Malpractice Methodology by Peter Orszag

Article in the NYT, October 20th, 2010

How can we encourage doctors to make evidence based decisions and while avoiding excessive care?

Aggressive national effort to protect doctors who follow evidence-based guidelines. That's how malpractice reform could broadly promote the adoption of best practices.

NASA-like mistake reporting system that provides immunity for reporting system failures.

Better align financial incentives for delivering higher-quality care.

Hospitals lose medicare dollars if they succeed in reducing readmissions. Medical professionals should be given incentives for better care rather than more care.

A Touch of Sense by Abraham Verghese

Patients and physicians connect through touch and trust

great article

Preparing Medical Students for the Continual Improvement of Health and Health Care: Abraham Flexner and the New "Public Interest"

AAMA publication by Berwick and Finkelstein.

need continual improvement of patient health and community health

need to learn scientific foundations of system performance

The physician is a social instrument

current quality of care is unacceptable, given the improvements that have been shown to be possible in some systems

physicians can lead and accelerate changes in care processes that are grounded in good data and sound theory

improvement of systems

Dartmouth Hitchcock Leadership Preventive Medicine residency program

Skills, knowledge and attitudes for improvement of care

a) personal excellence in clinical skills, reflective practie

b) mastering scientific foundations of system performance, psychology, conflict resolution, negotiation, group process, human motivation, cognitive and social psychology, creativity, epistemology (how to gain knowledge)

Case Western Reserve residency program

Then a whole bunch of stuff about how the education needs to change

pretty good article

Complications by Atul Gawande

Great essays on the search for perfection in medicine. Truly shows how far we have left to go.

Disturbing that lowest error rates occur in the most specialized procedures. Gawande explains in "The Computer and the Hernia Factory" how these clinics that specialize in one procedure come very close to perfection. This is disturbing to me because I don't want the medicine I practice to be super specialized super repetitive, yet the data shows that computers make fewer mistakes then human judgement and they show that humans who perform more repetitive tasks ( to a point) perform those tasks with greater precision.

Three parts to the book.

I Fallibility of doctors.

a) learning to cut

b) computer and hernia factory

c) when doctors make mistakes

d) surgical convention

e) when good doctors go bad

II Mysteries that remain in medicine 

a) pain

b) nausea

c) blushing

d) obesity

III Uncertainty and decision making

a) autopsies

b) SIDS

c) doctor vs. patient centered care. who knows best?

d) and of course an exception, when intuition pays off (necrotizing fasciitis)

Genome by Matt Ridley

The first book I've ever read about genetics, this book guided me on a layman's tour of the human genome, pointing out one interesting gene on each chromosome. I need to work on my genetic language and cannot yet express freely my intrigue with any of the ideas presented because I simply lack the vocabulary. 

It was nice to have chemistry behind me which gave some insight into how substrates and enzymes function, and how methalization and other changes might take place. 

Mad cow disease turns out to be particularly interesting because it is not created by DNA or RNA yet affects genes. These prion molecules are scary and mysterious. Crazy to see just how vast our ignorance is. 

Some other interesting issues raised about nature vs. nurture and how impossible it is to separate cause and effect. Both genes and environment affect behavior and trying to determine which is more important is futile and pointless.

Lots of other stuff which I'm sure will become more clear as I learn biology and biochemistry...

The Master and Margarita by Mikhail Bulgakov

Psycho-religious thriller in true Russian style. Took half the book to figure out who was who and what was going on. Pretty enjoyable because of all the twists and turns. Many references were a bit opaque. Would be fun to sit down and read closely again and analyze for political dissent of Stalin's regime, under which Bulgakov suffered. Interesting to think that had it not been for Russian imperialism, Bulgakov would have been Ukrainian and his books somewhat cheerier. 

Better; A Surgeon's Notes on Performance by Atul Gawande

Really got me thinking about performance as it relates to medicine. The differences in outcomes that we see are not due to varying education, finances or technology, but instead, these differences reflect human performance.

Gawande used various examples of...

I Dilligence
Handwashing
Polio in India
Battlefield medicine

II. Doing Right
Chaperones and nakedness
Malpractice
Doctors' salaries
Doctors of the death chamber
When to stop fighting

III Ingenuity
APGAR score
Inter-hospital competition
Performance of surgeons in India

How can I become a "Positive Deviant"? This is what Gawande suggests.
1) Learn something about your patients and co-workers by taking an extra two minutes to listen. It makes you remember the people you see.

2) Don't complain. It's boring, doesn't solve anything and it will get you down. Keep the conversation going down more positive roads.

3) Count something. Remember that medicine is partly science. Find something interesting and learn about it with the help of the numbers that define it.

4) Write something. Writing lets you step back and work through a problem. Lets you keep your sense of purpose. Your audience connects you to the larger world.

5) Change. Be willing to recognize the inadequacies in what you do and to seek out solutions.

People Care: Career-Friendly Practices for Professional Caregivers by Thom Dick and Friends

This book speaks to some of the reasons I want to become a doctor. It reminds healthcare professionals that caring is in the career title. For me the idea is wrapped up in patient advocacy, where as a doctor, I will be 100% on the side of my patients' best interests. This is a somewhat unique position especially for those people who cannot pay or who have been pushed aside by society. Almost no other professionals are 100% on their side to fight for what is right. Health and the pursuit of happiness.

A lot of this book is common sense, but a few parts really stand out in my mind. 

Taking care of myself has to come first. I cannot be a competent caregiver if I have not cared for myself.

Symptoms are real and it's not my perspective on the injury/illness that matters, it's how the patient sees it. We have to start there and then work toward an understanding.

A kind touch, warm smile are essential parts of compassionate reassuring care.

Situational awareness/perceptiveness and attention to all the details of the surrounding circumstances.

The very best care would be unconditional love, but since I'm not Jesus, I'll stick to my very best care for every patient.

It's not my emergency.

Suspend judgment and put yourself in your patients' shoes.

"God Has a Dream" by Desmond Tutu

This book took way to long to read, in fact, my borrowing privileges at the library have been suspended. Oops!
Once I sat down and just read it, I realized what a powerful writing and speaker Tutu really is.

I'll just write some powerful fragmented ideas that have stuck to the inside of my brain.

We make people inhumane when we remove their moral responsibility for some action. 

All people are family.

Our fear of failure drives an ugly competitiveness which often leads to putting down other people.

"Love is more demanding than law. No law tells an exhausted mother who wants nothing more than to collapse in exhaustion that they must get up in the middle of the night to comfort their baby, walking for hours until their child calms down, but this is what she does, because this is what love commands" (p. 36).

Valuing strength over weakness is a philosophy which leads people to despise weakness and weakness in others. "We can love others, with their failures, when we stop despising ourselves, because of our failures" (p. 39).

Prejudice is ridiculous, no matter what it's based on.

"Theologically, biblically, socially, ecumenically, it is right to ordain women to the priesthood" (p. 48).

"Ending sexism and including women fully in every aspect of society not only ends its own great evil--the oppression of women--but also is part of the solution to the rest of the world's problems" (p. 49).

"Confession, forgiveness, and reparation, wherever feasible, form part of a continuum" (p. 57).

Change and growth almost always occur through some pain.

Love is an action, a choice of will, not a feeling, or at least not always a feeling.

I can be a center of love, an oasis of peace.

Children are small people.

Death is physical. The mental/spiritual part can be overcome.

The physical can be truly spiritual. It can be transformed from the profane into the sacred. All Hellenistic dualism has sought to refute this idea, making the physical principally antagonistic to and alien from the spiritual. 

Tutu is on to some Quaker principles with his emphasis on stillness and contemplation and on all of us being able to hear God. 

An authentic spirituality is subversive of injustice.

I am waiting for a leaders "who are willing to take risks and not just seeking to satisfy the often extreme feelings of their constituencies. They have to lead by leading and be ready to compromise, to accommodate, and not to be intransigent, not to assert that they have a bottom line. Intransigence and ultimatums only lead to more death" (p. 119).

"So remember you are a moral agent, capable of creating a particular kind of moral climate that is impatient with injustice and cruelty and indifference and lies and immorality" (p. 123).

Three Cups of Tea by Greg Mortenson and David Oliver Relin

Verbose verbose verbose.  Man o man, way too many words, too many details, too many words. Did I say there were too many words in this book?

Quite a beautiful story of a mountain climbing nurse turned school-building-community-empowerer.

I was inspired to continue my study of languages and never forget the interlocking importance of health and education which form the foundation for justice. Or the other way around. Chicken and egg.

Rich Dad Poor Dad by Robert T. Kiyosaki

I was thrown off by the casual writing style and poor editing, but there were some good points.

Rich people think about money differently than poor people. This is pretty obvious, but it was interesting to think about some of the reasons behind this and the effects of these attitudes. It is good that Kiyosaki is concerned about the growing gap between rich and poor but his concern stems only from self-preservation instincts. He does not cite the injustice of this gap but rather the danger to our "empire".

I dislike that Kiyosaki...

1 believes that paying taxes is bad. He states repeatedly that most people "work from January to mid-May for the government just to cover their taxes". This is not working "for the government". Those tax dollars provide services create the conditions necessary for having a job in the first place. Try making money in Afghanistan...

2 forgets about the peace of mind that forgetting about money can bring. Decisions to 'buy' or invest in such "liabilities" as art, academic knowledge and love are the foundations of happiness. Education is an asset!

3 assumes that the government is somebody else, somehow separate, not made up of people

4 his constant differentiation between rich and poor which begins to imply some intrinsic difference within people themselves.

5 assumes that only profit fosters creativity.

6 thinks of money working for him. It's not his money that works for him but other people's creativity and hard work that adds value to his investments. He completely forgets about the human aspect of financial growth.

7 considers buying a Porsche some kind of accomplishment (what a looser)

8 brags about pre-tax "expenses"

9 Kiyosaki describes being a landlord and what happens when somebody does not pay. "The court system handles that" (p. 119). Yet this is the court system funded by the very taxes which Kiyosak intends to avoid. 

It's very interesting how Kiyosaki...

1 separates your profession vs your business

2 knows that "the rich are not taxed" (p. 95). It is enlightening and sickening to know how people can use the legal structure of a corporation to shelter their assets from taxation (p. 98).

3 Realizes that government fails when it does not incorporate good business principles such as efficiency.

Native Son by Richard Wright

How much of this book was influenced by Crime and Punishment?
Brash and forward, an economy of words that I would like to emulate.
Wright expressed with power that exceeded the extreme situations described in the book.
Spectacular.

The Places in Between by Rory Stewart

I want to walk like Rory. Knowing a few Persian languages, and walking from village to village, seeing, listening and walking. 

His views on international aid and interference were quite striking.

"I now had half a dozen friends working in Afghanistan in embassies, think tanks, international development agencies, the United Nations, and the Afghan government, controlling projects worth millions of dollars. A year before, they had been in Kosovo or East Timor and a year later they would be in Iraq or offices in New York and Washington." 

"They worked twelve or fourteen-hour days drafting documents for heavily funded initiatives on "democratization," "skills training," or "protection issues."

The pure hopelessness of this observation, how quickly outsiders come and go, makes me wonder if community development really should have nothing to do with outside aid. 

"Most of the policy makers knew next to nothing about the villages where 90 percent of the Afghan population lived." And all of the villages and regions are different.  How could you please everybody?

"These differences between groups were deep, elusive, and difficult to overcome. Village democracy, gender issues, and centralization would be hard-to-sell concepts in some areas."   That's for sure.

"Critics have accused this new breed of administrators of neocolonialism. But in fact their approach is not that of a nineteenth-century colonial officer. Colonial administrations may have been racist and exploitative, but they did at least work seriously at the business of understanding the people they were governing. They recruited people prepared to spend their entire careers in dangerous provinces of a single alien nation. They invested in teaching administrators and military officers the local language. They established effective departments of state, trained a local elite, and continued the countless academic studies of their subjects through institutes and museums, royal geographical societies, and royal botanical gardens. They balanced the local budget and generated fiscal revenue because if they didn't their home government would rarely bail them out. If they failed to govern fairly, the population would mutiny. 

     Post-conflict experts have got the prestige without the effort or stigma of imperialism. Their implicit denial of the difference between cultures is the new mass brand of international intervention. Their policy fails but no one notices. There are no credible monitoring bodies an there is no one to take formal responsibility. Individual officers are never in any one place and rarely in any one organization long enough to be adequately assessed. The colonial enterprise could be judged by the security or revenue it delivered, but neocolonialists have no such performance criteria. In fact their very uselessness benefits them. By avoiding any serious action or judgement they, unlike their colonial predecessors, are able to escape accusations of racism, exploitation, and oppression.

     Perhaps it is because no one requires more than a charming illusion of action in the developing world. If the policy makers know little about the Afghans, the public knows even less, and few care about policy failure when the effects are felt only in Afghanistan."

The White Tiger by Aravind Adiga (2008)

I had high expectations after Liam's glowing review, but I was really not impressed by Adiga's writing style.

For some reason, it just felt forced, with good voice, but somehow over-polished.

It was perhaps that Adiga intended to shock or awe with his descriptions of Indian human rights violations. However I was not touched by his descriptions, or even disturbed by the murder scene.  Just not Heller's level, descriptively or emotively. 

I failed to develop any consistent relationship with the protagonist, and can't even remember his name now. "If you write, you must believe--in the truth and the worth of the scrawl, in the ability of the reader to receive and decode the message. No one can write decently who is distrustful of the reader's intelligence, or whose attitude is patronizing" (Strunk & White, The Elements of Style, 84). Perhaps Adiga did not trust me to accurately perceive the horrors of India, and because he denied me this trust, his premonition was accurate.

Candide, ou l'Optimisme by Voltaire (1759)

What a delightfully naive protagonist.

The atrocities described in the 18th century remind me or our own atrocities these days. That was disturbing. Many passages were laugh out loud funny as Voltaire uses satire to make some social commentary on everything from war to literature. The self-aware style of his writing reminded me of Mark Twain, and the pure openness, which could have been shocking in his day, was fresh and sharp.

I found myself reexamining some philosophies on happiness and economics. It was an easy examination made very entertaining by Voltaire's parodies on many stereotypes. So who has had the most horrible experiences in their life? Yeah, go ahead, try to measure that!

 

The Diving Bell and the Butterfly (2007 film)

Full body paralysis, one blinking eye, yet wrote a book. I've got to read this book. Beautiful movie. Make sure you get the subtitles straight or know French really well.

The Tragedy of Pudd'nhead Wilson by Mark Twain (1894)

Leisurely paced tragedy that stands with Shakespeare in poise and delivery.

It was so pleasurable to have my own predictions come true. Twain maintains suspense and weaves each personality around a plot where really not that much happens. Omniscient narration creates empathy reminiscent of Dostoevsky's character development. Crime and Punishment, like The Tragedy of Pudd'nhead Wilson, was published first by installment.  

The "reader's note" at the hilariously describing how Twain really had a completely different plan for the plot and characters. I don't know how much of it to believe. 

Le Petit Prince by Antoine de Saint-Exupéry (1943)

Like Joseph Heller said, perhaps only the children will be left when you take out all the bad things from this world. The prince's travels from one adult's planet to another become successively more depressing. It's true that adults often live on their own restrictive planets according to rules that don't allow for other planets to exist.

"And now here is my secret, a very simple secret: It is only with the heart that one can see rightly; what is essential is invisible to the eye." But children can see these things. When did I forget how to see?

Catch-22 by Joseph Heller (1961)

I read this book for the first time before I understood much about adult life, when I was 13. This time around every licentious comment, bureaucratic breakdown and gruesome death made me smile, laugh or cringe. Yossarian challenged my English vocabulary with words such as cabalistic, saturnalia and callipygous. Catch-22 will help you prepare for any standardized test with a verbal section on it.


I want to share a section that I found particularly striking. I recently went on a road trip from Saint Louis to New Orleans and back, passing through Memphis, Jackson, and Baton Rouge on the way. That's one reason that the continuing racial segregation, economic disparities and social ills of our country are on my conscience. Heller expresses my own doubts and frustrations more eloquently than I.


"A boy in a thin shirt and thin tattered trousers walked out of the darkness on bare feet. The boy had black hair and needed a haircut and shoes and socks. His sickly face was pale and sad. His feet made grisly, soft, sucking sounds in the rain puddles on the wet pavement as he passed, and Yossarian was moved by such intense pity for his poverty that he wanted to smash his pale, sad, sickly face with his fist and knock him out of existence because he brought to mind all the pale, sad, sickly children in Italy that same night who needed haircuts and needed hoes and socks. He made Yossarian think of cripples and of cold and hungry men and women, and of all the dumb, passive, devout mothers with catotonic eyes nursing infants outdoors that same night with chilled anial udders bared insensibly to that same raw rain. Cows. Almost on cue, a nursing mother padded past holding an infant in black rags, and Yossarian wanted to smash her too, because she reminded him of the barefoot boy in the thin shirt and thin, tattered trousers and of all the shivering, stupefying misery in t a world that never yet had provided enough heat and food and justice for all but an ingenious and unscrupulous handful. What a lousy earth! He wondered how many people were destitute that same night even in his own prosperous country, how many homes were shanties, how many hubands were drunk and wives socked, and how many children were bullied, abused or abandoned. How many families hungered for food they could not afford to buy? How many hearts were broken? How many suicides would take place that same night, how many people would go insane? How many cockroaches and landlords would triumph? How many winners were losers, successes failures, rish men poor men? How many wise guys were stupid? How many happy endings were unhappy endings? How many honest men were liars, brave men cowards, loyal men traitors, how many sainted men were corrupt, how many peopl in positions of trust had sold their souls to blackguards for petty cash, how many had never had souls? How many straight-and-narrow paths were crooked paths? How many best families were worst families and how many good people were bad people? When you added them all up and then subtracted, you might be left with only the children, and perhaps with Albert Einstein and an old violinist or sculptor somewhere." (Heller, Chapter 39, THE ETERNAL CITY)


I wonder if Bob Dylan read this book and was similarly affected by  "how many how many how many" theme.


There are many powerful discourses between characters. Heller uses satire with in a restrained and effective manner that lets me take him seriously. 

Breakfast of Champions by Kurt Vonnegut (1973)

Satire here goes way over the top, across the line, over-sarcastic. There were two pages discussing the penile length of many characters and even non-characters. Why? For effect, I know, but come on, enough is enough. By the end of the book I just wanted it to be over. I much prefer how Russian authors commit their characters to insanity while allowing the reader to remain sane.

Postmodern perhaps, thinking now of similar traits in 1970s "classical" music. Gyorgy Ligeti often leaves me wanting something more solid and less repetitive to grab on to. Despite the uncomfortable sense I have while reading Vonnegut or listening to Ligeti, I cannot deny the power of their works, emotive in how they disturb.

There were many self reflective parts, about being an author, writing and what it means to be an artist. This reminds me of Voltaire and Twain. Self critical and skeptical of mainstream critical analysis. Or maybe they all just hate critics...