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Monthly Archives: August 2009

There has been a lot of talk about health care reform over the past month: much of the information has been repetitive, not based in fact, or purely sensationalist. However, there have been some well-written and meaningful pieces that have emerged above the din. I’d like to highlight a few of them here:

August 9, 2009 – NY Times – Robert Pear and David Herszenhorn – “A Primer on the Details of Health Care Reform”

This is a relatively concise and unbiased article covering some of the main issues of the Congressional health care reform proposals. It might be slightly outdated, but it’s hard to tell what real changes, if any, have been made since Congress is currently on recess. Various pundits and politicians can spread rumors about changes until they’re blue in the face, but it won’t mean much until the paperwork is presented again.

August 23, 2009 – Washington Post – T.R. Reid – Five Myths About Health Care Around the World

This article was passed along to me by a friend of mine who is much more internationally aware and better traveled than I am. It provides a brief education about some of the most common misconceptions about health care systems in other developed nations including the prevalence of socialized medicine and the overall quality of American health care compared to other systems. There are, in fact, several systems based entirely on (regulated) private insurance that have better health outcomes than the U.S.

One point I have stated previously and am always glad to reiterate is that many people in America fail to distinguish between medical care and health care: the U.S. likely has the best medical training, technology, and physicians (at least, on average, the best trained), but medical care is only one component of health care. Health care incorporates medical care, nursing care, rehabilitation, social work and case management, payment and insurance, drug and biotechnology development, hospital and systems administration, and perhaps most importantly, patient involvement and responsibility. In general, it appears that liberals seem to find fault in everything but patient responsibility, while conservatives find fault in nothing else but patient responsibility.

August 26, 2009 – Blog “Mind, Soul, and Body” – Repost: Medical Care, right or privilege?

One of my fellow bloggers reposted a piece he wrote last year. Although I don’t agree with everything in the post, there was a passage that I felt was particularly meaningful:

There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.

The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.

I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.

August 7, 2009 – Kaiser Family Foundation – Side-By-Side Comparison of Major Health Care Reform Proposals

Finally, if you want to actually be truly informed about the proposals being proposed by various sectors of Congress, here is a consolidation of the information currently available as collected by the Kaiser Family Foundation, a nonpartisan health information group. One thing you will note is that President Barack Obama has not proposed a health care reform plan: in many ways, it is very silly for people to keep referring to a single health care reform proposal as “ObamaCare.” It is definitely a worthy argument that President Obama could, or perhaps should, take a stronger role in directing health care reform, and a few members of Congress have asserted this. On the other hand, there are multiple plans currently being proposed, all of which have various advantages and disadvantages, benefits and flaws. Instead of reading a thousand pages of triple-spaced legal-ese (the Dingell-House Democrat bill H.R. 3200), this table is 44 pages long. A shorter version provides details on the Senate HELP committee and House Tri-committee proposals, the main proposals being debated currently. Educate yourself. “Fight the stupids.” – Maple Street Bookstore Bumper Sticker

Since I first started writing about converting my iPod Touch to a medical PDA early in 2008, the iPhone and the iPod Touch have become ubiquitous in the hospitals where I work. It would be an extraordinary challenge to walk through the hospital without spotting a nurse, medical student, resident, or attending physician tapping their fingers on the touch screen of an iPhone or iPod Touch. Much like the wooden wands carried by wizards and witches in the J.K. Rowling’s world of Harry Potter, these items appear indispensable and multipotent, making everyday tasks much easier (like converting Celsius to Fahrenheit or calculating Glasgow Coma Scale scores), augmenting the practice of medicine with rapid information access (prescription medication dosing, information on obscure syndromes and clinical signs), and occasionally saving one’s skin (e.g. putting together a rounds presentation with five minutes notice, not that this has ever happened to me).

Over the past year, my usage of these devices has evolved considerably. Here is an overview of how I am currently using my iPhone 3GS, in descending order of most frequent daily use:

Communication

iPhone: Although I miss Verizon’s superior network in the New Orleans hospitals where I work, the AT&T network seems sufficient in most locations except the operating rooms and certain central corridors. For better or worse, Tulane Medical School is not interested in providing its students with pagers, so my cell phone has been my primary means of communication with my team.

Text Messaging: My Stroke Service team and my Surgery teams were very avid texters – I probably sent and received at least 10-20 text messages each day.

E-mail: Everything regarding medical school administration and course administration revolves around e-mail, including first-come-first-serve picks for clerkship sites. Having constant access to e-mail has changed from an addiction to an essential condition of life.

Calculation and Conversion

Mediquations – There are many medical calculators available, but I have stuck with one of the original apps. The creator, a medical student, has updated the app frequently with many new equations, resulting in a fairly comprehensive listing that saves one the effort of looking up a dozen different scales or equations on the Internet. Some of the ones I use most often are: Glasgow Coma Scale, NIH Stroke Scale, Temperature Conversion, and the Modified Rankin Scale (you wouldn’t guess that I’m interested in Neurology, would you?).

ConvertBot – I picked up this app when it was free. Although several of the functions are available in Mediquations, I love the aesthetic of the app which turns my iPhone into a little robot with a touch wheel that can rapidly convert units for temperature, pressure, time, volume, speed, fuel, currency, etc. I guess it mostly has a spot on my device for its cool factor.

Writing Prescriptions

Epocrates Rx – Although I have not used the Medscape drug database yet, the Epocrates database is much more comprehensive than the Skyscape database which seems to lack information on adverse effects. One of the main disadvantages of the Epocrates Rx database on the iPod Touch and earlier versions of the iPhone was its speed, but the iPhone 3GS completely eliminates that barrier to effectiveness. Along with the Interaction Checker and Pill ID (pictures of the pills, and searchability by the patient’s description), Epocrates Rx remains an essential part of my medical PDA’s repertoire.

$4 Formularies – At this time, Target, Walmart, Kmart, Walgreens, Rite Aid, and CVS all have reduced price formularies that are very useful when prescribing generic medications for uninsured or underinsured patients. These are available at GenericMedList.com. And as a reminder, the vast majority of scientific evidence shows that generic medications are as effective as their brand name counterparts. However, the manufacturing and monitoring processes are marginally different, and some doctors will still prefer that their patients use brand name medications for some medications that are difficult to manage (e.g. warfarin) in order to avoid introducing another confounding factor.

Searching the Tomes of Medical Knowledge

• Sabatine’s Pocket Medicine – I have the red binder-paper version of this useful resource, but I have filled the little red binder with so many of my own clinical notes that I was happy to find a way to reduce the clutter in my white coat pockets. Of all the books to have on the wards during clinical rotations, I have found this book to be the most concise and useful across the board (I used it extensively during Internal Medicine and Family Medicine, and it also proved useful for consultations during Neurology, Ob-Gyn and Peds). Five years from now, I still expect to be referring to this book (most likely on the tenth version of the iPhone).

Massachusetts General Hospital Handbook of Neurology – This one was a very recent acquisition through Skyscape, an old name in the PDA book-porting business. I also have this book in paperback but again was excited to reduce the load in my pockets. The best part of the Skyscape format is that the book’s text is searchable, allowing for rapid retrieval (which is so important to maintaining efficiency on the wards). However, the tables and diagrams are not easily resizable when they extend beyond the screen’s borders: it is possible to zoom in, but using the “pinching” technique on the iPhone/iPod Touch also resizes the viewing window (making this maneuver unhelpful). Nonetheless, Skyscape, under pressure from users, has provided the option of allowing one to purchase full texts at full price as opposed to 1-year subscriptions.

Wikipanion – Although I do not approve of using Wikipedia as a research resource (e.g. citing Wikipedia = poor form), it sometimes proves to be the fastest method to find obscure information with a reasonable degree of quality (i.e. concise and direct explanations) and accuracy. For example, what are you going to do if your attending mentions Gradenigo’s Syndrome during rounds? Or what if your resident is talking about something called “Salaam spasms” that sounds a lot like West Syndrome but you can’t remember if they’re related? Like Google, Wikipedia is still useful when you need to cast a wide net to capture a piece of information you’re not familiar with before figuring out where you can find a more reliable resource.

Eponyms – Like Wikipanion, the free student’s version of Eponyms has its uses, particularly when faced with an old-fashioned (or just ridiculously brilliant) attending who likes to use the original names for various diseases and signs. For example, when your attending talks about the Monro(-Kellie) doctrine, she’s not talking about preventing further European colonization in the Western hemisphere.

Diagnosaurus – This little app from Unbound Medicine is a great, zippy resource; I just haven’t had the pleasure of using it much yet. Unfortunately, this app arrived after my Internal Medicine clerkship where the process of differential diagnosis is revered and protracted for the sake of education. I suspect it will become very useful once again when I do my preliminary year in Internal Medicine.

Brushing Up on Skills

Instant ECG – This program from iAnesthesia is well-designed and beautiful: I love the examples of real ECGs they provide as well as the video visualizations of the various arrhythmias (somehow, seeing the rhythms drawn out helps me remember them). I don’t consult it often on the wards, but I hope to keep referring back to it so until I know the major arrhythmias by heart.

Pocket Medical Spanish* – This program is another one I want to use more but haven’t had as many opportunities to recently. I like that the program facilitates communication between doctors and patient both verbally and visually (with enlarged versions of the Spanish phrases). I think this will become more useful when I do my Emergency Medicine clerkship. [Note: This is one that I actually received for free from the creator. It has also been one of the more expensive medical Spanish apps.]

Netter Neuroscience Flash Cards – This program has Netter’s beautiful neuroanatomical illustrations, but I find that it doesn’t always have the detail that I desire. Nonetheless, it is a useful resource when revisiting neuroanatomy during visits to Radiology or from Neurosurgery.

Everything Else

Things – Combined with the desktop application, this program is a wonderful GTD (get things done) solution that helps me keep track of my long-term tasks (e.g. the millions of things I need to do to apply to residency, to prepare for my wedding, etc.).

Groups – I just recently discovered this contacts management program which has provided me with a much needed service: helping me remember birthdays. Its main functionality allows grouping contacts (from the iPhone’s built-in app) based on user-defined categories or through “smart groups.” One of the neat features of this app is that you can e-mail entire groups, making it much easier to remember to invite everyone to dinner, to organize meetings, etc.

Clock – I like waking up to music, and the iPhone’s app and speakers makes this luxury possible. Maybe it’ll make waking up in the call room for prerounds slightly more palatable.

Tweetie, Facebook – Well, I need some way to stay connected with world beyond the white walls of the hospital. By the way, you can follow me (and my shorter thoughts, observations, and rants about medicine and related topics) on Twitter at LesterLeung.

WordPress – The engine for my weblog! I have posted or written drafts a few times while traveling, and it makes it easier for me to approve and reply to comments.

Shazam – The name even sounds like magic. I mean, it runs on magic right? How else can it identify the songs playing on the radio or in stores? Inconceivable!

Pandora – A radio station that actually plays good music based on songs and artists I like? And actually does an amazing job of selecting a decent variety like a good mix CD? If that’s not magic, I don’t know what is.

NPR News – While I prefer to use Google News to provide a broad range of news sources, I like that the NPR News app has streaming audio that I can listen to when driving to and from work. Sadly, radio in New Orleans sucks. A lot.

Camera – Not that other phones don’t have cameras, but I love that the iPhone has so many options for data transfer from the basic iPhoto synchronization to various apps that allow one to upload photos directly to online social sites or photograph storage sites. And it records video. Vraiment whoa.

* Disclosure: I received Modality’s Pocket Medical Spanish for free as a tester. There are numerous medical Spanish apps available for the iPhone and iPod Touch, but this is the only one I have tried so far (and thus cannot comment on its superiority or inferiority to other products).

When intelligent discussions about politics ensue, the fundamental basis of the discussion is always a question of human nature: it all comes down to how we see the people we are not, “the others.” Conservatives bemoan the creation of a welfare state, and they worry about the old adage about the hungry man. If you keep giving the man a fish, he will never learn to care for himself independently and will forever be a beggar (of course, conservatives in this country don’t really care much about teaching the man how to fish either). Liberals tend to have a wider, more diffuse set of reasons for helping the hungry man, but for them, it is always a question of mercy: for whatever reason, whether self-serving or mutually beneficial or truly altruistic, that man needs the help we can provide.

At face value, the conservative argument seems more compelling and solid. It is simple and logical. Conservatives hate the idea of their tax dollars going to pay for the next box of cheap wine that the bum on the corner is hustling for. Unemployed. Homeless. Dependent. Worse still, perhaps, are the thousands of Americans who could work, but are instead “gaming” the system through “disability,” perpetual “self-inflicted” impoverishment, etc. (These words come straight from the mouths of 15-year-old, Polo-clad teenagers at my high school responding to the question “Would you pay more in taxes for this? Why or why not?” posed by a history teacher.)

However, this fundamental argument lacks an understanding of the impact of sickness, and it is weakly supported by the conveniently muddled “chicken and egg” structure of its argument. Which came first, the poverty or the welfare system? In other words, knowing that there are people who abuse the welfare system, would the same amount of poverty exist if there were no welfare system to perpetuate it? Would providing more welfare worsen the problem or help it? If the government pays for health care for poor people who get sick, would those poor people keep themselves suspended perpetually in poverty to keep reaping the system for benefits? The answer: it doesn’t matter if the chicken or the egg came first. The solution: eliminate one of them – in this case, eliminate the burden of disease on the impoverished, those who cannot afford private health insurance.

Unlike other burdens of poverty, sickness is pervasive: it affects the mind and its ability to concentrate on working hard and keeping things together, it affects the will to keep fighting for a better life it affects the body and its ability to handle the stresses of labor and discomfort, and more practically, it affects the number of days we work, the type of work we can do, and our performance each day and in trials for career advancement. If you don’t have your own home, you can still try staying with friends or relatives, share housing with roommates, or stay in public housing or shelters. If you don’t have a car, you can still ride public transportation (sometimes) or try to find work close to home. However, if you don’t have health – the basic ability for the body and mind to function normally in our society – then you are subject to the greatest disadvantage and means for disqualification from standard routes for financial stability, independence, and success.

If only our society can remove the inequity of health care disparities, then maybe we can finally come a great deal closer to achieving the equality of opportunity our forefathers sought to promote and protect (and take seriously the typical fallback conservative criticism that people aren’t working hard enough to help themselves).

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