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.

Water for $4.00 a Gallon!

This past weekend, as many as 15 motorists in Seattle filled up their tanks with water-contaminated fuel. Evidently 500 gallons of water found a way into the Shell-supplied Safeway gasoline at a few stations around town... No one is sure how this happened. Greedy middleman? Honest mistake? Maniacal anarchist? Each seems a possibility to me in this passive-aggressive, economy-conscious, WTO-rioting city. But my favorite part of the story is a quote from one of the afflicted drivers:

"I didn't think I'd pay $4 a gallon for water," Fitts said. "But I didn't think I'd be paying $4 for gas, either."

Um. Wake up Mr. Fitts!!! That case of bottled water in the back of the SUV you were driving your kids to the hardware store in? I bet that water cost more than $4 a gallon...

By the way, gasoline is so expensive in Alaska that they don't even bother putting the price up on the station marquees. This weekend, I paid between $4.15 and $4.75.

Busy!

Fortunately for me, I've been busy with work and play this week. Who thought the blog would suffer even with interminable daylight. But fear not! There is plenty of material in the queue. Like pictures of bears and whales and moose. A little too close to each of them. And a new blog project about science and religion. And some thoughts about urgent care and ERs as safety nets. And...

But for now, I need to finish writing up two patients for my OB/GYN clerkship requirement. One who had a basketball-sized ovarian cyst (benign) and another who delivered a breach baby boy by Caesarian section.

Sorry for the delay.

Big Day

Three deliveries today.
I 'caught' one.
There was one other regular birth and also a Caesarian section.
But what really gets me is that 9:45 PM, driving home, I needed sunglasses...

City Moose/Country Moose

If you've been paying attention, you'll know that I'm in the process of moving all over kingdom come for the sake of my medical education. As part of the third year of medical school at the University of Washington, I've lived in Anacortes, Spokane and Fairbanks (in addition to Seattle). There are pros and cons to this lifestyle, some of which I've broken down for you at The Differential this week.

Need more reason to head over there? There's a sweet picture of a moose.

Students and Sedation

"Your time in the OR can be especially valuable because of the quality of pelvic exams you'll be able to do while patients are sedated."

Caution: squeamish topic ahead...

Last week, I wrote in The Differential about the blurred line in the operating room between humor between physicians and laughs shared with patients. With another week comes for me another state, another clerkship, and another uncomfortable situation in the OR.

Learning the pelvic exam is an important part of medicine. As a doc in a busy ER, I bet I'd average one a shift. But who wants a student doing their exam? Any manipulation downstairs is one that needs to be done with respect and professionalism. There are gender issues, privacy issues, and the question of whether the exam is medically indicated. (Many docs subscribe to a policy of giving a rectal exam to every patient with gastrointestinal problems or anal pain - a colorectal surgeon I recently worked with thought otherwise.) In the context of these issues is the fact that students don't have a clue what they're doing when they start doing exams!

Med students learn these important exams first with paid healthy volunteers (NOT each other!), and graduate to willing patients. With rare exception, a student's exam will need to be followed by a resident's or attending's exam. Two for the price of one. Would I volunteer? Many patients do not.

Which brings me back to the quote above. When a woman has a hysterectomy or other gynecological procedure under general anesthesia, it is very important to know where the uterus and cervix are. The patient has agreed to having a student in the OR, so implicitly agrees to an exam. The pain from the procedure far outweighs any discomfort caused by a pelvic exam, and the anesthesia leaves the patient without a trace of memory from the exam.

So why am I still uneasy about performing a pelvic exam on a sleeping patient? Strangely, I'm more comfortable with someone conscious. But I bet I need the practice.

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...

Ready, Set, Count!!!

Man is it going to be tough to sleep.
Sunrise, 4:30 AM. Sunset, 11:00 PM.
And gaining 7 minutes of light every day.

Welcome to Fairbanks

9:30 PM

As in, I took this photograph of my rental car at 9:30 PM.

I'm in Fairbanks for my obstetrics and gynecology rotation. My wife will be doing surgery. Today consisted of finding the hospital, the outpatient clinic, and a delicious Korean restaurant in a bowling alley's basement. We also paid visits to the Safeway for groceries. This evening, it's 63 degrees and party sunny. Notice in the photo above the power cord hanging out of the Subaru's grille. This isn't some alternative energy scheme, when temperatures drop, a preheated engine increases the chances of successful start and also reduces emissions. We don't expect to use the plug. After all, we noticed college co-eds from the University of Alaska walking down the street in shorts and bikinis this afternoon!

In Spokane, our apartment was adjacent to Lincoln Park, which offered a nice place for evening strolls. Here in Fairbanks, we're just next to a bird sanctuary called Creamer's Field. On our exploratory walk this evening, we saw sandhill cranes! Some were engaged in their silly mating dance.

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.

And The Sky Went Wild

The Wild Sky Wilderness is a reality!

Just northeast of Seattle is an area of amazing beauty and spectacular scenery that until today was just a patch of government land. Today, after many years of politcal wrangling, it has been Federally designated as wilderness, thereby protecting it for generations to come. This wouldn't be possible if Richard Pombo (R-Ca) had not been defeated in 2006 and if George W. Bush wasn't trying to salvage his 2000 campaign promises of expanding national parks and preservation areas.

The photo above shows an area just up the ridge from the Skykomish River, nearly at the point where I wrapped my canoe around a boulder two summers ago. I'd like to blame the scenery on my faulty steering, but really, I just read the river wrong... What's nice is that the 'Sky' river is just on the border of this soon-to-be pristene area. It will now be difficult to develop the river, thereby preserving the land, the sport and the fishery in that basin.

Put the Wild Sky Wilderness on your list of must-hike outdoors destinations. But not too many of you...

Photo credit to Joshua Trujillo and the Seattle P-I.

Bacertial Rasmosis

In the coming age of the electronic medical record, all of your health information will be stored as pixels and megabytes. The consequences of this are far-reaching. Hopefully, your record will be able to move seamlessly between doctors and accessible no matter which ER you find yourself in after one of your drunken tree-climbing escapades. Of course, EMRs are not yet standardized, what with 5 or 6 competing software companies hawking their services. And there is the Health Insurance Portability and Accountability Act (HIPAA) to deal with... (What we really need is a Health Information Portability and Accessibility Act!) But this is all to set the stage for a unique problem faced in health care.

How does all the information get into the computer?

Doctors from my generation (and especially my 5 year younger classmates) grew up typing. They'll be able to type their notes and orders real time. In the outpatient setting, many resident physicians carry a laptop into the office to enter patients' data. But what about the folks who can't type very fast?

Dictation.

Doctors have notoriously bad handwriting. As patient encounters became more important for the legal record and later were stored digitally, there needed a way for scribbles to be translated into typeface. Docs started using services that would transcribe speech into text. Sometimes 'in house' stenographers collect tapes at the end of the day and type them up the next day. In more urgent situations, docs can call an 800 number and connect with a service that contracts out the conversion from spoken to written word.

These days, voice recognition software is phasing out the transcriptionist. Voice recognition is good enough that docs can list the illness history, physical exam findings and treatment plans realtime between patients.

But whether it's human transcription or computer, there will be typos. Take for example my recent discovery of a patient who presented with a significant history of bacertial rasmosis. 'Bacertial' looks enough like 'bacterial' that my mind barely noticed it. But rasmosis? A new class of infection? I immediately consulted Dr. Google. About the closest I could find was the species name for the herbal called black cohosh. Cimicifuga racemosa. Black cohosh is bad enough for you - especially in women of child-bearing age. I hadn't heard of infection exacerbation. That's the funny thing about medicine - there's always something new to learn.

The other funny thing about medicine is that some of what you learn is wrong.

Enter the punchline. This woman had recurrent bacterial vaginosis. The record was an error of transcription. Welcome to the EMR.

This Morning

I went in to the hospital extra early this morning to get some studying in, but decided to visit the ER to see if anything was going on. The first person who rolled in at 5:30 or so had broken her arm last night. It was clear she would need IV access for a probable surgery. I jumped up and put in an anticubital IV like it was nothing. I know doing these simple tasks will get old after a while, but seeing her immediate relief after giving nausea and pain medicine (through the IV, of course) was quite gratifying.

Shown above is a schematic of a self-retracting IV catheter needle like we use to place peripheral lines.

I'm in the hospital's library studying right now and just heard the helicopter land. You might be an aspiring ER doc if the sound of chopper blades makes you think "Airway Breathing Circulation" and inspires you to flip in your trauma surgery notes to the section on the four main types of shock...

Must... Keep... Focus... On... Studying...

Rotten Politics

The time has come for two more states to weigh in on who will be the presidential candidates in November. My state has already caucused, so my opinion was heard. Technically it hasn't been counted yet. In such a state of limbo, I am forced to rely on my prognosticator of elections past present and future. This tool is also known as:

"These Colors Don't Run (they grow mold, ferment, degrade, are infested with insects, turn to slime and just plain smell bad):
A Long Term Study Of The Forces Of Nature On Assorted Fruits From The Western United States"
Wood, Glass, Found Berries
Thomas Robey
January 8, 2008 - May 6, 2008

Refresh your memory of what these candidates... I mean samples... looked like on Day 1. Of note is that the berries on the far right were collected in Hawaii, one of the places Barack Obama calls home. Also note how the other blue sample is molding from the bottom up. The red berries are white with mold, and the white berries are either a slimy mess or a tinge red... In past installments, I have ruminated extensively over the meanings of the relative degradation of the various red, white and blue berries, resulting in predictions that have ranged in accuracy. Obama appears aged, hardened and perhaps stale. Clinton is increasingly foul. More than that, all I have to offer is:

They're all rotten.

Let's get it over with, already. We need to start from scratch! It's beginning to be berry season in the Northwest and I'm anxious to move on with this piece of art...

Thinking Back On The Lab

My wife tells me I'm a hypocrite because I like reading PhysioProf's posts at his blog and at DrugMonkey. Those familiar with both PhysioProf and me immediately will know why. For everyone else: foul language usually makes me cringe.

One of the reasons I like reading his blog is that his insight reveals a connection with science, teaching and mentorship that I resepect. Exhibit A:

[One] thing to keep in mind ... is that by the time you reach the end-game of grad school, are finishing up the last few experiments, and are beginning to write the thesis, it is highly likely that you will be pretty much completely disgusted with the science underlying your project, life in the laboratory, and science as a career. This state of mind is a natural consequence of the grueling process of earning your PhD, and does not reveal anything particularly salient about how you really feel about a life in science.

It is similar to how Army recruits feel at the end of basic training: drained, exhausted, miserable, and wanting to quit. But this is no time to make life-altering decisions, such as leaving science for some other profession. As soon as the thesis is accepted, a huge weight lifts, and over the course of a few months, you begin to remember the joys of a life in science.

He sure hit the nail squarely, here. Except for one thing.

I'll let you know when the weight lifts.

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...

Patients As Healers

This week at The Differential, I take stock of some of my favorite patients, and discover how much my memories of them are good medicine for the times I feel down. Long-time readers may recognize some of these stories. Read the article here.

Looking For Medical Student Blogs

Has anyone out there encountered a medical student blog written by a first or second year, or by a recently accepted student? Perhaps you read it, perhaps you write it. Either way, I'd like to add good ones to my blog reader...

Thanks for your help.

Asked To Be Super, But Not Up To The Task

This one goes out to ScienceBlogs readers.

Last month, I received emails from two different science bloggers inviting me to be a ScienceBlogs "Super Reader." Since I read several of Seed's ScienceBlogs and think that blogging is a good way to diversify the conversation about science, I agreed to be a reader. So what does a Super Reader do? Basically, Seed wanted to present a more qualitative metric by which a 'best of' list could be compiled. In the large ScienceBlogs venue, some of the most thoughtful writing may not be the most emailed or the most commented on; the former often are funny or cleverly sarcastic, while the latter are usually posts by PZ Meyers.

In a nutshell, Super Readers are tasked to post at most 3 entries a week to a del.icio.us account that the Seed blog editors have access to. This information is fed into a sidebar that indicates the readers' picks. This way, when I only have 15 minutes to surf the net, I can rely on well-informed readers to clue me into the most interesting posts. I imagine each blogger is allowed 2 super readers so that every blog is given a fair shot at making the hot list. While the "Most Active" feature is like the populist House of Representatives, the "Readers Choice" list is like the Senate - equal representation from each blog.

Some bloggers posted invitations for their readers to apply. I was solicited by folks who know I am a regular reader and commenter. The funny thing is, after I received the invitations and replied that I was willing to do a little bit of Seed's legwork for them (see the comment in this post), I haven't heard a thing.

Now comes the part of the post that presents fanciful theories. I am surely in the minority of folks who have been critical of how, well, overtly atheist the ScienceBlog community is. Often, I wish that folks like Rob Knop were still around to stir the pot. Perhaps knowledge of my minority view is why the Seed editors have not replied to my emails 'accepting' the role of SuperReader, but I doubt it. I bet there are some bloggers over there with religious beliefs from the East or West, old and new who see the conflict between science and religion as either constructed or impertinent to their mission as writer bloggers. Maybe I got the wrong email address in my response accepting the invitation. Or maybe, the Borg (a lovingly pejorative term for the ScienceBlog community) somehow knows that I only read 15 of the blogs over there. But in the end, there are already too many crackpot conspiracy theories out there about the blog collective than are reasonable. I have the sense that good things make for big targets, and rather than continue to assail, I'd rather contribute. My emails were probably and simply lost. (Update: this last theory is the correct one!)

I'm still happy to participate - It's not very hard to click a button when something you read is interesting! And I do think that participating in a community of commentators such as exists at ScienceBlogs is important. And if I don't fit into the Borg's demographic as an enthusiastic unpaid volunteer, that's fine. It would have been nice to have been told as such.

After sending another email and posting this mini-rant, I'm ready to move on.

Thanks for listening.

Read This

Today, Francisco Ayala was featured in a NYTimes story. When it comes to the science and religion 'conflict,' this guy is one of my role models. I recommend you read the article.

Pigeon Brained

This takes the urban naturescape to a whole new level.

According to the Seattle Times, someone has been shooting pigeons with a blow gun. Given that most pigeons have pigeon brains, a shot to the head seems not to be fatal in several instances. The pigeon above was alive and a

quite athletic, good flier.

I have trouble approving of or denouncing this activity without additional facts. Does the shooter intend to eat the pigeon? (Probably not.) Is this part of a larger pigeon eradication effort? (Again, not so likely.) Is the problem with this the sport itself or the failure to quickly kill? (PETA probably thinks both, but I lean more heavily on the latter.) Is the pigeon from Capitol Hill or the University District, where piercing such as this would immediately elevate himto higher social circles? (Actully, the injured birds have been found downtown at Third and Union.) Wait a minute, Third and Union is awfully close to Benaroya Hall and the Seattle Art Museum. Is this some kind of sick urban art project? Hmmm... Where can you get a metal dart blow gun?

Image from Franziska Edwards and PETA

Getting Along Just Fine

This photograph taken in the Seattle backyard of two of my dear friends provides evidence of a harmony between species that some might say is impossible. These two people have a way of making the unimaginable real. They also got married yesterday!

Congratulations A & C!

Dealing with Death (& Medicine)

I have two recent articles over at Medscape's The Differential about my recent personal experience of losing a family member while in the midst of medical school's third year.
Too long for a single article, the story is broken into two pieces. There's "When the Stride Becomes a Stumble" and "Picking Up the Pieces."

As usual, writing offered me great therapy for this issue. I hope this story speaks to you.

Cult Fiction Meme

Bikemonkey assailed me with another meme. This one demands the admission of guilt in reading cult fiction titles as determined by the British Telegraph newspaper. They define cult fiction as:

books often found in the pockets of murderers; books that you take very seriously when you are 17; books whose readers can be identified to all with the formula " whacko"; books our children just won’t get…

If I've read the title, it's listed in bold. If I started but gave up, it's in italics. Unfortunately, memes don't go very far beyond me. None of the bloggers I ever tag ever put anything up, so I'm not going to try sending this one on. But since I like to read, here's my list. Does anyone think I should definitely read a title that I haven't touched?

• Slaughterhouse-Five by Kurt Vonnegut (1969)
• The Alexandria Quartet by Lawrence Durrell (1957-60)
• A Rebours by JK Huysmans (1884)
• Baby and Child Care by Dr Benjamin Spock (1946)
• The Beauty Myth by Naomi Wolf (1991)
• The Bell Jar by Sylvia Plath (1963)
• Catch-22 by Joseph Heller (1961)
• The Catcher in the Rye by JD Salinger (1951)
• The Celestine Prophecy by James Redfield (1993)
• The Dice Man by Luke Rhinehart (1971)
• Chariots of the Gods: Was God An Astronaut? by Erich Von Däniken (1968)
• A Confederacy of Dunces by John Kennedy Toole (1980)
• Confessions by Jean-Jacques Rousseau (1782)
• The Private Memoirs and Confessions of a Justified Sinner by James Hogg (1824)
• Dianetics: the Modern Science of Mental Health by L Ron Hubbard (1950)
• The Doors of Perception by Aldous Huxley (1954)
• Dune by Frank Herbert (1965)
• The Hitchhiker’s Guide to the Galaxy by Douglas Adams (1979)
• The Electric Kool-Aid Acid Test by Tom Wolfe (1968)
• Fear of Flying by Erica Jong (1973)
• The Female Eunuch by Germaine Greer (1970)
• The Fountainhead by Ayn Rand (1943)
• Gödel, Escher, Bach: an Eternal Golden Braid by Douglas R Hofstadter (1979)
• Gravity’s Rainbow by Thomas Pynchon (1973)
• The Holy Blood and the Holy Grail by Michael Baigent, Richard Leigh and Henry Lincoln (1982)
• I Capture the Castle by Dodie Smith (1948)
• If on a Winter’s Night a Traveller by Italo Calvino (1979)
• Iron John: a Book About Men by Robert Bly (1990)
• Jonathan Livingston Seagull by Richard Bach and Russell Munson (1970)
• The Magus by John Fowles (1966)
• Labyrinths by Jorge Luis Borges (1962)
• The Leopard by Giuseppe di Lampedusa (1958)
• The Master and Margarita by Mikhail Bulgakov (1967)
• No Logo by Naomi Klein (2000)
• On The Road by Jack Kerouac (1957)
• Fear and Loathing in Las Vegas by Hunter S Thompson (1971)
• The Outsider by Colin Wilson (1956)
• The Prophet by Kahlil Gibran (1923)
• The Ragged Trousered Philanthropists by Robert Tressell (1914)
• The Rubáiyát of Omar Khayyám tr by Edward FitzGerald (1859)
• The Road to Oxiana by Robert Byron (1937)
• Siddhartha by Hermann Hesse (1922)
• The Sorrows of Young Werther by Johann Wolfgang von Goethe (1774)
• Story of O by Pauline Réage (1954)
• The Stranger by Albert Camus (1942)
• The Teachings of Don Juan: a Yaqui Way of Knowledge by Carlos Castaneda (1968)
• Testament of Youth by Vera Brittain (1933)
• Thus Spoke Zarathustra by Friedrich Wilhelm Nietzsche (1883-85)
• To Kill a Mockingbird by Harper Lee (1960)
• Zen and the Art of Motorcycle Maintenance: an Inquiry into Values by Robert M Pirsig (1974)

That puts me at reading 13 and for some reason, not finishing 4. Okay, enough of that. On to studying inflammatory bowel disease.

Incarcerated!

And I'm not talking about the potentially very bad outcome from an abdominal hernia.

The U.S. has less than 5 percent of the world’s population but almost a quarter of its prisoners.

Sheesh.

April X Begets May Y

If April showers bring May flowers, what do April flurries bring?

Curries?
Worries?
Slurries?

This message brought to you by a man and his duck.

Duck Curries, that is.

The Green Service

I'd encourage you to consider taking a little time this week to read some of the articles in the New York Times' Green Issue that they've published in honor of Earth Day. In the interest of mixing things up a bit, I've taken the liberty to arrange some of my favorite articles and features into the structure of a church service.

Where I go to church, the service starts with singing. In churchgoer lingo worship is a way to transition from the business of the week or the day and focus on the time you plan to spend meditating, learning, reflecting and challenging the ideas that will come of the service. Worship can be just song, but could also include projected artwork, dramatic readings, instrumental expression or even dance. The online version of the green issue includes a funky tribute to the sculptures used as headings throughout the article.

Every church service features a scripture reading, whether it be from a pre-determined yearly schedule or selected by that day's service leaders. In most Christian traditions, this includes readings from the Old and New Testaments. It was reading some of the entries in the ACT/ EAT/ INVENT/ LEARN/ LIVE/ MOVE/ BUILD sections that I though of this theme. Scripture readings are small snippets from the Bible that can then offer digestible ideas for study or contemplation. Of these, I recommend the LIVE and INVENT sections.

For the personal testimony, head over to Pasadena, CA where the Dervaes family has gone 'off the grid.' As my wife listened to the video report with me, she pointed out, "Those people used to be called Hippies." Maybe so, but these days, there's a lot more hip to what they are doing. Contrast their strategy with the way rich folks go green a la Bill Nye.

The sermon, tucked in toward the end of the service, centers on the motivation, justification, and implementation of individual efforts to curb fossil fuel consumption and carbon emission. The garden is rich with metaphor. The seed and sower have a long tradition in secular and religious texts. Michael Pollan provides a fresh take on the garden as a social force for lessening climate change.

Finally, for the benediction, I quote Rabbi Julian Sinclair:

“The environmental movement has been overwhelmingly secular for 40 years and has achieved amazing things,” he says, “but it hasn’t yet figured out how to move people on a massive scale because it isn’t telling the right story.’ Sinclair says he believes that the “doom-laden apocalyptic narrative” favored by the mainstream environmental movement can paralyze rather than motivate necessary lifestyle adjustments. Conversely, he says religion — which has been “in the behavioral-change business for 3,000 years” — offers a distinct message of hope and boasts an impressive track record of moral persuasion: “There have been watershed moments when religion has barged into public life, blown away the windbaggery of politics-as-usual and declared with irresistible force, ‘This must change now!’ ”

Trauma Call Makes The News

Recently I experienced something a bit unsettling about working in a regional trauma center.

I was on trauma call. At my current hospital, the surgeon on call assumes the role of quarterback when a trauma case comes in the door. He (all of the attendings here are male) meets the patient and collects pertinent information from the emergency transport staff as they come through the door, does the initial Airway Breathing Circulation Deficit Exposure (ABCDE) evaluation and orders the requisite next tests and treatments. If two folks come in, he must asses them simultaneously and enlist the help of the ER docs to stabilize the patient(s). This is exciting to watch; in these situations, I just try to keep up with the decision making process. When patient are already stable as was the case this time, the best I could do to help was to collect supplies needed for exam or treatment.

This case was my first interaction with the outcome of a motor vehicle accident (MVA in ER lingo). The specifics of the case are interesting; some of the passengers died at the scene, so it is expected that there were serious injuries involved. There are two elements of this situation I had not expected.

First, (and this is not the unsettling part) the hospital's chaplain provided an amazing service to the patients. He was able to respond to their emotional state. Whether the patient wanted to begin acknowledging the loss of their loved ones or to wait to hear about the situation, he was able to support them. No one else in the ER was able to forge this needed connection - we were all concerned with placing lines, reading films, and preparing for surgery or transfer. What I learned about telling patients that their loved ones had died was to:

• Be prepared to report accurate account of what is known about the accident and fatalities. Names, ages and relationships are very important to discern. If this requires calling the state patrol, so be it.
  
• Patients know something bad has happened. But they may not be ready to hear the words until some of the physical shock has worn off. They may tell you this. When they say they are ready, then see above.
• If the information is kept from them, it will not be for long. News travels fast in hospitals. The ICU nurses, anesthesia techs and other docs will know snippets of the story. If the doctor caring for the patient does not tell the whole story, this could erode trust needed to best provide care.

This last part brings me to the unsettling part of the MVA trauma experience: news reports. News of this accident undoubtedly makes it into the local newspaper. Full names, hometown and hospital condition are always reported. When I came across the story of the trauma case I participated in, I imagined the patients' personal concerns, complaints, fear, and humor. I also remember digging glass out of a neck laceration in the operating room and then washing the wound with 3 liters of saline. There is always so much more behind the police report oriented news release.

The news reports are so cold. It's the truth underneath the report that is hot: exciting, heart wrenching, fast paced, uplifting - all with little room for error. That part of the story is tucked away in the confines of the physician-patient relationship. It's a privilege to be a part of that.

What's The Deal?

Someone recently said some Americans were "bitter" over the economy and chose to "cling to guns or religion or antipathy to people who aren’t like them" as a result.

Could someone please help me understand what's wrong with this assessment?

Thanks in advance.

Diagnose This!

You're a student on rotation at an academic medical center's walk-in clinic. A new patient presents with a one week history of pruritic 1-2 mm diameter vesicles and evidence of excoriation on the extensor surface of both hands that is most prominent between the metacarpophalangeal joint and the dorsal crease of the wrist. There are also some lesions at the proximal nail fold and distal phalanges. The interphalangeal skin and finger webbing is largely spared, except for the area surrounding the left 4th digit. There is no palmar rash. Upon closer inspection, the lesions have a diverse morphology, ranging from non-erythemetic fluid-filled indurated vesicles to bright red papules with a 3 mm diameter border to small salmon colored macules with crusted centers. A thorough skin inspection yields no other rashes. Complete physical exam is unremarkable except for dark circles under his eyes. The skin finding is shown below.

Further questioning reveals that this patient has developed irregular sleep habits over the past several months and has several other new stressors in his life, including physical relocation, new responsibilities at work, looming deadlines, personal grief, and a perception that his future depends on every daily task. He does report several adaptive behaviors to help manage this stress, including creative outlets that use all ten fingers... The rash has been refractory to cortisone and triamcinolone, and Actifed helps a little bit with the itching. He seems resigned to this condition, stating that his position will change in about a month.

After consulting your attending, you recommend which of the following therapies:
A) Bed Rest
B) Solar Therapy (Specifically In Zihuatanejo)
C) Desoximetasone Baths
D) Cutting Back On The Alcohol

Oh, I almost forgot: What's your diagnosis doctor?

Expelled

I was going to go to the Expelled movie this weekend to write a review for this blog. But it turns out that Expelled is more about Ben Stein flunking than getting expelled. For more information, please consult with TUIB Guy.

We now return to our regularly scheduled programming.

Trauma And Sore Throats

For those keeping track, I'm back in Spokane and in my surgery clerkship. On Saturday, I took call. Whenever a patient comes in to one of Spokane's ERs and needs surgery, they call the doc I'm working with to do it. In addition, today that surgeon was also on trauma call. After we rounded on the practice's patients on the floors, I could have gone home to study or wait for calls. (And the calls would come, a this is the first warm weekend of the year.) Instead of being unproductive at home, I hung out in the ER where the trauma cases would go. It happens to be the same ER I worked in previously as an internal medicine student, so I knew the staff and my way around. From noon to midnight, I managed the following problems:

• Torus fracture of the radius in a ten year old
• Sore throat
• Tooth pain
• Hypotensive emergency
• Strep throat vs. mono vs. peritonsilar abscess
• Bleeding in a 6 week pregnancy
  
• Altered mental status
• Wallpaper induced migrane
• Alcohol + ATV = Badness
  

Technically, the only trauma case was the last one. For that, I put in a chest tube to treat a pneumothorax. But that doesn't mean I only did one procedure. I also:

• Wrapped a soft splint
• Took throat cultures
• Placed an IV line
  
• Did pelvic and bimanual exams and ultrasound
• Inserted a nasogastric tube
• Spoke several times with a social worker

Even though only one actual trauma case came through (so far! I'm on call from home until 7AM), today was great. It's because I was in the emergency room. I'm comfortable enough there that I know where stuff is and can contribute as a team member. And that's what I like about medicine.

Open Access UpToDate

Yesterday I commented on how members of the University of Washington community were shocked to hear of the subscription cancellation of the UpToDate reference. Read this to get up to speed. The basic story is that UpToDate wanted to charge the UW a fee that amounts to 60% of the Health Sciences Library's budget. To that, the UW said no.

My peer group (medical students) were surprised, appalled, outraged, and saddened by the news.

I say, "eh..." Let me tell you why.

UpToDate is an extremely easy way to learn about the consensus understanding and treatments for a large number of diseases and medical conditions. Maybe it's too easy. For many years, it has been the one stop shop for clinical pearls, research and both general and specific information. The company knows this. Now is the time to cash in. For many students, it's the ONLY place they go for information. For some, it's just the first place. (Every article has extensive reference lists that lead back to the primary data.) What we (myself included) have fallen into is a reliance on an information monopoly. The funny thing is that this is a monopoly of convenience. Part of me thinks that UpToDate is within its rights to charge whatever they want for their well organized service - this is a free market, after all. The rest of me is repulsed by the price this company is charging for what amounts to information that is already in the medical literature.

So Duke, Johns Hopkins and now the University of Washington have said, "No, thanks" to a convenient tool. These aren't poor backwoods places. I have not heard much ideology behind these decisions; today our dean restated the financial motivation for canceling the subscription. Why might a few giants making this choice be good for medical education? Here are three reasons:

1. Intellectual Laziness. In a response to my article yesterday, one UW professor lamented that third year medical students no longer scoured medical literature, medicine textbooks and other information sources when researching their patients' conditions. I know that as a student, I very much appreciate the ease of using one resource for all of my inquiries. It leaves more time for patient care. BUT, UpToDate articles are authored by one or two people, and believe it or not, medicine is rarely definitive. It could be useful to know different opinions when relevant. There's a good chance that relevant professional societies (take the American Academy of Pediatrics, for example) already publish recommendations, and make them freely available. The problem is that you have to know where all of this information is. The benefit of knowing the location of all this information is that you are actually closer to the basic decisions that affect care. Here is where a web resource portal comes in handy. Health sciences libraries need portals like this one to help care providers find the information they need. UW's HealthLinks page is a good start, but in the post-UpToDate age, will need much improvement.
   
2. Conservation of Resources. I am guessing that residency programs, departments, and even medical schools may cough up the money needed for their trainees to access this resource. As I understand it, every single person with UW network access could use UpToDate. Because of the UW's size and far-reaching extent, this could be on the order of 100,000 people. The people that need the kind of rapid access to information that UpToDate offers are students and trainees who are pressed for time in the context of 80 hour work weeks. (and who are used to the convenience of a single information source). If the medical school pays for this smaller number of subscriptions, then the health sciences library can order more subscriptions to basic and applied sciences journals that researchers crave.
3. Open Access. For me, this is the elephant in the room, and one that I hinted to earlier. My premise here is that this information is not new. It's a repackaging of basic and clinical science that is already out there. I think there is a legitimate mechanism by which UpToDate-styled reviews could be published free. After all, how much do UpToDate's authors get paid? I hope it's a pretty penny given what they are charging universities. In other academic spheres, if academic publishing is a for-profit venture, it's the publishers who profit. The authors get paid in the currency of academia: peer reviewed articles. "Open access" is a system where authors subsidize the costs of making their work available so that any reader can access it. This is an important trend in academia. The ivory tower is being disassembled and reconstructed into a public works project. But wait, if UpToDate doesn't pay their authors much (this is an assumption that I have not verified), why does it cost so much? I think the company would argue that their easy to use platform is worth something, as is the verification of the information as legitimate. In basic, clinical and applied sciences, this is done through the volunteer system of peer review. I am guessing UpToDate pays people to verify the information. Even so, I do not see why this needs to be for-profit. Why not use an open access model for these review articles? Open access works for 3,314 other journals. There are very well established mechanisms for running such systems, including the Public Library of Science family of journals. I would imagine that an UpToDate-styled review could fetch the prestige among clinicians as a Nature paper does for basic sciences. If the academic currency of publishing these clinical review articles could balance their widespread utility, why inject large sums of money into the system?

In the end, I think there are good theoretical reasons for abandoning expensive subscriptions to clinical review literature. The information is already out there. With a little help from librarians, we'll be able to keep providing the quality of care that the UW, Johns Hopkins and Duke are all known for. Who knows! Maybe the system will come out better in the end.

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...

Coming Out Of The Closet

"I’m going into emergency medicine."

Head over to The Differential to discover how every medical student must come out - in a way - during the third year of med school.


I don't mean to diminish the stress and anguish involved with the GLBT meaning of the term. I do think it is a valid metaphor. Read the whole article to see what I mean.

One Week Of...

What a whirlwind my last week has been!

I think I know my way around three of Spokane's operating rooms; more importantly, I know where each OR's supply of non-powdered, size 9 sterile gloves is. One important (faculty-endorsed) location is my car's glove compartment - one of the hospitals doesn't have non-powdereds that large!

Boy am I glad I am outside of Seattle for my surgery clerkship! I'm not sure I'd be getting this much exposure to hands-on learning anywhere else... This week, I have:

• laparoscopically extracted a gall stone from the common bile duct during a gall bladder removal
  
• removed one appendix
• held countless retractors (more on that in a later post)
• clipped thyroid arteries in a parathyroidectomy
• learned 3 new knots and 5 new stitches
• sewn a colon into the skin
• coined a new term for a certain kind bowel adhesions and was subsequently pimped about said term ("fatty fibrosis" - another story for later)
• sewn large and small bowel together (using a really fancy stapler)
• imagined numerous uses for retractors and then seen them used that way...
• removed pounds of necrotic skin, fat and muscle off one person's shoulders only to have the infection spread to the heart.
• developed some annoying atopic dermatitis on my hands.
  
• eaten much more fiber than usual. Fiber can head off sooooo many bad things.

Did I mention that I am getting very familiar with retractors? I'm sure my fling with surgery will actually be an affair with retractors. Just in time for me to move on to OB/GYN (I hear they have retractors, too!!!), it will be my wife who picks up an affinity for those ubiquitously med student driven tools.

Meeting Bloggers in Real Life

I just realized tonight that on my list of things to do when visiting certain cities is meeting my favorite bloggers who happen to live in said city. The South Bay, Chicago, Minneapolis, Vancouver, San Diego, Charlottesville, Atlanta...

Is this silly?

Heston's Fingers

I think that we can finally pry that gun from his cold, dead fingers.

Unfortunately, gun control is not so much of an issue in the current political environment. I'll still have to learn how to treat gunshot wounds...

This One Just Fits

Bikemonkey tagged me with the song chart meme. As retribution, I present this:
I'm not sure if it really satisfies the rules of the meme, but it's what came to mind. I'm tagging Bunnies With Sharp Teeth, Dear Science, Dogs Bark At Night and Lid Upon My Head. If you are dying to figure this one out, take a minute and think about what Sarah said.

An Instance When John McCain Rightly Decides To Distance Himself From George Bush And His Wars

McCain may not be a Warmonger, and he is right to make this statement, but he has miles to go before I would agree with his position on the wars we're fighting. Check out other David Horsey cartoons. (Click on the image above to see a larger version.)

No Foolin': NIH to Cater to Young Scientists

Given this notice of a structural overhaul at the NIH, perhaps I should rethink my decision to pass on setting up a basic science lab in favor of the lucrative opportunities available to young scientists. With the champions of scientific humanities bowing to external pressures, I may need to discard my dreams of a career spanning the two cultures...

Social Medicine 101

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

Here's a hint on the last one:

20,000

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

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

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

Looking Over Your Shoulder

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

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

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

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

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

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

Autistic Politics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Race and Religion in 2008

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

A Prized Nest

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

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

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

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

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

Pay It Forward

How do you remember your grandparents?

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

Grace follows him in life and in death.

Debating Health Care

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

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

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

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

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

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

What is Trolling?

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

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

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

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

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

Right on!

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

One Book, PRN

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


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

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

Making a Difference

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

Springing Forward

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

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

Blogging As An Inpatient

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

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

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

Decision Tuesday

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


This compares to January 8:

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

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

The 'View

On my way to Harborview Medical Center...