have been (and might return). And perhaps this "loosening of the moorings", as Rushdie so beautifully puts it, can be a good thing if the end result is that it creates space for new thoughts to pour in.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"The king was not content with being. He was striving to become"
-Salman Rushdie, The Enchantress of Florence
April 30, 2009
Nourishment
It is we who nourish the soul of the world and the world we live in will either be better or worse depending whether we become better or worse.
-Paulo Coelho, The Alchemist
-Paulo Coelho, The Alchemist
a wonderful, gracious moving target
A solid request for a reprise along with some hope that I'll soon have a few more perspectives as my life moves in one big shift, I restart the blogging with a post for which I should really credit my mother.
Question: How does one most accurately predict the choices that will make one happy?
The answer is complicated:
My generation is apparently the least stable generation yet - not only because of the recent dip in the economy but because the relative ease of the economy we grew up in. It has meant that we can live more places (more apartments, more roommates), have more jobs (more work styles, more coworkers), try more things (yogalates, marathon-ing), and meet more people than ever before.
But what it also means is that there's a huge market for coping with transitions. People are very unprepared and anxious about change and it's hardwired into us to be worried about the future; scientists say that it's the distinguishing characteristic of humans versus everything else, this focus on the future. And we are terrible at predicting it - not only what will happen, but more importantly, how we'll feel about it, what we'll do about it, how capable we will be of handling it, and how much it will alter the course of our life. A good friend gave me Dan Gilbert's book, Stumbling on Happiness a few months ago to give me a new perspective to cope with an upcoming transition and I have to say this: I didn't finish it.
This was not because it wasn't a wonderfully informative, quirky, at times downright entertaining book (it totally was), but because his message that we will never ever be able to predict what makes us happy very well eventually starts to seem so obvious that it made me want to try to rework my thinking in order to disprove it.
What I came up with is that perhaps the more productive question is: How does one stop trying to predict what will make one happy?
Step 1: lose the idea that you are in control. apparently we put waaaayyy too much emphasis on control as the key to happiness, especially when there is just so much we honestly have very little control over.
Step 2: listen to my mother. Or for those of you who do not have the great pleasure of talking to her almost daily as I do, read on. She works with children with disabilities and their families as they make all sorts of difficult transitions from different parts of development to different school settings. These kind of transitions require a whole team of support - or maybe that's true of all transitions. Some of her uber-sage advice includes keeping some sort of continuity with the stuff that makes you happy (exercise routines, eating styles, reading bad magazines in the grocery line), clarity (about why you're going through this transition at all), and community (keep your support networks fired and ready to go).
Step 3: know that you have no idea. I talked with a coworker today who advised me that we always over account for factors that end up not mattering at all, and we completely forget how huge the mysterious unknowns end up being in the grand scheme of our future. This is somewhat Dan Gilbert's premise (though neither my coworker or Dan Gilbert explain how to actually do this) and emphasizes the stumbling part.
I have three roommates right now, two of whom are gorgeous, 6 feet plus, athletic, brilliant, very very gay men. When we take the subway together, we play a game we call "is my future husband on this train?" - the idea behind which is a) it's so much fun to blatantly check people out on the train alongside two much more obvious men and b) you never know when or where or how your life will intersect with people, places, ideas that stir your soul and excite your mind and send you soaring in an entirely new direction.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Our desire to control is so powerful, and the feeling of being in control so rewarding, that people often act as though they can control the uncontrollable..."
-Dan Gilbert, Stumbling Upon Happiness.
Question: How does one most accurately predict the choices that will make one happy?
The answer is complicated:
My generation is apparently the least stable generation yet - not only because of the recent dip in the economy but because the relative ease of the economy we grew up in. It has meant that we can live more places (more apartments, more roommates), have more jobs (more work styles, more coworkers), try more things (yogalates, marathon-ing), and meet more people than ever before.
But what it also means is that there's a huge market for coping with transitions. People are very unprepared and anxious about change and it's hardwired into us to be worried about the future; scientists say that it's the distinguishing characteristic of humans versus everything else, this focus on the future. And we are terrible at predicting it - not only what will happen, but more importantly, how we'll feel about it, what we'll do about it, how capable we will be of handling it, and how much it will alter the course of our life. A good friend gave me Dan Gilbert's book, Stumbling on Happiness a few months ago to give me a new perspective to cope with an upcoming transition and I have to say this: I didn't finish it.
This was not because it wasn't a wonderfully informative, quirky, at times downright entertaining book (it totally was), but because his message that we will never ever be able to predict what makes us happy very well eventually starts to seem so obvious that it made me want to try to rework my thinking in order to disprove it.
What I came up with is that perhaps the more productive question is: How does one stop trying to predict what will make one happy?
Step 1: lose the idea that you are in control. apparently we put waaaayyy too much emphasis on control as the key to happiness, especially when there is just so much we honestly have very little control over.
Step 2: listen to my mother. Or for those of you who do not have the great pleasure of talking to her almost daily as I do, read on. She works with children with disabilities and their families as they make all sorts of difficult transitions from different parts of development to different school settings. These kind of transitions require a whole team of support - or maybe that's true of all transitions. Some of her uber-sage advice includes keeping some sort of continuity with the stuff that makes you happy (exercise routines, eating styles, reading bad magazines in the grocery line), clarity (about why you're going through this transition at all), and community (keep your support networks fired and ready to go).
Step 3: know that you have no idea. I talked with a coworker today who advised me that we always over account for factors that end up not mattering at all, and we completely forget how huge the mysterious unknowns end up being in the grand scheme of our future. This is somewhat Dan Gilbert's premise (though neither my coworker or Dan Gilbert explain how to actually do this) and emphasizes the stumbling part.
I have three roommates right now, two of whom are gorgeous, 6 feet plus, athletic, brilliant, very very gay men. When we take the subway together, we play a game we call "is my future husband on this train?" - the idea behind which is a) it's so much fun to blatantly check people out on the train alongside two much more obvious men and b) you never know when or where or how your life will intersect with people, places, ideas that stir your soul and excite your mind and send you soaring in an entirely new direction.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"Our desire to control is so powerful, and the feeling of being in control so rewarding, that people often act as though they can control the uncontrollable..."
-Dan Gilbert, Stumbling Upon Happiness.
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