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  • News from the frontlines in Iraq

    Posted on January 17th, 2007 dabao No comments

    So I interviewed a GI today on R&R back from Iraq who is going back in two weeks. He actually said some interesting things

    1) it seems like the main problem all along has been the difficulty in distinguishing civilians and insurgents since by Iraqi law, all citizens are allowed one AK-47 and the US military is not allowed to take them away. This is apparently one of the issues behind the whole, rules of engagement issue.

    2) his perception was that Iraq/Iran and that whole mesopotamia region has been embroiled in a longstanding low grade religious conflict that we were audacious/stupid enough to believe we could ignore or even change with our intervention

    3) Also apparently weddings are celebrated over there by firing guns into the air (which has led to some controversy when US troops respond in a trigger happy way or mistake this as some form of aggression)

  • State of Me

    Posted on January 11th, 2007 dabao No comments

    In the new year spirit, this is a good a time as any to put down some of my thoughts about where I am in my career in my life, etc both for friends and family and just to have some sense of where I am and where I’m going.

    It might just be me, but does the idea of 29 years old scare anyone else? Its like I can still remember being 21 and having my whole life ahead of me and suddenly I will be in my 30s and in the stage of my life where my career, family and all of those things are supposed to all come together. In psych we talk about resolving “crises” which for those in “mid adulthood” is supposed to be career selection and advancement and social relationships the resolution of which takes us either in the direction of fulfillment and purpose or bitterness and despair. I guess this makes me pretty par for the course.

    As I think about my career thus far, I am pretty satisfied in the grander picture. The MD/MBA will be all that I hoped for. It will give me flexibility to be able to keep learning, help people, make an impact on people’s health and the health of organizations and contribute to the betterment of the human race either through development work, teaching, research. However, getting through the program is a bitch . . .

    By this point, I am 75% done with the “hard part” by which I mean the endless hours of lectures about disease mechanisms, drug actions, physiology and pathophysiology all of which sound a lot cooler and you appreciate a lot more when you don’t have to be tested on them. Whats worse is that med school makes you feel like there is only one path and that path leads to an increasingly competitive milestone like top percentile board scores, research fellowships, competitive residencies, and the like. So as most in my position would do, I am trying to hedge my bets IN CASE I do want a career in clinical medicine which means I need to match in the most competitive residency possible to assure a life of reasonable hours, interesting cases, flexibility in finding jobs. Unfortunately in the short term, this means exercising that part of my brain that I really don’t like exercising and in fact feel downright incompetent about: my ability to memorize lists of seemingly irrelevant minutia without a sense of its application. My bad memory in turn leads to me feeling like the dumbest member of my class (which btw, I can kinda back up with my test scores) which stresses me out and makes me study harder which makes me do less the things I like doing (extracurriculars, interesting talks with people, watching movies, having good food etc) which then stresses me out even more and makes me feel even more inadequate. The most frustrating part of course, is that I KNOW that in the grand scheme of things, none of my med school grades even matter but it doesn’t really matter. I suppose its really an issue of self-expectations, I expect that if I do something, I will do it well.

    That said, the bright spot has been that I think I have started to narrow down the realm of possibilities for careers IN medicine. First, I have become enamoured with the idea of neurosurgery and surgery in general as a field where you can actually DO something for patients by performing procedures instead of just talking about what might be wrong with them, adjusting their medications (which they don’t take) and doing paperwork (which sometimes takes up the majority of a doc’s time). In addition to this, you DO get to interact with patients (apparently 2 days out of the week at a minimum are clinic days for most surgeons) and much of the time counsel them on non-surgical techniques, deliver good or bad news. And contrary to popular opinion, you do manage patients over the long term for example after they have had a surgery. Philosophically, the idea of being for a patient at the most harrowing times of their lives (the idea of having someone else cut into them) is a perfect mix of challenge, responsibility and purpose. Finally, it also is perfect fit for a lot of the “other” things I want to do with my career such as do international health work, run a business etc. Being able to cut through all the bull of talking a lot and just getting a procedure done, and having an impact on someone’s life is exhilarating. Anyway, so I will probably be shadowing some docs in the near future to further explore this interest.

    On the life front, I have lately been feeling a bit inadequate socially, much of this is due to the stress I feel of not having enough time outside of studying to live or enjoy life much and I really feel it has limited my ability to explore and interact with other people around me. For example, I really haven’t gotten to know a majority of my classmates as well as I would like yet barring some obvious common interest, I do not have the time or inclination to make time to get to know them. This as well as my inability to make more of an impact on making DMS a better place has also been weighing on me.

    That’s about it for now in terms of an update. More later, hopefully after the board exams in June!

  • Great Times article by one of my Profs

    Posted on January 7th, 2007 dabao No comments

    NY Times

    What’s Making Us Sick Is an Epidemic of Diagnoses

    By H. GILBERT WELCH, LISA SCHWARTZ and STEVEN WOLOSHIN
    Published: January 2, 2007

    For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system.

    You might think this is because doctors make mistakes (we do make mistakes). But you can’t be a victim of medical error if you are not in the system. The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses.

    Americans live longer than ever, yet more of us are told we are sick.

    How can this be? One reason is that we devote more resources to medical care than any other country. Some of this investment is productive, curing disease and alleviating suffering. But it also leads to more diagnoses, a trend that has become an epidemic.

    This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction.

    Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.

    The other source is the drive to find disease early. While diagnoses used to be reserved for serious illness, we now diagnose illness in people who have no symptoms at all, those with so-called predisease or those “at risk.”

    Two developments accelerate this process. First, advanced technology allows doctors to look really hard for things to be wrong. We can detect trace molecules in the blood. We can direct fiber-optic devices into every orifice. And CT scans, ultrasounds, M.R.I. and PET scans let doctors define subtle structural defects deep inside the body. These technologies make it possible to give a diagnosis to just about everybody: arthritis in people without joint pain, stomach damage in people without heartburn and prostate cancer in over a million people who, but for testing, would have lived as long without being a cancer patient.

    Second, the rules are changing. Expert panels constantly expand what constitutes disease: thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population.

    Most of us assume that all this additional diagnosis can only be beneficial. And some of it is. But at the extreme, the logic of early detection is absurd. If more than half of us are sick, what does it mean to be normal? Many more of us harbor “pre-disease” than will ever get disease, and all of us are “at risk.” The medicalization of everyday life is no less problematic. Exactly what are we doing to our children when 40 percent of summer campers are on one or more chronic prescription medications?

    No one should take the process of making people into patients lightly. There are real drawbacks. Simply labeling people as diseased can make them feel anxious and vulnerable — a particular concern in children.

    But the real problem with the epidemic of diagnoses is that it leads to an epidemic of treatments. Not all treatments have important benefits, but almost all can have harms. Sometimes the harms are known, but often the harms of new therapies take years to emerge — after many have been exposed. For the severely ill, these harms generally pale relative to the potential benefits. But for those experiencing mild symptoms, the harms become much more relevant. And for the many labeled as having predisease or as being “at risk” but destined to remain healthy, treatment can only cause harm.

    The epidemic of diagnoses has many causes. More diagnoses mean more money for drug manufacturers, hospitals, physicians and disease advocacy groups. Researchers, and even the disease-based organization of the National Institutes of Health, secure their stature (and financing) by promoting the detection of “their” disease. Medico-legal concerns also drive the epidemic. While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for overdiagnosis. Thus, the path of least resistance for clinicians is to diagnose liberally — even when we wonder if doing so really helps our patients.

    As more of us are being told we are sick, fewer of us are being told we are well. People need to think hard about the benefits and risks of increased diagnosis: the fundamental question they face is whether or not to become a patient. And doctors need to remember the value of reassuring people that they are not sick. Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it.

    Dr. Welch is the author of “Should I Be Tested for Cancer? Maybe Not and Here’s Why” (University of California Press). Dr. Schwartz and Dr. Woloshin are senior research associates at the VA Outcomes Group in White River Junction, Vt.

  • back on the farm

    Posted on January 4th, 2007 dabao No comments

    the cold cold cold farm

    8 hours of class yesterday, 7 today . . . boards in 6 months . . . wait, why did I leave VC for this again?