Gene's Joint

News from the frontlines in Iraq

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

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

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

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?

Merry Xmas all!

Merry Xmas 2006 everyone from Addis Ababa, Ethiopia (well, the airport internet cafe anyway)!

pictures tell a thousand words (plus I am too lazy to type)

Got up a bit early today, some highlights from yesterdays trip to kigutu

On a street corner in bujumbura, one of my fav pics from yesterday

Deo’s bro and I @ Village Health Works !

Outside looking in

Laughing with the fam!

Hanging out in Burundi!

Amahoro (peace)

a quick entry from burundi

I am so tired having just spent 4hrs on a car going back and forth from kigutu and then coming back. I am also getting a bit queasy, I think I ate some bad juice the other day. Other than that though had a really good day. got to meet Deo’s parents and brothers and also got to see his home. Its a small brick building made of concrete with no running water or electricity, no rugs on the floors, only a couple of pictures on the wall, one of deo at his graduation etc and several gaudy pictures of plastic fruit. Dinner was being prepared while i was there. Casava, a low nutrient tuber/root that is ground into white powder and then mixed with water into a gruel like mealy substance and then eaten with beans and maybe some banana or rice. Deos parents look like they are in their eighties but are really 20 years younger than that. Despite all this, they offered to us what they had, hugged us all like their own children and wished us well on our journey. Its really quite amazing how human beings can exist in such disparate circumstances.

another interesting thing, one notices how developed often times by the language that is used for greeting. when i talked to Deos dad, the first thing he asked was, is everyone in your family well? an allusion I believe to wartime and the uncertainty of fleeing for ones life without being able to account for all of ones family members. anyway just some rambling thoughts which i will organize and tell you more about with pictures when i get back

Feeling at home

Long ride home. Two hours with Prachie and Rachel to Boston, 6am trip to Logan, 2hr flight to Detroit, 4 hour layover, 14 hour flight to Osaka, 1 hr layover, 2.5 hours to Taipei and an hour trip back from the airport. Its funny how much I like the experience of long cross pacific flights. Its usually a tiring prelude before long flights, a tough semester at school, a long week of work, a long time away from home and these flights are my time to take some time for myself not having anything else to do or that I CAN do on the flight besides read, watch, sleep and eat. After all of the stress of checking in, lugging around bags, getting through security I love being able to find your seat, sit down, kick off the shoes, reflect, read, write, watch movies. The anticipation of seeing a loved one, visiting someplace new is always good but I really do enjoy the serenity of being on a plane.

So that 24 hours to Burundi tomorrow is gonna be a piece of cake!

Poem for the stressed out

ITHACA
When you start on your journey to Ithaca,
then pray that the road is long,
full of adventure, full of knowledge.
Do not fear the Lestrygonians (*)
and the Cyclopes and the angry Poseidon.
You will never meet such as these on your path,
if your thoughts remain lofty, if a fine emotion
touches your body and your spirit.
You will never meet the Lestrygonians,
the Cyclopes and the fierce Poseidon,
if you do not carry them within your soul,
if your soul does not raise them up before you.

Then pray that the road is long.
That the summer mornings are many,
that you will enter ports seen for the first time
with such pleasure, with such joy!
Stop at Phoenician markets,
and purchase fine merchandise,
mother-of-pearl and corals, amber and ebony,
and pleasurable perfumes of all kinds,
buy as many pleasurable perfumes as you can;
visit hosts of Egyptian cities,
to learn and learn from those who have knowledge.

Always keep Ithaca fixed in your mind.
to arrive there is your ultimate goal.
But do not hurry the voyage at all.
It is better to let it last for long years;
and even to anchor at the isle when you are old,
rich with all that you have gained on the way,
not expecting that Ithaca will offer you riches.

Ithaca has given you the beautiful voyage.
Without her you would never have taken the road.
But she has nothing more to give you.

And if you find her poor, Ithaca has not defrauded you.
With the great wisdom you have gained, with so much experience,
you must surely have understood by then what Ithaca means.

— Constantine Cavafy (translated by Rae Dalven)

Great conversation

Probably the best thing about being in an academic setting is the opportunity to exchange ideas with extremely thoughtful and accomplished people like MC. MC is a professor at HBS, general partner at a Latin American VC firm that he founded, on the board of Accion a very successful microfinance organization and a member of the Board of Trustees of Dartmouth College. By some external measures of success, he’s got it all, a supportive and healthy family life, financial security (he had a lot of success in his career at KKR), social impact (Accion is one of the leading firms in providing financial services to the poor), academic advancement in his field of social entrepreneurship which he teaches about and researches at HBS. Today I had the opportunity to sit down with him and talk about his story, career advice and making money by helping the poor.

It was one of those memorable discussions where you are in the right place both physically and developmentally to really engage and benefit from a discussion with another person who has been through and experienced some of the things you want to experience.

MC started his career at Dartmouth in the 60s at a time of social change and revolution where governments were changed and the idea of government debated. After graduation he did not know what he wanted to do but knew firmly that he DID NOT want to paricipate in business which he believed at the time to be the source of social ills. He would tell his business friends that someday they would be up against the firing squad. Upon returning to Latin America and joining in the political opposition there he was given some words of advice by a friend who managed a part of what is today Unilever’s business in Latin America: “If you truly believe that business is the enemy, why not learn about the beast from within? And oh btw, I need a purchasing manager for my business here. From then on MC embarked on a successful career in business which took him to HBS for business school, BCG for consulting, and KKR doing leveraged buyouts. In the meantime he continued to tell himself that someday he was going to help cure the social ills of the world as he set out to do when he was younger. At some point, the same friend “Scott” from Unilever made him aware of an opportunity to be on the board of Accion International whose mission was to provide financial services to the poor. This became an opportunity which he began to learn fit in with both his beliefs of addressing social inequities and his skills and experience from the financial world. So at some point he had a choice to make – continue making a boatload of money doing very interesting things at KKR or taking a large paycut and being the person he has always said he wanted to be. Ultimately he decided on the latter because he realized if he did not, he would always be the person who “just talked about curing social ills” and would never actually do it. He realized that making such decisions will DEFINE who you are.

MC’s view is that there are no moral compasses or even social compasses by which you should judge whether a career choice is a good or a bad one, rather a given opportunity is simply the right one for you or not the right one for you. Simply the feeling you get when you walk into the door will tell you whether all the components are there that you hope to achieve. Analyze with your mind, choose with your heart. Don’t spend your career building a resume only to one day get hit by a car crossing the street (“what’s your tombstone gonna say? he never did what he wanted but he sure built a damn fine resume!”)

This was all extremely wonderful for me to hear about from someone who has been through it and made difficult choices but in the end was able to have his cake and eat it too. The key takeaway for me really was in how all of this came about without planning but with a crossing the stream by sensing the rocks approach. In that way, I also feel that in my past experiences I’ve learned more and more about what fits me and what will fascinate and challenge me for the future. For example, at JJDC this summer getting paid well, building a resume, doing interesting and important stuff with brilliant people was fabulous but the missing piece was the social impact of my work. In much the same way, seeing patients as I understand it so far in medical school is socially useful, personally gratifying but lacks a wider social impact and the intellectual challenges of creativity, initiative and risk that I love so much about entrepreneurship and venture capital.

In the course of talking about careers, I also learned a lot from MC about microfinance and social entrepreneurship that I would like to touch on briefly here. First, the now validated evidence that YOU CAN MAKE MONEY BY HELPING POOR PEOPLE is something that he has demonstrated through his career and success with Accion and this is one of my most fundamental beliefs or hopes about what I can do with my life and career. Second, MC pointed out that microfinance is NOT for everyone, you do not want to loan money to someone who does not have sufficient caloric intake to work. “The only thing worse than being desperately poor is desperately poor with DEBT”. Rather you want to provide microfinance to those who are already delivering the 6 bottles of oil every day and by allowing them through access to working capital to decrease their costs increase their supply and efficiency to lower the price of oil for everyone in that community, including the starving person.

Third, MC’s take on the current impasse in helping the poor is in health care DELIVERY. The treatments (such as vitamin A for blindness) are available often for pennies but the challenge is how to deliver these interventions to the poor? He has also learned that no organization for profit or not can succeed without four elements: SCALE, PERMANENCE, IMPACT and EFFICIENCY. For example, he is currently working on a joint project between HBS and Harvard School of Public Health called Antaries that aims to identify commercial interventions using the 80/20 rule where interventions can be rethought and redesigned from being “public goods” provided by government or NGOs to private goods that the private sector can validate and model and mass market to the poor. It involves rethinking of the poor as “end users” instead of the doctor-disease-patient centric approach in medicine or disease impact on society perspective of public health. For example, instead of treating iron-deficient anemics in low income communities with government mandated policies to distribute bad tasting pills through underresourced clinics or schools, how does one make a good tasting soda supplemented with iron and market it (say with Shakira advertising it) to the kids in these communities as great tasting and oh btw it will improve your health rather than the other way around. Ironically, the current soft drink makers that do similar things tout the “health benefits” of drinks rather than focus on making it a great product first.

Another example is paint that has anti-malarial insecticide in it which people would buy because 1) its a great color and has great protective properties 2) is affordable 3) will keep more mosquitoes away. This would help replace malaria nets which are hard to use and uncomfortable and potentially not useful for people to use. It would be distributed not by enthusiastic NGOs or inefficient governments but by the private sector who sees one organization being successful at it and that organization spawns an industry wide adoption of similar products and concepts. Like microfinance, success in a few leading organizations will catalyze an entire industry of profit seeking companies that because they are seeking profit delivery advertently or inadvertently a social good.

Another example is of drug stores that contract out the sales of condoms to peers and thereby allow young people to earn money by selling condoms that are cheaper than the competition. It is a superior product, sold in a more effective way that reaches more people.

Mexican “minute clinics” where you charge 2 dollars a visit for a no-wait consultation with a doctor and meds that are 30% cheaper than at the hospital which the poor prefer to no-cost 12hr waits at hospitals for “free healthcare”.

MC was quick to point out from his prior experiences that the key to success of Bancosol in Bolivia which is a commercial entity that provides financial services to low income community was a first mover advantage, scale and STRONG management which drives increasing cost efficiencies despite price competition. This example has spawned hundreds of similar banks throughout latin america.

Personal notes: MC has 1 son working for a NY law firm and lives in Boston. I will keep him updated on my career both in terms of the MD/MBA and my experience in Burundi this winter. I think documenting these rituals in Burundi and finding opportunities for commercial ventures is one of my goals for the upcoming trip to Burundi.