No Quick Fix

On History and Health Riffs in the musical, Bloody Bloody Andrew Jackson:

“If it’s chafed, put some lotion on it.”

– some practical advice, offered by the character portraying Andrew Jackson, speaking toward the audience in the last scene of Bloody Bloody Andrew Jackson, a play written and directed by Alex Timbers

Yesterday I had occasion to see the outrageous politicoemo-rock musical, Bloody Bloody Andrew Jackson, which recently moved to Broadway’s Bernard B. Jacobs Theatre. The production focuses on the life and times of the 7th President of the United States.

Now, Old Hickory comes on like a rock star. The story is narrated, in part, by an excitable, graying Jackson groupie who bumps around the stage in a motorized wheelchair. A wild and rattling cast sets the thing’s tone in a startling first number, “Populism, Yea, Yea!” An early review of this musical, toward the end of its early 2008 LA run, cites these lyrics:

Sometimes you have to take the initiative.
Sometimes your whole family dies of cholera.
Sometimes you have to make your own story.
Sometimes you have to shoot the storyteller in the neck.
Sometimes you have to take back the country…

(These words antedate the Tea Party, to which the play vigorously alludes in its current form.)

You get the idea: it’s lively, a bit disjointed and politically relevant. And fun. It messes with the facts, and is tangentially rife with medical topics:

In the play, Jackson’s father, upon witnessing the whoosh and arrow-in-her-back slaying of Jackson’s mother in a backwoods cabin somewhere in South Carolina or Tennessee, immediately and without hesitation attributes her death to cholera. A moment later, he and a cheery cobbler are felled by similar instruments. The future President Andrew Junior, who’s playing with toy cowboys and Indians while both of his parents are shot dead in this life-motivating scene of pseudo-history, refers later to his parents’ deaths from cholera.

Most historical sources and Jackson’s Tennessee home’s current website, attribute the mother’s death to cholera. According to a scholarly review of cholera epidemics in the 19th Century, the disease didn’t appear in North America until after 1831 or so. A fascinating, original New York Times story details the ravaging effects of this illness in Tennessee in 1873, but that would be long after Jackson’s death in 1837.

An unexpected medical writer’s gem of a song, “Illness As Metaphor,” cuts to the heart with a message about blood, symbolism, love and Susan Sontag’s classic essays on the meaning of tuberculosis and cancer in literature and in life. The lyrics of the song from Bloody, Bloody Andrew Jackson are hard-to-find on-line, but you can get it through iTunes, by which I found these words:

A wise woman once wrote that illness is not metaphor.
So why do I feel sick when I look at you?
There is this illness in me and I need to get it out, so when I bleed
It’s not blood, it’s a metaphor for love.
These aren’t veins just the beating of my heart.
This fever isn’t real it represents how I feel…

You can see a Spanish-sung, sickly romantic version on a YouTube video:

I’m not sure how Susan Sontag would feel about emo-rock in general and about this song in particular, but I should save that subject for some intense, future writing project –

A few other medical digs include mention of Jackson’s hepatitis – acquired on “the battlefield,” as he explains to his admirers, syphilis – a killer of Indians and, consistent with the play’s hemi-modern approach, Valtrex – which some of the prostitute-turned government advisees run to get when it’s given for free.

All in all, it’s a terrific play about Americans, Manifest Destiny, populism, anti-elitism, economic frustration, anger toward foreigners, fear of terrorism, emotions and the founding of the Democratic Party.

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Tomorrow is Election Day. Remember to vote!

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Eight Years

Today marks exactly eight years since Dr. L., the fine radiologist who may have saved my life, called to let me know about my breast cancer diagnosis.

With deep-felt thanks to my doctors, my friends, my family,

ES

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By |October 9th, 2010|Breast Cancer, from the author, Life, Life as a Patient|Comments Off on Eight Years|

Why I Went for My Screening Mammogram

Dear Readers,

This week marks eight years, exactly, since I had an abnormal mammogram that led to my breast cancer diagnosis. I was 42 years old, and lucky because the excellent radiologist who discovered my tumor was a super-specialist in breast imaging, the kind of radiologist who spends her work-time analyzing mammograms, performing breast sonograms and taking biopsies of suspicious lesions. She doesn’t often look at hip films or ordinary x-rays. She just does mammograms, mammograms and mammograms, and sometimes additional tests to evaluate abnormalities she detects in those. She knew her stuff.

I was afraid to get a mammogram because I didn’t want to learn I had cancer. Back then, my breasts were so glandular it was hard for me, an oncologist, to discern what might be a pathological lump, or not. I feared having a “false positive,” and undergoing multiple tests to evaluate abnormal images that would turn out to be nothing but big-bill inducing benign lesions.

Really I was hesitant in visiting her office. I didn’t have time for cancer, because I was in pain from a crumbling spine and needed to get my back fixed before even opening up the possibility of additional medical problems. I wanted to work as much as I could then, before and after that big reconstructive spinal surgery, so that I might continue research and publish more papers. Besides, my sons were young then – ages 8 and 10 – and I didn’t want to not be able to make dinner because I was throwing up, or die.

Not getting a mammogram was a way of not finding out. The shoemaker’s kids don’t get shoes. An oncologist doesn’t get a mammogram…

My general internist, whom I trusted, insisted that I go for screening. “You’re over forty, you know,” she said. But I had no family history of the disease, then – this has since changed, and I didn’t consider myself at increased risk. Ultimately I went for the mammogram because I knew it was the responsible thing to do, to take care of myself.

When I had the mammogram, and the sono to evaluate an abnormality, and the core needle biopsies in the next week, I wasn’t afraid so much as I was annoyed by all the inconvenience. “Who has time to be a patient?” was my attitude. I came to each doctor’s appointment armed with research articles and colleagues’ manuscripts to review. I had meetings to attend, and responsibilities, and participated actively in a typical two-career family kind of up-and-out-early way of raising our sons.

All of that is behind me now, as is the chemo,  hair loss, some incidental fractures, surgeries, generalized fatigue and sad times that followed. How lucky I am that I went that day. There is no doubt in my mind.

Next year, approximately 45,000 women in the U.S. will die of metastatic breast cancer. Why I advocate for screening mammograms is because I know that a significant fraction of those advanced cases, perhaps half or more, could be prevented by early detection. That benefit would be a boon to the public health: perhaps as many as 20,000 – 30,000 women spared per year from morbidity, suffering and mortality of metastatic breast cancer, which is currently an incurable, costly disease.

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A Walk, or Race, for the Cure

“You can get discomboobulated in this place,” a NYC police officer told me today when I asked him the way.

This morning, some 25,000 or so men, women and children converged on Central Park for the Susan G. Komen Foundation‘s 20th annual Race for the Cure. It was my first time witnessing the event:

pink shirts, umbrella and rainbow, waiting for the start

I AM THE CURE

woman in black, pushing stroller

woman with Victoria's Secret umbrella

men, walking together

WTFC poster, held high

walkers in blue, near the Sheep Meadow

finish line with red light

Scan Van in the Park

ML is learning to use her camera.

School tomorrow!

p.s. 9/13: discomboobulated is not a typo!

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A Visit to Suffragette City

For two days I’ve been traveling on a short road-trip with my family in Upstate New York. As far as this turning to a medical lesson, all I can say is that for the first time in my life I witnessed, first-hand, the vaguely digital, elongate and eponymous geography of the fine Finger Lakes.

morning view, by Seneca Lake

It’s beautiful around here. I’ve found it a fine place to get some reading and writing done, besides taking in some local college scenery. While here, we had the opportunity to review some New York State’s history and, in one memorable moment for yours truly, stopped briefly in the village of Seneca Falls.

There, in 1848 a group of local women, mainly Quakers, organized an early convention here on the topic of women’s rights. Some 300 progressives attended the Seneca Falls Convention. Among those pioneering lady leaders  – feminists if you will – were Jane Hunt, whose home we visited today, Lucretia Mott and Elizabeth Cady Stanton. Approximately 40 men attended, including  Frederick Douglass, a former slave and then-editor of an abolitionist newspaper, the North Star, published in Rochester.

Which takes me back to this blog’s communication theme. We’ll be home again, in NYC, late tomorrow, and I’ve got an early class to teach on Wednesday morning.

What this means, dear readers, is that summer’s over and we’ve got to bet back to hard Medical Lessons. We’ll cover more serious stuff, for a while at least and for the most part –  journal articles, some new science and, well, learning about diseases, pathology, and how we might treat some of those.

Stay posted!

Women's History Postage Stamp

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adjusted, AM 9/8/10

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Why Physicians Shouldn’t Tweet About Their Patients Or O.R. Cases

I fear this post may be a bit of a downer for some e-health enthusiasts, Internet addicts and others who might otherwise follow @medicallessons, but after nine months of “studying” medicine on Twitter, I’ve reached the conclusion that it’s probably not a good idea for most practicing physicians to use 140 character Web-broadcasted messages for communicating with or about their patients.

Sorry if I’m ruining a tweetchat, tweetup or doctors’ virtual party somewhere. I just don’t think these belong in the doctor’s office or, especially, in the O.R.

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Cooking With Universal Precautions

A half-billion or so eggs were speedily pulled off semi-cooled supermarket shelves this week. The concern is that bacteria-laced eggs can cause serious and even deadly illness. The companies that produced and disseminated those marked eggs fear more lawsuits. Some people who usually enjoy their eggs in the morning, sunny-side up, are thinking twice.

The greatest egg recall ever set off alarms on CNN (Paging Dr. Gupta), on the front page of my newspaper’s business section, on some health blogs and in some homes. I’m concerned and saddened by this, about the cost of all this – the frank wastefulness of it. Our food supply is not infinite.

But I’m not particularly worried about getting sick from eating eggs at this time. Rather, I’ve been aware of this potential problem at least since 1984, when I took classes in microbiology. That raw or undercooked, runny eggs can effectively deliver salmonella to the digestive tract is something doctors learn in medical school. (And, maybe, the rest of the population should be taught in what used to be called home economics?)

In my home we don’t eat a lot of eggs, mainly because of my personal aversion and fear of cholesterol-lowering drugs. We go through perhaps a dozen eggs in most months. But when I do cook with eggs, whether that’s in baking a quiche, vegetable soufflé or cake, or rarely, for breakfast in omelet or scrambled form, I cook them thoroughly, applying heat through-and-through, and keep any utensils that have touched raw egg apart from anything else in the sink or on the kitchen counter.

Shifting gears, just a bit – this story reminds me of a gradual change in how we practiced medicine in the years after the start of the AIDS epidemic. In 1983, when I entered medical school, few doctors wore gloves except when they were performing surgery. At Bellevue Hospital in 1985 and 1986, my classmates and I helped to deliver babies with our bare hands.

Gradually, and as fear caught on, some doctors started to discriminate – they’d wear gloves while drawing blood from a patient with obvious risk factors for HIV, such as a promiscuous homosexual man or an intravenous drug user. But I always thought to myself, you never know who’s got what virus, we should be careful more often.

A few years later, when I was a resident physician and pregnant fellow, the concept of universal precautions came into widespread practice.  Doctors and nurses learned – had to be instructed – to don gloves whenever they drew blood or potentially came into contact with any patient’s body fluids because, the idea emerged, anyone might have HIV. Better to be careful in general, without prejudice.

These practices annoyed some at first. For doctors, they cost us time and the value of touch. Among other problems, it became suddenly more difficult to insert an IV catheter in one shot because feeling a patient’s vein is a lot harder when there’s a layer of material between your fingers and the patient’s skin. I suspect, also, that some hospital administrators must have resisted, too, because of all the money needed to buy all those gloves and new-fangled needle-dispenser boxes.

Some food-minded folks and editorialists suggest that risk might be reduced by buying less-travelled eggs from local producers. But regardless of where you live and shop for food, local farmers vary in their practices and habits. As for organic farms, there’s no real evidence that those are cleaner than other agricultural sources. (Some may be, but which? It could go either way.)

This situation bears some analogy to the reason why doctors implemented universal precautions in medicine. Some of us harbor prejudice (and maybe even some anger or resentment…) against efficient, industrial-sized food-growers and may be, accordingly, biased and even lenient in attitudes on standards and regulations for local farmers’ markets. And so the danger is, we may be less careful with eggs from a small-scale farm down the road. Those eggs seem OK, or at least we feel better about their purchase.

My point is, it’s generally better to behave without bias.

I think it would be smart for cooks to use universal precautions when handling eggs. There’s always some risk of contamination by salmonella and other disease-causing bacteria. I cook eggs well, regardless of their source or what’s picked up in today’s news.

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Another Take On An Ordinary Day

A few weeks ago, on August 1, I threw out the concept of living life every day as if it’s Shark Week. The line, delivered by 30 Rock‘s Tracy Morgan in that show’s first season, has stuck with and puzzled me for years.

Then I came upon a striking post called Live Each Day Like There’s a Lot of Them Left, dated August 2. Jen Singer, a blogger with two sons and a history of lymphoma, expresses the considered notion that maybe the best thing to do after cancer is to live, essentially, as you would do otherwise, except with a bit of added balance.

She writes:

… I — the one who has been so close to the end of life – am supposed to tell you to treat each day as though it’s your last. Except, if it were my last, I certainly wouldn’t be tanking up my mini-van for the rest of the week’s carpools…

Rather, I suggest that you treat every day as though you’ve got a whole lot of them left, precisely because you don’t really know if you do. Go about the everyday, do the drop-offs, get out the knots. Clean the house. Go ahead and get through the stuff that fills your To-Do list…Slog, if you must, because that’s perfectly okay…

Still, every now and then, don’t forget to turn up the radio and listen…

Her point, I think, is that we all have to move on with our lives if we can. It’s the nitty-gritty, mundane activities that keep families on track may also keep us sane, safe and sound. Cancer can be liberating, but that doesn’t necessarily mean we should exploit that as license to escape from responsibilities.

The pressure to “treasure each moment” can be counterproductive. To live life as usual is a challenge of another sort, important for the normal development of our kids and ourselves.

I like this perspective.

Like Jen, I take pleasure in the ordinary stuff – cooking, helping my family and yes, checking off items on the list of things I’ve been meaning to do for years. It’s a long list, and I’ve lots to take care of.

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Eye Care

On Friday I had a slightly, subtly dehumanizing experience at the eye doctor. It’s no big deal, really, almost not worth mentioning –

It was an entirely ordinary set of events that triggered this near-rant from this determinately positive blogger. But maybe the commonality of it – the blandness of what happened when I visited the doctor the other day – typifies what’s as a tragedy in modern health care: the loss of caring.

eyeglasses on a table (Wikimedia Commons)

How it went was like this:

That morning I raced (or, rather, walked quickly – but dangerously quickly for a woman with poor balance and limited gait) to catch the bus to take the train to reach the optometrist’s office on time. And I did.

The office was crowded but not full. A receptionist sat behind a partly glass-enclosed counter with desks, fax machines and filing cabinets and other workers.

“Name, please” she asked me.

I told the woman my name.

She nodded. “Take a seat, someone will be right with you.”

I waited just over half an hour, during which time I had the opportunity to look around and listen.  A man, who said he’d undergone Lasik surgery the day prior was “seeing great” as he chatted enthusiastically with a couple to my left, one half of which was contemplating the procedure.

“It’s a miracle,” he said. “I’m having each done separately, one at a time.”

After a while I returned to the receptionist’s window and noticed a sign having to do with Botox injections and information on a doctor who might provide those.

My mind wandered… I never knew that eye doctors do Botox. Then again, maybe they don’t…Perhaps this office maintains a reciprocal relationship with an office that provides those, where the staff posts notices about Lasik surgery. Either way, the sign is nothing more than a business strategy, which is fair enough if you believe that health care can or should be run as a money-making enterprise. (I don’t.)

Back to my optometrist, who was running late (OK, usually forgivable, human):

How I first met this capable woman was through the long-ago care of my semi-retired ophthalmologist, a medical doctor (MD) who provided start-to-finish eye examinations and might, if you ever needed it, perform eye surgery. I trusted him and always felt good about visiting his office.

Some time ago he expanded his practice, taking in some less-established doctors and optometrists. The idea, I imagine, was to have a doctor of optometry (DO) carefully perform the initial eye exams, patiently fit vision-impaired people with just the right prescriptions for their lenses and, finally, refer any questions or concerns to the ophthalmologist in the same office. In this sort of setting, he could spend more of his time helping, and doing procedures, for patients with serious eye problems like glaucoma.

I was happy with the system for most of 10 years. I genuinely liked the optometrist, and still do – she did a terrific job evaluating my vision and optimizing my lenses. Around the time I had breast cancer, bald and walking with a needed cane, she looked into my eyes with extra care. She was sympathetic and spent an unusual amount of time making sure that my glasses would be all right, if nothing else.

The problem – what I’d diagnose as a change in the practice’s character – manifest a few years ago after the group moved to a new office space where there seems to be a lot more traffic. The carpeting on the floors, once fresh-appearing, is no longer. The waiting area, formerly quiet, has a TV broadcasting CNN. But I don’t care much about the floors or media selection.

What bugs me is that the office has expanded and become so systematized that when I go there I don’t feel like I’m visiting a doctor, the kind of professional who sincerely cares about my health. Instead I feel like a commodity, which I suppose I am.

Back to the visit:

As has happened before, a technician called my name  and asked me to come with him, so I did. He was young and unfamiliar. He told me his first name and, without further explanation, indicated where I should sit while he used a machine to take pictures of each retina, the light-receiving membranous surface at the back of the eyes. Next, he asked me to follow him into a small room where he proceeded to open my chart and question me, sketchily, about my recent medical history.

I wasn’t thrilled about sharing, but went along up until a point. Then, when he began to perform my eye evaluation – the exact sort of work that the optometrist used to spend her time with me doing, I asked him what was going on. Where was she?

“She doesn’t do this part any more. It’s been like that for a while. Now please, can you read the letters in the first row…”

So now the optometrist, who had for years assisted the ophthalmologist, has an assistant who would evaluate my vision instead. This saddened me, first and selfishly because I’d spent the better part of my morning going to see her so that she could check my eyes and write another ideal prescription I could rely on, and now I couldn’t count on that small part of my health care going smoothly ever again.

What’s more – and the bigger picture – is that she no longer has time for me and my eye glasses. I see this simultaneously as good and bad:

Good – I suppose, because we don’t really need people with MDs, and probably not even with DOs, for routine examinations and procedures that could be handled by someone with less training and who is, therefore, less valuable in our limited health care system.

Bad – It happens that the particular technician who started to check my eyesight did a poor job until I stopped him at that. The machine he used to project letters into a mirror shook so much that the small blurry letters in the lowest row wobbled clearly.

More generally – it’s bad because the time I once valued with my optometrist, as previously with the ophthalmologist, is gone. I guess it wasn’t sufficiently worthwhile for them to keep the relationship going as it was. No more annual, while they’re flipping the glass circles, questions like “how are your kids?” or “how’s your summer going” or a generous, once-credible “how are you feeling?”

My visit was almost reduced to a series of standard interactions with a technician of unknown credentials who I don’t expect to ever see again. I intercepted that, this time, but this scenario will surely recur, overwhelmingly, as health care delivery becomes more checklist-based and efficiency-minded.

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Some definitions – for those of you who aren’t completely confident in your knowledge of the distinctions among eye care specialists:

An ophthalmologist is a medical doctor (MD) who specializes in eye diseases and might perform eye surgery.

An optometrist is a professional who’s earned a doctor of optometry (DO). Usually this requires four years of post-graduate education that covers eye diseases, pharmacology, anatomy and more. Optometrists are trained, extensively, to examine the eyes, give prescriptions and perform certain procedures.

An optician is someone, typically a licensed professional, who helps people get the eye care they need and may prescribe eye glasses or contact lenses.

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Today’s Calls

This is an easy post with a simple message. Maybe it’ll even help some people.

Earlier today, in the midst of a deep water exercise class, I remembered that I needed to  call my eye doctor before the weekend. You see, I’ve been meaning to get a new pair of glasses and it doesn’t make sense to get those without a current prescription. Then I realized that I hadn’t been to see her in two years. Time flies –

Like many people, I’ve been carrying around a mental stack of offices I’ve been meaning to call. So instead of taking care of some serious writing for a book proposal, that I really need to do, I ran the list:

  • internist
  • ophthalmologist
  • dermatologist
  • physical therapist
  • gynecologist
  • oncologist
  • orthopedist
  • other appointments (for your kids, spouse?, partner, whoever depends on you …)

Done!

It turns out that late summer is a great time to call medical offices for routine appointments. (Sorry secretaries, I know the doctor’s vacation is when you tidy up, even electronic paperwork and filing.) But seriously, someone answered the phone promptly or readily returned my call today. What’s more, I beat the post-Labor Day rush for adult doctors’ visits.

Calling is, unfortunately, too often an obstacle. But it’s no excuse.

(Not having insurance is another story, of course.)

Just do it!

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Back to Basics – But Which Ones?

A front-page story on the Humanities and Medicine Program at the Mount Sinai School of Medicine, here in Manhattan, recently added to the discussion on what it takes to become a doctor in 2010. The school runs a special track for non-science majors who apply relatively early in their undergraduate years. Mount Sinai doesn’t require that they take MCATs or the usual set of premedical science courses – some college math, physics, biology, chemistry and organic chemistry – before admission.

The idea of the program is two-fold: first, that the traditional med school requirements are a turn-off, or barrier, to some young people who might, otherwise, go on to become fine doctors; second, that a liberal arts education makes for better, communicative physicians and, based on the numbers published in a new article, a greater proportion who choose primary care.

Today Orac, a popular but anonymous physician-scientist blogger, considers the issue in a very long post. His view, as I understand it, is that if doctors don’t know enough science they’ll be vulnerable to misinformation and even quackery.

On the side of the spectrum, perhaps, Dr. Pauline Chen, a surgeon who puts her name on her blog and essays. In a January column, “Do You Have the Right Stuff to Be a Doctor?” she challenged the relevance of most medical schools’ entry requirements.

I see merit on both sides:

It seems fine, even good, for some students to enter medical school with backgrounds in the humanities. Knowledge of history, literature, philosophy, art history, anthropology and pretty much any other field can enhance a doctor’s capability to relate to people coming from other backgrounds, to recognize and describe nonparametric patterns and, perhaps, deliver care. Strong writing and verbal skills can help a doctor be effective in teaching, get grants and publish papers and, first and foremost, communicate well with patients and colleagues.

Still, there’s value in a doctor’s having a demonstrated aptitude in math and science. Without the capacity to think critically in math and science, physicians may not really understand the potential benefits and limitations of new medical findings. What’s more, doctors should grasp numbers and speak statistics well enough so they can explain what often seems like jumbled jargon to a patient who’s about to make an important decision.

Thinking back on my years in medical school, residency, fellowship, research years and practice in hematology and oncology, I can’t honestly say that the general biology course I took – which included a semester’s worth of arcane plant and animal taxonomy – had much value in terms of my academic success or in being a good doctor. Chemistry and organic chemistry were probably necessary to some degree. Multivariable calculus and linear algebra turned out to be far less important than what I learned, later on my own, about statistics. As for physics and those unmappable s, p, d and f orbitals whereabout electrons zoom, I have no idea how those fit in.

What I do think is relevant was an advanced cell biology course I took during my senior year.  That, along with a tough, accompanying lab requirement, gave me what was a cutting-edge, 1981 view of gene transcription and the cell’s molecular machinery. Back then I took philosophy courses on ethical issues including autonomy – those, too, proved relevant in my med school years and later, as a practicing physician. If I could do it again, now, I’d prepare myself with courses (and labs) in molecular biology, modern genetics, and college-level statistics.

My (always-tentative) conclusions:

1. We need doctors who are well-educated, and gifted, in the humanities and sciences. But for more of the best and brightest college students to choose medicine, we (our society) should make the career path more attractive – in terms of lifestyle, and finances.

(To achieve this, we should have salaried physicians who do not incur debt while in school, ~European-style, and who work in a system with reasonable provisions for maternity leave, medical absences, vacation, etc. – but this is a large subject beyond the scope of this post.)

2. There may not be one cookie-cutter “best” when it comes to premedical education. Rather, the requirements for med school should be flexible and, perhaps, should depend on the student’s ultimate goals. It may be, for instance, that the ideal pre-med fund of knowledge of a would-be psychiatrist differs from that of a future orthopedist or oncologist.

3. We shouldn’t cut corners or standards in medical education to save money. As scientific knowledge has exploded so dramatically in the past 30 years or so, there’s more for students to learn, not less. Three years of med school isn’t sufficient, even and especially for training primary care physicians who need be familiar with many aspects of health care. If admission requirements are flexible, that’s fine, but they shouldn’t be lax.

Critical thinking is an essential skill for a good doctor in any field. But that kind of learning starts early and, ideally, long before a young person applies to college. To get that right, we need to go back to basics in elementary and high school education. If students enter college with “the right stuff,” they’ll have a better understanding of health-related topics whether they choose a career in medicine, or just go to visit the doctor with some reasonable questions in hand.

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Living Like It’s Shark Week!

Today is the start of this year’s Shark Week on the Discovery Channel.

shark (adapted image from Wikimedia Commons)

Dialog from NBC’s 30 Rock, Season 1, Episode 4 “Jack the Writer” (2006)*:

Tracy Jordan: But I want you to know something… You and me, it’s not gonna be a one-way street. Cos I don’t believe in one-way streets. Not between people, and not while I’m driving.

Kenneth: Oh, okay.

Tracy Jordan: So here’s some advice I wish I would have got when I was your age… Live every week, like it’s shark week.

(No further explanation is given. In the next scene the comedy writers take a one-minute dance break and then Jack provides an intro to GE’s six sigma program.)

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What the Dermatologist Did Right

Kudos to my newest doctor, a dermatologist whom I met yesterday for evaluation of a small, benign-appearing mole I recently noted on my right leg. What she did right:

1. She saw me promptly, at the time of my scheduled appointment.

(Thank you, you seem to value my time, as I do yours.)

2. In her initial clipboard-bound paperwork, along with the usual forms about my history (always with insufficient space for my case and, unfortunately, still non-electronic) she asked not only for emergency contact information, a standard, but for the name and relationship of someone besides me – such as a family member or close friend – with whom she might discuss my condition, if I permitted.

(Thank you for asking this and really, I’d prefer that you not speak with my parents about my results. I’ll be turning 50 next month.)

3. In the same short set of greeting paperwork, she didn’t just ask for my phone numbers and other contact information. She took this to another level and asked if it’s OK to leave a message on my home’s answering machine.

(Thank you again, for asking. I have teenage sons and don’t particularly want them hearing about my appointments or biopsy results before I get the message.)

4. Her assistant walked me into a room and told me to stay dressed. “The doctor likes to talk to people with their clothes on, before they put on the gown,” she explained.

(This was really terrific, and I hadn’t even yet met the doctor!)

I wasn’t disappointed: when Dr. G. entered the room, she was professional, considerate and thorough. I got the feeling she works conscientiously and carefully. And that she cares.

——

I can’t help but reflect on what a difference these sorts of details can make in a patient’s experience. How many times had I been in an orthopedist’s office for the first time, or at a different dermatologist’s, pleading with a nurse or technician that I might keep my clothes on until I’ve met the doctor and we’ve spoken.

It’s inefficient, I suppose, for doctors to meet patients in a small exam room, to exit and then re-enter after they’ve changed into a gown. But it’s humiliating, I feel, for an adult woman or for any person to meet the physician, especially for the first time, when they’re not wearing clothes.

A dermatologist, or any doctor for that matter, can’t necessarily take away the condition you have, which may or may not be serious. They may not have an easy remedy. But if they treat you with courtesy and respect, that makes it easier to cope with any situation.

Fortunately the lesions Dr. G. removed are likely nothing more than benign moles with Greek-derived names. One was a bit vascular. The lesion bled once she snipped it off, and so I can’t swim for a few days until the wound heals. But otherwise I’m doing fine.

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Staying Healthy in Hot Summer Travel

Hiking, or even just walking, in the hot summer heat to see ancient ruins, national monuments or spectacular vistas can sap the energy of healthy people. For someone who’s got a health issue – like chronic lung disease, reduced heart function or anemia – or anyone who’s pregnant, elderly or just frail, summer travel can knock you out in the wrong sort of way.

Slowing down is not something that comes naturally to me. I’m always eager in sightseeing and keen on keeping up with my teenage sons; learning to pace myself and insisting that they go ahead uphill or down into a cave, without me, has not been easy for any of us. But after a few episodes of stumbling, lightheadedness and exhaustion so severe that I had to cut out of museums I’d traveled across the world to see, I’ve adapted a prophylactic, healthy approach to summer visits to remote places:

1. Don’t plan too much for any one day.

This means you may have to forfeit some activities and sites you’d like to see. Just as, while vacationing, some parents plan for “down-time” for their kids by a pool or beach, adults should set aside time each day for resting in a shady place.

2. Plan visits to hot sites in the early morning or evening.

Museums can provide terrific respite from the midday heat. Theaters, shopping malls and modern hotels are all fine places to wait out the sun’s peak.

3. Drink lots of water.

Depending on where you are traveling, this may require that you buy bottled water. Fake mineral water is rare, but you have to watch carefully for it by checking that the bottle cap is properly fastened.

(The movie Slumdog Millionaire includes an instructive and unforgettable take on this tourist’s nightmare; one scene depicts children systematically sealing plastic caps onto bottles of tap water in an unnamed, Mumbai restaurant. The film’s medical lesson: try to avoid buying beverages in places that seem untrustworthy.)

Keep in mind, restaurants usually wash and rinse the glasses with tap water. So if the tap water’s no good, drink your beverage straight from the bottle. And, if that’s the situation, don’t put dirty hands or fingers at the bottle’s opening because that’s where you’ll put your mouth.

4. Skip the ice if you’re not sure the water’s safe to drink.

If water or another beverage is served with ice in a glass, send it back. At some risk of seeming pedantic, I’ll repeat what my mom taught us while traveling: tap water is not safe to drink just because a hotel or restaurant proprietor says so. Rather, trust in your good judgment and common sense.

5. Bring tissues to handle bathroom doors.

Drinking fluids may lead to increased urination, which means you may find yourself in unclean restrooms that may not even have running water. Here, the most important thing is to avoid touching the toilet or any sink-handles or knobs with your hands.

6. Take time to sit and rest periodically.

Walking and standing for long stretches can cause back pain and fatigue. So even in a museum, typically a comfortable kind of place, whenever I spot a bench I’ll sit there for a few minutes. While out in a city, I might stop and buy a cup of tea at an inexpensive restaurant just for the purpose of sitting, or get on the bus just for the opportunity to take a seat.

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I find that if I pace myself, which means admitting that I can’t necessarily do all I’d like as fast as I want, I can see the world!

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Avoiding Blood Clots During Long-Distance Travel

A few years ago my family took a trip to China. Even before we arrived, I learned something about an unfamiliar health care culture. What I observed en route was that many of the older passengers on that long flight to Beijing were getting up from their seats and stretching. Not just once, but regularly and systematically – they were doing slow motion, isometric calisthenics on the airplane.

I took notice of their behavior first because it seemed a simple and inexpensive, albeit strange example of preventive medicine. Second, as a hematologist who cared for patients with blood clots upon traveling, I pondered the risks and benefits of their on-board exercises. Third, as a patient who’s had a blood clot, or deep venous thrombosis (DVT), I thought maybe I should follow their example.

Thrombophlebitis – the old term for DVT – happens when a vein (as opposed to an artery) gets clogged with platelets and fibrous proteins. These tend to develop in people who are immobilized – after a hip or spine surgery, for example, or during long, cramped trips in airplanes with little legroom. For this reason, long-distance travel (in any sort of vehicle – it could be a car or bus or a train) is a major risk factor.

Dehydration and some medications can exacerbate the risk of developing blood clots during travel, as can having some kinds of cancer. (Pancreatic cancer, prostate, ovarian cancer and other tumors in the pelvis are particularly troublesome in this regard.) Some people inherit an increased tendency to develop clots; in general these can be evaluated by blood tests.

Most often DVTs arise in the legs but sometimes these also occur in the arms and other body parts. The condition can cause discomfort, pain, redness and swelling of an affected limb. These clots are most dangerous, and potentially lethal, if they spread to the lung – what’s called a pulmonary embolism. So there’s good reason to avoid these as best you can.

Here’s a list of some precautions to avoid blood clots when traveling:

1. Try to get an aisle seat. This strategy allows you to periodically stretch your legs into the aisle, and to get up without disturbing others.

2. While seated, move your feet and legs around as much as circumstances permit, and at least every hour or so. If you absolutely must remain seated, flex your feet 10 times, and stretch your legs as best you can, bending and extending the knees, one at a time, in any available direction, 10 times each. Another exercise is to raise each foot and swivel it, pivoting the toes from side to side while keeping the ankle relatively still.

3. Get up periodically and walk, every hour or two if permitted. (This means getting less sleep if you’re lucky enough to fall asleep, but I think the trade-off is worth it: being tired upon arrival is unpleasant; getting a blood clot is worse than that.)

If you’re on an airplane – once you’re up and out of your seat, seek out a place near the kitchen, restroom or elsewhere where you might stand. Then, hold onto the wall or the back of a chair, lift and stretch each of your legs repeatedly and then march in place: one knee up, then the next for two minutes or so, as conditions (and flight attendants) allow.

4. Stay well-hydrated by drinking ample water. Alcohol is a diuretic and should be avoided or minimized; caffeine too. Of course, for some travelers with weak bladders drinking lots of fluids can create a need for frequent bathroom trips. But this isn’t such a bad thing if you’re at risk for DVT, because this gets you up and out of your seat.

5. Dress sensibly – avoid tight clothing. (Some doctors recommend TED (thrombo-embolic Deterrent) or other compression stockings for patients with DVTs who travel, but I find these graduated compression nylons so uncomfortable that they reduce mobility, besides the capacity to bend and flex my ankles and knees.)

For women: avoid “knee-high” stockings with compression bands pressing just below the knees. These are a set-up for reduced blood flow from the lower legs to the larger, central veins.

6. Talk to your doctor if you’re concerned about DVT and are planning a trip. Ask about what precautions you might take in the context of your specific medical circumstances. Some people use heparin, a blood-thinner, or other medications while traveling to reduce their risk. Keep in mind that for most people, the risk of forming a significant blood clot is low.

—–

The trip to China was fabulous, well worth the distance.

More on travel next week –

ES

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Follow-up on the Harlem Heart Tests

Last month I examined the serious case of the overlooked heart tests at Harlem Hospital, as told initially in the New York Times. Since then, Times journalist Anemona Hartocollis has followed-up on the disorder at the medical center.

The problem is older and wider in scope than first indicated. Another 1,000 echocardiograms, beyond the first 4,000 told, went without review by a cardiologist.  The situation dates back to 2005, rather than 2007.  An additional 2,000 exams were reviewed by doctors who didn’t complete or sign reports on those studies, taking the total number of missing reports to the range of 7,000.

Concern persists that the errors arose due to administrative decisions and a shortage of cardiologists at the hospital. According to the paper:

…After the backlog was discovered, some doctors at Harlem Hospital said they had complained of understaffing to the administration but had been ignored. At one point, they said, the hospital was down to one cardiologist, who could not possibly review all of the echocardiograms.

Last week the hospital finished an internal investigation. Approximately 200 of the patients who had echocardiograms died before their tests were analyzed. According to the Times, a hospital spokeswoman stated that 14 patients received an incorrect diagnosis because the tests were mishandled.

Upon further contemplation, I’ve upped my lessons learned from 2 to 3:

1. For hospital administrators:

When doctors complain that they’re overworked, so much so they can’t meet their clinical responsibilities, don’t dismiss their concerns. A stressed system – with fewer clerks, escort workers, nurses, phlebotomists, aides and other workers – is a setup for rushed or frankly skipped work. These kinds of errors (delayed reports) might apply to how physicians interpret other kinds of complex medical tests including CT and MRI scans, pathology reports, bone marrow findings and other specialized evaluations.

Most physicians I know work long days, weekends and nights. Many work putting out one fire and then the next; it seems unlikely that this problem is isolated to a single department in one hospital. Rather, it’s a flag.

With so much new emphasis by law on restricting resident physicians’ hours, perhaps there’s insufficient attention to the workload of senior (“attending”) physicians. Their responsibilities should be limited, too, such that they can accomplish their work in a careful manner in a reasonable number of hours per week.

2. For doctors:

If neither you nor the patient has sufficient reason or even the inclination to check a test result, don’t order it. As I’ve suggested previously, we might save a lot (billions?) of dollars, besides precious medical resources – personnel, transport workers, clerks, machines and patients’ valuable time – which are limited whether we acknowledge that or not, by thinking more carefully about the tests we order.

This is not just about heart tests. I’m thinking of urine examinations, routine chest x-rays, nerve conduction studies, pulmonary function tests, swallowing tests, etc.

3. For patients:

What happened at Harlem Hospital is, among other things, a lapse in communication between patients and their physicians. The responsibility is shared. So if you don’t understand the reason for a test, ask for a better explanation. If you need a translator, ask for one. Ask for results. Be persistent.

Aspire to be pro-active, not passive in the health care system which, otherwise, may treat you like an object. “Own” yourself!

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On People Who Receive Care From Physicians

This week’s medical blog Grand Rounds will focus on posts having to do with “customer service” in health care. A problematic concept, it seems to me.

As a physician I never considered my patients as buyers or consumers. People came to me as their doctor, or I visited them in the hospital, and I thought my job was to identify if something was wrong and, if so, to identify the exact nature of the problem and then take care of the person as best I could. I didn’t contemplate the situation with a business mind-set.

As a patient I don’t think in shopping terms when I visit my doctors or my physical therapist, although I do sometimes pay significant bills. Even for lab services, such as at Quest Diagnostics, I don’t feel as if I’m making a purchase. Sure, I’m annoyed when there’s a long wait or my results are inexplicably delayed. And I sometimes prefer one technician to another. I might mind the costs, and if there’s an error in my bill I’ll challenge that. Still, I don’t perceive myself as a health care customer.

In medical journals a patient typically is called a person, an individual, a subject in a clinical trial or (unfortunately) a case. But in some blogs and other sources I’ve been reading lately, most often having to do with health care delivery or IT, consumers pop up constantly. A good example occurs in a recent article in the journal Health Affairs, “Evidence That Consumers Are Skeptical About Evidence-Based Health Care.” This study generated a small brouhaha (in my opinion undeserved) about the public’s alleged blind faith in their personal physicians’ advice.

In reviewing that story, what most surprised me most about the paper was not so much the study’s findings (limited) or sponsorship (by the National Business Group on Health), but its language. The term “consumer” or “consumers” appears in the article’s title, no fewer than 5 times in the 125-word abstract and a noteworthy 39 times in the main paper excluding captions, tables, and references.

My point, which is really a question, is whether people who seek out or need health care should be referred to as consumers or customers. My gut feeling is that neither term is appropriate. But then again, I don’t believe that medicine can be or should be run as a business. Here’s why:

If physicians are in a position that they might be influenced by a profit motive, they’re less likely to make decisions based in evidence and are more likely to make recommendations that include income-generating procedures and treatments.

If people receive medical care from physicians who might generate greater income by recommending particular treatments, procedures or referrals, they may not receive the most appropriate care. What’s more, they are less likely to trust that their physicians are providing sound advice. The upshot is that when expensive medical care is needed – say, for the sake of this discussion, in the case of a young person with a curable leukemia – some individuals may be less trusting of physicians if they think they are motivated by money and may decline helpful and even life-saving treatments. So the profit motive, or even the appearance of a possible profit motive, has the potential to lessen the patient-doctor relationship and undermine good care.

What’s worse, though, and even more off-putting, is that in a financial transaction for medical care – in which a person with or without an illness is referred to as a “consumer” in a business called the health care industry – what’s really happening is that the illness, and maybe even the patient who has an illness, is rendered a commodity.

Ultimately this is the greatest downside of medicine as a business. No. I don’t think patients should be considered as customers or clients by any other name.

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Traveling

Information for Travelers

Dear Readers,

I’ve been on vacation for a few days, in Woods Hole and Boston, Massachusetts. I’m learning about my family.

Have a great weekend,

ES

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A Tapestry, and Double-Dose of Magic (on Carole King and James Taylor, Troubadour and Breaking Addiction)

My plan for today was to write on evidence-based medicine. But that can wait, at least until the morning comes.

I came upon the most wonderful recording of a concert by Carole King and James Taylor played in November, 2007 at LA’s Troubadour Club, a place I’ve never been. PBS aired the video, about an hour long in its fuller form, for its June fund-raising drive. I have tickets to see the pair at Madison Square Garden in a few weeks, and had seen yesterday morning a heartening review of the old friends’ joint concert tour.

Sweet Baby James (1970)

Even within the limits of our old TV and nothing approaching a Dolby sound system in our living room, the images – the sounds and smiles generated by Taylor and King, fixtures of my childhood – made me tremble with joy. It was lovely beyond verbal expression and I felt, among other things, glad.

Here’s the medical lesson – a surprise for me was Taylor’s astonishingly well appearance, in a born-in-1948-and-still-strumming sort of way. I’m speaking as a doctor now, as someone who’s used to eying people for signs of ill health. He looked fit, comfortable and happy in jeans and a button-down blue collared shirt. He grinned broadly while he sang, surely taking none of this for granted.

I couldn’t help but reflect on his past. He seems to have made it out of the woods. And how dark those were – to a teenager listening and watching him from afar, circa 1973, it seemed like he might not pull through. For purposes of this post, I’ll stick with the parts of Taylor’s health history that fell into the public domain long before the Internet entered our homes and minds.

Taylor, the son of a Harvard-trained physician, struggled with depression and serious drug use, including heroin addiction, for years. In 1969 a motorcycle accident broke his hands and feet.  In the same decade as he offered fabulous ballads – anthems like “Fire and Rain” and King’s “You’ve Got a Friend,” familiar even to my parents’ generation – he ravaged his body and then his marriage.

Tapestry (1971)

King’s personal story is less known to me, but the lyrics to Tapestry are deeply ingrained. I know them as I know the red carpet, flowered wallpaper and stodgy furniture of my old bedroom. She looks beautiful now. Older and gray, for sure, but natural, lovely, lively and playing strong.

The two together, even on TV, deliver a double-dose like magic. They’d performed together, in 1970, at the Troubadour and now were doing it once again, with grace. The genuineness of the friendship between them, manifest in King’s glances over the piano toward Taylor and what might have been a few tears, and his beaming toward her, could not have been staged. They’ve had some difficult times, for sure, but this was beautiful.

I’m afraid I’m gushing romantic, but as a doctor I’ve seen so many patients who’ve suffered through hard times alone, physical and mental illnesses without anyone to turn to. You have to wonder, to what extent did Taylor’s support system – his dad, who reportedly drove to retrieve him from some tough spots – and his enduring friendships and his family, old and new, help him to recover.

Not all drug abuse stories end like this one. Our government reports, based on a large 2003 survey (which may underestimate use of an illegal substance), that nearly 120,000 Americans said they used heroin in the month before the survey and 314,000 took it the year prior. From 1995 through 2002, there were approximately 150,000 new heroin uses per year in the U.S. Most were over 18, male and addicted. As for depression, the numbers are huge and deaths, very real.

What I’m thinking is this – how lucky Taylor is to have had the friends, family, financial resources and courage to get the help he needed. The message he conveys is that it is possible, at least for some, to get through it, to get better and to move on.

And for me, how lucky I am to have those tickets. I can’t wait to see them in concert later this month, in person, live.

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About Those Skipped Heart Test Results

Harlem Hospital Center stands just three miles or so north of my home. I know the place from the outside glancing in, as you might upon exiting from the subway station just paces from its open doors. The structure seems like one chamber of its neighborhood’s heart; within a few long blocks’ radii you’ll find rhythms generated in the Abyssinian Baptist Church; readings at the Schomburg Center and artery-clogging cuisine at the West 135th Street IHOP.

So I was saddened to hear about the missed heart studies. Or should I say unmissed? No one noticed when nearly 4,000 cardiac tests went unchecked at the Harlem center, a public hospital managed by the city’s Health and Hospitals Corporation. The skipped beats began sometime in 2007.

According to the Times report, that’s when hospital administrators, hurting perhaps for doctors sufficiently skilled in reading echocardiograms, OK’d a process by which technicians scanning the images would alert the responsible physicians if they noticed abnormalities. Otherwise they stored the results – pictures of the heart’s contractions, wall thickness and size, valves and some large vessels – for review, later.

Usually when a person gets an echocardiogram there’s a reason. Mine, for example, was done before I received a chemotherapy drug, adriamycin that can affect the heart’s function and, another time, before I had a major operation – basically to make sure my heart was strong enough to handle the stress of surgery. Years earlier, I’d had an echo (as doctors sometimes call these tests) to evaluate shortness of breath I experienced while pregnant. I like echocardiograms, as cardiac imaging methods go, although I must admit I find the blobby representations cryptic if not frankly rorschachian. These tests rely on ultrasound, the same technology we routinely use to examine unborn fetuses by projecting and canvassing sound waves. There’s no radioisotope or x-rays. Not even a magnet’s involved.

Echocardiogram reveals 4 heart chambers - adapted from Wikimedia Commons

What generally happens is that after the procedure a doctor, usually a cardiologist, inspects the images and provides a written assessment. Ideally, the test report reflects the reason for doing the procedure. So if a teenage soccer player has an echo to evaluate an episode of fainting on the field, the physician-reviewer would focus on structural heart abnormalities associated with sudden death in some young athletes. Sometimes the studies reveal enlargement of the heart; this can occur in alcoholics, in people with chronic forms of severe anemia like sickle cell disease, and in other conditions. For patients with atrial fibrillation – a disorder in which the heart flutters irregularly – doctors might look to see if there’s clot inside the heart’s walls that might, unmitigated, migrate through the arteries to the brain. Echocardiogram can assess the heart’s condition after a heart attack or in congestive heart failure. They can visualize holes in the heart chamber walls of infants, lapsed valves and more.

The Times story indicates that doctors didn’t review images for over half of the echocardiograms performed at Harlem Hospital since 2007. The medical center, staffed by doctors from Columbia University, had six attending cardiologists and six fellows in 1999, according to the paper. Now the hospital has only three full-time cardiologists and lacks a fellowship program. The hospital runs approximately 2,500 echocardiograms each year. Among those 4,000 patients whose tests went unread, some 200 have died since the time of the procedure. Hospital officials say it’s unlikely that any deaths are attributable to the lapse.

Since the story emerged last week, a squad of doctors has been scrambling to review the images. Heads rolled at Harlem Hospital: the clinical director was fired and the medical director has been demoted. An investigation, led by Dr. John N. Morley of the State Health Department, is underway. The press, or at least my local newspaper, is all over the matter.

So what’s to be learned from this oversight? My take’s two, so far:

1. It appears that at least some physicians working at Harlem Hospital felt it was understaffed and that they were too overworked to meet their clinical responsibilities, and that the administration did not adequately address their concerns. And while Health and Hospitals Corporation has indicated this problem is unique to that particular department – the echo lab – at one hospital, I’m not convinced.

Having worked for years in hospitals where cardiologists, gastroenterologists, hematologists and even pathologists spend much of their time putting out fires, so to speak, it’s scarily easy for me to envision how non-urgent tests could pile up without review. When hospitals operate with money as a bottom line, the difficult work doctors do doesn’t get easier. So we might blame individual physicians for not signing those reports. But I’d take the system to task, and not just at one Harlem hospital.

2. No one’s mentioned the patients’ role in all of this, which seems strange to me. These days, we expect that most patients will enter into discussions with their physicians about what tests they need done. Maybe at a medical center like Harlem Hospital, which serves a relatively poor population, the expectations differ regarding patients’ involvement in medical decisions. But if that is the case, those separate standards reflect another problem – of poor communication between physicians and their patients – equally demanding of our attention.

Lastly, as I’ve said previously here and elsewhere, we waste a lot of medical resources by ordering procedures without thinking. If a person undergoes a medical test there should be a reason for it, sufficient that either the doctor or the patient cares enough to find out the results.

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