Culture of Medicine II

The saga continues.

President Obama made some comments in the news regarding McAllen, Texas, suggesting that he read Dr. Atul Gawande's article on "the Cost Conundrum." Indeed, a recent New York Times article "Health Care Disparities Stirs a Fight" confirms this:

The [Gawande] article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”

There's a fundamental difference in approaches between politicians and doctors. Docs are taught to care for every patient as if they were a member of our own family. Perhaps healthcare spending reflects this attitude. Politicians often abuse their constituents as if they are unwanted members of family. Perhaps they are willing to sacrifice X number of lives to save Y number of dollars in an annual budget. I say this only half-jokingly; it is a political necessity to be separated from the issues since there will always be a passionate dissenting group that protests any sort of stand they make. The difficulty, in politics as well as medicine, lies in controlling our emotions so they do not rule our intellect.


But how do you resolve the most personal and emotional issue of all?
I agree with Obama's eloquent response to the question: "Is healthcare a privilege, right or responsibility?":

I think it should be a right for every American. … for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that.

What price do you put on the health and welfare of your family? The New York article mentions data that provides EXACTLY what sort of numbers the government has been willing to spend on each person in 2006:

Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.

Researchers at Dartmouth Medical School have also found wide variations within states and among cities. Medicare spent $16,351 per beneficiary in Miami in 2006, almost twice the average of $8,331 in San Francisco, they said.

Wow! Hawaii? I wonder if the fact that we also have mandatory healthcare (Pre-Paid Health Care Act of 1974) for full-time workers (>20 hours per week) in the nation has anything to do with these statistics. Massachussetts has a cool system too. Unfortunately, I don't know how well it is working out for them with the confluence of crises.

While it might sound appealing to adapt practices Aloha-style... that really would be doing things just for the love of it. A lot of doctors in Hawaii (regardless if they were Hawaiian doctors or not) are retiring, leaving the state or cutting back on their practice because of low reimbursements for Medicaid/QUEST and Medicare patients. So on the surface, it sounds appealing from a political point of view to slash wasteful spending but this can run antithetical to the goal of improving primary care by chasing doctors away.

Another thing that clogs up the gears of the glimmer of hope for Hawaii's healthcare... recently, the Medicaid/QUEST contract has gone out by two Mainland firms: UnitedHealth Group Inc. and WellCare Health Plans Inc. These companies were under investigation in billing fraud and improper claims scandals. Also, there is concern that the 37,000 enrolled aged, blind and disabled patients may have to change providers and lose continuity of care. Waianae and Waimanalo, the two regions on Oahu with the most Native-Hawaiians ironically are the two areas where the Community Health centers have opted out. (citation DENIED, see below)

I hope that the nation does not look at Hawaii for all the answers. It's much more likely that our docs have just gone uncompensated for a lot longer.

(Disclaimer: My commentary comes from the point of view of a medical student trying to stay informed on health-related news while studying to become a doctor in these changing times. As such, notmysecondopinions are not the best source around on health policy! I wish I could provide better local references... unfortunately the archives for the Honolulu Advertiser are on a pay-per-article access of $2-3! That model is detrimental to quick online Google News Searches for proper content.... gr.)

Culture of Medicine

“So, what brings you in today?”

The young Filipino lady before me wrung her thin hands together. Her eyes betrayed a sense of fatigue as the corners of her eyes crinkled with anxiety. “Doctor, I am still feeling dizzy.”

Dizziness is a common complaint, but a difficult one to get a handle on. So many different things manifest themselves as dizziness… an unsteadiness with walking, the presyncopal feeling like you are going to pass out or just the sensation of violent spinning (the same as how you felt as a child after twirling in circles in the park or on an office chair). “What do you mean?”

“Well, it started almost two months ago. I had two episodes of dizziness that went on throughout the day that lasted for a few seconds. It felt like I was spinning in a circle. I was worried so I went online to see what could cause it. And I tried to make an appointment with my family physician but that would be in a few weeks so I saw an audiologist, a neurologist and a psychiatrist too. The audiologist tested me for nystagmus and had me perform the Dix-Hallpike maneuvers and asked me if I was dizzy. I told her no, but she noted some eye movements with the electronystagmogram so she diagnosed me with bilateral benign paroxysmal positional vertigo anyway. She prescribed some modified Epley maneuvers. The neurologist thought I might have migraine-related vertigo and put me on Amitryptyline. And this whole time I was doing research online I would read about these different symptoms and I would start to get them! My parents were very worried and suggested that I see a psychiatrist for my anxiety. He put me on Sertraline and Clonazepam.

Wow… I thought to myself. That’s quite a few specialists! This was a highly educated woman… she understood what nystagmus and Epley maneuvers were, and she could pronounce BPPV which put her pretty much at my level as far as I was concerned. Yet after seeing all of these different doctors, she was still here in the FM clinic even though her last visit was *flips through the chart* two weeks ago… when she was given meclizine for nausea.

“Uhm, I’m sorry…” I apologized. “I don’t understand. You’ve been diagnosed with BPPV and anxiety with the possibility of migraine-related vertigo… what can I do for you today?”

“I just want help. I am not feeling the spinning dizziness anymore. That was a long time ago. Now it is more of a… it’s hard to describe. It’s a rocking sensation.” “Like you’re on a boat?” I offered. “Sort of.”

It took me a while to piece the whole story together, but it seemed like her main complaint of dizziness had resolved but she was having residual anxiety and a number of other unusual symptoms -- getting visually overwhelmed by venetian blinds and patterns on carpets and being unable to go into a store without feeling anxious. However, she persisted on calling it dizziness with her subsequent physicians, although perhaps “uneasiness” would be a better way to put it. She told me that when she saw the audiologist and the neurologist, she was feeling very anxious about what was going on… but aside from performing tests like an ENG and an MRI of her head, they offered little comfort or support except to say “Go see your family physician.” She saw the psychiatrist about a week ago and after some persistent questioning about functioning, she said that she felt much better with the SSRI and benzodiazepine.

While I do not doubt the technical ability of the audiologist to interpret an ENG or a neurologist’s ability to identify and treat a migraine headache, these skills have their time and place. Her underlying problem was the anxiety she was having about the dizziness which took over and became a general sense of worry and unease. These specialists were ill-equipped to deal with that aspect -- and it was not until the Family Medicine doctor intervened that the whole picture could be assembled for the patient.

“You’ve seen a number of specialists and they have helped us rule out dangerous things like a brain tumor. You are still able to work and you have not had any difficulty walking, so functionally you’re doing really well. I understand that you’re feeling dizzy. The good news is that it is nothing serious as far as we can tell so far!” She left feeling reassured and I saw her with the psychiatrist as well to keep up the continuity of care.

---

The culture of medicine has changed and I feel that this is the crux of it! This patient had fallen through the cracks of the system. She tried to get an appointment with her PCP and when she couldn’t see her immediately, she resorted to a series of more expensive but ultimately unfulfilling specialists before her family helped her find someone address the underlying problem. She needed someone to put the pieces of the puzzle together. All too often, patients think that specialists are better than primary care for everything and this fragmentation of care leaves the patients with the pieces. Even worse, they assume that their primary care physician is automatically receiving all of these specialist reports! It is hard to piece all of these things together from a confused patient. I think that family medicine physicians are more than care coordinators or a bouncer at the specialty doorway. Similarly, specialists are more than just procedural technicians who punt back even small things like reassurance and education back to a family physician. All doctors go to medical school instead of OR or ER or psych ward school for a reason. We all know the basics of patient care.

A recent New Yorker article by Atul Gawande, entitled the “Cost Conundrum” also addresses this “Culture of Medicine.” Gawande outlines the problem of controlling health care costs by comparing the habits of physicians living in McAllen, Texas to nearby El Paso, Texas. He also went to Mayo clinic in Rochester, Minnesota, where he expected that their world-wide renown, high-tech and high quality of care would equate to more money.
McAllen’s Medicare expenditures per enrollee in 2006 were $15,000.
El Paso’s were $7,500.
Mayo clinic's were $6,688, less than either McAllen or El Paso!
What accounted for this difference?

McAllen physicians were highly enterprising and saw more patients each day, ordered more tests, and performed more aggressive interventions earlier. This padded their pockets a little bit more and thus rewarded, they continued onwards. This cycle of greed and profit is perfectly legitimate in our system of Relative Value Units (RVUs) where procedures are valued above cognition and doctors are compensated not be the quality of their patients’ health or their ability to make a diagnosis in a cost-effective manner… they are paid based on how many patients they see each day. This drives them to maximize their patient numbers and minimize their time with each of them! It becomes much easier to check a box and order an MRI of the brain than it is to spend an extra TEN minutes with a patient to sort out the true history and duration of dizziness -- but which one is more ideal?

I think that healthcare will be the next bubble to burst, now that dot.coms, real-estate markets, Wall Street and Auto makers collapsed under similarly empty value-for-cost pressures. Our healthcare dollars are being poured down a hole with little regard about whether they are spent on the RIGHT things. Gawande made a comment that I found Twitter-worthy:

“the most expensive equipment is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.”

The culture of medicine needs to change if we are going to fix our “broken system." Doctors cannot sit idly by and complain that it is insurance reimbursement or Medicare that is causing the problem. We need to admit that we are a part of the problem -- and seeing patients as a revenue stream and maximizing “business” by turning up the speed on the conveyor belt is not the solution! There is a sense of entitlement that because we have worked so hard and studied for so long to get to the position that we are in today (or in my case, soon will be,) we deserve the highest compensation for our services as possible. We measure our success based on how our income and lifestyle compares to our peers -- and so, in medical school, ironically fields like anesthesiology and radiology are highly valued despite the minimal patient contact. (It's a a pissing contest, if you pardon my French.) Our value to society and our true measure of success should be based on how healthy we keep our patients and how comfortable we make them feel when we cannot. That's our value to keep healthcare costs down!

We do not gain the sympathy of the general public by complaining -- “I don’t get paid enough to see patients!” Many patients who go to the doctors only to find a nurse practitioner or a physician assistant may just reply -- “You never saw me anyway.” We need to ground ourselves again and remember that our duty is to Care for patients before ourselves. That’s my interpretation of the words “Primary Care.” And that’s Not My Second Opinion!

Bystander Affect/Effect

This is another question sent in by a reader.

I was on my way back to the school, after a student's parents had asked me to lunch and something terrible happened. A woman was hit (hard) by a truck about 50 feet from where we were getting into the car. She had a child (about 2 years old) who she had been carrying who landed maybe 15 or so feet away from her. I was appalled, as I have never seen anything like that. A bystander went and picked up the child.

I seriously doubt there is much I could have done to helped, but of course it tortures me that she picked up the child. I feel like maybe if I had gone into the road to help I might have been able to stop her. I kept thinking of what I would have done ("help call 911" and realizing that wouldn't work at all, and I don't even know the number).

I thought... I remember stuff from first aid and the army. I could have checked for a head wound, with my hands first then checked for breathing, then... wait. I realized if I had done anything, and my hands come back with blood on them, that creates a whole new problem. I am not a medical professional, and I'm not even in my own country. I don't have gloves, or one of those safety masks for giving CPR. I've heard lots of horror stories about getting tested, and re-tested for HIV because of touching someone else's blood as a teacher.

How do you (as a soon to be professional, and yet not an EMT yourself) reconcile the two, the safety of the individual, and potentially comprising your own health by doing so.

I've got good friends here who made me immediately snap out of any bad feelings that I had after seeing that, but I am curious about what you think would be an appropriate response by someone like me (with a little relevant medical knowledge)... or what you would do if faced with a similar situation outside of the hospital.

There's a few levels I can address this. The legal one is the most clear, since it has been spelled out in the Good Samaritan law: bystanders are protected from liability in acting to help someone else when it is "in good faith and in accordance with their level of training."

The level of training is important for a health professional like myself... because if I were to rush over and pick up the child, I might be at risk for a lawsuit if the kid had a broken neck and I just paralyzed him or worse. We'll ignore the issues of compensation and volunteerism or I'll just get sidetracked.

So an accident just happened. It's something that's unexpected and you were in shock. That's totally natural! I dread the day when everyone looks to me when a crisis is happening and I don't know what to do. (I'm hoping that I'll be ready and able!) Your situation is complicated by a cultural and language barrier. I imagine knowing the phone number for an emergency "911" call should be the first number you learn when you go to a new country (or at least know where to look, i.e. travel book) to be prepared. Disclosure: I went to Spain and Japan and I even visited a bunch of hospitals in Japan and I don't recall how to call "911" offhand.

Regarding the blood exposure... it's not that bad to get tested for HIV, but turning HIV(+) after helping someone in an accident... that would be a major bummer. Universal precautions are nice, but not everyone has a set of gloves and a bag-mask in the trunk of their car. Don't worry about that. There are other measures you can do like towels and shirts that can limit exposure risks too. There's a lot of prophylactic drugs you can take as long as you request testing of the victim and yourself in a timely manner. If someone is bleeding and you are worried about getting blood on your hands... well, there'll just be more blood the longer you worry about it. There's a few things to do BEFORE rushing over and stopping the bleeding though.

The ABCDE of trauma should be a starting point for figuring out what to do. I've talked about it before in my trauma call post.

I think it's good that you are thinking about what you could have done in this situation. If it ever comes up again, maybe you'll be better prepared to take action.

Dilemma: Care of an Unresponsive Patient with a Poor Prognosis

NEJM Clinical Decisions Case:
Care of an Unresponsive Patient with a Poor Prognosis
Arthur S. Slutsky, M.D., and Leonard D. Hudson, M.D.

A 56-year-old homeless man was found having a seizure and was transported to the hospital. He was found to have a subarachnoid hemorrhage and acute hydrocephalus. He underwent intubation, and mechanical ventilation was started. ... The patient's condition did not improve over the next 3 days, and both the neurologist and the neurosurgeon opined that he had a chance of approximately 80 to 90% of being in a long-term persistent vegetative state and a chance of 5 to 10% of any recovery. His prognosis, at best, was to have a severe disability that would leave him dependent on care by others.

In this picture:

* A son who, under the law of the state, was the legal next of kin for making medical decisions if the patient was unable to do so himself. The son described the patient as "a fighter" who would want aggressive care until the prognosis was much more certain.
* A brother and a mother. They were all in agreement that the patient would not want to live in a state in which he would be largely dependent on others for daily care and would have severely impaired cognition.
* A counselor at a homeless shelter with whom he had talked at least every couple of weeks. The counselor came to see the patient and related that the patient had told him that he wished to avoid hospitals and that "when his time came" he wanted no aggressive medical care.

Given the lack of improvement in the patient's neurologic state, the extremely poor prognosis for any meaningful recovery of cognitive function, and the high probability of cancer, the care team strongly believed that all aggressive and supportive measures should be discontinued and the goals of care changed to those of providing comfort. The brother and mother, who had been quick to respond to queries from the beginning, agreed with the shift to comfort care. However, the son, who had become increasingly difficult to contact and rarely returned telephone calls from the caregivers, disagreed. He had hardened his position, wanting full aggressive-care measures to be taken, including clipping of the aneurysm.

What would you do?
1) Continue Aggressive Care and Pursue an Ethics Consultation with the Patient's Surrogate
2) Write a Do-Not-Resuscitate Order and Transfer the Patient to a Skilled Nursing Facility
3) Withdraw Life Support on the Basis of Substituted Judgment

Cast your vote!

---

My response:

I chose three online. To demonstrate my convictions, I've provided my extended comments below.
This case shows that decisions cannot be made with broad brush-strokes (all decision making must be handled exclusively by legal next of kin). Rather, it must be understood in the context of the case. The son with durable power of attorney (DPOA) is "holding the line" so to speak, on the basis that his father is "a fighter" who would desire aggressive care until a prognosis was much more certain.

Surely, this is a sentiment we can all agree with -- fighting for someone we love. However, the clarity of the prognosis and possibility for recovery is understood by all (but him) to be minimal at best. The prognosis was declared by a neurologist and neurosurgeon to be ~80-90% of being in a long-term persistent vegetative state and a chance of only 5-10% for any recovery! Even if he did recover, he would no longer be independent, something inconsistent with his values.

The father has not formally declared any DPOA, but it becomes apparent that the son is estranged and the counselor from the shelter is more familiar with the patient's desires. The son is exhibiting a common grief reaction of denial, withdrawing himself from the situation while simulataneously insisting that everything be done. Given the family support from the mother and brother and the coinciding words by the counselor, I would elect to place the decision-making in their hands and withdraw life support and provide hospice for the patient and family counseling. A full discussion of the SAH and subsequent coma should be initiated with the family with maximal encouragement to have the son attend!

Fast Food Economics

Maybe you've heard the commercials for 3conomics by a certain fast food company.

Here's a personal story of another fast food chain and how they run things.

I order a Jumbo Burger and a soda (needed food on the run before evening Urgent Care clinic since I didn't make any sandwiches for the day.) She tells me "Would you like to get our Jumbo deal? You'll get fries and two tacos with it and it will be cheaper." (emphasis mine!)

BWA? I hesitated because I'll be honest, I was tempted. Ooh, more food for less money? I turned it down knowing that my stomach could not hold more than a burger. Besides, America is fat enough as it is. I needed to take a stand.

"Just trying to save you money," she told me.
"Well, I think it's ethically irresponsible for your restaurant to offer more food for less money. I'll eat what I can eat." I replied.
She cocked her head to the side, obviously surprised to be under attack by proxy, but conceded. "Yeah, sorry," she said as I drove off.

By the way, the burger was delicious. I went home that evening and had a salad with carrots to make amends. :)

Octuplet mom "obsessed" with kids -- all 14 by IVF

Octuplets' Mom "Obsessed" With Having Kids:
Her Mom Says All 14 Of Unmarried Daughter's Children Resulted From In-Vitro; Ethics Debate Rages On

The woman who gave birth to octuplets this week conceived all 14 of her children through in-vitro fertilization, is not married, and has been obsessed with having children since she was a teenager, her mother said.

A physician has clear ethical responsibilities to primum non nocere, first do no harm. In-vitro fertilization is a process in which eggs are collected from the mother, the "shell" is cracked and sperm are incubated with them in a "test-tube" environment. When an embryo is ready, it is placed in the mother. It is not guaranteed that this embryo will implant itself on the endometrial lining, nor that it will persist to full-term. To increase the likelihood of a successful pregnancy, the U.S. allows up to TWO embryos to be implanted (except in unusual circumstances.)

EIGHT embryos were implanted in this woman! What sort of infertility condition does she have that warrants this risk to herself and her babies?!?

Angela Suleman said her daughter always had trouble conceiving and underwent in-vitro fertilization treatments because her fallopian tubes are "plugged up."

That doesn't count for squat. If she has no uterine anatomic defects or dysregulation in her menstrual cycle (problems involving the ovaries)... it doesn't make sense to me that she needs this! Except for the fact that she's obsessed -- clearly something that a physician should discuss in depth with a mother-to-be. At the very least, a referral to a good psychiatrist as this obsession clearly was affecting her relationship with her parents.

There were frozen embryos left over after her previous pregnancies and her daughter didn't want them destroyed, so she decided to have more children.

Her mother and doctors have said the woman was told she had the option to abort some of the embryos and, later, the fetuses. She refused.

Her mother said she doesn't believe her daughter will have any more children.

"She doesn't have any more (frozen embryos), so it's over now," she said. "It has to be."

....
Ah. Now the story is being made more clear, although in somewhat oblique terms. Here's a mother who believes that it would be unethical to discard her other embryos. I can imagine what this discussion went like with the doctor.

"Doc, how many embryos do I have?"
"We have eight embryos left over from your previous IVF."
"Doc, I'm pro-life. I don't want to kill these babies. Will you implant all of them?"
"Uhm, ok."

Sarcasm aside, this woman's belief (after artificially creating embryos) about the sanctity of life endangered her own life and those of her children. Most people are not aware that as women age, many embryos do not even make it to term due to chromosomal abnormalities, failure of implantation, etc. We do not blame women for these silent miscarriages. The idea of being "pro-life" is attractive because of its simplicity... but the reality of the situation is that "life" itself begins on a spectrum of convening factors. It's not merely the union of an egg and sperm. The full extent of this topic should be the subject of another post -- and if I'm going to compose my thoughts well enough to make a statement that I'd stand behind, it would have to be a damn good one.

Yolanda Garcia, 49, of Whittier, said she helped care for Nadya Suleman's autistic son three years ago.

"From what I could tell back then, she was pretty happy with herself, saying she liked having kids and she wanted 12 kids in all," Garcia told the Long Beach Press-Telegram.

"She told me that all of her kids were through in vitro, and I said 'Gosh, how can you afford that and go to school at the same time?'" she added. "And she said it's because she got paid for it."

Aaand this speaks of even more ethical grayness. I really feel bad for this lady now. Not only is she single with fourteen kids, at least one of them has special needs. I don't get it though. She was paid to do what? Donate eggs? Participate in an experiment for multiple gestation pregnancy? This story has opened up so many doors to all sorts of controversies in medicine, it's quite incredible. Even more so because I imagine that the general lay-public has enough understanding to wonder at technology producing octuplets but not enough to feel the chill of incompetence in doing so.

"When should I start teaching my children about sex?"

Dr. Karen Rayne has an excellent answer to this question that touches on the underlying implicit emotional issues that are often ignored in our often explicit and graphic culture. Here is an abbreviated version of her typical answer:

When you “should” start teaching about sex doesn’t really matter - you DO start teaching about sex when your children are infants.
...
You teach them what a gentle touch feels like and what it is to be loved.
...
We teach them the names of their body parts, and the names of everyone else’s body parts too.
...
We teach our young children how to be a good friend, how to share, and how to reconcile arguments and disagreements graciously and with love.

This is a wonderful lesson for everyone to have -- I think there are many ADULTS who still haven't been had proper sex-education in this context.

Read more from Dr. Rayne @ Adolescent Sexuality

DNR does not = Do Nothing

I'm finishing up my write up tonight and my last Problem to be addressed in the Assessment/Plan is a terminal condition. I found this article on the subject from Family Physicans/Residents pondering the subject. I'm wondering if this is something I should bring up with my patient since I've avoided it in all of my previous conversations with her.

Discussions of "code status" on a family practice teaching ward: What barriers do family physicians face?
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=80314

One of the things that bothered me when I was a hospital volunteer in high school was the very STRANGE pronouncement in my opinion, on the doors of some of the patient rooms: "DO NOT RESUSCITATE." Even as someone tangentially related to the healthcare field at the time, I thought it was an overtly insensitive and harsh statement. I think my reaction could be summed up as "Why are you banning people from getting healthcare?!?! Isn't that the REASON they are in the hospital?"

I'd like to emphasize that no decisions are final and “Do Not Resuscitate” does not mean “do nothing”. A term like “Allow Natural Death” is equivocal in meaning, but very different in the eyes of a patient and their family. It adheres to their wishes to have “everything done” so they do not feel like they are giving up, without prolonging their suffering with unnecessary and futile medical care.

Ultimately, “Allow Natural Death” is a permissive activity, asking patients if they feel at peace and are willing to let go.
“Do Not Resuscitate” is a dismissive activity and patients may feel ignored or that they would get worse care this way.

As an aside, this is a great example of connotation versus denotation. I struggled to remember these two vocabulary words for about half an hour now. Whew!

This is not the case! One thing I am learning right now by following my residents into the ICU is that many patients who are "Full Code", meaning they will be resuscitated to the fullest extent regardless of the quality of life and eventual outcomes for the patient receive TERRIBLE care as a result... getting hit with all sorts of hospital acquired illnesses from drug-resistant bacteria, thrashed with drugs that work so hard to provide blood to the heart and brain that they literally amputate limbs from within... my goodness.

What is necessary in the hard times when a patient is on their last limb before they go is an honest and heart-to-heart discussion between a knowledgable individual (the doctor) and the people who will ultimately have to make the decision for someone to die. NOT live or die. Just die. There's no other options for a lot of these folks and THAT is the concept that must be conveyed appropriately to the general public who don't know what tonic-clonic twitches are, the different categories of death ranging from asystole to brain death to cessation of all biological function and a shift to true equilibrium. I know I've made no effort of my own to define these words. That makes me a hypocrite (for now.)

Feel free to discuss this topic in the comments (and I'll chime in with my definitions later.)

JABSOM is not Pharm-Free

AMSA PharmFree Scorecard 2008 ranks 150 medical schools on their pharmaceutical rep policies. Only 7 schools received an A while 60 received a failing grade.

JABSOM was the first F.... shame on you, JABSOM! We failed to provide any policy whatsoever on this matter. Comments below:

University of Hawai’i John A Burns School of Medicine has implied that it is not a clinical facility and therefore it is not necessary to create policies in many of the domains on which it was assessed. It should be noted that other schools and colleges of medicine, which are not clinical facilities themselves, have created policies on conflicts of interest that apply to many of the domains assessed.

I've done s presentation about drug reps with my classmates and one of the lecturers in our EBM course expounded on the influence of drug companies in academic medicine. These are just small measures on the part of individuals though and easily tuned out as "just another boring lecture" by students.

AAMC and AMSA are pressuring schools to become more proactive in reducing financial conflicts of interest and lead by example for future doctors. This means banning all gifts and free drug lunches at University events. It means refusing industry support for CME. It means keeping our hands clean and doing our business.

There are some doctors who think that this is impractical. They think that they are immune to influence by pretty women with convincing papers on their latest drug. They think that CME will die without hefty financial support by pharmaceutical companies.

I'm not that naive.

• I know I'm easily impressionable... that's why I do my best to surround myself with good examples.
• In the long run, free samples aren't cheaper if the fancy new designer drug is 10x as expensive and just as effective as a generic drug.
• I don't fret about CME... just checking my blogroll every day is a hefty dose of up-to-date medical education.

A spoonful of Obecalp

At first, it started off as a joke. I mean, it's easy to ask the question. In a clinical trial, if a placebo actually improves a patient's health almost as much as a regular drug, shouldn't we be selling placebo pills? It's certainly a funnier (and more marketable) idea than ditching the drug undergoing clinical trials... especially after the drug company forked over $100 million for research and development up until that point.

Graham at OverMyMedBody! brought the idea of Obecalp to the blogging scene earlier this year.

45% of doctors who responded to a survey said they’ve given placebos to
patients. That number certainly seems high, but sometimes patients don’t
want to hear what you’re saying–namely, that no drug will help them. ...
I’ve certainly wanted to write for “Obecalp 1 tab PO BID” (’placebo’
backwards) but I find it totally unethical and undermining of the doctor-patient trusting relationship. (emphasis mine.)

So now what?

According to the NY Times, Obecalp will now be for sale as a dietary supplement. The example cited? A child with "a nagging case of hypochondria." I'm not sure how I feel about this.

Would you have to deceive Obecalp recipients in order for it to be "effectual?" I mean, I up my Vitamin C content and drink chicken long rice soup (with lots of ginger) whenever I get sick... that's placebo and I know it! Regardless, I feel better knowing that I did something.

Why limit the marketing to harried adults with whiny kids? This drug will fit in perfectly alongside Airborne and herbal remedies. In many ways, I'd prefer something that tells you up front: "I'm completely useless!"

via The Happy Hospitalist: Ma! Ma! I Need Another Fix

image by Djenan (creative commons license)

Inspired

This is a letter that I've written to apply for a scholarship, something I rarely do because I hardly ever feel qualified... but it came to me in a flash of inspiration this morning and it really reflects my thoughts on a lot of different things that have been going on lately in my life.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

These three rights are often quoted, but the definition of “Life” isn’t as fully explored as the idea of “Freedom.” When I reflect on it, the connection to medical ethics becomes apparent: Beauchamp and Childress’ bioethical principles of Beneficence, Nonmaleficence, Autonomy and Distributive Justice echo the same theme. I shared my ideas through an Ethics Workshop that I organized this year for the Medical Student Mentorship Program (MSMP.) The idea of “basic human rights” is a fundamental notion – treat each other with kindness, respect and love. These are very deep topics perhaps, but they are entirely relevant to why I’ve chosen to go into medicine and serve others.

The right to Life equates to a right to be healthy, in my opinion. I’ll admit, I do not know if this was the intent of our founding fathers. However in this day and age, we have the knowledge and the power to help everyone in this respect! It frustrates me how something so obvious to me could be stymied by the short-sightedness of some political parties and insurance companies. The money problems of rising health care costs cannot be solved by putting power into the hands of private insurance companies who focus solely on their bottom line and how they can cut costs and deny coverage. Only by having a huge pot and nationwide coordination may we have a basic, free healthcare plan available to everyone. Until that day, some disadvantaged populations will continue to suffer and they will never get the same opportunities as everyone else. This is why I joined the Hawaii Homeless Outreach and Medical Education (H.O.M.E.) Project where I am currently a second-year clinic manager. I volunteer at the Kaka’ako and Waianae homeless shelters where we provide free outpatient healthcare for the residents. Instead of blithely accepting an unjust system, I have sought out opportunities to be a part of something that could catalyze change and help people recognize their right to Life.

I am committed to helping the people of the Pacific region and I dream of big things for our future. As a small state with diverse cultures and strong communities, Hawaii has the unique opportunity to show the rest of the nation what Aloha really means and how we can truly care for all people. I want to be a part of that and inspire others to help as well. I feel that my current work in MSMP and HOME are only the beginning of these good things.

I hope it doesn't come off as overly pompous, cheesy or insincere because it is the truth as I see it. One of my pet peeves is when people declare something "BS" -- to me, it is only if YOU think it is and it isn't if you think it isn't. Depends on whether you have a cynical or an optimistic eye of the beholder.


^Beholder

Emotions and the Way

"This commercial actually made me cry a little bit.
I wish I had a family."

I was chatting with my friend tonight and he sent me a youtube link with that message on AIM. I'll let you take a chance to watch it before I continue.




----------------




Done? Good. The part at the end translates as "Thai Life Insurance."
So it's a totally fake commercial, but it made me tear up anyway. Decisions that don't make sense to doctors AREN'T bad decisions per se. Patients might have a completely different perpective that is totally valid.

If you open your eyes and listen, you might even be touched.
*sniffle*
Oh my. Sometimes I worry that my emotions will get in the way. Other times, well... allow me take the scenic route towards another conclusion.

This commercial reminded me of a class I had last year.

A guest lecturer came for a "blood banking lab" which turned out to be a confusing session on making checkboxes in the appropriate columns to "type and crossmatch" blood so we don't inadvertently kill patients in the future. While this isn't the job of a doctor typically, Dr. R wanted to impress upon us the difficulty of this task.

"Blood banking isn't as easy as 'giving them O blood.' There's a lot that goes on," he stressed. "As a matter of fact, a lot of difficult decisions are made every day. How many of you know about rationing? No? Basically, each unit of blood that is ordered for a patient is a unit of blood that CANNOT be given to another patient. If everyone demands Type O blood and we only have a dozen units, it gets used up very quickly."

"Let me tell you a story. I was called to see a patient who was delivering a baby and ran into some complications. She had Disseminated Intravascular Coagulation (DIC) and started to bleed out of almost every orifice. She was rushed into the Intensive Care Unit with nurses literally squeezing bags of blood, but she was losing blood faster than we could put it in. We might as well have opened up the bags and spilled them directly onto the floor."

"The blood wasn't enough. Platelets and Fresh Frozen Plasma too. But there was something else we could try. The magic blue juju vial."

Ok, so I made that name up. Keep in mind, that I'm recalling a story from a year ago and I haven't actually PRACTICED medicine in any hospital situation so I don't know what the indications are for using FFP vs platelets vs the magic blue juju vial (MBJJV). What matters to me is the story and the lesson I got from it.

"The only thing is, MBJJV would cost the hospital ten-thousand dollars. On top of that, she would only live for fifteen or twenty minutes, tops, even if we gave it to her."

There was a quaver in his voice and a gleam of anger in his eyes. Dr. R's voice rose to a shout.

"What would YOU do?" He challenged a few people in the class who had no idea what answer would appease this boiling man.

"What if I told you that those 15-20 minutes would give her enough time to spend with her daughter. An occasion that the husband could recall, at best bittersweetly rather than traumatically." (Ah yes, this is the connection with the Youtube clip.)

"What if I told you that the hospital had only one MBJJV and it would take months until another one came -- and another patient who could have otherwise been saved -- died because it had already been used."

"What would you do..." he trailed off, taking the time to remove his glasses and wipe his tears away.

I mustered up the courage to speak up, my own voice wobbling and wavering as I imagined the situation before me. "There's two sides to this -- payment and resources on one side and the needs of the patient on the other. When we talk about futile care, resources should not... hm, ought not to be expended if they can save a life. But in this case, we aren't talking about what best benefits the patient, are we? It's about what will be best for the husband and her daughter. Is the hospital willing to pay the money that insurance surely won't cover?"

So what happened?
She held her baby for the first and last time. She held on two hours. (Or my memory is adding in this detail for the sake of the story.)

-------------------

Afterwards, I learned that some of my classmates completely misinterpreted Dr. R's position. "That guy got really pissed off about ten-thousand dollars," someone told me. Wha? I thought his anguish over the ethical dilemma was obvious.

Do emotions get in the way? Do they cloud our judgement on what is right and wrong?
Perhaps, it's wrong to distance ourselves.
Maybe mmotions should guide us along the Way. They can reorient us to what actually matters.

Dear Congress,

Hello,

My name is Clinton. I am a second year medical student at the John A. Burns School of Medicine and I'm a minority in my class. Why is that? I want to go into a primary care field -- Family Medicine. I have long recognized the need in our country. We have a shortage of primary care physicians, dedicated people who coordinate care across our entire health care system. Family doctors have the greatest potential to impact the lives of many patients with the tools for early detection, prevention and education, in terms of cost (insurance savings) and benefits (better quality of life.)

Many of my classmates have been discouraged by the long hours, endless paperwork and low reimbursement rates seen in Primary Care. Many of them seek careers in more lucrative, more "successful" specialties. Is this really the direction we want to drive some of America's best and brightest? Is the message "We don't Care about Health Care" really an idea we want to spread?

There's something you can do to help. I'm not expecting you to change our health care system overnight; I'm merely asking for your support on a bill that will greatly benefit our Family Physicians. Hopefully, this will be a step that will take us in a new direction and everyone will have the care they deserve.

As a future family physician, I urge you to support S. 2785, the Save Medicare Act of 2008 and stop the Medicare payment cut that will take place after July 1, 2008, and guarantee an 18-month positive update so that Congress and the White House can work on fixing the Medicare payment program.

Unless Congress acts, family doctors will be hit with a decrease of more than 10 percent in payments after July 1. This sort of shifting Medicare reimbursement makes it harder for them to take new Medicare patients - do you want them to pay out of pocket to take care of patients?

Congress MUST replace the current, confusing Medicare physician payment formula that determines payment amounts. We need a NEW formula that makes sense and provides predictable annual increases that reflect the cost of providing care to patients. Family physicians deliver the primary and preventive care seniors need to stay well and to better manage chronic conditions - the leading drivers of health care spending. As the population ages, family physicians are positioned to keep seniors healthy and cut U.S. health care costs. But, they can't do it unless Congress acts now.

I urge you to help family physicians stay in business. I would like to be able to provide quality care for America's elderly without worrying about "breaking even." Please support the Save Medicare Act of 2008 to stop the payment cut by July 1 and ensure an 18-month positive update to the Medicare physician payment rate.

Change can start, here and now! Care about Primary Care, please. :)

PLoS Medicine: How Drug Reps Make Friends and Influence Doctors

Clinical Cases and Images shares a refreshing insight into the manipulative drug rep mentality from the POV of an ex-drug rep.

This article reminded me a lot of a book a friend loaned to me about the way physicians are "bought out" to sell drugs. Unfortunately, I cannot remember the name of that book now... but it made some good points that made me wary of drug reps before I entered medical school.The thrust of the book was that it is unethical to accept gifts from drug reps because they would unconsciously influence prescription writing in their favor. Doctors are not as objective as they would like to think.

However, I was met with an uncomfortable scenario as early as my third day of orientation week in medical school. We had a recruitment fair and some organizations gave out "free stuff" with pharmaceutical names stamped all over them. I wanted free stuff. I didn't want to turn my Ethical Upbringing into a big deal. As a result, I came up with this reluctant compromise... I would be OK accepting small gifts (pens, pads of paper, etc.) as long as I erased the name from their free products.

I bought some acetone that afternoon and scrubbed the names off of those products. I can tune out the names pretty well... but I do feel conflicted if I learn about a new drug in school and I go "hey, that's just like the name on those sticker tabs!" I'd like to come up with a better solution for dealing with drug reps when it really counts.

On oops disclosures

Dr. Michael Wilkes's Second Opinion on KCRW on disclosure.

I've commented with my thoughts on disclosure of a cancer diagnosis to a Japanese patient before in "Shh! He doesn't know!" Culturally, it is acceptable for the family to request that this information be withheld from the patient -- something that I found ethically repugnant a year ago.

If a patient asks "why am I getting this treatment", is the family asking us to lie for them? How far is this betrayal of trust expected to go?

However, my recent visit to Japan made me reconsider this. There is a trend in Japan towards more Western values and practices in Medicine (among other things) and cancer disclosure is still a contentious topic there. I asked a few doctors (one was a cardiologist, the other, a resident training in GI) how they approach the subject.

The resident told me point blank that he followed the family's wishes and didn't tell the patient. He echoed the sentiment "a lot of patients cannot handle a diagnosis of cancer." I was surprised to hear this. Cancer isn't the death sentence that it used to be. The elder cardiologist agreed with me and told me that he tells his patients regardless of what the family wants. "It's their right to know," he said. Of course, he did have training in the U.S., so that might have affected his cultural judgement.

I'm not sure how I feel about the situation mentioned by Dr. Wilkes. If I were the surgeon, what would I do?

*deep inhalation*

I'd like to think that I could do the right thing and respect the family's wishes while still fulfilling my role as a doctor. Before the diagnosis is even made, I would like to approach the patient and tell him/her "now, one of the things we are testing for is cancer. If it turns out to be cancer, how would you like this to be handled?"

This gives the patient an opportunity to "opt-out" and puts patient decision-making in the hands of the family. I think this is culturally sensitive for both parties and it has the advantage of forewarning the patient of their potential diagnosis. If they are keen, they probably suspected cancer all along. Perhaps it's just reassuring for some patients to know that they are being taken care of as best as possible without having to worry about the prognosis.

Healthcare Blogger Code of Ethics

I just came across this concept through Nick Gene's Pre-Rounds Interview with Dr. Lei of Eye on DNA.
Med Blogger Code of Ethics:

1. Clear representation of perspective - readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the professional perspective from which they are blogging.
2. Confidentiality - Bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients’ identity cannot be inferred.
3. Commercial Disclosure - the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.
4. Reliability of Information - citing sources when appropriate and changing inaccuracies when they are pointed out
5. Courtesy - Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.

I agree with these ideas, especially those about Reliability of Information. There's so much garbage out on the internet that obscures the truth... it's important for health professionals to ensure that they are providing a refuge from this refuse!

Shhh! He doesn't know!

Scene: A Japanese patient goes to a clinic complaining of abdominal pain and trouble eating. In the waiting area, a strange man greets him and tells him a story. "I know a man who had stomach cancer," he says. "He had terrible stomach pain." The patient's face pales as he hears this. "He had black stool that smelled terrible." The patient shudders and looks away. "They told him it was just a stomach ulcer. He could eat whatever he wanted as long as it wasn't too rough. He died a few months later."

The patient is called into the office where he is told that he had he only has a stomach ulcer and he can eat whatever he wants, as long as it isn't too rough. He looks the doctor in the eye and says "is it cancer? Tell me if I have stomach cancer!" The nurse keeps her head low and scurries away. Another doctor cannot meet his gaze.

Implicitly, he knows what this means and resigns himself to his fate.
/end scene

This is a scene from Ikiru, where a dying bureaucrat decides to spend the remainder of his life building a playground.

Why didn't a doctor disclose the cancer diagnosis to his patient? He outright LIED to the patient who was under considerable distress. This scene bothered me a lot when I saw it for the first time. Then I learned a little bit more about the Japanese cultural aspects that made this behavior acceptable. It's still something I'm not comfortable with, but at least I know what they are thinking now.


In traditional Japanese culture, a terminal diagnosis is not disclosed to the patient. It is thought that this knowledge of an impending death only brings stress and consternation for the patient, who would have otherwise died in a happier state. So instead of telling the patient, the Japanese doctor tells the family. They decide what is best for the patient in what has been termed "family autonomy."

Japanese people have a more interdependent construal of self. They are more prone to say things indirectly to avoid conflict and confrontation. They want everyone to get along.

An important Japanese value is amae. This is "indulgent dependency," or "the accepted perogative of the individual to depend on the benevolence of another." It is tolereated by Japanese people, but it might seem like spoiled whining to Americans. The way I'd interpret it is something along the lines of:
"Please help me, I cannot help myself, I need someone to take care of me!"
This type of pleading puts responsibility of care into the hands of a loved one, boss or someone else that's of a higher position.

Still, this runs at odds with everything I'd want from a doctor. Paternalism, the feeling that "doctor knows best" is an idea we've abandoned for about 40 years now. It is starting to be discarded in Japan as well, as more and more people expect the truth from their physicians, no matter how painful the news may be.



Resources
Fetters, Michael. “The Family in Medical Decision Making: Japanese Perspectives” Journal of Clinical Ethics. Summer 1998. 9(2)132-146.
Powell, Tia. “Culture and Communication: Medical Disclosure in Japan & U.S.” American Journal of Bioethics. 6(1):18-19, 2006.

Proxy consent

Is it morally right for society to allow parents of children too young to make their own decisions to deny them the medical attention they require for survival for religious reasons?

• Yes, it is their child after all
• No, absolutely not
• I'm Not Sure

I see this as a question of responsibility. Ultimately, who is held responsible for the death of a Jehovah's Witness child if they get into a serious car accident and need stat blood transfusions in the ER? Is it the person who drove the car? Is it the ER physician? Is it the parents for refusing to give their child blood? Is it God? Everyone has different answers. "It was God's will" is often invoked as a way of accepting the passing of a loved one. However, gods do not swoop down and cast their miracles, blessings and curses down upon us on a daily basis, manipulating our fates in the same way that a storyteller casts roles for his characters and tells them what to say and do. We all have free will to do as we wish.

If we have the power, the capacity and the opportunity to save a life, then I feel that we are MORALLY OBLIGATED TO DO SO. With power comes responsibility, because where we once had no options but to grit our teeth and pray, we now have Choice. We can Choose to alter the fate of a human life in the case of emergency medicine.

Not everyone will choose to follow the same course of action.

"You have the right to choose", the Watchtower says. This biweekly publication for Jehovah's Witnesses originally introduced the ban on blood transfusions in 1945 and since then, it has complicated the treatment for their adherents. While I find it regrettable that JW's would refuse treatment, by the ethical principle of autonomy, they are allowed to do so as long as they give informed consent. This means that they fully understand all of their options and perform a cost-benefit analysis according to their own principles and make a decision. The difficulty underlying this is how it can be applied to young children.

The British Medical Journal has this to say on the subject of proxy consent:

With regard to religious based refusal of blood products by parents, courts in the western world are of the opinion that the child’s welfare is paramount and blood can be given. Consideration should be given to parental views and treatment moderated where possible but if conflict occurs, the child’s interests always come first.

Regarding adolescents, there is no worldwide consensus on the legal position of adolescents refusing blood transfusions, but recent cases suggest that the UK’s approach is probably the most acceptable. While many children raised in JW communities may never experience the "outside world", the judiciary would be wrong not to give them that opportunity. Religion is a powerful persuading voice, but it is also an individual belief. A limited life experience cannot truly give one the opportunity to rationalise a belief that may eventually lead to death.

Archives of Disease in Childhood 2005;90:715-719

Past courts have ruled similarly, citing differences between developed adult beliefs and those of their undeveloped children. In 1944, Prince v Massachusetts set out the reigning legal principle:

Parents may be free to become martyrs themselves. But it does not follow that
they are free, in identical circumstances, to make martyrs of their children...

In 1999, Alexis Demos was a 17 year old who refused to undergo a blood transfusion when she lacerated her spleen after a snowboarding accident. Her decision and that of her family was challenged by physicians and ultimately went to the Massachusetts Supreme Court where they ruled in favor of the physicians. What parents often forget is that they are not solely responsible of their child's welfare; doctors and nurses who care for the patient are emotionally affected as well. The death of a child who would have been saved under any other circumstances rests on their consciences.

However, the beliefs of Jehovah's Witnesses are not to be dismissed or ignored by the medical community. For them, this is not a routine medical procedure, it might be a test of their faith and a gauge for their quality of life. As one Jehovah's Witness told me, "If I receive a blood transfusion, I won't be living in the face of God and it would be better to die than face that." Those are strong words to live by (and die by.) Blatantly disregarding these strong beliefs would violate her autonomy and her personal well-being. Many surgeries can be performed with alternative blood products, saline infusions and "bloodless surgeries" that cater to their particular beliefs.

When I encounter patients with strong faiths, I will ask them about their faith in medicine and their faith in me. If I am going to help them, I think it is important that they believe in me and my dedication to best serve them.

Community Health

There are four main principles of ethics in medicine: beneficence, non-maleficence, autonomy and distributive justice. Beneficence means to simply do good things, while non-maleficence means doing no harm. Autonomy refers to patient empowerment, giving them the right to choose their course of action in treatment.

Many doctors have no problems following the first three principles, even considering that a lot of very stubborn patients make aggravating and even detrimental health choices. However, the last principle proves to be the most difficult one to accomplish in medicine. Distributive justice reflects our Founding Fathers’ ideals on equality in the same way that autonomy reflects our nation’s independence.

Health disparities are a growing problem in our nation that can only escalate without a few policy and cultural changes. Universal health care is something that we have difficulty “buying into” because of our capitalist thinking… but the way our economy runs should not dictate the level of care that we administer to our citizens. Only recently have I start considering this equality of care as a true, guiding ethical principle alongside “do no harm.”

When I first heard about medical schools offering “free clinics,” I was very excited to be a part of something like that. I did not know what distributive justice was at the time -- I only saw it as an opportunity to get early hands-on clinical experience while being capable of providing a community service in healthcare to an underserved community. In my opinion, this provision is vital in the creation of a bond between students (like myself) and the people we would be seeing in our later years. I have a special interest in Primary Care, so learning how to cultivate this sort of connection was very important to me.

Much to my surprise and delight, My Medical School opened up the “Homeless Outreach and Medical Education (HOME) Project” at the Next Step transitional shelter right next to campus! A few months later, I matriculated. I showed up to the clinic the week before orientation started to get a feel for what we would be doing and I knew at once that this was something I wanted to be a part of. After going through interview after interview with various community health organizations during orientation week, I was selected to be a part of HOME. On my first day as a HOMEy (as we affectionately call ourselves,) I got to draw blood from a family medicine resident, before I even started my curriculum in medical school! I love the sorts of positive experiences and opportunities that HOME provides for us, bridging the gap between the science and clinical aspects of medicine with the art and community aspects.

We learned about community resource mapping and the importance of communicating with various organizations. We learned how to conduct valid surveys which would play into the first phase of our community projects, the needs assessment surveys. Dr. O was very gung ho about involving us in various projects to help the homeless. A few of the projects we are working on involve setting up various clinical services in the areas of dental health and mental health. The project that I am working on involves a mobile clinic that will go out on the road and take health services to the people who need it most. Since the future of the Next Step shelter residents is uncertain next year when the warehouse contract expires, I thought that it was very important for us to be able to go out on the road and see patients.

Last month, we had the opportunity to do just that. HOME set up a tent in a beach park with the “Helping Homeless/Hungry Have Hope” H5 program. We offered blood pressure screenings and first aid alongside the food and entertainment that H5 brought along. We had volunteers to spare, so a bunch of us went roaming through the homeless campsites with needs assessment surveys. The beach residents had a lot of very interesting stories to tell and I left with a sense of sadness and resolve. There were so many children there, just like those at Next Step, who are denied so many things and it is not their fault! The same applies for many of the adults as well, who cannot afford a home or even work at a job. One veteran I met wants to go back to work as a longline fisherman, but he needs surgery before that can be done. As a veteran, he only can get this surgery at an army hospital, but they won’t cover the cost. Another woman I met cannot go to work because she is afraid of losing her government benefits if she tries to raise her income for her family. It is a vicious cycle of poverty, but it is my hope that we can alleviate the problems for a few of these people to make a lasting positive difference in their lives.

We had a Halloween carnival for the kids of Next Step, transitional home to 92 homeless children. It took a lot of planning on the part of the medical students and Dr. O, but we had an incredible amount of support in terms of donations and manpower. I helped organize our volunteers and I also helped make some of the games. The children really enjoyed themselves and a lot of them spent the time cycling through the bouncy castle over and over and over again. Each health-related game came with a set of prizes they could win and their bags already started off with so much toys and candy, it was no wonder that many of them struggled to carry around their big bags of loot around. It was ironic that we had so much candy while we were trying to teach them about healthy habits and perhaps the kids knew that too. One MS-III told me "I asked the kids if they wanted any Reese's Pieces and they just wrinkled their noses... but when I asked them if they wanted pencils, they were really excited about that!"

What I love the most about HOME is the enthusiasm and dedication that everyone involved has and what I admire the most is the way that they excel at the tasks they are put to. Each Tuesday night, we set up clinic and see about two dozen patients in a few hours with just a handful of medical students! The attendings are all very open and friendly with us. It is a good time to get to know the third-years during their family practice rotations and sometimes we get to step beyond doing vitals to perform basic parts of the history and physical examination under their supervision.

I feel that HOME is a great integrating experience that ties in what we learn from clinical skills and basic science lectures with the psychosocial aspects of medicine (the “touchy-feely” stuff) that we discuss in our small group sessions and I am glad to be a part of it!

Should suicide be legal for people in pain?

I am on OkCupid. While I will admit that I like looking at profiles of people who "match" with me, I am not in the right emotional state to start dating again, since my last girlfriend broke up with me a week through med school and moved to Japan to teach high school English. Ah, but don't feel too bad for me... we talked about it for months and I couldn't convince her to maintain a long-distance relationship together.

I like taking the tests on OkCupid... but I don't really like answering the polling questions. I recently learned that they added some features, allowing you to blog about the questions so you can argue some of the points... and I realized that many of the ones I have problems answering are the medical-ethical ones! Here's my latest entry on suicide:

Should suicide be legal for people in pain?

• Yes
• No

Technically, suicide IS legal, because you can't punish someone who is already dead. Also, we probably should limit this question to "physician-assisted suicide," aka PAS, since that is likely the issue that the question is intended for.

So the question becomes: Should it legal for doctors to help patients in pain commit suicide? My first liberal inclination is to say yes, however, the term "pain" must be defined.

Are we talking about someone with emotional pain? Did they just get dumped?
Are we talking about someone with physical pain? Did they just hit their knee?
Are we talking about someon with spiritual pain? Uh... I don't even know what this would be.

Are we talking about someone with an incurable medical condition which causes them intractable pain and they have 6 months or less to live? Cancer patients, very old people (who have "failed to thrive") and perhaps a few other special conditions may apply.

People have a right to death with dignity (DWD) in OR... perhaps the gentle euphemism encouraged the proposition to pass in 1994 and again in 1997 under the name Pain Relief Promotion Act.

There has been efforts to have DWD approved in HI also, under the last set of conditions listed above. Since 2000, less than 50 people die with dignity as many go through a process screening for depression, coming up with alternate palliative measures like increasing pain medications, encouraging family support, etc. That is only 0.0014% of all deaths in Oregon.

This is a rare situation... just because people like Dr. Kevorkian abuse the system and commit ethically and legally unsound acts doesn't mean that Death with Dignity should be a rule.

Everyone wants to die with dignity, surrounded by the people who care for them. However, physician-assisted suicide should not be a RULE. However, I strongly believe that there should be EXCEPTIONS.

More to come.