Physician Assisted Suicide

Last weekend's New York Times Magazine ran a story on former Washington governor Booth Gardner, who has Parkinson Disease, and his campaign to legalize physician assisted suicide (PAS) in Washington.

What piqued my interest about the article was that it discussed opposition to PAS that has come from progressive academics rather than the evangelical Christian community. One argument is that legalization of suicide will result in disproportionate number of deaths among women, minorities, disabled, and uninsured individuals who are more likely to see themselves as a burden to family and society than white men are. PAS in essence could be discrimminatory. Moreover, this is complicated by the fact that most doctors are white men and may be more likely to see suffering individuals as a burden and - directly or not - influence a woman's decision to end her life by merely initiating a discussion about suicide. Interestingly, 75% of Kevorkian's PAS patients were women, and more often middle-aged than elderly and frequently with non-terminal, but very disabling conditions such as multiple sclerosis. In Oregon, the only state to have legalized PAS (now over 10 years!) however, the data does not reflect a gender disparity. Nor in the Netherlands apparently, the country with the most progressive laws regarding end of life termination. But not all states have the same demographics and disease burden of Oregon and are unlikely to have the same PAS laws if passed in the future. Nevertheless some points are worth bearing in mind.

In Oregon at least PAS does not empower people to take their own lives - those that have used the law are already capable of doing that on their own. The dying patient must be capable of taking the lethal dose of medication on their own - the physician cannot actively participate. My guess is that these people are also capable of sitting in a closed garge with their cars running. It is very hard for me to see how providing people who already have the ability to end their lives a means to do so with dignity, peace, and social acceptance, will somehow promote a rash of suicides. Gardner's proposal is different. He want PAS to extend not only to terminally ill individuals but to those, like himself, with non-terminal diseases. Alzheimer's would play prominently in this debate as we see more and more baby boomers reach their 70s and 80s.

First, the conventional image of the white male doctor is rapidly becoming obsolete: over 50% of medical school graduates are now female, and there is no indication that this trend will do anything but increase. Moreover, when considering the younger physician workforce, women predominate in primary care, and it is primary care docs who will most likely be providing PAS. Second, the fact that there may be gender/racial disparities in how a law or a medical practice is carried out doesn't necessarily render that law or practice immoral. Unfortunately blacks have a higher rate of amputations (when other medical and socio-economic factors are controlled) than whites, but that doesn't mean we should stop doing amputations...

Getting to the bottom of an exotic disease

Patient A is a 62 year-old woman who is a carrier for Fragile X syndrome (she has had 3/5 Fragile X sons) who is otherwise healthy except middle ear disease with hearing loss and vestibular dysfunction, a mild tremor in her hands and pain with decreased sensation and in her feet. She comes into neurology clinic because she is worried that she may have a very rare manifestation of carrying the Fragile X mutation that presents as ataxia and tremor. She is armed with literature printed out from the internet from a Fragile X website and was told by a friend or hers who works in health care that she should have some tests run to determine if her neurological symptoms are due to the X. Her physical exam confirms the tremor, mild sensory loss in her feet, and balance problems with walking but is not ataxic.

She has been seen by half a dozen doctors, none of whom have given her a diagnosis. She has been taking medications to help with the pain in her legs - this is called neuropathic pain because it is pain generated by damage to the nerve itself, unlike normal pain that is due to damage from tissue. Neuropathic pain is notoriously difficult to treat and she has tried all the medications at some point, but only with moderate relief. However, this is not really why she has come to the clinic. She has come because she wants an answer to her neurological symptoms - the balance problems, the tremor, and the neuropathology in her feet. She is typical of many patients who have unclear or unknown causes of their ailments. Unfortunately, there is nothing that modern medicine will be able to do for her - I know this right away. A patient bouncing from doctor to doctor in search of diagnosis is a familiar pattern and it almost always means that the disease is idiopathic and there is no cure, and only treatment of symptoms at best.

My preceptor tells her that he wants to check her for diabetes, hypothyrodism, and some nutritional deficiencies. She expresses some dissatisfaction with this approach because she states she has had these tests done in the past; she is convinced she is not diabetic. We explain to her that it is best to rule out reversible and common causes of neuropathy before running down the path of an uncommon, exotic disease that will be expense to diagnose. Even her balance problems are much more likely explained by her ear disease than the Fragile X. But she possessed by the idea of having Fragile X carrier ataxia-tremor although it is rare (even in carriers). Finally my preceptor gives in and orders the $2000 MRI that would make the diagnosis. This frustrates me not only because it is a senseless waste of health care resources, but because it feeds patient A's fantasy about her disease. This was a wasted chance to inform her about the logic of medical decision making. The key point that my preceptor did not convey was that even if she did have the Fragile X syndrome it would not change anything - there is no treatment one way or another. Sure, it is nice to know if you got a disease or not, but in this case if that knowledge does not affect prognosis or treatment, then the expense of reaching the exotic diagnosis should fall on the patient (not their insurer).

A side note - yesterday I complained about specialists being expensive. This is another case in point. A good (primary care) doctor would have eliminate several possible diagnoses from a good history and physical exam, then ordering studies (imaging, lab tests, etc.) to confirm or rule out the top 1-3 diagnoses. My preceptor, a neurologist, took a shotgun approach by ordering a a battery of tests to rule out all the competing diagnoses, including many obscure, rare causes of neuropathy. I think this is pretty typical of how specialists work, and it makes sense on occasion, say when the patient has already been worked up for common causes with simple, inexpensive tests. Still a question I am always asking is why order this study if it is not going to change what we do?

Medical specialist use and over-use

I've been grumbling a lot lately about the over specialization of medicine in this country. There is good evidence that liberal use of specialists does not improve health outcomes, but most certainly increasing costs by comparisons between communities that use specialists heavily and those that rely more on primary care. Obviously, the key issue in the efficient use of specialists is determining when to make a referral. Neurologists don't need to see run of the mill headaches. Gastroenterologists don't need to see every patient with hemorrhoids. In general, a patient should be referred to a specialist when the diagnosis is difficult or uncertain, or if the patient has a set of medical conditions that make treatment particularly complicated.

Yesterday in neurology clinic I saw an 84 year-old man with rheumatoid arthritis, a hiatal hernia (stomach punching through the diaphram), and depression who comes in for an evaluation of his Parkinson's disease symptoms (mostly tremor) at the request of his community neurologist. The patient had a tremor that had worsened over the past 6 months despite medications, so the community neurologist referred him to OHSU for a general neurological evaluation and an evaluation for possible deep brain stimulation. This story is really representative of what I am talking about with fragmented, expensive care that is overly dependent on specialists. After speaking with the patient it was clear that the community neurologist had not increased his dose of anti-Parkinson medicine enough, which is the obvious first step when Parkinson patients begin to progress. Additionally, the patient was on a medicine for the hiatal hernia (this was a past, not a currently active, medical issue) that has a well-know side affect of Parkinson-like symptoms. Nevertheless the OHSU neurologist and neurosurgeon discussed the possibility of deep brain stimulation, which seemed to me utterly inappropriate given that medical therapy had not been remotely optimized and that the patient was on a medication that was likely creating the worsening symptoms. The patient's wife stated during the visit that she was frustrated with all the doctors her husband has seen because none of them really seemed to talk to each other. In short, his problem was not a medical one, but a medical management one. The primary care doctor should have been closely involved with the management of the disease and referral to OHSU. In the doctors at OHSU did not think the patient was a candidate for deep brain stimulation at this point until medical management was improved - thankfully! Nevertheless this illustrates that saying "when you're a hammer everything looks like a nail" - and coming off of family medicine rotation this certainly did not look like a nail.

The medical community - us doctors - are largely responsible for this. We privilege specialists by paying them more and treating their work as more valuable than that done by the generalist (family doctors, pediatricians, and primary care internists). This encourages students and residents to choose specialties, creating a politico-medical brain drain in the generalist community, which widens the economic disparity and promotes over-use of specialist care since there are more providers. Generalists are also to blame for this when they turn medically difficult patients over to a specialists because they are not willing to manage them on their own or at least with a simple consult. This annoys me, especially whey I hear generalists complain that their specialists colleagues are making 2-3x more money.

What to do about costly health care?

In today's NY Times there was a good summary of the high cost of health care. Briefly -

Why is it so damn expensive?
The high cost of health care is not reducible to a single problem; it is multi-factorial. Malpractice, expensive brand-name medicines, and over-paid hospitals are contributing factors but probably not the real drivers, which are

• Over-dependence on specialists (Bend, Oregon, I hear has 7 MRI scanners!)
• Complex third-payer system (private insurers) which adds bureaucratic and inefficiencies, not mention a profit-seeking middle man
  
• Costly chronic diseases like obesity and diabetes that have become epidemic
• A large pool of uninsured individuals who use costly visits to the emergency room in lieu of less expensive office visit
• Medical errors that result in prolonged hospital stays
• Poor adherence to evidence-based medicine that leads to costly medical interventions with unproven outcomes

What can we do?
Given the complexity of the cause, there will not be a simple silver bullet, and the problem will not be solved during the next few presidencies. Nonetheless, it is exciting (and sad), that things have become so unsustainable that many people are talking about the issue of health care reform. What I think needs to happen is this -

• Promote primary care and decrease our dependence on specialists (many studies have shown that health communities which depend more on primary care doctors cost less and have equal health outcomes as communities with high use of specialists)
• Find some way to get everyone insured, whether that be through a socialized system that is used throughout most of the developed world, or through a mandate as in Massachusetts
• Incentivize doctors to follow evidence-based guidelines (doctors need to take an active leading role in establishing quality metrics)
  
• Fund more research looking into the cost-benefit ratios of medical interventions, then incorporate these into the above guidelines
• Tort reform that provides some protection to doctors from frivolous lawsuits

Disease mongering

I recently ran across an interesting series of essays in the Public Library of Science (PLoS) from April 2006 on a phenomenon called "disease mongering":

"aspects of ordinary life, such as menopause, being medicalized; mild problems portrayed as serious illnesses, as has occurred in the drug-company-sponsored promotion of irritable bowel syndrome and risk factors, such as high cholesterol and osteoporosis, being framed as diseases."

But hold on, is this anything new? The distinction between bona fide diseases and mere medical complaints has probably always been blurry. Every culture I'm aware of, has the equivalent of the guy on the corner selling snake oil to cure your impotence or whatever. In traditional medical cultures based around shamanism there is by no means the clear and distinct separation of disease and suffering. Plus, people suffering seek relief and don't care if we in the medical community consider it to be from a real medical condition or not.

Sure menopause may be a natural event in the life of an aging woman, but it really can suck. Is there anything wrong with easing the symptoms of menopause in women who have a particularly hard time at it? Some say we have become a culture of whiners; but then why suffer needlessly? It may be true that suffering makes us stronger and more compassionate. It may be true that suffering brings us closer to god and the afterlife. Nevertheless, not many people refuse to have their suffering alleviated because they think suffering is a good thing for themselves!

There are two issues, however, that should concern the medical community regarding this "corporate-sponsored creation of disease" (I ripped off this phrase because I like it). Since we are treating more and more simple ailments (mostly of aging) as diseases that means we are using more pills, interventions, procedures and tests.

1. All this stuff carries new risks and complications to our health
2. This stuff is expensive and may divert resources away from more disabling diseases, indigent populations, and children

National Health Care - my take

I just finished my rotation in family medicine in a small community outside Portland where I had some interesting discussions about health care reform. The big issue that sets doctors one side of the political fence is national health care. Historically the medical community in the US has been strongly opposed to it, priding itself on freedom and innovation that comes with a more free-market approach. Of course, we do have government-run health care in the US (medicare, medicaid, the VA, and health plans for government employees), but we refuse to extend membership into these systems to the public at large. Obviously many political and economic interests are at stake in keeping the system largely private for the majority of citizens.

My own personal opinion on the matter is that national health care (single-payer system) is the way to go, although I do not profess to really understand all the complicated aspects of health care and policy relevant to the issue. I also recognize that the free-market approach has some obvious advantages, the most admired probably is technological innovation. Nevertheless this is my reasoning, briefly.

1. Health care is not a product like cars or computers and so we cannot expect the free-market to provide the most efficient, high-quality, and cost-effective system the way it does for consumer goods. There are many ways in which health care is really not a regular consumer good. Here's one example: we understand that the profit motive is key to delivering excellent products, and so we are more than willing to accept that some people are going to get very, very rich if they make a really good product. Yet the public has mixed feelings when the same logic is applied to doctors and biotech. Frankly, we find it repellent that somebody is getting rich off of people suffering. Another example of the difference is that in a free-market the consumer drives product development (demand). This principle applied to health care would mean that more and more of our resources will be targeted to the aging baby boomers - those with money. Such as system, however, will divert resources from children, which is a far more rational investment of health care resources from a public health stand point.
2. Fortunately we live in a world with several wealthy, developed countries, each with their own type of health care system. The vast majority are socialized systems - our fee-for-service, free market approach is actually the exception. We should embrace American ingenuity by all means, but a thinking person who has done a little reading cannot but come to the conclusion that socialized systems are better in terms of overall health markers (longevity, infant mortality, etc.) and resource use per capita than ours is. We spend more than twice that of the next developed country (Switzerland) per person on health care and still leave 20% of the population without practical access to a doctor. Indeed, the US system is excellent at providing top-tier, high-tech medicine to patients who can afford it. But comparatively speaking it performs poorly from a public health stand point. This may be a logical consequence of privatized medicine, or it may be an unfortunate perversion of the free market. Regardless, the statistics speak for themselves.

Being a patient in the US is like being a diner in a city that only has high-end restaurants. Of course you are going to get great food, but it will break your budget, and a lot of people won't be able to eat out at all, ever. The analogy of a socialized medicine would be a city with no high-end restaurants but a lot of low- and mid-range options that guarantees everyone will be able to afford some place to eat out, but at the cost of having no gourmet options.

American doctors and patients like to berate the Canadian (or other socialized) system because of things like the amount of time it takes to get a procedure done, or the fact that you might have to travel to a large city to get a brain MRI scan. "If our system is so bad, why does everyone come here for their surgery?" I have heard over and over. Sure, if you have money, why not come to the US and get a great operation when you want? A large obstacle to radical health care reform - going to a single-payer system - is our attitude that health care is like a car when it should be thought of as something like national security. We don't let private interests fight our wars because we believe that national security is an interest of the public collective not of individuals - and health care should be the same.

"I'm a firm believer that when you're dead, naming a street after you doesn't help your metabolism."

"I'd like to make a great film provided it doesn't conflict with my dinner reservations"

Woody Allen

Bloomberg.com: Health Care

Bloomberg.com: Health Care

Just mention "physician ranking" and I get shivers down my spine. That may sound reactionary in this era of transparency and metrics, but seeing how medicine works on the inside, I can only say that evaluating the quality of a doctor is no facile task - and it is certainly more complex that any insurance company will admit. Image having a lawyer ranking system. The bottom line is: who's doing the ranking and what model are they using?

Costs in deer case: $40,000 -- so far - OregonLive.com

Costs in deer case: $40,000 -- so far - OregonLive.com

Keeping domestic deer is illegal in Oregon. A couple's country property was recently raided by police and 2 deer that were injured and nursed back to health were seized. By all accounts the deer were happy and loved. Now an ensuing legal battle over the deer. The public finds the government's action absurd. Now the costs are starting to come in.

Why is this problem, which is not a problem, a problem for us? We have chosen to live under a legal system in which more and more of our lives are scrutinized under law. Can anyone do anything anymore without at least a remote possibility of being sued? The merits to that system are obvious, but it comes at the price of common-sense.

Measure money tops $22.5 million - Oregon and National Politics news from The Oregonian - OregonLive.com

Measure money tops $22.5 million - Oregon and National Politics news from The Oregonian - OregonLive.com

Many supporters of this Ballot Measure 50 even knew it was a crappy piece of legislation. This is what happens when we have a government that can't do right by the public interest: we in Oregon here send the issue to the voters themselves. Which, in itself is a fine idea just as long as the issue is not laden with too many legal technicalities. Unfortunately, BM50 was. Many people opposed it simply on the grounds that it was a bad idea to write a tax into our constitution. I don't know squat about whether that is good or bad, and I am pretty sure that nobody aside from the policy wonks, scholars, and politicians themselves else does either. People were convinced that this was bad - ask them why and few could explain themselves. We can pat the tobacco industry on the back for driving this idea home with voters - their contribution was over 4 times that of the side supporting the measure.

A Fairy-Tale Ending Eludes Separated Twins - New York Times

A Fairy-Tale Ending Eludes Separated Twins - New York Times

An extremely large amount of money spent on just two children. These kids will have lifelong medical and social needs and most likely a shortened life expectancy. It just seems like an irrational use of health care resources when so many other children - or even adults - don't have basic adequate care. This is just nuts when you consider that any kind of health care spending is ultimately a public investment.

The obstacle to more rational resource allocation is cultural. And the way the media present these stories as human interest dramas certainly doesn't help the public understand the underlying economics. Our culture values individual life to such an extent that it obstructs rational thinking about when and if we should use medical technology to intervene in the natural course of disease.

Wellpoint, Zagat join to give doctor info - UPI.com

Wellpoint, Zagat join to give doctor info - UPI.com

Gotta say this sounds really stupid: a Zagat guide to doctors. There are so many problems with this concept that I don't know where to begin to criticize it. How the data is going to be gathered? From patient surveys? You can't just walk into a doctor's office like you can a restaurant. Ok. So what really bothers me is that it assumes that doctors should be like anyone else in the service industry. Good doctors are often not your best friend, like a good waiter might be; doctors are trained to be an advocate for your health, not an advocate of your pleasure.

Lethal Injection Under Scrutiny - washingtonpost.com

I never thought it would be so difficult to kill somebody. Obviously the simple solution is to train the executioners better so they don't futz up the drug dosages. Or just use rifles. The guillotine is efficient too I hear. An execution is violent, no matter how you do it, and all this talk about making it painless and humane just sounds like people ashamed of the act wanting to wash their conscience.

Lethal Injection Under Scrutiny - washingtonpost.com

More Profit and Less Nursing at Many Homes - New York Times

More Profit and Less Nursing at Many Homes - New York Times

This is a gross story, and another example of when the free market fails us, dreadfully. The bottom line is that regardless of how much you believe the market will solve problems at the best price, there are simply some areas (education and health care, namely) when the motive to make money is an obstacle to fulfilling the mission of the enterprise.

FDA Moves To Ensure Safety of Supplements - washingtonpost.com

FDA Moves To Ensure Safety of Supplements - washingtonpost.com

Finally the FDA is going to start regulating the content of dietary supplements. However, we are still a ways away from the FDA ensuring that supplements are safe and effective.

Yesterday I saw at Costco a huge palette of "Coenzyme Q" for sale. I snapped some comment to Naomi about how I dislike the supplement industry, although I am not sure why and she did not totally understand. I think it may be that it drives the pill-popping mindset, distracting people from the common sense of just eating a good diet. I even have friends in medical school who are vegetarian and eat very well and who still pop 1000s of units of vitamins each week, even though they know most of it will go down the toilet.

Med School Year 2. Done.

The didactic portion of medical school ended a few weeks ago. It was a bright sunny day, but I was so tired I couldn't enjoy the day as nearly as I should have. In fact, I think a lot of us has already checked out of class.

So that's it two years done, half way to go, and probably even more winging along the way too. The first two years can be summed up as one giant vocabulary lesson. A lot of it was fascinating, but by about winter of my first year the cram-and-dump cycle of continuous nonstop exams began to get tedious. Some faculty member said one time that a lot of learning medicine boils down to learning how to identify relevant information from the noise. That's the other thing I learned over the past two years, in addition to a lot of fancy words and hyphenated eponyms for obscure medical conditions.

Just about everyone in med school is pretty sharp, some phenomenally so. But those who get the good grades are either those with freakishly superb memories or (most likely) those with freakishly high tolerances for self-flagellation burning the midnight oil in front of a text.

Free Market Medicine - Is it Rational?

This weekend J, who is an ER doc, said that universal health care would not be a good idea. His reasoning was straight-forward: if you provide the public with something free they will exploit it. By not providing things for free we encourage people to work and plan for what they want and need. This encourages responsibility and industriousness.

I agree with this. Except that J is not talking about a typical consumer good like a car or computer. Health care is different, and for two basic reasons.

1. People don't think of their health like their cars. Any American will agree that if your want a car, work hard and save the money. If your car breaks down, you'll be responsible for fixing it. No money, no repairs. But disease is different. If someone has diabetes they expect to have some level of care regardless of they ability to pay. Many Americans - especially those with chronic diseases - would think it is unfair that a diabetic who needs to see a doctor could not do so because they had no way to pay.
2. Doctors don't think of medicine like a mechanic thinks of repair work. A mechanic can be successful if he follows the basic principles of business: provide good quality at a low price. Profits shape his business and motivate him to work. Although many doctors too are motivated by profit, the large majority are more motivated by their professional code of ethics. This code is about caring for the patient, not making money from him, and as a society we allow people to practice medicine because they follow this code rather than chasing after profits. If my car breaks down perhaps I will chose to go to the mechanic who, though not the best in the city, is good enough and inexpensive to fit my budget and the value I place on my car. If I get sick it is unlikely I will use the same thinking: no, I don't want to see a doctor who cuts corners to save me some money. I want the security that I am getting the best care I can get. Yet on the other hand I don't want to get gouged or spend money on my car repairs than what is really necessary for my needs.
   

When it comes to medicine we have a "spend whatever it takes" attitude about solving problems about our own health of that of those we hold dear. This is untenable from a public health standpoint, but it is nevertheless our attitude about the matter. There is nothing else - save national defense - about which we would think the same.

We drove down to Eugene to see mom for mother's day. It was pretty nice weather so she took us and the dogs to a large pond outside Springfield. It was a relaxing 1.5 mile walk around with the trail to ourselves. Afterwards we had lunch at the Outback. Mom had steak and Naomi and I shared some baby back ribs. I was happy that she didn't break out a smoke during the walk - in fact I think she only had one the whole time we were there. Naomi thinks she had lost weight, but I think she has been pretty thin ever since I came back from Japan in 2003. She was happy about her recent outpatient surgery to remove a basal cell lesion on her eyebrow - although I find it amusing that she is so concerned about how she looks after the surgery (it was pretty minor in my view) but continues to trash her lungs and voice. Over lunch we talked about Alan Jr., my cousin, and his unorthodox views religious views. Mom and I last saw Alan and his family at Ty's wedding a few years ago.

Friday I took the day off and went mt biking in post canyon Hood River with Jon and Cam. I had a pretty nasty fall - nothing spectacular, but ended up with a painful goose egg bruise on my left thigh. Cam also fell a few times - once off one of the narrow bridges - and was a little shaken.

I rode my bike to Powell's on Hawthorne to browse some books - one on Lance Armstrong and Malcom Gladwell's Blink before Jon and Cam picked my up to go to Sinju in the very So-Cal Bridgeport mall. Pete tried to put Jon in a headlock and spilled a cocktail in Cam's lap. Cam then threw a glass of water into Peter's lap. Classy guys, but good carousing fun. We headed back into town after that for beers at Life 'o Reilly's where we meet a group of girls working for in the pharma industry. For some reason Peter took an extra toilet paper spindle from Shinju. Being a married doctor with bike shoes, in turns out, makes you a chick magnet in this city (haha).


From what I could gather about Blink - snap decisions based on intuition can be effective and efficient or disastrous. One way to stack the odds in our favor is to place ourselves in situations - created environments, that is - where our intuition can work uninhibited by prejudice and noise. For instance, in evaluating a musician we should blind ourselves to the person. Studies show that what we know about a person affects the way we hear, thus potentially misleading our intuitive sense of their quality.

This Naomi and I attended the clandestine marriage of two friends in the Rose Garden. Stupidly, I thought the ceremony was at the Rose Garden arena, which was unfortunate since we decided to ride bikes. I nearly took us over the Hawthorne bridge when Naomi finally stopped me to ask where the hell I was going. She rightly pointed out too, that had she made the same mistake I would have been more mad that she had been. She wasn't so much mad actually as annoyed that I led us all the way downtown only to climb back up to the park.

We saw the newest film by Kore-eda, Hana, an unusual variation on the 47 ronin theme, at the Portland Art Museum.

Saturday I joined about 20 other medical students for the Community Health Fair in the Columbia housing development in North Portland. As brainy and snobbish as I can be, I actually had a pretty good time meeting with people in the community. The kids, especially, were fun. On my way home I stopped in at Powell's for a coffee and some time with new books that looked interesting - Deep Economy (McKibben), The God Delusion (Dawkins), and Collapse (Diamond). One (at least I) doesn't have enough time to actually read full books outside one's profession anymore - unless on vacation. But I find that the introductions/prologues/epilogues do just fine.

Doctors push law on clinics in stores | Chicago Tribune

Doctors push law on clinics in stores | ChicagoPublish Tribune

Young, Gifted, and Not Getting Into Harvard - New York Times

Young, Gifted, and Not Getting Into Harvard - New York Times

This short story describes rather well the difference between today's college-bearing kids and those when I was finishing my high school years. Recently it seems a lot has been in the media about how pressured adult adolescents are at being over-successful, much of which is a matter of class and income.

As for myself, I took the SAT the end of my junior year. That was it as far as college resume crafting went. No Kaplan review, not even a pre-SAT, no tutors, only 2 AP classes (biology and european history - but I didn't take any of the AP exams). I played sports every season and was involved with the music and drama department. I played in a rock band. I didn't work really at all during summer. Life was pretty easy-going for a high school kid back then when you look at how middle and upper-class kids are raised today. Of course we were on the bottom end of middle class I think. Probably I would have been pressured a little more to achieve if my parents had been professionals, or at least college degrees for known schools.

The bottom line, however, is that the competition for achievement that we push for in our kids today is more for us than them. It is placing our fantasies and insecurities on their shoulders while robbing them of the freedom to be who they really want to be.

Future of primary care

The OMA House of Delegates meeting was this weekend at the Salishan lodge. We, the students, proposed a resolution to establish a student leadership fund with a $10000 budget and to change our membership status to full members. The delegation approved the budget, which is great news for future students who will have plenty of seed money to grow interest in the OMA.

There are a lot of gray hairs in the organization, which is all the more reason for students to get involved. The more I consider the various stresses on the profession and how it is changing, the more I believe that doctors need to get their crap together and start advocating for their own interests and for their patients.

Saturday night was spent over some beers thanks to some former presidents of the OMA and a continuation of the heated discussion about compensation parity between primary care and specialists.

The larger question beyond income parity is access. Fewer med school grads are choosing primary care - I put myself in that category right now. But it is not, I believe, due to low income as many people argue. $150K may be a fourth of a cardiologist's income, but this is still enough money to make a good living, even with a large loan debt load. People who really want to do primary care are going to do primary care; the main reason (there are many, including income and loan burden) I think many do not is because the biomedical sciences for a few decades now have become so information-dense and the growth of new knowledge (and procedural skills) so rapid that it is extremely difficult to be good - or possibly even competent according to community standards - without being a specialist.

The health care "system" and market understand this and therefore reward specialists much better than generalists because it is specialists who more less produce the results we want. In a larger urban area, such as Portland, it is standard of care for someone to see a specialist if they have complex organ-specific pathology. My primary care preceptor last year refered virtually every "difficult" patient to a specialist. Those who remained were patients with chronic diseases, aches and pains, psychosocial issues, common infectious diseases, and other non-acute, non-serious problems. For me this was all pretty boring from a medical point of view (although the patients as people were always interesting). It struck me as a waste of resources for an internal medicine physician to treat these kind of patients as his bread and butter (it requires 7 years of training for internal medicine). I think many young doctors-to-be feel the same way. A specialist career track will allow them to earn money that is more commensurate with their extensive training, and provide them with a job that is challenging and that lets them work on the leading edge of medicine.

So the question remains: wherefore primary care? My personal feeling is that the progress of medicine will require more specialists to deliver competent care, and these can only be MDs. So we are going to have to look towards lesser trained health care providered to fill the primary care vacuum: nurse practioners and physician assistants. For much of the ailments I saw in my primary care preceptorship, I am pretty confident that a NP or PA working under an MD could provide just as good of care. In fact, for low grade complaints - the majority of primary care visits - the quality of care is often determined by factors irrelevant to technical training, such as so-called bedside manner and listening skills. That said, there will still be chronic disease patients who should be managed by an MD, such individuals with diabetes or hypertension.

Physician assisted suicide in CA

Looks like Californians are getting closer to being the second state to recognize physician-assisted suicide.
I understand that conservatives squirm at the idea of a law allowing something they find morally heinous.

But hey, why can't we all just hug each other and say "passing judgment on our fellow neighbors is God's domain, and God's domain only." If God doesn't like a terminally ill person choosing to end his life because of some dysfunctional biology that God gave him, then so be it. But who are any of us - Christians or self-pronounced Bible experts - to say we know better than that man suffering and entitle ourselves to act on behalf of God?

There's also the California Medical Association's opposition to the proposal as well. Providing a mentally competent, terminally ill patient with the means to kill himself apparently goes against the Hippocratic oath of "do no harm." Unfortunately, the Hippocratic oath has been used too often in the past as a way to circumvent patient wishes when those wishes contradicted established medical practice on moral grounds.

Debate rages in Calif. over physician-assisted suicide - USATODAY.com

I guess doctors are not smart enough: the FDA wears the big brother hat again

I appreciate the FDA's concern for public health. However, I am not sure how much I like FDA requesting manufacturers to remove drugs whose risks outweigh their benefits. I feel the decision to use a drug, regardless of the risk of adverse side effects, should be made by the clinician and patient. Every clinical situation is unique. Many of those patients on Zelnorm (or Vioxx, even) are very low risk for a cardiovascular event. (Zelnorm will still be available as an "investigational drug")

A friend of mine who is a gastroenterologist was annoyed at the decision since Zelnorm is a good, and often only effective, treatment choice for inflammatory bowel syndrome accompanied by constipation.

Patients treated with Zelnorm were 10x more likely to have a heart attack, stroke, or chest pain. But this was still only 13 out of 11,601 people. Good clinical judgment by the doctor should identify fairly easily a group of people that would be at risk for these adverse events.

Wacko bill in SC requires women to view an ultra-sound image of their fetus prior to abortion

I'm not sure what the intent of this asinine legislation is, but it smells like requiring doctors to force some kind of Christian guilt crap onto pregnant women seeking an abortion. This can't be constitutional. It certainly is not ethical from a medical point of view.

Friday was such a beautiful day that I skipped lecture and went mountain biking with Dan, Mark and Justin...and Sango. I told Justin I felt a little guilty about it and he replied, rather sternly, that I should squelch that attitude as soon as I can before it is too late. What he meant was that I should resist the pressure and expectations the medical community places on doctors to commit themselves to medicine all or nothing. I understand his point, however for me at least I want to be the best doctor I can be, and I know that will mean spending more than 40 hours a week at my job. I don't want to be just "a doctor," as if it were a 9-5 job. I decided to enter medicine in part because it is a challenging, demanding profession. If having plenty of time to play around outside when the sun was shining was a priority, I could have stuck with my previous career. The reason I didn't was because I have always wanted a career that would be something that would require of me passion and perseverance.

Akiko came up from Corvallis to hear the first Portland Taiko concert of the year. To my surprise, Byron Au Yong was a guest artist. One of his pieces, Ji Mo, was performed. At intermission Naomi asked what kind of music he composed. That's hard to describe, so I just told her it was like contemporary ritualistic music, like something you might image for a film or theater. I wonder how disappointed Byron would be in that statement! The piece was unusual musically, but has some very nice visual and performative aspects I thought. That fact that I am still thinking about today, however, more than the more traditional pieces, is a testimony to its impact I suppose.

After the show we went to Doug Fir to me Peter and Cam, who were pretty lubed up with beers. Peter was annoyed at the New Year's post I made, which surprised me since I didn't really think the pictures and text could be taken seriously by anyone. They are pretty clearly stupid party pictures, etc. etc.

Spring break this week. Actually rather uneventful - Naomi was very responsibly working for the both of us every day. I sat home a did pretty much nothing. The internet is a great tool of procrastination! We did go see The Flying Dutchman on Tuesday night. The music - ah, Wagner - is really spectacular. It is no wonder that so much commercial film music is based on it. The music from Star War could be right out of the Wagner opa.

I spent Thursday in the OR with Dr. Schindler (ENT). The OR can be a strangely exciting and mundane place at the same time. I wonder if I could still be excited to scrub in for a procedure I have done a thousand times. I guess even fighter pilots probably get bored of taking off from an aircraft carrier at some point.

Walking to the OR that morning a pharma rep called my name out in the hospital entrance way. I turned and saw a guy who looked totally unfamiliar. He asked if I was "Chris Molson" and I corrected him. He introduced himself as my old pledge mate at Beta Theta Pi fraternity. (I though being in a frat would be a good idea my sophomore year in college. I joined BTP, but then depledged right at the point when we would be induced into the brotherhood. It was an insane few months of my life.) At any rate this guy apologized for not remembering my name completely, and shit, I felt retarded for not remembering his name at all. Scott was nice enough, and in retrospect he did look a little familiar. I wonder if was time that made him hard to recognize, or just that I have more or less blotted that part of my life away.

I think about memory a lot. I fret over it. I start to think that I am more forgetful that I probably am. I worry that I have already let many precious moments of my past slip away. (Actually, this blog is a manifestation of that anxiety.)

The fact is, memories are something that fade if they are not enjoyed and shared. So I just pretend to myself that my poor memory is a facet of my disinclination to tell stories.

Squidsniffer

Acting themselves in Harajuku circa 2002 at the height of their under-recognized creative talents.

Max guitar vocals humor
Christian bass croaking jackassery
Kenji drums weed zensation

Two winter pictures

Just a couple of random winter pictures. Me on a very nice winter day at Mt. Hood. Naomi on a trip to Bagby hotsprings (Mt. Jeffereson wilderness)

I took Naomi to a classical Indian music concert at the Unitarian church on Friday night. The vocalist was from south India. I had forgot how long these concerts go - in Seattle when I used to go to the Ragamala shows I don't think I ever recall staying until the end. Did they ever end? We left sometime after 11pm, 3 hours into the performance, and I had the feeling she was just getting warmed up. I only with there was some kind of supratitles at the vocal performances like in opera.

Tuesday was taco night at Brian and Briar's place. All the climbers were there - they had just returned from LA where they were down for the Ellen Degeneres Show. Needless to say the media attention must be overwhelming. You have to wonder, however, how much of this is because of Velvet, Matty's dog, who sprang from back stage to make a brief cameo on the show.

The last two weekends have been kind of blah blah. The weather has been very balmy. The cherries are starting to blossom this week in fact. The snow is quickly melting and I have had really not big desire to go ski in the rain.

I am into the hematology and oncology course, which is pretty fun actually. Ah, the faculty and syllabus make such a big difference; this is far and away the best taught course. Plus, well, blood is kinda cool, actually really flippin' cool, and cancer, the evil beast it is, is pretty fascinating too. In fact, before I did my premed biology class I never realized that cancer was a model of evolution via natural selection on a cellular level.

Friday and Saturday were conference days - the regional Society for Academic Medicine and a Global Health Alliance Symposium on immigrant health. The symposium, I thought, turned out rather well, although Alex, Jonah, and Erin the main organizers were less enthusiastic. The panel discussion, however, got a little side-tracked from the topic of health by comments from the audience regarding being "bi-cultural." I put this is quotes not because I don't believe in it - I do - but because terms like this are used liberally and with little agreed-upon understanding of what they mean. The result: debates going in circles about nothing substantial between people who have nothing to disagree about.

Saturday night I met Aaron and Dan and Slabtown for some beers and really crappy, loud indie music. I'm pretty cool when it comes to pop-rock, indie or not, and it takes a lot to win my interest. A recent favorite, however: Andrew Bird.

Walter Reed scandal - who's to blame?

Today the Army's surgeon general retired...er...was fired, in the wake of the Walter Reed Medical Center scandal regarding squalid patient conditions. There is something about this story that is just not right. Walter Reed is the biggest Army hospital. Many patients, many visitors, and right inside the beltway. How could it be that nobody noticed until now?

And how could the executive MD running the place, General Kiley, have let things get so bad? Either he is not worth his salt as a professional or is an incompetent manager. Considering his rank, both seem unlikely.

For me at least, this raises some question of where the motivation to hide the rats came from. As I said, no doctor with an iota of the Hippocratic oath could have let this happen under his watch. Certainly the military's medical services are stressed at this point. Has the White House ignored requests for more support? And too ashamed to let that be known?

Anyway, something smells of another fall guy scenario...

Congress considers laws to prohibit junk food at schools

I don't want no damn government telling me what my kids can and can eat! That's MY responsibility, and when they get older, they can make that choice on their own.

Except your fat kids who will become obese are going to (a) probably really resent you when they are realize how miserable it is to be obese and how difficult it is to lose weight once you've grown up with it, and (b) are going to end up costing all of us in terms of reduced economic productivity and poor health resulting from the morbidity that is associated with being over-weight.

Case 1 for said draconian law
Today's parents are stupid or irresponsible or lazy or all three and it's time the government step in get a control of these kids' bad habits (and show 'em a little discipline too! yeah!).

Case 2 for said draconian law
Poor health is not merely a personal matter. It affects others as well in direct and indirect ways, and when poor health reaches epidemic proportions, the mass effect can be crippling to society. Visit the Center for Disease Control website if you're not convinced.

Case 1 against said draconian law
Why bother? Kids are still going to get their empty sugar and fat fix at the 7-Eleven down the street from campus anyway.

Case 2 against said draconian law
If the goal is to get kids to quit so much crap, then we need encourage incentives to be healthy. We could

• messages about how totally un-hip it is to be unhealthy (might as well include smoking and drug abuse too)
• lots and lots of education about how miserable you're gonna be when your 30 years old and can't walk up two flights of stairs
• provide healthy alternatives to Cokes and Snickers
• encourage parents and community to set better examples
  

The uninsured middle class

Here is a series of stories on the effects of being uninsured for the middle class (NY Times, 5/5).
What bothers me is that there is just so much unwillingness to embrace a single-payer system run by the government in this country. I respect choice, but I feel that Americans opposed to national healthcare are either ignorant of the public health superiority of these systems in many other developed countries or so stubbornly wedded to the principle of individual freedom that it trumps any good judgment.

And even if you do want to let people choose, I don't hear many free-market libertarians or conservatives trumpeting proposals that would ensure everyone could get affordable coverage. The woman in the story had a history of cancer; her premiums amounted to 27K a year, with a 5K deductible. You gotta be bringing in a lot more than a typical middle-class income (47K) to pay for that. So we have choice in our system. In principle. In reality, asking someone to pay 30-50% of their pretax earnings is not giving them a choice at all.

The stupid thing is this: if she gets really sick or injured and ends up in the ER, her care will come out of the public trough anyway, and the chances of that happening are increased by the fact that she can't afford to take the full dose of her chemotherapy meds, which cost several hundred dollars a month.

Although to be honest, a national healthcare system would probably only address a few of the reasons why costs have sky-rocketed, namely by reducing administrative overhead and the massive expenses incurred when an uninsured person arrives in the ER for an illness that could have been treated or even prevented much more cheaply by a primary care doctor.

Saturday we met mom and a couple of her friends for breakfast at a old sports bar dive north of the Pearl. They had come up for a country music concert and had a good time staying up late on Friday. Mom's hand tremor looked really bad at times, which made me start thinking about mine. It's probably a benign essential tremor, but neurological disorders are puzzling for the lack of tests available for diagnosis.

Saturday night we went to the ballet, which premiered three modern pieces, whose choreographers were present. The dancers all looked very strong, and of course, the choreography seemed challenging. Afterwards we went over to Hilary-Rachel-Casey's house with Sango for a kegger. The place was packed by 11 o'clock, but as usually we were the first to leave. Sango was getting exhausted anyway. It's fun to socialize with everyone outside of school, but understanding the drunk slang through the din of 25 people squished in a kitchen is tough for Naomi.

I nearly wrote mom an email about her smoking and drinking. We've talked about it seriously during the holidays at the end of 2005. But since then nothing's changed, and I am not sure if she's really made any real effort to quit either. That's what upsets me. A big part of me wants to tell her she's selfish; I told her what the most likely consequences of smoking and drinking hard at her age were - a stroke, heart attack, and dementia - and that she could place the responsibility of her care in my hands prematurely. And then there is the matter of being functional for her grandchildren. I don't think she cares about living to a ripe old age, but I can't give her a morphine OD if she is gorked from a stroke or dementia, like she thinks. On the other hand maybe calling her selfish is being selfish on my part.

When does the sanctity of life lead to medical waste?

A true story.
There was a patient that arrived in the ER with acute abdominal pain. Imaging revealed air in his abdomen, indicating a perforated bowel. The patient had a very complicated medical history, the most outstanding component of which was a late-stage glioblastoma multiforme tumor. This is the worst kind of brain cancer you can get. It is inoperable, highly resistant to chemo or radiation and has a prognosis of 3-8 months without treatment from the time of diagnosis. Median survival is 14 months with treatment.

So the question for doctors in the ER, the patient and his family members is: what, if anything, should be done about the bowel? Normally this would require an operation to remove the damaged bowel or suture the hole. But any kind of surgery carries complications - which are compounded in this patient's case considering his illness and current anti-cancer medications - and bowel surgery in particular can result in the patient requiring tubes to assist in feeding or defecation. Plus there is the financial cost. Is any of this worth it for someone who has a terminal disease and is expected to die in 2 months?

You might say, well, that's up to the patient. But you might also say, unless that patient is going to pay for the operation out-of-pocket then it is not entirely up to the patient because we, as a community, are going to being paying. Say the operation and hospital fees amount to 50K. Is it ethical to spend this sort of money - public money, let's say - on a terminal patient rather than say a non-terminal patient, or child? Plus we need to consider the health care costs in case their are complications (remember, he is high-risk). We like to pretend that economics don't, or shouldn't, matter when it comes to medical treatment. But they always do impinge.

A last nugget to ponder.
The patient was on a new type of chemotherapy call Avastin which targets a chemical messenger involved in the formation of new blood vessels. Tumors love to make new blood vessels as they grow, so attacking their supply of nutrients and oxygen has shown to be an effective strategy. In some cancers. Avastin is indicated for only a few types of cancer, namely colon. There is little to no evidence that says the drug works against the kind of brain tumor this patient had. Avastin itself is very expensive. A year's course including medical fees is around 200K. Wow! Now, that, is some serious money to drop on a dying patient when there is no evidence it will change his prognosis. On the other hand, there is no evidence to say it won't.

[Update Actually Avastin costs up to 44K for a 10-month treatment, but that is the medication alone, not including the hospital stays and support. Some people have complained to Genentech about the price]

You can find situations like this every day in every hospital. I know it sounds cold-hearted to suggest that this is wasted money, but money spent on a dying patient is money not spent on a living one. Always think of kids, who are, unfortunately, the most under-insured demographic in the country, but who have the most to gain from medical intervention and the most to give back to the public if those interventions work.

ATV now or bypass later?

rangelMD.com has an insightful commentary on Americans' personal financial decisions regarding health care. Without a doubt our health care system is broken and unaffordable. Nevertheless for many middle class Americans it is possible to save and plan for future health care - or retirement - although few do.

It has become customary in the US nowadays to forgo saving for the future (such as for health care one will need as one ages) for expensive, gratify-me-now consumer items purchased with credit cards. Credit card debit has balloned in recent years and although some of this is a result of costly health care, most is not. As Rangel points out, it ultimately will be younger taxpayers that will foot the bill (assuming Medicare is still around!) for irresponsible spending as the middle class ages with their huge credit card debit.

Saturday BT, Tasha, and I skinned up the Palmer Glacier on Mt. Hood. It was a warm, sunny, spring-like day, but the snow - if you could call it that - was bullet-proof ice above the Palmer lift. We decided not to carry on to the hog's back and instead enjoyed a leisurely lunch at 8500 feet, talking with other climbers and skiiers.

The hike up from Timberline Lodge was not so bad except for the fact that I did not have heal raisers on my skis. The pitch is pretty steep and one does not ascend with switchbacks. While we were up there we ran into the climbing party that required rescue the next day. These were all of friends of BT and Sasha. People ask "what were these guys doing up there is such bad weather?" The fact is, there is always a weather risk with outdoor activities, and especially so with mountaineering. The weather Saturday was so nice that it was hard to image every needing help getting of the mountain, but in extremely low visibility the simplest operations become very difficult. The rescue stirred a nation-wide media blitz because of the three climbers that died on Hood in December and the "courageous" little Velvet, the black lab that tumbled down into White River Canyon with Matty and the two women.

Anyway, on Saturday the three of had Indian food and saw "Host," a horror-genre spoof/political satire from South Korea about a giant river monster that terrorizes Seoul and the impotent and incompetent response from the Korean government, the WHO and the CDC.

Sunday Naomi and I watched another film from the International Film Festival (it has been really fun seeing the films this year), "Hula Girls" from Japan. The Willamette Week shredded this movie in a short review, which was really a shame as we both thought it was good film. Of course it was not a self-consciously clever indie film or a slick Hollywood production, which is what the reviewer seemed to be expecting.

This week I had a small epiphany. I know that neurosurgery is not a reasonable option considering my diverse extra-career interests, but it is what I really would like to do, and what I would do if I was 10 years younger. Now that I am nearing the end of the neuroscience course I can say with certainty that nothing else in school so far has piqued my interest as much. So I will make an effort to do some extracurricular work with the neurosurgery department, perhaps with trauma, since that will be most useful for emergency medicine and anesthesiology.

Friends found on Hood

What a nerve-racking day. I'm glad these guys, whom I've met through a medical school friend of mine, are back safely. Here's the latest story.

These are pictures I took of three people in the climbing party on Saturday - when the weather was gorgeous and balmy. On Saturday BT, Tasha, and myself skinned up Palmer glacier and met their friends for chat.

So let the Japanese hunt whales!

Here is a good review of the whaling issue and Japan, although I was a disappointed that the "scientific evidence" was not discussed either for or against whaling.

From an environmental viewpoint this really doesn't seem like it should be a problem. Whales are like any other animal that we exploit, and so there should be some empirically-based management policy people can agree on. I cannot image that such a policy would completely ban whaling - which is precisely what most European countries, the US, New Zealand and Australia want. How much of this is driven by emotional sympathy for the beloved cetaceans is unclear, but I am sure that in-your-face environmentalists like Greenpeace are happy to exploit those feelings. Japan, Iceland, and Norway, on the other hand, want the ban on whaling to be lifted (they are all taking whales anyway, the Japanese claim it is for scientific research) and say that they have plans for sustainable whaling and only hunting non-endangered species.

In Japan at least, the whaling industry has withered to a fraction of what it used to be. Whale meat is not popular anymore and the industry if cut from its government subsidies would not survive. The pro-whaling stance in Japan is not at all about the need for food. It is about national pride and taking a stance against non-whaling countries that have denounced Japan as barbarous and the heritage of whaling as evil. Even though I know the US beef industry is horribly unsustainable and inhumane, I too would be pissed off if India tried to force us to stop eating cows because it was immoral (to them). So the reaction in Japan is complicated by emotions too.

Why not lift the ban, make the whaling nations hunt under a sustainable protocol that has been agreed upon by the International Whaling Commission, put in place a monitoring system, and pressure whaling governments to end taxpayer subsidization of the industry?


A side note - the fight over whales is one more ominous sign of the stress that human populations are placing on natural marine resources that cannot be farmed or harvested. Today it may be whales, and Chilean sea bass, but tomorrow it will be mackerel and tuna.

This last weekend Naomi, Brain C, Toshimi, and Yulija and I drove down to Bagby Hotsprings for a good, long soak. The water was super hot, and the trail - bulletproof ice the whole way. Lucky for Naomi and I, Brian, Yulija, and Toshimi had snowshoes with spikes.

The hotspring itself was not to crowded - probably only about 30 people the whole day, but you can just image how trashed it must get in the popular summer months. Even in the dead of winter there was garbage laying around. It baffles the mind why people shit in the place they come to enjoy.

That night we went over to their house for some Russian pork dumplings with dill and white wine. After eating Brain showed us photos from their recent family vacation in Turks & Caicos islands and then we watched the coral reef episode from Blue Planet. Naomi was in dreamland - oh, me too of course

Big pharma comes to med school - for a nice talk

We had a provocative session at school last week regarding the role of big pharma in medicine - mostly discussing the ethical considerations of direct-consumer marketing of drugs and the ever-more aggressive marketing to doctors.

Drug companies spend millions of dollars trying to persuade doctors to use their product, and they are not shy in their methods. It is commonplace today that drug companies provide free lunches or coffee during grand rounds, small gifts like stationary stuff, huge gifts like trips to the Bahamas for a symposium on the products, large gifts like tickets to big name sporting and musical events or green fees a golf course. And even if there are no gifts, every doctor, resident, and medical student has seen a drug company sales rep lurking around the clinic or hospital. Many of them make visits several times a week.

So one of the panelists worked for Merck. His main defense was that we, as medical students, should not prematurely shut any doors to gaining information about drugs. We should keep an open mind and be critical of all information - not just that coming from the drug companies. It is a actually a very familiar argument made by the tobacco and firearms industries: the government should not legislate behavior since ultimately it is up to every individual to make responsible judgments.

Texan gov wants mandatory vaccinations

Wow, can't believe Texas's governor passed a law requiring mandatory vaccination of girls for HPV. This is great news, and in a so-called morally conservative state like Texas too.

Opponents of the vaccine come from a few sides, but to break it down in real simple terms there are those who oppose it for on sexual-moral grounds (typically conservatives) and those who opposite on conspiracy-theory grounds (typically liberals).

Anyway, it represents an interesting example of bioethics. Some parties involved are:

1. The public that makes a modest investment in vaccination for a huge return in life-long protection from a deadly disease
   
2. The girl who may get the cancer if the vaccination is optional and her parents refuse
3. The girl who may have a rare side effect of the vaccine if it is mandatory (autism in the worst case, although this link is not proven)
4. The parents who lose autonomy to decide care of their child if vaccination is mandatory
5. Merck, who is the sole manufacturer of the vaccine
   

Maryland parents freak out over vaccine for girls

The HPV vaccine bill in Maryland was yanked, and for no really good reason. People claimed it would promote promiscuity (I'm sure a lot middle-schooler girls are not having sex because they're afraid of getting cervical cancer in 10 years, right); others simply knee-jerked against the idea of more vaccinations, as if these things were poisons or something.

The saddest thing is the failed effort of the medical community and local government to educate people out of the ignorance for huge public health impact vaccines have.

I finished off the week with part 2 of neuroscience and immediately hopped on a plane to Park City with Naomi. The Sundance Festival was very fun - and expensive. All told we saw 12 movies in 2 days and an evening, with several award winners on Sunday. (Grace is Gone, Rocket Science, Manda Bala, Padre Nuestro). The weather was beautiful, blue and crisp. The snow was hard and old, so instead of waste money on the slopes I borrowed some skate skis and flailed through 11 km with Kari (who also flailed) and Jon (who learned us some pole technique).

Naomi arrived with a crushing migraine that put her out of commission until Saturday late afternoon. I think it was possibly a little headache aggravated by the high altitude. She was in a better mood on Sunday after some good sleep and lots of rehydrating OJ. I believe she really enjoyed watching the films, although my favorite, Rocket Science, was a hard one to follow without subtitles.

Saturday night was the obligatory drinking night. Jon, Kari, and Jason (Jon's neighbor) provoked some young scrawny snowboarder types that were smoking in a non-smoking bar. Jon threw their cigarettes into their cocktails and Jason rubbed their face in it by making inflammatory homoerotic guestures in their direction.

The flight was clear and pretty. Naomi did a kid's crossword and spent the rest of the time dreamily glued to the window.

The snow melted and the city started to return to normal. I didn't ride my bike to school at all, but instead enjoyed the (still new) gym at the March center. I had sweat in the dry sauna with Aaron - a great suggestion actually. There is something really cleansing about sweating crap out of your body - plus the smell of the new cedar is delightful.

We watched a rather quirky Japanese movie this weekend, Dr. Akagi (Kanzo sensei) about a rural doctor trying to contain a hepatitis (probably Hep B) outbreak in his small town.

Sunday Dan, Naomi, and I met with Sam and Yae at Hakatamon, the new Japanese restaurant in Uwajimaya. Dan and I interviewed them for PCM - a crap assignment if there ever was one. Anyway we enjoyed their company and of course the food, which is really good for the price. Afterwards, Dan and I met Ben, Drew, and John Rodakowski at the bottom of Leif Erickson drive for a freezing ride through slush. Ahh, but it was fun to get out with the boys and get a little exercise.

The new ketchup!: probiotic yogurt

Strap in for the latest food trend. Americans just love them (and loathe the old-fashioned time-tested advice about moderate diet and exercise).

So we'll see these new probiotics showing up everywhere, which of course, is beside the point. And you'll only need a gallon a day to reduce your risk of colon cancer.

In Live Bacteria, Food Makers See a Bonanza
(New York Times, Sunday, February 4, 2007)

Global health in Foriegn Affairs

Here's a very interesting piece in Foreign Affairs on some problems facing global health.

The take home point as I see it (from the eyes of someone new to this area) is that the health problems facing people in the developing world need to be addressed at local political and economic levels. One of the main reasons that NGOs, foreign aid, and teams of doctors and nurses have failed to provide sustainable public health results abroad is insufficient integration of these activities into long-term structures and policies that involve the local governments. More money is easy to come by (there has not been a lack of this in recent years), but political and economic reform is not. This view is iterated by some development experts (Nicholas Kristof has a good review).

I wonder what the role of doctors and nurses should be in global health. It is hard to know if one is part of the problem or part of the solution anymore. At any rate my training in medicine is fundamentally to diagnose and treat patients. However, I am also ethically compelled to wear two hats which often conflict with each other: one, being the advocate of my patients, the other being an advocate for public health. This conflict applies to any doctor in the US as well, but I think the difficult thing to recognize is that the public health hat is ultimately more important when it comes to providing health in developing countries. Treating HIV or Tb in impoverished Africa with fancy new drugs is all and good, but strikes me as an odd use of resources when these same patients - or their children - don't have access to clean drinking water or even sufficient daily nutrition.

An additional issue raised in the Foreign Affairs piece is the health care professional brain drain from developing areas is promoted, albeit unintentionally, from both

1. a failing US health care system that must recruit foreigners to meet the demand for primary care doctors and nurses.
2. NGOs that hire local doctors and nurses at salaries greater than those of local hospitals and clinics. Good for doctors, but not so good for the patients of those government clinics.
   

I also think that the criticism leveled at many American NGOs - that they focus too much on single diseases and miss the big public health picture - probably derives from our medical system in the US that itself focuses on treatment rather than prevention of diseases (or, as a professor of mine has said, on illness-care instead of health).

1. My training in medical school (7 years all told for an internal medicine physician) is aimed at treating the 1 patient in a 1000 that has the complicated syndrome. Nevertheless, the large majority of patients will be much less complicated and will not need to be admitted to the hospital or visit the ER if they have good access to a family doctor. And an even larger majority of patients would not need any medical intervention provided they have access to some form of preventative medicine.
2. Medicare, the national health insurance system for people over 65, will pay for your heart surgery once you have a heart attack, but provides very poor access to primary care, which with good, non-invasive, low-cost, medical management, would prevent the heart attack in the first place.

Sango

Our dog Sango on a snow day. Teasing her (lovingly) is one of our favorite things to do - like rubbing snow on her rear end.

For the next two weeks I'm moderating a series of panels on health care as part of our PCM class. Last week John Kitzhaber visited.

Friday I took off from school and went skiing, hoping to beat the holiday crowds and enjoy the nice weather and new snow. The vista's from Hood were spectacular. My tele turns are coming a long, I think. Unlike alpine skiing you gotta really commit to every turn you make.

On Sunday we met dad and Marsha for a celebration of her birthday for brunch at Le Pigeon. Naomi shared some extremely delicious French press coffee. After, we spent the rest of day at the new March fitness center (I got Naomi a free day pass). We tried all the weights and cardio machines, swam 20 laps then soaked in the jacuzzi.

Monday was MLK day. The weather was still clear and dry, so we took Sango to the little Cedar Hills park with pond. It was full of noisy ducks and geese standing on the iced over water.

Saturday night we watched Grave of the Fireflies by Miyazaki. It is a very sad, moving story about orphanage during times of war; an enduring theme, it seems, and ever more a propo in today's political landscape.

Mandatory HPV vaccination

The Washington Times reports today about a bill proposing mandatory vaccination for 13 year-old girls for HPV (human papilloma virus), which is transmitted sexually and some varieties of which may cause cervical cancer.

It estimated that nearly 75% of women are carriers of HPV, which is one of the reasons why yearly pap smears are recommended for all sexually active women. Development of cervical cancer requires HPV infection, although most women do not get cancer because their bodies are able to control the growth of the virus.

Americans typically value individual autonomy over societal good, and resistance to mandatory vaccinations is a perfect example. Mandatory vaccination for polio and small pox in school children is widely considered the reason why our society remains immune from these diseases (the so-called herd immunity theory). However, being forced to take a medication strongly irks many in this country who feel that nothing trumps individual freedom of choice.

Complimentary and alternative medicine

Today we had a very provocative session on complimentary and alternative medicine (CAM). CAM includes naturopathic medicine, oriental medicine, acupuncture, chiropracty, and homeopathic medicine.

More and more people are paying for CAM services in supplementation to or in place of allopathic medicine. Many MDs hold strong critical opinions regarding CAM providers since much of what they practice does not meet the standards of evidence-based medicine. Evidence-based medicine are therapies (drugs and interventions) that have shown to have measurable, predictable benefits through controlled studies.

Although we may not understand how much of CAM works from a physiological or pharmacological level, I still think there is a valuable role for CAM in health care alongside Western medicine. For one, Western medicine does a poor job at prevention and treatments that integrate psychological/lifestyle aspects into care. Second, Western medicine often uses aggressive therapies which carry risks of complications (procedures) and side effects (drugs). CAM, on the other hand, approaches illness from a holistic perspective that places greater value on prevention, the mind-body connections, and typically uses very conservative, low-risk methods.

Controversy in Western medicine centers around the following questions

1. When does an MD refer his patient to a CAM providers?
2. What should be the scope of medical practice legally and ethically permitted by CAM providers?
3. To what medical standard should CAM providers be held?

A hypothetical case
A CAM doctor treats a cough for 6 months with little resolution. The patient sees an allopathic doctor who immediately discovers a tumor that could have been diagnosed earlier, altering the treatment and outcome for the patient. In this case, the CAM doctor will probably not be sued and not be held professionally responsible as a primary care doctor might be.

At any rate it seems that in the future a multi-modal treatment approach will be the most successful for many common conditions. Ideally a patient seeking help for back pain would be treated by a team of allopathic and CAM doctors who work together and know each other's practice philosophy intimately. Treatment for cancer might fall primarily to the MD, with palliative pain therapy support from the acupucturist. Treatment for lower back pain may fall primarily on the chiropractor with support from the MD and Oriental medicine doctor.

Also, I hope that with better scientific understanding CAM therapies will become more accepted in Western medicine, and that CAM doctors will embrace a critical approach to their respective fields as scientific knowledge of CAM practices grows.

Why is health care so expensive here?

Many people in the US wonder why our health care system is so expensive, and why costs are spiraling out of control even as more people find themselves without any insurance each year.

What many Americans do not know is that despite the high cost of medical care in the US, we typically rank midstream or lower in many standard measures of health care delivery (e.g., infant mortality rate and disability-adjusted life expectancy).

To give some perspective of how much we spend on health care in the US consider this: Switzerland spends the most per capita dollar on health among high-income countries. The US spends nearly double this.

Every industrialized country has some form of national health care that extends benefits to all citizens. The US also has a national health care system. However benefits are only extended to the elderly (Medicare) and to impoverished women, children, and people with disabilities (Medicaid).

The high cost of health care in the US is typically attributed to these key factors:

1. Rising costs of novel medical technologies (tests, drugs, procedures, therapies) and consumer expectations of access to them, whether not the technologies are indicated or proven to be effective
2. Administrative costs resulting from a complex multi-payer system
3. Extremely expensive medical care provided in emergency rooms to uninsured patients who have no access to primary care. These costs are shifted to payers, increasing insurance premiums
4. Aging, less economically productive, population that requires more medical care
5. Medical errors and complications from treatments that are serious enough to require expensive hospitalization
6. Underuse of the medical system: people lacking access to affordable care (e.g. uninsured) and preventative counciling are sicker and require more medical care in the end than people with affordable access
   

Christian at 37

Naomi treated me to a wonderful dinner at Lovely Hula Hands. The chocolate panna cotta was sublime.

New Year's Eve

Mclean grabs for any sex organ that's in reach.


Later on Mclean hooked up with Jonnie. Word has it that Rettmann doesn't mind sloppy seconds.







Note Mclean's hand playing with Jonnie's new nipple piercing.

Mclean was pleasantly shocked to learn there was a chain connecting it to a all-on 24/7 New Year's Eve platinum cock ring, a hand-me-down from Compton.

"I thought I had seen that before!" Mclean remarks on the way home to Newberg.


Mitchell still hasn't figured out why the women at the next table leave. "Could it be the hair?" he wonders.


...but he's still convinced that hair's hot.








Dazed as to how they ended up in a Texas border town jail, Mclean and Jonnie discuss who gets to use the 12" black dildo first.

Both are bitchy that Kari didn't show up in the bright green Rio boomerang speedo (and cape), as promised, to give Jonnie a Brazilian wax so Mclean would finally shut up about the ass hair.

Our 2006

This year Naomi and I celebrated a belated honeymoon. We spent the month of July bumming around Costa Rica, sticking mainly to beaches, with one short, but cooling, trip into the mountains. Our favorite places were Corcovado, a vast, remote and wild wildlife refuge in the southwest, Samara, a lazy surfing town set within a picture-perfect bay on the Pacific, and Puerto Viejo, a colorful Jamaican-influenced surfer town on the Carribean. Although we grew tired of the zip line canopy tours and expensive food, we found the locals, like the weather, relaxing and warm, and the ecological diversity astonishing.

I continued on to Argentina for three weeks were I met up with a few classmates from medical school. Our plan was to establish a medical rotation/exchange program for students from our school. We spent time in Buenos Aires and Rosario, shadowing doctors in the ICU and ER. My most memorable moment was probably witnessing an unfortunate man die in surgery from a complication related to anesthesia. On a happier note, however, the physicians who hosted us expressed immeasurable generosity and kindness. I was very impressed by how caring and dedicated the doctors in Argentina were to their patients. Moreover, visiting the clinics and hospitals with local doctors was a precious opportunity to see how different a national health system is from ours.

Naomi still works at the Japanese restaurant, picking up lucrative weekend shifts that fit nicely into her busy schedule. She has also continued to work at the Wild Salmon Center with their Japanese conservation project. She has tentatively decided on earning a BS in biochemistry.

My second year of medical school is a lot like the first: mostly academic with tiresome exams that just never seem to stop. I will take the first step of my medical licensing exam in July, then continue straight on to clerkships - the part of our training where we rotate through difference services of the medical system (internal medicine, surgery, OB/GYN, pediatrics, psychiatry, rural medicine). Here I'll work side by side with residents and physicians 24/7 as if it were a job. I won't be at home much, but at least I won't be falling asleep in medical textbooks any longer either.

In addition to all that stuff, I am actively involved with global health organization, play city league indoor soccer, run, swim, ride my bikes, am learning how to telemark ski and, of course, enjoy myself with Naomi in the kitchen making delicious food, and playing with Sango, our dog, in the park. I miss playing music, but I simply don't have the time to stick with a practice schedule or commit to a group.