•April 15, 2013 • 1 Comment

At hospital committee meetings these days, the disconnection between medicine as once taught by prerevolutionary physicians and medicine as now codified by compliance-minded, MBA-qualified “medical directors” is startling; the author feels as though she arrived at such meetings by time machine.

In the new “integrated delivery systems,” the organizational chart reigns. Physicians are boxed into defined categories, next to the bottom of the chart, just above the patients; together with the patients (now known as “covered lives”), they form the “medical loss ratio.”

It is a world of paradox. Talk of “ethics” generally means talk of “resource allocation,” often by means once called unethical. One drowns in information, but the key of knowledge is lost. Facilities and personnel are present in excess, and yet they are scarce.

The scarcest item of all appears to be the clinician’s time. Thirty seconds may be too long to spend searching for a reference. In some settings, there may be no time to look in the left ear if only the right one hurts, much less to listen to the patient’s grief or despair. And when can today’s managed provider stop and reflect?

Concepts are imported from industry, such as “six sigma quality”–the goal to reduce errors below 6 standard deviations from the mean of a normal distribution. This means that all but 3.4 out of 1 million patients are supposed to meet a certain indicator, such as timely Pap smears or mammograms, regardless of individual needs and desires.

Quality experts in industry do recognize that one cannot control outputs without controlling inputs–a fact that health policy experts seldom acknowledge. But even if we could control the behavior of patients and physicians, there remains the problem that human beings are not stamped from an industrial die. Even if not totally unique in genetic endowment, each human being has had a different interaction with the world.

As the art of medicine is being lost, the science is also threatened. “Evidence-based” medicine is coming to mean based on the consensus of a committee of experts: the Prussian Geheiin Rath with many heads (and no heart). Clinical reasoning is replaced by following a practice “guideline” from one prescribed information bit to another, and a diagnosis means a number with five significant digits (never mind that the first one is dubious) attached to an appropriate procedure code. The very altar of truth–the autopsy table–is being dismantled.

It is telling that bureaucratic quality assessment is almost always based on process (read compliance) measures such as number of blood pressure determinations or prescriptions for the medication du jour, not outcome measures such as all-cause mortality or ability to function independently. Regardless of the reading on the “continuous quality improvement” dashboard, almost everyone on the front lines of patient care believes that American medicine and health are in decline.

…[Even so,] Medicine is a living thing that will survive and flourish, despite the dinosaurs of “health care delivery,” and long after inhuman systems fail. There are still students who aspire to be physicians, not providers, gatekeepers, resource managers, or box-checkers. There are still those who consider medicine to be a human and a humane endeavor, not an industry.

– Dr. Jane Orient

From the preface to the Fourth Edition of Sapira’s Art and Science of Bedside Diagnosis


•April 15, 2013 • Leave a Comment

From the day when the first members of councils placed exterior authority higher than interior, that is to say, recognized the decisions of men united in councils as more important and more sacred than reason and conscience; on that day began lies that caused the loss of millions of human beings and which continue their unhappy work to the present day.

– Leo Tolstoy

On Doctoring

•January 7, 2013 • 1 Comment

People still ask me (yes, even this far removed from medical school interviews) why it was that I wanted to become a doctor. In college I’d thought of becoming a writer, but my girlfriend told me I was impossible to read, which apparently was also sufficient grounds for breaking up.


•August 12, 2012 • 2 Comments

I write neither often enough nor seriously enough to be considered a writer. Or a “real writer.” I’m not even an accomplished reader. And yet, when I read other writers, especially when they describe the way in which they write, or how they write, or why they write, I feel a distinct connection. Like somehow I am part of that community. I’m starting to feel this way amongst doctors; this is both pleasant and expected. But doctoring itself does not often lend itself to personal expression. (Or at least it shouldn’t. There must be some sort of ethics statement by the AMA about this.) Sometimes I feel traces of this around earnest musicians, but when they become excited, again I become an outsider.

I enjoy reading fiction most of all, but I find it incredibly difficult to write. I can’t be bothered to stick to a same character or plot for any length of time. I think it would be good for me to try, but because I can’t sit down and systematically do it (at least, not with the real life schedule that I also must consider), I’ve started collecting things to eventually use in a bigger piece. They’re mostly nonsense things: word combinations that I find amusing, descriptions of objects or events that stick in my head, poignant couplets, or thoughts that deserve further exploration. Yes, I’m writing a novel, haven’t you heard? It’s going to be terrible, and it’s never going to happen.

I went to a bookstore the other day and raided their three dollar shelf. Half the books I bought were ones I’ve already read, but either I didn’t own it or I was getting it as a gift. Potentially. A potential gift. I seem to have a compulsion by which I always buy a copy of Franny and Zooey if I find it. I’m well aware that Mel Gibson’s character in Conspiracy Theory has the same affliction, only it’s with Catcher. The situation isn’t serious enough to cause me financial distress (only because it doesn’t happen on each of my daily visits to Amazon.com), so I don’t think I need to seek help just yet. Plus I eventually end up giving away all (but a couple) of my copies. So I feel the purchases are ultimately justified. I also picked up The House of Sand and Fog. My roommate tells me it’s a fantastic movie, which is intergalactic code for “the book is even better.”


this may have been better if i’d instead tried to write poetry

•July 2, 2012 • Leave a Comment

Sometimes before I can write I have to wait for a while for something to happen. Something to inspire me. Something to reawaken my desire to put words on a page and allow others to wander about them. And I’ve been waiting now for some time, and that crystallizing event has yet to occur.

In such a situation as this, I’m aware that there is not an ending in sight. There is not an aim or a goal to this discourse. It is without design or ambition. Unlike many of my dealings.

I was going to write a letter, one to a dear friend who had not long ago written to me, but I’m afraid an open letter may not be the best course of action. I’m not quite sure how to know when an open letter would be appropriate. Our conversations often provoke me to thought, fantastic thoughts. The kinds I only hope to read about in great books. How could I not want to share those with others? And yet, they’re fiercely personal. To tell you of them would be to reveal a great deal about myself. Things I didn’t even know until recently. Have you tried to write about something like that? Something so big you’re still trying to wrap your mind about it? Something that’s so profound that you’re still trying to figure out all of its implications? I’m not very comfortable taking such ideas public.

I would like to explain about my broken tooth, but I should wait until there’s more to say on the matter. For now, it hurts, and will need to be fixed soon.

I considered writing in a way as to use words inappropriately but smartly enough that the intent would be preserved. But my mind doesn’t do that naturally, and it would take a lot of time. Instead, my mind works with slashes and dashes and parentheses. It works with hooks and strings. It works with symbols and allegories. It works with double meanings and rhyme schemes and misspellings. Not misspellings for the sake of trying out something that’s wrong, but rather using them to suggest alternative interpretations. Sometimes I misuse syntax the same way.

In my mind, this always seems like a great way for flirting. Cute and clever all at once. Somehow this is rarely ever well received. What typically happens is that I become very pleased with myself, the other person becomes confused (both at my words and subsequent behavior), and (if I’m lucky) the interaction ends shortly thereafter.

OK, next time I’ll choose a topic. Something to hold it all together. That way there’s a trail to return to. When it’s like this, I feel like I’m traipsing around a meadow, sitting down from time to time but ultimately wondering what I’m doing here in the first place.

Vacation and life decisions

•March 31, 2012 • Leave a Comment

I write this now as I wait for the sunrise from the northern corner of the deck that skirts the perimeter of an immodestly large rental house here on Kaua’i. Today looks as if it will be similar to yesterday, and all the days of this past week. I will eat and drink, grow dark and fat, listen to the birds and tune out the waves, run some and sit more, and forget about hospitals and patients and research and evals and duty hours and journal clubs and snow.

The biggest concern I had yesterday was a mosquito that absolutely torched me. Retrospectively I find this amusing, as it was the first time that I’d been bitten in the past few years and hadn’t wondered immediately thereafter if maybe I should have taken malaria prophylaxis. No, instead, once I had smooshed her (isn’t it a she? Somehow I remember thinking that it was only the female ones who suck blood. Or is that for spiders?) and smeared my own blood, the contents of her previously swollen abdomen, across my tanning forearm, I happily returned to my book, only to be bothered by the occasional itching of the chains of bite islands that I now wear as anklets.

I’m reading a couple books right now. Oh but first, I should alert you to a change. I’ve decided I want to be a hematologist. This in itself is not new. I’ve long been intrigued by the benign blood conditions, but acute leukemia truly frightens me. I’m falling off task, so I’ll write of it’s terrors another time. I’m reading The Magic Mountain by Thomas Mann, and The Emperor of All Maladies  by Siddhartha Mukherjee, and Orthodoxy by G. K. Chesterton, a book that I truly can’t believe is over a century old. I may have mentioned  before that I often choose the books I read by the recommendation of others or even if I see them as a reference in another work I enjoy; for instance, I remember seeing The Magic Mountain in one of my Murakami novels, probably Norwegian Wood, which wasn’t my favorite. I think it was also in Cancer Ward, by Solzhenitsyn, which is a favorite.

I’m trying now to think of what other books remain on my To-be-read (TBR) pile. Surprisingly, nothing comes immediately to mind, though I know there is a stack at home that begs otherwise. Oh, my semi-photographic memory returns; that stack has a work by Pynchon, the newest of the Song of Ice and Fire series, Dandelion Wine, Middlesex, and now I forget the rest. If any have other recommendations, your input is welcomed.


No air

•February 5, 2012 • 1 Comment

Good morning and hello. I have not disappeared in the past couple months. Not permanently, anyway. A little space can be a good thing. A place to decompress and regroup. Breathing room.

A breathing room sounds like a good idea. Sounds like something the crunchies would want to put into the airport, like a smoking room but without a real purpose. But I think I’d rather have one either at work or at home.

Oftentimes when I find myself alone with a brisk pace, I find that I’ve reverted to my trumpet breathing exercises. 10 steps breathing in, 10 steps hold, 10 steps breathing out, 10 steps hold. You want your lungs to fill and empty completely, and you want to breathe evenly the entire time. That is, don’t fill up too fast or two slow.

The hardest part is the 10 steps you take when your lungs are empty (that is, if they’re truly empty and you dont cheat and hold some air in reserve). If  you haven’t tried it you should, because you feel like you’re suffocating for these few moments. And when you’ve finished those 10 steps and get to inhale it’s near impossible not to make that first breath just a little bit bigger than the ones that are to follow.

This is supposed to repeat itself for about 10 minutes, at which point your lungs are burning and screaming, and your neighbor is wondering why you look winded from just a little walk.