Social Medicine 101

Head over to The Differential for my latest post there about life as a medical student. I wrapped the frequent moves between clerkships, my own insecurities about interacting with other medical students in non-medical settings and an announcement about which rodents we are currently feeding in Spokane, WA.

Here's a hint on the last one:

20,000

Today - March 26, 2008 - at 4:18:48 PM local time, an unsuspecting web surfer entered the Hope for Pandora website. This visitor hails from Melbourne, Australia, uses the Safari browser on Mac OSX, and accessed the internet through an Australian provider called TPG. Evidently, Hope for Pandora is traded on the virtual stock market called Blog$hares. I'm not sure how this works and don't have time to figure it out. This is from the What is BlogShares panel on their site:

BlogShares is a fantasy stock market where weblogs are the companies. Players invest fictional dollars on shares in blogs. Blogs are valued by their incoming links and add value to other blogs by linking to them. Prices can go up or down based on trading and the underlying value of the blog.

I hope my stock is rising. Judging though from the amount of time (not very much!) I've had to make posts recently, I'd bet the value is holding steady or dropping. Some blogs I read have 20,000 readers in one day. It took me ten months.

Looking Over Your Shoulder

As a medical student, everything you say and do is noticed. This is important when you talk about patient information. For some, it's a reminder to not slip up in potentially evaluative settings. Others treat evaluation as an additional motivation to be your very best. A rare number of students don't care. Take for example an experience I had today:

I finished my work on Harborview's wards early today so was able to leave before the sun went down. My wife is on call tonight at the VA hospital. In my quest to be the best husband in town, I paged her to propose a dinner datein between admitting patients. She was happy to let me head over to the International District to pick up some Chinese takeout, and I was thrilled for the opportunity to sit in the hospital lobby eating delicious food with her.

When we first started our clerkships together, no one knew that we were married. Since we were both MD/PhDs, it probably seemed natural that we knew each other and chatted more than with other students. For an example, read this post from November.

One of the students from our first rotation together last fall happens to be rotating at the VA with my wife. We don't mind telling people any more, especially since we're more comfortable with both our career choices and our positions in what I've recently taken to calling the medico-educational complex. Anyway, we sat just to the side of the main entrance of Seattle's VA hospital. As I finished my minimally Americanized food, I got a strange feeling like I was being watched. Was it my wife's intern? Our classmate? When I turned around, I was surprised to see, not more than a foot from my face, this exact sight:

This very photo - larger than life - was there smirking at me. His head was about 16 inches across. Just hanging on the wall. Looking over all I was doing. Listening to every word from my mouth.

You never know who's listening to you in the hospital.

Autistic Politics

Autism is a real disease. Its prevalence in the United States and other Western nations is increasing. It causes suffering for many parents and children each year. I do not intend in this post to downgrade the significance of autism in society today. I wish to use autism as an example of the wrong way health policy is made in our country.

In reviewing the candidates' health care plans, I noticed that two of them make specific prominent mention of one disease: Autism. McCain says on his website,

As President, John McCain will work to advance federal research into autism, promote early screening, and identify better treatment options, while providing support for children with autism so that they may reach their full potential.

He also has an entire policy platform built on autism which you can read here. I noticed that autism is the only disease he specifically mentions in his health platform. Basically he argues that federal money needs to be spent on learning about and combating autism. Pretty harmless, right? I'll get back to McCain in a minute. Obama has also pledged support of autism research. He says he will:

Support Americans with Autism. More than one million Americans have autism, a complex neurobiological condition that has a range of impacts on thinking, feeling, language, and the ability to relate to others. As diagnostic criteria broaden and awareness increases, more cases of autism have been recognized across the country. Barack Obama believes that we can do more to help autistic Americans and their families understand and live with autism. He has been a strong supporter of more than $1 billion in federal funding for autism research on the root causes and treatments, and he believes that we should increase funding for the Individuals with Disabilities Education Act to truly ensure that no child is left behind.

More than anything, autism remains a profound mystery with a broad spectrum of effects on autistic individuals, their families, loved ones, the community, and education and health care systems. Obama believes that the government and our communities should work together to provide a helping hand to autistic individuals and their families.

I like this statement better. Instead of just spending money on research, he recognizes that the autism epidemic can be attributed to "broadened diagnostic criteria." Rather than to promise cures and treatments, he suggests "we can do more to help autistic Americans and their families understand and live with autism." Oh yeah, he also supports spending a billion dollars on autism research.

I couldn't find Clinton's position in her health policy material, but I bet she supports autism research...

Why is this physician scientist concerned about political leaders' pledges to fund research for a specific disease like autism? The physician in me sees hundreds of other disease that aren't adequately studies that cause pain and suffering to millions of people. The scientist in me imagines thousands of questions about the natural world (answers to which invariably contribute to tomorrow's medicines) that remain unanswered. There is only a limited pool of cash that researchers draw from every year. Why does autism get such a big chunk???

The answer is (drum roll pleas...) patient advocacy groups. Using the most sophisticated research tools available to me (Dr. Google), I found the Autism Society of America, Autism Speaks, Unlocking Autism, the National Autism Association, and many more. Almost all of these sites pledge to support research, make a difference in Washington and provide information about vaccines. And this is where McCain comes back into the picture. At the end of February, McCain's response to a question from a mother of a boy with autism was,

"It’s indisputable that (autism) is on the rise amongst children, the question is what’s causing it. And we go back and forth and there’s strong evidence that indicates that it’s got to do with a preservative in vaccines." He added that there’s "divided scientific opinion" on the matter, with "many on the other side that are credible scientists that are saying that’s not the cause of it."

What's wrong with this? Plenty of other people will tell you what's wrong with this. The upshot is that he is using language of the controversy to lend scientific credibility to an idea that is not scientific. It is therefore ironic that McCain wants to

dedicate federal research on the basis of sound science resulting in greater focus on care and cure of chronic disease.

Sound science. That's a good name for a nerd rock band.

So why is the autism lobby bad for health care policy in America? The first reason is that it puts contingencies on basic science funding. The second is that American health policy is so inept at keeping Americans healthy that we cannot even treat diseases we know how to cure. Your best chance at staying healthy is to be rich. While autism is a disease that affects many social and economic classes, its the rich parents that are driving the emphasis on a national autism program. I believe that disease advocacy groups should focus their resources on identifying worthwhile recipients for research funding. The Feds have much bigger fish to fry if the United States is to develop a health care system that affords access to all Americans.

In the end, autism is an important disease that should have access to national resources. But what I hear is "Vaccines cause autism" (which is not a scientific claim) and "We need more money for scientific research on autism." Autism advocates can't have it both ways.

Do you want to vote for health in 2008? Read my other posts about presidential health policy.

Race and Religion in 2008

Barack Obama made a speech this morning about race and religion in America. It cheered me after a rough and tumble day and a half on the wards. On a tip from a friend, I started listening to it in the background while I studied lung cancer. I had to put down the book to consider the elements of our life, culture and nation bigger than the little problems I'm facing today. If you have half an hour, I encourage you to listen. Here's a link to one recording of the speech. Don't worry -it's not a campaign speech until minute 27, and even then, it really doesn't have that feel. His words are part sermon, part lecture, part address to the nation, and yes, part campaign speech.

A Prized Nest

Old-tyme readers may recall that I enjoy cataloging nature around my apartment. Blog posts and art projects are my primary documentation. One of my favorite little birds is the common bushtit. Not only is the bird's name funny, it is a fun bird to watch. I often see them traveling in groups of 15-30 birds, hopping between bushes and trees in search of insects and berries. As very social birds, they tend to cheep up a storm. Last year, one of my birding friends alerted me to the fact that these birds build amazing nests. I never imagined that North American birds constructed anything other than, well, birdnest shaped nests. Bushtits build socks! Employing nature's wonder-material (spider webs) as the main structural element, these little birds build deep (and toasty) sacks.

After a year of casual searching for a nest, last weekend I spotted one during my required daily ambulation period! (Too much studying turns my brain to sludge, and walking/running around is excellent DVT prophylaxis.) These nests are amazing. Here's a photo of the nest I found; it's silhouetted against a typical Seattle grey sky:

Evidently, bushtit nests are warm enough that the jelly-bean sized eggs need only be incubated 40% of the day. The nests are used for a period of 8 weeks and support two broods each year. If they are disturbed, adults will abandon the nest and build a new one. It takes 3-5 days for a nest to be built. In urban areas, crows like to tear apart the nests and devour the babies; some observers report that the crows do this 'just for fun.' Humans also tend to collect these nests. Sadly, a week after I snapped this photo, the nest was gone. Someone clipped the branch from which it hung. I have since spotted two other bushtit nests in the area. Hopefully, those socks will support a few broods before falling victim to predators.

If you're in Seattle and want to know where the other nests that I've spotted are, I'll tell you if you promise not to disturb them!

For more info about bushtits or any other bird in Washington State, visit the BirdWeb site. It's an excellent resource for pictures, habitat, songs, distribution and behavior. (That's where I got the nice little bird picture above.)

Pay It Forward

How do you remember your grandparents?

Trombones, the importance of hard work, singing, a warm smile, morning walks, unconditional love. This is how I remember my grandfather. Evidently, Amos Buchwalter touched more than his grandchildren. This story in the Oregonian about a United Way executive is a testament to the value of having a large heart.

Grace follows him in life and in death.

Debating Health Care

My piece about the remaining presidential candidates' positions on health care is up over at The Differential. Since I refrained from offering any of my opinions over there, I'm using this space to point out more opinionated perspectives that wouldn't be appropriate for a non-partisan site. The one liner for me about the three remaining candidates plans is:

Each of the plans has good ideas built in, but the Democrats' proposals far better at addressing the critical challenged faced by our health care system today.

By the way, I think one plan is the best, I voted for a different person than who I think has the best plan and see many good ideas in the third person's plan. Stick with me, and you'll learn which names go where. Unfortunately, I cannot devote enough time right now (exhibit A: the 80 hour work week) to post all of the information about the plans, so I'll periodically post follow-ups and link them here. The first post (maybe you've read it) is my primer on the health care platforms over at The Differential. When I write a new article, I'll link it from the list below, or you can click on the Vote for Health link on my Readers' Favorites sidebar.

1. Vote for Health in 2008
2. Autism
3. Walk-In Clinics
4. Electronic Medical Records
5. "Socialized Medicine"
6. Paying For It
7. "Increasing Quality"
8. Generic Drugs
   

That's a fair start. Now you know what to expect. I hope you come back to visit early and often. When you do, be sure to chime in when I'm off my rocker or when I'm right on.

Oh yeah: my biases are: Clinton's plan is the best, I voted for Obama, and McCain has good ideas that the other two should pick up on.

What is Trolling?

This post is for only the hardest of the hardcore blog readers.

Because I have a different view about some topics people write on various science blogs out there, I have been occasionally labeled as a Troll. Usually it's for when I speak up in the comments sections of others' posts for some middle of the road perspective about the science/religion conflict or (more rarely) if I say something good about a Republican. I welcome critical conversation on my blog, and sometimes wish I got more trolls. (I've had two that have corrected me and one that was merely annoying.) Mostly, I get spam. That's why you have to wait for my approval for your comment to show up.

You should know about a blogger out there who goes by the name of PhysioProf. His posts (now featured on the ScienceBorg) are frequented by words I care not for, but his ideas and points I almost always appreciate. PP has gotten into a little tiff with another ScienceBlogger named Greg Laden about a post Laden wrote about the recent retraction of a research article by Linda Buck. (She's a Nobel Prize winner who happens to be the mentor of a good friend of mine in the UW MD/PhD program.)

At the end of his long dissection of Laden's imprecise statements, PP makes a nice observation about blog trolling:

Is it "trolling" to use the Socratic method to lead people to novel understanding? Is it trolling to force people outside their comfort zone in particular domains, as a means for encouraging personal growth? Is it trolling to vigorously advocate for and defend positions using coherent arguments based in fact and logic? Is it trolling to identify bu#$&it as such? Being comfortable all the time is no way to grow, to expand one's capacities, one's scope of knowledge and expertise.

Right on!

Elsewhere in his article, PP discusses the Nobel Prize, blogging ethics, the biomedical research complex and more. I started to read it with the intent to tire my eyes before a post-call mid-afternoon nap, but seem to have fired myself up, instead. Maybe curling up with a medical text under a blanket before the fireplace will do the trick. Maybe I should nix the textbook part...

One Book, PRN

In medical abbreviations, PRN stands for "pro re nata" or "when necessary." In my article for The Differential this week, I review the practice of giving one book to each kid at every well-child check between the ages of 6 months to 5 years. I learned about this strategy to increase literacy and the love of literature at Seattle's own Odessa Brown Children's Clinic when I rotated there last October for my pediatrics clerkship. Go on over to my article to read more.


Then come back here and pick out your own title from the book pharmacy.

The one about Ceasar Chavez is good. So is Goodnight Moon.

Making a Difference

Rush Holt (D), Vernon Ehlers (R) and, now Bill Foster (D).

Springing Forward

One of my current heroes is often touted as the originator of daylight savings. These days, the government says it saves money on electricity. Skeptics argue that the effect is paradoxical and the real reason savings time was instigated was to get people to shop at stores more in the evenings. At 48 degrees north, summer daylight is long at baseline. The sun is early to rise and late to bed. But for a nice take on DST, read this.

To be sure, daylight savings doesn't mean much for me. For example, last night when I looked at the ER wall clock while admitting a patient, I had to pause: "Is it 9:30 AM or PM?"

Blogging As An Inpatient

If I don't take care of myself by sleeping and eating properly this next month, I'll have to admit myself to a hospital, rather than work at one. So I must curtail my posts for only a small while in favor of crafting a better hospital note or reading up on a medical condition afflicting a patient. I have a few posts in the queue over at The Differential for the next few weeks, and I am sure I won't be able to steer completely clear of Hope, but I have to go for now.

I'll be sure to treat you to some reflections from my current stint at Seattle's county hospital. These stories need more time for crafting - time that I do not have right now. It's also, in my opinion, inappropriate to write real-time about patients who cannot consent to be the subject of an article here or elsewhere. Time and distance are good cofactors for anonymity. I could write about the practice and education systems of medicine, but fear that my accounts would emerge more cynical that I mean.

I hope my regular readers will keep me in their site feeders. I'll be back.

Decision Tuesday

Another Tuesday, another decision. Pundits say that by tonight, we could have nominees in both parties. If my political decision making device is accurate, however, I wouldn't be so sure. Past readers will recall the back story of this science/art experiment/installation. Basically, I've employed red, white and blue berries collected from various Western states to predict the outcomes of the presidential primaries. At various major elections, I present a snapshot of the electorate and offer a critical review of the candidates' positions. Since setting this up back in January, I have not uncapped the tubes. You can track the changes on this collection of posts. But for contrast's sake, just take a look at what politics does to the voters in just 3 short months:


This compares to January 8:

The entire collection of specimens has dulled, even accounting for the differences in lighting. (The artist apologizes for having a day job.) This clearly represents the dulling effect that the increasing rancor has on common citizens. Another striking finding is the bold assault of the red berries with mold. Earlier observations identified some of the mold as being blue, suggesting the possibility of formerly red voters crossing over. (If no one has coined the term, "Obama Republicans," let me take this opportunity to do so.) Today, however, the white snowberries show intense degradation. In fact, it appears as though small gremlins have spun cocoons in that sample. Snow. Fresh. Pure. These all could be represented by this specimen. These all are no longer present in the race. Biting attacks, political dirt and stale refrains now dominate. It is still unclear which berry correlates to which candidate. Perhaps the dear reader can offer a suitable explanation.

But what of my predictions? Or shall I say, what of the experiment's predictions. It is obvious to this observer that neither set of blue berries shows a dominating difference of decay. At the end of the night, neither will have sufficient reserve to claim victory. On the red side, however, both samples are bathed in mold. My guess is that a more intensive analysis than observation will be needed to correlate the presentation at hand with the apparent victory about to be handed to John McCain. And by 'more intensive analysis,' I am thinking 'taste.'

The 'View

On my way to Harborview Medical Center...