tag:blogger.com,1999:blog-81288257660628747282024-02-18T21:22:26.080-08:00Following LasagnaRicahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.comBlogger71125tag:blogger.com,1999:blog-8128825766062874728.post-33656692660912928292011-04-04T18:12:00.000-07:002011-04-04T19:08:31.074-07:00The saddest roundsToday's rounds were the saddest I've ever been a part of.<br /><br />Mrs. R has tracheal cancer. It is metastatic and terminal. She's received treatment already- a trach tube, chemotherapy- and there is no more that we can offer her. She can't speak, so she writes, whenever there is something more complicated than can be communicated with a nod or a gesture. Her level of education is low, and she writes in all capital letters, and mis-spells words- which somehow makes thing even more poignant. Something about those few words in large capital letters, a few letters swapped here and there, seems very urgent, very desperate. We ask her how she's doing, and she shakes her head.<br />"What is it, Mrs. R? What's wrong?"<br />I push over the pen and paper, and lower the table so she can write to us.<br />I CALL AND NO ONE COME 4 HOURS<br />"You tried to call your nurse? You needed something?"<br />6-10 LAST NIGHT<br />We apologize, we try to reassure Mrs. R that we will do everything we can to make sure she's comfortable. She had had trouble breathing last night, and nursing reports this morning were of liquid tube feedings oozing out around her trach site-- not a good sign, and not something you'd want to happen to a woman receiving "comfort care". Suffocating on your food is far from comfortable. In fact, we discuss in the hall, what may be best for Mrs. R's comfort right now is to stop the tube feeds altogether. Which is a dismal thought, but indeed perhaps better than a death due to choking on liquid feeding formula.<br /><br />From there we go upstairs to visit Mr. M. Mr. M has bladder cancer that obstructs his urinary tract, and for which the only treatment is surgery. Which he cannot have, because his heart is not strong enough to survive it. He has been on our service for weeks, first while we negotiated with the surgery team whether there wasn't some way to get Mr. M the only surgery that would save his life- and then, when that failed, to arrange for hospice placement. Today we have good news: there is a bed for him at a small facility run by nuns, that the social worker assures us is lovely. <br /><br />When we walk in the room, a chaplain is sitting on the edge of Mr. M's bed, and I can tell by his body language that they have gotten to know each other well over the last few weeks. We tell Mr. M the good news. It's hard to hear his response because he speaks softly and has no teeth, so we are all leaning forward. The resident is about to answer the question he thinks was asked, which is, "How long do I have to live?" when the chaplain corrects him. <br /><br />"No, he said, 'how long will the rehabilitation be?'"<br /><br />We look at each other, a little panicked. The resident wants to be straightforward, to convey to the patient what everyone else in the room understands and accepts, because it is not our life's end that we are discussing, and it is much easier to avoid denial when it is someone else's death. But he also does not want to be blunt and heartless; he wants to maintain good rapport with his patient. And so he dances around his words a little. Not enough to seem dishonest; but enough to seem a little uncomfortable, which to me is reassuring: seamlessness when discussing the end of a patient's life betrays overconfidence, or something worse.<br /><br />"Mr. M, what we want you to understand is that this cancer that you have, we think it's the thing that... that will ultimately be the cause of your death."<br /><br />More questions from Mr. M., increasingly desperate: Why can't I have the operation? Why didn't they find my cancer sooner? Why can't you just take the tubes out and let me be?<br /><br />"Mr. M," the resident continues, still trying to find the right mix of straightforward and comforting, "you need to understand that if we take those tubes out, you'll... you'll pass away in the next few days."<br /><br />Mr. M is struck silent, finally tells us that he wants to be alone, and we walk out. We talk about the difficulty in accepting an approach that does not have cure as its objective, and the necessity of explaining the same thing several times over, of not assuming the patient is at the same stage of acceptance that you are. We write our orders and move on to the next patient, because there's no time in the middle of rounds to linger on sadness.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com3tag:blogger.com,1999:blog-8128825766062874728.post-28325519005505127662010-12-01T19:55:00.000-08:002010-12-01T20:02:26.809-08:00On case presentationsThe attending's advice:<br /><br />"Tell it to me like you're trying to sell me a car.<br /><br />...But, you know, tell the truth too."Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-76743154352333414022010-09-13T18:49:00.001-07:002010-09-13T18:56:35.623-07:00Revelation of the DayUncanny similarities....<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYHLeWAeIlbhgVjVT73KOsDcCPkXqruv5Q-IELtJs8Fy32R-EGo8rGqAVvbyQ67_B9rHGmzZB49gYSV8x8MrZL3T3tYANR737QCAnDJtVRYE3XoyXHMQjmJ2REhYyzZiquqRzMUF4_FivS/s1600/laparoscopy.gif"><img style="float: left; margin: 0pt 10px 10px 0pt; cursor: pointer; width: 320px; height: 314px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYHLeWAeIlbhgVjVT73KOsDcCPkXqruv5Q-IELtJs8Fy32R-EGo8rGqAVvbyQ67_B9rHGmzZB49gYSV8x8MrZL3T3tYANR737QCAnDJtVRYE3XoyXHMQjmJ2REhYyzZiquqRzMUF4_FivS/s320/laparoscopy.gif" alt="" id="BLOGGER_PHOTO_ID_5516581144292615698" border="0" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiC31bm7paVDa3zQOJWk1LC3ZRSJY1R4JrFOI0LMhgi0d-WpGr4HONJ6bYCvUU8-nMoMIVGpIHHb3okX_F_4xmHqz3sPK7qgg6nryq8bq2XpxfbtYhsl7dK_R8Z7bOge8UiC-BUKWfJS47x/s1600/maxi-claw-crane.jpg"><img style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 194px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiC31bm7paVDa3zQOJWk1LC3ZRSJY1R4JrFOI0LMhgi0d-WpGr4HONJ6bYCvUU8-nMoMIVGpIHHb3okX_F_4xmHqz3sPK7qgg6nryq8bq2XpxfbtYhsl7dK_R8Z7bOge8UiC-BUKWfJS47x/s320/maxi-claw-crane.jpg" alt="" id="BLOGGER_PHOTO_ID_5516581284353850930" border="0" /></a>Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-26647558771849734212010-07-07T16:34:00.000-07:002010-07-07T17:16:53.139-07:00On surgeons and being nice"Nice doctors kill people," the surgeon told me, apropos of a question I'd directed elsewhere.<br /><br />He explained: when doctors spare their patients pain by skipping tests or aspects of the physical exam that are uncomfortable, they end up harming the very people they'd set out to help. And he has a point: If you don't palpate an abdomen because your patient has belly pain, you could miss a surgical abdomen, and your patient could die (this resembles something that happened recently on the pedi ward, although I don't think that death was preventable; but that was the version of events that happened in the responsible resident's head).<br /><br />But I wondered: can't you be nice and competent at the same time?<br /><br />Sometimes I think, yes, of course, the best doctors are those who are nice and who listen and explain things clearly and give an encouraging smile before leaving the room. With something as complex as health, in which the power of the mind is startling and patients' outcomes have more than a little to do with their attitudes, being nice may actually heal.<br /><br />But, I do understand his point. And the more I work with surgeons, the more I get it: being nice doesn't take you very far if it means you skip more tests or spend less time learning about more effective treatments and procedures or pay less attention to the detailed nature of your daily tasks. There's only so much time for learning and teaching in one day. If you're the average patient, you don't want a doctor who will scream at you, but you really don't want a doctor who doesn't know enough to perform procedures well. <br /><br />So, while you can always be nice, and there's no justification for flat-out aggression, there probably is some trade-off between niceness and competence.<br /><br />And it might just be that I've spent the last two weeks walking amongst them, but I'm feeling more like an asshole surgeon every day. What do I need to know before walking into the OR-- the name of the patient, or the name of the procedure? Well, it would be nice to know the patient's name, but as a surgical student, what's more important is the procedure. And I kinda like working with assholes: at least you know where you stand, and you know you can push back and have that be perceived as strong rather than pushy.<br /><br />This probably has a lot to do with my background of being a nice person with a focus on the more behavioro-psycho-social aspects of medicine. Coming from a place in which surgeon is a dirty word (a figurative place, that is; wouldn't want to implicate of my previous places of learning), I can only be pleasantly surprised by the surgeon's perspective as I learn to adopt it. Competence, after all, is what any patient wants more than anything else that his or her physician might offer.<br /><br />So, another realization in the road to medical knowledge, and another goal: to find the right balance between competent and nice.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com4tag:blogger.com,1999:blog-8128825766062874728.post-86234673797726237192010-02-08T22:28:00.000-08:002010-02-09T16:08:28.707-08:00Eulogy for ENMy assignment was to write a reflection on the experience of having, or not having, a longitudinal geriatric patient. I wrote this. It's probably not what my teacher wants.<br /><br /><br /><span style="font-family: arial;">My patient, EN, was overall a very healthy 81 year-old at our first meeting in April of 2008. She had also recently been diagnosed with SCLC in January of that year, as an incidental finding on CXR taken when she was in the ER for a pulmonary embolism. When I first spoke to her, she seemed to understand what that diagnosis implied, but was resigned to everything her future had in store – especially in light of having been a “heavy smoker” in her youth and middle age. However, she was quite upbeat throughout the interview, joking about family members and friends in the residence in which she and my preceptor lived. I was also able to create a good rapport with her because she was friendly and welcoming, and because we shared a love of travel – hers evident in the world photographs on the walls of her apartment. For a few moments after the H&P was over, we had a chance to talk about Africa, where I had spent two years as a Peace Corps volunteer and a few months as a researcher. She had been to South Africa recently, saying that after Apartheid ended, she “just had to go”. And that people in her generation never thought they would “see a free South Africa”. </span><br /><br /><span style="font-family: arial;">EN clearly valued family and spoke fondly of her daughters, but was too independent to follow them to the cities in which they lived. Instead, she spoke of traveling with them. At our third visit, EN told me she and her three children had traveled over the Christmas holiday to the home in which she grew up in Connecticut. It was something she had long hoped to do; I got the sense that having accomplished that visit, EN felt that much closer to a peaceful death. </span><br /><br /><span style="font-family: arial;">My visits with EN were not free of awkwardness. Knowing something about the prognosis for SCLC, I never knew exactly how to ask about EN’s plans for how she would maintain her health, which was necessarily unsteady. I said goodbye not knowing if I would be able to greet her again. On our third visit, EN was hooked up to an oxygen tank, which was out of sight in her room as we talked in the living room. The cannula snaked around the coffee table and back through the doorway. I tried to appreciate the freedom that the device allowed, rather than concentrate on the loss of function that it signified. </span><br /><br /><span style="font-family: arial;">My preceptor wrote me that EN died a few months after it happened. He told me he’d spoken at her memorial service, and told everyone that she had insisted on following up with the medical students whom she’d begun to see despite its increasing difficulty. I appreciated this, and, strangely, didn’t feel sadness, exactly. I felt the loss of a strong and unique person, and I imagined the photographs being taken down from her apartment by her children and the oxygen tank returned to the hospital or medical supply unit. But it occurred to me that sadness is a syrupy emotion, provoked by displays of pathos. EN, never wishing to be anyone’s victim, never projected that. She resisted portraying herself as weak and incapable, choosing instead to relate to others on the basis of shared interests and ideas. She will be missed, but never whimpered over.</span><p face="arial" class="MsoNormal"></p>Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com2tag:blogger.com,1999:blog-8128825766062874728.post-74636335193883004562009-12-09T11:22:00.000-08:002009-12-09T12:21:33.769-08:00Sympathy for the factitious patientI went to the student health center last week for my annual exam. I showed up a few minutes late, and so rushed to fill out the paperwork while in the waiting room, expecting to be frowned at and told I should have arrived on time.<br /><br />Instead, I was met with smiling faces, as the nurse ushered me in to an examining room, allowing me to drop my bag and jacket, before guiding me to a seat in the hall from where to take my blood pressure and temperature.<br /><br />"Well, isn't that nice," I thought. "Like having a personal aide who tells you where to be and administers personalized services." Right then, I understood -- well, to some extent -- <a href="http://www.patient.co.uk/doctor/Munchausen%27s-Syndrome.htm">Munchausen Syndrome</a> patients. <br /><br />Patients with this disorder manufacture symptoms in themselves, usually through ingestion of toxic substances or inappropriate medications, in order to receive attention from healthcare professionals. While I don't really think I'd ever be capable of that -- Munchausen patients generally have personality disorders or history of abuse, so there's more going on than just a desire for some attention.<br /><br />But in a very impersonal world, in which you can get through a day, or maybe a week, or maybe more, without any real meaningful human contact, especially if you're perhaps a little introverted or perhaps have a small-feeling job in a cubicle, this kind of attention feels really nice. It's attention not to how much work your team has produced or when you have entered and exited the building, but to you and your well-being. For a few moments, the efforts and thoughts of several professionals are focused just on you, and nowhere else. I don't have a small-feeling cubicle job, and am a student in what is maybe the most attention-intensive medical program in the country. But I can most definitely understand the desire to prolong those moments in the clinic.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com3tag:blogger.com,1999:blog-8128825766062874728.post-53772406863018573882009-11-17T16:32:00.000-08:002009-11-17T16:33:43.191-08:00It comes from all sidesMe: "Do you have any advice for me as a medical student?"<br /><br />Patient: "Study incessantly."Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com2tag:blogger.com,1999:blog-8128825766062874728.post-40438436440022487512009-11-11T22:27:00.000-08:002010-01-03T10:53:30.252-08:00Jumping off the hedonistic treadmill<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMHNImr_p4RlLzReN4ydgeH-q-Mn_iC-Xhh9YbnAxrx6hh3lyBPWrMliX6nW5q3ke6S51wXjXbGUaYIwqjCDNLHFVj0-JHLJIsaoiK1f3uKCx-TN7nw5Pr-t6JOM1lzn3NtFKVBuiV5Txj/s1600-h/treadmill.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMHNImr_p4RlLzReN4ydgeH-q-Mn_iC-Xhh9YbnAxrx6hh3lyBPWrMliX6nW5q3ke6S51wXjXbGUaYIwqjCDNLHFVj0-JHLJIsaoiK1f3uKCx-TN7nw5Pr-t6JOM1lzn3NtFKVBuiV5Txj/s320/treadmill.jpg" alt="" id="BLOGGER_PHOTO_ID_5403101112301180066" border="0" /></a><br />I really like <a href="http://www.slate.com/blogs/blogs/happinessproject/archive/2009/11/02/a-secret-to-happiness-that-i-overlooked-until-now.aspx">this entry</a> from Slate's Happiness Project. In it, the author talks about how, after getting a case of conjunctivitis, she had to stop wearing contact lenses. And it was only through this experience that she realized how happy she was to have the convenience of contact lenses -- which, without this deprivation, she took for granted and even sometimes complained about, given how much of a pain it was to put them in and take them out.<br /><br />The problem is that becoming accustomed to all of our conveniences and privileges creates a "hedonistic treadmill", in which we continue on at a steady pace without appreciating what we have.<br /><br />Having a fluctuating hearing loss is often frustrating, bothersome, and difficult, but there's this thing: when it bounces back up from its low dips, I get insanely happy. Having five senses that work! Being able to meet new and interesting people! The world is my oyster. Somehow, having this hearing loss has allowed me to jump off the hedonistic treadmill.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-68433538847623817062009-10-27T16:52:00.000-07:002009-10-27T17:07:49.740-07:00Only in Berkeley event of the dayI participated in a 12-minute <a href="http://www.dailycal.org/article/107190/why_healthcare_reform_is_personal_and_needed_now">die-in for health care reform</a> today on Sproul Plaza. We had to move a little down the path because of a huge display of <a href="http://www.jillstanek.com/archives/2009/10/gap_takes_abort.html">bloody fetuses</a> by an anti-abortion group, and the <a href="http://www.indybay.org/newsitems/2009/10/27/18626847.php">counter-protest</a> 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.<br /><br />Just another Tuesday in Berkeley.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-80435570783530025732009-10-25T23:02:00.000-07:002009-10-25T23:27:12.357-07:00NarrativesI heard a talk from <a href="http://www.rachelremen.com/">Rachel Remen </a>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:<br /><br />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."<br /><br />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."<br /><br />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."<br /><br />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.<br /><br />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 <a href="http://www.imdb.com/title/tt0209958/">The Cell</a>, how the patient constructs his narrative is everything.<br /><br />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?"<br /><br />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. <br /><br />The approach becomes not, "what is the stonecutter <span style="font-style: italic;">actually </span>doing?" but rather, "How does the stonecutter construct his narrative about what he's doing?"Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-6322806516279501702009-09-13T13:37:00.000-07:002009-09-13T13:50:32.800-07:00Counting Down the HoursThese are lyrics from a band that I'm a little obsessed with. On bad days, this is what I feel like about my hearing.<br /><br />And I go on<br />Wondering if I've got a soul and<br />Counting down the hours 'til it goes<br /><br />-- Ted Leo and the Pharmacists, "Counting Down the Hours"Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com1tag:blogger.com,1999:blog-8128825766062874728.post-23949102841984961332009-09-09T16:42:00.001-07:002009-09-09T17:15:14.515-07:00Insight and humanityThere'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. <br /><br />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.<br /><br />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.<br /><br />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. <br /><br />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 <span style="font-style: italic;">before</span> the play starts. Things only turn tragic when Oedipus realizes what has occurred -- when he gains insight.<br /><br />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.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com2tag:blogger.com,1999:blog-8128825766062874728.post-75173106268762020922009-08-29T16:27:00.000-07:002009-08-29T16:37:15.948-07:00O.I.B.I have an ongoing mental list of "only in Berkeley" occurrences, that I'm now going to start as an electronic list.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />More to come, I'm sure; never a dull day in the Republic of Berkeley.<br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-49114236634125722122009-06-16T22:58:00.001-07:002009-06-16T23:37:08.033-07:00HIV in the porn industry: time for regulationI know, it seems like a strange cause to take up.<br /><br />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!)<br /><br />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 <a href="http://www.latimes.com/news/local/la-me-porn-hiv11-2009jun11,0,2783528.story">revelation</a> that a porn actress had tested positive for HIV and possibly infected a costar and her boyfriend prompted the apparently hushed-up fact that <a href="http://www.latimes.com/news/local/la-me-porn-hiv12-2009jun12,0,3569962.story">several others</a> in the industry have become infected with HIV in the last 5 years. Thousands have tested positive for Gonorrhea and Chlamydia.<br /><br />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.<br /><br />As <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040126">this article</a> (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. <br /><br />(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.)<br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com1tag:blogger.com,1999:blog-8128825766062874728.post-13414043759357625972009-06-11T11:22:00.000-07:002009-06-11T12:16:26.711-07:00F*@# the AMA<a href="http://www.nytimes.com/2009/06/11/us/politics/11health.html">This </a>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 <a href="http://en.wikipedia.org/wiki/Louis_Lasagna">Lasagna Oath</a>, which <a href="http://themedschoolblog.blogspot.com/2007/09/med-school-blog-take-i.html">we know</a> I love!) to "do no harm" can oppose a system that would improve health coverage to Americans is beyond me.<br /><br />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 <a href="http://www.huffingtonpost.com/bob-cesca/the-health-insurance-mafi_b_214098.html">this blogger</a> 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.<br /><br />I guess the AMA's stance shouldn't surprise anyone, because it seems that it has a <a href="http://www.huffingtonpost.com/2009/06/11/american-medical-associat_n_214132.html">long history of opposing plans that help people</a>, 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 <span style="font-style: italic;">can </span>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.<br /><br /><a href="http://www.pnhp.org/">Physicians for a National Health Program</a> is an organization that advocates for single-payer healthcare -- care provided to <span style="font-style: italic;">all </span>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.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com2tag:blogger.com,1999:blog-8128825766062874728.post-1948803670882467062009-05-18T21:50:00.000-07:002009-05-18T22:00:24.187-07:00Ah, the internet<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu6v22aM9C14cy6US3TssfnMjKLZFe5_qXDHSxqDsE72-sEVgvv7hvTx6lGRj-EzR5uw2r5ZWkYmKCU5m8bEwnvdSoV4c54pTm_g43aBpk8GxcPXXjW0gUiPtGeYmRkLoubZjLNBLyKoLY/s1600-h/mcp.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 211px; height: 307px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu6v22aM9C14cy6US3TssfnMjKLZFe5_qXDHSxqDsE72-sEVgvv7hvTx6lGRj-EzR5uw2r5ZWkYmKCU5m8bEwnvdSoV4c54pTm_g43aBpk8GxcPXXjW0gUiPtGeYmRkLoubZjLNBLyKoLY/s320/mcp.jpg" alt="" id="BLOGGER_PHOTO_ID_5337393466104638162" border="0" /></a><br />I'm trying to write up some materials for the project I'm working on, which looks at the role of multiple, concurrent partnerships in the HIV epidemic in Mozambique. I probably should have known better than to Google Image "network concurrent sexual" to find a good illustration of network characteristics when partnerships are concurrent.<br /><br />Along with some racier stuff (and some things about computer programming...?), I got the picture above, which made me laugh. It's actually from a <a href="http://www.psi.org/">PSI </a>site, and PSI is one of our main partners on the project. So it really does have to do with what I'm studying. I guess I sympathize with wanting the page to be visually appealing, and yet not having a picture that represents what's being discussed. <br /><br />But still... this is funny. Some PSI intern is now patting herself on the back for being able to sneak in there a picture of a guy grabbing his lady friend's tuchas.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-22455714398713499592009-05-04T18:37:00.000-07:002009-05-04T19:13:52.839-07:00Disconnected<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT3pEOfLiP3yZqI3xd2iH8JH51RrUDX5cQs4y7ocuB7mnV9-q_5vJMtNb7Zl-EVkvbjik8L5Gh62meVygGkFuXyv-aJvbmOo8v-zzBr5V7vjTK4EMSxTQ2SMPEacnLFqco7bLzanryuc4g/s1600-h/gapjunctionmodel.gif"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 275px; height: 270px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT3pEOfLiP3yZqI3xd2iH8JH51RrUDX5cQs4y7ocuB7mnV9-q_5vJMtNb7Zl-EVkvbjik8L5Gh62meVygGkFuXyv-aJvbmOo8v-zzBr5V7vjTK4EMSxTQ2SMPEacnLFqco7bLzanryuc4g/s320/gapjunctionmodel.gif" alt="" id="BLOGGER_PHOTO_ID_5332150648112347474" border="0" /></a>According to my new ENT, there's a problem with my <a href="http://en.wikipedia.org/wiki/Connexin">connexins</a>. These proteins, pictured above, assemble in a pretty flower shape on cell membranes, interacting with connexins on neighboring cells to form gap junctions. Gap junctions turn out to be important to neurochemical signaling. So, specific types of mutations in the genes encoding connexins can lead to deafness and/or hearing loss. <br /><br />I elected not to have any genetic testing done at this point, because it wouldn't change my treatment, but the doctor said that connexin mutations are the most frequent causes of slowly progressive sensorineural hearing loss -- and that these mutations, autosomal recessive alleles, occur at a higher prevalence among Ashkenazic Jews (who, it turns out, are also susceptible to fat metabolism disorders and GI disorders, probably among other things I haven't learned about yet. All those population bottle-necks, I guess?). So it's likely that this is what's wrong with me.<br /><br />I guess it's nice to know that. It gives it some closure, and gives me a good idea what might be in store in the future. It's also a little weird, though, being someone with a "rare genetic condition", whom I should be seeing on an evening news story rather than, well, the person who is looking out through my eyes. It took me awhile to get used to being "the girl who wears hearing aids"; now I guess I'm also "the girl with the rare genetic disease." I got used to the hearing aids, though, so I'm sure I'll get used to this -- it'll just take some time.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com6tag:blogger.com,1999:blog-8128825766062874728.post-11077906157151166722009-03-02T20:31:00.000-08:002009-03-02T21:32:03.764-08:00Finding your BoxToday my STI seminar was led by a guest lecturer, a specialist on the health of transgender people. The information was really fascinating, highlighting the great diversity of sexual identity and expression of people. The session just came to life, though, with the funny, dynamic facilitation skills of our guest, himself a trans person.<br /><br />In talking about finding one's sexual identity, he spoke about looking at intake forms in clinics, in which there were only two sexes/genders represented. "Where's <span style="font-style: italic;">my </span>box?" He remembered thinking. He identifies as "genderqueer", one of more than a hundred labels that transgender people use.<br /><br />There was something really familiar about this thought to me, although I've never has a struggle with sexual identity, or even racial identity. What resonated with me was the whole concept of identity search in a broad sense -- finding how you want to express yourself, how you want others to perceive you, with what groups you identify most closely with. Life is all about finding your box.<br /><br />(For info on trans health, spend some time here: <a href="http://transhealth.ucsf.edu/">http://transhealth.ucsf.edu</a>. You won't regret it.)Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-49326461187279024982009-02-25T19:36:00.001-08:002009-02-25T19:39:27.320-08:00Snide comments from the DocSweet young gyn patient being perscribed oral contraceptives: "Will I get fat?"<br />Darling older Ob-gyn: "You might get fat, but it won't be from the pills.<br />[Backpedaling...] I mean, er, that's not one of the side effects. These pills won't make you gain weight."Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-61743826152606103512009-02-24T18:11:00.000-08:002009-02-24T18:14:57.288-08:00Lucky<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfqIaNtZzJn9Bf964Whg1dHmporytTagKrHDCRr8R3nbKVxlQWYV1eJFsEQ8DT_xoMM9AOR3pe85jvLXIZwn9EOOZCJQV8k3Wxr1QRNQG1ZTKKMHM7VKTgCqQ15PDro530kb97n-_oByLr/s1600-h/sunset.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfqIaNtZzJn9Bf964Whg1dHmporytTagKrHDCRr8R3nbKVxlQWYV1eJFsEQ8DT_xoMM9AOR3pe85jvLXIZwn9EOOZCJQV8k3Wxr1QRNQG1ZTKKMHM7VKTgCqQ15PDro530kb97n-_oByLr/s320/sunset.jpg" alt="" id="BLOGGER_PHOTO_ID_5306552015058039218" border="0" /></a><br />Today was long: gym, then gyn preceptor, then finishing research and writing on pulmonary hypertension, then reading for my climate change class, then meeting with a classmate to plan out our in-class discussion to take place this Thursday.<br /><br />But then, out the window, this scene. And later, dinner with friends. Life is full of obligations, deadlines, things to hand in; but when you can take in this much beauty at the end of the day, and appreciate good food with your friends, you're pretty damn lucky.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-19999777898108686272009-02-18T18:35:00.001-08:002009-02-18T19:56:21.697-08:00Baby LoveLately many of my friends have been coming down with Baby Fever. It's just the age all of us are entering, I guess, and maybe the fact that some of our friends and siblings are starting to have their own babies. (A history of exposure to babies, it seems, is the greatest risk factor for the Fever.)<br /><br />I've mostly been spared from the mindless desire for, as my program director would say, a germ bag. Not that I don't love spending time with my little niece, or appreciate her extreme cuteness or think that she's a genius. It's just that spending time with her doesn't make me want to run home and have my own (or wherever that would be done...). <br /><br />So today I was a little taken aback when I was hit hard with Baby Love. The offending little one was a two-week-old preemie and maybe the smallest human being I've ever seen. He was so tiny as to be a little alien-like, hands trembling as he raised his skinny arms. But he was "fiesty" -- even his NICU nurses had called him that -- sucking vigorously from his bottle and later tilting his shoulders as if trying to roll over and crawl away.<br /><br />His young parents were so excited and nervous that they couldn't stop talking; I'm pretty sure I don't want to ever be in a pediatrician's shoes. But their baby had such an earnestness, in an extremely tiny little form, that it made me want to take care of him.<br /><br />I don't know if it'll develop into a full-blown bout of baby fever, but I'm pretty sure it was love.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com1tag:blogger.com,1999:blog-8128825766062874728.post-59406557907157738572009-02-18T18:14:00.001-08:002009-02-18T18:21:18.586-08:00You know your pediatric clinic is underfunded when...... the sports stars in the posters on your walls are from two decades ago.<br /><br />I walked in today past a Mugsy Bogues height chart. Then in an examining room saw Mark McGwire, Jose Canseco (yes, A's era), and Tim Hardaway. Which was great for me, because these guys are from the time when I paid attention to sports, but I'd guess a little confusing for today's pediatric patients.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-70039964546241697882009-01-31T20:28:00.000-08:002009-02-01T08:59:45.871-08:00Coffee: is there anything it can't do?<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCoLQ1QyQuNOJZ5z6bBvEgJgBVf0Wi6KSbum7q2r0gAY9SFbBPtWPRFkSlH3pyc2tCQN7Ye4AYa-crXOjZi_0_59KCQNe0OmMpNncvwVA7frIhaheBQK9hwcPA5-KA-Xvul1VM5iYjQzF5/s1600-h/enlightenment.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 286px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCoLQ1QyQuNOJZ5z6bBvEgJgBVf0Wi6KSbum7q2r0gAY9SFbBPtWPRFkSlH3pyc2tCQN7Ye4AYa-crXOjZi_0_59KCQNe0OmMpNncvwVA7frIhaheBQK9hwcPA5-KA-Xvul1VM5iYjQzF5/s320/enlightenment.jpg" alt="" id="BLOGGER_PHOTO_ID_5297690873527617858" border="0" /></a><br />I just caught the author of <a href="http://www.amazon.com/gp/product/1594488525/ref=s9_sdps_c2_s1_p14_i1?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-3&pf_rd_r=1WK0BGJSFHXNPQX54VKC&pf_rd_t=101&pf_rd_p=463383391&pf_rd_i=507846">this book</a> on a Science Friday podcast, and am dying to read it; it sounds like a paradise of intellectual nerd-dom. The book tells the story not only of <a href="http://en.wikipedia.org/wiki/Joseph_Priestley">Joseph Priestley</a>'s discovery of oxygen, but also of his role as enlightenment leader (which was controversial enough to get him expelled from England) and his relationships with the American founding fathers.<br /><br />As a side note, the author offered this:<br /><br />"It's not an accident that the age of reason accompanies the rise of caffeinated beverages." Apparently, before coffee came to Europe from Africa (it originated in Ethiopia!), the drink of choice for those who could afford it was alcohol. Once coffee became popular, there was no stopping enlightenment leaders, who, wired on caffeine, went on to lay down the foundations for modern science and government.<br /><br />You can listen to the author <a href="http://ieet.org/index.php/IEET/more/johnson20090124/">here</a> -- or just go to the coffee shop and fuel your own personal enlightenment.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0tag:blogger.com,1999:blog-8128825766062874728.post-6397573046946351142009-01-25T14:55:00.000-08:002009-01-25T18:56:48.589-08:00Inked by science<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-Qqm4mj1xPBo90uWOs-NbX9RKmp86ivvcoauhYQPVXzQnL-SOhmEDT9RWlk60eBJQBbPNeiDbk82ZWEHNL8EjifS29wAjxZSODEclQNcA4cQR8hGPngeW6Nm7c_QLydQKn14qAHKqOvPq/s1600-h/origin.jpg"><img id="BLOGGER_PHOTO_ID_5295428379623167042" style="DISPLAY: block; MARGIN: 0px auto 10px; WIDTH: 320px; CURSOR: hand; HEIGHT: 297px; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-Qqm4mj1xPBo90uWOs-NbX9RKmp86ivvcoauhYQPVXzQnL-SOhmEDT9RWlk60eBJQBbPNeiDbk82ZWEHNL8EjifS29wAjxZSODEclQNcA4cQR8hGPngeW6Nm7c_QLydQKn14qAHKqOvPq/s320/origin.jpg" border="0" /></a><br /><div>I really want to get a tattoo, so today I started doing web searches for ideas and tips on what might work well. (I do know what I want to get, but not yet sure where or what the design will look like.) I found <a href="http://blogs.discovermagazine.com/loom/science-tattoo-emporium/">this website of scientific tattoos</a>, which is good for at least 3 hours of time wasting. They all fall somewhere on a range of super-dorky to... well, super dorky but also really awesome. </div><div> </div><div>I particularly like the <a href="http://blogs.discovermagazine.com/loom/2008/05/27/origin-of-an-epidemic/">one above</a>, a picture of the phylogenetic family tree of HIV. On the back of a researcher looking into the origins of the virus. It reminds me of my work with rotavirus phylogenies, and a particularly zealous phylogeneticist. There were a lot of days when I'd come in, check my email, and find that this guy had poured hundreds of virus strains into a similar family tree -- because he thought it would be interesting. When he started color-coding, I considered blowing up the tree pictures and wallpapering my room with rotavirus. I never considered painting my skin with them, though.</div>Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com2tag:blogger.com,1999:blog-8128825766062874728.post-19332588226927802442009-01-23T20:26:00.000-08:002009-01-23T20:27:38.160-08:00Un-gagged!<a href="http://news.bbc.co.uk/2/hi/americas/7847651.stm">This</a> just made my day.Ricahttp://www.blogger.com/profile/08669064320435636029noreply@blogger.com0