Apprenticeship in America

Recently, Cathay Pacific instituted a program titled "I Can Fly," which hopes to give juniors and seniors in high school 8 weeks of direct experience to aviation. Not flying, but aviation - learning about everything from passenger sales to airports, cargo to catering. This is a Canadian program, partnering Toronto with Cathay Pacific.

America lost it's apprenticeship culture years ago. Sure, we all read of our Founding Fathers learning watchmaking, or silver smithing, or printing at the hands of someone else. But by the end of World War II, America's government-subsidized public high school network was robust enough to provide basic education. People graduated, applied, and got jobs. Then they received on-the-job training.

As the economy developed and higher education became more important, that model persisted. Now, some companies are going back to Europe to study their apprenticeship systems. The hope is that large companies, like Siemens in Germany, can help counterparts in the USA close a gap where 4 million jobs sit unfilled although 10 million people are unemployed.

The problem is, this hasn't extended to one sector of the economy gravely hit by this labor shortage - health care. Physician training, specifically, is woefully inefficient - a byproduct of this stage-by-stage top-down, myopic, it's-always-been-done-this-way approach. Since the Flexner report in 1910 (see pdf), American medical education time has been seen as an empty cardboard box to be filled with whatever is possible until the timer dings. As medical knowledge advances, we try to shove more and more into the box faster and faster, without stepping back and reimagining the box itself, or the method of pouring.

"Then I wised up and got out while I still could."

It is time for a serious look at the ACGME, AAMC, and LCME - the accreditation bodies of American medical education. They are bloated dinosaurs that do not move fast enough to deal with the times. With expected shortages of up to 52K physicians by 2025, it's past time to look at other ways of educating future medical professionals.

We need to shorten medical education by at least 2 years. We need to decrease debt incurred by physicians in training. We need to change the culture to make medicine more family friendly. We need to increase responsibility given trainees to help them progress to self-sufficiency faster.

Perhaps we could learn something from Cathay Pacific. We should at least look.

Lang Co Clinic

Three days of working in a rural clinic went by like a whirlwind. This is incredibly different than my previous medical experiences in Hanoi and Ho Chi Minh City (HCMC), but, it really is about what I expected. The disparity in care (and life) is amazing here. Some stats from a Vietnam News article I read yesterday:

1. HCMC accounts from 21% of the nation's GDP (this is an improvement, I think, because it used to be 75%. Now Hanoi and Da Nang have grown tremendously, siphoning this off) including 44% of tourism dollars.
2. Average income is 2.4 times higher in HCMC than the rest of the country.
3. The city has an average economic growth rate of 11% over the last 25 years - 1.5 times the national average.

What does all this mean? It means if you live outside of HCMC (and definitely outside of it plus Hanoi and Da Nang) you are markedly poorer than the rest of the country. It logically follows that your health care will also suffer, since all the major hospitals are in HCMC or Hanoi, and you will have little if any ability to travel for medical services.

Consequently, clinic saw both run-of-the-mill malnutrition and parasites (probably 80-90% of cases) mixed with really interesting cases that had little to know previous medical follow-up.

In the three days I was in Lang Co, I saw an average of 40 patients per day. One young boy, about 2 years old, came in with his mother who complained about a large lump behind his left knee. On examination, I noticed he had a rather large (7cm by 5cm), non-tender, immovable, solid mass behind the right knee. Nothing noticeable on the left. Mother stated that the mass had been there since at least 3 months of age, and had gotten bigger as he had grown. A local physician had seen the child early in the course, performed no tests, and said it was totally normal.*

*(aside: this is common in Vietnam, where medical tools are scarce and money to pay for them more so - to do almost no tests, except an ultrasound of the abdomen which is done for everyone regardless of chief complaint because ultrasounds are so prevalent - and not explain to the patient anything. Although, in America we explain everything and the patient never hears or understands what we say, so perhaps that is just universal...)

So, I ordered some xrays of the bilateral knees and femurs and told the mother to return the next day. Early the next morning, in she walks with xrays in hand, showing growths on both femurs (left markedly greater than right). Luckily, one of the other physicians on the team, Mark, is an orthopedic surgeon, so I walked next door to get a specialist consult. He had the child walk, looked at the xrays, then declared it was most likely an osteochondroma - a benign tumor of the bone. It's monitored through periodic xrays and removed if it impacts function (walking in his case) or grows rapidly (small chance of becoming malignant).

Mother went away happily knowing a diagnosis, and knowing what to look for, and I moved on to the next patient - more worms.

In all, I saw probably three or four cyanotic heart lesions, a previously undiagnosed brain mass, juvenile idiopathic arthritis, hodgkins lymphoma not receiving treatment because of no money, cleft lip, and - jewel of the diagnosis crown - Russell-Silver Syndrome (stories for another day). Sleep was welcome each night. It's amazing how much good you can do with so little.

My First Clinic

Lang Co is a small hamlet between Da Nang and Hue.

This month I have two different medical experiences designed to let me see the disparities of care between rural and urban Vietnam. For four days at the beginning of the rotation,i will work in a small rural clinic in Lang Co, Vietnam with an organization called Vets With A Mission. They are a nonprofit organization that provides medical missions to Vietnam with a Christian background.

Today was my first day in the clinic. VWAM had their in country representative contact local leaders who sent flyers ands invitations out ahead of time to residents advertising them that we would be providing free medical care over four days. Of course the prospect of American physicians and free care is incredibly popular, and we saw 153 patients between four doctors: family practice, orthopedic surgery, chiropractor, and myself ( pediatrics).

A typical house in rural Vietnam near Lang Co

A clinic like this provides unique challenges. Many parents being their children just because we are American, even though their children have already seen doctors and received medications. Usually the normal Vietnamese doctor takes the week of because we make crowded and siphon patients. We also see children incredibly sick, who have not received care because their families cannot afford it.

The rural clinic where we practiced

Today was a "get the hang of it day," so I only saw 29 patients. Most children came for two reasons: inadequate weight gain and horribly rotten teeth. The chief complaint was " my child is a lazy eater." I am very good now at explaining that milk is not healthy in Vietnam when they mix sugar with it. This causes cavities, which cause pain, which leads to decreased eating and poor weight gain.

The communist government provides free care "in theory," but in practice those doctors are not respected, wait times are so long, that people don't see them. They go instead to private physicians, but often do not have the money to buy the medicines prescribed. So, in practice the Vietnamese have a very capitalistic health care system with two tiers, similar to the USA system, and very low access for the poor.

The waiting area on the morning of day 1

In-N-Out Burger and LAX

There are few things in life as amazing as a hamburger from In-N-Out. Anyone who has lived in California understands what I'm talking about. I think they secretly put drugs in the burgers because how else could they be so addictive? Seriously, part of the draw is the fresh - almost HEALTHY - taste of their burgers, and another part is the secret menu. It's so secret that even the menu posted online doesn't have everything that they actually offer. Each time I go, i invariably learn something new on the menu.

Well, when I booked my ticket to Vietnam, i realized that I would have about five hours at LAX before boarding my flight for Korea. This had me wonder on Facebook if it was possible to grab some delicious grub while waiting. Thanks to my friend Daniel, who pointed me to a forum about this exact subject, i realized I'm not the first ( and surely not the last) to think these same thoughts.

It looks like there's actually a pretty established way to get there. Following these tips, i walked about 25 minutes with my carry-on, to reach In-N-Out. On arrival, i found the line out the door, and the line of cars out the parking lot. Seems everybody loves In-N-Out. A little ahead of me in line was a middle aged Hispanic woman with a suitcase - i want even the only airport denizen there! LOL.

Of course the food was delicious, and I couldn't have asked for a better finals meal in America. I hear In-N-Out has finally reached Texas. Perhaps I'll be so lucky as to one day see it in Louisiana. We can only hope...

Tam biet,

Global Health Vietnam: An Overview

I have had this blog for quite some time, and have written extensively about my experiences in vie team. However, this trip marks another first: the first time i am an actual physician and responsible for treating people here. As a third-year pediatric resident, i have had many "firsts" medically over the last two years. Now i am the first resident from my program, Our Lady of the Lake Children's Hospital (OLOL), to do an international elective.

I set this rotation up in collaboration with my boss, Dr. Roberta Vicari, with the hope of establishing a perpetuating global health experience that helps those less fortunate, develops resident medical skills and empathy, and furthers the mission of OLOL.

So, over the next five weeks, i hope to blog various posts about my experience. Perhaps we will all learn about the Vietnamese, their culture, and their medical care together. I look forward to sharing this time with you, and maybe next time our roles will be reversed. Feel free to comment, question, or pontificate on my posts. Social collaboration is key!

Tam biet!

Home Run by the CDC

Let me join the blogosphere in congratulating the CDC on a job well done. The recently published "Social Media: Preparedness 101: Zombie Apocalypse" is an excellent example of the use of social media to convey a message and awareness of target culture to make the message meaningful.*

The CDC webpage starts with this:

We’ve all seen at least one movie about flesh-eating zombies taking over (my personal favorite is Resident Evil (External Web Site Icon. [rate:6.4] 78,991 votes), but where do zombies come from and why do they love eating brains so much?

...The Zombie Survival Guide identifies the cause of zombies as a virus called solanum.

While I agree that Resident Evil (the first one) might be my favorite movie as well, we need to thank the spread of the Zombie Survival Guide to image boards like 4chan.org. Many meme's start from its sundry (and not all safe-for-work) pages, including the infamous "you got Rick Rolled" meme.

KnowYourMeme.com explains the origins of a now ubiquitous Zombie Survival Sheet on 4chan.

According to the Lurkmore wiki the meme originated from the 4chan’s /k/ board, a board about weaponry, around the late October 2008.
The board began to be invaded by what they called “zombie threads” in which they were asked to give pieces of advice about the best weaponry choice and plan when facing a zombie outbreak. It was usually resulting in a division between those who wrote the most accurate response they could find and those who didn’t believe in zombies, leading to fiery arguments between the two.

...The 29th of October 2008, the meme went to /b/ where another zombie thread popped up. There, the picture began to be reused to fulfill the requests.
It then came back to the /k/ board, having more and more threads created.

Instantly, the meme expanded to other boards and other chans, mainly those that got a zombie board.
That kind of zombie threads, since then, are always present on a regular basis on 4chan as well as other boards.

It's now almost 24 hours since the CDC tweeted about zombie preparedness, and it's still trending worldwide. In the 30 seconds it took to snap the picture, over 100 new tweets mentioning the CDC zombie preparedness guide rolled in.



Two opinions on this PR coup by the CDC:

1. Whomever had the idea for this should get a raise and promotion. Good fresh thinking needed in the government.
2. This provides a great avenue to remind the public that the CDC isn't wholly comprised of staid, stogy professors sitting in laboratories doing esoteric research. It very much is comprised of smart and lively men and women who often live and do very interesting things. They are much more than the sparse natural disaster warnings that we read about.

For example, the CDC Epidemic Intelligence Service (EIS) is a 2-year postgraduate fellowship for applied epidemiology. Eyes glaze over? Let me tell you again. The EIS is a small group of people who leave at the drop of a hat to investigate outbreaks like SARS and Ebolla. They fly INTO the eye of the storm while everyone else wants to get away from the diseases. Pretty cool, eh?

Congratulations, CDC, on a job well done. Now, back to polishing my AA-12.



*I'll also add a shout out to President Obama, who, for reasons he's responsible for or not, has presided over a government that has made progress by leaps and bounds in the "use of social media" and "awareness of target culture" departments.

Expensive Health Care

Over the last year, as we in America have been swept up in political wrangling over health care, and the inherent power struggle between democrats and republicans that is ultimately at the bottom of it all, I have had the opportunity to have a front row view. I sat on the board of trustees for the Texas Medical Association and sat through numerous conference calls and strategy sessions with doctors in Texas, the American Medical Association, and politicians in Washington DC.

For sure the problem with healthcare is multifactorial, and our solution undoubtably must be as well. However, a favorite argument thrown out by both sides is the "cost of health care." One need not look far or read many webpages to hear someone opine about needing to reign in those outrageous costs (and his or her solution). This past July, Veronica Gunn, MD, chief medical officer for the Tennessee Dept of Health spoke to us about this and other topics.

The scare tactic she used was common: put up a graph that shows $12.7B spent on healthcare in 1950 and $2400B (yes, $2.4 trillion) spent in the USA in 2008.

"Holy cow!" you say?

Yep. That's right. An almost 188-fold jump in spending. That's like going to McDonalds and wanting a $1 hamburger only to be told it now costs $188. You'd choke then & there - way before you got the hamburger! Anyone and everyone should rightly be concerned about such a jump.

"Why would the hamburger cost so much," you ask?

Well, McDonalds gives you the standard answer: yesterday we made hamburgers, but our board decided overnight to do a couple things. We now have all new state-of-the-art machines for making patties the same size every time, and a super fryer that makes our delicious fries even more so - and healthier! We've also decided that you have to buy your own buns separately - but only the ones we decide for you to buy (and write you a prescription to get) and the bun makers say they have special no-fat buns that taste good but cost a fortune to invent. Oh, and don't forget the new program to give free hamburgers and fries to everyone who comes in without the money to pay.

You see, we've decided it's immoral to refuse hamburgers to someone who doesn't have the cash on them, so we give it out free and charge you more. But don't worry. If $188 is too much, we'll allow you to pay $40 a month (whether you'd have eaten 40 burgers a monh before or not) to another company who pays us, and then you can get each dollar hamburger for $1.

Now, before we hear the cries of "Health care is a right! Eating hamburgers is not!" I want you to put aside your righteous indignation at an admittedly flawed (but I still think decently effective) parable, and follow me to the numbers.

Ms. Gunn said $12.7B spent on healthcare in 1950 and $2400B spent in 2008. If adjusting for inflation according to the consumer price index, $12.7B was really $112.4B in 2008 dollars.
Now, that's still a large gap, but the 188-fold difference that made your eyes pop out of your head has dropped to 21-fold. Crazy large? Yes. Space-time continuum splitting? No.

Now let's adjust for population. 1950 - 152,271,000 people. 2008 - 301,621,157. That increase in spending just dropped to 10-fold.

10-fold is a lot different from 188-fold.

Essentially McDonalds is saying, "Our hamburger now costs $10 a burger, from $1 in 1950. So, pay us $40 a month regardless of the amount of hamburgers you eat, and you can have your hamburgers for $1, plus, we can give free hamburgers out to people who can't pay for them."

Even if you believe ideologically that you should give free hamburgers to the poor, spending $40/month is a lot harder to stomach when the price of the hamburger is only $10 and not $188. The Democrats and certain special interest groups (including many physician organizations) understand this, so they play up the $188 burger. Health care becomes an easy way to redistribute wealth.

[+/-] read/hide the rest of this post

Kneel at the Altar of Your God

Yesterday I was reading an article at The Reinvigorated Programmer (hat tip to my brother for the link) about the changes in computer programming and coming to grips (or not) with them. The writer laments the metamorphosis of programming away from a creationary enterprise.

Today, I mostly paste libraries together. ... Is that programming? Really? Yes, it takes taste and discernment and experience to do well; but it doesn’t require brilliance and it doesn’t excite. It’s not what we dreamed of as fourteen-year-olds and trained for as eighteen-year-olds. It doesn’t get the juices flowing. It’s not making.

How universal is this desire to create? It drives humanity, and has since the beginning. Adam & Eve got kicked out of the Garden of Eden and started creating our race. The Pharaohs of Egypt built huge pyramids to remind us of their power. America boasts of creating an environment (government and economy) that fosters creation of products and ideas.

EBM not only takes the individuality out of case management, but stifles innovation

Medicine is the same. To some extent each of us, definitely myself, got into medicine to help others. Put another way, we wanted to create health from sickness. Surgeons say "a chance to cut is a chance to cure," but it could also be said "...a chance to create a new, healthy patient." 80% of physicians are still in private practice instead of large, academic settings because - in part - we enjoy creating that medical practice. We enjoy hiring our nurses, finding our own building, being our own boss. We enjoy creating a relationship with our patients.

Quoted in the article is Don Knuth, from Peter Siebel's book Coding at Work:

There’s the change that I’m really worried about: that the way a lot of programming goes today isn’t any fun because it’s just plugging in magic incantations — combine somebody else’s software and start it up. It doesn’t have much creativity. I’m worried that it’s becoming too boring because you don’t have a chance to do anything much new. Your kick comes out of seeing fun results coming out of the machine, but not the kind of kick that I always got by creating something new.

...The problem is that coding isn’t fun if all you can do is call things out of a library, if you can’t write the library yourself. If the job of coding is just to be finding the right combination of parameters, that does fairly obvious things, then who’d want to go into that as a career?

The current trend of Evidence-based Medicine (EBM) is the mirror of Don Knuth's antagonist. We are taught in medical school and Continuing Medical Education (CME) seminars that we must practice EBM. Medicare has adopted it as measures of quality and tied it to repayment. for example, hospitals are rated by Medicare according to how fast a heart attack patient gets to angioplasty once arriving at the ER.

This isn't a bad thing. When numerous studies show that mortality improves when a patient gets to the cath lab in under 60 minutes, who will argue with saving lives?

But the problem with implementing EBM on a systems level vs a personal level, is that the physician becomes the cog in a machine.

In an article on insurance companies using EBM to determine care, it says,

Under EBM, medical treatment decisions are made primarily using guidelines from existing literature rather than a doctor's own expert opinion. Advocates of the practice say such guidelines limit variation in physician practice thereby improving quality of care.

But critics dismiss a reliance on such standardized treatment protocols as "cookbook medicine" and argue that EBM not only takes the individuality out of case management, but stifles innovation by removing insurance companies' obligation to pay for treatments they may deem "experimental."

And so the problems are two-fold for physicians:
1. The adoption of systems-wide EBM results in elaborate flow charts and checklists that impart a feeling of "cookbook medicine" on the viewer. For a physician this negates the creator feeling. As this pervades the profession, would-be physicians who understand this will follow that creator feeling to other professions & medicine will lose a valuable part of its talent pool.
2. Without individuality, the decision-maker leaves the physician-patient relationship. A third-party insurance company who stands to gain from denying care, interprets the literature and decides whether a procedure is necessary or not. More physicians will leave when they feel their position usurped by these companies, and the talent base of medicine is further eroded.

It’s not what we dreamed of as fourteen-year-olds and trained for as eighteen-year-olds. It doesn’t get the juices flowing. It’s not making

Plus, it's bad for patients. Last month I was learning ultrasounds in a high-risk Ob/Gyn office. One morning an Indian woman arrived for a scan due to previously seen IUGR (her baby wasn't growing). However, the family were immigrants, and mother was small. Talking about this with my attending, she remarked that the growth charts we used were standardized among middle-class Caucasian New Englanders. Totally inapplicable to the patient before us. In Britain, they've determined that many IUGR babies are normal when plotted on curves specific to that ethnicity. The same would be true with this woman's child. However, we as physicians couldn't make that decision because too many third parties would look at us not following up this baby's weight as bad medicine because it didn't follow EBM. So, she was here to get a second scan, wasting her time and money.

Let's see EBM for what it is -- a wealth of accumulated human knowledge that elucidates the generally best way or an individual physician to practice medicine. Following it is the right thing to do. But let's not kneel at the altar of EBM. You go to medical school, and establish a practice, and cultivate relationships with your patients so that you can have the knowledge-base and intuition tailored to your patients so you can understand when the rule and when the exception is applicable. It's at that point we physicians step back from connecting libraries into a program and start to create again.


[+/-] read/hide the rest of this post

100 Books to Read

Obviously I'm not writing much. Why? Because I've spent the last year and half going insane. About a year ago, I went to work in the research lab and I was talking to my professor, when he made an interesting comment.

"So, it's good to see you looking happy," he said.
"Well, I am. I really am."
"A lot of people have a hard time with third year [of medical school], but you seem to be doing well."
"Umm...I think I really like third year much better than the first two. I feel like I'm really learning medicine, and I get to work with people -- no more nose in my textbooks all day long."
"That's good to hear. A lot of students that move to the wards have a hard time with it. Over my years, I've seen a lot of them crack under the pressure."
"Well, I dunno about that, but we did have one girl drop out a month or so ago."
"No, I mean they really need to see psychiatrists. They just can't handle the responsibility and the change from being a student."
"Oh... That's not me. I'm liking this much better than before."

His reference to people cracking under the pressure rang too true then and now. I've been ruminating over it for the last four days. Mainly, I find that doing medicine all day, every day, kills me. I need a release. Mostly, I need a book to read.

Throughout third year, I longed for the day when I could read what I wanted to read, because it piqued my interest, not because I had to. Even medical books -- I used to go down to the medical library in the Texas Medical Center and read medical journals for fun, because I found them interesting. Now those same journals are a chore, because I'm forced to read them daily.

Things turned for the better when my friend posted a list of 100 books on his facebook page. Supposedly the BBC thinks the average American has only read 6 of the 100. I've read 29. But therein lay my release! I'd been wondering what to read to get my mind off of medicine, and now I'd decided: I would read each book until I'd read all 100.

As my fourth year of medical school got underway, I was amazed at how much free time I truly had. Medicine started to become fun again - outside of the required courses, I could study what I wanted and typically had a little free time to read something outside of medicine.

Trying to find the list online, I ran into some other lists. Every list is a little different, but there are many similarities between them, which I think speaks to the strengths of those respective books.

http://artofmanliness.com/2008/05/14/100-must-read-books-the-essential-mans-library/
http://www.time.com/time/2005/100books/the_complete_list.html
http://www.randomhouse.com/modernlibrary/100rivallist.html
http://www.guardian.co.uk/world/2002/may/08/books.booksnews

Here's one list from the BBC that had the most interesting (to me) books. In April 2003, by popular vote (one person, one vote), it tried to find the most popular book of all time among UK readers. This is the list in order:

1. The Lord of the Rings, JRR Tolkien
2. Pride and Prejudice, Jane Austen
3. His Dark Materials, Philip Pullman
4. The Hitchhiker's Guide to the Galaxy, Douglas Adams
5. Harry Potter and the Goblet of Fire, JK Rowling
6. To Kill a Mockingbird, Harper Lee
7. Winnie the Pooh, AA Milne
8. Nineteen Eighty-Four, George Orwell
9. The Lion, the Witch and the Wardrobe, CS Lewis
10. Jane Eyre, Charlotte Brontë
11. Catch-22, Joseph Heller
12. Wuthering Heights, Emily Brontë
13. Birdsong, Sebastian Faulks
14. Rebecca, Daphne du Maurier
15. The Catcher in the Rye, JD Salinger
16. The Wind in the Willows, Kenneth Grahame
17. Great Expectations, Charles Dickens
18. Little Women, Louisa May Alcott
19. Captain Corelli's Mandolin, Louis de Bernieres
20. War and Peace, Leo Tolstoy
21. Gone with the Wind, Margaret Mitchell
22. Harry Potter And The Philosopher's Stone, JK Rowling
23. Harry Potter And The Chamber Of Secrets, JK Rowling
24. Harry Potter And The Prisoner Of Azkaban, JK Rowling
25. The Hobbit, JRR Tolkien
26. Tess Of The D'Urbervilles, Thomas Hardy
27. Middlemarch, George Eliot
28. A Prayer For Owen Meany, John Irving
29. The Grapes Of Wrath, John Steinbeck
30. Alice's Adventures In Wonderland, Lewis Carroll
31. The Story Of Tracy Beaker, Jacqueline Wilson
32. One Hundred Years Of Solitude, Gabriel García Márquez
33. The Pillars Of The Earth, Ken Follett
34. David Copperfield, Charles Dickens
35. Charlie And The Chocolate Factory, Roald Dahl
36. Treasure Island, Robert Louis Stevenson
37. A Town Like Alice, Nevil Shute
38. Persuasion, Jane Austen
39. Dune, Frank Herbert
40. Emma, Jane Austen
41. Anne Of Green Gables, LM Montgomery
42. Watership Down, Richard Adams
43. The Great Gatsby, F Scott Fitzgerald
44. The Count Of Monte Cristo, Alexandre Dumas
45. Brideshead Revisited, Evelyn Waugh
46. Animal Farm, George Orwell
47. A Christmas Carol, Charles Dickens
48. Far From The Madding Crowd, Thomas Hardy
49. Goodnight Mister Tom, Michelle Magorian
50. The Shell Seekers, Rosamunde Pilcher
51. The Secret Garden, Frances Hodgson Burnett
52. Of Mice And Men, John Steinbeck
53. The Stand, Stephen King
54. Anna Karenina, Leo Tolstoy
55. A Suitable Boy, Vikram Seth
56. The BFG, Roald Dahl
57. Swallows And Amazons, Arthur Ransome
58. Black Beauty, Anna Sewell
59. Artemis Fowl, Eoin Colfer
60. Crime And Punishment, Fyodor Dostoyevsky
61. Noughts And Crosses, Malorie Blackman
62. Memoirs Of A Geisha, Arthur Golden
63. A Tale Of Two Cities, Charles Dickens
64. The Thorn Birds, Colleen McCollough
65. Mort, Terry Pratchett
66. The Magic Faraway Tree, Enid Blyton
67. The Magus, John Fowles
68. Good Omens, Terry Pratchett and Neil Gaiman
69. Guards! Guards!, Terry Pratchett
70. Lord Of The Flies, William Golding
71. Perfume, Patrick Süskind
72. The Ragged Trousered Philanthropists, Robert Tressell
73. Night Watch, Terry Pratchett
74. Matilda, Roald Dahl
75. Bridget Jones's Diary, Helen Fielding
76. The Secret History, Donna Tartt
77. The Woman In White, Wilkie Collins
78. Ulysses, James Joyce
79. Bleak House, Charles Dickens
80. Double Act, Jacqueline Wilson
81. The Twits, Roald Dahl
82. I Capture The Castle, Dodie Smith
83. Holes, Louis Sachar
84. Gormenghast, Mervyn Peake
85. The God Of Small Things, Arundhati Roy
86. Vicky Angel, Jacqueline Wilson
87. Brave New World, Aldous Huxley
88. Cold Comfort Farm, Stella Gibbons
89. Magician, Raymond E Feist
90. On The Road, Jack Kerouac
91. The Godfather, Mario Puzo
92. The Clan Of The Cave Bear, Jean M Auel
93. The Colour Of Magic, Terry Pratchett
94. The Alchemist, Paulo Coelho
95. Katherine, Anya Seton
96. Kane And Abel, Jeffrey Archer
97. Love In The Time Of Cholera, Gabriel García Márquez
98. Girls In Love, Jacqueline Wilson
99. The Princess Diaries, Meg Cabot
100. Midnight's Children, Salman Rushdie

So, since last June, I've tried to broaden my reading, and perhaps read the books on these lists. So far I've read:

All 7 Harry Potter novels
All 5 Dan Brown novels
Blink by Malcome Gladwell
Watchmen by Alan Moore and Dave Gibbons

and I'm currently reading Open by Andre Agassi.

Plus, my scholastic freedom culminated last month on ultrasonography. There I worked 8 to 5 but could read whatever I wanted, allowing me to study things I found interesting. Since I didn't work nights or weekends, I had the freedom to read Watchmen - a decidedly un-medical novel - to help me unwind. That was a truly great month.

So, as I continue my exploration outside of medicine, how many novels on the list above have you read? What are you currently reading?

Health Care Reform

I haven't blogged about the health care reform bills going through Congress (nor anything else for that matter) because I've been doing what good medical students do, and have had my head in a book (or my hands inside someone's body) for the last three months now. This probably won't change.

But, as I take a five minute break from studying cardiology, I wanted to share with you this:

The New York Times (7/30, A19, Goodnough) reports that the Massachusetts legislature "failed to restore enough money to the budget to provide full benefits for 30,000 legal immigrants." But, lawmakers did "provide for partial coverage, relieving some supporters of the program, who had feared that the cuts would be deeper." The legislature had "eliminated health insurance for the immigrants, which cost about $130 million a year" in order to cover the state's budget deficit. Now, $40 million will be restored, "leaving unclear just how much care the affected immigrants would qualify for." At issue is coverage for "permanent residents who have had green cards for less than five years." Currently, "the affected immigrants are covered under Commonwealth Care, a subsidized insurance program for low-income residents." Under federal law, "the 30,000 immigrants affected by the loss of coverage do not qualify for Medicaid or other federal aid." But, "Massachusetts is one of the few states...that nonetheless provide at least some health coverage for such immigrants." [emphasis added]

The reason I point out this article is that this is what we must come to expect from any government intervention in health care. If Washington D.C. is going to draft a new health care system for America (and they are), then whether you like their plan or not, you better be ready for this to happen to you sometime down the road.

In any system where politicians decide funding, cuts will come based on what is expedient politically. In any system where funding comes from a government that also funds other sectors, cuts will come based on what is fiscally necessary at that moment. When they are together (as we see in Massachusetts and will undoubtedly see in any national plan), cuts come from either or both of those reasons.

This means that nobody is guaranteed coverage, or the same coverage, from year to year. While yes, some people who may not have any coverage now will be covered, WHAT will be covered is not guaranteed. And for those who have coverage now, the same goes. So, in a system where it's already hard enough to understand what your insurance covers and what it doesn't, how will you feel if those rules change yearly?

That may be palatable now, but wait until you get sick. Maybe this year you can get your medicine, but next year, who knows?

Now I Lay Me Down To Sleep ...

Life has been as crazy as ever, and blog posts have been very scarce of late. That does not mean I have not written them in my head! Oh no! Usually I get great ideas for things to share, pontificate upon, etc., but because school and the hospitals keep me away from computers, the words never make it from my mind to my blog.

For two months before Christmas, I was on my Pediatrics rotation. Working with children was very rewarding, but one of the hardest parts of being in the hospital was that truly sick child -- the one that for whatever reason, was not going home.

Working with adults, when someone finally succumbs to their disease, you can chalk it up to their previous bad habits (like smoking, eating fatty food, not exercising, etc), but with children, it's either dumb luck (infection) or other people's problems (abuse).

The most depressing is probably seeing the newborns pass away. My newborn experience while on pediatrics was confined to the well baby nursery, and it was enjoyable to see happy parents with their new children. I also remember when my son was born, and the extreme joy -- no, spiritual experience -- that I had when holding him in my hands for the first time.

The dichotomy to all that joy must be the hurt when a baby dies, and historically physicians have encouraged parents who know their baby will be born with a fatal condition to terminate the pregnancy early and not grow attached to the fetus. A couple that attends church with us recently had a son with anencephaly -- a fatal condition where the child is born basically without a brain -- and chose to do the opposite of the physician's wishes. She bore him to term, they named him, held him until he passed, and buried him. It helped them gain closure to the experience -- especially given their belief that they can be together as a family in the hereafter.

Now there is a non-profit organization that helps parents that choose to gain closure like our church friends. Now I Lay Me Down to Sleep is a network of professional photographers throughout the United States that are on call 24/7 to take photos of families, parents, and the newborn during the short time the child is on this earth. Then they put the photos on an archival DVD for keepsake.

Wonderful. I wish nobody had to go through the death of a child, but if it happens, it's nice to know there are organizations and people like this to help. This year -- barring something monumental -- I will play in the second annual TBE March Madness Pool for them.

"I am a Mole." & "Do you read?" Revisited

Sacrifice your life for the grade. Sacrifice your family for the future.

Light. Blinding light. My eyes squint, teary; blurred images -- silhouettes -- shift along a field of white. Months of living below ground in the dark are over, and I poke my head out of the hole. A mole above ground ... for a weekend.

In order to practice medicine in the United States you must pass three licensing exams. The first one, dubbed "Step 1," is taken after your first two years of medical school. This is because the first two years are predominantly class-based basic sciences, and the Step 1 tests student aptitude on these core subjects.

Due to quirks in the US system, the Step 1 exam has become the primary arbitrator of what residency you get, which in turn decides what specialty of medicine you practice for your life.

It's pretty important.

At UT-Houston, second-year classes are year-long, in part because studying for finals helps double as studying for the Step 1. This is when the moles dive DEEP.

My wife and son left for Utah mid-March, and spent a month there with family so I could study unobstructed at home. At the beginning of April I forwent all fun activities. It was total business. From sunup to sundown, studying was the game. My family returned as block exams rolled around, and I took my studying to school. After that came finals. After finals came five weeks of studying strictly for the Step 1.

Every day I'd wake up about 6am, get ready and hit the books by 7am. A friend, Marie, picked me up at 8am, and we studied at the library until 3pm. I had a review class from 3pm until 7:30pm M-F, and after getting home, ate dinner and studied some more until midnight. On the weekends it was the same, except no class in the evening.

Day after day went by. After reading the article that engendered "Do you read?" I started keeping track of the time I spent with my family. Typically, I warmed a bottle for my son when I got up in the morning, and spent 15 minutes feeding him about 7am. Although I saw my wife when I got home about 8pm, I really didn't spend time talking with her. Any "meaningful" time came about 11pm to 1am. Typically for about 1 hour, before I hit the hay.

That is the high pressure life of a second year medical student. Sacrifice your life for the grade. Sacrifice your family for the future. If you don't get two standard deviations above the mean, you can't choose what you do for the rest of your life. Imagine that...wanting to be an engineer, but someone else telling you that you'll be an electrical engineer versus a chemical engineer. That's the state of medicine today.

But now the exam is over. I have poked my head above ground. My wife and I spent four days in Corpus Christi to recuperate. Too bad on Monday I start working 120 hours a week during my General Surgery rotation. Here we go again...

Do you read?

Today L. Gordon Crovitz, in his article, "The Digital Future of Books," for the Wall Street Journal, said,

"The not-so-positive case is that, at least so far, we're not giving up on books for the same words on screens – we're giving up on words. Pick your data point: A recent National Endowment for the Arts report, "To Read or Not to Read," found that 15- to 24-year-olds spend an average of seven minutes reading on weekdays; people between 35 and 44 spend 12 minutes; and people 65 and older spend close to an hour." (emphasis added)

They obviously didn't poll medical students. Right now I average 14 or 15 hours reading a day. I average 5 minutes of seeing my son (while he's awake) and 30 minutes of meaningful conversation with my wife (while she's awake).

How much do you read?

I am a Mole

There's a lot people don't know about medical school. I once tried to blog specifically about it, but two blogs and school took way to much time, and it had to go. I've determined I should post more about my experiences here.

Medical students are moles. Yes, many of us are hairy and most of us have four appendages.

Moles live below the surface of the earth. They have full lairs and networks of tunnels connecting one hole to another. They can pop their head up in one yard, only to dive down again and surface far away in another yard.

Medical school forces even the most intelligent student to study. People tell you medical school is hard, but you never really get it until you're in the fire. Here at my school, we have exams every six to eight weeks. This produces a predictable pattern.

The first week after an exam you can see medical students all over town. They go clubbing, out to movies, and date. They may even spend time with family. If married, a spouse may remember that he/she is married when the medical student walks in all of a sudden.

"Oh you. Yeah, a couple years back, we did that thingie with the tuxedo and the white dress and church...you remember don't you?"

The second week medical students get back to the grind. They start attending classes again, catch up on lectures missed by streaming them online, and go out only during the evenings or on weekends (and usually to do planned activities). This routine extends through weeks three and four, if you're on the six-week schedule, or three through five if you have the eight week version (I'm the latter).

On the eight week course, things start to get serious in week six. Exams are coming up, and the medical student spends most of the day studying. You can find him or her at school or the library late into the evening. If lucky, you might pull him/her away for a couple hours on the weekend for a big event.

The seventh week is when the mole fully enters his chambers. The exams are palpable, and stress is everywhere. Men lose hair and women go gray just standing near medical students. If you ask how they're doing, you're liable to get a stare saying "what do you think?" and a verbal "you know ... surviving..." Medical students this week don't exist. They move like wraiths through the house; you notice they're around only because books and piles of papers are moved and food is conspicuously missing from the fridge.

The eighth week is exam week at my school. One exam a day. Medical students are ineligible to give blood during this week, as they have no blood -- pure coffee courses through their veins. For those whom caffeinated beverages aren't enough, there's caffeinated gum and amphetamines. This week medical students are nowhere to be found -- they get home long after you've gone to bed and arise before you wake up. You notice the sheets are rumpled, but that's about it. If you do run into one during the day, they'll probably mumble something about Tinel's sign, metacarpophalangeal joints, or lupus (the answer's always lupus).

Friday night, after the last test, the mole pokes his head out of his hole again, and realizes there is life outside of medical school. Time to party; we've got more exams in eight weeks.

Predicting the Texas Democratic Elections

I was going to write this amazing post about the upcoming Democratic primaries/caucuses in Texas, but after researching it for a hour and a half, I realized that 1) I don't have the time right now, and 2) someone's already done it.

I'm not sure if I agree 100% with the outcome, especially since it's done by an open Obama supporter, but I think it's pretty close. In fact, if anything, I think Obama might win more delegates.

The key will be the caucuses. Over the last couple weeks, I've been working with some other students and the Harris County Medical Society (HCMS) to get a spokesman from both the Clinton and Obama campaigns to speak about the candidates' stances on medical care. The Texas Medical Center, the largest medical center in the world, seems like the ideal place for such a discussion. Now seems like an ideal time, given the primaries are March 4th, and the Democrats seem like ideal candidates, since they're locked in a bitter battle for delegates.

However, all is not well. Clinton has a well-run organization in Texas. It was easy for a student to contact her campaign and get a staffer willing to do the meeting. Obama has no official campaign office. Everything around here is grassroots, and the student found no person with the permission or knowledge to come to our meeting. He even contacted Obama's national campaign headquarters and came away empty.

So, we're now seeing if the HCMS can come up with anything. With exams coming up, and the primary soon after, time is running thin.

But this story brings me back to my point that Obama will win lots of delegates in the primary because largely Black districts get more delegates than largely Hispanic ones, and various other demographic intricacies. However, Clinton's well organized campaign staff will do wonders at caucuses. It will be interesting to see how the cards fall.

The Texas Democrat's political process is incredibly intricate. Go to Election Inspection to get a decent overview of the situation. You can also go to this article by the Houston Chronicle. The writer of Election Inspection has a blog, Texans for Obama, which does the aforementioned good job at predicting the results.

O Muse 2

Oh Muse, the best laid plans of Men are folly!

When I wrote my post, O Muse ..., I originally had it many pages long, but after reflection, truncated it. I feel the thoughts were best elucidated separately, although they do connect. As I pondered the (de-)evolution of blogging, I realized that I had seen this phenomenon before.

Blogging has changed like medicine. Once it too was a brotherhood. Physicians went through years of schooling to understand the mysteries of the body; heal people. The community respected them. If a physician got sick, he needn't worry about paying, for other physicians would treat him pro bono.

Then something happened. Physicians in California sold their souls to Kaiser Permanente, and their fellows in Dallas, TX sold theirs to Blue Cross/Blue Shield. In the name of the patient, these physicians sold their autonomy to HMOs. They thought,

"I can help my patient if I worry about the billing and not him/her."

The HMOs said,

"We will entice patients into preventative care if they know they have already paid for it monthly, instead of paying up front."

Oh Muse, the best laid plans of Men are folly! Gone went the direct payment to physicians, and the hidden became the cost of medical care. Instead of preventative medicine, patients demanded the "million dollar workup" for every disease, because, hey, they had paid for it. Physicians spent less and less time with patients, because they needed to see more and more to cover the overhead of their billing requirements.

And in the community's eyes, the physician became a well-read technician. Sure, more respected than a plumber, but in stature much like a nurse or a physician's assistant -- someone who looks at a patient, checks a set of boxes, and sends them to a machine (xray, MRI, blood test) that diagnoses the sickness. A glorified car mechanic.

Except that true medicine is so much more than that. Hence the crisis in Health Care today -- it is an identity crisis. Many talk today about the need to “fix” Health Care. Most propose some combination of patches that extend coverage, and change billing structure. However, the true solution will only come when physicians wake up from their self-imposed slumber, and throw off the dichotomy that afflicts them.

Health Care must be put back in the hands of the physicians. Patients must be in control of their own health. Blogging has followed much the same path, and similarly, bloggers must never relinquish their camaraderie. It is these bonds of friendship and acquaintance, although spawned first over the virtual web of cyberspace, that keeps the reader questioning reality. It keeps him aware of his surroundings; looking through others' eyes at things which may have been mundane before.

Only through our ever present desires to push how people view the world, to share insights into life, and to refute complacency, can blogging truly be constructive. It is for that end we must continually strive.

Closing a Chapter pt. 1

I sympathize for the dilemma that faces American women today

Last week my wife finished her maternity leave and went back to work. My wife had reservations about returning to work. She, like many women today, grew up expecting to work, gained meaning from her experience in the workforce, and enjoyed it. The housewife role is rapidly disappearing from US life, and is preceded by disappearance in little girls' dreams.

My wife was afraid she'd miss her child upon returning to work, yet she felt guilty every day of maternity leave for yearning to be working. Now that she's returned to work, she feels guilty for not missing him, but enjoys the sense of purpose that an 8am to 4pm job brings.

I sympathize for the dilemma that faces American women today. It would be hard to give up my dreams, my years of schooling, to stay home and raise children. Promises that, "you are doing a better work, raising your children. What you could achieve as one person, you're multiplying by successfully raising many outstanding children" sound incredibly trite and hollow when actually faced with the prospect that my dreams are being ended prematurely.

The other day I was reading a post on a friend's blog (which mysteriously isn't there anymore, so I can't link to it...but it's still in my RSS reader!) and she (I'm not using her name because there might be a reason why the post is no longer available) related accompanying her husband to a law function.

Anywho, while at the dinner, ...I tried to converse with some sense of grace and poise, while I attempted to look the part of a lawyer-to-be's wife, I started questioning...Would I ever feel at home all "dolled" up? Can I really be that kind of woman?...

This introspection caused me to view my wife's predicament more fully. Would she ever feel at home all "dolled" up at physician functions? Does she want to live that life? The answer, not surprisingly, is NO.

So I should change to accommodate her. How, I don't know. But I do understand that she wants to get a Masters in Public Health, and she wants to work for non-governmental organizations--preferably overseas. Balancing these dreams with the bonuses of being home to raise your children will be hard. I believe strongly that a mother in the home is FAR better than any child care agency on earth. However, I have faith both can be done--my wife's that amazing of a woman.

Medical Word of the Day (MWD)

While studying for Physical Diagnosis, I came across a word that peaked my interest, and since I'm living a pseudo-bachelor life right now, I had nobody to share it with.

Therefore, I have decided to share it with everyone, in my new (hopefully the first of many) post, Medical Word of the Day (MWD). MWD is not WMD (weapon of mass destruction), although sometimes it has the same effect on my life.

So, for all of you who want to be a doctor, answer me this (hint, I was studying the neurological exam, and focusing on cerebellar problems):

Medical Word of the Day: Dysdiadochokinesis

Dysfunction in performing rapid alternating movements. Movements are irregular in both range and rate.

[+/-] Click here to read/hide the definition.

I'm Alive!!!

That is my long excuse for not posting for two months

That's what I imagined my baby boy said on October 3rd.

Yes, I do have an excuse for not posting in almost two months.

As you can see, my last post was October 2nd, 2007. That's because, that night, after telling people at school he could come any day, I went to bed confident he wouldn't come until the weekend. About 3:30-3:45ish in the morning, I hear an,

"Anh. Anh! Wake up! I think my water broke."
*still groggy* "...ugh, what?? Are you sure?"
"I don't know. I had to go to the bathroom, and it just keeps coming."
"What color is it?"
"Clear, I guess..."
"Ok, ok...let's think...go stand in the bathtub for now so it doesn't get everywhere, and I'll grab the bags. What do we need to do now? Any contractions?"
"Ok...we need to call Kelsey-Seybold and let them know before we head to the -- ah!! -- hospital..."
"Was that contractions??"
"Yes, I think so.. --ah!! -- they're coming pretty close toge --ah!! -- already."

... a couple seconds later, "Anh, the fluid is clear, kinda rose-ish --ah!--" as she braced herself against the shower wall.

Flipping open the cell phone, i dialed the doctor's office (on speed dial). After punching all the requisite buttons to navigate the electronic forest I hear a voice on the other end say,

"Hello sir. How may I help you?"
"I think my wife is in labor."
"Ok. And did her water break?"
"Yes, about 15 minutes ago."
"Alright, and is she having contractions?"
"Yes..."
"how far apart?"
"I dunno...how far apart honey?"
"--ah!-- I think 4 minutes!"
"Yeah, she says 4 minutes."
"Already? Are you sure?"
"Yes!"
"Ok, we'll have the doctor on call call you back. If he doesn't call shortly, please call again."

I got off the phone and paced the room. My wife, still propped in the corner of the shower, continued to wince in pain every couple minutes. She grabbed her abdomen and said "ow ow ow..." then her face would relax as the tension and pain passed.

Eventually, I called back the receptionist -- the doctor never called. She paged the doctor again. Eventually, he called, and said they were ready; come on over.

I swung the bags over my shoulder and helped my wife get dressed. With her leaning on me, we went out to the car, backed out, and navigated our way out of the condo complex.

The hospital was only three blocks and five minutes away. We were at the front door by 4:30am. Popping out of the car, I handed the keys to the valet, grabbed the bags from the back seat, and raced around to the other side to help my wife out. Grabbing the ticket, I walked her to the elevator and up to the labor and delivery ward.

As told, the nurse staff was expecting us. The room was ready, and they wheeled her into it immediately. I set my stuff down and turned around to do the fatherly duties of filling out papers and paying the hospital.

The nurses were incredibly nice and skilled. My wife writhed in pain every couple minutes as I held her hand and shot pictures. Eventually, I stepped outside while the anesthesiologist placed the epidural and when I returned, gone were the contorted faces and cries! In front of me was a tired but smiling wife. Those epidurals truly are amazing.

By 5:45am my wife was dilated 10cm, and we had a choice--go with the on call ob/gyn or wait for our ob/gyn who was in transit. We opted to wait, and promptly about 6:30am he walked in. After taking a quick look at my wife, he gave the orders to prep and walked out.

"Push!"
"Push!"

After a couple pushes, she was ready. Our ob/gyn reentered, and

"Push!"
"Push!"

Those epidurals truly are amazing

Out popped the baby. Our ob/gyn deftly slid his two fingers under the umbilical cord wrapped around the boy's neck, freed him up, and held his wailing body to the world.

"Waa!! Waa!!"
"Do you want to cut the cord?" he asked.

Eagerly, I grabbed the scissors and cut in between the clamps. The doctor tied the knot, and the nurses whisked the baby over to the other side of the room to get weighed and scored. I followed.

"He scored an APGAR 9" the nurse said. "Let's see how much he weighs....5lbs. 14.5oz. Do you want to take a picture?"
"Of course! We've got lots of people who want to see this kid," I replied.

And so entered Braeden into the world, at 7:10am (after only 3 hours of labor) on October 3rd, 2007 and weighing in at 5lbs 14.5 oz and 19 in long.

That is my long excuse for not posting for two months. The birth of my first baby, exams the two weeks after the birth, and getting used to being a father and a student since then, has taken up almost all of my time.

Now, however, I promise to reclaim my life -- at least until exams in two weeks or Braeden needs to be held.

My hurting ear

Insurance companies are the "whore of all the earth"

My last post was two weeks ago. It's been a crazy and painful two weeks. Ironically, this blog is called The Bleeding Ear, because of this, and although my ear did not bleed, it did hurt mightily.

You see, somehow, I got an ear infection -- Otitis externa and Otitis media. For those of you who did not grow up speaking Latin, I had both outer and middle ear infections.

I was never one to get ear infections as a child. Sure, I had one or two, but most everybody does. Typically came after swimming, i.e. "swimmer's ear," that horrible, painful condition you get by not getting all the water out after swimming. Pseudomonas aeruginosa loves that environment, and can't help making you feel miserable while it grows.

On that note, I looked up "home remedies" for ear aches and found people attributing swimmer's ear to fungus and all sorts of things. One lady even said "use vinegar because it works well against fungi, but don't use it against bacteria because it makes their infections worse." Sorry, lady, but I got news for you: you're advocating vinegar for a bacterial infection, not a fungal one--directly contradicting yourself.

Back to the main topic: My story starts about 18 months ago in the wet and hot streets of Saigon ... actually, it was there that I got my first "adult" ear infection. It was painful, annoying, but bearable. I saw a doctor -- a pediatrician -- because it was better to go to a private physician, trained by Americans, who worked out of his home, and new my in-laws for many years, than to go to a government-ran hospital. If I had done that, I probably would have left Vietnam with only one ear (and no paintings of haystacks).

In Vietnam, pharmacists are unlicensed doctors. You can go to them and buy whatever drugs you want, without a prescription. Two years ago, I went to a pharmacist in Hue complaining of flu-like symptoms. She promptly gave me a plastic bag with a bunch of nondescript, generic pills, told me to take so many at such and such times, and I slept through the bus ride to Hoi An. But I got better, so she probably knew what she was doing, and gave me real medicine.

Because the Chinese will often grab a real looking bottle, with real looking gel caps, but fill it with chalk instead of acetaminophen, and then you get sicker instead of better ... but I digress.

The pediatrician wrote me a prescription, since I saw him first, and I went right next door to his neighbor that ran a pharmacy out of his home. I picked up the drugs, which purported to be sulfamexazole-trimethoprim ("Bactrim") and took it for a week or two. I got better, but my ear has never felt perfect since.

Then, a couple Thursdays ago, my ear hurt. I mean, it hurt bad. I didn't sleep well Thursday night -- only a couple hours -- and on Friday I went into the student health center. Got prescribed amoxicillin 500mg po tid and ciprofloxacin/hydrocortisone drops to put in my ear. Cost me an arm and a leg.

Back in Vietnam, I could have gone to the pharmacist, spent $5-7 USD, and got all that medication. Or, like I did, spend $2 USD to see the doctor, have him prescribe me correct meds, and then spend $5 to $7 USD on them. Everything out of pocket. I was able to go whatever doctor and pharmacy I wanted. No forms to fill out.

I probably would have left Vietnam with only one ear (and no paintings of haystacks)

Similar sickness, different setting. I had to go to my student health center, because my insurance won't pay for any doctor outside of it (without me paying a fortune), and then had to drop over $130 USD for the drugs (the amoxicillin was $10 USD copay, at the center, but the drops were $120 USD out of pocket at Walgreens). If I want to get reimbursed for the drops (minus copay) I have to fill out forms, attach the prescription, and mail it to Dallas. Some paper-pusher who knows nothing about my medical case or history (or medicine, probably) will then decide if the doctor was correct in prescribing those drops, and if I filled out all the forms, so i can get my $100 USD back.

Insurance companies are the "whore of all the earth" ... but that's another story.

Friday night I tried to rip my ear out of my head --with all cochlea and small bones attached. I called a "nurse hotline" (because evidently, the doctors I could call when I was growing up have now given all their expertise to nurses) who told me to take a decongestant and put heat on it. Great. I did those things, and tossed and turned throughout the night.

Eventually, after finishing my 10 day course of antibiotics, my ear is bearable. Not better, but bearable. It doesn't feel "normal." A lot of times I feel like that ear needs to be "popped," like when you ride in an airplane. Other times, it feels discomforting, not quite painful, but definitely not fine. Maybe I need to see and ENT...but I don't want to fill out any more forms...


[+/-] read/hide the rest of this post