Barack Obama the Scholar on Obamacare

Obama

President Obama has done something quite unusual. He has just published an academic article in a well respected academic journal. It is widely reported that he is the first president to do this while in office. Obama’s publication appeared in the Journal of the American Medical Association on July 11th, 2016.

This contribution, (focused on the motivations behind The Affordable Care Act (ACA) – also known as “Obamacare” – and its place in present and future of health policy) is considered a special communication “which requires prior inquiry before submission”. My understanding is that President Obama and the White House didn’t just decide to submit this, JAMA had to do some “inquiring” for a contribution. It is also not peer-reviewed in the sense that other experts in the field reviewed the paper prior to publication. However, it definitely has gone through fact-checks and rigorous revisions. Moreover, it is up for discussion criticism and  peer reviewed ex post facto.

I wanted to take a critical look at what our sitting President has to say about the lessons learned from arguably the biggest part of his legacy.

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Literature About Medicine

literature and medicine

Sharing a Piece

Here’s a post from Andrew Solomon on literature about medicine. It includes some great recommendations on books related to medicine. You can find the piece in multiple places (here, and here). It includes some great insights about language and medicine. It’s quite a long piece. Perhaps it’s more useful as a reference list of books to read. Solomon provides commentary on for each book he mentions which isn’t as useful. Also, honestly, I felt he goes in too many directions in the later parts of the piece.

However, the introduction cannot be more true. He describes the “sticky communication” plaguing doctor-patient relationships. Moreover, it feels like an injustice that, “in fact, there is some evidence that people who can speak more fluently receive better medical care; patients deprived of language are often subject to abuse.” If you can’t handle the length or the disparate 2nd half of the piece maybe keep in mind the books mentioned. I think all these books are well regarded and worth the read.

 

 

 

Working Stiff (2014) – Judy Melinek MD and Thomas J. Mitchell

working stiff

Working Stiff by Judy Melinek and Thomas J. Mitchell

Working Stiff: Two Years, 262, Bodies, and the Making of a Medical Examiner

by Dr. Judy Melinek and Thomas J. Mitchell

A true story of all the deaths that occur and the work of a person who continued to serve the dead and their families. Told from Dr. Melinek’s perspective, she chronicles her journey from a overworked surgical resident to her discovery of a new calling as a pathologist. She outlines her year as a forensic pathologist in the medical examiner office in New York City the year that 9/11 occurred. She witnessed the event firsthand, “cumulating the human toll” of the World Trade Center attacks. Her unique perspective of that event is in itself worth picking up this book. Continue reading

Shortcuts in Medicine: Borderline Intellectual Regurgitation

Borderline Intellectual Regurgitation

Borderline Intellectual Regurgitation I suspect is a phenomenon that exists in all fields. It’s definitely rampant in medicine. But is it a bad thing? Is it a necessary thing? In medical school you are taught a certain way to collect and share medical information. Then when you step into the actual world you witness a completely different system being used in real life practice. Sure, the tenets of what you learn still remain, but you realize it comes down to the ideal versus the practical. Experience teaches us to constantly strive for the ideal, but often times shows us the limitations that exist which hold us back from achieving it. That’s when shortcuts occur. One of the many shortcuts used is what I’ve termed, “Borderline Intellectual Regurgitation”

What do I mean by that? Let me give you a common scenario.

You show up with a white coat and stethoscope, well dressed, hopefully with energy and enthusiasm. You ate breakfast, have your coffee in hand. Check!

Switching back to the day shift, you are given four new patients from the team’s census. You are told to pre-round on them and come up with a plan on all four patients prior to rounding in 2 hours.

What does a typical person do? You look at the sign-out sheet, the last H&P, last note, relevant labs or studies, and try to recall what you can remember from 90 seconds of verbal signout you were given on each patient. Right before rounds you have a passable plan that makes some clinical sense for your patients. Then when you talk with your team you use what I would call borderline intellectual regurgitation constantly! There are countless times when I’ve heard something along the lines of, “But I read it in her last note and I agree with Dr. A about B because of C” or “But the signout sheet says X.” You have your own original plan, but much of the details or reasonings are based on other ideas. You haven’t really thought through your patient.

It’s not about stealing as much as it’s about ignorance. Plagiarism has a bad connotation, but occurs more than we think. Often it is unintentional. It is still a matter of degrees from plagiarism if the person who wrote the sign-out or the last note EXPECTS you to use their information.

We need the ideas of others all the time because we are ignorant. Medicine is not a one person activity. However, it still feels shoddy and even not ethically ideal. The crux of the dilemma lies in the problems that arise.

  1. You accept the clinical plan based on someone else’s reasoning (and from the PAST) instead of thinking for yourself.
  2. Copy and paste occurs way to much in notes. I intend to address this issue further separately.
  3. Attending physicians are not immune either. How often do you hear an attending teach the same 5 topics over and over (Self-regurgitation)?
  4. The same rehearsed phrases are used in difficult patient conversations.
  5. Emphasis on study M for condition N is highlighted because in this institution it is so often regurgitated whereas another medical institution has a completely different practice for condition N because study O is regurgitated there.

Maybe, I’m being too sensational. There is already way too much in medicine to deal with and being systematic and uniform is honorable. We learn by learning how someone else thinks. We copy and paste because we need to include a detailed history of something that won’t change (ie a person’s cancer history, date of recurrences, his chemo schedule etc). Repetition is a key to learning. Some phrases are just more effective when telling someone they will die soon. Medical institutions have different populations in which different practices are warranted. But I started this series of posts to at least highlight that we shouldn’t succumb to laziness. We are too often beholden to practical limits rather than striving as hard for the ideal because we often can get away with it.

Reflection on a Bias in Medicine

South Platte River

South Platte River

Mr. “frustrating patient” had come into the hospital after his first round of chemotherapy complaining about fevers. He would be getting in house radiation treatments for his advanced cancer, while we treated his infection before traveling back to Nebraska. My patient, I soon learned had developed an infection. The source was thought to be an abscess forming near his primary cancer. Unfortunately, no intervention or treatment option was feasible and my patient languished days on end – stuck in that same sad room. This was a frustrating patient. However on reflection, no blame for that frustration was his fault. I felt there was a bias to inaction (with the required “action-esque” masquerade) from the multiple providers involved in his care. Unfortunately, it’s not uncommon for the “stably sick” – those requiring (debatable) inpatient care, but without a clear treatment plan – to sit in a hospital bed for the passage of time to reveal a branch point where the course of care finally moves in a direction away from the endless stasis. The common example is the dispo nightmare – Mr. frustrating patient’s case was a bit different.

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Personal Genetic Testing: Part V – Conclusion

Part V: Conclusion

train tracks

So where does this personal genetics testing journey lead? On a personal level, the path ahead remains relatively straight for the near future. I have learned quite a bit about myself by embarking on this journey about 4 years ago. However, even though an uncertain destination lies ahead I don’t see myself making any major changes based solely on this genetic knowledge. In contrast, on a societal level, I think the path ahead is rather murky. Many stakeholders are at the wheel steering the realm of genetic testing and its associated scientific advances in many directions. Meanwhile health care providers and many consumers are riding along waiting to see where all this takes us. How revolutionary will this be? Maybe the areas where genetic testing has the most benefit (testing for genetic syndromes, cancer genetics, prenatal testing) has already taken the leap forward from the original discoveries and other areas will get left behind. Yet I strongly doubt that genetic technology won’t continue to change much of medicine. If that change is good or bad I’ve yet to decide. (This SA article was a recent read that made me think about this uncertain future).

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Genetic Testing: Part IV – Health Overview

Health Overview

Part IV – Health Overview

23andMe provides both an ancestry overview and a health overview based on its genetic testing services. Here I will discuss my health information results. I intend to share a much smaller sampling of results. My ancestry post was overall more complete (see Part II). There are 4 main categories of health information as seen below:

1. Health Risks 2. Inherited conditions 3. Traits and 4. Drug Responses

Health Overview

Health Overview from 23andMe

The above screen-shot is just the quick overview. I will review my results in each of these four categories below in more detail. As you can see, I have blurred out selected results. I have seen others be more forthcoming, but have decided against it at this point. I won’t explain my personal reasoning in length, but I suggest you see Part III for a brief overview of some questions surrounding genetic testing and some of the considerations used in my decision. Now onto the results.

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Personal Genetic Testing: Part III – A Word on Ethics

Part III – A Word on Ethics

butterflies

Butterflies at Deer Creek Canyon – Thienan Nguyen

Sharing personal information over the Internet is often not a thoroughly thought out decision with many ethical implicants. I’m certain many of us have made that mistake and gone on to regret it to some extent. Genetic information is arguably as personal as you can get. Yet many people don’t mind and are very willing to share this type of information (link). Do they realize how much genetic information could reveal? It can tell the story of your ancestral history, the likelihood of getting diseases, your response to certain drugs, and possible carrier status for sensitive health variants such as BRCA mutations, Tay-Sachs disease, phenylketonuria and many other health associated conditions. Genetic information guides some of the most important life decisions. Most notably, it guides the decision to partner with a particular person to have kids. But additionally, it affects decisions on what to do about higher or lower risks of a certain disease. It can guide what food and drink you consume, what drugs you take and how you use those drugs, and what lifestyle changes you pursue. Moreover, genetic information affects what your friends may think of you, and possibly even how your employer or insurance company may treat you.

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Reflective Writing 2014

Seal Family Sleeping on Rocks

Seal Family Sleeping on Rocks

Written 12/19/14

It was so hard to sleep because it was so easy to not feel sleepy. That’s what I remember most about that night. I had adrenaline rushing through my body in multiple waves. I had witnessed some terrible things in the OR and was anxious about what I was about to witness a few hours later – something very unnatural and so unfamiliar. That’s when the rush was its most intense, but throughout the night there would be multiple volleys bombarding me.

We were starting a new case in the afternoon and towards dinner time, our patient had a terrible complication. I could just remember thinking over and over again how people who need CPR have such a poor prognosis. I also kept thinking how privileged I felt being a witness to what I had just seen in the OR. Was this patient going to die in front of my eyes? The surgery was to remove a liver cyst. Midway through, after the cyst came out, she started having dangerously low blood pressures despite several anesthesia interventions. Anesthesia was rushing, making calls, giving fluid, blood products, tons of pressors and the patient kept dropping. The surgeons were getting more and more frustrated. I cannot recall the specific turning point, but could vividly remember the aftermath. She had gone into Vtach or Vfib. I vividly remember that somehow there were tons of people in the OR. They – the people who found their way into the room – made sure internal paddles were ready and closely monitored the heart rhythm, while the attending and resident traded off giving CPR. The brutality with which they forcefully pushed their body weight into the women’s chest was stunning. The fellow in the room told me to just leave after they somewhat stabilized the patient. Still it was a continuing struggle for her life. There was a chance that I could eventually go on my first organ procurement late that night with the transplant team, and thus I needed some rest. It was already late into the evening. One part of me wanted to see the conclusion of this drama, but I didn’t need to be there. I could somehow telepathically or cosmically understand that I should go. Not because I shouldn’t see this, or because I didn’t need to be there for this patient. I felt I should go because I was being a burden on the frustrated medical team. This patient deserved better in this situation.

I ended up attempting to sleep on a friend’s couch while I waited for the text later that night that would call me up to go see a dead patient. It was so surreal driving across town. I really did not know what to expect at all. I hesitantly changed into my scrubs and then began to find my way to the patient’s side. I remember not being able to comprehend that this was a dead patient. They looked, sounded like, felt like a very sick unconscious patient. The chest was rising below her gown with the ventilator, the monitors were beeping and whirring. I also made the mistake of asking one of the nurses about the patient. Knowing her story, even the slightest snippet of how she ended up in the hospital made her alive in my mind. We soon rolled back to the OR from the ICU room. That’s when the second wave of brutality I would witness began. We made a gigantic vertical laparotomy incision and slowly worked our way towards removing organs.

Wow, what a learning experience, seeing all that anatomy. The situation divulged into education. I was not seeing a human body, but an anatomy lesson. However, when it came time to close the body, and I was allowed to sew up the huge incision, I remember thinking again how privileged I was. I began to see this lifeless body with half their body cavity carved out as a patient again. I noticed how sewing this incision needed to be done carefully to line up her tattoos. I noticed how closing her up, she would again look whole. Finishing up, I needed to take a pause, not to sleep, but to think and process. However, the surgeons were finishing up on the back table and prepping to go transplant their next patient, telling me to make my way back to UCH. I switched my mind back to the patient who was going to receive the pancreas and kidney we had just procured. On my way back to UCH, morning traffic hit and I don’t know why I couldn’t process much on that hour-long drive. I did not need to sleep, but could only think about the next thing, and feel this buzz in my body… I wonder why I did not think about the patient coding in the OR last night or contemplate my feelings about death in light of the patient I met who was already “dead”. The whole night I didn’t feel the need to sleep. Maybe sleep allows you to reset instead of pushing forward with the next thing. Maybe sleep allows renewal for processing the day’s next challenge. However, I’ve slept many nights since and still don’t really know what to make of that intense night.

Personal Genetic Testing: Part II – Ancestry

Part II – Ancestry

ancestry

I grew up very much separated from my ancestors. My parents were immigrants from Vietnam and I was born in the United States. As many first generation Americans/second generation Asian-Americans can attest, you are assimilated into the culture in which you are born and often struggle to hold onto the identity passed down from your parents. When I sent in my DNA to get tested, I knew I would get some ancestry information, but brushed that off as an interesting and fun novelty to the 23andMe testing services. I had always thought the health information would be much more informative and interesting.

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