1811

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.

Hospital Diversion

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

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.

Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

Dr. Goatee

In searching the internet for possible residency interview questions, I stumbled upon some other 'tips' about interviewing. Most notably, one site from Rush University offers the following prescription for a successful personal presentation:

Dress should always be conservative, tasteful, neat—and comfortable.

Have the appearance of a successful, mature physician, not a medical student.

MEN should wear a suit, not sport coat or khakis.

• Navy or gray, solid or pinstripe.
• White or pale-blue shirt.
• Conservative tie: solid, stripes, or small pattern (red or navy).
• Keep jewelry to a minimum.
• Short hair, preferably no goatees.

It's not just the Chicagoans at Rush that offer this advice. I found websites penned by schools from LA to Boston arguing for a clean shaven face. But there are other things I noticed about these suggestions:

Dress should always be conservative, tasteful, neat—and comfortable.
Okay, I buy this. Comfortable helps when you're running to catch your next flight, too.

Have the appearance of a successful, mature physician, not a medical student.
I think I have this down, what with being older than most of the residents at some programs; in five interviews (three schools, so far), I've received the follow-up question, "How old are you?"

Men should wear a suit, not sport coat or khakis.
Okay, I'll give here. Although when I interviewed at UW for the MD/PhD program, I wore khakis and a tie - no jacket. Look where that got me!

Navy or gray, solid or pinstripe.
Evidently black is out?

White or pale-blue shirt.
Whoops again. I don't own white or pale blue.

Conservative tie: solid, stripes, or small pattern (red or navy).
My real goal here is: not ugly.

Keep jewelry to a minimum.
Nickle allergy keeps this in check for me.

Short hair, preferably no goatees.
Does a shaved head count for short hair? Maybe shaving up there will cancel out the apparent transgression I make with this:



I did end up shaving, but it was the top of my head...

Really Tough Stuff

Lately, I've been complaining about the residency application process on this site and elsewhere in the non-digital world. It's been nice to be on rotation and have daily reminders of why you are going through the cumbersome process. Sometimes however, giant "reset" buttons come your way. Gianter (grammar intentionally misused) then catching a DVT or sewing a laceration, and not quite like the reset weekend to help me switch from day to night shifts that I wrote about this morning.

The reset I'm referring to tonight is more important. Today I visited a blog that I had not been to in a while. It's Ben Towne's online journal.


Ben is the three year old son of one of the pastors at the church I attend. He was diagnosed with an aggressive neuroblastoma last August (2007). Ben and his family have endured ups and downs of treatment and remission, hospitalization and time at home. They have had a large body of supporters, many of whom may have never even met Ben. I count myself as one of the folks who first heard about the family's story in a pew and have followed it by periodically reading the blog.

Much of the art of medicine is related to empathy with patients and families we encounter them in the hospital or clinic. It's a gift to be able to achieve this emotional skill, and it's one that can always find a new place in the physician's toolkit. There is even more to learn from witnessing non-medical aspects of patients' experiences. Some people go into medicine because of these experiences: a grandparent who may not have received the best care, a sibling who couldn't be saved from a disease, or a friend who was paralyzed in a car accident. I was not one of these people. That's why it has been a privilege to follow along with the Towne family's trials. Their web journal also makes it easier for me to think about and pray for them.

After aggressive radiation and chemotherapy, Ben's tumors are back with a vengeance. There is little that medicine can do for him except control his pain. The family has taken him home from the hospital and will pursue comfort care for him. By any account they have a tough road ahead of them. Yet, the journal reports this week that:

Many times last night Ben told [his mom] not to worry and that he loves her.

If you are inclined to pray, meditate or reflect about Ben and his family, I am sure that the Townes would appreciate it.

Hello. I'm Thomas. And I'm a Blogaholic.

Okay.  It's time to dive head-first into the medical blogging controversy.  One of my colleagues at the University of Washington is interacting with administration there to possibly set guidelines and recommendations for medical blogging.  He's got me thinking again about this issue.  As you recall, I thought a lot (and still do) about the line between sharing a patient's story (anonymized) and respecting her rights.  I settle with asking patients or masking identifying facts so much that the patient would not recognize the account as his own.  You can imagine there are a lot of people who have things to say about this.  I respond to my professional society's position in this week's article for The Differential.  Check it out if you have the chance.

Regarding blogaholism, I actually do score positively on the CAGE screen for blogging (A and E).

The HIPAA in the Room

I've been a little gun-shy of my posts on Hope for Pandora recently. It seems as though a Seattle medical version of big brother may be watching... watching blogs. One of my friends - a blogging friend and real-life friend - was asked to remove material or shut his blog down because a compliance officer at a hospital where we train was concerned that certain of his posts violated patient confidentiality. Check out Noel's blog, aptly named, Constructive Procrastination.

I have sought to maintain the integrity of my writing by anonymizing my stories or asking permission of my patients to write about them or folding several patients into one pseudo-fictional account in the interest of telling a good story. Each of these techniques fall within the guidelines of the Healthcare Blogger Code of Ethics. What bothers me is that my friend had also observed these behaviors in his writing.

What bothers him is the manner in which he was approached. I'll let him tell the story in his own words, which started a couple of weeks ago. It seems as though our hospital wants to have more control over what gets into the public domain from experiences inside the hospital. Since I have vague aspiration to publish some of my own expereinces in a format more commercial than a blog, this got my ears up. After all, I already write for lunch money over at The Differential. I contacted folks in the community relations department before starting that gig - I wonder if someone else is trying to enforce some element of control or oversight on writers like me.

I think that my hospital administration is a little out of its league right now. One in ten Americans have tried their hand at blogging or something like it. I'm betting that health professionals are no exemption to that. I'm a little worried about an Orwellian move here. Why isn't the Health Care Blogger Code of Ethics or something like it good enough?

The compliance office may be full of friendly faces and good intentions, but do they really know what they are trying to do? Fortunately, my friend has volunteered to provide a voice for us bloggers.

Blogging My Needle Stick

Taking my lead from ScienceBloggers Abel, who blogged his vasectomy, Dr. Free-Ride, who blogged her mammogram, or Zuska, who blogged her dilation and curettage, I decided to blog a recent personal medical experience of my own: a dirty needle stick.

Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.

It was in one of these cases that I incurred my first dirty needle stick.

Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.

We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.

My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.

In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:

• Would you like me to make a sterile field around the wound?
• What size gloves do you wear?
• What do you think about clamping this small artery? and
• Would you like me to move the sharps off your field?

I'm pretty sure I asked that last question immediately before I felt a sharp twinge in my left ring finger. The resident had put down an old needle in a rather precarious spot, and I thought, "he's going to stick himself with that when he reaches for his forceps." I grabbed the remaining stub of thread from the field, careful not to let the dangling hook catch my glove while he took a sweeping pull at the current suture on his first knot. Ouch! Quick inspection showed the cutting needle had caused a rent in my glove and that my blood was mingling with the patient's. I immediately left the sterile field, washed my hand with soap, all the while milking the wound like a blood drive phlebotomist checking your hemoglobin. My hand was in the wrong place at the wrong time.

At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.

So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.

The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.

Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?

This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.

Perhaps.

A Big Burly Joke

A few weeks ago, I came up with what I thought was a great riddle. After none of my hand-picked readers figured it out, my wife suggested I rephrase it in the form of a joke. One intrepid reader offered a good guess (Burl Ives Trio) that was not what I was looking for.

So for those of you reading this for the first time, here is an (improved?) version of the joke:

A surgeon, a pathologist and an oncologist are hiking through forest when they encounter a burly tree (shown at left). Curious by nature, they sit down to ponder their discovery. Of course, the surgeon proposes to cut open one burl. The pathologist thinks that's a good idea; she whips out her pocket microscope to examine it. The oncologist goes on about a two-hit hypothesis and proposes dumping toxic chemicals onto the tree's base. What do you call this conclave of MDs which also happens to be a name for the piece of wood being examined by the pathologist?









A Tumor Board!



I tried to tell this riddle/joke at a recent party I held at my house when I realized that a few years ago, I had actually sliced up a small burl with the intent to make a set of coasters out of them. (The slices warped, and will need additional work to make them functional.) I got some laughs, but not because of the joke. Mostly, my guests thought something about the back-story was hilarious.

This group of mostly medical professionals proceeded to hypothesize the origins of burls. We all decided burls are some sort of tumor. Perhaps it's caused by a genetic cancer, but also perhaps by insects, fungus or viral disease. (Viruses cause tumors in humans, too!) That burls often congregate in groves could support a genetic or infectious cause. But the tendency for burls to form on golf courses and orchards speaks to a traumatic origin. Maybe the burls I saw in Alaska are residual from moose antler scraping behaviors or aborted assaults by beaver?

For those out there who have never heard of the second meaning of "tumor board," you will probably not think this as funny as I did (and still do, by the way). At most hospitals, there is a special meeting of specialists every week that serves to discuss the new, complex or complicated cancer diagnoses. Since every cancer is a little bit different, and every patient is different, you can imagine there could be a very large number of approaches to cancer therapy. In an effort to provide the best care, pathologists (who have the final word on diagnosis), surgeons (who provide the important skills to remove some tumors) and oncologists (typically the doctor in most contact with the patient) all meet to present and deliberate information. This meeting is called a tumor board.

Clue

Activity on this blog been down of late, mostly 'cuz I've been busy finishing my Ob/Gyn clerkship. Well, then there's that pesky truth that I mostly write for myself.

But I thought I might get one guess for my previous riddle. Yes, it was complicated and as my first blog riddle, maybe too hard. My wife suggested I turn the puzzle into a joke. So here's your first clue:

A surgeon, a pathologist and an oncologist are on a hike in the forest when they encounter a burly tree (See the recent post for a picture). Curious, they sit down to ponder their discovery. The surgeon proposes they cut open the burl. The pathologist thinks that's a good idea; she whips out her pocket microscope to examine it. The oncologist goes on about a two-hit hypothesis and proposes dumping toxic chemicals onto the tree's base. What do you call this conclave of MDs?

And your clue is this: the answer is the same as one of the items in the pathologist's possession.

Grand Rounds

From Alaska to the South Pacific, they're blogging about medicine. And David at Marianas Eye has got the best from this week. Head over there for a large collection of clever lead-ins for each entry to Medicine Grand Rounds.

Reducing and Reusing, if not Recycling in the OR

Over at The Differential, I recently wrote about waste in medicine; lots of stuff gets thrown away, especially in hospitals. One of medicine's most egregious offenders is the OR. Items ranging from blue towels to cautery equipment to paper drapes to laparoscopic instruments to suture to bowel staplers all are pitched at the end of each case. In the past few weeks I've enlisted the help of scrub techs and circulating nurses to cut down on the footprint of the cases I'm involved with. Here's what we came up with in the reusing category:

1. Suction irrigators run on 8 AA batteries and are designed to run for two hours. After the case, the irrigator is pitched - including the pump. If you salvage the batteries from each suction irrigator used for ectopic pregnancy or cholecystectomy cases you assist with, you'll amass 10 hours of digital camera usage per irrigator, or put another way, a lifetime powering of remote controls per surgery clerkship.
2. Blue towels are the sterile, lint free linens that surgeons dry their hands and arms on after scrubbing but before donning gown and gloves. For folks like me, who 'scrub' using the germicidal alcohol-based Avagard chlorhexidine cleanser and come into the room 'dry,' there's a good chance that towel will go unused in the case. This makes a perfect car-drying towel. (For after you go through the automatic car washes, of course - they save water and reduce toxic runoff.)
3. Specimen containers are especially useful for my natural history collections. (See my entries on Wunderkammern for clarification.) The sterile cylindrical canister that comes with Foley catheter kits is good for spices when you go camping. Unused but opened pathology specimen containers work well for storing small parts. Any clean container works well for storing captured insects or categorizing bark samples or some other random hobby.
4. Sutures are thrown away all the time. Many ORs save the packets for student use and practice. Before grabbing extras off of the scrub tech's Mayo tray, be sure to ask. Not only because there's a chance open suture is contaminated with patient parts, but NEVER TAKE ANYTHING FROM THE SCRUB TECH'S MAYO TRAY!

It's hard to reduce consumption when you are a student. Since embarking on this mission, I have noticed that some providers are careful about ordering disposable items into the sterile field, asking for tools to be ready but not opened until it is absolutely necessary. This saves the patient money and reduces consumption. I'd say that counts as killing two birds with one (unopened) stone. Not that I'm advocating avicide.

Recycling will be a tough thing to implement in the OR. Most paper gets contaminated with blood, poop or iodine. I don't think we want that stuff getting into the recycling waste-stream. In the end though, shouldn't reducing and reusing decrease carbon footprint even more than recycling? Anyone have other ideas about reducing waste in the OR? Or in the hospital?

Waste in Medicine

It's time for you to check out another of my articles at The Differential. This one's about how little recycling occurs at hospitals and what could be done to stem the waste-stream. Click it to Read it!

"Rounds"

Have I mentioned before that I'm not fond of patient rounds?

Some rotations I've been on consist of half your time in "rounds," a quarter of your time in "sign-out," and the rest split between conferences and patient care. (I know, rounds and sign-out technically are patient care, but they hardly feel personal to me...)

It's no wonder residency programs have to keep their residents over night every fourth night. When else would work get done?

By the way, "rounds" is when a team of students residents and an attending physician walk around on the ward updating each other on patient status. "Sign-out" is when one team tells the next all of the details from the patients' care that day.

Ella Ella Eh Eh Eh

This week has been busy, if a little disorienting. I do not think I'll get used to the daylight round the clock. It will make it easier to stay up all night if I am so called. For the next few days, I'll probably be humming Rihanna's Umbrella tune. Not because it was raining yesterday, but because of this. (Warning: if you're not familiar with this pop song, watching this video could be really painful.)



Didn't know the words to this song in the first place? Now you can sing along about the microbes you don't want to get...

The Ethics of Laughter

Have you ever been uncomfortable with humor in medicine? Or experienced uplifting laughter with a patient or your doc?

My recent entry over at The Differential explores this idea in the context of some of my recent patient experiences.
Check it out. If you have a chance, let me know what you think about humor as therapy.

If...

If I didn't have sensitive hands...
If I were 5 years younger...
If I wasn't married...
If I could be content doing one thing at a time...
If I could put up with the hierarchy just a little longer...

I would totally pursue a career in cardiac or vascular surgery. In its favor is:

The 'get in there and fix it' mentality,
The meticulous microsurgery,
The dependence on bioengineered technologies,
The adrenaline of cutting open the aorta (on purpose), and
Working on a team.

I suppose I can find those things and a lot more elsewhere. Well except for the cutting open the aorta part...

UpToDate OutOfDate

Where do most academic medicine providers get their information about the latest understanding of disease and treatment?

A web search engine called UpToDate. This service provides review articles of the medical literature that range from pretty good to excellent.

Imagine the horror medical students, residents and providers across the University of Washington system experienced today when they read this email:

"As a result of extraordinary price increases to provide UpToDate access for our distributed community of UW Health Sciences students, faculty and staff across the Pacific Northwest Region I have had to make the painful decision to cancel this heavily used resource. In spite of extensive negotiations with the publisher over the past two years we simply were unable to negotiate a price that our Health Sciences Libraries budget could afford. The price for UW is much higher than for other institutions, in large part, because we are a regional health sciences center with regular faculty and students across Washington State as well as in other states throughout the WWAMI region. This means that simple onsite access as provided by some Health Sciences Libraries (e.g. walk into the Health Sciences Library physically and access the resource) will not work for many of our students and faculty who would need to get into a car to come here or worse, fly for several hours!"

For more details about the specifics of this situation at the University of Washington, visit the UW UpToDate alert page. As a medical student spending the majority of his third year outside of Seattle, I am particularly aware of the crux of this issue. What I want to know is how they can charge so much money for what is basically a bunch of review articles. Just how much are their writers being paid? Do the authors get paid per hit? I kindof doubt it. The last time I checked, basic science professors don't get paid jack for writing review articles. (Actually, I just (this evening) reviewed the preprint proofs for a review article I was the first author on. Far from being paid, we had to pay the journal because we include color plates...)

Johns Hopkins refused to subscribe last year, and now the UW. As of July 1, 2008, UW students, residents and faculty will no longer have access to the most used resource for medical decision-making. In a way it is too bad, because the articles on UpToDate were the best annotated and easiest to read of any online medical resource. Because I am a (small potatoes) employee of WebMD, I've done a little bit of research in to the reference services provided by that company. So far, I haven't been able to use it for comprehensive reference information as seamlessly as UpToDate, but I think that will have to change. And, the WebMD portfolio includes a large amount of other cool information that is more media-friendly than UpToDate. Other services available to providers in the UW system include:

MDConsult (WebMD's healthcare provider page)
Cline-guide
DynaMed
AccessMedicine

If you are logged into your browser with your UW password, these links will send you directly to all of the subscription services.

Despite the inconvenience it will be for me not to have an UpToDate subscription, I am glad that UW just said no to big publishing. This info should be open access, anyway!

Anyone out there have tips for an UpToDate-free world?

As I discover tips, I'll try to post them under the tag, OutOfDate. But that reminds me, I've got a series about presidential health care politics I was going to write, too...

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.