I participated in a 12-minute die-in for health care reform today on Sproul Plaza. We had to move a little down the path because of a huge display of bloody fetuses by an anti-abortion group, and the counter-protest by a pro-choice group. As I left, a student was stepping up to a microphone and welcoming everyone to a celebration of Filipino Awareness Month.
Just another Tuesday in Berkeley.
Tuesday, October 27, 2009
Sunday, October 25, 2009
Narratives
I heard a talk from Rachel Remen last week, whom I found extremely charming and inspiring, even though the talk was projected from a DVD. Apparently some people's charisma comes through even in virutal presence. Anyway, she offered the following anecdote:
Three stonecutters are sitting at their work stations cutting stone. The first is asked, "what are you doing here?" He answers, "I just sit and do the same thing every day, putting the stone through the cutter. It's terribly boring and mindless and I can hardly stay awake."
The second stonecutter is asked the same question and answers, "I am making money to support my family. Because of me my children are growing up healthy and learning about the world, and my whole family is happy."
The third stonecutter is asked, and responds like this: "I am helping to build a cathedral -- the most beautiful, most monumental building and a wonderful accomplishment of human cooperation and ingenuity."
The story tells us about the importance of the narrative. Each stonecutter is doing the exact same thing, but each bestows his own meaning to it. This is, of course, a lesson we can personally all take home as we try to bestow meaning to our own lives.
It's also relevant to my learning as a physician. A patient has his or her own narrative that will always affect the clinical encounter and the outcome of the case. In psychiatry, which I am just beginning to learn about and which for some reason makes me often think of the Jennifer Lopez movie The Cell, how the patient constructs his narrative is everything.
I asked my teacher, "But the idea of 'early life stresses'... doesn't it get blown out of proportion, and lead to blaming everything on the parents?"
But, and as her answer hinted, I don't think this is the right way to think of things. A medical model would tell you, well, stress here (and maybe a genetic predisposition) leads somewhere along the line to illness. But in psychiatry, we're not diagnosing that way. We're listening to what's going on in the patient's inner world, trying to understand how she conceives of her health, thoughts, and relationships to other people and things. It's not so much about what "really happened" but about how the patient has experienced those things.
The approach becomes not, "what is the stonecutter actually doing?" but rather, "How does the stonecutter construct his narrative about what he's doing?"
Three stonecutters are sitting at their work stations cutting stone. The first is asked, "what are you doing here?" He answers, "I just sit and do the same thing every day, putting the stone through the cutter. It's terribly boring and mindless and I can hardly stay awake."
The second stonecutter is asked the same question and answers, "I am making money to support my family. Because of me my children are growing up healthy and learning about the world, and my whole family is happy."
The third stonecutter is asked, and responds like this: "I am helping to build a cathedral -- the most beautiful, most monumental building and a wonderful accomplishment of human cooperation and ingenuity."
The story tells us about the importance of the narrative. Each stonecutter is doing the exact same thing, but each bestows his own meaning to it. This is, of course, a lesson we can personally all take home as we try to bestow meaning to our own lives.
It's also relevant to my learning as a physician. A patient has his or her own narrative that will always affect the clinical encounter and the outcome of the case. In psychiatry, which I am just beginning to learn about and which for some reason makes me often think of the Jennifer Lopez movie The Cell, how the patient constructs his narrative is everything.
I asked my teacher, "But the idea of 'early life stresses'... doesn't it get blown out of proportion, and lead to blaming everything on the parents?"
But, and as her answer hinted, I don't think this is the right way to think of things. A medical model would tell you, well, stress here (and maybe a genetic predisposition) leads somewhere along the line to illness. But in psychiatry, we're not diagnosing that way. We're listening to what's going on in the patient's inner world, trying to understand how she conceives of her health, thoughts, and relationships to other people and things. It's not so much about what "really happened" but about how the patient has experienced those things.
The approach becomes not, "what is the stonecutter actually doing?" but rather, "How does the stonecutter construct his narrative about what he's doing?"
Sunday, September 13, 2009
Counting Down the Hours
These are lyrics from a band that I'm a little obsessed with. On bad days, this is what I feel like about my hearing.
And I go on
Wondering if I've got a soul and
Counting down the hours 'til it goes
-- Ted Leo and the Pharmacists, "Counting Down the Hours"
And I go on
Wondering if I've got a soul and
Counting down the hours 'til it goes
-- Ted Leo and the Pharmacists, "Counting Down the Hours"
Wednesday, September 9, 2009
Insight and humanity
There's a concept in psychiatry that most of us don't consider often. Insight, defined in my intro to clinical psychiatry book as, "the patient's awareness of his or her mental illness and the ability to connect this disturbance to other problems", is not really the most important important aspect of a patient's mental state from a diagnostic perspective.
But what strikes me is that insight is perhaps the most important factor in determining our emotional reaction to the patient. Consider an older patient with dementia, for example. He is losing his mind, forgetting who his children are, giving them gruff and slightly wary welcomes when they come to visit. Maybe we roll our eyes, shake our heads a little as we repeat what we've been telling him for weeks, that his visitors are his family, and he should be nice and sit and talk with them for awhile.
Now consider the same patient, who, in a moment of insight, realizes that his mind is slipping away past his reach. A lifetime of professional accomplishments and personal connections is blurring into an oblivion that he recognizes as the path towards the end. Our patient has now gone from a sweet old nuisance to a tragedy.
Why? What is it about this one feature that evokes such a an empathetic response? I think it's because insight gets at what makes us human. Ants will never have the insight into their situation aside from an instinct to run when they see large objects moving quickly near them. Insight implies a broader realization, a conceptual understanding of illness and one's relationship to it.
Ancient playwrights knew that insight is the stuff tragedy is made of: the entire, horrible events that lead to Oedipus's putting his eyes out happen before the play starts. Things only turn tragic when Oedipus realizes what has occurred -- when he gains insight.
Although embedded within the endless descriptive terminology that psychiatry uses, insight describes more than a symptom of an illness. It describes an expression of humanity.
But what strikes me is that insight is perhaps the most important factor in determining our emotional reaction to the patient. Consider an older patient with dementia, for example. He is losing his mind, forgetting who his children are, giving them gruff and slightly wary welcomes when they come to visit. Maybe we roll our eyes, shake our heads a little as we repeat what we've been telling him for weeks, that his visitors are his family, and he should be nice and sit and talk with them for awhile.
Now consider the same patient, who, in a moment of insight, realizes that his mind is slipping away past his reach. A lifetime of professional accomplishments and personal connections is blurring into an oblivion that he recognizes as the path towards the end. Our patient has now gone from a sweet old nuisance to a tragedy.
Why? What is it about this one feature that evokes such a an empathetic response? I think it's because insight gets at what makes us human. Ants will never have the insight into their situation aside from an instinct to run when they see large objects moving quickly near them. Insight implies a broader realization, a conceptual understanding of illness and one's relationship to it.
Ancient playwrights knew that insight is the stuff tragedy is made of: the entire, horrible events that lead to Oedipus's putting his eyes out happen before the play starts. Things only turn tragic when Oedipus realizes what has occurred -- when he gains insight.
Although embedded within the endless descriptive terminology that psychiatry uses, insight describes more than a symptom of an illness. It describes an expression of humanity.
Saturday, August 29, 2009
O.I.B.
I have an ongoing mental list of "only in Berkeley" occurrences, that I'm now going to start as an electronic list.
1. At the live broadcast of new president Obama's inauguration speech on the Berkeley campus, the mention of "nonbelievers" gets the biggest cheer of the day. OIB.
2. On an afternoon jog up in the Berkeley hills, on a quiet residential street, I run into a group of Code Pink protesters, apparently camped out in front of the house of a Berkeley professor who has been implicated in some sort of Evil. OIB.
3. The squirrel that has come into the Free Speech Cafe on campus wanders around freely for several minutes, gaining only some raised eyebrows and shrugs, even from the cafe staff. I finally chase it out, because I realize no one else will. OIB.
More to come, I'm sure; never a dull day in the Republic of Berkeley.
1. At the live broadcast of new president Obama's inauguration speech on the Berkeley campus, the mention of "nonbelievers" gets the biggest cheer of the day. OIB.
2. On an afternoon jog up in the Berkeley hills, on a quiet residential street, I run into a group of Code Pink protesters, apparently camped out in front of the house of a Berkeley professor who has been implicated in some sort of Evil. OIB.
3. The squirrel that has come into the Free Speech Cafe on campus wanders around freely for several minutes, gaining only some raised eyebrows and shrugs, even from the cafe staff. I finally chase it out, because I realize no one else will. OIB.
More to come, I'm sure; never a dull day in the Republic of Berkeley.
Tuesday, June 16, 2009
HIV in the porn industry: time for regulation
I know, it seems like a strange cause to take up.
But the fact is, being a porn actor puts one at huge risk for STIs including HIV. I wish I had a good and shocking comparison, along the lines of, "being an average porn star for one year is equivalent to riding a motorcycle on a crowded indie speedway without a helmet for a month without stopping", but I don't have any statistics. (And someone should really look into calculating that risk!)
You get the idea, though; being in pornography with the very limited regulation currently in effect is running a huge health risk, and no one should be required to do that to keep his or her job. The recent revelation that a porn actress had tested positive for HIV and possibly infected a costar and her boyfriend prompted the apparently hushed-up fact that several others in the industry have become infected with HIV in the last 5 years. Thousands have tested positive for Gonorrhea and Chlamydia.
The heterosexual porn industry has rejected suggestions that regulation include mandatory condom use, and actors who demand condom use are often not asked back for further work. (Meanwhile, because HIV is so prevalent in the gay community, gay porn studios generally require condom use.) The current regulation around safety in the industry is that actors must arrive on set with the results of an HIV PCR test. However, HIV testing is not flawless, as a cluster of cases in the porn industry in 2004 showed; further, requiring that actors pay for testing on their own, and dismissing anyone who is HIV-positive, is illegal.
As this article (which you can download for free! I love Plos Medicine!) argues, regulation of the porn industry must involve condoms, which will lower risk of STIs and HIV significantly -- and carry the added bonus of normalizing condom use for viewers. The industry apparently thinks that people will stop watching porn if actors are wearing condoms, something that hasn't played out in the gay porn industry. State regulators need to show some backbone and stand up to the industry in order to protect porn actors and their partners.
(On a side note: is this blog getting too soapboxy? I figured that if there was anyone reading this blog, a good use of it might be to write persuasive arguments about issues arising in medicine and public health... but if no one reads it because it's too preachy, it defeats itself.)
But the fact is, being a porn actor puts one at huge risk for STIs including HIV. I wish I had a good and shocking comparison, along the lines of, "being an average porn star for one year is equivalent to riding a motorcycle on a crowded indie speedway without a helmet for a month without stopping", but I don't have any statistics. (And someone should really look into calculating that risk!)
You get the idea, though; being in pornography with the very limited regulation currently in effect is running a huge health risk, and no one should be required to do that to keep his or her job. The recent revelation that a porn actress had tested positive for HIV and possibly infected a costar and her boyfriend prompted the apparently hushed-up fact that several others in the industry have become infected with HIV in the last 5 years. Thousands have tested positive for Gonorrhea and Chlamydia.
The heterosexual porn industry has rejected suggestions that regulation include mandatory condom use, and actors who demand condom use are often not asked back for further work. (Meanwhile, because HIV is so prevalent in the gay community, gay porn studios generally require condom use.) The current regulation around safety in the industry is that actors must arrive on set with the results of an HIV PCR test. However, HIV testing is not flawless, as a cluster of cases in the porn industry in 2004 showed; further, requiring that actors pay for testing on their own, and dismissing anyone who is HIV-positive, is illegal.
As this article (which you can download for free! I love Plos Medicine!) argues, regulation of the porn industry must involve condoms, which will lower risk of STIs and HIV significantly -- and carry the added bonus of normalizing condom use for viewers. The industry apparently thinks that people will stop watching porn if actors are wearing condoms, something that hasn't played out in the gay porn industry. State regulators need to show some backbone and stand up to the industry in order to protect porn actors and their partners.
(On a side note: is this blog getting too soapboxy? I figured that if there was anyone reading this blog, a good use of it might be to write persuasive arguments about issues arising in medicine and public health... but if no one reads it because it's too preachy, it defeats itself.)
Thursday, June 11, 2009
F*@# the AMA
This is making me so angry I can hardly even think. The American Medical Association has a stated mission "to promote the art and science of medicine and the betterment of public health." How an organization with this mission, composed of supposedly human beings who have taken the Hippocratic Oath (or the Lasagna Oath, which we know I love!) to "do no harm" can oppose a system that would improve health coverage to Americans is beyond me.
They say that having a public insurance provider would "restrict patient choice" by driving out private insurers, a logic I'm not even sure I understand. But let's look at the "patient choice" available right now: how many people, even those lucky few with good private coverage, can say they have the choice they'd like in providers? And as this blogger points out, the private insurers enjoy such hegemony over the industry right now that they can raise premiums as they wish, padding the pockets of their wealthy CEOs, thus often driving individuals and businesses into bankruptcy. (Health care costs are the main cost of individual bankruptcy filings in the U.S.) In a free market system, which the AMA seems to tout as king, supply and demand are in communication -- they aren't mediated by HMOs with price-setting behind closed doors in a mysterious, non-transparent process probably influenced by big Pharma and big Insurance.
I guess the AMA's stance shouldn't surprise anyone, because it seems that it has a long history of opposing plans that help people, including Medicare. I honestly don't think the AMA is an evil cabal of specialists trying to make sure they can easily afford next year's timeshare in the Hamptons, although there's probably some of that too. I think most of it is a subconsious reaction that many Americans have that equates "government-controlled" with "inefficient". What Americans must realize is that health is not a commodity like any other, and that American health and productivity do not benefit when health insurance companies make money. Sure, government can be inefficient; it would be the responsibility of the overseeing agencies to make sure that it is run well and makes use of all the current technologies and strategies for maximizing service output. But the current system of armies of actuarial specialists setting premiums based on risk is far more inefficient. A public system has the potential to make Americans healthier than they've been for decades, at lower costs. Under the current, privatized system, there will always be people slipping through the cracks. Anyone who wants to get as angry as I am should just visit a community free clinic and chat for awhile with its clients.
Physicians for a National Health Program is an organization that advocates for single-payer healthcare -- care provided to all Americans by government agencies, with provision of care managed privately. This is the only way to give Americans real choice in their care, and real coverage for their health problems. Obama's plan doesn't go far enough, but it's a step in the right direction. The AMA's stance is 50 steps back.
They say that having a public insurance provider would "restrict patient choice" by driving out private insurers, a logic I'm not even sure I understand. But let's look at the "patient choice" available right now: how many people, even those lucky few with good private coverage, can say they have the choice they'd like in providers? And as this blogger points out, the private insurers enjoy such hegemony over the industry right now that they can raise premiums as they wish, padding the pockets of their wealthy CEOs, thus often driving individuals and businesses into bankruptcy. (Health care costs are the main cost of individual bankruptcy filings in the U.S.) In a free market system, which the AMA seems to tout as king, supply and demand are in communication -- they aren't mediated by HMOs with price-setting behind closed doors in a mysterious, non-transparent process probably influenced by big Pharma and big Insurance.
I guess the AMA's stance shouldn't surprise anyone, because it seems that it has a long history of opposing plans that help people, including Medicare. I honestly don't think the AMA is an evil cabal of specialists trying to make sure they can easily afford next year's timeshare in the Hamptons, although there's probably some of that too. I think most of it is a subconsious reaction that many Americans have that equates "government-controlled" with "inefficient". What Americans must realize is that health is not a commodity like any other, and that American health and productivity do not benefit when health insurance companies make money. Sure, government can be inefficient; it would be the responsibility of the overseeing agencies to make sure that it is run well and makes use of all the current technologies and strategies for maximizing service output. But the current system of armies of actuarial specialists setting premiums based on risk is far more inefficient. A public system has the potential to make Americans healthier than they've been for decades, at lower costs. Under the current, privatized system, there will always be people slipping through the cracks. Anyone who wants to get as angry as I am should just visit a community free clinic and chat for awhile with its clients.
Physicians for a National Health Program is an organization that advocates for single-payer healthcare -- care provided to all Americans by government agencies, with provision of care managed privately. This is the only way to give Americans real choice in their care, and real coverage for their health problems. Obama's plan doesn't go far enough, but it's a step in the right direction. The AMA's stance is 50 steps back.
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