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)
August 26, 2009
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
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