Tuesday, September 28, 2010

Spokane and Family

Another weekend post. :)

I flew out to Spokane, Washington on Friday night after my test to surprise my brother Matthew and sister Ellen at Whitworth College, where Matt is a senior and Ellen just started her freshman year.  Saturday was Matt's birthday and homecoming football game, so the whole family went out for the fun.  Dad's terrible poker face gave me away before I managed to get there, but I think it was an ok surprise anyway.  :)

It was WAY too short of a trip (had to fly right back on Sunday), but every minute of the weekend was more than worth it.  I got to see an Air Force friend who is stationed in Spokane, got to spend time with Alex, Matt's girlfriend, the Pirates won their game on Saturday, and we squeezed every last quality-family-time drop out of the 36 hours or so that we were all there together.  I also got to catch up with Kaitlin, a good friend from years ago in Fort Collins (so weird to say that it was years ago, but true).  It was absolutely wonderful to see her and her husband Phil, and to meet their beautiful daughter Mara.  I loved seeing Matt play college football one last time, and we all spent the whole time enjoying each other's company, eating some great meals, and laughing until our faces hurt.  I am beyond blessed to have been born into such an amazing family.  I won the life lottery with these people.

Alex, Oliva, me and Ellen

Kaitlin and her cute girl :)

Daddy goes in for a smooch

MVP <3
CUTE couple!!
Dad channeling his inner pirate


intense round of night putt-putt
rough conditions on the course - visibility is low
morning-after breakfast
not quiiiiite awake yet
puffy mcdermott morning eyes :)

Sunday, September 26, 2010

Knights or Knaves

Societal Perceptions of Physicians

Knights, Knaves, or Pawns?
Sachin H. Jain, MD, MBA
Christine K. Cassel, MD
New England Journal of Medicine

The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as “knights,” “knaves,” or “pawns.” Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns). A society’s view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive.

Le Grand’s observations were drawn from his studies of British social welfare policy and civil servants but could aptly be applied to physicians and their role in the US health care system. Many health care debates—especially those relating to health care financing, quality, and education— implicitly prescribe a view of physicians and their underlying motivations. Depending on the perspective, physicians are either in practice for the betterment of society or their own selfish gain; or they are automatons whose actions are defined more by external rules and regulations.

In this Commentary, we explore the ways in which physicians are variously represented as knights, knaves, and pawns in public discourse and relate the importance of designing policies that match the true motivations of physicians—whatever they may be.

Physicians as Knights
If a society conceives of physicians as ever well-intentioned knights, it places stewardship for the health care system firmly in their hands. Physicians can be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow individual and specialty interests to protect the system as a whole. Individual physician decision-making and autonomy are given the highest priority. The physician is the ultimate champion of the patient and policies are structured to support the physician’s work. Physicians practice medicine to save and improve lives; any financial gain is secondary. Physicians read medical journals and texts because of their love of learning and a desire to provide the best care to their patients. They perform clinical and basic research to advance science. The role of policy and payment is mainly to get out of physicians’ way and let them do their jobs as professionals and to seek and respect their advice when policy affects health of the public.

Physicians as Knaves
If a society conceives of physicians as knaves” then policy, management, and educational efforts are designed to com- bat and work against physicians, not with them. Physicians are interested in themselves and their financial wellbeing first and their patients second, if at all. Physicians must be given rewards and incentives to motivate them to what is right by their patients and any such schemes would have to be carefully monitored for abuse, fraud, and waste. Physicians learn new techniques and procedures and order tests and studies for personal gain. Any participation in scientific research is driven by self-glorification and narcissism. The health care system works in spite of knave physicians, not because of them. Policies and regulation must guard against their malfeasance, and the public must be protected by regulation and report cards.

Physicians as Pawns
If a society conceives of physicians as pawns, then efforts are applied to building systems to ensure that physicians do what is right for patients because physicians cannot be trusted to do so on their own accord. Left to their own de- vices, physician behaviors are unpredictable. The pawn physician is merely a function of the environment in which he or she practices; accordingly, physicians must be given guide- lines to follow and policy makers and regulators must decide clinical priorities. Physicians may or may not enjoy learning, but they study and maintain knowledge because licensing and board examinations require that they do. If physicians are required to do more laboratory tests, they will; if required to obtain fewer, they will. Place physicians in a particular practice setting and they will adapt to the local culture and expectations. The role of health policy and regulation for the pawn physician is to guide his or her every behavior because he or she lacks individual agency and judgment to reliably do what is right.

Le Grand’s work on post–World War II British social policy found that perceptions of human motivations gradually trans- formed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining an expensive welfare state increased.

US perspectives on physicians have undergone a similar transformation with the increasing cost (both to taxpayers and to individual patients) of health care delivery. As physician behavior has been tied to these rising costs and in- creasing scrutiny has been applied to the quality of care de- livered, policy discourse often reflects the perspective that physicians are an obstacle not an enabler to a functioning health care system. Rather than being counted on to exercise their professional ethic to address problems in health care delivery, physicians should be guided to do what is right with an increasing menu of incentive payments (ie, pay for performance or value-based purchasing) or strict regulations. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiency.

These views are grounded in evidence of unwarranted variation in care, clear evidence of waste and even fraud, and decline in knowledge over time. The modern US physician is regarded as either a knave or a pawn and is seldom regarded as a knight. But the evidence that has led to distrust of physicians does not apply universally and many physicians still are the knights in the health care system. How can society be sure not to undermine those motivated by professionalism while guarding against those motivated by self-interest?

Not all policy prescriptions have abandoned the view of physician as knight. Prepaid models of health care payment such as accountable care organizations and the patient- centered medical home place responsibility in the hands of physicians—with the idea that physicians will be responsible stewards. In these examples, physicians must be counted on to organize and structure care delivery, responsibly use resources, and measure and improve individual and population outcomes. Still, it is perhaps the knavish conception of physicians that makes these physician-driven models of health care delivery more the fodder of pilot projects and demonstrations than models that are rapidly adopted and widely disseminated.

Le Grand offers an important lesson and warning: it is critically important to understand and get “true motivations” right. Disaster may follow if persons largely of a knavish quality are treated as knights; but the same may be true for “policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses and hence destroy part of their motivation to pro- vide a quality public service.” Le Grand further warns that policies that “treat people as pawns, may lead to de- motivated workers . . . again causing adverse outcomes for the policies concerned; while policies that give too much power . . . may result in individuals making mistakes that damage their own or others’ welfare.”

The US public would be wise to heed Le Grand’s advice and carefully consider whether its perceptions of physicians match reality. For their part, physicians must thoughtfully consider whether and how they contribute to the perception that they are knights, knaves, or pawns.

Monday, September 20, 2010

GA Aquarium and Cranial Nerves

On Saturday I went to the Georgia Aquarium, which is the largest in the world.  I LOVE aquariums (probably because I have not watched The Cove yet).  Growing up, I wanted to be a marine biologist forever... I have always been fascinated by marine life.  I just think it is endlessly beautiful.  I also got to test out the "aquarium" setting on my camera.  Probably not going to come in handy all too often, but I do like the way the pictures turned out. :)

me with my friend Caroline
whale shark!
manta ray - these guys are HUGE
whale shark feeding time - so cool
Caroline and Matt

In less exciting news (since I realized that this blog is quickly becoming a "what I did over the weekend" blog and not so much about medical school), this is what I am currently studying, in preparation for my neural function exam on Friday.  I am not a huge mnemonic device person (because if I memorize things that way, then I end up sitting in the test repeating it and counting on my fingers instead of knowing the answer) but there are some really good ones for remembering the names of the cranial nerves.  One of my favorites (and, let's be honest, I will probably end up using it): "Obviously Once One Takes The Anatomy Final, Very Good Vodka Alleviates Heartache."

This unit is hard and overwhelming with the amount of incredibly detailed information... by far the most work so far.  Trying to keep a positive attitude as I slug through it all.  Wish me luck!!

Tuesday, September 14, 2010


It is tough to get back to the studying after a really good weekend that didn't feel nearly long enough.  On Friday night, I celebrated another test completed with some classmates... a little drinking, a little talking, a lot of dancing.  On Saturday, I went to brunch with a friend at a restaurant in Decatur called Sun in My Belly.  The owner of the restaurant named it after a quote of Picasso's in which, asked what drove him to create, he replied, "the sun in my belly."  The food was amazing, the service was friendly, the ambiance was perfect, the company was excellent... perfect way to start a day.

After that, I got out of Atlanta much later than I thought I would, but had an enjoyable drive to Birmingham to hang out with Martin and Marielle.  At 2.5 hours away, it is not nearly as close as I would like, but I am so grateful to be close enough to make a quick weekend trip out of visiting them.  Even if we had had no plans at all, it still would have been relaxing and restoring to just be there.  We did have plans, though, or at least Martin did.  Marielle studied hard all weekend for an exam she had on Monday morning, so Martin and I had a lot of time to hang out.  We went to an arts walk in downtown Birmingham, where we enjoyed a beer from a local brewery's tent and spent a couple of hours wandering a few blocks, in and out of local artists' exhibits.  I love going to art-related stuff with Martin; it's always so cool to get his take on things.  (And also funny... at one point he said, "I can't really take art seriously when it looks like my students did it."  Umm, hope that artist was not standing within earshot.)  The paintings were mostly just ok, but the photography stuff was really cool... we both bought a couple of prints.

We took pizza to Mar and ate dinner with her in the UAB med school building, and then rented and watched Where The Wild Things Are.  Sunday morning was all about food... a quick trip to the grocery store for waffle ingredients (we decided to pull out the waffle maker that I gave them as a wedding gift and they have used maybe once since then... great gift.)  This was our delicious result:

Mar out of hiding for a waffle study break :)
Then I continued to cook up a storm for my supper club (gazpacho, zucchini bread and cookies) before Martin almost killed me with one of his crossfit workouts.  My entire body is still painfully sore two days later.  It was hard to leave and make the drive back here, literally and figuratively. :)

Tuesday, September 7, 2010

Best Job

Primary Care — The Best Job in Medicine?
Beverly Woo, M.D.
N Engl J Med 2006; 355:864-866 

I first met Mr. B. during my internship, when he was a 29-year-old musician who had been admitted to the hospital with atypical pneumonia. After he was discharged, he kept his follow-up appointment with me, and I became his primary care physician. During the next 10 years, he succeeded in stopping smoking, and his major concern was his lack of steady employment. Just before turning 40, Mr. B. developed idiopathic thrombocytopenic purpura (ITP). His thrombocytopenia responded to corticosteroids, but it recurred when the dose was tapered. Between the medication and the uncertainty, he became depressed.

During the next 10 years, Mr. B. divorced and remarried, and he found a terrific job. He then developed hypertension and painful attacks of gout. Management of these two new conditions along with his ITP required constant juggling of his medications. In 2004, Mr. B. came to see me because of right-lower-quadrant abdominal pain. A screening colonoscopy in 2003 had shown only an adenoma, but now another colonoscopy revealed adenocarcinoma of the cecum. I referred him to an excellent surgeon and then an oncologist and helped him make important clinical and life decisions until his death last year from bowel obstruction at the age of 60.

After he died, I reflected on my 30-year relationship with Mr. B. I recalled that he had often called or sent me notes with updates and questions. In his medical record, I found a note he had sent after seeing the hematologist for his ITP in 1983: “Great phone call from Dr. G. He said bone marrow perfect. Body is making antibody against platelets. . . . Steroids fixed blood count. . . . See Bev, she will take care of you!” It meant a great deal when Mr. B. told me, at several points in our relationship, how grateful he was that I was caring for him and how important it was to have a doctor he could trust. It was a privilege to be Mr. B.'s physician, and it is a great source of satisfaction that I was able, with my colleagues, to help him, whether his needs were big or small.

The opportunity to develop long-term relationships with patients like Mr. B. is only one of many rewarding aspects of being a primary care physician. It is endlessly fascinating to me, for instance, that patients' symptoms can be manifestations of so many different disorders. In my practice, an older woman with forgetfulness turned out to have central nervous system Lyme disease, and a younger woman with a subtle change in her speech had amyotrophic lateral sclerosis. Another patient's fatigue was caused by Addison's disease — but it could have been a symptom of heart failure, cancer, depression, or even transient ennui. Recently, a woman who came seeking advice about a diet because she could no longer button her blue jeans turned out to have ascites and ovarian cancer.

As a primary care physician, I see firsthand how social factors affect patients who have chronic diseases. Mr. S. had a relapse of alcoholism after separating from his wife, Ms. R.'s glycated hemoglobin level skyrocketed when her daughter became ill, and Ms. H. had an exacerbation of her colitis when she lost both her job and her housing. Because primary care doctors are often the only physicians whom a patient visits, we must identify problems that are frequently difficult to talk about, such as alcohol and drug use, domestic violence, and risky sexual practices. And there is the need to care for an increasing number of patients with multiple complex medical conditions in this era of shortened hospital stays. Clearly, practicing primary care medicine is much more challenging than “just learning how to use Dyazide” — the scoffing description that the director of a residency program offered a colleague of mine when he said he wanted to go into the field.

So I should have had plenty of ammunition ready when a third-year medical student made an urgent appointment with me to talk about her future. “I just came here so that one person would tell me that I wasn't crazy to go into internal medicine,” she said. She had come to medical school because she wanted to take care of patients, she said, but she was discouraged by negative remarks about primary care medicine made by faculty members and fellow students. Then she asked me whether I liked being a primary care doctor.

I hesitated before I answered — after all, I thought, it was true that morale had declined among primary care practitioners during the past few years. I told her, honestly, what I considered to be the problems as well as the rewards of this career path, and said I thought that primary care was a really good job. Later, I wished that I had told her what I really think: that taking care of patients as their primary care doctor is the best job in medicine.

When I was a third-year medical student in the 1970s, like her I was attracted to primary care medicine and was discouraged by my mentors. My career choice was aided, in part, by a prevailing sense that primary care medicine would be part of a larger social and political movement toward more equitable health care. Also, the timing was right: I was able to enter one of the recently established residency programs in primary care internal medicine, which were funded by the federal government and private foundations that believed the country needed more primary care physicians. Primary care practice has been a challenging and deeply satisfying career for me. So I couldn't help feeling disappointed when I learned that this student chose another specialty. I'm sure she would have been a wonderful primary care doctor.

It is disturbing to me that changes in our health care system have made primary care medicine less satisfying for practitioners and less attractive to students and residents. Primary care physicians are under pressure to see patients at a faster pace than ever before, even as their responsibilities increase. Add to these difficulties the increasing administrative burdens and the fact that the remuneration for primary care specialties is at the bottom of the pay scale for physicians, and it is no wonder that primary care medicine is in crisis.

Students and residents see that primary care physicians are dissatisfied and have little optimism that this part of our dysfunctional health care system will be fixed anytime soon. They are voting with their feet, choosing more lucrative specialties that have more “controllable” responsibilities. The proportion of U.S. medical school graduates entering the three primary care specialties (internal medicine, family medicine, and pediatrics) dropped from 50 percent in 1998 to 38 percent in 2006 — that is, a loss from primary care of more than 1500 students this year, as compared with 1998. Moreover, the percentage of third-year residents in internal medicine planning to become general internists who are not hospitalists decreased dramatically during this period, from 54 percent in 1998 to 27 percent in 2003, a year in which only 19 percent of first-year internal medicine residents were planning on such a career.

Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool's errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline.

With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system. A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations. There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.

More on primary care and waste in the health care system....

Monday, September 6, 2010

Labor Day Weekend

Just a few pictures from the beautiful weekend...

On Saturday night I went to a sangeet - basically a big Indian dance party the night before the day of the wedding.  It was my roommate's friend's sister's wedding, so naturally my roommate invited me along.  There was so much awesome food and music and dancing, and the night ended off with hours of traditional group folk dances, which were a ton of fun and not too hard to learn.  The best part of the night, by far, though, was the people watching.  

with Ajanta, my roommate

Yesterday, I got to see Martin and Marielle, who stopped through on their way home from a wedding in North Carolina!  It was so fun to see them.  We got delicious homemade popsicles at the King of Pops' popsicle stand and ate them in a little park before they had to drive the rest of the way to Birmingham.

Saturday, September 4, 2010


It legitimately feels like fall here today!!  This is very exciting... temperatures will be back up in the 90s again next week, but this morning I could be in New England or Colorado - the air is cool and dry and the sun is gorgeous.  I think this is going to help put me in more of a study mood, which is good because I have a test coming up on Friday that I have a LOT of work to get ready for.

Here are a few pictures of my place for the curious.
dining room/study space
new ikea dresser

flowers [picked up with weekly groceries :)]

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