Meanwhile, in the NFL

The NFL's "Cardiovascular Committee" is mulling over the idea of requiring all NFL players to have echocardiograms when they enter the league, as a way to screen for abnormalities such as hypertrophic cardiomyopathy (which Adam Gaines is presumed to have died from).

It's fascinating to see how sports leagues address the health of their players, particularly in football, where young men are part of one of the world's most finely-tuned and closely-watched experiments in traumatic injuries.

It's also a little grotesque.

The ranting will continue until morale improves

To anyone bothering to read this blog, a few notes about the recent barrage of posts on health care reform (HCR), I just want to say why I'm ranting so much. Here are two (somewhat) unrelated thoughts as to why:

1) If you go to med school, you have decided you want to get into the health care "game." Therefore, you become a part of this "game" - you and it are linked. Like in avatar, you take your pony tail and fuse it with the health care dragon. You and it form a connection. To deny this is to not just be ignorant; it almost suggests nihilism - if you fail to care about what you do for the majority of your life, how can you say you really care about anything?

2) Empathy. Empathy. Empathy. The very best doctors all have empathy. And cultivating a sense of empathy is a lot harder than it seems. I think that, at the age of 26, I'm only beginning to think about how to live with a sense of empathy. It's perhaps the most important quality one can have. After all, we care for other human beings. That might sound cheesy, but it's the truth.

The imperative for HCR

I am always going to have good health insurance. As an MD/PhD student, I am covered well by my home institution. As a resident, I will be covered by my employer. And as a future faculty member, I will have coverage. And I will always have work, because there certainly isn't a surplus of physicians. But to me, doing something about health care is so vitally important because how medicine is done in the future depends on reform. Right now, the practice of medicine (the science, techniques, decisions, etc) is, for better or worse is tied to institutional realities (profits, contracts with insurance, medicare reimbursements, kickbacks from pharma, etc). So forgetting the moral argument for making health care accessible for the uninsured, the very manner in which I as a future physician practice health care is threatened by inaction by our government. I have a HUGE stake in all of this. I want to practice medicine in a sustainable fashion. I want more end-of-life consultations (a.k.a. "death panels," which have been shown to lower costs), comparative effectiveness research, evidence-based medicine, value-based insurance pilot programs; I want an end to fax machines and paper medical records. In short, I want to be a part of the future movements that solve health care's problems, rather than exacerbate them. To me, as a future American physician, it's a form of patriotism.

And here, for me, is the moral argument. What has grated me the most during the HCR debacle is that the nihilists running Washington (I leave the president out of the nihilists camp, because I believe he actually gets the importance of HCR.) have some of the best and most expensive health care in the world. They say, "Let's take a breather, the American people are frustrated with how we are approaching this...Health care reform can wait." Yes, to those who have coverage, HCR can wait. Tomorrow, when a member of congress experiences chest pain - worried he might not be re-elected in the fall - he can go to a medical center of his choice and be worked up for a possible myocardial infarction (heart attack). When the barrage of medical bills arrive, the employer (we, the people, of whom 30 million plus lack any kind of insurance coverage) will pick up the tab. And so, the congressman returns to work, owing nothing for his care. A second job will not be necessary to pay for stenting the congressman's coronaries. Bankruptcy will not be necessary. The belt will not need tightening. In short, there will be no sacrifice required to treat the congressman's damaged heart. You see, I don't think lawmakers really understand what it's like to lack health insurance. I don't think they really get how bad it is, to be sitting in the emergency department or intensive care unit knowing that financial ruin looms. I don't think they get it. As a medical student, I have seen patients who don't have insurance, and their look is noticeably different from those blessed to have health insurance. They become consumed with trying to emerge from illness and bankruptcy. Just like you can spot homeless people in a crowd, you can spot uninsured patients in a hospital. The weight of their problems is palpable.

The Senate bill is far from perfect. But it's a vital first step. And I just don't think the privileged few who run Washington really get it. They seem totally devoid of empathy. I hope President Obama shows that he does and fights.

HCR experts: Senate bill far better than nothing

The New York Times has a link to the PDF of a letter from 47 health policy experts, many who are progressive and many who are non-partisan, urging the U.S. House to pass the Senate's bill and negotiate the contentious points through reconciliation later. I couldn't agree more. It's time to turn the corner on health care and do something. Now.

Medicare coverage and outcomes

This is a recent NEJM piece, broadly discussing how medicare considers coverage for treatments, diagnostics, etc; it suggests it isn't easy - but is essential nonetheless - to define short and long-term outcomes (not just medical but also economic and social) in deciding how limited resources are appropriately allocated.

I'll try to post more on this, and other topics relating to how health care reform should and can happen, in future posts.

Health Care Reform: The Urgency of SOMETHING

It was only a matter of time before my blood began boiling over the current health care debacle in Washington, D.C. The nihilism that ensued yesterday after the Democratic party lost its "supermajority" in the U.S. Senate was no doubt the catalytic event. So, with that brief preamble, I enter the murky waters.

As a stakeholder in the health care system - a future MD/PhD academic physician - I am deeply concerned about the current state of affairs in the system. The cost of delivering care is astronomical, with health care expenditures comprising ~16% of GDP, with no signs this number is going down anytime soon (by 2020, it will be close to ~20%). Despite the amount of treasure (personal, governmental) being devoted to health care, 15% of Americans have no health insurance. The largest government-run health insurance program - or more accurately, entitlement program - is Medicare. Estimates are that with no changes to the current system, Medicare will be insolvent by 2018. If future physicians think that this is no big deal, consider the fact that Medicare funds residency programs - it provides the salaries and other institutional support. So this is a big deal.

OK, those are some of the grim numbers. In short, we spend too much, we have no way to pay for health care if the status quo persists, and something must be done. Physicians don't wait for patients to go into multi-system organ failure (MSOF) before treating a patient with antibiotics, blood pressure support ("pressors"), ventilation assistance, and dialysis, etc, so why have we as a nation waited for the health care system to spiral into the shape it is currently in?

It's hard to say exactly why things have gotten so bad, and even more, it's hard to explain why the government has been so complacent. I think a big part of the problem is that bringing all of the players in the health care system - the doctors, the hospitals, the nurses, the technicians, the labor unions and employers who decide how to fund insurance policies, the insurance companies, the pharmaceutical companies, the diagnostic companies, the medical device manufacturers, the government, the patients, the lawyers - and having them agree on how to change the system and on which sacrifices they can accept is a massive (some think insurmountable) challenge. That is easier said than done, especially when said interest groups have varying degrees of influence ($) on Republican, Democratic, and Independent members of Congress.

I cannot say how exactly we should fix the economics of this broken system. I haven't looked at enough data, I don't understand all of the market forces at work, medical reimbursement practices; and I don't think most people in congress truly understand this either. And that's one of the first problems: the blowhards on both sides of the aisle in Washington use their opinions and empirical observations as a guide. Few (if any?) employ a rigorous treatment of the data. And that's the first place we need to start. As someone who has invested years of my life to learning how to design and execute good research, I think a first bold step would be to take the same hard look at medical care. That is, we need all of the pilot programs, evidence-based medicine approaches, properly placed incentives for good care, data sharing, electronic medical records, preventative measures - we need it all. These are the relatively cheap components of current proposals out there.

Whether - and how - to mandate insurance coverage for the whole citizenry of the United States is another question. The current proposals have done nothing to significantly change the costs of delivering care with respect to a mandate. They simply say that people should have coverage, the government will help if financially people have problems, and once covered, it's business as usual. So that's really not a good aspect of the current legislations.

Here's my take on health care reform: First, I want the death panels! So-called death panels - rather, having medicare reimburse physicians for having the difficult "goals of care" or "end of life" discussions is actually one of the best ideas that has been floated around, and it's one of the most politically polarizing elements of the reform legislation. And yet, it's one of the best damn ideas out there. Think about it: the bulk of medical care costs in a lifetime are incurred in the final months of a patient's life. Do a degree, this is unavoidable: if you get cancer and there's a chance to be cured, you'll try to treat it. But what if there is "no hope"? Or, more elegantly put, what if the realistic goals of care are palliative rather than curative? At that point, costs can be reduced dramatically (consider some of the data: http://www.reuters.com/article/idUSN06415881). But what's interesting is that when interventions are halted, usually suffering diminishes. The problem is that, all too often, doctors, hospitals, and providers in general either don't want to, don't know how to, or are financially incentivized not to have discussions about drawing down care and bringing people home. And so, more drugs are delivered, more treatments performed, more suffering ensues, all because who really wants to pull the plug on grandma? And sadly, most of the time, no one bothers to ask grandma what she thinks! And when they deem it time to ask grandma, she's already drugged up on sedatives/anti-anxiety/anti-psychotic drugs, in a hopeless ICU-induced delirium. At that point, few family members would be willing (and fairly so) to make executive decisions about where to go with care. Wouldn't it make good sense for patients - starting at a young age - to periodically have discussions with their doctors about end of life goals? Doctors ask whether patients sleep with men, women, or both; they ask whether it's cocaine, marijuana, heroin, meth, and/or all of the above; they ask about booze; they ask about depression; they ask about aches, pains; they ask about what concerns us the most. Why aren't they paid to have discussions about dying. After all, it's the one thing that will happen to every patient. And yet, this is the kind of stuff that has been maligned by opponents of health care reform legislation.

I want the pilot programs. The same kinds of government-funded and maintained programs that helped the agricultural industry in the U.S. become modernized could benefit health care immensely. And some of the privately- or state-funded programs already in existence prove this can work. Atul Gawande talks at length about this in a recent New Yorker piece. Note that he spends little, if any, time talking about public options versus mandates versus deals with pharmaceutical companies. He's talking about fundamentally changing how health care is delivered in the United States by empowering doctors and hospitals to make changes that benefit themselves, their patients, and the nation's finances as a whole. It will not happen overnight, but it can transform health care.

To make health care a truly sustainable and cost-controlled industry in the country will require more than just giving more people coverage in the same broken system. It will require innovative and progressive approaches to delivering care in the years to come. As examples, end of life discussions, in addition to numerous pilot programs embedded within current proposed legislation, offer some (of many) compelling ways to cut costs and do something rather than nothing when it comes to health care in the United States.

Stakes is high.

"How To Talk"

This is an excellent primer for preparing research talks. I like how the author focuses on the bigger picture - having a premise for everything you talk about is as important as all the little stuff.

You may need to be on a university campus to access this article. Email (mstpla at gmail dot com) us if you want the PDF.

The new decade begins...

So it does. 2010 has arrived. After answering some version of, "Where are you in your schooling?" for much of the holiday season, I thought it was high time I checked back in on this blog.

For those of us who matriculated into the MSTP in 2006, this *would* have been the year we graduated from medical school, matched, and became interns. Instead, we are all deep in the PhD phase of training.

Time seems to be flying by. Not too long ago, I would tell people that I'll be in school the rest of my life. Now, I'm halfway (maybe more) through the program. Strange how time plays these tricks. The current line I use is that I'm almost done with a second (four year) undergraduate education. As silly as that sounds -- given that I have focused solely on science and medicine -- it makes some sense. The MD/PhD program is rather disjointed for the first several years, with all of the introductory medical curriculum and exams, followed by the start of the PhD training with all of its introductory programs. And now, as I prepare for the Oral Quals (the "pre" dissertation defense), I feel not so differently from the way I felt when I was about to graduate from college. As I said then, now I really need to learn something.

This is not to say I haven't learned a great deal in the past three and a half years. I have. But I think the same desire to develop even greater skills - in clinical reasoning and in my area of research - speaks to the fact that much of the MSTP training is a preamble for serious intellectual engagement down the road. It isn't the culmination of anything. It's just another stepping stone, an educational interlude before more refinement and specialization.

All the other issues with which I have grappled - the challenges facing scientists today, trying to balance clinical and research interests, and attempting to stay informed about where science and medicine are heading as we begin the second decade of the new millennium - remain important and relevant as ever. And I continue to explore and plan to post about them on this blog.

Also: Anthony and I will try to pick up the pace of our posts in the weeks ahead.

Things I Appreciate: Very good teachers

A very good teacher doesn’t have to work in academia: people don’t need degrees to teach. I’m going to focus my post on the learning that occurs inside of the classroom, however, for simplicity’s sake.

I have taken courses from two very good professors in college and one in medical school. From the experiences, I have found trends:

Going into the course, there are expectations, high ones. Building expectations requires myth-building, the established lore. When the name is dropped, people respond. A percentage will have negative things to say. But a general, resounding positive aura will prevail over the hours of work and anxiety that follow the class. Students feel overwhelmed by newfound naivety. But everyone else feels the same way, so it’s okay to an extent. And the professor is understanding and knows what the students are feeling: they’ve been there too; they keep on pushing. The expectations are real and are not fulfilled. A lot is learned, but there is always more. The learning continues after the class so that when nostalgia calls, the student thinks about how on point they would be if they sat down on the class today. That’s what a really good professor does.

Things I Appreciate: Words

Medical school has brought an appreciation for words. For example, I can appreciate the word “appreciate.” The word is thrown around so much, almost making it cliché, yet it continues to carry import. Appreciate implies complexity, often an observation without the knowledge of mechanism. The word is a lame attempt to describe something that we can't, a limit. From one word a sentiment of what it is like to be human explodes. At the same time, medicine (and science and any other field) tries to collapse a myriad of descriptors into neat packages. Consider the words “septic shock.” The words provides parameters of different variables that paint a clear picture of Shit. Words like septic shock allow for effective communication, especially when presenting. Things get spicy, though, when words like appreciate and septic shock, that expand and condense coexist: appreciable septic shock: Oh-Shit.

The Things I Appreciate in Medical School Series

Stay tuned. In the hope of posting more consistently, I've created a theme. Let's see whether I can trick myself into writing on this blog.

Katrina Redux

This is a long read, but worth considering. I'm still trying to digest it all.

Business and Medicine collide

And the results aren't so pretty. But to ignore the trends in medicine and the economics of being a physician is to be on the sidelines. We will all have to be active and informed participants in the arena of medicine and business in the future. Now's as good a time as ever to understand the issues.


(The Groopman/Hartzband piece is here. You need to be at university or other location that has an NEJM subscription to read it.)

brownian motion

I didn't know what to say when I was asked for advice during revisit weekend. I could've told the prospectives which books to buy, what lectures to skip or attend, how to approach PBL, or why you should selectively listen to your classmates and professors. While tiny nuggets of wisdom may have emerged from my mountainous rant, I decided that my advice was specific to my experiences and it wasn't fair to project my MS1 onto the listening. I couldn't provide an answer.

I cannot lie: I inundated Chuck C with a myriad of questions before I matriculated. Most were petty, some were practical, all were motivated by uncertainty. I didn't know what to expect then, and I don't know what to expect now. But I'm not worried. With time, a lot of questions have been addressed, as I have navigated my way through the first year of the MSTP. I tried to express this vague sentiment – intentionally omitting examples – to the revisit-ers. “Just go with the flow” was the gist of my answer. I imagined they were unsatisfied. At least I told them the truth.

I've been lazy

It's been a while since I last posted. I'll be honest: I've been lazy. I have a resolution, though, and that involves a series of posts, snapshots of moments or ideas that have rattled around my skull for some time. Let the regurgitation begin.

MJ

In cased you missed it, Michael Jackson died today.

The UCLA Ronald Reagan Medical Center across the street from my lab was the epicenter, the place paramedics took the unconscious King of Pop, the place where there weaved around for several blocks countless sattelite-dish-toting news vans, and above which a handful of helicopters buzzed incessantly from about 2 pm until dusk.

What a surreal moment it was when I realized he had been taken in full cardiac arrest to the UCLA ED and that the place was about to be swarmed with people.

As I left at around 9 PM this evening, much of the commotion had died down. But the day will have a lasting impression on me. When I walked outside in the late afternoon for a break from my work, I saw a crowd of people gathering in front of the Med Plaza buildings (just south of the hospital). Amidst the honking cars, chatter of voices in all directions, cameras flashing, and newspeople primping themselves for their live reports, I heard a boombox begin, at first softly and then more loudly (and grainily), playing "Thriller." Putting all of the insanity of the moment aside, that to me seemed like the perfect tribute to the triumphant, troubled, and tragic life of MJ.

Goodbye, Michael.

Checklists

Here's another piece I meant to post a long time ago. Dr. Atul Gawande discusses the value of checklists in the medical setting. No, not just the checklists interns and residents make for overnights on-call. We're talking institutional checklists, from janitors' to nurses' to physicians' tasks.

Yikes!

And the radiation oncologist behind nearly 100 botched procedures at a Philadelphia VA hospital was/is an MD/PhD on the faculty at UPenn.

There are numerous troubling aspects to this story, poor regulatory oversight within and outside the institution and a fundamental lack of peer review.

An overdue post on the occasion of the start of PhD training, year two

As I start my second year of Ph.D. training and fourth year in the MSTP, I thought it was high time to reflect on the current State of Things. A testament to the busy nature of my research, I started this post on 6/10/09 and just today am revisiting it.

The past year has been filled with what seemed like highs and lows at the time, but reflecting on it now it all seems like low peaks and shallow valleys. In short, it hasn't been all that crazy. And yet I have covered much ground -- I've been all over the place. So I'll cover the past year in numbered form, as briefly as possible.

1. Coursework: as of this moment, I have completed all required courses in Molecular, Cellular, and Integrative Physiology. What's left now are qualifying exam(s) [I have submitted my written qualifying exam, no word yet if I passed...I'm shooting to do orals by the end of the fall quarter], publish, thesis, defend, submit. To have time solely dedicated to research is a huge bonus. But the coursework of the past year has been a valuable part of my training.

Incidentally, the Powers-That-Be have decided that the didactic elements of the two core courses I took (Biochemistry and Cell Biology, Fall and Winter, respectively) this year are the least productive aspects of said courses, and the emphasis is shifting to a more problem-based learning (PBL) format in the future. I think this is a big mistake. Sitting in lectures five days a week covering a large array of biological science research was hugely important in helping me think about my research. Just because it's boring as hell does not mean it isn't (or wasn't) time well spent.

2. Research Progress: one year ago, almost to the day, I began setting up my own patch clamp rig in lab. Since then, I have learned a boatload about electrophysiology, data analysis, cell culturing, radioactivity handling and experimentation, electronics, handyman problem solving, and a little bit of molecular biology. My project appears to be well underway, and my PI remains confident I will finish the PhD by the end of my third year of graduate training. Things are progressing nicely.

What's more, I have made some important realizations about what it means to do research. A recent conversation with a cousin clarified what I mean by this: research can be either boring as shit or deeply meditative. And often times, it's a blend of the two. This is probably the case because research, when stripped of the flowery explanations, is really just making big observations and repeating experiments enough times to convince yourself and the world that results have physical significance. This may explain why I've logged hundreds of hours of patch clamping, performed tons of radioactive uptake experiments, and many of these experiments were the second, third, fourth, or even tenth repeats of earlier experiment.

So it can get really monotonous. But somehow, when things are working, it all seems OK - it's for a purpose. And even when nothing works, it's also OK, largely because outside intellectual joys [clinical activities, cooking, music, exercising, romance, et cetera] occupy more of my time. Something has to get you through the difficult and discouraging times.

And finally, I think the most important lesson from the research part of my training comes out of [Los Angeles Lakers'] coach Phil Jackson's playbook: nothing too high, nothing too low. No matter how exciting the experimental result or promising the progress, there's no good reason to be manic, euphoric, or irrationally dazed with excitement. And there certainly is no good reason to slip into a melancholic stupor if a project isn't working. It all requires disciplined moderation.

3. Clinical work: I have been less and less to the ICU to take nights/overnights of call. This is a function of many more side projects in lab, and yet I plan in the next month or two to make it in for an evening. That I am in this predicament is as much a testament to research consuming my time as it is evidence of the fact that I value my social life. The clinical skills will be there, even if I take call much less frequently than I used to. Plus I'm waiting for my colleagues who will be doing 4th year sub-I's in the ICU, figuring I can be less of a burden to the residents/interns if I'm bothering a med student.

4. Socially: it's all good. Doing a PhD is definitely a full-time job, but somehow all of the quiet (and monotonous) moments make the requirement for super-charged social interactions less than it used to be. I'm at peace with it all, even if my social life is laden with challenges, successes, failures, and everything in between, just as much now as it was before I started the PhD.

Night with the guys, circa 2006

Last night, Jeff, Kevin, John, and I returned to our old stomping ground of Westwood village. We even had liters at "Maloneys." (It's now apparently "Ohara's") That was how authentic we went for it. In three short years, a lot has happened. Half way through medical school, entrenched in research, and John has a ring on his finger. In some ways it seems like just yesterday that we were entering the program, unaware of what med school was going to bring. In other ways, it seems like an eternity.

In any event, congratulations John (and Tiff)! How far you've come. How far we've all come.

(How far we have to go...)