Ethical Principles in Research

One part of developing a narrative research study is applying to my institution for an Ethical Principles in Research Program number (EPRP). 

Perhaps I should back up. 

I'm putting together some ideas for this summer. I'd love to travel to Central America to see what I can learn about how to age with grace. I have been interested in this subject ever since I was able to grasp the vast differences between how people in Ukraine age and die versus how people in the United States age and die.

In Ukraine, elders are often taken back in by their children and nursing homes are virtually non-existent.

In Ukraine, elders are given chores and tasks to help support their family, whether chickens to look after or napkins to sew.

In Ukraine, people die at home without extreme or radical (often expensive) attempts to prolong life a few more months.

In Ukraine, people accept death as part of life and are able to talk about it with ease.

Note: all of the above are vast generalizations and not always true in Ukraine, just as the converse is not always true in the United States.

Anyhow, this fascination with the transition from life to death has lead me to pursue funding for a trip to Central America where I will be able to talk with and observe a third culture dealing with aging and dying. My institution will fund such an enriching trip so long as it meets basic requirements, such as being scientifically based and completely ethical. My proposed research will most likely be of narrative qualitative design with data being collected in interviews, photographs and documents. The ethical benchmark is tested by completing an EPRP education program and taking a test at the end.

The Ethical Principles in Research Program requires that I read the Belmont Report. This document was written by a panel of experts in 1976 after the full extent of the Tuskegee Airmen syphilis atrocities had been revealed. It seems to be a whole-hearted attempt at achieving more ethical research by applying the principles of "respect for persons", "beneficence", and "justice". I found their definition of justice to be particularly interesting. 

"Almost all commentators allow that distinctions based on experience, age, deprivation, competence, merit and position do sometimes constitute criteria justifying differential treatment for certain purposes. It is necessary, then, to explain in what respects people should be treated equally. There are several widely accepted formulations of just ways to distribute burdens and benefits. Each formulation mentions some relevant property on the basis of which burdens and benefits should be distributed. These formulations are(1) to each person an equal share, (2) to each person according to individual need, (3) to each person according to individual effort, (4) to each person according to societal contribution, and (5) to each person according to merit."

It is good to think with this recently ignored part of my brain about broad philosophical concepts such as justice. 

Here's another great quote, apparently one that Ron Paul has not read and thinks is a matter of belief rather than fact.

The Belmont Report goes on to speak to the application of the three comprehensive principles.

Application includes:

1. Informed consent (information, comprehension, voluntariness)

2. Assessment of risks and benefits

3. Selection of subjects.

"Injustice may appear in the selection of subjects, even if individual subjects are selected fairly by investigators and treated fairly in the course of research. Thus injustice arises from social, racial, sexual and cultural biases institutionalized in society. Thus, even if individual researchers are treating their research subjects fairly, and even if IRBs are taking care to assure that subjects are selected fairly within a particular institution, unjust social patterns may nevertheless appear in the overall distribution of the burdens and benefits of research. Although individual institutions or investigators may not be able to resolve a problem that is pervasive in their social setting, they can consider distributive justice in selecting research subjects."

When medicine is overruled

So much of medicine is prevention. Now even things that we were trying to pin on genes are coming back to lifestyle. Check out this visual representation of cancer risks. It strikes me that most of these changes do not require doctors, yet failure to learn from this data results in the need for many doctors.

In another example of when doctors may not have enough sway to advocate for health, a team of surgeons donated their time to provide a kidney transplant to this man, yet were denied an operating suite by their hospital. Extremely frustrating that Republicans argue against a lifesaving and money-saving operation simply because this man is from Mexico. How can they claim Christian religion and say it's okay for undocumented immigrants to donate organs but not receive them?

"Organ registries do not record illegal status, but a study estimated that over a 20-year period noncitizens donated 2.5 percent of organs and received fewer than 1 percent."

"They should not get any benefit from breaking the law, especially something as expensive as organ transplants or dialysis," said Representative Dana T. Rohrabacher, Republican of California, who contends that care for illegal immigrants is bankrupting American health care and has sought to require that emergency rooms report stabilized patients for deportation unless they prove citizenship or legal residence.

"If they're dead, I don't have an objection to their organs being used," Mr. Rohrabacher added. "If they're alive, they shouldn't be here no matter what."

It sounds like the old "us vs. them" crap that has lead to immoral and unjust policies for all of recorded history...

Last week of the first semester. Positive thoughts

As I drove out to my last indoor soccer game of the semester last night along with fellow medical students, we talked a lot about the difficult and frustrating parts of medical school. It led me to think about how much easier it is to complain and vent about the frustrating parts of school rather than recognize all of the amazing things we are learning.

Today was our last day in the anatomy lab, though I'll go back for one more review visit before the final exam on Friday.

The physiology part of our final covers renal function and gastrointestinal secretion+absorption. The physiology is extremely interesting though I often don't have time to delve into the small details. Without the mechanistic details down to the smallest level, I often feel that the ratio of memorization/understanding gets too large. Looking forward to getting to NM for a little sunshine next week.

Time to pay attention to this radiology lecture again. Most of it is going over my head, but it is a good anatomy review.

The End of Merv Logging, for now...

I just can't keep up with blogging, logging and my journal. I end up shortchanging all of them.
I've read a number of interesting things recently, the most notable being my stopwatch.
Hopefully I'll clear it more often in the future.
here are the laps, and best guesses as to what they correspond to.
I run almost daily so these go back through all of November.

25:09 -- 11/3/11
34:56 -- 11/4
32:53 --  11/5
--------------------------
44:34 -- 11/6
39:10 -- 11/7
36:50 -- 11/12
Didn't run much this week because my foot hurt after stepping on a giant rock on an old railroad bed.
-------------------------------
57:35 -- 11/13
12:17 AM shakeout --11/14
28:52 -- 11/15
41:12 --  11/16
27:05 --  11/17
25:39 --  11/18
1:03:31 -- 11/19
-------------------------------------
53:37 --11/20
12:21 AM shakeout

47:05 -- 11/22
Drove out to Mendon ponds with Gears and Mguy.
Didn't have much time because we had to get me back to school for end of semester orchestra concert.

23:41 -- 11/23
Quick graveyard loop before drive to Boston with classmates.

1:15:29
Thanksgiving day. Perfect and sunny in Providence, RI.
Some cool trail by the harbor.

36:26
Day after thanksgiving.
Run ended on closed open drawbridge. The bridge was closed to trains and open to boats. Good old relativity. Wish I had a camera because I climbed up quite high.

1:10:42
Glastonbury with Paul and friends.
Slowest run in months.
Thank goodness.
--------------------------------------------------------------------
47:47 --11/27
Pinnacle hill and area after long drive from Elo's to Rochester.

40:04 --11/28

41:09 -- 11/29

1:07:36 -- 12/1
Loop of Hill with Mguy.

29:45 -- 12/2
Lunchtime run with Gears.
Found the most industrial part of Rochester in mixed rain + snow.

1:21:01 -- 12/3
Long run with Gears. Abandoned railroad beds make for very flat runs. We kept it uptempo though...
------------------------------------------------

39:03 --12/4
Night run solo after preping for my hour long interview + physical exam tomorrow. I'm playing doctor and the whole thing is getting video taped.

Personal Best: top athletes and singers have coaches. Should you? by Atul Gawande

Read the full article here.

The search for constant improvement was introduced to me by Tom Donnelly, my track coach at Haverford College. Excellence to him is something that we can all attain, in any number of pursuits.

Really interesting how all but one of the teaching departments here is really good. I've noticed that these departments always have faculty in attendance that are not teaching, but instead evaluating how well the presenter is getting across information. They also keep tabs on how many people come, how many people are asleep, and can write test questions based on the information provided in lecture.

The department that is not good at teaching does not send anyone but the presenter to the lecture. Thus I feel that they have a lack of coaching within their department.

Unfortunate to see how much of our curriculum being test driven, without any more meaningful outcomes extrapolated from beyond the test. (referring to the USMLE step 1s here)

Fun fact.

Our brains are oil cooled and air cooled. Cavernous sinus us filled with venous blood on it's way back from near the surface of the skull. This blood cools arterial blood (the internal carotid artery runs through the cavernous sinus) without mixing and makes the blood 

Tests and More Tests

I'm writing this post during a lunch hour in which I should be preparing for a written final for interviewing and physical examination skills. Unfortunately, I lack all motivation to cram these things into my head because I am unconvinced that a written test about skills that are fundamentally not written will make me a more skilled doctor.

Frustrating that changes are made without measuring outcomes.

I read another blog post last night that speaks to the same issue.

http://well.blogs.nytimes.com/2011/11/03/being-a-med-student-take-two/?ref=health

Yes it would seem bad that some people would take an open book test and not actually learn something, but are there any data to suggest this is what was happening? Instead, these tests were changed from open book to closed book based on some perception, without getting a baseline on performance and then seeing if making the tests more formal actually improves patient care.

Public perception perhaps drives many things in the end. If the American Board of Pediatrics wanted to go back to open book re-certification exams, the media might have a field day reporting how you could just "cheat" on your exam to be a pediatrician. 

Whatever the media says, I would bet that if outcomes were actually measured, it would turn out that people who were better at accessing accurate up to date information from literature and colleagues probably provide better patient care.

Seem to remember reading something else about standardized testing in MA reducing teacher freedom and leading to poorer outcomes, not on the tests, but in some things that matter more than the tests, like getting into college. Anyway, just thinking...

Cardiology

I went on rounds this afternoon with a cardiologist.

We went around and listened to people's hearts, felt their impulses, percussed and asked questions.

I don't think I want to have such a specific focus in medicine, on one organ, but it was a fascinating window into an interesting profession.

The second exam quickly approaches, and I find myself settling into this ebb and flow of these three week blocks. There is a ton of information, but also enough theory and logic to hold it all together where the data scientific understanding puts its rubber on the life roads of real life patients.

Now I'm calculating everything I can think to calculate regarding cardiac output and oxygen delivery for a case I'm working on in a small group. The case was real, and we're being presented the information piecemeal, just the way it would come into our view in the CCU. Difficult stuff and I'm really not sure we can save her, as she's still bleeding 16 hours after delivering a baby. Ironic that it could be because she didn't breast feed to trigger the natural release of hormones that would have completely tightened up her uterus. The more and more we intervene, the more we learn that nature had it right in the beginning.

Re: anatomy

On Mon, Oct 17, 2011 at 5:47 PM, Tim wrote:

"Dude, how's it going?"

It's going well!

Anatomy is particularly fascinating as we explore the secret chambers of the heart.

Of course I am tempted to write about all the grisly cuts that we have to make in lab, but that stuff is by far overshadowed by the knowledge and understanding that come with actually fingering a tricuspid valve as we study determinants of cardiac output in physiology class.

The amount of information is sometimes overwhelming, and the intelligence and maturity of my classmates is admirable in tackling such a large task. I was spoiled at BMC with time to learn every word of Dr. W's lecture and time to practice Orgo concepts repeatedly. Here, that extra time is needed to learn physical exam skills, motivational interviewing and the stages of child development. This means that averages on each exam are much lower than at BMC, despite steady 12 hour work days. I almost forgot about all the time we spend in labs (Anatomy, Histology, Physiology). We were dissecting the neck for over 3 hours yesterday. Very detailed dissection that must be performed in a very small space.

Of course to maintain sanity, I've joined two orchestras and continue to exercise every day. Next race will probably be on snow shoes, as I've been recruited to join a relay team for a series of races in January and February.

Off to lab!

Health Insurance: A Primer for Medical Students

What follows are my notes from a friend who is a md/phd up here.

He researches the economics and policy of health care.

Why do I care?

1. Reimbursement for medicaid and medicare are not enough to cover overhead, so the policy affects how I can serve those who need it most.

Also best practice is affected by what things are reimbursed, because I'll prescribe things and they must be covered to ensure that my patients take their meds.

2. Many people will seek my advice and opinion as a physician.

3. Issues of cost are becoming more pertinent and resources become scarcer.

Why do we have health care?

The costs of healthcare are extremely unpredictable. Risk aversion to income variations make people willing to pay some amount to avoid the huge fluctuations in their income.

What are the pros of insurance?

1. Shields against risk and uncertainty.

2. Insurance companies can buy service in bulk.

3. Can encourage the use of better services.

a. Vaccines as example because better for society than for the individual.

b. Improves efficiency especially with preventative services. Some individuals won't do preventative care unless insurance pays for it to prevent future costs. 

4. There are proven consequences that living without insurance is more dangerous (strong literature supports this).

What are the cons of health insurance?

1. Cannot guarantee good health care.

2. Inefficiency of the middle man.

3. Overuse due to the moral hazard, because if you don't have to pay for it, you'll use more of it.

How much insurance is enough?

1. Most important to cover catastrophic events.

2. Services that are worth more than they cost.

a. preventative services

b. vaccines

How much should patients pay out of pocket?

Some out of pocket costs can reduce moral hazard overuse.

Good patient care does not always equate to good health population.

The greater good is often different.

Antibiotic resistance was in part caused by all kids getting antibiotics for ear infections.

So now individual patients have to suffer for a little longer in order to prevent multiply resistant bugs.

Another example is the use of CT scans in the emergency departments.

The good of the population is better served by not scanning everyone even though the individual would be better served by getting the scan, just in case something is very wrong.

Is a mandate to buy health insurance a good idea?

Yes, premiums will go down if penetration is high enough.

Companies can drop premiums if they get both sick and healthy patients.

Comparative effectiveness vs. rationing

rationing already exists.

Infinite need and finite resources.

Allocation decisions are being made all the time, but not backed up by evidence.

Prostate screening as example, very well funded but relatively irrelevant test, because all old men get prostate cancer and very few die from it.

Let's use evidence.

How do you make sure policies actually work?

12 year old kid had tooth ache but couldn't find dentist who would take him (because medicaid reimbursement sucks), then ended up in the hospital getting $280,000 and then dying from brain infection.

But maybe this is an extreme case?

It's not, because upwards of 10% of uninsured patients that hospitals see were on medicare.

Death panel controversy which got blown out of proportion started as a provision that would provide physicians with reimbursement for end of life counseling. The major push was a facebook post by Sarah Palin that was based on no truth whatsoever. 

Misinformation is powerful and the American public is susceptible to believing whatever the media supports.

Good news is that when people understand the truth, they generally choose correctly.

Solutions will require rational discourse informed by 

Suggesting Reading

Health Economics Phelps, 2009

The Social Transformation of American Medicine, Starr, 1984

Kaiser Family Foundation (kff.org)

"Rationing Health Care: What Does it Mean?" NYTimes, July 3rd, 2009. Uwe E. Reinhardt

"Providing High-Value, Cost-Conscious Care: A Critical Seventh Generation Competency for Physicians." Annals of Internal Medicine" Steven E. Weinberger

Sleep

This afternoon we had brief lecture on behavioral psychology and it's applications toward depression and insomnia.
Really interesting to learn how sleep is cyclic, with deep, slow wave sleep at the beginning of the night and REM toward the morning.

The behavioral modification part was cool as well. The doc presented data on the success of sleep rationing to increase sleep time vs. various drugs. The behavioral methods worked much better.

In other news, I took my first serious exam of medical school on Monday.

Started with 25 questions about various structures tagged/pinned on cadavers or x-rays.
I felt pretty good about this part, but definitely forgot some simple information from the very beginning of the block. (each block is three weeks, so we're on to block II now)

Then I had 45 questions about various micrographs and light microscope images pertaining to tissue types and classification.
This went fairly well I think.

Monday morning finished with 37 multiple choice questions about cardiac physiology and ECG interpretations.
These were really challenging.
There were also some more short answer anatomy questions that were clinically oriented. I had not read enough of the textbook to feel really comfortable with these.

After lunch, we immediately started in on block II. Intensity is good.

Goethe quote

If you treat an individual as she is, she will stay as she is, but if you treat her as she ought to be and could be, she will become what she ought to be and can be.

Forks Over Knives documentary

The first real exam of my first year of medical school quickly approaches.

Even as the muscles, nerves and arteries of the arm, hand, back and shoulder become part of my vocabulary, a movie I saw recently constantly forces the question of how our diet relates to the health problems of our country.

Forks Over Knives is a documentary based on "The China Study", a book about cancer etiology in China.

Go see this movie if you have a chance. My vegetarian lifestyle was very strongly reinforced as the links between animal based diets and a dozen diseases were laid out clearly with solid evidence.

Allow Natural Death and other Advance Directives

The first block of medical school has passed quickly, and left me in a better place to find and understand scientific literature. Our second block is centered around anatomy and physiology and will include the complete dissection of a dead person. I feel well prepared to undertake this exploration of structure and function in part due to the recent exploration in a small group setting of palliative care and end of life treatment options.

As an EMT, I was already familiar with DNR (Do Not Resuscitate) orders that any person may prepare in case of cardiac or respiratory arrest in order to instruct health care personnel what measures should be taken. I did not realize that a patient's right to refuse extreme resuscitation efforts had only been protected legally since 1991, with the Patient Self-Determination Act. 

Then there are some states that recognize living wills and health care power of attorney (health care proxy). Thus if you are left incapacitated, your power of attorney can make all medical decisions for you. This is much safer because it does not allow the "crazy aunt from California" to fly in and demand that you be put back on the ventilator.

Finally, there are state specific documents that allow thy will be done even when you are unconscious. In NY, this thing is called MOLST (Medical Orders for Life-Sustaining Treatment). This document details your orders to physicians in various situations.

1. No pulse and/or Is Not Breathing

2. Patient has a Pulse and the Patient is Breathing

For situation #1, you can choose CPR or not.

For situation #2, you can choose 

a. comfort measures only

b. limited medical interventions

c. no limitations

For #2, you can also mark your preferences for 

a. intubation

b. hospitalization

c. artificially administered fluids and nutrition

d. antibiotics

e. other instructions

Other end of life decisions include organ donation or getting an advance directive in your medical record by having your physician note it down. It seems that the most effective way to ensure that your end of life wishes are met is to fill out as much legal paperwork as possible, and appoint a health care power of attorney to somebody who you really trust to follow your directions.

And this leads finally to the anatomical gift program and my sincere gratitude to the individual who has gifted his body to be my first patient and individual tutor on the inner structure of man. 

Blink by Malcolm Gladwell

The most intriguing idea in this book is how too much information can cloud effective decision making.

Gladwell uses examples ranging from war to medicine to illustrate the power of subconscious parts of the mind while at the same time remaining very aware of the limitations of "thin slicing" any situation. "Thin slicing" = rapid cognition.

Too much information was clouding ER docs' decisions regarding chest pain, thus algorithms were introduced that dramatically improved diagnosis.

Gladwell even goes on to suggest a constitutional amendment regarding the right of the accused to see and confront her accuser and jury of her peers. However, the data shows clearly that black males are "13 times more likely to be sent to prison on drug charges than a white man" (275). This is when these two men, white and black, are charged and convicted for an identical crime.

Thus Gladwell remains optimistic that errors in rapid cognition will continue to be identified and appropriate fixes put in place. Examples include the introduction of blind auditions to prevent sexism in classical music.

Gladwell proposes that rapid cognition is most effective at a certain level of stimulation, but too much arousal "leaves us mind-blind" (229).

Hopefully I'll get a chance to read some of Gladwell's other books in the future.

Physician Decision Making

Another guest lecture this morning which I will attempt to condense into a more readable account than my last attempt at sharing my notes.

What does it take to be a good doctor?

fundamentals + experience = good doc

1. Information needs to be sorted according to how it is used.

2. Communication may be the most important part of medicine.

3. Art of healing includes empathy and ritual.

4. Judgment is still necessary even with perfect information.

Here's one way to use data.

Generate evidence-->synthesize evidence-->develop clinical protocols-->apply protocols-->re-evaluate

Then have to balance patient's preference, research evidence, clinical circumstances and clinical judgment.

Every decision is founded on goals, objectives, options, people and preferences.

Situational awareness = observe (data/information/task environment), orient (mental model, anticipate potential future states), decide, act.

OODA loop

often includes an awareness of what decision making process is most 

Intuitive vs. Analytical decision making

Most choices are intuitive = heuristic

really fast, but susceptible to characteristic mistakes

Others become more analytical =systematic

takes a lot of time

Specific practice to develop clinical judgment

1. know and be aware of common decision making errors

2. routinely inquire into and discuss the reasons and rational for decisions that are being made.

3. Simulate with hypothetical cases

4. Reflect and consolidate recent experiences (hopefully that's what this blog is helping me do)

Genes, Environment and Epidemiology

This isn't technically something I read, but rather a lecture in which I am sitting currently.
The problem is that I am already focused on the long weekend ahead, and I don't think this stuff is on any upcoming exams. Therefore, sharing some of these ideas with you may help them stick in my mind.

Central Dogma
Gene transcribed into mRNA then translated into protein and stuff.

Human Genome
3 billion base pairs
30,000 genes
46 chromosomes

Genetic Variation
a. Mutations include deletions, insertions, gene rearrangements, chromosome translocations, copy number variants
b. Polymorphisms are when alternate forms are present. Single nucleotide polymorphisms (SNPs)

Penetrance = strength of the association between a mutation/allele and risk of disease.
expressed by the proportion of variant carriers who develop phenotypic manifestations.

Genetic Epidemiology Approaches
Hope to figure out relative contributions of genetic and environmental factors.
Example: Down syndrome associated with leukemia or alzheimer's?

Time trends = compare disease rates over time.
sharp increase over time points to environmental factor because genetics don't change very quickly.
Melanoma is an increasing very quickly, but why?

Age of onset can also give clues about etiology.
Germ-line mutations have earlier onsets.
Somatic mutation/environmental exposure take longer to lead to disease state.

Family studies
look in family trees (pedigrees aka genogrames)
a. segregation analysis -- is observed pattern similar to mendelian theories?
b. linkage analysis --can help to identify and localize where the guilty gene is.

Twin studies
a. monozygotic twins share 100% of genes.
b. dizygotic tins share 50% of genes
compare the concordance rate between the two.

Adoption studies
can show if some disease is genetic or environmental
especially interesting with behavioral things

Migrant studies
Comparison of disease rates between people in their home country and the same people once they migrate to a new place.

Genetic Markers
DNA markers
SNPs
RNA markers
Protein markers

When disease process identified, try to think which of the following area is most likely for some malfunction.
Metabolism genes
DNA repair genes
Immune function genes
Cell-cycle control genes

Genome-wide association studies (GWAS)
Simultaneous scanning of markers (SNPs) across complete sets of genomes.
Case-control study design.
New pathways can be identified.
Unfortunately variations identified are likely not causal.

Phenylketonuria (PKU) is a metabolic disorder resulting in mental retardation in children.
Requires genetic mutation and dietary exposure to phenylalanine

Nature vs. Nurture
Genetic factors explain only a small proportion of disease.
Remainder can be attributed to environmental factors.
But really it's the interplay between the genetic and environmental factors.
Gene-environment interaction (GE interaction)
Again can use 2X2 tables to figure out relative risk.
This is effect modification.

This lecture is going way to fast to really catch anything or have a moment to think.
Presenter is literally speaking at double speed.

Pharmacogenomics
Genetic variation can impact whether or not a drug is beneficial or toxic.
Gene expression profiling.

Four Habits of Highly Effective Clinicians: A Practical Guide. Frankel RM and Stein TS

Much of our learning about basic clinical skills centers around the doctor-patient relationship. As such, we have begun to learn and practice a number of techniques for ensuring that our interactions with patients remain patient-centered.

 

After each lecture, we divide into groups of ten and practice interviews with professional standardized patients. We take turns and after each scenario, we ask the patient how we did, and then each of nine classmates for constructive criticism. There is also a senior faculty member present to facilitate or fill in with wisdom gained in practice that may concern each situation.

 

The first week (last week) we learned and practiced:

1. initiating the session (introductions, titles, putting the patient at ease, ensuring comfort, establishing rapport, naming the patients main concerns, and setting a common agenda).

 

2. patient-centered interviewing --> amazing how efficient my information gathering can be if I let the patient answer open ended questions about herself. The main concerns and worries and surrounding circumstances, disease timeline, and much more can come out of a natural conversation rather than the typical closed ended questions that we used in EMS. It is very tricky to direct these conversations and there are many cues that I fail to recognise.

 

This week we learned and practiced:

3. Clarifying the patient's concerns. This task was more familiar to me after my year as an EMT. It is important to give the patient a "sign post" so that she knows that we are moving into more specific questioning. We practiced using the idea of "coning" where we take something that started out as an open ended question, and work it down to a specific detail.

["What did it feel like?" --> "Tell me more about that sensation" --> "Was it a burning pain?".]

The difficult part for me was climbing back out of the cone and using other things that were mentioned in the earlier narrative to repeat the coning process with other useful data.

 

4. How to build the patient-doctor relationship.

This is cool. Empathic listening skills drawn from the principles of nonviolent communication.

It's been proven, using actual data, that empathy is "highly associated with patient satisfaction" (Wasserman et al 1984). Thus our task yesterday was to demonstrate empathy using the full range of human communication. I found the empathy part natural, but to combine this with an interview that must accomplish certain clinical aims will take years to master. The most striking part of the demonstration in lecture was how reassurance and encouragement do not help a patient feel connected to her doctor. Only empathy makes people feel that they are being listened to and truly understood.

First you have to recognize verbal or nonverbal statements that give insight into an underlying feeling (potential empathic opportunities). This comes pretty easily from active listening, where I verify my understanding of what the patient said. Then it gets tricky as you have to identify the specific emotion and its strength. Again I'll ask the patient if I've understood correctly and readily accept any corrections. Then I'll reflect on her situation portraying my empathy without searching for solutions or reassurance (this is really tough). From this heavy moment, I need to learn how to focus on

a. legitimation "I can understand how that must be incredibly difficult"

b. support "I want to help"

c. partnership "how can we begin to address these issues?"

d. respect "you're doing great"

 

I did fairly well with legitimation, but I need more practice with the last three.

 

More practice tomorrow.

Now I'm off to run a local 5k...

Class Schedule and Nonviolent Communication by Marshall Rosenberg

I should explain that I'm in two classes.
1 epidemiology/biostatistics
2 basic clinical skills
Both have lecture and small group components.
The small groups are especially useful.
In the small groups for #2, we've been practicing patient centered interview techniques.
Awesome concepts centered around the ideas that Marshall Rosenberg put forth in his life works, especially a  book called Nonviolent Communication.
I wonder where Rosenberg got these ideas from?
The Center for Nonviolent Communication is in Albuquerque.

Let this be a reminder to myself to read something by Rosenberg before I graduate.

First Standardized Patient

On Wednesday, in small groups, I was the first to try out our new "patient centered" interviewing skills on a real, live, standardized patient. It was very realistic, all the way down to what you'd find in a doctor's office and my white coat. Tough with 9 classmates + real doctor watching.

I forgot to make her comfortable during the introductions (she wanted to put her leg up on something), and failed to fully explore her worries concerning her injury (other than that, I did okay). Got to work on these open ended questions, using the patient's ideas to direct the flow of conversation. It's so strange after a year of asking very specific questions in the choppy manner of an EMT. Turns out you can actually get most of the same information more quickly and then additional helpful information as well if you just let the patient direct the flow. It won't always work, but it is pretty successful.

What I learned in biostatistics today: "The average human has one breast and one testicle." Des McHale

On average, physicians interrupt their patients after only 18 seconds. Source forthcoming

Class of 2015 Code of Conduct URSM&D

We, the URSM&D Class of 2015, gratefully embrace our diversity of backgrounds, personalities and ambitions. We gather united for the purpose of serving humanity, arriving at this moment not simply through our own work, but indebted to innumerable others.


Excellence in this endeavor requires our adherence to certain principles. As students and physicians, we recognize our role as ambassadors for our institution and the field of medicine. We accept responsibility to adhere to a moral and ethical code in our words and actions. We believe that this life of service must be rooted first in compassion and empathy: for our patients, for our peers, and for our community. In the framework of the biopsychosocial model, we acknowledge that our patients, and all people, are more than their ailments.


We share a belief that challenges are better faced together than alone. We trust that our curiosity, patience, and humor willhelp us in our journey. Maintaining balance and strength in our personal lives and relationships is crucial to the optimal care of our patients. As we are at our best, so we give our best.


The value of our beliefs lies in our commitment to live them out through our actions. Recalling the privileged contract we have made with society, we dedicate ourselves as physicians to be advocates for our patients and agents of social justice. We will maximize our potential through continued introspection, embracing our limitations as opportunities for growth. As we mature in our understanding of medicine, we will strive to be innovative leaders and teachers of the next generation.


In the spirit of Meliora, we will remember this pledge in the hope that we may find renewed energy and commitment to our beliefs and purpose.




We pledged the above in unison after we received our white coats yesterday. It was written by sending one representative from each small group to a threshing session where the details were worked out. While not every word was unanimously agreed on, this pledge captures the spirit of our class and what we hope to achieve.  

Reservation Blues by Sherman Alexie

I am

homesick for the west

inspired to seek employment on a reservation

angered by our continued mistakes with the first nations

saddened in solidarity

daunted by the height of the obstacles facing American Indians

Baha'u'llah, an introduction

I read this book one page at a time as I was falling asleep each night. Though a more readable account of his life and work is probably available here, I found great comfort in the words and language contained in this book.

Many of the ideas in Baha'i faith remind me of Quakerism, but the very existence of Baha'u'llah and his supposed greater than average "messenger of God" abilities really strike me as antithetical to the whole idea of equality and equal access to God's wisdom. But I am no theologian, and I have much to learn. I will keep an open mind as I broaden my religious horizons.

Musicophilia by Oliver Sacks

Suddenly I'm interested in neurology. And absolutely amazed by how mysterious and unknown the brain remains.

This book was full of anecdotes, some extremely fascinating, and some incredibly boring. My favorites included:

Brainworms

Absolute Pitch

Musical Savants

Synesthesia and Music

Music and Amnesia

Aphasia and Music Therapy

Parkinson's Disease and Music Therapy

Phantom Fingers

Athletes of the Small Muscles (Dystonia)

Will probably revisit this book as I learn more about each of the disorders. Great to put a human face on each condition and learn how music is related. I really want to keep music in my life.

Is Sugar Toxic (New York Times Magazine) by Gary Taubes

This article is fascinating. Actually the research and hypotheses that Taubes investigate are fascinating. I really need to learn some more biochem before I feel absolutely comfortable agreeing with all the ideas put forth by Lustig at UCSF.

The most frightening part of this article was actually not how sugar becomes fat, but how policy comes from agricultural and industrial lobbyists. Frightening...

Omnivore's Dilemma by Michael Pollan

Unbelievable how much corn we grow in this country, and how the free market forces have attempted to shape the inelastic demand of human hunger into a profitable enterprise that can sustain continuous growth. Also fascinating how artificially low oil prices have supported this bubble of energy intensive agriculture. Not going to be pretty when it bursts.

The Long Lonliness by Dorothy Day

Interesting historical insights, but poorly written in a really rambling style.

At least I know who Dorthy Day is now...

International Service Corps for Health

This is a great idea!

some quotes

"Cuba provides an imperfect but
potentially informative example
of the dividends of "exporting"
doctors. Having put key principles
into practice domestically,
particularly the principle that
health care is a right and is essential
to economic and social
development — albeit with unclear
results for its own population's
health — Cuba extended
this mandate to international
public service. The country hoped
to focus on bridging gaps in the
health care workforce and invested
invested
in training and educating
local professionals in developing
countries. The impact has been
noteworthy: between 1999 and
2004, Cuban foreign-service workers
increased doctor visits in resource-
poor communities by 36.7
million, provided health promotion
outreach for millions of
underserved
people, and taught
900,000 medical education courses
to local personnel."

Treat the Patient, not the CT Scan by Abraham Verghese

The advantages and dangers of computers
the "ipatient" vs. the real patient
how physical exam skills are atrophying as American physicians increasingly just rely on technology.
"But all that training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be "throughput" — getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge. And the engine for all of that, indeed the place where the dialogue between doctors and nurses takes place, is the computer."

http://www.nytimes.com/2011/02/27/opinion/27verghese.html?pagewanted=2&_r=1

Hot Spotters by Atul Gwande

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

1% of patients account for 30% of costs


Really inspiring ideas.
Improve care for the most costly patients.
That will bring overall costs down.
That really makes sense considering how prevention can reduce emergency costs.

The idea of health coaches really stood out.
This is taken from the international arena of community health workers.

Also, Dr. Brenner used many of the community mapping ideas widely used in international development.
The analysis of data is vital in improving care.
Use insurance billing data or EMS data to find out where patients come from and then go find out why these patients are not receiving adequate care.
Each ER visit is a failure in the web of society, whether a result of crime, transportation, lack of access, drugs or economic circumstances.


Another great idea is the salaried doctor office. Doctors paid for their time, not for procedures.
This results in better outcomes.
Team approach to care, with nurses, front desk staff and health coaches included.
Nurses as case managers in medical home model.
Calling, following up, being like the patients mother.

Helene Gayle, guest speaker at bmc

CARE CEO Helene Gayle Accepts 2011 Hepburn Medal

More than 200 guests watched President Jane McAuliffe present the 2011 Katharine Hepburn Medal to Helene Gayle, president and chief executive officer of the international humanitarian organization CARE, in honor of her efforts to fight global poverty and reduce the transmission of HIV/AIDS

Saw her speak at BMC. Really inspiring.

http://news.brynmawr.edu/?p=7955

An Imperfect Offering by James Orbinski

A general account of James's service in MSF. 

The descriptions were rambling and long, but the overall ideas were solid.

By giving examples of the many political failures that lead to humanitarian crises, Orbinski argues that MSF is correct in maintaining separation from political powers while still speaking out on behalf of all victims. He argues that there must be a humanitarian response to humanitarian crises and a political response to political crises. 

Examples include:

Rwandan genocide fueled by colonial divide and conquer strategies. Then the incredible failed international response due mainly to the US's reluctance to become involved following our embarrassing exit from Mogadishu. 

Balkan war of the 90s and the Clinton policy of tying humanitarian aid to military action. 

And many others. Interesting book but could have expressed the same things in many fewer pages.

The Hedgehog and the Fox: An essay on Tolstoy's view of history by Isaiah Berlin

"The fox knows many things, but the hedgehog knows one big thing" -- Archilochus

Perhaps there are two types of thinkers:

Hedgehogs:
relate everything to a single central vision,
one system less or more coherent or articulate,
in terms of which they understand, think and feel,
a single, universal, organizing principle,
in terms of which alone
all that they are and say has significance

one unchanging, all-embracing, sometimes self-contradictory and incomplete,

at times fanatical, unitary inner vision

Berlin includes in this group of thinkers the following people.

Dante

Plato

Lucretius

Pascal

Hegel

Dostoevsky

Nietzsche

Ibsen

Proust

Foxes:
pursue many ends,
often unrelated and even contradictory,
connected, if at all, only in some de facto way,
for some psychological or physiological cause,
related by no moral or aesthetic principle.
Foxes lead lives, perform acts and entertain ideas that are centrifugal rather than centripetal,
their thought is scattered or diffused,
moving on many levels,
seizing upon the essence of a vast variety of experiences and objects
for what they [the objects] are in themselves,
without, consciously or unconsciously,
seeking to fit them [the objects] into, or exclude them from,
any one unchanging, all-embracing, sometimes self-contradictory and incomplete,
at times fanatical, unitary inner vision
Berlin includes the following people as foxes:
Shakespeare
Herodotus
Aristotle
Montaigne
Erasmus
Moliere
Goethe
Pushkin
Balzac
Joyce

But when it comes to Tolstoy, Berlin proposes that it is difficult to classify him as either hedgehog or fox because Tolstoy himself was not unaware of the division, and did his best to falsify the answer.
"Tolstoy was by nature a fox, but believed in being a hedgehog".
Berlin states that his gifts and achievement are one thing, his beliefs, and consequently his interpretation of his own achievement, another. His ideals have led him, and those whom his genius for persuasion has taken in, into a systematic misinterpretation of what he and others were doing or should be doing.

Then the meat of the essay hinges on the proposition that the conflict between what he was and what he believed emerges nowhere so clearly as in his view of history.

And I still have to read the essay...
I just wanted to get this bit out about the introduction because it is the framework I used for my medical school personal statement.

Cutting for Stone by Abraham Verghese

This is a novel set in a clinic outside of Addis Ababa. Really fun to read, and medically centered. I thought the novel was a really great way for the author to express many things that are obviously important to him.

Foreign medical students in the US, especially for their residencies, doing jobs that no US educated doctors will do. 

The physical examination as the centering point for diagnosis. 

The relationship of culture to the patient doctor relationship. 

How life and work can be in conflict. Some people can be really good at their life's work. Some people can be really good at relationships with other people. And a few very rare cases where somebody is good at both.

Definitely made surgery sound attractive...

My Own Country by Abraham Verghese

A book written from Verghese's own experience as an infectious disease specialist at the peak of the HIV epidemic in Johnson City, TN. He uses his own experience as recorded in his journals to describe how quickly HIV can affect a small city in Tennessee. I was particularly touched by his descriptions of learning how to help his patients die more comfortably. 

Verghese's diverse medical training shone through as did his respect for the physical examination. I hope to emulate his sensitivity to a multitude of sensory inputs which he so lovingly described in multiple places. First the art of percussing the body while "listening" with another finger so that you are clued into exactly what to listen for when you finally use your stethoscope. Second, the multiple olfactory clues provided to the attentive doctor, which can help diagnose even before you see your patient. 

Overall, I was very pleased with his open and honest writing style, and willingness to present rural primary care without polish, as tough as it is, and in the end, too tough for him.