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.