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.