Even though my posting here at Pandora has been anemic, I've continued to write columns at The Differential. (After all, I'm under contract for a few more weeks.) If this portal is your reminder to read them, and you're looking for convenient links, here are my most recent posts.
May 17: As I tried to pack for my cross-country move, I categorized my stuff left over from umpteen years of education. If only I'd figured that out earlier! May 23: You may have already read my musings on the significance of graduation - the day that is. June 2: While teaching some second year students during their transition to the wards, I learned that an expert medical student is only a mediocre intern and a horrible attending. June 14: I jotted down dome of my thoughts and emotions on the eve of my first responsibilities of internship. June 27: It took a little while until I actually had my first shift. But soon after, I wrote just a bit about that. July 4: I think hand washing is one of the easiest ways to reduce complications in medicine. Yet it remains the hardest for us health workers to actually do...
I've a few more entries in me until I put blogging on hold in favor of learning to be a doctor. But at least this will give you something to chew on. And maybe you'll see me back at Medscape in another capacity someday!
In my first weekly conference as an emergency medicine intern at Yale, we had several lectures. Topics included D-dimer in pulmonary embolism, atrial fibrillation, chest x-ray reading and emergency medicine advocacy. What? Advocacy in the classroom? One of our EM professors is an expert in the subjects of accident prevention policy, so she gave us a primer on what we can do as new doctors to contribute to the current health care debate. Here's the letter I wrote this morning on my day off.
Dear (Insert CT lawmaker name here),
I am a resident physician in the Yale-New Haven Hospital emergency department. I'm writing to tell you a little bit about ER conditions so that you will have a sense of how emergency care is an important issue that should be included in the currently debated health plan. A health care plan in our country cannot be comprehensive if it does not address emergency care.
When I show up for my 12 hour shift at Yale's level one trauma center, I am immediately inundated with an atmosphere that to an outsider could be perceived as chaos. The scene is far from the clean depictions on your television set, and believe me, there is not time for the intrigue that home viewers expect from “Grey's Anatomy.” Every night at many of the top hospitals in this country, patients sit in emergency room hallways for lack of private rooms. It is not unusual for these folks to receive all of their care in the hallway. I will personally wheel patients in and out of rooms so that they may have the dignity of a private exam. It breaks my heart to tell these folks, “We'll only be in here for 10 minutes before I take you back out into the hallway.” Can you imagine your doctor saying, “You have appendicitis and will need surgery, but until then try to make yourself comfortable on this hallway stretcher,” like I have? When you are having the worst pain of your life, you can't understand there is someone sicker than you.
This brings me to the health plan. There are always really sick patients. President Obama has been championing primary care as the centerpiece of his plan; and rightly so: prevention and a steady relationship with one doctor will go far to reduce health care costs. But increasing resources to primary care will not alleviate the overcrowding problems we face in delivering emergency care. For example, with 97% of the population in nearby Massachusetts insured, ER use has increased by nearly 10%. A refrain we physicians wish to emphasize is: coverage does not equal access. Where do people go when they get sick after hours?
I am familiar with and applaud sections 214 and 215 of the current Senate bill (“Systems for Emergency Care...” and “Trauma Centers...” in “Quality, Affordable Health Care for all Americans” submitted by Sen. Reid), and hope you will support these provisions. The grants and mandates are based on recommendations a 2006 Institute of Medicine report and will go far to improve care through one of the most frequent access points for people in need. In the interim, I'll do my part to see as many patients as I can safely handle so that our ER's hallways are used for walking, not patient care.
Sincerely,
Thomas Robey, M.D., Ph.D.
If you are wondering why I don't post more here in the next year, it's because I'll be using my time to write other things. Such as letters like this...
We made it to New Haven and have unpacked most of our boxes. My Facebook friends out there will know that I've finished my orientation week, and have started my orientation month. If there's one thing important about being a resident, it's being oriented...
My posting frequency will be much less this year. I'm afraid I just won't have the time to polish my writing in a way I'd be comfortable presenting to the blogosphere. But I am still writing. And I'll be back. There's still plenty of 'Hope' around. Hopefully I won't lose it through internship!
By this time tomorrow, the entirety of our belongings, including this desktop computer, will be packed into an 8'x9'x16' space. That excludes clothes, an air mattress, family photos and a few beloved plants. I will spend my REM sleep this evening summoning the requisite packing skills for the job.
We are packed. I've been reading Connecticut newspapers even though I haven't quite found one I like. There's a house waiting for us in New Haven, and my wife and I are debating the merits of being called Yalies or Yaliens. She prefers the latter. We're squeezing as much as we can out of the nascent Seattle summer. Two recent activities we recommend are hiking at Ingalls Creek (on US Highway 97 between Bluett Pass and Leavenworth) and an afternoon canoeing through the Washington State Arboretum on a boat rented from the UW WAC.
The black bear that seen earlier this week in Seattle was found yesterday in Everett, WA, just 30 miles north of where is was first sited. The bear turned up in another urban area, so wildlife officials tranquilized him and transported him out of the urban area. Hopefully for him, the adolescent male was dropped off along Highway 2 in an area that is not already claimed by an older, stronger bear. In the end, I'm happy the animal did not meet the same demise that the poor creature found in the University District three years ago.
According to wildlife officials, at no point were humans at risk from the bear; they claim that the bear was more at risk from cars or from dumpster diving. Evidently, human food doesn't do much good for bears. It probably doesn't do best for humans either!
Today's my last day in clinic or hospital. At least of medical school. How will my wife and I celebrate? By packing, of course. But school is not quite over. After two days off next week, we teach second years procedures for a few days and then have a week of a summary course called "Capstone." I think that consists of advanced procedure training and learning the basic stuff that may have slipped through the cracks the first time.
Anyway, I am so happy to be finished with one more task that I could yip with joy. Fortunately, I can save myself the embarrassment because the neighborhood coyotes are at this moment doing just that. Well, at least they are yipping for some reason.
If you would like to read more of my reflections, consider following this link to my column at The Differential.
No. We are not getting another sports team. (Though I hardly noticed the NBA SuperSonics' absence.) A few years ago, a bear was found in Seattle's University District. It met a grisly demise at the hands of untrained law enforcement officers. Hopefully, the city has learned its lesson. Because there's a bear in Ballard. It's been sited in Seattle's West Shore: Magnolia, Ballard and the area. According to the Seattle Times, wildlife officials are involved. This guy is reading the ingredients on a tranquilizer dart. I hope this bear is not destroyed. I wonder how much cash has been spent on the bear thus far. Multiple squad car chases and a helicopter have been involved... Read the article. You're not going to believe it.
Update 5/20/09
The bear, now named "Urban Phantom" has made his way back north and east of the city. Hopefully, we will find a spot more to his liking in the Cascades. Here's a map detailing many of the animal's sightings.
As I've been packing, I've begun to realize which "stuff" from medical school is important and which is not. Read about my ideas over at MedScape this week. As a bonus, I can offer you a glimpse into the social dynamic between my wife and me as we pack for the big move! Need a hint? My wife is an awesome packer. I am not.
When Susan and I move next month, we are planning to leave our televisions behind. Part of that decision is that they are older. Part of it is to reduce the volume of stuff to move. One of the things I am looking forward the most to is not having cable television. Lately I've been sucked in to programming (namely on the SciFi, Animal Planet, History and Comedy Central channels) when I should have been writing, studying or packing. So the move is something like a "practice what I preach" opportunity. (As an adult, I alternate between tolerating and railing against the boob tube.) Find stronger opinions than mine at the Kill your Television web site. Rather than release lead and mercury into whatever space I'd be weilding a sledgehammer, I've turned two old TVs into fish tanks...
So what will I do with my time? I'll try gardening, home improvement, internet ideas and reading... These things I already do and actually enjoy more than commercial programming. For example, I liked this piece in the New York Times by its editorial observer Verlyn Klinkenborg about reading aloud. Reading aloud is fun. I just need to find some people who agree with me. I bet there are a few in New Haven!
And what about other screen entertainment? Movies? Internet? We will still be able to do that, but on my desktop computer. I think the screen is bigger than our TV's anyway. And shows I really want to see? I guess I'll have to try out BitTorrent for size. In the mean time, I've got some packing to do!
This week, I assumed my place in the national online call reqistry known as amion.com. (That's pronounced, "Am I on?") Like every other resident, my call schedule is available to anyone with the proper login. Since I'm not sure how protected said logins are, I'll relay for all those who are interested which rotations I've been assigned.
6/21 - 7/20 Yale ED & Orientation 7/21 - 8/17 Bridgeport Hospital ED 8/18 - 9/14 Bridgeport Hospital ED & EMS 9/15 - 10/12 Bridgeport Hospital ED 10/13 - 11/9 Pediatrics at Bridgeport Hospital 11/10 - 12/7 Medical ICU at Yale 12/8 - 1/4 Ultrasound & Anesthesia 1/5 - 2/1 Ob-Gyn at Bridgeport Hospital 2/2 - 3/1 Yale ED 3/2 - 3/29 Cardiac Care Unit at Yale 3/30 - 4/26 Orthopedics 4/27 - 5/24 Medicine at Yale 5/25 - 6/21 Yale ED
This is just one more step in my transition to residency!
ED Shoes, click on the image for a Flickr interactive view.
There comes a time when all that's left to be said is, "Goodbye old friend." This week I used that phrase twice. Once to the Harborview emergency department and later in the same day to my clinic shoes. Over the past 2 years I've used a dedicated pair of shoes during ED shifts and overnight call. The day I stepped out of the Harborview ED was the same day I said goodbye to these old friends. The left toe bears the badge of ortho (plaster). The right foot has a spatter from irrigating my last wound in Seattle. Both bear marks from my away rotation at San Francisco General, as the heels and laces retained a tinge of the scrubs' cranberry pink dye. The real reason for discarding this pair was the torn apart left heel and loss of sole traction. Otherwise, with a splash of bleach they'd be ready for another shift!
There's a blog published by the now online-only Seattle Post-Intelligencer called Seattle 911: A Police Blog. Many cities have similar sites that act as 21st century police scanner bulletins. While surfing for news this morning, I happened to find that the topthreestories on the site involved patients I saw at Harborview Medical Center during my last shift. There are also pictures to help understand the injury mechanism. Here's one:
The entries each indicate transport to the hospital where I was on call. My willing compliance with HIPAA and patient confidentiality rules prevents me from saying any more about the specifics of the cases, but I will comment briefly on a facet of patient care that could use improvement. Information is often lost in the transition from witnesses to emergency response personel to emergency physicians to their hospital consultants. (I was a student on the orthopedics team at the time.) We hope that the important information is maintained, but invariably, there is something that we wish we had known at the time.
Even with excellent sign-offs between providers, patients come in to the hospital with limited histories. Patients could be 'out of it' due to shock, pain or pain medicine. There could be a language barrier. Patients are sometimes intubated. Important features may have been observed but not documented on the scene, in transit or during an initial physical exam.
One of the important questions in the patient's history for emergency docs are: How did this occur? Among providers, this question becomes: What was the mechanism? Discovering or confirming this info with the patient is one way emergency providers evaluate patient alertness and orientation while they do their injury surveys, so patients sometimes get annoyed at having to tell the same story over and over again. But that's if the patient can tell the story. Sometimes they cannot.
It turns out that the Seattle 911 blog had information that may have been helpful for providers to understand these patients' injuries. In two of the cases from Friday, the entry was made while (or soon after) the patient was in the emergency department, further underscoring the potential utility of electronic documentation of pictures. One of the patients described the accident in a way that when I saw the image, I thought, "I saw the person involved in that accident." The other image generated a, "So that's how that happened" response in me. The importance of pictures (yes, worth a thousand words) is well known in emergency care; the soon to be history Polaroids of automobile accidents are often taped to critically injured patients' charts. The photo below is more a reminder of how beautiful it was on Friday that how the accident occured.
It wouldn't have changed how we treated these patients to know the specifics documented in the blog entries; the primary determinants of treatment are derived from the physical exam and what the x-rays and CT scans reveal. But one wonders if speedy documentation of accidents and injuries in the field could ever be incorporated into the electronic medical record. iPhone medicine is already being practiced in many emergency departments. The fellow on our service used his Blackberry to photograph one of our patients' wounds. He only partially joked with the radiology tech that he needed it to plan for a surgery. The image was later used to communicate with the attending surgeon and was reshown the next morning during a sign-out conference.
Reforming and universalizing the electronic medical record is central to the Obama plan to reduce health care costs. I hope the software programmers include a mechanism for documenting accident photos. In the mean time, maybe I should keep the local injury blogs open on one of the ER's computers.
Photos are from the Seattle 911 blog and were taken by Ben Otteson and Dana Vander Houwen.
Earlier this week, I was feeling a bit wiped out from my overnight call on the orthopedics trauma team. I made the mistake of rambling a bit about my thoughts over at the Differential. Today I'm post-call and haven't been able to sleep yet. What a difference two hours in a call room makes!!! Yes, this is the obligate link to another page post. Sorry about that.
In relation to this week's Earth Day the New York Times is running a comparison between the energy costs of stainless steel water bottles and disposable plastic ones. Given the intensive energy input to steel production, it will take between 50 and 100 reuses of the steel water bottles to balance out an equivalent usage of disposable bottles. That seems reasonable enough to me. In my water drinking prime, I refilled my Nalgene bottle twice a day, which was the volume equivalent of 4 or 5 disposables. The problem I have with this analysis is that the author used disposable plastic as a straw man. I'd like to see the balance between a stainless steel container and the polycarbonate bottles that you can use just as much. I know, if you drink 6.02x10^23 liters of water from polycarbonate bottles, you might get cancer. But there are other durable plastic choices.
There's another kicker in the feature (that seems a little off): the carbon costs of marketing and storing a steel bottle on the shelf of an REI or equivalent store may be as much as producing it in the first place!
The bottom line seems to me to be: Use old stuff. Reusing anything is better than buying a new 'green' object. The worst steel bottles are the red colored ones - every time I see someone drink from one, I think, "Noooo! Don't drink that kerosene!" But that's just the Boy Scout in me...
Not that I'm not a sports fan. I root for the Cubs and try to find places to watch my beloved Pitt Panthers. But it's the other stuff I'd rather do. And the study has particularly suspect scoring methods for 'misery.' Namely not including pro soccer, for which many Seattlites go bonkers for and for giving more misery points to teams that reach the finals but lose... Maybe Seattle residents just find ways to celebrat that they actually got to the finals...
Lest you think this cartoon inaccurate, I live in Seattle, and routinely see eagles, owls, red tailed hawks, Cooper's hawks and ferocious hummingbirds from my window. Salmon spawn within city limits. Seals hang out near the Ballard locks to harvest said fish. And we see snow-capped mountains on any day with clouds above a 7,000 foot ceiling. You can rent a kayak two blocks from my apartment.
Evidently, television coverage of the "Tea Party" on tax day was pre-empted by another story. Since I've given up using the television for acquiring my news in any form other than presented on Comedy Central or in live broadcasts (debates, live speeches, CSPAN and the lot), I didn't catch this other story until it was echoed in the morning newspapers. Yesterday, a 47-year-old Scot performed a rendition of "I Dreamed a Dream" from "Les Miserables" on the UK's equivalent of American Idol and brought down the house. Much rubbish was made of her frumpy appearance, older age and romantic status in advance of (and after) the performance. Which reminds me that our current day conception of talent is inectricably linked to looks and social status. I'm glad that the show (titled "Britain's got Talent") actually brought out the talent it advertises. Especially if it drowned out some of the shouting about the illogical Tea Party. I actually enjoyed sending in my check this year. But then again I like the idea of the government funding science, cleaning the air, caring for the poor sick and lame, building roads and even defending freedom. I think the rich conservative broadcasters who orchestrated this Tea Party are celebrating a la David Horsey...
I've not embedded the clip because YouTube has restricted it and because if you are visiting my front page, you still get to hear the "Imperial March" in the background. Wondering why? Read this. Then watch Susan Boyle live a dream.
This week at The Differential, I took a stab at suggesting an entry for the new Diagnostic and Statistical Manual of Mental Disorders. (The DSM V will be coming out in May 2012.) Nothing serious, though. My disease has been informally diagnosed for decades: senioritis. Head over there to check if you feel any of the symptoms or demonstrate any of the major or minor signs... I'd say I had some senioritis before I started my current orthopedics trauma rotation. The schedule alone cured it for me...
Was I ever excited a few minutes ago when I learned that New Haven is located in USDA climate zone 6b! That's the dark yellow zone on this map.It's no 9a as in Seattle, but 6b is better than Chicago's 5a or Pittsburgh's 5b - two places I've gardened in the past. It's looking good that we will have a yard (0.09 acres minus the house's footprint), so if we have any time after (1) being residents and (2) minor remodeling projects, the yard will offer us an urban oasis. And vegetables. This year even!
Anyway, this is the sort of information that helps you get through the labor of packing...
Now that I'll be moving to Connecticut to further my medical education, I've tried to start paying attention to health policy in that state. An article in the New York Times today sated my weekly appetite for such information. The punchline is that in this difficult budget cycle, the governor of CT (M. Jodi Rell) has proposed cutting state support to the state's only emergency flight system. LifeStar is headquartered in Hartford, but as this map shows, conducts about 250 flights a year to the Yale-New Haven Hospital.
If the cuts are approved, there will be financial capacity for only about half of the flights now made. The governor's office cites that this program is run from a private hospital as a reason to be included in the cuts. The problem with this reasoning is that there is no other service in the state making this kind of transport. According to the article, legislators on an appropriations subcommittee recently recommended restoring the entire $1.4 million that was cut. Even so, I think it's reasonable to engage in discussions about the cost of emergency transport. It seems to me the $9000 per flight cost is worth saving a life.
It's clear from earlier posts I've made that I'm not the biggest fan of the residency match process. One thing that I can get excited about is the move across country. A small part of that is that if I don't get excited about it, I don't think I'd be able to finish all the tasks associated with the relocation. We're headed to New Haven on a red-eye tonight. Which is the beginning of the end of my career as a medical student. It's also the beginning of the end of my contributions to The Differential. Which is just more reason why you should head over there an read my latest column.
In Seattle, there's an apartment complex at 1811 Eastlake Ave. where homeless alcoholics can stay for free. They are not prohibited from drinking alcohol. They stay there at no charge. This program costs the King County taxpayers $4 million a year. Are you outraged?
What if I told you that these same 95 homeless folks cost the city $8.2 million dollars a year before enrolling in the program? That's a savings of $4 million a year!
A study describing this finding was published in the Journal of the American Medical Association yesterday, and was described in a brief article in the (now online-only) Seattle Post-Intelligencer.
We're off to New Haven this weekend search for a domicile, which right now is one of the most pressing thoughts for soon-to-graduate medical students. But if you're a third year medical student, you're thinking about plans for next year. There's a lot that you can control about your life, and it starts with arranging a good curriculum. Check out my tips for doing it just the way you want at The Differential. And don't tell me you can't read it because you've no password. Log-ins are free!!!
On and off for the past 7 weeks, I've been working at the Seattle Veterans Affairs hospital. Many medical students spend part of their time at VA hospitals, but I was not assigned to one until last month. (I completed my geriatrics rotation and part of my radiology clerkship there.) But as with a lot of things these days, the day has come that I will not return to this place for a while.
The reason I am sharing this is to share a funny (if strange) phenomenon I experienced every day on my morning walk from the bus stop or the parking lot. By the time I approached the entry, I had started humming The Imperial March. It didn't matter if I was reading a book on my way in, listening to music or news radio. In the meters approaching the door, I had moved from the well recognized drumbeat to that catchy progression.
I cannot explain this. I mean, it's not like the hospital looks like an Imperial battle cruiser or anything.Or does it...
If your bandwidth is low, you may experience jumpiness in the music.
This post is for students in the Issues and Values in Biology course at Seattle Pacific University. I'll be visiting you later this week to talk about how the media interacts with science. There are a lot of great examples of how science is well represented or misrepresented in the news, but I've picked one story from a field I'm familiar with and that hopefully is interesting to you.
Even before President Bush signed an executive order restricting Federal support of embryonic stem cells, there was considerable attention paid to the differences between adult and embryonic sources of the cells. If you aren't sure what is the difference, I'd encourage you to check out this website sponsored by the National Institutes of Health. Knowing the basics will help you understand why I've chosen the following example. There is still considerable conflict - especially in faith communities - about embryonic or adult stem cells. (See my post about President Obama's recent press conference for more details.) The field of stem cells is very large - there's something in the news every week; I'm focusing on one issue that was in the news about two years ago.
In the January 2007 issue of Nature Biotechnology, a group of scientists from Wake Forest University led by Anthony Atala published an article titled, Isolation of amniotic stem cell lines with potential for therapy. (The link needs a university subscription or an email from Dr. Hunter.) The bottom line in this report is a claim that there are cells in amniotic fluid (the nutrient that fetuses consume/breathe before birth) that have some of the same potential to form tissues as embryonic stem cells.
Nature Publishing Group publishes many of the most respected journals in science, and Nature Biotech is one of their gems. Each issue probably generates 5-6 press releases. The relationship between these top tiered journals and the mass media is important. It is the stock pathway for the dissemination of cutting edge science into public knowledge.
Unfortunately, 'cutting edge' in science rarely equates with 'breaking news.' Breaking news is too dependent on context. In this case, the work presented took about 7 years to complete, AND stem cell funding was near the top of the Dems' political agenda for 2009. And when a news story overlaps with politics, there is invariably hype and hope attached to what the science could someday do. (Some social scientists studied this in relation to stem cells a few years ago. If your'e interested, read this paper - you'll need a school subscription or the email from Dr. Hunter.) Did this get published for the hype?
The lab where I got my PhD held a journal club focusing on this paper about 3 weeks after the news broke. (Journal clubs are opportunities to assess for ourselves the merits of a publication, how our experiments might need to change in light of others' results, etc.) Our lab has a reputation for being one of the most skeptical in the field of cardiovascular stem cell biology. The outcome of this animated discussion was unanimous agreement that these cells were much more like (maybe identical to) a type of adult stem cell (mesenchymal stem cells) that are multipotential, but not pluripotential like embryonic stem cells. I could outline about 8 reasons for this conclusion, but that would distract from the real issue I want to bring up: what happens when 6 pages of dense scientific data is condensed to 500 words?
Interestingly, when a paper DOESN'T publish science stories, it raises eyebrows. Science writer Michael Fumento announced a cover-up of this information committed by the New York Times when that paper opted not to publish the report. It turns out that their genetics reporter looked at the Atala paper last week and
deemed it a minor [scientific] development.
Hooray for Times reporter Nicholas Wade and his science editor Laura Chang! Ms. Chang went on to say,
There is so much hope invested in stem cell research that we have grown increasingly concerned about prematurely fanning these hopes.
it's too bad many editors don't realize they have science writers who don't understand - or worse, misrepresent - science.
Exactly! Isn't it strange when we can agree on a statement but not a sentiment?
I believe there are some key questions left to be answered:
Why did Nature Biotechnology permit publication of a paper that presented mundane data in conjunction with amazing claims?
Is the manner by which science writers collect their information about scientific reports thorough enough?
Since it increases visibility of science in general, could it actually be better for science that the public gets this information? (Misrepresented as it may be.)
I look forward to meeting you in class this week. If you were not able to access the scientific papers linked above, Dr. Hunter will make them available to you as .pdfs. Also, feel free to post questions here if you have any before class.
Last week, the Seattle Post-Intelligencer stopped printing newspapers. It was my favorite Seattle paper. All that's left of the storied news agency in town are a few reporters and an online only paper that is a glorified news feed. It's not even worth posting the link. I wonder if they will keep their offices and the rooftop globe downtown. More importantly, will anyone get paid to serve as public watchdog the way formal reporters were? It's just another newspaper that has bit the dust...
I'm blogging from Ipswitch, MA today. It's a crisp spring day on the New England coast. I'm here for the executive council meeting for the American Scientific Association. You may have seen their booth at the annual AAAS meeting. I'm the early career representative to this organization of scientists who are Christians. This is a relatively small group (~2000) of folks from around the country who are united in the following beliefs:
As an organization, the ASA does not take a position when there is honest disagreement between Christians on an issue. We are committed to providing an open forum where controversies can be discussed without fear of unjust condemnation. Legitimate differences of opinion among Christians who have studied both the Bible and science are freely expressed within the Affiliation in a context of Christian love and concern for truth.
Our platform of faith has four important planks:
We accept the divine inspiration, trustworthiness and authority of the Bible in matters of faith and conduct.
We confess the Triune God affirmed in the Nicene and Apostles' creeds which we accept as brief, faithful statements of Christian doctrine based upon Scripture.
We believe that in creating and preserving the universe God has endowed it with contingent order and intelligibility, the basis of scientific investigation.
We recognize our responsibility, as stewards of God's creation, to use science and technology for the good of humanity and the whole world.
These four statements of faith spell out the distinctive character of the ASA, and we uphold them in every activity and publication of the Affiliation.
The organization's web site aims to provide resources for Christian (especially Evangelicals) who face conflicts between faith and their understanding of science. The executive director also plays a role advising other groups like AAAS's Dialogue on Science Ethics and Religion (DoSER) and other groups. Our latest project is to help produce science materials for home-schoolers that maintain the high level of scientific integrity that the ASA upholds.
If you are interested in learning more, visit the ASA website or feel free to contact me.
He did just sign an executive order lifting the August 9, 2001 restrictions on Federal funding for research involving human embryonic stem cell (ESC) lines, but President Obama still doesn't seem to understand the science involved in the decision. Of the thirteen questions he fielded in tonight's press conference, the one he did the worst answering was the one from Washington Times journalist John Ward.
Watch the Q&A and then indulge me by reading my take on Obama's response.
Did you catch the sections where Obama displayed a strangely Bush-in-the-headlights look. I'll remind you as we read through it again together.
QUESTION: In your remarks on stem cell research earlier this month, you talked about a majority consensus in determining whether or not this is the right thing to do, to federally fund embryonic stem cell research.
I'm just wondering, though, how much you personally wrestled with the morality or ethics of federally funding this kind of research, especially given the fact that science so far has shown a lot of progress with adult stem cells, but not a lot with embryonic?
PRESIDENT OBAMA: Okay. No, I -- I think it’s a -- I think it’s a legitimate question.
Actually, no! The question is not entirely legitimate. The questioner added on the to the end of his question the words, "especially given the fact that science so far has shown a lot of progress with adult stem cells but not a lot with embryonic." This is horribly misleading. Adult stem cells have been "researched" for half a century. Human embryonic stem cells were first characterized in 1998. The speaker sets up a straw man that the two types of cells are on level ground. So the question isn't legitimate if it isn't true. By calling it legitimate Obama ceded ground because everybody has in their mind that last phrase. To clarify, embryonic stem cells have shown more promise in the past 10 years than adult stem cells did in their first 25.
OBAMA: I -- I wrestle with these issues every day. As I mentioned to -- I think in an interview a couple of days ago, by the time an issue reaches my desk, it’s a hard issue. If it was an easy issue, somebody else would have solved it and it wouldn’t have reached me.
Look, I believe that it is very important for us to have strong moral guidelines, ethical guidelines, when it comes to stem-cell research or anything that touches on,
AWKWARD FUMBLING-FOR-WORDS SILENCE... So this is why you use the teleprompter so much!!! By the way, it's not cool to conflate morals with ethics. Morals can influence ethics, but they are not the same. This confusion is a big reason so many scientists are upset with the religious right. Morals are personal standards. Ethics inform a social standard. By definition, defining ethics is a consensus-dependent activity. Players on both sides of this argument are still not ready to talk with each other.
you know, the issues of possible cloning or issues related to, you know, the human life sciences.
COME ON! "possible cloning or issues related to, you know, the human life sciences?" I would have liked to hear a reference to the main issue here: when do we think humanity begins?
I think those issues are all critical, and I’ve said so before. I wrestle with it on stem cell; I wrestle with it on issues like abortion.
Okay, there it is. Finally, there's a politician willing to call a spade a spade. The reason this debate is so lively is that the pro-life contingent already has a high-functioning political machine... Now we just need some effective communication about how stem cell research isn't the same as abortion.
I think that the guidelines that we provided meet that ethical test. What we have said is that for embryos that are typically about to be discarded, for us to be able to use those in order to find cures for Parkinson’s or for Alzheimer’s or for, you know, all sorts of other debilitating diseases, juvenile diabetes, that -- that it is the right thing to do. And that’s not just my opinion. That is the opinion of a number of people who are also against abortion.
Nooooooooooooooo! Not the C-word! What we scientists are after is understanding that leads to treatments. Politicians LOVE cures. The thing is, there aren't many cures in medicine. (And some ill-informed autism advocates want to take those away from us!) When there is no cure, the adoring crowd supporting research could turn to an angry mob. And another thing: When are the politicians' science advisors going to step in to help them understand which diseases stem cell research is likely to yield treatments for??? Stem cell research might have a chance at curing neurological diseases. There's a chance that Parkinson's could be treated because its a pretty well-defined region of the brain that's affected. Even then, I'm not sure we've figured out how to convince the ESCs to become substantia nigra (that's the region of the brain involved) cells, much less how to get them to integrate. But Alzheimer's Disease (AD)? We still know relatively little about how AD occurs. We know it hits different people differently and have really good tests to identify dementia or to diagnose the disease at autopsy, but even the expensive medicines so many people take hardly work at all. Nancy Reagan pleaded with GW Bush to lift his restrictions because of AD. Politicians who support ESC research use Alzheimer's because 1) a lot of people get it and 2) everyone is scared of it. Okay, so I don't like AD or Parkinson's. What are the diseases that could benefit from ESC research? Try spinal cord injury - the first FDA approved human trial for any ESC therapies is underway already. Diabetes is another good one, though my cynical side believes that disease was thrown in because the Juvenile Diabetes Research Foundation is one of the biggest science lobbying groups. The disease no one talks about is CANCER. What we are learning about reprogramming stem cells will likely inform future treatments for cancer.
Back to OBAMA: Now, I am glad to see progress is being made in adult stem cells. And if the science determines that we can completely avoid a set of ethical questions or political disputes, then that’s great. I have -- I have no investment in causing controversy. I’m happy to avoid it if that’s where the science leads us.
Fair enough. In an ideal world, we will be able to learn from ESCs in order to reprogram other stem cells to do the same thing. And that is exactly what a couple of scientists did recently with induced pluripotent cells (IPCs). Read about them at Wikipedia. A future Nobel Prize may be awarded for this work... But this work would not have been possible without ESC research.
OBAMA: But what I don’t want to do is predetermine this based on a very rigid ideological approach. And that’s what I think is reflected in the executive order that I signed.
Way to finish strong. Let science ask the questions, but have a more-or-less consensus ethical framework within to let them work.
QUESTION: I meant to ask as a follow-up, though, do you think that scientific consensus is enough to tell us what we can and cannot do?
PRESIDENT OBAMA: No. I think there’s always an ethical and a moral element that has to be -- be a part of this. And so, as I said, I don’t take decisions like this lightly. They’re ones that I take seriously. And -- and I respect people who have different opinions on this issue.
But I think that this was the right thing to do and the ethical thing to do. And as I said before, my hope is, is that we can find a mechanism ultimately to cure these diseases in a way that gains a hundred percent consensus. And we certainty haven’t achieved that yet. But I think on balance this was the right step to take.
The president wisely ended on the ethics part of the question, so finished strong, but I hope that Mr. Obama's science advisers help him understand this topic so that it's not the science question at his next news conference that he flubs.
And I'll be honest with you: in terms of the potential for the cells to become any tissue in the body, I didn't think that the IPCs would stand a chance against ESCs back when they were first derived. But the great thing about science is that opinions only matter until the data comes back. And if you don't accept the data that everyone else does, you can do the experiment yourself. Unlike politics, the central element of all science is honesty and integrity; when proven wrong, the best scientists dust themselves off and start asking new questions. The investigator who does not will soon be out of a job.
Now that I'm posting with a little more frequency, I submitted one of my recent entries to the bloggers' grand rounds. They're up to Vol. 5, No. 27 over at Code Blog, and since I was linked, I'm glad to be able to send some readers in that direction. Enjoy this week's best in medical blogging.
It's been a little while since I've posted anything at the science and religion blog Clashing Culture. But my co-bloggers over there have kept the place free of cobwebs. I spent a little bit reacquainting myself for the ever-present creation vs. evolution issue this weekend. There's a Texas School Board meeting this Friday to decide science standards for the next 10 years. And of course, some last minute insertions by the board's chair have the scientific community worried that creationism will find its way into science text books... It turns out that the chair of the board Don McLeroy has written an anti-evolution book Sowing Atheism and calls clergy who accept evolution morons. Sounds like the typical anti-intellectual name calling that makes this issue so frustrating to folks like me who just want to get along. In not very related news, one of creationism's champions, Ken Ham, has taken to leveling hypocritical complaints about radio interview ambushes. Read more at Clashing Culture.
Read more about the Texas School Board issue here and the Clergy Letter Project here.
There are some news stories that demand your attention. Those of us who gather information online are used to seeing the eye-catching news stories (like in the column of story links on CNN's webpage) that keep you from surfing to the next site. It says a lot about the media that headlines like Woman on horse shops at Target are adjacent to 3 Oakland police officers killed in shootings. I admit that I typically avoid the news stories about killings equally with the stupid sounding ones. So why did I read the articles about the tragedy in Oakland?
I think it was the personal connection.
In my career as an EM doc, I will see plenty of shootings.
I've already been a part of care for a man down.
I admire how firemen, police officers and medics put themselves at risk for a greater good.
In the recent match, I ranked the emergency medicine residency at Highland Hospital (in Oakland) very high on my list.
That I had already imagined myself living in Oakland, working at Highland and being a part of the trauma team that received victims like this struck a chord with me. Unfortunately this is not the last time I will face a situation such as this. Part of me believes that reading about this, reflecting on it and greiving in absentia will help me prepare for when I'm the one applying pressure, pushing fluids and wheeling the patient to the operating room as soon as possible. Would I also be among this group? Police officers, ministers, community organizers, political leaders and concerned citizens are gathered all around Oakland in groups shown in this photo. This scene just happens to be in an ER waiting room that I've walked through. A different kind of mourning was no doubt going on behind the waiting room walls.
Photo: Justin Sullivan/Getty Images
Is there is also a role for EM docs outside in the community talking about violence, safety and emergency response? I'm sure the answer is yes. I wonder what that would look like.
I think it is. We're waiting the extra hour to check my results from the comfort of home. So be patient, family! Since I believe in both free speech and the possibility of reform, I went ahead and listed a few reasons why the emphasis on the Match (even I use a capital letter) could be misplaced. You'll have to go over to The Differential to read it. And yes, you will still need your free login. One of my blog friends recently asked me if the same computer that compares my rank list with 30,000 other lists and the lists from thousands of programs was the same that made Bowl Championship Series calculations. I am inclined to think that this present figuring very well could be an off-season task for the BCS brain. Like the bowl placements, there will be folks happy with the outcome and folks that are not.
By the way, which are the other professions than medicine that use similar systems for job placement as that for medical residents?
The Military
Professional Sports
Anything else?
Match, Smatch... They should just call it what it is. Today is Draft Day!
Last week, one of my patients gave me some elk jerky cured from a buck his 14 year old grandson shot last season. Read about my experience at the Medscape blog. Of course you'll need to use or sign up for a free login to read it.
I don't mean any direct offense to John Marburger by re-posting this cartoon by David Horsey, but today's stem cell announcement reminded me just how lame science had become in the executive branch over the four years.
Promoting science isn't just about providing resources -- it's also about protecting free and open inquiry. It's about letting scientists like those who are here today do their jobs, free from manipulation or coercion, and listening to what they tell us, even when it's inconvenient -- especially when it's inconvenient. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda -- and that we make scientific decisions based on facts, not ideology.
That's the part that will actually change how politics uses the information science offers.
It troubled me to learn that rates of non-accidental trauma has risen by more than 2-fold at Seattle Children's Hospital. Non-accidental trauma is the medicalized word that describes injuries incurred by children that are the result of abuse. This trend is evident across the country.
This reminds me of a theory I once read about kids born in the Great Depression. When money got tight, parents fought and drank more, leaving children bewildered and often alone. Many kids' childhoods were remembered as periods of unpredictability; in their high school years they lacked direction or a sense of confidence.
Childhood depends on a sense of security. I'm guessing there are a lot of parents who will need to work extra hard to provide that emotional support even as the financial backing has failed.
As you may recall, one of my posts from last year was selected for the Open Laboratory 2008 compilation, which gathered 50 posts from the science blogoverse for a print edition that you can buy. It may seem backwards to take internet material and print it on paper, but there's a good reason for it. The collection's proceeds go toward supporting ScienceOnline'10, a science blogging conference next January. The book is also a nice way to see how bloggers make legitimate literary and journalistic contributions to whatever conversations are being held on matters relevant to science, society and beyond. I've had only a few sciencey things published thus far, so will probably permit vanity to reach into my wallet to buy a print version. It's also available in .pdf. And if you wish to read each post in its original context, each one is linked at A Blog Around the Clock. If you do buy it, do so from lulu.com. The conference organizers get more funding that way.
If you couldn't tell from my post yesterday, I approve of the president's impending action to lift funding restrictions on human embryonic stem cells. While, I've not had the time to post much about this issue, I have been reading others' takes. The Washington Post has a nice blog/column about religion and gives good time to science and religion bits. A piece likening stem cell ethics to organ transplantation caught my eye, because I've thought about this connection before and wanted to read what an 'expert' would say about it. I'd recommend you check out the article by Susan Brooks Thistlewaite, and the counterpoint by Thomas J. Reese, but what I did a doubletake on was this image: This type of tube is commonly used to store frozen cells, including stem cells. The tube is thawed, because the red media is clearly not a chunk of ice. I'm thinking the photographer wanted an illusion of pipetting into the vial. But in the picture, the scientist is actually pipetting into the cap. There is a good chance that the diagonal tube is a forceps (tweezers), but with the cinematic techniques used so often on CSI and other science-enriched TV shows, I'm still putting my money on the theory that we're supposed to think there's pipet action going on.
The five or six readers who have stuck with me these last few months and haven't banished me from their readers will know that the claim to health care is one of my personal, ethical and political interests. Which reminds me that I need to read up about Health and Human Services nominee Kathleen Sebelius. But one of the reasons I've not been able to do my homework on her, or write in this blog is the Ethics in the ER course I'm teaching this quarter. I've been using a blog to move the discussion beyond the classroom. I think it's been working. The students who post comments have shown great insight and offered poignant reflections.
Anyway, while researching this week's topic, I ran across a couple of media clips that could be interesting to folks who think health care reimbursement needs to be reformed. Remember Harry and Louise? They were the middle class couple in the mid '90s who didn't take very kindly to the Clinton health care plan. Last year, a consortium of lobbying groups turned that technique on its head. I think they even found the same actors. It's worth heating over to the Ethics in the ER blog to check them out side by side!
My latest essay at The Differential makes the rounds on rounds. For this emergency medicine bound medical student, I am glad that rounds will not be a big component of my future career. They make me dizzy. Rounds is an element of medical culture that is core to medical education, but in my opinion is rarely done well. Fortunately for you, I don't go into my criticisms in this piece...
If you haven't yet, you'll need to sign up for a free account with Medscape. Sorry about that. And if you have had trouble with the links before, I think that problem's been fixed, too!
This creates a tough challenge for me. As the newspapers and ACEP present it, this policy clashes with my reasons for choosing a career in emergency medicine. But I've also held that innovative solutions for improving access to medical care should be able to be implemented from within the ED. I didn't hear much about the UHI when I interviewed at the University of Chicago. But in a recent email to applicants, the U of C emergency medicine residency program director did say that training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. And as Ben points out below, it is important to see both sides of this story. But the impression of the program will suffer. Is that a risk I want to take in assembling my rank list?
If you're in my ethics class, we'll be focusing on this issue in two weeks.
Finished with interviews for 3 weeks and I'm still brimming over with thoughts about the process. This time, I'm concerned about my horrible carbon footprint secondary to traveling to so many cities. Read about it at The Differential. You may need to sign up for a free account.
There are a few emergency medicine programs that require residents to fly on helicopters. I will not be ranking those programs at the top of my list. MedEvac is an important part about emergency response and I respect the folks who fly a great deal, but I'm not sure it is a necessary part of my hospital training. Especially when more that 35 people have died in the last year on medical helicopter flights. The National Transportation Safety Board is hearing testimony about this issue this week.
I'm finishing up preparations for a lecture on confidentiality and privacy for my Ethics in the ER course Wednesday, and came up with what I think is a great hook for discussion about a topic that is usually greeted as dry by many in the medical field. Here goes:
Who remembers their online HIPAA training course? If your experience is like mine, the topics of privacy and confidentiality seem like boring topics. This week on the blog, several of you posted very interesting accounts of dilemmas concerning confidentiality. If you didn't get a chance to read them yet, I'd encourage you to do so. So perhaps privacy isn't as dry as I first thought? Let's say you're not convinced by your classmates' challenges.
I'll step back a bit. Our medico-legal system may reinforce privacy as a topic learned by rote and repetition, but it gets a lot more interesting when you consider that this issue is at the core of the arguably most controversial Supreme Court ruling in the last half century. Can anyone guess what I'm talking about?
Roe v Wade was decided not based on statutes governing assault, or autonomy, or even Aquinas' principle of double effect. You couldn't guess that from the expressions, “right to choose” or "right to life."The case was decided on matters of privacy. Roe v Wade held that a woman's decision of an abortion falls well within privacy afforded by the 14th Amendment and the Bill of Rights. And since abortions these days are almost always in a medical setting, it's easy to see how the privacy from the state bleeds into the confidentiality afforded by patient-physician relationship.
If you are in the course and happened to find this post early, consider yourself a planted answer if no one responds to my question!
Sometimes information in medical records cracks me up. Take for example these excerpts from a note for a patient I helped care for:
Interval History: Had a good day, with an especially lucid morning. Enjoyed throwing rubber chicken into sink. Family pleased with progress.
Exam: NEURO: Continues tremulousness, is mostly non-verbal (per family, is exhausted and getting cranky after busy morning). Throws rubber chicken onto attending physician and into sink.
ATTENDING STATEMENT: I personally saw and evaluated the patient. She did seem to enjoy throwing a rubber chicken at me and into the sink. I discussed the patient with Dr. XXX. I agree with the findings and plan as documented in his note.
The moral? Rubber chickens never fail to amuse.
Critical and identifying information has been changed to protect this patient's privacy.
I've been blogging over at The Differential for a year, and have a few more stories/rants/ideas to broadcast in that venue before I finish medical school. This week, I've reflected a bit on the logistics of interviews and the parts that I'm not so keen on.
But this isn't my standard refer you to The Differential post. I must also alert you that the whole blog has migrated from the Typepad interface to the Medscape platform. That's good for me because I can post entries myself and not have to email them to my editor first. But it COULD be bad for you because you'll have to sign up for a free Medscape account. If you want to bask in the old, all of my articles are available here.
Some pundits have commented that President Obama's inaugural address lacked the catch phrase or memorable line that JFK or FDR offered us in "Ask not what your country can do for you, ask what you can do for your country" or "We have nothing to fear but fear itself."
Perhaps this is true, but what I remember is:
We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost.
Let's focus on that first part:
We will restore science to its rightful place.
Does that mean the science adviser's office will be moving back into the West Wing???
With regard to the science in its rightful place goal, it looks like one step is
tripling the number of undergraduate and graduate fellowships in science, to help spur the next generation of home grown scientific innovation.
I wonder where all of those students will go after they have their science degrees? Will industry support them? Because I'm pretty sure academia won't. What about those young scientists who are finding it difficult to get their first grants?
Moving on, I think we should talk about the inaugural promise to wield technology's wonders to raise health care's quality and lower its cost. How exactly will we wield the wonders? According to the same Recovery Metrics document, the US government hopes to
computerize every American’s health record in five years, reducing medical errors and saving billions of dollars in health care costs.
Riiiiiggght... This one needs a little talking about.
I recently finished interviewing at 12 emergency medicine residency programs. As part of this, I toured some of the country's busiest emergency rooms; in many places I donned scrubs and saw how things worked 'on the inside.' Many places do have an electronic medical record (EMR), but some hospitals said that they probably wouldn't have a system in place by the time I finished residency (that's in four years). So that's a first strike against this goal. If the emergency departments - who provide primary care for more than 50 million Americans and are the first access point for unscheduled medical problems for everyone else - don't have an EMR, how will everyone's record be computerized?
This problem aside, there are additional barriers that need to be overcome if a 5 year goal is to be achieved.
A standard computer laguage that all EMR platforms use, so when patients move from one office to another or from one system to another, their info can be brought up in the same interface. As it stands now, this is not even standardized in the same hospital. In many places the emergency room's EMR is different from and cannot communicate with the hospital's!
For patient safety to be increased, more time and/or staff needs to be allowed for computer entry. In emergency rooms with medical records, I was amazed by the amount of time residents and attendings spend in front of computer monitors instead of with patients. In place of noting information on a clipboard while talking with patients, doctors have an extra hugely time-intensive step of data entry. Technology needs to improve. What about notebook style touch screen terminals? Except that would increase cost...
Is computerized care better? This seems to be a moot question, because everyone's headed in the digital direction. I'm probably just not well enough read on this topic, as the VA health system and large HMOs like Kaiser are all computerized. Are improvements to care there because of computers, or because everything's in the same system?
I see the computerized record as one of the important first steps in developing a single-payer model of health care, but the biggest impediment I see is getting the companies who make EMRs to talk to each other.
I applaud both of these goals of training more scientists and making health care safer, but want some more details, too.
My latest article at The Differential focuses on one component of my interview experience: illegal and inappropriate questions. Check it out, and if you are so inclined, back me up! And while you're there, check out a companion piece by co-blogger Anna Burkhead ponders another ageism related issue. By the way, special thanks to DrugMonkey for inspiring the legwork to sort out the legal and social rules for this topic.
Hope for Pandora is a place for a conversation about science and medicine. This site is one attempt to build a dialogue about science, medicine and society. You'll also find plenty of vignettes about my experiences in graduate school and as a medical student en route to becoming an academic emergency physician. I welcome and appreciate comments.
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I'm an emergency medicine resident at Yale-New Haven Hospital. My academic interests include medical humanities and the social and political influences on science and medicine. At home, I like to garden and tackle do-it-yourself projects.
