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Many senior physicians would have one think that young physicians are like their children: easily distracted and absorbed by the growing culture of electronic connectivity. These physicians fear that younger doctors are in danger of ignoring clinical responsibilities in favor of the social obligations that accompany these devices: social networking, instant messaging and texting. And yet, the rapid adoption of tablet computers (predominantly iPads) and smartphones among training physicians represents the entry into the next stage of information technology in medical care. Mobile technology now permits instantaneous access to the most up-to-date pharmacopeias, practice guidelines, clinical trials and reviews, and also electronic versions of medical textbooks, training videos, medical calculators, and in some cases, electronic medical records. The adoption of the last wave of technological evolution, electronic medical records, has proceeded at an achingly slow pace, particularly due to the high startup costs that necessitate initial investment by a well-funded organization such as a hospital, group practice, or a practitioner with seed money. How can one balance the benefits of connectivity with the detriment that might come from distraction?

As is the case with many other solutions to problems encountered in the practice of medicine, the answer must come from within: the cultivation of greater self-discipline. One of the most important skills learned by interns and later refined throughout residency is the art of time and expectations management. The expectations and time demands imposed on training physicians by program leadership, attending physicians, chief residents, nurses, case managers, hospital administrators, and (last but not least) patients and their families are inevitably unrealistic and conflicting. For example, training physicians are expected to be in multiple places at once, frequently criticized for poor attendance at mandatory educational conferences or teaching rounds whilst simultaneously performing a necessary invasive procedure for patient care or discharging several patients timed to deadlines set by the case manager. Pagers are constantly invading the conversational flow of patient interviews, sometimes with messages urgent and other times mundane, sometimes informative and other times meaningless (the classic number page). New parties now have a greater foothold in the domain of attention of the training physician through electronic connections: loves ones, friends, and family. Physicians, previously unanimously choosing “dedication” and “commitment” to their patients in the form of long, isolating hours at the hospital over the cultivation of family and non-professional friendships, now have new methods that help maintain connections to the outside world during the breaking down and remolding process of medical school and residency training, a process that often involved the shedding of relationships. The current task at hand for the young physician is to develop the most appropriate methods of triaging the demands for their attention: focusing first on immediate patient care needs, attending to urgent personal matters when time allows, and delaying less time sensitive matters to off-work hours.

Underlying the criticism, however, is an unsustainable proposition: that technology is the enemy of the patient-doctor relationship. Over time, the impression has developed that computers and information technology draw training physicians away from the bedsides of their patients. In reality, the major factors that remove physicians from the patient’s room are the exponential paperwork demands (produced at the computer) and the processing of greater amounts of clinical data (read on the computer, in the form of laboratory values, imaging scans, or consultant reports and physician notes). In other words, the technology itself isn’t the problem: technology merely facilitates the information and documentation overload demanded by a litigious and defensive culture of practice. Technology can, in fact, bring physicians back to the bedside: doctors can update patients on their most recent lab values, check and update medication lists, explain their medical conditions in the context of an MRI or CT scan displayed on a tablet, use three dimensional models to explain basic principles of the function and dysfunction of individual organs (such as the brain or heart), and show them where to find trusted medical information sources on the Internet. Eventually, more digital documentation such as progress notes and discharge instructions will be easily generated by physicians at the bedside, minimizing the time spent at computer bays. In due time, both senior and training physicians will need to face the true problems within the practice of medicine and the delivery of health care that are underscored by the adoption of new technology.

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I used to show my patients the phrase “The Saints are going to the bowl this year” to test comprehension; I could tell if they understood it if they laughed.

Well, the Saints did it. They went to the Superbowl. They won. We won. Who dat say New Orleans couldn’t come back, couldn’t win. WHO DAT, WORLD!

Five years ago, Dr. Paul Farmer was invited to be a guest lecturer for my Social Analysis course at Harvard College. The course opened my mind to the needs of the world with respect to public health and medicine. While my primary demographic interests in medicine are more oriented to domestic, urban, inner-city populations, one sentence in Dr. Farmer’s talk with respect to international medicine bothered me for quite some time. In an effort to call upon our sympathy and recruit motivation to support efforts to bring first world medicine and people to third world, resource-poor settings as Partners in Health was doing with Haiti, he said that in the end, it all comes down to one thing: mercy. At the time, my skeptical mind wondered, “Is this pseudo-religious/spiritual talk of mercy really going to convince a cynical, selfish human race to help those in need thousands of miles away?”

That was the year of Hurricane Katrina. Even in the chaos and the demonstrations of the worst part of human nature, the vast majority of humanity on display was that of grace under fire-and mercy. The past four years of my life as a listener of stories is filled with anecdotes like an easy-going counselor at my school jumping in his fishing boat to ferry neighbors and strangers from rooftops to safety, the sending of food to my parents and other survivors stuck in a flooded hospital from people all over the country, and the rapid response of firemen and policemen who flew down from New York City who felt they owed something to New Orleans, one of the cities that donated fire trucks and equipment to NYC after September 11, 2001. Despite the cynicism, so many people around the U.S. and around the world helped New Orleans rise out of the ashes to the city it is today: as fun-loving, free-spirited, and full of life as before.

Now, another group of people is in desperate need. To the vast majority of humanity that recognizes our oneness as a people, as one human race united by an everlasting desire to grow and find a better future, ignore the cynicism and skepticism and do what you can to help those suffering in the wake of a terrible natural disaster.

Stand with Haiti – Partners in Health

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

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).

Glancing across the headlines and tuning in to the sound bites of angry protesters, it is remarkable to witness the various demonstrations of the qualities that make us human. Unfortunately, these demonstrations often display the ugly sides of our nature: the twisting of truths into fear-inspiring slogans, the murder of Kansas abortion practitioner Dr. George Tiller, and the carrying of an unconcealed firearm to the President’s town hall meeting in New Hampshire (legal, yes, but is there any question of the message this man was trying to send?).

The subject of health care – tending to our sick – is called a “deeply personal issue” by some, but it may be more accurately described as a “deeply interpersonal issue”: our distant ancestors, the first humans, broke with thousands of years of prior evolution to abandon the doctrine of strict Darwinism (the survival of the fittest, every man for himself) to care for our injured and sick and thus achieve a different type of community existence. Who will argue with the brilliance of the past few millennia of sophistication, cultural and technological development, and vastly improved quality of life? In the process of healing and caring for others, humankind has learned to shed suspicion and fear in order to trust another to aid one’s return to health. And yet, although we might see ourselves as more evolved, more advanced, more free, many of us still tend toward our old habits: terrified of the involvement of others in personal matters (e.g. invasion of privacy), the need to dominate others in lieu of being overpowered (e.g. shouting down others), and the fear of losing that to which we are entitled (e.g. rationing).

Underlying the landscape of fear is the one thing as of yet unachievable by the American dream, the holy grail of our modern age: immortality. Our people, our society, is deeply afraid of death in all of its forms: we are unwilling to think of it, unwilling to face it, and unwilling to admit that it may one day visit us – our loved ones, our friends, our parents, our children, and ourselves. Is our species a victim of its own success in its everlasting quest to prolong life? Is death so unfamiliar, so foreign, a thoroughly unwelcome stranger in our lives? Coupling our deep-set suspicion of others, of authority, with the thought of discussing the topic of dying, we suddenly work ourselves into a frenzy over state-mandated euthanasia. Who would want to talk about dying? How can any discussion of death be benign? Such are questions asked by those who have never seen excruciating pain in the eyes of someone who cannot speak, someone suffering in a frozen tomb of a paraplegic body. Such are questions asked by those who have not reached a stage of life where they can imagine being satisfied with the years gone by, with a life lived as fully as one can ask for. Such are questions asked in a society where the process of dying is hidden and enclosed within four white walls and the fog of privacy. In our society, families talk about death about as much as parents talk to their children about sex. It’s not prohibited as in some cultures, but it’s not welcomed either. Perhaps no life is lived perfectly, no life has a perfect ending, but every story, every life has an ending. Is it too much to ask to allow those who wish for it to know what’s to come, to plan ahead so that the process of dying is not as prolonged or painful?

One of the most important roles of physicians is the role of the guide: we might not always be able to save a life, but we can guide someone through sickness and death, where most people fear to tread. We save lives when and where we can – and we’re usually very aggressive about it – but there are times when our life-saving techniques and technologies lead to more suffering and pain. There is no role for physicians in assisting or intentionally causing death, but there is definitely a role for physicians in advocating for a patient with respect to minimizing suffering and pain. Most people would agree that they wouldn’t want to live the rest of their lives on a ventilator, with a needle in the neck and one in each arm, with a plastic tube through one’s urethra and another into the rectum, and the lowest likelihood of ever leaving this state of existence while alive. Of all the people in the world who can comment on life and death issues, physicians are the only ones who know whether or not their methods and treatments can help a patient recover some quality of life, whether independent or supported. Who honestly thinks it is a good idea to discourage physicians from taking this role as guide, leaving patients to squander in confusion and despair in the last months or years of their lives without any direction?

We may imagine that we are invincible, that we are immortal, but our bodies are more fragile than we would like them to be. It is not without reason that it is common for medical students to go through a hypochondriac phase: how can we live life knowing the hundreds of debilitating mistakes we can make with each passing moment, the thousands of ways in which our bodies can deteriorate and fall apart? The most common and adolescent response at our disposal is also the first stage of the grieving process: denial (that we, and our loved ones, will die). Many of those making headlines today have reached the next stage: (irrational and misplaced) anger – at the government for trying to “get between me and my doctor,” at doctors and hospitals for trying to “tell my mom and dad that they won’t receive care at the end of their lives so that they can save money,” and at everyone else for “taking my health insurance away from me.” It may be a very long time before our nation, as a whole, comes to the last stage, acceptance: that we all must die, that death is not shameful, that dying is natural – some even argue for the “right to die.”

The human body is an amazing creation, but like all machines, it will eventually reach a stage when it is irreparable and unable to function meaningfully. Determining what is irreparable is in the hands of the doctor; determining what is meaningful is in the hands of the patient. Finding the overlap between these two is the purpose of end-of-life discussions. At this time, these discussions don’t occur frequently enough, and not enough patients have living wills or powers-of-attorney to clearly designate their wishes. What many people do not understand is that doctors are not required to “do everything”: a patient or his family may “ask for everything,” but physicians can proclaim life-preserving measures futile and discontinue medical support. There are, of course, measures in place to prevent this power from being abused, and furthermore, physicians are in the practice of saving lives: the default is to do everything. If a patient can communicate and is conscious and competent (e.g. not delirious, suicidal, etc.), there is no problem: he or she can clearly say “I want to live” or “I am ready to die” and we can continue to do our work either way. However, too often we enter situations where a patient temporarily or permanently unable to communicate is stuck in limbo in the Intensive Care Unit: unable to survive without aggressive (and either painful or uncomfortable forms of) life-support from ventilation, intravenous fluids and nutrition, etc. Out of habit, the children and spouses of these patients often want everything done to keep their loved ones alive – at any cost. Unfortunately, that cost is not only paid in dollars but also in pain and suffering for the patient.

The leap from providing Medicare coverage for end-of-life discussions between physicians and patients to euthanasia achieves a unique level of preposterousness.

“This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law,” House Minority Leader John Boehner, R-Ohio, and Rep. Thaddeus McCotter, R-Mich. said in a statement last month.

As emphasized by the legislators and the Obama administration, this measure is designed to promote these discussions, not mandate them. End-of-life discussions between physicians, patients, and their families are important in ways that most people inexperienced with death fail to comprehend: the current process of dying can be very emotionally painful and financially expensive when the desires of family members do not match the desire of a patient who cannot communicate (e.g. comatose, delirious, severely aphasic, etc.). The most sensitive and caring doctors I have worked with (who happen to be excellent arbiters of end-of-life discussions and decisions) hate situations where a spouse or child pushes to “have everything done” for a patient, resulting in months or years spent in a twilight daze with tubes and wires in every orifice and exposed blood vessel. Some of these physicians have submitted to me the observation that when critically ill patients are able to communicate their wishes in situations where the physician and the patient both understand that he is unlikely to recover an independent livelihood (away from advanced medical and nursing care), 99% of these patients will choose a comfortable, quiet and not prolonged death (withdrawing support). The hasty decisions of the spouse or child, then, seem to draw more from a selfish desire to “keep” the loved one “alive” in any shape or form. These situations occur very frequently, putting enormous financial strains on the family (after the prolonged hospitalization) and the health care system (thus overall reducing services that could be provided to other patients). In many ways, the advancement of life support technologies and techniques has outstripped our country’s philosophical and cultural maturation regarding death: we still want to live forever, but we don’t know what life is.

End-of-life discussions, when occurring outside of the setting of an acute and critical illness, should not be rushed, but they should be emphasized. Given the extreme shortage of time that physicians are able to provide to patients and their families, a great deal of medical care surrounds activities that are billable. Adding a financial incentive to offering end-of-life discussions can make these discussions more of a reality when desired.

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