While the average television viewer obsesses over details from last week's episode of Grey's Anatomy, Scrubs, or Discovery Health's reality shows, many involved in the health care system criticize the accuracy of medical shows in representing American health care. Their concerns are not unfounded. Numerous studies have demonstrated that what we see on TV is not what happens in hospitals-- one investigated CPR and the marked difference between reality and television (Diem et al, 1996). Ultimately, however, these shows serve as entertainment and do not purport to have any other purpose. To this end, writers producers, and networks are incredibly successful. Such shows are advertised as entertainment, no more -- consumers must take responsibility for this fact and look for education elsewhere.
It would seem that in recent years television programing has made the distinction between entertainment and education clearer than ever. Unlike the melodramatic shouts to shock a heart or order "CBCs" heard in ER, many newer shows don't take themselves so seriously. Scrubs takes the form of a sitcom, engaging the reader with realistic issues and emotions interspersed with musical interludes, hyperbolic characters, and protagonist J.D.'s daydreams. Episodes go so far as to show a medieval reenactment of an amputation, a daydream of the doctors as cavemen during prehistoric times and an entire episode in the style of a musical. Even the traditional "doctor dramas" have jumped the shark, distinguishing themselves from medical advice or realistic portrayal. Grey's Anatomy and House, MD both include doctors and medical conditions that entertain because of their outlandishness. They focus increasingly on the personal lives of doctors -- the drug addiction of Dr. House or the incestuous relationships in Grey's -- clearly delineating themselves from reliable sources of medical information.
On the other hand, reality shows such as Trauma: Life in the ER shown on the cable channel, Discovery Health, do not attempt to fictionalize medical drama, but instead film the actual events that occur in an Americanb hospital. While the events that make it to viewers are no doubt the result of careful selection, such shows still portray actual conditions, procedures, and doctor-patient interactions. At the end of the day, any television with medical content will not be representative of actual medicine -- it aims to entertain, not inform -- but a savvy viewer can easily make this distinction.
Sunday, November 29, 2009
Saturday, November 28, 2009
Medicine in the Media
“Media” is a broad word that refers to the substance through which matter moves—in the case of medicine, the various technological forms of communication through which information moves. The advancement of communication technology, ranging from TV to the Internet, has led to advancement in medical culture, both in terms of healthcare management and treatment and the exposing of doctors’ personal lives.
The recent focus on doctors’ personal lives reveals a public fascination with doctors rooted in a cultural ideal of the stoic caregiver. For so long, doctors have been regarded—and have protected their image as—omnipotent healers whose personal motives are not relevant to patient care. Now, under the influence of standpoint history and increasing concern for emotional exploration and health, memoirs, often deeply personal and philosophical, of the medical training experience or medical practice are commonplace in bookstores. News sources have jumped on this trend as well. For example, Pauline Chen is a regular columnist for the New York Times, and Atul Gawande is a staff member of the New Yorker. Doctor dramas, such as ER or Gray’s Anatomy, show that doctors are human, too (what a surprise!). However, since doctors are the main characters in these shows, they still gain a hero-worthy status (one has only to look to House, MD), often at the expense of other people in the healthcare system. One study in the readings showed that patient characters, when they did show up, were usually overly anxious, demanding, or unconscious/dead. Given that the patient is one half of the doctor-patient relationship, it would be better to portray patients in a more sympathetic, or at least realistic, light. However, this might detract from the drama and hero-making of doctors that producers seek to create. The portrayal of patients also hints at the intended viewership of these shows. The creators understand that these shows are most popular among aspiring medical students or people with some knowledge of the healthcare system, who may not be most interested in the mundane aspects of healthcare, realistic portrayals of human interaction.
While I think that doctor dramas can be a good venue for explaining doctors’ thought processes and discussing controversial issues in medicine, in the real world, medical journalism does not seem to be living up to its full potential. Doctors are wary of journalists, who can “make” a career by reporting medical success, or break a career by reporting medical error. While it is understandable that doctor dramas would not take on policy or economic issues in healthcare, the failure of journalists to generally do so is not. One of our readings shows how Dr. Kevorkian gained publicity for his pro-euthanasia acts, but instead of broadening the story to bioethical concerns, the news media spun it as a crime-and-personality story. There is a place for entertainment and catching the audience’s attention, but journalism is supposed to report on broad-reaching societal issues. The news media can enliven the discussion about important issues such as end-of-life care and consequences of lack of insurance in a way that human dramas cannot. Doctors need to be involved in the accurate portrayal of facts in the media and be vigilant about making sure that journalists are not sensationalizing the story.
The recent focus on doctors’ personal lives reveals a public fascination with doctors rooted in a cultural ideal of the stoic caregiver. For so long, doctors have been regarded—and have protected their image as—omnipotent healers whose personal motives are not relevant to patient care. Now, under the influence of standpoint history and increasing concern for emotional exploration and health, memoirs, often deeply personal and philosophical, of the medical training experience or medical practice are commonplace in bookstores. News sources have jumped on this trend as well. For example, Pauline Chen is a regular columnist for the New York Times, and Atul Gawande is a staff member of the New Yorker. Doctor dramas, such as ER or Gray’s Anatomy, show that doctors are human, too (what a surprise!). However, since doctors are the main characters in these shows, they still gain a hero-worthy status (one has only to look to House, MD), often at the expense of other people in the healthcare system. One study in the readings showed that patient characters, when they did show up, were usually overly anxious, demanding, or unconscious/dead. Given that the patient is one half of the doctor-patient relationship, it would be better to portray patients in a more sympathetic, or at least realistic, light. However, this might detract from the drama and hero-making of doctors that producers seek to create. The portrayal of patients also hints at the intended viewership of these shows. The creators understand that these shows are most popular among aspiring medical students or people with some knowledge of the healthcare system, who may not be most interested in the mundane aspects of healthcare, realistic portrayals of human interaction.
While I think that doctor dramas can be a good venue for explaining doctors’ thought processes and discussing controversial issues in medicine, in the real world, medical journalism does not seem to be living up to its full potential. Doctors are wary of journalists, who can “make” a career by reporting medical success, or break a career by reporting medical error. While it is understandable that doctor dramas would not take on policy or economic issues in healthcare, the failure of journalists to generally do so is not. One of our readings shows how Dr. Kevorkian gained publicity for his pro-euthanasia acts, but instead of broadening the story to bioethical concerns, the news media spun it as a crime-and-personality story. There is a place for entertainment and catching the audience’s attention, but journalism is supposed to report on broad-reaching societal issues. The news media can enliven the discussion about important issues such as end-of-life care and consequences of lack of insurance in a way that human dramas cannot. Doctors need to be involved in the accurate portrayal of facts in the media and be vigilant about making sure that journalists are not sensationalizing the story.
Medical Drama: Accuracy Issues!
Sometimes, the widespread wariness towards the accuracy of medical dramas is seems a bit over-rated. Of course, my perspective is likely limited since I never watched any medical shows that existed before ER, cited by Goodman as the beginning of more accurately-portrayed medicine in drama. By definition, drama has the inherent license to stretch facts and stimulate each individual viewer’s imagination, from minimal to great extents. No accepted standard upholds the drama genre to clearly demarcate where fiction and fact cleanly divide. In this sense, I find that a simple gesture, like an additional written note at the beginning of each episode indicating that the ensuing presentation has not been meticulously prepared to give accurate medical facts, can answer much of the public concern. Goodman captured my perspective well in writing: “The relationship between audiences and media texts is more complex than is commonly recognized in popular discourse. Audiences do not passively receive messages in media texts, they actively engage with them to negotiate meanings according to their personal sensibilities, but also according to socially determined categories such as race, class, gender and nationality.”
Dramatized, abridged, and emotionally and ethically charged drama most often serves as a starting, versus ending, point for most engaged audiences. I personally grew up watching ER every Thursday evening. Perhaps more so because I was a kid, with minimal knowledge of medical terminology or politics, I loved the show because of its high level of person-to-person interactions and emotions. For me, the most that the show taught me about the medical profession or field itself is that, like many other settings, it is a site where all sorts of human interactions, emotions, and circumstances converge and interact dynamically.
That said, as more and more medical dramas are produced and enthusiastically received by the global public, standards for accurate portrayal are definitely on the rise. Because of this (in some ways, beneficial) trend, I think it has become harder for audiences to passively separate out aspects of fiction from those of fact in medical dramas. To discern, for example, whether the director is purposefully and artfully exaggerating insurance-related social issues to make a political statement in an episode, or is accurately and objectively portraying a truly dire situation, can require much active reflection and inter-personal debate. However, I believe this is part of the merit of medical drama—that it can galvanize critical thinking of societal issues (both specific and non-specific to medicine) and open up conversations outside the political floor.
Dramatized, abridged, and emotionally and ethically charged drama most often serves as a starting, versus ending, point for most engaged audiences. I personally grew up watching ER every Thursday evening. Perhaps more so because I was a kid, with minimal knowledge of medical terminology or politics, I loved the show because of its high level of person-to-person interactions and emotions. For me, the most that the show taught me about the medical profession or field itself is that, like many other settings, it is a site where all sorts of human interactions, emotions, and circumstances converge and interact dynamically.
That said, as more and more medical dramas are produced and enthusiastically received by the global public, standards for accurate portrayal are definitely on the rise. Because of this (in some ways, beneficial) trend, I think it has become harder for audiences to passively separate out aspects of fiction from those of fact in medical dramas. To discern, for example, whether the director is purposefully and artfully exaggerating insurance-related social issues to make a political statement in an episode, or is accurately and objectively portraying a truly dire situation, can require much active reflection and inter-personal debate. However, I believe this is part of the merit of medical drama—that it can galvanize critical thinking of societal issues (both specific and non-specific to medicine) and open up conversations outside the political floor.
Wednesday, November 25, 2009
Media and Technology in Medicine
The relative newness of the debate of how media and the internet should coexist with medicine creates an interesting and evolving discussion. My generation was raised on the accessibility of information via the internet and electronic technology sources. I still remember my family’s first computer, an oversized (and now incredibly outdated) PC that would keep me entertained for hours as I would look things up on the encyclopedia software my grandmother gave me as a gift. It is incredible that today I can find information on everything, from clinical trials to disease treatment plans, prognoses, and the best doctors in a particular field.
I think that it’s relatively archaic for doctors to argue against access of information for their patients. Sure, things get misinterpreted and there will often be patients who will attempt to self-diagnose but it also gives patients a sense of empowerment over their healthcare that they’ve never had before. The beauty of the medical system is that although patients may come to false conclusions it is ultimately their doctor who will prescribe drugs and treatment plans. The reality is that doctors are over-emphasizing the power of the internet as a “healthcare provider.” Even relatively popular sites such as WebMD provide many possible differentials for a patient’s set of symptoms; it is by no means a diagnosis but a good way to gauge the urgency of a patient’s healthcare needs.
Additionally, I think it’s crucial for doctors to consider the likely evolution of healthcare as our nation undergoes what will likely be a drastic change in doctoring practices. If our country goes to a universal healthcare system doctors will be further overworked and the doctor-patient relationship will surely deteriorate as primary care physicians (an already underserved field) receive an influx of new (and likely needier) patients. It is astonishing to me that doctors argue that the internet is a “depersonalizing” or deteriorating entity for the doctor-patient relationship. Low reimbursement rates lead doctors to see more patients in a workday, so the days of long doctor visits of an invested knowledge in one’s patients has been reduced to a fifteen minute visit that results in a perfunctory run through of symptoms.
In addition to being a source of information for patients, the internet offers the great potential for patient records to be accessible at all times by the patient and doctors. Considering the great number of subspecialists that the average American sees these days a comprehensive list of a patient’s healthcare history and drugs could greatly increase the efficiency of the health system.
Another issue in Media and Medicine that arises is the prevalence of doctoring shows that offer an unrealistic image of the medical field and potential for treatments. I agree that there is a huge dichotomy between what is presented in these shows and what is actually medically feasible; however, I don’t know if the entertainment industry has an obligation to “inform” the public about medicine, this could be done more efficaciously by organizations such as the AMA or NIH (or better yet the government could place more money into public awareness campaigns and rather than cutting down screening guidelines it could practice medicine that will provide better health outcomes rather than cheaper healthcare).
The bigger concern should really be on how the news media depicts medicine. One of the points in our reading was that shows such as Grey’s Anatomy present unrealistic depictions of procedures such as organ transplantation, which usually occurs under very rigid guidelines. However, in my local newspaper The Miami Herald there was an article a couple of years ago about a young boy who immigrated to the US and lacked any familial support system and was thus not a candidate for organ transplantation. However, public outcry led to the boy eventually receiving the life-saving transplant. I don’t think that news stories such as these are any less harmful than the “fiction” presented in TV dramas since they both posit that healthcare functions very differently than it actually does. Yet I would say that it’s far more deleterious for the local newspaper to perpetuate these falsities since people tend to take these as truth.
Honestly I think that increased involvement of the media and internet in medicine will only continue to grow as our society becomes more technological proficient. This change (like all others) poses both benefits and challenges as patients will inevitably be better education but also face an influx of either false or exaggerated information that they will have to shift through. However, I think that it’s irrational to assume that just because some people will misperceive information that we ought to maintain a level of ignorance over society at large. So we should accept it, learn from it, and find ways to have the media make medicine more efficient and effective.
I think that it’s relatively archaic for doctors to argue against access of information for their patients. Sure, things get misinterpreted and there will often be patients who will attempt to self-diagnose but it also gives patients a sense of empowerment over their healthcare that they’ve never had before. The beauty of the medical system is that although patients may come to false conclusions it is ultimately their doctor who will prescribe drugs and treatment plans. The reality is that doctors are over-emphasizing the power of the internet as a “healthcare provider.” Even relatively popular sites such as WebMD provide many possible differentials for a patient’s set of symptoms; it is by no means a diagnosis but a good way to gauge the urgency of a patient’s healthcare needs.
Additionally, I think it’s crucial for doctors to consider the likely evolution of healthcare as our nation undergoes what will likely be a drastic change in doctoring practices. If our country goes to a universal healthcare system doctors will be further overworked and the doctor-patient relationship will surely deteriorate as primary care physicians (an already underserved field) receive an influx of new (and likely needier) patients. It is astonishing to me that doctors argue that the internet is a “depersonalizing” or deteriorating entity for the doctor-patient relationship. Low reimbursement rates lead doctors to see more patients in a workday, so the days of long doctor visits of an invested knowledge in one’s patients has been reduced to a fifteen minute visit that results in a perfunctory run through of symptoms.
In addition to being a source of information for patients, the internet offers the great potential for patient records to be accessible at all times by the patient and doctors. Considering the great number of subspecialists that the average American sees these days a comprehensive list of a patient’s healthcare history and drugs could greatly increase the efficiency of the health system.
Another issue in Media and Medicine that arises is the prevalence of doctoring shows that offer an unrealistic image of the medical field and potential for treatments. I agree that there is a huge dichotomy between what is presented in these shows and what is actually medically feasible; however, I don’t know if the entertainment industry has an obligation to “inform” the public about medicine, this could be done more efficaciously by organizations such as the AMA or NIH (or better yet the government could place more money into public awareness campaigns and rather than cutting down screening guidelines it could practice medicine that will provide better health outcomes rather than cheaper healthcare).
The bigger concern should really be on how the news media depicts medicine. One of the points in our reading was that shows such as Grey’s Anatomy present unrealistic depictions of procedures such as organ transplantation, which usually occurs under very rigid guidelines. However, in my local newspaper The Miami Herald there was an article a couple of years ago about a young boy who immigrated to the US and lacked any familial support system and was thus not a candidate for organ transplantation. However, public outcry led to the boy eventually receiving the life-saving transplant. I don’t think that news stories such as these are any less harmful than the “fiction” presented in TV dramas since they both posit that healthcare functions very differently than it actually does. Yet I would say that it’s far more deleterious for the local newspaper to perpetuate these falsities since people tend to take these as truth.
Honestly I think that increased involvement of the media and internet in medicine will only continue to grow as our society becomes more technological proficient. This change (like all others) poses both benefits and challenges as patients will inevitably be better education but also face an influx of either false or exaggerated information that they will have to shift through. However, I think that it’s irrational to assume that just because some people will misperceive information that we ought to maintain a level of ignorance over society at large. So we should accept it, learn from it, and find ways to have the media make medicine more efficient and effective.
Tuesday, November 24, 2009
Military Medicine
It is difficult to believe that the military bureaucracy cannot provide adequate medical care to its own soldiers who are returning from wars in Iraq and Afghanistan. I believe there should even be a priority for the soldiers who sacrifice their lives for their country to receive the best medical care available and the emotional and mental support needed to help them transition back into civilian life. The article from the Washington Post gives a short description of what it is like for a soldier returning home.
The typical soldier is required to file 22 documents with eight different commands -- most of them off-post -- to enter and exit the medical processing world, according to government investigators. Sixteen different information systems are used to process the forms, but few of them can communicate with one another. The Army's three personnel databases cannot read each other's files and can't interact with the separate pay system or the medical recordkeeping databases.
No wonder soldiers are frustrated in addition to being plagued by stress, depression, and PTSD. Instead of the warm welcome and treatment the soldiers expect for being heros, the soldiers are isolated and neglected. Civilian care coordinators, case managers, and social workers who work at medical military facilities with good intentions are supposed to track injured soldiers and help them with appointments, but they often do not understand the bureaucratic system of the military and are also helpless to the system that they work in.
Why has no one noticed? I am sure if this issue was brought to the public attention, there would be a large public outcry that would lead to more structure and reorganization. In turn, the demand could facilitate more funds and legislation to provide support and medical services for soldiers. Before all of this, I think there needs to be more attention placed on the services of soldiers and the least we can do is to assist them when they get home because they are deserving of the same level of care that any of us receive at our medical facilities.
The typical soldier is required to file 22 documents with eight different commands -- most of them off-post -- to enter and exit the medical processing world, according to government investigators. Sixteen different information systems are used to process the forms, but few of them can communicate with one another. The Army's three personnel databases cannot read each other's files and can't interact with the separate pay system or the medical recordkeeping databases.
No wonder soldiers are frustrated in addition to being plagued by stress, depression, and PTSD. Instead of the warm welcome and treatment the soldiers expect for being heros, the soldiers are isolated and neglected. Civilian care coordinators, case managers, and social workers who work at medical military facilities with good intentions are supposed to track injured soldiers and help them with appointments, but they often do not understand the bureaucratic system of the military and are also helpless to the system that they work in.
Why has no one noticed? I am sure if this issue was brought to the public attention, there would be a large public outcry that would lead to more structure and reorganization. In turn, the demand could facilitate more funds and legislation to provide support and medical services for soldiers. Before all of this, I think there needs to be more attention placed on the services of soldiers and the least we can do is to assist them when they get home because they are deserving of the same level of care that any of us receive at our medical facilities.
Monday, November 23, 2009
Medicine in the military
Military medicine, in many regards, is unlike the other branches of medicine that we have discussed so far in class. Coming into this class, I had a vague idea that doctors on active military duty would see horrific injuries and have to make harrowing triage decisions. I also knew from various emails sent through the PLME listserv and a couple of physicians I know who are in the Army that the Army generously pays for their doctors’ education and gives them all the privileges of being a member of the Armed Forces. However, after the readings, and the insightful presentation by Dr. Hayda, I have come to realize that military medicine is much more complex, and yet also simpler, than I had imagined.
The patients that military doctors must treat usually have more severe injuries, of a traumatic sort rather than chronic diseases—unfortunately, they also tend to be younger, and otherwise healthy. It was interesting to note that military doctors don’t seem to have to triage on a regular basis like ER doctors, but employ a “damage control” model that allows them to treat multiple patients in steps. The use of leaner mobile units reflects an overall revised strategy in the military, and their use will continue to grow. I think that our discussion about the role of biotechnology in medicine last week ties nicely into the NYT article on the use of new technologies like QuikClot that aim to improve mortality rates from traumatic battlefield injuries. It is apparent that in addition to public health agencies and private companies, the military also has a stake in developing new medical technologies, for the purposes of sustaining its soldiers—however, this military technology may also become available to the civilian population.
I was struck by the NEJM’s account of military officials’ insistence that becoming a physician is “not a sacramental vow” and that the military doctor “is a combatant, not a physician”—this goes against the other works we have read which portray medicine as a calling, as a noble lifestyle rather than vocation. The conflict of interest that arises then is interesting. Does the doctor follow Hippocratic/civilian protocols of do no harm, and are they beyond the chain of military command? Or does the doctor obey orders and carry out the wishes of higher-ups? As the authors suggest, the answer lies somewhere in-between: they imply that a doctor should follow commands insofar as they do not cause harm to another human being. With this conclusion, it was disturbing to read evidence that doctors willingly participated in the abuses at Abu Ghraib by helping to design interrogation techniques and sharing detainee information with interrogators. As Atul Gawande writes, civilian physician codes of conduct are often inadequate for military doctors, who face sometimes very different challenges, and it is evident that greater attention needs to be paid to creating effective, ethical military medical guidelines.
I was horrified by soldiers’ accounts of shoddy treatment and profound bureaucratic unhelpfulness at Walter Reed. However, their complaints do not surprise me, as they echo those of people with disabilities all across America that I have learned about in Pathology to Power (a class on people with disabilities). In general, there is a weak and vague structure of compensation and rehabilitation that is exacerbated by bureaucratic demands—brutal overhaul of the system is necessary. The public is also somewhat to blame for this sorry state, though, since there are many people who claim to support the troops and applaud enlisted men and women, but also become infuriated by the idea of these same men and women receiving governmental aid for injury/disability paid for through taxes.
The patients that military doctors must treat usually have more severe injuries, of a traumatic sort rather than chronic diseases—unfortunately, they also tend to be younger, and otherwise healthy. It was interesting to note that military doctors don’t seem to have to triage on a regular basis like ER doctors, but employ a “damage control” model that allows them to treat multiple patients in steps. The use of leaner mobile units reflects an overall revised strategy in the military, and their use will continue to grow. I think that our discussion about the role of biotechnology in medicine last week ties nicely into the NYT article on the use of new technologies like QuikClot that aim to improve mortality rates from traumatic battlefield injuries. It is apparent that in addition to public health agencies and private companies, the military also has a stake in developing new medical technologies, for the purposes of sustaining its soldiers—however, this military technology may also become available to the civilian population.
I was struck by the NEJM’s account of military officials’ insistence that becoming a physician is “not a sacramental vow” and that the military doctor “is a combatant, not a physician”—this goes against the other works we have read which portray medicine as a calling, as a noble lifestyle rather than vocation. The conflict of interest that arises then is interesting. Does the doctor follow Hippocratic/civilian protocols of do no harm, and are they beyond the chain of military command? Or does the doctor obey orders and carry out the wishes of higher-ups? As the authors suggest, the answer lies somewhere in-between: they imply that a doctor should follow commands insofar as they do not cause harm to another human being. With this conclusion, it was disturbing to read evidence that doctors willingly participated in the abuses at Abu Ghraib by helping to design interrogation techniques and sharing detainee information with interrogators. As Atul Gawande writes, civilian physician codes of conduct are often inadequate for military doctors, who face sometimes very different challenges, and it is evident that greater attention needs to be paid to creating effective, ethical military medical guidelines.
I was horrified by soldiers’ accounts of shoddy treatment and profound bureaucratic unhelpfulness at Walter Reed. However, their complaints do not surprise me, as they echo those of people with disabilities all across America that I have learned about in Pathology to Power (a class on people with disabilities). In general, there is a weak and vague structure of compensation and rehabilitation that is exacerbated by bureaucratic demands—brutal overhaul of the system is necessary. The public is also somewhat to blame for this sorry state, though, since there are many people who claim to support the troops and applaud enlisted men and women, but also become infuriated by the idea of these same men and women receiving governmental aid for injury/disability paid for through taxes.
Military Medicine for Local Civilians
For civilians in developing countries, the presence of the American military can be a lifesaving source of medical care where such resources are scarce. For example, the U.S. Navy has its own medical laboratory for the study of diseases endemic to certain regions of the globe. Because U.S. servicemen have no built immunity against diseases specific to these regions, the young children native to that region serve as a good model for researchers. Treatments for children are used for studying the natural course of certain diseases and the effects of possible vaccinations or therapies. Though, throughout history, various legitimate ethical concerns have been raised of this self-interest, it has on the other hand benefited civilian populations significantly in some, though not all, cases. This self-interest, then, has had a role in promoting global health in some of the places where such attention is most needed.
Our speaker’s extensive work in working with local healthcare providers to bring surgical services to civilians near his base, confirms the potential this relationship has for the future. As he pointed out, however, there does not seem to be an official system in bringing medical attention to local populations. Though the unofficial work is great when it comes to individual clinicians and their work for individual patients, I would advocate a more formal relationship when it comes to working with local populations to study endemic diseases for the goal of benefiting U.S. servicemen. To this system, there should also ideally be a built-in formalized process to overlook ethical concerns, in the general or case-by-case basis.
Our speaker’s extensive work in working with local healthcare providers to bring surgical services to civilians near his base, confirms the potential this relationship has for the future. As he pointed out, however, there does not seem to be an official system in bringing medical attention to local populations. Though the unofficial work is great when it comes to individual clinicians and their work for individual patients, I would advocate a more formal relationship when it comes to working with local populations to study endemic diseases for the goal of benefiting U.S. servicemen. To this system, there should also ideally be a built-in formalized process to overlook ethical concerns, in the general or case-by-case basis.
Tuesday, November 17, 2009
Biotechnology
Biotechnology has mobilized the globalization of medicine. In Good's article, she states that "the dynamics of the global-local exchange challenge our notions of “universalism” in clinical science and “local” knowledge in clinical practice, stimulating a rethinking of the boundaries not only between science and society but also between “the local” and “the global.” Medicine has been able to expand to remote areas in parts of the world that have not been reached before. The growth and development of the practice of medicine and biotechnology go hand in hand. When I think of the word biotechnology, I imagine robots and artificial organs. In the United States, biotechnology and the important research in this field has helped prolong lives especially of the rapidly growing elderly population. However, the implications of biotechnology in developing countries also have profound effects. Medicines and drugs created by pharmaceutical companies take on a different context in various cultures. Americans depend on drugs from ailments ranging from headache to depression. Other countries use drugs as well as traditional therapies like acupuncture in a new type of hybrid biotechnology. I believe biotechnology has definitely positively influenced the international cooperation of medicine.
notes from the M&M Conference
1st case: 18 year old woman presented with neck lump and pain in right hip
-panelists seem to consider diagnoses from their own specialty perspectives (infectious disease doc says mono, IBS possibly, “HIV is always a possibility, however much you believe someone’s sexual history”; oncologist says diffuse lymphoma).
-How much does specialized knowledge help/hurt the differential?
-although the patient didn’t present all the symptoms of LeMierre’s disease, the point of M&M is to find foolproof ways of diagnosing it next time. This is a learning experience. Quantifying symptoms, putting them in a checklist, and teaching doctors to recognize them next time.
-detective novels!
2nd case: 80 year old British man presented with shortness of breath, dyspnea, hoarseness
-panel members should and can ask questions
-the multiple lab data bits, EKG, types of scans, were all standard procedure.
-How do we actually know what a “disease” is? Just an accumulation of lots and lots of cases that have the same/similar pathology and we extrapolate from there/continue to add new symptoms/subdivide and name it after the “discoverer”
-if you sit up there on the panel and say nothing, you don’t look so good. Or when you say things like, “Lifespan doesn’t cover chimney sweeps.” Seriously? Apropro?
-the docs discuss the mechanism of death, not the emotional experience per se, though I suspect that it means something to these people, to know what it “feels like” when you have a certain biological condition
-they constantly compare patient to the available literature. Staying up to date with research and clinical cases is important!
-“it would be crazy” to aggressively treat someone in such poor condition. This man was resuscitated instead of being allowed to die in his sleep, but to what avail? Dr. Flanigan (!) makes the point of “delivering bad news” and the presenter said that he “made no bones” about telling him that it looked bad… discussion with wife and the patient was made CMO.
-panelists seem to consider diagnoses from their own specialty perspectives (infectious disease doc says mono, IBS possibly, “HIV is always a possibility, however much you believe someone’s sexual history”; oncologist says diffuse lymphoma).
-How much does specialized knowledge help/hurt the differential?
-although the patient didn’t present all the symptoms of LeMierre’s disease, the point of M&M is to find foolproof ways of diagnosing it next time. This is a learning experience. Quantifying symptoms, putting them in a checklist, and teaching doctors to recognize them next time.
-detective novels!
2nd case: 80 year old British man presented with shortness of breath, dyspnea, hoarseness
-panel members should and can ask questions
-the multiple lab data bits, EKG, types of scans, were all standard procedure.
-How do we actually know what a “disease” is? Just an accumulation of lots and lots of cases that have the same/similar pathology and we extrapolate from there/continue to add new symptoms/subdivide and name it after the “discoverer”
-if you sit up there on the panel and say nothing, you don’t look so good. Or when you say things like, “Lifespan doesn’t cover chimney sweeps.” Seriously? Apropro?
-the docs discuss the mechanism of death, not the emotional experience per se, though I suspect that it means something to these people, to know what it “feels like” when you have a certain biological condition
-they constantly compare patient to the available literature. Staying up to date with research and clinical cases is important!
-“it would be crazy” to aggressively treat someone in such poor condition. This man was resuscitated instead of being allowed to die in his sleep, but to what avail? Dr. Flanigan (!) makes the point of “delivering bad news” and the presenter said that he “made no bones” about telling him that it looked bad… discussion with wife and the patient was made CMO.
Monday, November 16, 2009
Technology and Medical Innovation
Hanson’s The Edge of Medicine touches on many pertinent issues in the increasing importance of technology and medical innovation in our healthcare system. Some rhetoricians have the belief that even though Americans may not have access to universal healthcare, American medical innovation continues to make our system one of the best in the world. Whether or not this is true is disputable, but Hanson’s timely and optimistic book shows that technology and research are vital to the practice of providing healthcare in this country. Some may argue that this comes at the expense of humane patient treatment, but Hanson shows that technology may be incorporated in a way that actually benefits patient care.
One case in which this is true is his exposition on the growing number of laparoscopic surgery. These surgeries are less invasive and quicker than traditional surgeries, and probably improve the doctor-patient rapport as a result. In addition, electronic medical records are a godsend for many hospitals and clinics that would otherwise have to juggle easily damageable paper records. Of course, EMRs raise questions of privacy and are also not foolproof, but they represent a way in which medical innovation has been not just physical or on a biological level, but organizational as well. Overall, technology has been the driving force in improving patient care—although we cannot let it draw a veil over the importance of maintaining humanism in medicine and extending the benefits of that technology to every citizen in this country.
However, the increasing amount of technology raises the question of whether computer-run machines and “intelligent algorithms” will one day render people obsolete. This is most evident in Hanson’s description of Tug, an affable little robot who can deliver drugs to patients’ rooms, performing the same task that would ordinarily be done by a human. Thus, technology has profound economic implications that I think are not unlike those encountered in the Industrial Revolution, when artisans found themselves being outmatched by machines that were more accurate, more reliable, and less likely to complain. In addition, doctors may struggle to keep up with all the new medical techniques (see http://www.bmj.com/cgi/content/full/313/7064/1062) or may even find their diagnostic powers being challenged by an algorithm that can weight patients’ symptoms against illnesses.
Medicine truly continues to evolve before our very eyes. In face of the intersection between medicine, technology, and science, it is obvious that medicine will only continue to advance technologically as new scientific discoveries can be applied. However, I find it interesting that Hanson did not devote more attention to the relative paucity of funding for pioneering medical technologies. In addition, it seems that technology affects different specialties and different practices to varying degrees. I wonder if it has increased the divide between various specialties because of the increasingly specialized information that a doctor in that particular field would need to stay up-to-date on.
One case in which this is true is his exposition on the growing number of laparoscopic surgery. These surgeries are less invasive and quicker than traditional surgeries, and probably improve the doctor-patient rapport as a result. In addition, electronic medical records are a godsend for many hospitals and clinics that would otherwise have to juggle easily damageable paper records. Of course, EMRs raise questions of privacy and are also not foolproof, but they represent a way in which medical innovation has been not just physical or on a biological level, but organizational as well. Overall, technology has been the driving force in improving patient care—although we cannot let it draw a veil over the importance of maintaining humanism in medicine and extending the benefits of that technology to every citizen in this country.
However, the increasing amount of technology raises the question of whether computer-run machines and “intelligent algorithms” will one day render people obsolete. This is most evident in Hanson’s description of Tug, an affable little robot who can deliver drugs to patients’ rooms, performing the same task that would ordinarily be done by a human. Thus, technology has profound economic implications that I think are not unlike those encountered in the Industrial Revolution, when artisans found themselves being outmatched by machines that were more accurate, more reliable, and less likely to complain. In addition, doctors may struggle to keep up with all the new medical techniques (see http://www.bmj.com/cgi/content/full/313/7064/1062) or may even find their diagnostic powers being challenged by an algorithm that can weight patients’ symptoms against illnesses.
Medicine truly continues to evolve before our very eyes. In face of the intersection between medicine, technology, and science, it is obvious that medicine will only continue to advance technologically as new scientific discoveries can be applied. However, I find it interesting that Hanson did not devote more attention to the relative paucity of funding for pioneering medical technologies. In addition, it seems that technology affects different specialties and different practices to varying degrees. I wonder if it has increased the divide between various specialties because of the increasingly specialized information that a doctor in that particular field would need to stay up-to-date on.
Sunday, November 15, 2009
Biotechnology Fever
Since the 1980 law enabling universities and hospitals to profit from research through licensing new drugs, biotechnology has had an increased need for ethical surveillance. Given our capitalist market economy, it is unsurprising that this financial incentive for academic institutions has generated more momentum in the biotechnology industry. I would even argue that this intersection of academic and business medicine is ultimately beneficial for more aggressive, albeit money-driven, research & development. The qualm I have on this academic-industrial relationship, especially from reading of cases like that of Jesse Gelsinger and U. Penn. (1999), is the impact for patients in the clinical setting. This issue coincides in part with our discussions on the relationships of doctors with pharmaceutical companies. In that case, I argued that hospitals take greater control over checking and balancing this relationship. In this case, however, I wonder how efficient more communications and awareness-training for physicians, especially younger ones in training, at the individual level would be. More fast-acting structural changes might be needed, however, since currently, it is the older, more powerful physicians in the hospital or research administrations that might be heavily influencing choices on trials for patients.
At the more microscopic level, in the article “The Biotechnical Embrace”, Good argues: “Enthusiasm for medicine’s possibilities arises not necessarily from material products with therapeutic efficacy but through the production of ideas, with potential although not yet proven therapeutic efficacy.” Good goes on to argue that patients tend to invest in this “medical imaginary” enterprise—culturally, emotionally, and financially. As doctors invested in our patients’ health, I think that we need to be cognizant of the fact that conversations involving biotechnology-trials can have a sentimental effect, which in turn, can significantly affect life-altering decisions. However, I would argue that for many patients, hope is urgently needed in battling disease, and that this hope is sometimes simply clothed in the form of hope in the promising future of biotechnology. As discerning doctors, then, our job might be to recognize and continue to foster this need for hope, but not let it coincide 100% with a trust in the “medical imaginary.”
At the more microscopic level, in the article “The Biotechnical Embrace”, Good argues: “Enthusiasm for medicine’s possibilities arises not necessarily from material products with therapeutic efficacy but through the production of ideas, with potential although not yet proven therapeutic efficacy.” Good goes on to argue that patients tend to invest in this “medical imaginary” enterprise—culturally, emotionally, and financially. As doctors invested in our patients’ health, I think that we need to be cognizant of the fact that conversations involving biotechnology-trials can have a sentimental effect, which in turn, can significantly affect life-altering decisions. However, I would argue that for many patients, hope is urgently needed in battling disease, and that this hope is sometimes simply clothed in the form of hope in the promising future of biotechnology. As discerning doctors, then, our job might be to recognize and continue to foster this need for hope, but not let it coincide 100% with a trust in the “medical imaginary.”
Tuesday, November 10, 2009
Emergency Medicine
Although emergency care is necessary, the system is definitely being abused by too many people. The number 9-1-1 is not just for emergencies anymore, but may also present the idea that maybe we can get free medical care without having to see a primary care doctor and pay a co-pay. This mindset is common, but if one stops to think is it really worth it to pay $10,000 per night if one ends up getting admitted to the hospital? What about all of those real emergencies that we do not have enough ambulances to respond to? It is selfish for people to use and abuse our health care system. I can see that although it is wrong for people to do this, these are definite consequences of the current state of the health care system.
Within the Emergency room itself, there is the issue of overcrowding. Doctors provide care to thousands of people especially to those who are uninsured and have a lower socioeconomic status. People cannot afford insurance and cannot afford to see a health care provider and thus, wait until they are in dire need of medical attention to even go to the hospital. Doctors who work in the Emergency room are faced with these new challenges day in and day out. I am impressed by the obstacles they overcome outside of the clinical cases that they see. These obstacles can be anything from a language barrier to financial issues and not being able to pay without insurance. It is in the ER that many of America's health care issues surface and are brought to light. These are complex topics that I hope with the health care reforms will be addressed.
Within the Emergency room itself, there is the issue of overcrowding. Doctors provide care to thousands of people especially to those who are uninsured and have a lower socioeconomic status. People cannot afford insurance and cannot afford to see a health care provider and thus, wait until they are in dire need of medical attention to even go to the hospital. Doctors who work in the Emergency room are faced with these new challenges day in and day out. I am impressed by the obstacles they overcome outside of the clinical cases that they see. These obstacles can be anything from a language barrier to financial issues and not being able to pay without insurance. It is in the ER that many of America's health care issues surface and are brought to light. These are complex topics that I hope with the health care reforms will be addressed.
Monday, November 9, 2009
Reflecting on the E.D. Advantage
It is upsetting that the emergency department has become a source of primary care for so many Americans. I agree with Woo that the quintessential component and reward of primary care is longitudinal relationships. For example, she describes the joy of “[seeing] firsthand how social factors affect patients who have chronic diseases.” She also describes her fascination at witnessing how patients’ symptoms are a manifestation of various pathological, social, and personal factors. The use of emergency departments as primary care undermines this long-term and comprehensive patient-doctor relationship. And quite frankly, as a member of the future physician workforce, I feel a bit “cheated” of a fully meaningful relationship with my future patients as the American healthcare system depends more heavily on emergency rooms.
However, I tried out reflecting on this matter from a slightly different angle. I tried identifying myself as a member of the future generation of healthcare workers, or of social justice advocates, versus of physicians. From this angle, I was able to see more optimism in current trends of American healthcare usage. For example, the recent rise in emergency department use opens a critical portal for social workers to reach those who need such help. Were I a social worker, this trend would indicate the inadequacy of the current system to fully and timely meet individuals’ or communities’ health-related needs. However, because disease is often a physiological manifestation of less-than-ideal social, economic, and mental conditions, this national trend would identify for me a pool of individuals who could benefit from social services. I realize, though, that finding people in need of a social worker’s expertise is hardly a high-ranking enigma for the social work task force. There are probably plenty of people in America who would benefit from social services, and, as is the case for the health care system, need is not the factor in short supply.
However, I tried out reflecting on this matter from a slightly different angle. I tried identifying myself as a member of the future generation of healthcare workers, or of social justice advocates, versus of physicians. From this angle, I was able to see more optimism in current trends of American healthcare usage. For example, the recent rise in emergency department use opens a critical portal for social workers to reach those who need such help. Were I a social worker, this trend would indicate the inadequacy of the current system to fully and timely meet individuals’ or communities’ health-related needs. However, because disease is often a physiological manifestation of less-than-ideal social, economic, and mental conditions, this national trend would identify for me a pool of individuals who could benefit from social services. I realize, though, that finding people in need of a social worker’s expertise is hardly a high-ranking enigma for the social work task force. There are probably plenty of people in America who would benefit from social services, and, as is the case for the health care system, need is not the factor in short supply.
Saturday, November 7, 2009
Life and Mortality
Death is probably one of the most difficult issues that I would personally feel uncomfortable dealing with. After reading Pauline Chen's Final Exam, her experience reassured me that death isn't something that one will get used to even after many years of experience in medicine. The words, "I'm sorry for your loss," may unintentionally lose its meaning after being used thousands of times, but the emotions surrounding the death of a patient is a new and different one for the doctor every time.
What interests me the most are the various ways doctors handle discussing death and coping with death afterward. Doctors enter medicine in order to save lives. It is hard for them to give up on a patient when they have entered a field to learn the skills that could possibly help people with their illnesses. Who wouldn't want a doctor that will not give up and will do everything in their power to keep their patient alive? Although I think all of us want this to be our doctor, doctors are humans too. They get fatigued, cry, and laugh. A quote from Pauline Chen's novel reads:
"To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced."
I have to disagree with Dr. Chen. Doctors need both their emotional and scientific selves together in order to remain human and humane. Dying want care in their last hours and doctors should be able to provide it. Doctors shouldn't take one look at a patient and see medical cases. They should see the patient as a human too.
What interests me the most are the various ways doctors handle discussing death and coping with death afterward. Doctors enter medicine in order to save lives. It is hard for them to give up on a patient when they have entered a field to learn the skills that could possibly help people with their illnesses. Who wouldn't want a doctor that will not give up and will do everything in their power to keep their patient alive? Although I think all of us want this to be our doctor, doctors are humans too. They get fatigued, cry, and laugh. A quote from Pauline Chen's novel reads:
"To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced."
I have to disagree with Dr. Chen. Doctors need both their emotional and scientific selves together in order to remain human and humane. Dying want care in their last hours and doctors should be able to provide it. Doctors shouldn't take one look at a patient and see medical cases. They should see the patient as a human too.
Friday, November 6, 2009
Emergency!
In Hospital, the chief of emergency medicine at Maimonides explains why ER medicine is different from other kinds: our goal, he says, is not to cure the patient, but rather to make sure that the patient doesn’t die. ER doctors take particular pride in their line of work, as well they should—as seen in the Emergency! stories, they work brutal shifts, see bizarre and terrifying cases, must triage overflowing waiting rooms, and often deal with the sickest members of society, who have waited to seek medical care at the ER because they are not insured or their insurance does not cover them adequately.
One of the ironic things about emergency medicine is that it is probably one of the specialties that generates the most “press” about medical oddities and stories that might be found in News of the Weird, but it is also one of the most financially strained specialties as well. Similarly to the articles we read about financial disincentives behind the shrinking number of primary care doctors, ER doctors also feel that they are not entirely well-compensated for the life-saving measures they must take on a daily basis. Although many doctors complain about the sheer number of patients they have to see in order to keep waiting times down, the fact of the matter is that they are compensated per patient and not for the quality of work that they do, so that if the number of patients were reduced, their financial disincentives would be even greater. They must take on more and more cases just to stay in the red. This has to change in healthcare reform efforts. In addition to ER doctors’ woes, here is a New York Times article that reveals just how much EMTs and firefighters are becoming a part of peoples’ primary care as well: http://www.nytimes.com/2009/09/04/us/04firehouse.html?scp=1&sq=EMS%20firefighters%20medical&st=cse. I find it troubling that for so many, the ER has become the last and only resort for medical attention. Getting more people better primary care access must be pushed in legislation so that ER doctors can focus on truly life-threatening cases and so that these peoples’ health doesn’t deteriorate to the point at which they need to be taken to the hospital by ambulance for preventable diseases.
Many of the people who are taken to the ER for preventable diseases are also among the poorest and most stigmatized members of society. I feel that that the inconsistencies and emotions surrounding unequal economics really comes out in Rescuing Providence. Morse repeatedly admonishes the alcoholics, gang members, and other so-called “plagues” on society for not pulling themselves up by the bootstraps. Although they are victims of an inadequate social support system, they have to pull themselves out of the gutter to make it to the street, and although I found myself agreeing with Morse, I was also uneasily reminded about discussions about moralizing health and attaching stigma in my health inequality class. When and how can we blame people for their health condition? How can we convince people to take preventive measures? If more people took preventive measures, hopefully we would see less people in the ER.
One of the ironic things about emergency medicine is that it is probably one of the specialties that generates the most “press” about medical oddities and stories that might be found in News of the Weird, but it is also one of the most financially strained specialties as well. Similarly to the articles we read about financial disincentives behind the shrinking number of primary care doctors, ER doctors also feel that they are not entirely well-compensated for the life-saving measures they must take on a daily basis. Although many doctors complain about the sheer number of patients they have to see in order to keep waiting times down, the fact of the matter is that they are compensated per patient and not for the quality of work that they do, so that if the number of patients were reduced, their financial disincentives would be even greater. They must take on more and more cases just to stay in the red. This has to change in healthcare reform efforts. In addition to ER doctors’ woes, here is a New York Times article that reveals just how much EMTs and firefighters are becoming a part of peoples’ primary care as well: http://www.nytimes.com/2009/09/04/us/04firehouse.html?scp=1&sq=EMS%20firefighters%20medical&st=cse. I find it troubling that for so many, the ER has become the last and only resort for medical attention. Getting more people better primary care access must be pushed in legislation so that ER doctors can focus on truly life-threatening cases and so that these peoples’ health doesn’t deteriorate to the point at which they need to be taken to the hospital by ambulance for preventable diseases.
Many of the people who are taken to the ER for preventable diseases are also among the poorest and most stigmatized members of society. I feel that that the inconsistencies and emotions surrounding unequal economics really comes out in Rescuing Providence. Morse repeatedly admonishes the alcoholics, gang members, and other so-called “plagues” on society for not pulling themselves up by the bootstraps. Although they are victims of an inadequate social support system, they have to pull themselves out of the gutter to make it to the street, and although I found myself agreeing with Morse, I was also uneasily reminded about discussions about moralizing health and attaching stigma in my health inequality class. When and how can we blame people for their health condition? How can we convince people to take preventive measures? If more people took preventive measures, hopefully we would see less people in the ER.
Tuesday, November 3, 2009
The Chaos of the American ER
I’ve always thought of emergency medicine as one of those fascinating realms of medicine and hospital culture that are only attempted by the true “cowboys” of medicine. The men and women who crave the late hours, the adrenaline rush, and the truly frightening and fascinating cases. It is a realm of medicine that I would love to try for a month and probably burn out from within the course of a year.
Emergency is clearly the source of extraordinary fodder for medical drama shows. The “couple” who presented with a fork in the head and an injured groin was clearly adapted by Grey’s Anatomy. It is crazy and at times heartbreaking and leaves you with a group of stories that either reifies or makes you question your desire to go into medicine.
Some of the most impactful stories in Emergency were certainly those pertaining to the death of young children. It is one of those experiences and references that shakes one’s faith in healthcare and seems to defy the very point of medicine, to save the (once) young and healthy. The anguish felt by parents and as a result the human emotion perceived by doctors is one of those things that I imagine is and will be impossible to forget.
Another aspect of emergency room culture that becomes very clear while reading the book is that one will inevitably face bizarre and “unbelievable” patient encounters and as future doctors we are still expected to deliver healthcare in a judgment free way. The bizarre (and even gross) situations that patients get themselves into, whether it be self-castration or the insertion of foreign bodies into one’s body, will undoubtedly be jarring and even horrifying to deal with. Another apparent trend in emergency medicine is the increased use of hospitals as primary care facilities for the poor. Amidst the true emergencies and medical dilemmas that enter the emergency room each day, doctors and residents also face the time commitment of treating people for more common illnesses. While the number of cases treated in ERs are clearly trying, the stress felt by the doctors becomes apparent in books such as the House of God where one of the interns paid a patient to leave the ER.
The nature of ER medicine seems almost fantastical to me. In internal medicine or primary care one generally has a certain sense of normalcy or predictability that they can expect. Hopefully most patients will be scheduled and a doctor can plan accordingly. However, in EM the expectations are entirely different; a doctor must be able to respond to and treat a patient with little notice and often in the most trying of situations.
Emergency is clearly the source of extraordinary fodder for medical drama shows. The “couple” who presented with a fork in the head and an injured groin was clearly adapted by Grey’s Anatomy. It is crazy and at times heartbreaking and leaves you with a group of stories that either reifies or makes you question your desire to go into medicine.
Some of the most impactful stories in Emergency were certainly those pertaining to the death of young children. It is one of those experiences and references that shakes one’s faith in healthcare and seems to defy the very point of medicine, to save the (once) young and healthy. The anguish felt by parents and as a result the human emotion perceived by doctors is one of those things that I imagine is and will be impossible to forget.
Another aspect of emergency room culture that becomes very clear while reading the book is that one will inevitably face bizarre and “unbelievable” patient encounters and as future doctors we are still expected to deliver healthcare in a judgment free way. The bizarre (and even gross) situations that patients get themselves into, whether it be self-castration or the insertion of foreign bodies into one’s body, will undoubtedly be jarring and even horrifying to deal with. Another apparent trend in emergency medicine is the increased use of hospitals as primary care facilities for the poor. Amidst the true emergencies and medical dilemmas that enter the emergency room each day, doctors and residents also face the time commitment of treating people for more common illnesses. While the number of cases treated in ERs are clearly trying, the stress felt by the doctors becomes apparent in books such as the House of God where one of the interns paid a patient to leave the ER.
The nature of ER medicine seems almost fantastical to me. In internal medicine or primary care one generally has a certain sense of normalcy or predictability that they can expect. Hopefully most patients will be scheduled and a doctor can plan accordingly. However, in EM the expectations are entirely different; a doctor must be able to respond to and treat a patient with little notice and often in the most trying of situations.
Morbidity & Mortality
In her book, Dr. Pauline Chen discusses the role Morbidity & Mortality workshops play in doctors’ professional and personal lives. She discusses first her reactions at the ironic futility of it all—the emptiness that is left when a patient’s life and death are concisely summarized in such a workshop, then dismissed from conversation for eternity. She talks about the realistic mindsets of surgeons presenting in these sessions, defendants in a covert tribunal to decide where blame, if any, should be allocated. But then, later along in the book, Dr. Chen states that she finds such formalities to be potentially powerful, as long as their limitations are always kept in mind. I agree that there must be such formal avenues for doctors to discuss the morbidity and mortality of patients. By nature, these workshops can seem largely bureaucratic, or overly simplifying. However, as with Dr. Chen, these can and should play a role in stimulating often uncomfortable sentiments and further thinking for physicians at the individual level. Human words can sometimes play the role of gross and ironic understatement, especially in genuinely grave situations, I believe that formally set-up efforts to discuss or explore death is useful in helping physicians re-see the irony of how little words can account for human life and death.
Something that has been discussed during class throughout the semester is the morbidity and mortality of doctors themselves. Hacib Aoun, whom Dr. Chen writes about, experiences this first-hand when he is transmitted with HIV from the blood of one of his patients. In his lecture in published in Annals of Internal Medicine, he writes of seeing the artwork created by one of his patients: “It hit me violently that I had lost sight of my patients as human beings and had begun to see them as a different species: the patient species… The process of becoming a doctor is so protracted and arduous that it is easy to forget along the way the initial reasons and ideals for wanting to become a doctor, especially because the current medical curriculum is disease-oriented, not patient-oriented.” Dr. Chen discusses recent re-structuring of the currently Flexner-based medical curriculum around sessions that resemble M & M workshops. I also wonder if the medical curriculum could additionally incorporate opportunities for medical students and residents to reflect on and discuss their own vulnerabilities. This might prove to be a potent angle from which to develop more compassionate doctor-patient relationships that can deal more maturely with the morbidity and mortality of future patients.
Something that has been discussed during class throughout the semester is the morbidity and mortality of doctors themselves. Hacib Aoun, whom Dr. Chen writes about, experiences this first-hand when he is transmitted with HIV from the blood of one of his patients. In his lecture in published in Annals of Internal Medicine, he writes of seeing the artwork created by one of his patients: “It hit me violently that I had lost sight of my patients as human beings and had begun to see them as a different species: the patient species… The process of becoming a doctor is so protracted and arduous that it is easy to forget along the way the initial reasons and ideals for wanting to become a doctor, especially because the current medical curriculum is disease-oriented, not patient-oriented.” Dr. Chen discusses recent re-structuring of the currently Flexner-based medical curriculum around sessions that resemble M & M workshops. I also wonder if the medical curriculum could additionally incorporate opportunities for medical students and residents to reflect on and discuss their own vulnerabilities. This might prove to be a potent angle from which to develop more compassionate doctor-patient relationships that can deal more maturely with the morbidity and mortality of future patients.
Monday, November 2, 2009
Death and Mortality
As Chen writes in Final Exam, death is one of the most common experiences that physicians are not prepared for. I appreciated her completely open writing, and found that my own thoughts and experiences with death mirrored hers. Like her former medical student self, I have little experience with death, but am realizing that it is something I will deal with more and more as my family and friends grow older.
One of the medical student’s first experiences with a dead body is the anatomy lab. I have heard stories before about medical students moving from uneasy respect to nonchalance around their cadavers, developing affections like naming them, or what would seem like insults, like playing football over the bodies. This indicates that there are many responses to these cadavers, which are the manifestation of death. I found it interesting that Chen reconstructed her cadaver’s life through dissection. It is nigh-impossible, and perhaps not desirable, to overcome the empathetic instinct of trying to feel for a patient’s life story. Chen was attaching herself to her cadaver even though, as she writes, doctors are taught to exhibit “detached concern, secure uncertainty, and humanistic technology.” These descriptors, while they might seem to describe ideal clinical standards, are incredibly difficult to learn, and are truly ideals that medical students undershoot and overshoot until reaching some semblance of equilibrium. There is an illusion that all doctors can indeed be clinically detached, and when it comes to an issue as sensitive as death, this illusion can be difficult to maintain. Along with this notion, there is the expectation that a doctor, in being able to save lives, also has command over death, which is not true. Doctors struggle to reconcile external and internal expectations of being all-powerful medical professionals with the inevitability of death.
Similarly to Chen, I think that I have conceived of death as something mystical, that defies ordinary description and has an air of solemnity attached to it. It is a “big deal” as Dr. Israel writes in her New York Times piece, that doctors have to face on a weekly, if not daily, basis. Like many things, with repeated exposure, death can lose meaning, and a medical student might develop the coping mechanism of treating it as if he didn’t care, or even derisively. I wonder if doctors might have something to learn from the therapeutic methods that other groups of people who witness death teach. Doctors have the unique position of being the caregivers, the ones held responsible for a patient’s life or death, but could they learn from the experiences of nursing home workers? Soldiers’ accounts? Residents of neighborhoods with high homicide rates? One of the most powerful works I have encountered that explores the concept of death is All Quiet on the Western Front. While violent death by barbed wire is different from death on the operating table, I think it is the powerful idea of someone’s innate spark fading from existence that we can look at as some kind of shared human understanding.
One of the medical student’s first experiences with a dead body is the anatomy lab. I have heard stories before about medical students moving from uneasy respect to nonchalance around their cadavers, developing affections like naming them, or what would seem like insults, like playing football over the bodies. This indicates that there are many responses to these cadavers, which are the manifestation of death. I found it interesting that Chen reconstructed her cadaver’s life through dissection. It is nigh-impossible, and perhaps not desirable, to overcome the empathetic instinct of trying to feel for a patient’s life story. Chen was attaching herself to her cadaver even though, as she writes, doctors are taught to exhibit “detached concern, secure uncertainty, and humanistic technology.” These descriptors, while they might seem to describe ideal clinical standards, are incredibly difficult to learn, and are truly ideals that medical students undershoot and overshoot until reaching some semblance of equilibrium. There is an illusion that all doctors can indeed be clinically detached, and when it comes to an issue as sensitive as death, this illusion can be difficult to maintain. Along with this notion, there is the expectation that a doctor, in being able to save lives, also has command over death, which is not true. Doctors struggle to reconcile external and internal expectations of being all-powerful medical professionals with the inevitability of death.
Similarly to Chen, I think that I have conceived of death as something mystical, that defies ordinary description and has an air of solemnity attached to it. It is a “big deal” as Dr. Israel writes in her New York Times piece, that doctors have to face on a weekly, if not daily, basis. Like many things, with repeated exposure, death can lose meaning, and a medical student might develop the coping mechanism of treating it as if he didn’t care, or even derisively. I wonder if doctors might have something to learn from the therapeutic methods that other groups of people who witness death teach. Doctors have the unique position of being the caregivers, the ones held responsible for a patient’s life or death, but could they learn from the experiences of nursing home workers? Soldiers’ accounts? Residents of neighborhoods with high homicide rates? One of the most powerful works I have encountered that explores the concept of death is All Quiet on the Western Front. While violent death by barbed wire is different from death on the operating table, I think it is the powerful idea of someone’s innate spark fading from existence that we can look at as some kind of shared human understanding.
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