Ok, so if you check this you've probably already seen this on Facebook or Google plus, but just in case there are people who look here who aren't on one of those sites:
This Google doc is an open letter I sent to President Obama, and my congressmen and senators. It's about the debt crisis and recent proposed medicare funding changes, which have been inappropriately linked by devious republicans. I've been upset about these issues. (See 2 posts ago.) It's long, but I hope some of you might read it and find my perspective interesting.
https://docs.google.com/document/d/1fbzqePmDkogV-LT0IMqDBwoKVBVaL-NfkLSMuGufMoc/edit?hl=en_US
Thursday, July 21, 2011
Monday, July 18, 2011
Planning a trip outside my comfort zone.
I came to Laos with few expectations. Not none, but I really tried to come with an open mind, so that I’d be able to enjoy my time here with lots of surprises - pleasant and odd - but few disappointments. However, if you had asked me before leaving whether I would get involved in helping to organize resident research while I was here, I would have said “No way!” I like research, don’t get me wrong. It guides my practice, and I respect people who are inspired to plan, organize, and complete valuable research projects that add to our collective knowledge base. But I’ve never had the urge to get involved in it before. Sure, I did microbiology research in college - it was fun - there are days when I miss my micropipetter and gels. (Usually these days correlate with some interpersonal relationship/communication issue at work when a patient or colleague is frustrating me, and they have been extremely uncommon since coming to Laos.) But I don’t really miss academic science - the idea of spending my entire career studying a single bacteria, or even a handful of them, just never really grabbed me. And I’m no more a clinical researcher than I am an academic scientist. I don’t think I really have the focus, drive, or organizational skills necessary to make research an integral/important part of my career.
So why am I e-mailing people left and right to help the residents organize a group senior research project? Yes, residents here do research. In fact, they’re required to complete a research project before graduating. This seems pretty crazy. Lots of american residents do research, of course. They tend to be the ones applying for competitive fellowships, and they may take up to 2 months off during residency to work on it. But it’s not a graduation requirement. Our residents get 2 weeks to do theirs. (Really they get a month of vacation/research.)
Unfortunately, they start their class on how to do research in September-October of their 3rd year, and then they’re suppose to write, revise, and have approved a proposal. So most of their actual work takes place in a few months - January-April/May - which limits the amount of valid data they can collect whether they’re doing a cross-sectional survey of behaviors related to a chronic disease or trying to chart review each patient that comes in blood cultures positive for a specific pathogen to find common presentations that should prompt provincial doctors (who don’t have access to cultures) to think of, and treat, that bacteria. This all seems kind of silly to me - but the requirement is theoretically to be sure that residents understand some basic stuff about how good research is done. In a country with very little data about what’s happening here now currently, and where there are lots of people trying to do research who might approach the residents for help once they return to their provincial hospitals, I guess it does make sense for them to have some basic understanding. After all, there is a really good chance they will be asked to participate in research, so it would be good if they had some way to assess whether to do it. But in practice, they are super stressed about finishing their projects, which tend to be small and maybe don’t contribute much to the knowledge base here.
However, this past year, Amy included the pediatrics residents in her Blue book and Oxygen projects, so all the peds residents worked on a component of a bigger project. They still had to understand the same stuff to do and write up their component, but they were able to work together more, with some support from Amy, and the data they gathered will likely be very useful and relevant to Laos. This excellent example is how I came to be e-mailing people about a group project with subcomponents for each of the 3rd year residents this year.
My idea is much less useful than Amy’s project - but it will address a topic I’m interested in - dementia - (Thus the inspiration) and if we can organize it they should come out of it with one useful assessment tool. Chronic disease is under-recognized here as well, so it might generally highlight some neglected topics as well. Now I ‘just’ have to get permission from the university, the medicine teachers, the creator of the test I want to adapt to Lao language and culture, work with the residents to map out a plan, and arrange good support for the residents when I finish work in September. In other words, what have I gotten myself into? We’ll see. . .
Last week at Setta I saw a young woman with fever and pelvic pain. She happened to also be an albino - almost certainly with occulocutaneous albinism, a disease which I only learned about when I searched the literature for “nystagmus albinism.” Her pelvic pain complaint ended up leading to a diagnosis of vaginal candidiasis. Unfortunately, she also had oral candida, and a herpes simplex virus outbreak on her face. And a folliculitis on her neck. And a resolving vasculitic looking rash on her legs. An unpleasant cornucopia of medical problems for a woman so young, and we kept our visiting dermatologist busy for several minutes figuring it all out. She was ‘not married’ but after encouraging my residents to ask again, we determined that she did have risk factors for HIV - she was sexually active. And all of the above problems in a 22 year old sexually active woman are from HIV until proven otherwise. The residents agreed she needed testing, as did the ID doctor when asked Friday afternoon. Unfortunately, the on-call person over the weekend either sent or allowed her to go home, so we’ll never know for sure. Tonight, I’m praying we were wrong.
So why am I e-mailing people left and right to help the residents organize a group senior research project? Yes, residents here do research. In fact, they’re required to complete a research project before graduating. This seems pretty crazy. Lots of american residents do research, of course. They tend to be the ones applying for competitive fellowships, and they may take up to 2 months off during residency to work on it. But it’s not a graduation requirement. Our residents get 2 weeks to do theirs. (Really they get a month of vacation/research.)
Unfortunately, they start their class on how to do research in September-October of their 3rd year, and then they’re suppose to write, revise, and have approved a proposal. So most of their actual work takes place in a few months - January-April/May - which limits the amount of valid data they can collect whether they’re doing a cross-sectional survey of behaviors related to a chronic disease or trying to chart review each patient that comes in blood cultures positive for a specific pathogen to find common presentations that should prompt provincial doctors (who don’t have access to cultures) to think of, and treat, that bacteria. This all seems kind of silly to me - but the requirement is theoretically to be sure that residents understand some basic stuff about how good research is done. In a country with very little data about what’s happening here now currently, and where there are lots of people trying to do research who might approach the residents for help once they return to their provincial hospitals, I guess it does make sense for them to have some basic understanding. After all, there is a really good chance they will be asked to participate in research, so it would be good if they had some way to assess whether to do it. But in practice, they are super stressed about finishing their projects, which tend to be small and maybe don’t contribute much to the knowledge base here.
However, this past year, Amy included the pediatrics residents in her Blue book and Oxygen projects, so all the peds residents worked on a component of a bigger project. They still had to understand the same stuff to do and write up their component, but they were able to work together more, with some support from Amy, and the data they gathered will likely be very useful and relevant to Laos. This excellent example is how I came to be e-mailing people about a group project with subcomponents for each of the 3rd year residents this year.
My idea is much less useful than Amy’s project - but it will address a topic I’m interested in - dementia - (Thus the inspiration) and if we can organize it they should come out of it with one useful assessment tool. Chronic disease is under-recognized here as well, so it might generally highlight some neglected topics as well. Now I ‘just’ have to get permission from the university, the medicine teachers, the creator of the test I want to adapt to Lao language and culture, work with the residents to map out a plan, and arrange good support for the residents when I finish work in September. In other words, what have I gotten myself into? We’ll see. . .
Last week at Setta I saw a young woman with fever and pelvic pain. She happened to also be an albino - almost certainly with occulocutaneous albinism, a disease which I only learned about when I searched the literature for “nystagmus albinism.” Her pelvic pain complaint ended up leading to a diagnosis of vaginal candidiasis. Unfortunately, she also had oral candida, and a herpes simplex virus outbreak on her face. And a folliculitis on her neck. And a resolving vasculitic looking rash on her legs. An unpleasant cornucopia of medical problems for a woman so young, and we kept our visiting dermatologist busy for several minutes figuring it all out. She was ‘not married’ but after encouraging my residents to ask again, we determined that she did have risk factors for HIV - she was sexually active. And all of the above problems in a 22 year old sexually active woman are from HIV until proven otherwise. The residents agreed she needed testing, as did the ID doctor when asked Friday afternoon. Unfortunately, the on-call person over the weekend either sent or allowed her to go home, so we’ll never know for sure. Tonight, I’m praying we were wrong.
Sunday, July 17, 2011
Politics and Health
Skip this post if you're tired of hearing about American politics particularly the ongoing discussion of health care funding.
I’m a bad blogger. It’s just that things here have been busyish, and I feel like there’s been so much to say that it’s been hard to sit down and just start writing, because then I’ll have to choose what to talk about, and inevitably some important / interesting stuff will be left out.
First, a few words about American politics: it is very tempting for me to completely ignore it. I’m not at home. It’s not my problem right now. I don’t have to seek out information on what’s going on; (because so many of my friends are actively thinking and talking about what’s going on, posting comments and articles on facebook, blogs etc.) but it also wouldn’t be hard for me to ignore it either. In residency I pretty much did that. Taking care of my patients, my team and myself was all I could worry about. I didn’t have the time or emotional energy to invest in worrying about our national health policy, or much other than how I would vote in elections for congress, the senate, and the presidency. But while things have been busy here, I’m still working a normalish work week - in the 40 hour range - and the emotional burden of patient care is much less as I am not directly responsible for any patients. Don’t get me wrong, I still care about these patients and I want to make sure they get the best possible care they can with the resources available, while raising the overall standard of care and trying to get better/ more resources. But I don’t come home and have nightmares or trouble sleeping because of worry that I forgot to order something or missed something the way I did in residency. I come home and look things up if it occurs to me that I should have thought of something else, or if there’s something I want to be able to explain better the next day, but the connection is different. So I have some time an emotional energy to devote to something else, and as a relatively well educated, thoughtful citizen, perhaps the current American political situation should be one of the things I choose.
The incredible amount of time and energy being put into talking about the republican challengers for Obama is distressing to me. The election is more than a year away still, and I think the earlier and earlier start of campaigning for the presidency is both distracting from the very real issues and problems we should be talking about, and skews this discourse when it does happen. The candidates themselves are distressing as well - it seems there is no end in sight to the dominance of the extreme christian right’s focus on ‘conservative values’ and trying to force all Americans to live by them. I would be so delighted to see an “old-school,” small government, civil liberties preserving republican have an actual chance at the nomination that I might forgive them for dominating the discourse for the next 16 months. There are so many real, important problems we could be fixing in that time - of course health care funding being the one nearest and dearest to my heart. In some ways, I’m glad we are finally talking about this in the budget negotiations. However, the direction the debate has taken is also distressing. Cutting funding even further for medicare and medicaid, and especially the proposal to cut GME (Graduate medical education) funding is an incredibly backwards approach to the problem. And I don’t understand why the democrats continually allow the republicans to set the tone and topics available for discussion. Yes, American health care is the most expensive in the world (and not the best quality for all patients) Should we be able to do more with the same amount of money? Absolutely. Should we be able to do the same amount with less money? Absolutely. Should we be talking about whether we want to do more (cover everyone with basic, decent quality care) or the same amount for less? Absolutely. Should we be talking about cuts in corporate welfare for big pharma and maybe malpractice reform, and definitely how much money the people at the top of HMOs and insurance plans are making? Absolutely. Should we be talking about who and how much we pay for various services and what they actually cost and are worth? Absolutely. Should we be cutting funding across the board, most of which goes to pay for the poorest patients, and much of which goes to primary care doctors, nurses, and ‘safety net hospitals’? No.
This is a nuanced, complicate issue and it should be approached as such. Apparently none of the people I elected have the guts to stand up and say that, though, which makes me sad. Residency doesn’t cost hospitals money, it saves them money they would otherwise pay staff physicians to do the same work. Does that mean we can cut GME money without repercussions? No - hospitals with residency programs tend to be those same ‘safety net’ hospitals that are taking care of (often very sick) uninsured or underinsured patients. That money isn’t going into the pockets of the hospital administrators or attending doctors, its going to help pay for high quality care for people who need it. Residents learn from taking care of these patients, everyone wins.
I can’t claim to know how to fix our system. I don’t know how to answer the questions I asked above. After spending 3 years intimately enmeshed in the American health care system and having this year to step back and look at the (bigger) picture and think about how my experiences relate to the bigger issues, all I know is that things are really, really broken, and that this is a complicated, nuanced issue that will take lots of critical thinking, problem solving, compromise from all parties, time, and trial and error to fix. However, it is clear that our leaders beating each other over the head with the cudgels of “you’re wasting money” and “you hate poor people” isn’t helping anything.
Umm, that turned into quite a few words. I think I shall post this with the promise to write another post soon that will have less rant and more cools stories about what’s been going on recently in Laos.
I’m a bad blogger. It’s just that things here have been busyish, and I feel like there’s been so much to say that it’s been hard to sit down and just start writing, because then I’ll have to choose what to talk about, and inevitably some important / interesting stuff will be left out.
First, a few words about American politics: it is very tempting for me to completely ignore it. I’m not at home. It’s not my problem right now. I don’t have to seek out information on what’s going on; (because so many of my friends are actively thinking and talking about what’s going on, posting comments and articles on facebook, blogs etc.) but it also wouldn’t be hard for me to ignore it either. In residency I pretty much did that. Taking care of my patients, my team and myself was all I could worry about. I didn’t have the time or emotional energy to invest in worrying about our national health policy, or much other than how I would vote in elections for congress, the senate, and the presidency. But while things have been busy here, I’m still working a normalish work week - in the 40 hour range - and the emotional burden of patient care is much less as I am not directly responsible for any patients. Don’t get me wrong, I still care about these patients and I want to make sure they get the best possible care they can with the resources available, while raising the overall standard of care and trying to get better/ more resources. But I don’t come home and have nightmares or trouble sleeping because of worry that I forgot to order something or missed something the way I did in residency. I come home and look things up if it occurs to me that I should have thought of something else, or if there’s something I want to be able to explain better the next day, but the connection is different. So I have some time an emotional energy to devote to something else, and as a relatively well educated, thoughtful citizen, perhaps the current American political situation should be one of the things I choose.
The incredible amount of time and energy being put into talking about the republican challengers for Obama is distressing to me. The election is more than a year away still, and I think the earlier and earlier start of campaigning for the presidency is both distracting from the very real issues and problems we should be talking about, and skews this discourse when it does happen. The candidates themselves are distressing as well - it seems there is no end in sight to the dominance of the extreme christian right’s focus on ‘conservative values’ and trying to force all Americans to live by them. I would be so delighted to see an “old-school,” small government, civil liberties preserving republican have an actual chance at the nomination that I might forgive them for dominating the discourse for the next 16 months. There are so many real, important problems we could be fixing in that time - of course health care funding being the one nearest and dearest to my heart. In some ways, I’m glad we are finally talking about this in the budget negotiations. However, the direction the debate has taken is also distressing. Cutting funding even further for medicare and medicaid, and especially the proposal to cut GME (Graduate medical education) funding is an incredibly backwards approach to the problem. And I don’t understand why the democrats continually allow the republicans to set the tone and topics available for discussion. Yes, American health care is the most expensive in the world (and not the best quality for all patients) Should we be able to do more with the same amount of money? Absolutely. Should we be able to do the same amount with less money? Absolutely. Should we be talking about whether we want to do more (cover everyone with basic, decent quality care) or the same amount for less? Absolutely. Should we be talking about cuts in corporate welfare for big pharma and maybe malpractice reform, and definitely how much money the people at the top of HMOs and insurance plans are making? Absolutely. Should we be talking about who and how much we pay for various services and what they actually cost and are worth? Absolutely. Should we be cutting funding across the board, most of which goes to pay for the poorest patients, and much of which goes to primary care doctors, nurses, and ‘safety net hospitals’? No.
This is a nuanced, complicate issue and it should be approached as such. Apparently none of the people I elected have the guts to stand up and say that, though, which makes me sad. Residency doesn’t cost hospitals money, it saves them money they would otherwise pay staff physicians to do the same work. Does that mean we can cut GME money without repercussions? No - hospitals with residency programs tend to be those same ‘safety net’ hospitals that are taking care of (often very sick) uninsured or underinsured patients. That money isn’t going into the pockets of the hospital administrators or attending doctors, its going to help pay for high quality care for people who need it. Residents learn from taking care of these patients, everyone wins.
I can’t claim to know how to fix our system. I don’t know how to answer the questions I asked above. After spending 3 years intimately enmeshed in the American health care system and having this year to step back and look at the (bigger) picture and think about how my experiences relate to the bigger issues, all I know is that things are really, really broken, and that this is a complicated, nuanced issue that will take lots of critical thinking, problem solving, compromise from all parties, time, and trial and error to fix. However, it is clear that our leaders beating each other over the head with the cudgels of “you’re wasting money” and “you hate poor people” isn’t helping anything.
Umm, that turned into quite a few words. I think I shall post this with the promise to write another post soon that will have less rant and more cools stories about what’s been going on recently in Laos.
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