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Here are some poems to read if you are too far away to get shalekhmones from me. Or if you don’t celebrate Purim at all…these poems are still for you.


Purim Doggerel 2014

I covered one of the chief residents in our hospital for two days this past week, seeing more than 40 patients in total. My off-the-cuff remarks on Facebook still apply:

Twenty-two inpatients later, it is time once again to declare my awe and admiration for all who do this work daily: hospitalists, housestaff, nurses, techs, custodial staff (et al., et al.). And, of course, the patients who are – on the other side of the hospital mirror – working harder, in their way, than all of us.

What’s more, I was struck – not for the first time – by the differences between the hospital and clinic, not just in tone, atmosphere, communication, and pace, but in how those things affect medical thinking and decision making.

I am not talking about critical care or emergency medicine, nor about “codes” (cardiac resuscitation) – merely because I do not participate in such care regularly. But I think my observations might still apply.

Simply put, the hospital operates under the assumption that things have to move faster. That tempo, I believe, encourages a certain frame of mind: we should treat, do, test. People are sick, we want to make them better, and lab tests and interventions are an avenue to this.

You already see where I’m going, because – if you know me or my blog – you know my bias. If anything, I think we tend to over-order as a health care system….and the scientific literature bears me out.

What would it mean to apply evidence-based medicine to hospital care, in a thorough-going fashion? I mostly do outpatient medicine, and guarantee you that I assume no superiority for the application of EBM in that realm: no, much of what we do in clinic is still based on intuition, externalities, unsupported lore, personal preference (not the patient’s, God forbid, but our own as doctors), or some other blend of bias and conviction.

Would it be harder in the hospital to take stock? Would workflow be disrupted?

Or is it just that I am unaccustomed to the hospital, and things are really changing in that direction? What do you think?

Noncompliance means I think the patient should do it this way and the patient didn’t do it this way.

“Noncompliance” makes no effort to figure out why the patient did what they did, or what alternatives they might have selected instead.

“Noncompliance’ makes no effort to figure out if the alternative suggested (or: mandated) by the doctor was the best of all possible alternatives in the first place.

The noncompliant patient is by definition not a team player. Not the sort of patient you want to be – or the sort of patient you want to treat (if you are a provider).

“Noncompliance” is never good.

Can we get rid, once and for all, of “noncompliance”?

Can we talk about what people do and why they do it?

Can we quit assuming that doctors know better?

Can we advise and let patients choose?

Still waiting.

My Facebook feed is riven in two. On the one hand, there are free-thinking, scientistic doctors, patients, and those who love them (or tolerate them enough not to hide their status updates). On the other, are Jews: and, for some reason having to do with personal curiosity and involvement with Yiddish speakers, many of them are Jews who are Chasidic, used to be, or are somewhere in between.

Both camps are in the throes of realignment. The former, because evidence-based medicine is screeching towards the end of a game of chicken, the other competitor being (unfortunately) the patient as a person, with power over her own decision making.

Let’s take the most recent example of this hair-raising collision: statins. Cholesterol medicines, in other words, and what to do about them. Yes, we should probably get rid of these artificial numerical targets, it seems like most people agree on that. But the new guidelines, according to which (grosso modo) everyone with an estimate 10-year heart disease risk of 7.5% “needs” to be on such a medication, are rightfully controversial. If you are the type to read JAMA articles, you will be entertained by John Ioannidis (he of the “half of all scientific findings are wrong”) on the one hand, who darkly prophesies “one of the worst disasters in medical history” due to vast overtreatment with statins. (Um. Flu? AIDS? The plague?), and, on the other hand, a professional, prudent take by some collaborators on the new guidelines themselves, who take what seems to be the best defense possible: The science is better; we are working towards incremental improvement of guidelines. In short: nothing’s perfect. This is a step forward from where we were.

If you read the articles back-to-back, it seems an awful lot like the internal breakup currently convulsing ultra-Orthodoxy. Belief and practice are at loggerheads, and tiny fish are getting squished between the logs. Are you a believer or not? Are you an incremental advancer or a revolutionary? Are you willing to listen to doctors by virtue of their social standing and hereditary place as healers, even if their advice might not be better than random chance?

Does medicine need a revolution to upend received wisdom – even the new received wisdom of our day, which is the dogma of evidence-based medicine – enthroning in its place the empowered singular patient? Sure, if you are the type to upend and revolt. But not even the most engaged of patients want to get rid of everything the medical establishment has to offer. Similarly, even those about to leave their hidebound religious communities sometimes find themselves at peace with a stable compromise. They don’t have to believe in everything.

If a revolution is possible, but we choose an incremental change, are we being sensible – or hypocritical?

I am doing some research for a book I am writing – more details anon, at least if it gets written, finds favor in the eyes of my agent, and turns into a bound-and-published butterfly. Some of the resources I needed were only available in the stacks of the Johns Hopkins medical library. To their credit, rather than turning the huge, high-ceilinged bibliotemple into yet another office complex, or tearing it down for laboratory space, the librarians – sorry, informationists – asked the users what they wanted. “Let’s keep the library,” said the users, “but renovate it.”

I use the library an awful lot, mostly as a route to borrow resources from other libraries (often on medical themes but just as often on Jewish topics, which probably confuses somebody). Usually, the library brings books directly to my office, which for me is the equivalent of lying on a couch in my toga being fed peeled grapes. The delivery guy is as reliable as the mythical appointed couriers of the Post Office, making it to my office with snow-covered boots and a plastic bag full of library holdings.

Last week, I got an email that a book I had requested was already available, so I would not get it delivered. “See Notes,” said the email, and then, on the line below: “See stacks.”

Stacks! I had never ventured into the Welch Library stacks. In previous stages of my career and years of school, I had always spent time among the books when I least needed to. I found it a refuge. When everything is supposedly available at your fingertips, sometimes you need to be lured into a space where you find by serendipity, not by search. But here, I have not made the time, or, more likely, not allowed myself the luxury of wasted time.

A friendly staff person showed me the way: “Go down that hallway. Take the elevator.” Then she flitted away as if she had divulged a secret to me and was worried she might be found out. The elevator was a rickety thing, a banged-up box set on a shaft: “Be kind to the next user and close the gate AND the door!” The inspection certificate, defying my expectations, was up to date.

I found the book I wanted, but the quiet was an added gift: a surround sound version of that stillness found in a conservatory, a botanic garden, a chapel. I browsed a set of an Italian biology journal: glossy pages, full-color illustrations, the work of generations of scientists I would never know and never read.

The variety was luxuriant, rich, and ignored, a buried garden inside the very walls of biomedicine’s fortress. When would the voice of the granting authority find me and cast me out? Where was the flaming sword to guard against intruders?

The security guard smiled on my way out. “Did you find what you needed?”

I nodded, showing her what I could from my brief voyage: a bound book.

Last week I was invited to talk at the DC offices of One Medical Group, which was a healthcare startup back in 2009 when I finished residency (I interviewed with them for a job, as a matter of fact). Now it’s a going concern, with branches in San Francisco, New York, and DC — and, now that I look at their web site, in Chicago, Boston, and LA, as well. One of my friends from residency, Will Kimbrough, is the medical director of the DC office. He is an incredibly smart guy, consummately professional, innately humble, and not afraid to call out bullshit: powerful virtues make for a clinical leader and builder.

Nevertheless, before I knew Will was working there (and, to be honest, maybe for a bit after) I had my assumptions about One Medical Group – because it practices concierge medicine. Concierge medicine is for rich people, I thought. “Thought” is maybe a strong term: it was my assumption, born of ignorance and lack of acquaintance with such a model.

I can’t say that I am now intimately acquainted with a concierge model after an afternoon at One Medical Group. But I had a good time giving a short talk to a group of energetic, young doctors who told anecdotes about patients that sound an awful lot like mine. I still wouldn’t rely on the concierge system to fix our American health care holes, but it might indeed be a reasonable way of providing care to those that can afford it. And, who knows, maybe the price and quality transparency that have long been a natural, unquestioned characteristic of markets for other goods – cars, groceries – might make its way into the health care market in part through such private companies.

* * *

Sean Looney was a high school friend of mine, a tall guy who was often smiling. Our group of nerds thought we were hot shit (in a quiz-bowl, socially awkward sort of way), but he alone among us seemed to realize that it was worth our while to try and act like normal people, even though we were more academically oriented than others. Or, at least, not to be irremediably dorky.1045090_10151929081984001_1913062913_n

After getting a liberal arts degree, he went back to medical school and completed a family practice residency in Cheyenne, Wyoming; he told me about an instructor who could tell the caliber of a bullet by the sound it made falling into a metal bedpan. He then practiced medicine in many places across the country, but in these last years in Pikeville (county seat of Pike County, Kentucky), and in Louisville. He got married.

We weren’t really in close touch since high school, and I couldn’t make it to his wedding. But I did remember the kind of patients he said he took care of in Louisville: alcoholics with schizophrenia. Problems that are not, to be honest, on the pages of the New England Journal too often, and not the subject of fancy clinical trials.

Sean died suddenly last week at the age of 40. His close friends, wife, and family are heartbroken. When I called his mom, I tried to tell her that he is, and was, an inspiration to me.

Sean’s sympathy for people was informed by a love of literature. Sean, me, and our mutual friend Jon (who I have known for a long time, even longer than Sean) used to quote El Cid and Spanish romances to each other. He freely cited musicals and I remember he loved opera.

A healing art needs humaneness, a fertile mind and heart, like those Sean had.

* * *

Like concierge medicine, we can’t build our entire health care system on the safety net, but we want such humaneness for people of all strata.

I am coming at this question as a reader. There are a lot of health care practitioners and patients who write what can be loosely termed “creative writing on health-related [or medical] topics,” which for lack of a better definition (that’s near at hand) I will term anything that aims to get at the non-empirical truth of what it means to be sick, or take of those who are. I struggle with one fact: many of these pieces (short stories, articles, poems) are not interesting aesthetically. Let me put this bluntly: when I read them, I am bored.210269526

I am not jerky enough to name which writers or pieces I am talking about, but I do want to outline the conflict I feel when saying this.  On the one hand, the intention is good: the writer wants to illuminate an aspect of the life of a patient (or a provider) which has been overlooked in the empirical literature.

On the other hand, if such a piece is cliched, overwritten, or – most often – leads to a thuddingly obvious conclusion (suffering does not redeem; pain is bad; illness can be isolating; doctors can lack empathy), the intention can be undermined. But can we still take something away from the piece in that case to help inform our understanding of illness?

In other words: are we looking to be impressed as discerning readers, enriched as human beings, or both? Or should I leave my esthetic expectations aside if I want to enter into someone else’s world of illness?

Note: This piece has been edited based on comments below and on Facebook. Previously, I had directed this post to “medical humanities” writing, but I was using this term in a narrow and unhelpful way.

Without noticing it, I crossed a threshold. Or perhaps I walked right into a mirror without realizing it? Do I look different? Do I have bruises?

It’s been ten years since I started blogging, first here, then here. Now I’m blogging at the book site too, in parallel.12_Pictures-Generation_Kruger_Untitled-You-Are-Not-Yourself_1981

As the Hebrew poet Y.L. Gordon asked, “Le-mi ani ameil?” Who am I laboring for? As a doctor, the answer is clear: I have a patient I am trying to help. As a researcher, there is a community of peers I am trying to satisfy (and a hoped-for public that the research benefits).

For the writer, whether creative or expository, the answer is less clear. Sometimes there is no other reader, and that’s okay. Sometimes the blog is a diary. Thoughts sound different when let out in the open air than when kept inside the head. I can be a writer and reader at the same time. This might help me develop thoughts which are useful to others, or can be expressed in longer form with greater attention to satisfying a certain public.

Talking To Your Doctor has been out for six months, and there is still a steady trickle of purchases. I am grateful for that. But it’s time to move on to the next book. That means less frequent posts – perhaps a decrease here and there in the level of polish and rationality. Maybe some more experimentation as I try and flesh out some thoughts.

Happy New Year to all, and I look forward to providing more details about this coming project as it finds form.

I had a great interview with Gail Zahtz last week. She really gets it all: the importance of encouraging relationships between patients and their primary care providers; the inequality pervading our current system; and the tensions between academic and community medicine. The interview was two hours by the clock but it went very fast. Have a listen.

A country is like a person. Initial impressions matter, but if you really want to know them, you have to spend more time.

The Chinese health care system has many problems in common with the US: inequalities, lack of access, and widespread corruption due to the profit motives of pharmaceutical companies. Both systems are afflicted by overuse of services without clear health improvement. In the US, doctors get paid more if they order more tests; and in China, doctors’ salaries often do not meet their cost of living, while they are allowed to make direct profits on pharmaceuticals and tests: the resulting incentive is clear.

But generalizations don’t go very far in the hugeness of China. Beijing has 18 million residents or so, but Shanghai is China’s largest city, and its health care system is significantly different from Beijing’s, thanks to the reforming efforts of its vice-mayor who is implementing the Chinese equivalent of accountable care organizations, reforming residency education, promoting family practitioners as the integrators and gatekeepers for health services, and pushing through vertical and horizontal EMR integration. (The article from which I gleaned this information is based on an interview with this very vice-mayor, so the successes should probably be taken with a grain of salt.)precepting at PUMCH

In the cities, where two-thirds of Chinese now live, public hospitals deliver the vast majority of health care services (accounting for 65% of health care costs nationally), but do so inefficiently and ineffectively, and are thus a chief target of governmental efforts at reform.

Out in the villages, where significant numbers of Chinese still live, the situation is very different from these big cities: access to care is dismal and quality a big question mark.

For now, I am grateful to have come to China not just as a tourist, but to learn something, share some of my knowledge with my hosts at PUMCH, and hopefully to start up some substantive collaboration.

Thanks to Dr. Jun Zeng and the entire GIM division at PUMCH. Thanks also to Junya Zhu of the Johns Hopkins School of Public Health for a crash course in the Chinese health system.