My Paradigmatic Assumptions

As a family physician with an undergraduate degree in cellular/molecular biology and a relationship-centric graduate and post-graduate training, I possess a blend of different paradigmatic assumptions.  On the one hand, positing initial conditions with cause-effect relationships seen in the physical sciences, I believe in the ability of Science to justify and explain phenomena that we experience. I take it on faith that we all experience slivers of a True Reality through our perceptions.   (This is called Positivism by my own admission of prior ontological and epistemological  programming as a scientist.)  On the other hand, I also believe that a simplistic, reductionist approach pursuing an "objective, external truth" removes a key humanist component in appreciating a "shared social 'reality'" and a "shared social good," a category in which non-physical phenomena dwell.

I do believe there are demonstrable benefits in medicine and science for pursuing an external, objective "one Truth, one Disease" reality when a physician meets a patient and diagnoses them, with say, hypertension.  However, I also acknowledge that our collective beliefs shape our "shared social 'reality'" and our approach to disease.  Each person possesses a unique blend of background human in-born traits like race/sex/personality.  In contrast, sociocultural and epigenetic factors like ethnicity/gender/socioeconomic status. are constructed over time atop these background traits and become structural fixtures as well.  (This is called Constructivism in which truth only gains meaning [and is only known] through social construction.)

Two patients with the same disease may act in very different ways, since they have different constructs.  Similarly, two physicians may act very differently, depending on whether or not they treat the disease... or they treat the patient... the community... or even society itself.

I plan to propose a robust and evocative model that addresses the philosophical differences between the Positivist and the Constructivist, as well as the potential conflicts between patients and physicians.  Firstly, [my thesis] draws upon the positivist principles of natural order-assembly present in physics in phase-change states, and biology in the synthesis of organic molecules like proteins or DNA.  Secondly, it accounts for constructivist scaffolding structure of inborn traits, epigenetic components, sociocultural factors, and educational influence as the basis for idea generation.  Concepts like a disease-diagnosis form, catalyzed by principles of pathophysiology, cognitive "toolkit" heuristics, or past experiences.  The core of the diagnosis is primed by an organized, medicalized mental case presentation pattern-matching to prior illness scripts (or instance scripts.)  In looping back and engaging patients in education and shared-decision-making, aligning a patient's self-perception of disease empowers them to change themselves in cases where a disease is in part a social construct -- moving from a disease-oriented model to a patient-oriented health model.

For example, a physician may react to a patient with hypertension as a machine with an elevated number that can be titrated downward with successive dosing of medications to relax the internal blood pressure.  In contrast, another physician may view hypertension itself as a result of structural violence resulting from generations of low socioeconomic status, poor education, low literacy, living in a food desert without access to healthy low-salt options, lacking safe places to exercise and all things considered, a lower priority given to costly medications relative to other financial imperatives.  Yet another physician may try to advocate for policy on improving access to care and reversing the obesity epidemic.

Alternately, the relationship of the doctor-patient on the subject of an "invisible, risk-factor" disease like hypertension or early stages of type II diabetes is strictly paternalistic.  The physician requests a bond of trust that the number they report (be it blood pressure or blood sugar) is elevated to an unhealthy or possibly even dangerous degree and the patient has to decide whether or not this is credible data.  Do some patients see a physician in the same light as a mechanic who may try to convince a naive car owner to pay for additional parts and labor for something that they don't understand?

Anathem Review

On my interview trail, I purchased this book for my Kindle DX -- and boy, am I glad that I got it electronically, since it clocks in at 960 pages and nearly 3 pounds in the hardcover edition!

It is a work of Science Fiction in the classic sense, inventing a whole world of "compossibility." A world where concents (monasteries) outlive surrounding civilizations by millenia, watching them rise and fall. The Avout (monks) revere Science, Reason, Logic and Physics instead of religion. Indeed, orders of the avout are called "maths." They strive to preserve the world's knowledge and seek out new discoveries, even though a Saunt (Saint) Lora of the 16th century proposed that all possible ideas had already been thought of, which includes Saunt Lora's own Proposition as well.

Stephenson dreamed up this world after participating in the 10,000 Year Clock of the Long Now project, where he thought of the idea of a church that had a clock with a set of individual gates, each programmed to open only at a set time: everyday, every year, every decade, every century and every millenia. A group of monks tended to the clock and were cloistered until such time that their specific gates opened.

The story follows a young "Tenner" who was collected at age 9 and finds himself released back out into the Saecular world shortly after completing his ten-year term. World-altering events call upon young Fraa Erasmus and his fellow clock-winders to solve a great mystery and save Arbre.


Stephenson definitely does not cut you any slack in the novel as you are introduced to the "Orth" language of the people Arbre on the first page and he never lets up. Slowly, the definitions for all of these words unfold in the novel. The payoff is rich in the form of contemplative prose in classic Plato and Socrates style dialoging that encompasses the physics of geometric coordinate phase space, the philosophy of consciousness, the existence/non-existence of time, the power of observation, and the exciting possibilities of science fiction (yes, there are parts of the book that include classic sci-fi space-opera elements to make geeks and nerds glomph and squeal and huggle and hurr.)

If you enjoy xkcd comics, Snow Crash, His Dark Materials, or anything along this vein where education itself is a form of entertainment for you, then this book is a definite buy.

It is quite a struggle for me to describe how this book has affected me, save to say that I have some upsight into the possible tracings of my own Narrative along multiple Worldtracks as they progress along a Directed Acyclic Graph in a Wick fashion, leaking in from the Hylean Theoric World. Complete nonsense to most, but I could put it best in no other way.

And that's Not My Second Opinion.

Family Medicine?

A question I get asked a lot is "Family Medicine, huh? Is that like a GP?"

It is strange but a lot of people do not know what a Internist does, much less a Family doc.

I was pleased when I came across this article in the Annals of Family Medicine: FAMILY MEDICINE: WHAT ARE WE GRADUATING?
From the Association of Family Medicine Residency Directors

The original guidelines from family medicine covered a mere 3 pages laying out the length of training, and general content, as well as proposed categories of programs that reflected and embraced the wide variation of locations where family medicine physicians lived and worked. Our founding document also defined the family medicine physician in 4 domains

First, the family medicine physician was to serve as the physician of first contact with the patient who provided an entry for the patient into the health care system.

Second, the family physician was tasked to evaluate the patient’s total health care needs and to provide personal medical care and referral management.

Third, our graduates were to provide continuous and comprehensive care as well as the coordination of care.

Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu.

Primary care. Primary as in First contact. Total care as in from beginning to end. Family medicine -- with a focus on the context of interrelationships, family, and society. I love it! It's all in the name but the IDEA is somehow so foreign to the sort of fragmented, disjointed care that we have now that we've lost sight of these sorts of basic principles.

----------------
The Residency Directors ask this question:

Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?

I answer with an emphatic No.
I will strive to have a committed relationship with each and every one of my patients. One of the most frustrating thing about being a medical student is the time and effort required to get to know a patient in a 30-45 minute time span only to see them vanish into the Healthcare system never to be seen again. So I look forward to a time when a patient is scheduled for a follow-up appointment in 6 months and I actually get the chance to follow-through.

Adventures in Brain Tumors (Prolactinoma!)

notmy2ndopinion: Adventures in Brain Tumors, (by @mathowie) http://bit.ly/37DMa4 (via @JoshuaSchwimmer)

My favorite part comes in the conclusion and it is very revealing about how AWFUL the patient experience can be. All too often, health care professionals feel pressured by their own time schedule and do not take the time to move at the pace more comfortable for the patient. Even small, simple things can make a big impact, like pulling up a chair to sit while talking, tuck the blanket in after pulling it down to examine their abdomen, etc...

The days in the hospital didn't go by so much as a blur as they did a smear. I was either asleep, passed out and seizing, lethargic, and very briefly completely awake each day as an army of medical professionals grilled me with a couple dozen identical questions and eventually life altering decisions were presented to me when I had been awake for all of 30 seconds.

I came away from this experience feeling the OHSU hospital in Portland continues to impress me with its amazing staff, but that the process of dealing with patients could be done in a more efficient manner. I know they all sort of kept an internal log of my story but to constantly be asked the same things by different groups of people and then not know who is your main decision maker was a challenge. Given my state of sickness and exhaustion, I felt like what an elderly man might feel like in the medical system. I had trouble understanding what people were saying as they woke me from sleep, I was constantly poked and prodded without descriptions of what results entailed, I literally wanted to "phone a friend" when those surgeons asked me in the early morning hours what I wanted to do.

Pong's Postulates (II)

Pong's Postulates
1) Health is something we have until we notice we do not.
* Preventive services help people notice their health.
2) There are two types of disease: those we live with and those we do not.
3) "Docere" in latin means "to teach." Doctors primarily help people know their illnesses.
* It does not matter what doctors say; what matters is what patients hear.
4) Comprehensive Generalists see the big picture.
* Interventions happen all they way along the natural history of health to disease to complications.
5) I want to be a part of my patients' long lives through sickness AND health acting as their advocate and guide.
Therefore, I want to be a Primary Care Family Physician.

Elucidating Pong's Postulates

Health and illness:

One of my early experiences with disease is unusual. It was nothing more than a nuisance at worst but it affected me greatly. I have a condition called hyperhidrosis, characterized by excessive sweating. As a child, my palms would literally drip with sweat, sometimes for hours. I went to a dermatologist and after failed trials of topical antiperspirant and uncomfortable iontophoresis, I considered Botox or surgery. So in the midst of applying for medical school, I had a bilateral thoracic sympathectomy performed. Now I can take notes, read books and put on gloves without a struggle. I reflect upon it every time I greet a patient, now that I can shake their hands without hesitation. I am thankful for the help of my dermatologist and the skills of my cardiothoracic surgeon who have boosted my confidence as a physician.

Disease and dealing with it:

In the summer following my first year of medical school, I shadowed a few doctors at a clinic for the underserved. One patient in particular stands out in my mind. She was an obese Micronesian woman who came in with her teenage daughter complaining of fatigue, thirst and frequent urination. The resident made the diagnosis of diabetes. The plan seemed simple enough: diet, exercise and metformin. I was impressed with the way that the resident delivered the information but I noticed that she stopped listening. She broke down and started to cry. Her sobbing grew even louder as the resident started to raise his voice -- as if it would help her hear what he had to say!

"I'm sorry," I said as I handed her a tissue. "I know this is all coming as a shock to you..." I struggled with what to say next. "Are you afraid you'll be like your father and need an amputation?" Suddenly being diagnosed with the same disease that almost killed her diabetic father was too much for her. The resident apologized; "I'm sorry. Sometimes I forget that this is not as routine for you as it is for me." I have never forgotten those words -- it does not matter what doctors say; what matters is what patients hear. What can be a straightforward routine for physicians is often a life-altering alien experience for patients.

We comforted her. Diabetes was something that she could learn to live with instead of dying from it. "You need to lose weight. I do not want to say 'go on a diet.'" I said at the end of the visit. "That is temporary. We really ought to work on lifestyle changes for you AND your family... you do not want your daughter to follow in your footsteps, do you?" Both of their eyes welled with tears at that and they silently shook their heads. I was gratified to see that her daughter's half-full soda was swiftly discarded as they left the exam room.

The Big Picture and Interventions:

In my first elective as a fourth year clerk, I rounded with a cardiologist covering his partners' patients in the hospital. One of the patients we met was an elderly Hawaiian man with forty grandchildren who clotted off his stent. Three weeks ago, he was told very emphatically to gather up his family and say goodbye. Three weeks later, we found ourselves face to face with a restless grandfather. "I don't want to die here in the hospital." It was a sentiment I could understand except he had a surprising recovery. The cardiologist tried to negotiate with him to stay to make sure he was stable on the correct medications. "You may die if you leave the hospital. Do you understand?" The patient frowned and replied "Do you have grandchildren? Do YOU understand?" "No. But I understand. Do YOU?" It went back and forth until the cardiologist left abruptly.

I could see them slicing past each other trying to press their points. No doctor had given him the simple courtesy of three minutes of time in the past three weeks. He was frustrated and confused. At first, he was told that he was going to die in the hospital, then he could go home for hospice and now he was supposed to stay. I do not have any grandchildren, so I could not understand how he felt. This man cared more about his family than his own health. Perhaps it was a pervasive trend; there were many interventions that could have guided him down a different path. Yet here we were with only one thing to do: I just listened to him.

I want to be a Primary Care Family Physician:

I often wonder how the story ends for these patients. I wish I could be a guide for the mother and her daughter through health and an advocate to fight for the grandfather. I know that this is precisely what I will get to do as a family physician.

My doctors helped me prepare my HANDS for medicine. My teachers in medical school helped me prepare my HEAD as well, but it is my patients that have prepared my HEART for a lifelong commitment to medicine.

Pong's Postulates (I)

In the movie Pi, by Darren Aronofsky, a paranoid mathematic genius recites a near daily mantra:

Restate my assumptions:
One: Mathematics is the language of nature.
Two: Everything around us can be represented and understood through numbers.
Three: If you graph the numbers of any system, patterns emerge.
Therefore, there are patterns everywhere in nature.
Evidence: The cycling of disease epidemics;the wax and wane of caribou populations; sun spot cycles; the rise and fall of the Nile.

So, what about the stock market? The universe of numbers that represents the global economy. Millions of hands at work, billions of minds. A vast network, screaming with life. An organism. A natural organism. My hypothesis: Within the stock market, there is a pattern as well... Right in front of me... hiding behind the numbers. Always has been.

I found it to be an excellent, albeit strangely rigid way of honing in on a mission statement so to speak for this character. He proceeds from an axiom: math = nature, follows a logical set of basic principles and subsequently derives a set of values and his motivation for his current project. A way to predict the numbers in the stock market.

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

I would like to derive my own set of postulates.
A mantra that I can repeat to myself on a daily basis to remind myself of what keeps me going. My personal mission statement, if you will. The abstract version at least. If all goes well as I review my entire medically related personal history in preparation for the all-encompassing personal statement... I'll discuss each section in turn over the next week.

Pong's Postulates.
1) Health
Health is something we have until we notice that we don't. (or is it "aren't"?)
2) Illness
There's two types of illness: those we live with and those we don't.
3) Physicians
Doctors help people notice their diseases.
4) Primary Care/Prevention, Family Physicians
Primary Care helps people notice their health. Some doctors value long-lasting relationships with all sorts of patients, treating them as a part of a family-unit striving for health.
5) My Role. My Choice. My Calling.
My observational and problem-solving skills qualify me to be a great clinician, since you only see what you notice and what you notice is what you know.
My passion for science, my love of learning and my joy for sharing knowledge qualifies me to be an excellent educator in disease and prevention.
My strong sense of duty to help those in need, my commitment and my desire to make a difference in the lives of those I work with qualifies me to do hard work for the underserved and push for changes where they are needed most.

Therefore, I want to be a Family Physician -- an advocate, a coach, a guide, a mentor, a healer. It's almost like being married -- I want to be a part of my patients' long lives, through sickness and health.

Rights vs Expectations

Even though I disagree with a lot of what Happy Hospitalist writes when he waxes political, I find myself drawn to his blog. Perhaps it gives me something to react against. In any case, he wrote the following short bit yesterday:

Does America Have A Right To BASIC Health Care?

I hear it everyday. Affordable access to basic health care should be a right.

Could someone please define to me what constitutes basic in the basic health care arguement? I want to hear examples of what is basic health care and what would not be considered basic and why you have a right to one and not the other.

Why should we have a right to health care but not health? Should we not have a right to stay healthy? Should we not have a right to free gym memberships? How about a right to free vegetables. If you have a right to basic health care, we should also have a right to services that prevent the break down of health as well.

Right?

My response in the comments section:

There are a lot of things we take for granted -- clean water, sewage treatment, uncontaminated needles for IVs and sterilization procedures before surgery.

These are PUBLIC HEALTH measures that have greatly affected our quality of life. So much so that their effects are practically invisible.

When we say "basic," I think of something along the lines of "do or die." There are a lot of things that factor into this... obviously someone with untreated hypercholesterolemia and diabetes for 40 years who comes in with a heart attack could have received appropriate intervention before this life threatening event.

The question is this: What OUGHT to be covered?
Primary prevention: healthy living (free gym memberships, shelter, access to fruits and veggies)
Secondary prevention: screening for CAD risk factors (checking lipid panel per ATPIII recommendations or just total cholesterol per USPSTF.)
Tertiary prevention: intervening after disease is detected to prevent complications (starting off treatment with statins and metformin.)

A lot of people would argue that it is fully within the scope of medicine to intervene with Secondary and Tertiary preventive measures (which SHOULD be covered as basic health care to some degree.)

Primary prevention... like the rest of PUBLIC HEALTH falls more under the scope of the government in my opinion, not accounting for the occasional harassment by a PCP to "eat right and exercise." As needed, I'm sure there are a number of excellent docs who can go more in depth into personalized primary preventive measures but when this is not reimbursed... not many will opt to do it with all their patients!

This made me realize that the Rights argument is very progressive (in more ways than one.) We all expect some certain unalienable rights to Life, Liberty and the Pursuit of Happiness.

What does it mean to have a "right to Life"? This draws an issue like abortion (ugh! let's keep that at least 10 feet away for now) to the forefront when really, there is a much more fundamental right that this draws upon... one that I have not seen clearly defined or reflected upon. Is it a right to a healthy life? A right to live?

I think it is a Right to Live as others live. There is an element of Expectation to this as well. We expect that we can all live equally in a democratic society.

Access to healthcare is becoming more of an issue than our forefathers expected because our medical knowledge and power to intervene has increased dramatically. This has created new power relationships and health deficits in socioeconomic status that cross generations! It goes beyond doctors and hospitals. That's why the government must play a role "to Secure these Rights," "deriving their just Powers from the Consent of the Governed."

I expect this from my government. A lot of people are afraid that the government will mess this up and want it to stay out of the Healthcare debate as much as possible. This is not a dig, but merely an innocent question: Republicans/conservatives in congress, if you distrust government so much and are afraid of its collective incompetence, why are you in office? I would much prefer it if you created some solutions rather than saying "the best thing we can do is to stay out of it."

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!

We Do what is Needed.

New York Times: Where Life's Start is a Deadly Risk

BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. Now two lives were at risk, and there was no choice but to operate and take the baby right away.

It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.

Mr. Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants.

Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.

One of my early dreams in medicine was to volunteer for Doctors Without Borders (aka Medicins san Frontieres) after the completion of medical school and residency. I was a pre-med at the time and a part of the Medical Student Mentorship Program at UH. I told my mentor what I wanted to do and he said "That's charity work. Your debts will accrue and you'll fall behind." He went on for a few more minutes and I got the distinct impression that A) it would not advance my career if I wanted to pursue a fellowship and B) it would bring about financial devastation.

If I cared about those things, I would have taken his words to heart. Part of the reason why I did some research (a sideline to medical school) on Malaria was to get in contact with some of people with similar interests. I worked with a lab that has extensive connections in Cameroon and participated in research with involving the risks of malaria infection in pregnant women. (more on that to come.)

"Am I ready for something as big as this? Can I handle it? This would be a huge change in lifestyle." These sorts of anxious questions give me pause in pursuing such ambitious dreams wholeheartedly. The NY Times article has a real sense of urgency and fatigue to it. These undertrained, underappreciated doctors and nurses are working so hard and with such little help. What could I do? I would be but a drop in a bucket.

I found the words of Paul Farmer to be very inspirational.

For me, an area of moral clarity is: you're in front of someone who's suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act.

My future plans to have a private practice with greatly motivated patients is tempered by my equal desires to become a teaching faculty member for a medical school and train young physicians, as well as travel to rural areas. Why do I want to do all of these things? I am reminded of something I said at a homeless clinic to my preceptor -- "We Do what is Needed." As a physician, I feel a sense of strong duty to the world to ensure that I make the biggest difference possible... and that means tackling the problem from as many angles as possible. That's my dream at least. We'll see how it all plays out.

"Change Your Heart..."

The song lyrics in the montage at the end of Omega sounded very familiar and when I realized it was from "Eternal Sunshine of the Spotless Mind," I got goosebumps. The core of the stories are the same (wiping the brain, but retaining the soul.)


[MOVIE SPOILER FOR ONE OF MY MOST FAVORITE MOVIES EVER!!]

The song gets looped over and over at the end when Joel and Clementine are at the beach throwing snow at each other... hinting that they are going in an endless loop too.


[END SPOILER]

Just like Echo! We fight to find meaning in our existence and we struggle just like Echo to hold onto one lesson each day (or each episode) that will make us stronger and better. "I try to be my best" is the motto of the dolls. Naive, but even more misguided is Alpha -- his flaw is that he thinks he IS his best.

I love this episode sooo much! At first, I thought that this show was going to nothing but a flashy lovefest for Eliza but I've had a change of heart. It really does a great job at addressing a lot of issues of free will, identity, and righteousness not to mention aesthetics as well. (btw... I LOVE YOU ELIZA!!! lol)

[The preceding post is a re-entry that I wrote on the Hulu discussion boards after watching the season finale for Joss Whedon's show Dollhouse. If you like to ponder the ephemerality of memory, you admire the ease of programmability of Matrix i.e. "I know Kung Fu", and/or you think that Eliza Dushku is a hottie... you should watch too! :)]

Resonating Quotes

A series of quotes have dropped into my lap during my daily blogwanderings that I found striking for one reason or another. They reflect parts of my own philosophy and I am pleased to find kindred spirits. U.S. President John Adams:

"Children should be taught ambition, not for fame but for excellence."

I couldn't find the quote directly attributed to Adams, so it might be more of a summary.

The sentiment that exists is certainly applicable to my approach to life. The only person I really care to measure myself up against is the person I want to be.

hat tip to the Honolulu Star-Bulletin for the great "Family First" article in which I discovered the quote.

Picasso: All children are born artists. The trouble is, remaining an artist when you grow up.

Ken Robinson says something to this effect... in essence, school stamps out creativity. I feel like that from time to time in the fact-munching, patient-crunching churning Combine of an education I currently endure. Lately, I've discovered my refuge in the patients I see everyday. They spur me to be my best at every (precious) moment I have to spare with them.

I am a small piece of the universe observing itself.

I stumbled across the blog "Existence is Wonderful" after hearing the TED talk on creativity and the importance of diversity. Neurological diversity in all of its wonderful pathology is celebrated in the stand alone novel "This Alien Shore," by C.S. Friedman. The blog writer is autistic which only adds to the poetry of her review on the book.

Ideals

Let me tell you a little bit about my ideal job. Maybe that will tell you something about my ideals, my values, my goals, my hopes and dreams.

I would like to be a family medicine primary care physician for a small community. I would be in private practice, but I would have excellent connections with local supportive ancillary services like dieticians, diabetes educators, physical therapy, and sub-specialty care. I would have a broad and diverse patient population that challenges me on a daily basis. Babies, baby-boomers, the extreme health-nut that wants education on alternative medicine, the extremely sick obese/DM/HTN/CAD/COPD/CHF/hypothyroid patient on dialysis and home O2 that needs education on everything, the ethnic-mish-mash, the indulgently elite and the financially-challenged -- I'd like try to juggle it all and coordinate care with other doctors as appropriate.

I would reduce the co-pay for my patients that get started on an exercise program and lose weight, quit smoking, go to support groups, become educated on their disease processes and start taking charge of their health -- with me as their coach. I will brainstorm other incentives for patients to these ends.

I would encourage my patients to have their own health records -- available online through Google Health or similar services to allow for seamless care if they are admitted to the hospital. I would encourage my patients to interview their families to provide an in-depth Family History. I would provide up to date patient handouts. I would create monthly emails/newsletters and update my patients on the specific conditions they have and encourage them to come in and see me if there are any concerns or changes that can be made.

I would make sure that I have adequate time with both new and complicated patients. I would make sure that patients can call and make a same-week or even same-day appointments. I will use services like GrandCentral and Google Voice to screen phone calls and organize my life with a single phone, but multiple numbers for the office, family and friends. I would take care of patients on an urgent care basis too... so they don't have to go to the ER when they don't need to. Sure, this means that I would see less patients every day but if I do my job right, then I don't have to scramble to see them again and again for the potentially-preventable things I may have caught in the first place with an additional 5-10 minutes sitting one-on-one with a patient. If that means that I have less staff to keep overhead costs low, so be it. I would like to be self-sufficient as much as possible.

I would like to take care of a young couple. I would like to counsel them about preparing for pregnancy and then be there for the delivery of their first child. (Maybe even deliver the child?) I would then take care of the kid until he/she is old enough to have children as well, completing the cycle. THAT would make me feel a sense of satisfaction as a true Family Medicine practitioner.

I would like to get to know my patients so intimately that I can provide a narrative about them, like some of my preceptors are able to do seemingly without any effort. If my patients are admitted to the hospital or sent to a specialist, I can glance at their Problem List and their Patient Narrative (two sheets I would update at each and every visit) and provide a clean, concise history that is only 1-2 pages but addresses the relevant biopsychosocial issues.

I would like to be an expert on broad differential diagnoses; ones that encompass the long-tail diagnoses on a cost-efficient yet cognitively appropriate basis. I would strive to avoid becoming a diagnostic robot and instead, really think about each individual patient.

Most of all, I would like to be a part of the SOLUTION for our current health care problems. I would like to come up with new innovative ways to integrate today's technologies with traditional doctor-patient relationships that are built upon the fundamentals of trust, confidence, competence and mutual respect.

I've read a little bit about the "Ideal-Micro-Practice" and it outlines pretty much the sort of thing that I want to do.

Of course, this is a dream job. And I'm a dreamer for thinking that I can do anything close to this in today's economic climate. There's a lot of harsh realities involving paperwork, bureucratic red tape, the BUSINESS of medicine and making enough money to stay afloat. I am only a medical student. I have a few more years to figure that sort of thing out... and I'd like to find a residency program that can prepare me for my ideal job.

These are the things I strive for in my work and think about on a daily basis, even now, to prepare myself for the future. It is exhilarating.

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients

Terminally ill cancer patients who drew comfort from religion were far more likely to seek aggressive, life-prolonging care in the week before they died than were less religious patients and far more likely to want doctors to do everything possible to keep them alive, a study has found.

The patients who were devout were three times as likely as less religious ones to be put on a mechanical ventilator to maintain breathing during the last week of life, and they were less likely to do any advance care planning, like signing a do-not-resuscitate order, preparing a living will or creating a health care proxy, the analysis found.

The NYT article speculates further as to why this is: citing "to religious people, life is sacred and santified and there's a sense that it's their duty and obligation to stay alive as long as possible."

Really? I can think of a confounding factor in this study. Perhaps there's an independent factor that is influencing the choice for terminal patients to meticulously conduct advance care planning... perhaps there's another reason why some patients are more accepting of the limitations of their physicians.

Maybe they know better. They know that Docs aren't Gods. We all come to the end of our ropes at some time or another. Is a hospital bed really the place where you want to die if you had the choice? Hospice is a better option. Home hospice is even better, in my opinion.

I think that this attitude reflects a level of higher intellect and critical thinking (on average) among the less devout patients who use rational thought to guide their everyday lives rather than blind faith and misplaced hope.

I do realize that I'm a bit biased since I consider myself a part of this group. No offense, religious peeps.

What If God Disappeared?

This made me chuckle.



hat tip to Pharyngula

---

I used to read Pharyngula posts religiously (pun intended) but his plethora of atheistic(sp?) and politically charged posts overran his other more science/education related posts. Ranting about Dawkins and Creationism and Christianity made him very popular/renowned/reviled on ScienceBlogs though.

And in many ways, I do agree with a lot of the things that he says as a staunch defender of the Atheistic ways.

However, his contempt and dislike for religious people does rub me the wrong way. My personal feeling is that a lot of people happen to be religious and they happen to be good people as well. In many cases it provides as much guidance (as there is mischief and misguidance,) but that could be said for any other institution.

Atheism is not immune either despite its rational and empirical/experiential roots.

One of my dreams/nightmares is that the world as we know it may get wiped out someday and all that would be left is our books, our information, our knowledge. Rebuilding civilization on these documents would be interesting. Institutions would be created that would worship Rationalism in defiance of common sense things -- despite an ability to blast off into space and take a picture of earth for example, the newbies would assume that the Earth is round.

All of the things that they might be taught would still be founded on assumptions -- and who is to say that these people would not lose their sense of skepticism when so much of what they read turns out to be true anyway? They'd take things at face value. Unquestioning. Unyielding. Yet, still right for the most part.

I guess what I'm getting at (before I get lost in a tangent again) is that it is not about being Right or Wrong. I used to focus on this a lot, when I held some disdain for the truly religious -- especially classmates in science. How could they hold such different concepts in juxtaposition without considering themselves to be hypocrites? I'd wonder.

It's all about the perspectives that we hold and slowly becoming Aware that we only see things from a certain angle. Sometimes we are blessed with new points of view and these glimpses help us to understand others as long as we keep our eyes open. That's the point of religion, in my opinion. Through understanding comes love and acceptance for our fellow man.

Quantum Thought Mechanics

Discover Magazine: Is Quantum Mechanics Controlling Your Thoughts?

One of the most significant quantum observations in the life sciences comes from Fleming and his collaborators. Their study of photosynthesis in green sulfur bacteria, published in 2007 in Nature, tracked the detailed chemical steps that allow plants to harness sunlight and use it to convert simple raw materials into the oxygen we breathe and the carbohydrates we eat. Specifically, the team examined the protein scaffold connecting the bacteria’s external solar collectors, called the chlorosome, to reaction centers deep inside the cells. Unlike electric power lines, which lose as much as 20 percent of energy in transmission, these bacteria transmit energy at a staggering efficiency rate of 95 percent or better.

The secret, Fleming and his colleagues found, is quantum physics.

...

Electrons moving through a leaf or a green sulfur bacterial bloom are effectively performing a quantum “random walk”—a sort of primitive quantum computation—to seek out the optimum transmission route for the solar energy they carry. “We have shown that this quantum random-walk stuff really exists,” Fleming says. “Have we absolutely demonstrated that it improves the efficiency? Not yet. But that’s our conjecture. And a lot of people agree with it.”

...

Stuart Hameroff, an anesthesiologist and director of the Center for Consciousness Studies at the University of Arizona, argues that the highest function of life—consciousness—is likely a quantum phenomenon too. This is illustrated, he says, through anesthetics. The brain of a patient under anesthesia continues to operate actively, but without a conscious mind at work. What enables anesthetics such as xenon or isoflurane gas to switch off the conscious mind?

Hameroff speculates that anesthetics “interrupt a delicate quantum process” within the neurons of the brain.

...

He speculates that the action unfolds like this: When certain key electrons are in one “place,” call it to the “left,” part of the microtubule is squashed; when the electrons fall to the “right,” the section is elongated. But the laws of quantum mechanics allow for electrons to be both “left” and “right” at the same time, and thus for the micro­tubules to be both elongated and squashed at once. Each section of the constantly shifting system has an impact on other sections, potentially via quantum entanglement, leading to a dynamic quantum-mechanical dance.

I did my best to try and preserve a few key passages of the article for you.

Basically, what it's saying is that through the process of quantum mechanics, life follows a path of least resistance, the shortest possible route, through a bloom of possibilities as reality collapses in and chooses the best one. This goes to show, in my mind that we do live in the best possible world!

Not only that, but quantum mechanics makes the seemingly impossible possible -- namely that greatest mystery of all -- consciousness. Through a similar process of quantum calculation in neuronic wiggling, Dr. Hameroff proposes that our neurochemistry is influenced in a way to optimize our circuitry. I've posted in the past about quantum mechanics. I find the topic absolutely fascinating, because of the mind-boggling weird science involved and what it implies in our world. My slim grasp of the topic informs my philosophy: we live in a macroscopic cause-and-effect world as we see it, but this is all undermined by a submicroscopic boiling chaos of potential (and optimization!)

It affirms and informs previous comment I had made:

It is cool to think that [consciousness] is an aggregation of quantum activity that takes off as massive butterfly effects in our heads. I don't think that this necessarily implicates the additional driving meta-physical force of consciousness, nor does it happen continually. Every so often, metaphorical dominoes are dumped out onto a table and a few of them align, waiting for the quantum flutterby. This is the exception, not the rule.

hat-tip to Medgadget
Image by LoreleiRanveig

What Kind of Person are You?

In my Senior year of college, I performed a monologue at the end of the semester. I read through a few and I really liked the two I found, back to back, in the play entitled A Thousand Clowns. It's about a funny writer who quit his job working for a syndicated children's show. Because he lacks financial security in his life, he might lose custody of his very bright, very mature nephew. His brother tries to convince him to get back into working for the show... and they both reveal their character secrets. It's a very powerful moment on the stage.


MURRAY: Oh, Arnie, you don’t understand anymore. You got that wide stare that people stick in their eyes so nobody’ll know their head’s asleep. You got to be a shuffler, a moaner. You want me to come sit and eat fruit with you and watch the clock run out. You start to drag and stumble with the rotten weight of all the people who should have been told off, all the things you should have said, all the specifications that aren’t yours. The only thing you got left to reject is your food in a restaurant if they do it wrong and you can send it back and make a big fuss with the waiter…

Arnold, five months ago I forgot what day it was. I’m on the subway on my way to work and I didn’t know what day it was and it scared the hell out of me…

I was sitting in the express looking out the window same as every morning watching the local stops go by in the dark with an empty head and my arms folded, not feeling great and not feeling rotten, just not feeling, and for a minute I couldn’t remember, I didn’t know, unless I really concentrated, whether it was a Tuesday or a Thursday… or a … for a minute it could have been any day, Arnie… sitting in the train going through any day… in the dark through any year… Arnie, it scared the hell out of me.

You got to know what day it is. You got to know what’s the name of the game and what the rules are with nobody else telling you. You have to own your days and name them, each one of the them, every one of them, or else the years go right by and none of them belong to you.

And that just ain’t for the weekends, kiddo… here it is, the day after Irving R. Feldman’s birthday, for God’s sake… And I never even congratulated him…

ARNOLD: MURRAY!

MURRAY: What’s so funny?

ARNOLD: Wow, I scare myself. You hear that voice? Look at that, I got you to stop, I got your complete, full attention, the floor is mine now… and I can’t thing of a God-damned thing to say…

I have long been aware, Murray… I have long been aware that you don’t respect me much… I suppose there are a lot of brothers you don’t get along… But in reference… to us, considering the factors… Sounds like a contract, doesn’t it? Unfortunately for you Murray, you want to be a hero. Maybe if a fella falls into a lake, you can jump in and save him; there’s still that kind of stuff. But who gets opportunities like that in midtown Manhattan, with all that traffic. I am willing to deal with the available world and I do not choose to shake it up but to live with it. There’s the people who spill things, and the people who get spilled on; I do not choose to notice the stains, Murray.

I have a wife and I have children, and business, like they say, is business. I am not an exceptional man, so it is possible for me to stay with things the way they are. I’m lucky. I’m gifted. I have a talent for surrender. I’m at peace. But you are cursed; and I like you so it makes me sad, you don’t have the gift; and I see the torture of it. All I can do is worry for you. But I will not worry for myself; you cannot convince me that I am one of the Bad Guys. I get up, I go, I lie a little, I peddle a little, I watch the rules, I talk the talk. We fellas have those offices high up there so we can catch the wind and go with it, however it blows. But, and I will not apologize for it, I take pride; I am the best possible Arnold Burns.

Speculations on Life (2)

Energy is infinite. It hops in and out of "existence" constantly, summoned forth in exactly equal amounts of counter-energy, thus giving us the illusion of stability when really, every point is boiling over with this completely balanced, but supremely connective notion. My grasp of the physical world as we know it, is that we are a series of values and positions, most likely composed of vibrating strings of energy/mass... but the closer we examine things, the more they break apart.

I like to think that life is the same way. However, life is a force that is by nature, unbalanced. It is wild, wrestling with energy of all sorts, taming it and finally locking it down into painful staticity. It moves with direction and it has but a single intent. Stay alive. PERSIST in this roil of chaos. Other goals crop up later, should this one fail (and it always does.) Make a legacy. Make an impact. Change the world, whatever that might be.

Life's attempts to build a world are ultimately futile. Everything that is harnessed, altered or "created" is someday broken, destroyed and lost, from the kindergarten ash tray art project to the glucose molecules you've stolen away from some other poor struggling organism, as devoted to life as you or I. I feel no guilt eating the flesh of another creature or chomping the vegetable matter of one of my really distant plantcestors. My moral pain or their physical pain -- it's a choice I make everytime I sit down to eat.

Life is a terrible competition. We fight daily in ways that we aren't even aware of. I kill myselves everyday just to stay alive. If I didn't, I would be so selfish that all sorts of cancers would take over my body and totally cripple me. WE aren't what we think we are. There is no I, only a collective ME/WE. Every cell in my body struggles to live as much as the next, but some make sacrifices. They all devote themselves to tasks assigned to them following day one when the Originator-zygote was formed from the union of dad-sperm and mom-egg.

Speculations on Life

Let's start at the beginning.

In the Book of Genesis, Adam was formed out of the dust of the earth (hence his name, which means "red earth"), and God breathed into his nostrils the breath of life. In the Korah, God created man out of clay and told him to "Be!" and he was. (wikipedia told me so.)

In my opinion, these symbolic texts are closely linked with the current views on the more scientifically derived speculations on the origin of life. The panspermia/exogenesis theory proposes that life drifted down from the stars on the dust of comets. These lumps of ice and rock are known to have biological precursor molecules. The silicate theory claims that the slow accumulation of the right rudimentary particles on the surface of clay gave rise to life. Of course, there are problems with these theories.

Despite Biology's current insistence that there is no such thing as "spontaneous generation," which was a belief carried into Medieval times that things like flies were created from dead meat... the question of First Life begs the question. How did life derive from non-life?

Does it have to? How do we define life? Here are a few biological requirements:
1) metabolism -- processing of chemicals for sustenance
2) growth -- gaining complexity/maturity
3) reproduction -- generation of offspring
4) response to environment -- reacting appropriately to situations
5) made of cells

However, this is not all encompassing. It still has embarrassing holes. If it could exist, what would we consider artificial life? What about digital, artificial, manufactured intelligence? Why do we sometimes confuse dead things, or inanimate objects with live ones? What about viruses? They fulfill the first four pre-requisites, but it is not a cell. Perhaps our scientific definition works for our world, but it needs revising to match the more basic, simpler world when life as we know it did not exist.

A few years ago, a friend asked me to fill in the blank for "Life is ___." It took me a while to come up with a thoughtful definition that I liked, but I decided on "Life is directed, anti-entropic force."

I still find it to be the most relevant and striking definition I've ever come up with... reminiscent of Buckminster Fuller's definition of the universe:

"Universe is the aggregate of all humanity's consciously apprehended and communicated nonsimultaneous and only partially overlapping experiences."

`` `Aggregate' means sum-totally but nonunitarily conceptual as of any one moment. `Consciousness' means an awareness of the otherness. `Apprehension' means information furnished by those wave frequencies tunable within man's limited sensorial spectrum. `Communicated' means informing self or others. `Nonsimultaneous' means not occurring at the same time. `Overlapping' is used because every event has a duration, and their initiatings and teminatings are most often of different duration. Neither the set of all `experiences' nor the set of all the words used to describe them are instantly reviewable nor are they of the same length. Experiences are either involuntary (subjective) or voluntary (objective), and all experiences, both physical and metaphysical, are finite because each begins and ends.''

Some might find this overly technical... but in my mind, its pure philosophical poetry.

A Man of Principles

Perhaps it is because of the intersection of my free time, my "expertise" in the health field and my selection of friends, but I had multiple encounters with the charged topic of politics today.

#1) I was in a chatroom with some friends on AIM and someone linked to a blog entry discussing Christmas. In it, the author (a friend of my friends) said "if I were rich, I'd like to take in lonely people and feed them to let them know that not every rich person is a cold-hearted bastard" (or something to that effect.

One of my friends replied (with some degree of underlying hostility, probably fanning the flames of some old argument) and quoted the author's position on universal healthcare and said "no wonder there are depressed and lonely people; they don't have access to mental health services! rich people prefer to buy them dinners to feel better about themselves rather than pay taxes to help them." Whoa!

#2) While I read this exchange, my mom knocked on my door and said "your brother wants to talk with you about healthcare and tell him why Hillary has a good plan (and Rudy doesn't.) Obviously she doesn't have an opinion on the issue. :-\ I'm completely incompetent on this issue, so I talked about basic principles of governing with my brother to feel out his position on capitalism, its values, the role of government in serving its people, what society should do to support itself and the questions he should be asking.

A few things emerged from these conversations.
I boiled it down to two questions:
"If you had money and power, who would you help?"
and the follow-up question: "who is 'not deserving' of this help?"

What I look for in a leader is someone of principles. What does that mean? To me, it means someone who can tell me what their philosophy of governance is and is consistent with my own views. Someone who would answer question 1 with "Everyone!" and #2 with "I don't know."

I'm going to go out on a huge limb here and tell you my idealistic, blazing future for America that fixes all of our woes as I know them, in my completely zany worldview.

First of all, I think that capitalism plays up the wrong traits for a functional society. It breeds smart, cutthroat people who care about success and sneak by with as much as they can get away with. People who don't buy into this philosophy don't rise to power, whereas a true democracy would speak out for the rights of the impoverished and disadvantaged over those of the rich and powerful. Everyone deserves a chance at an equal footing and in this day and age, that applies to healthcare!

Secondly, I think we've got the priority of our National Budget all wrong. A large chunk of our spending goes towards "Defense" when it could be better spent on Education, Health Care and Science/Research, in that order, with defense and everything else following that. Having a core of healthy, well-educated individuals would go far. What would we do with our military that would suddenly be out of a job? I'd make them part of our new Peace Corps. They'd be "invading" other countries with education, like missionaries without the religious agenda. It'd be a share-the-wealth-and-spread-the-goodwill-agenda. Building up relations, networking and if necessary, make a few bucks here and there.

Immigration policy would be relaxed because I'd like to have people cycle through to become trained. They might even be inspired to become a part of the Peace Corps so they can return home and better serve their friends and family back home.

Social security is a difficult subject ethically because the better that our health care gets, the more of a burden we develop with this. I don't think we should ignore senior citizens and delegate them to the "useless waste of money" category. They have proven their worth to our society and they can still provide value! We just need to find more ways to keep them connected with society so we don't see them as a burden on our tax dollars.


I've got more insane ideas. They need to be better honed, because I feel like I'm starting to spout off garbage already...

Chatting with a friend

This is something that I'd like to come back to later on. The AIM names have been changed to protect the innocent. ;-)

NotMySecondOpinion (11:34:22 PM): are you going to join the air force?
religiousfriend (11:34:37 PM): I'm not sure
religiousfriend (11:34:43 PM): they need leaders in the air force
religiousfriend (11:34:50 PM): I don't have much leadership experience
NotMySecondOpinion (11:36:27 PM): i think it would be good for you to join, but at the same time, i wouldn't want you to go
religiousfriend (11:36:37 PM): ah
religiousfriend (11:36:40 PM): why do you think so?
NotMySecondOpinion (11:37:16 PM): the military would give you discipline and direction
religiousfriend (11:37:27 PM): that's true
religiousfriend (11:37:36 PM): I don't know about direction
NotMySecondOpinion (11:37:38 PM): but its dangerous, even in the air force
religiousfriend (11:37:40 PM): but discipline, yes
NotMySecondOpinion (11:37:55 PM): and you'd become a part of the military culture, which i dislike
religiousfriend (11:39:29 PM): I don't care for military culture
religiousfriend (11:39:45 PM): I don't want to become a further drain on taxpayer resources
religiousfriend (11:39:56 PM): besides which, the AF is scaling down its officer corps
NotMySecondOpinion (11:42:37 PM): what do your other plans comprise of?
religiousfriend (11:43:27 PM): I'm thinking of entering a monastery
religiousfriend (11:43:40 PM): other than that, law school/grad school
NotMySecondOpinion (11:45:04 PM): is there any incident you can think of that prompted your religiosity?
religiousfriend (11:45:20 PM): a realization of my own finitude
NotMySecondOpinion (11:46:12 PM): thats rather abstract.
religiousfriend (11:46:23 PM): When I was ten, I remember thinknig
NotMySecondOpinion (11:46:31 PM): was it from reading something or doing something?
religiousfriend (11:46:31 PM): "ah, I've lived through one eighth of my life"
religiousfriend (11:46:49 PM): I've read a lot of things
religiousfriend (11:46:54 PM): I've done a lot of things
religiousfriend (11:47:18 PM): but faith is something from God. You can't get it by your own efforts
NotMySecondOpinion (12:02:28 AM): how do you define faith?
religiousfriend (12:02:41 AM): I'm still working on that one
religiousfriend (12:02:54 AM): But ultimately Faith is personal
NotMySecondOpinion (12:04:05 AM): i'm just wondering why you think it comes from God
religiousfriend (12:04:37 AM): Well, from the Materialist side people could say it comes from all kinds of chemical reactions
religiousfriend (12:05:27 AM): but at any rate, I don't have enough faith to faithfully answer your question
NotMySecondOpinion (12:06:18 AM): I disagree with the statement that it comes from all kinds of chemicals
NotMySecondOpinion (12:08:09 AM): I think Faith comes from a strong desire/belief in the connections you make with others and the world around you. Those connections are immaterial, but they might be represented by chemical reactions that take place concordantly or disconcordantly, depending on whether or not your Faith is misplaced
religiousfriend (12:10:54 AM): that's a bit over my head
NotMySecondOpinion (12:14:43 AM): i didn't know what faith meant until i loved someone. i could never really know if they loved me back. that's when i had to decide whether or not I could step back and relinquish control of ... almost everything and just have faith.
religiousfriend (12:15:36 AM): I think you're getting close
religiousfriend (12:15:56 AM): but I don't have much faith, so what can I say
NotMySecondOpinion (12:16:02 AM): yeah, i don't know where God fits in there.
NotMySecondOpinion (12:16:20 AM): thats what i was hoping you could help me with
religiousfriend (12:16:35 AM): mmm, it's hard for me to give what I don't really have
religiousfriend (12:16:42 AM): It's important to be humble, first of all
religiousfriend (12:17:06 AM): Hell is full of people who think they're too good for Heaven
NotMySecondOpinion (12:18:31 AM): what does that mean?
religiousfriend (12:19:16 AM): Well, according to the Faith, Hell and Heaven are the same place
religiousfriend (12:19:34 AM): Think of Gollum
religiousfriend (12:19:44 AM): and how he hated the Lembas bread
religiousfriend (12:20:04 AM): and other elvish things
religiousfriend (12:20:39 AM): Those "in Hell" experience the glory of God in the same manner
religiousfriend (12:20:57 AM): because their hearts are too prideful
NotMySecondOpinion (12:21:31 AM): we make our own heaven, then.
religiousfriend (12:21:57 AM): We don't really "make" it
religiousfriend (12:22:00 AM): we accept it
religiousfriend (12:22:12 AM): but yes, ultimately Faith is a matter of the heart
religiousfriend (12:26:40 AM): http://fatherstephen.wordpress.com/ anyway, this site is much more articulate than me in expressing this sort of thing
religiousfriend (12:26:51 AM): I suggest you add it to your google reader
religiousfriend (12:28:09 AM): http://fatherstephen.wordpress.com/christianity-in-a-one-storey-universe/ this might be of interest to you
NotMySecondOpinion (12:29:20 AM): he spells story weird
religiousfriend (12:30:48 AM): that's to distinguish storey as in a building with story as in a book
NotMySecondOpinion (12:35:07 AM): ah
NotMySecondOpinion (12:52:59 AM): i'll definitely have to read more of that later
NotMySecondOpinion (12:53:10 AM): for now, i'm off to do more work. ttyl!