Month: August 2014
It’s that I suffer from xenofilia. I want to see and to know the entire world: people, languages, customs, lands, seas, deserts, forests, mountains. But I realize that if everyone is your brother, who is your brother. And if every land is your home, where is your homeland. So my true home is Northern California; I always return here, and perhaps here I shall die.
To judge from places I’ve lived over the years, I am 25% Chileno, 10% Mexican, 5% Panamanian, 10% Canadian, 1% Peruvian, 1% Brazilian, 1% Uruguayan, and 1% Argentino, and the rest USA. What irritates me most about my Americas are nationalisms, borderisms, racisims, and sexisms. Xenofiliacs are allergic to all.
Es que tengo xenofilia. Quiero ver –y quiero conocer –a todo el mundo: los pueblos, los idiomas, los costumbres, las tierras, los mares, los desiertos, las selvas, las cordilleras. Pero reconozco: si todo el mundo es su hermano, quien es su hermano; si todo el mundo es su tierra, donde es su tierra. Por eso mi tierra es norte-california, aquí vuelvo siempre, y espero quizás me muera.
De acuerdo a donde he vivido soy: 25% chileno, 10% mexicano, 5% panameño, 10% canadiense, 1% peruano, 1% brasilero, 1% uruguayo, 1% argentino. Lo que mas me irritan de mis américas son los nacionalismos, los fronterismos, y los racismos; y los sexismos. La xenofilia causa un rechazo total a todos.
E que tenho xenofilia. Queiro ver —y queiro conhecer– a todo o planeta: a gente, os idiomas, os costumares, as terras, os mares, os desertos, os bosques, as montanhas.
Mas intendo que si todo o mundo e o suo irmão, quem e suo irmão; si todo o mundo e a sua terra, onde e a sua terra. Por isso a terra central mia e o norte de Califórnia. Aqui volto sempre. Aqui moro, aqui espero morrer. De acordo com as mias residências, só 25% chileno, 10% mexicano, 5% panamenho, 10% canadense, 1% peruano, 1% brasileiro, 1% uruguaio,1% argentino. O que mais dor tem das américas, só os nacionalismos, fronterismos, racismos, y os sexismos. O xenofilico tem alérgia a todos.
Así confieso mi xenofilia, con disculpas por mi pobre portugués do Brasil; y mi ignorancia de los idiomas indígenas,–a pesar de que soy miembro del cuasi extinto tribu Concow del Norte de California.
So I confess my xenophilia, with apologies for my poor Brazilian Portuguese,, and, for my ignorance of indigenous languages. despite being a member of the near distinct Concow tribe of northern California,
Isso e o meu xenofilia, com desculpas por mi pobre portuges do Brasil, y mi ignorância dos idiomas indgeneas,– a pesar de ser parte do quasi extinto tribu Concow do Norte California.
It seems clear a public majority demands we collectively provide for US medical care in the 21st Century. Our legislative representatives, responding that demand, are assuming control of medical care. That includes, of course, the medical record:
Whose medical record is it?
Historically, the practice of medicine has been secretive. The Oath of Hippocrates includes this:
‘I will impart a knowledge of this art …to disciples bound by an indenture and oath according to the medical laws, and no others.
Prescriptions written in archaic apothecary symbols and cryptic abbreviations from Latin are only rather recently being replaced by English and metric scribbles, and by e.prescriptions. In an ED 65 years ago, if a patient survived a knife wound in the back, and claimed it was self-inflicted, no physician reported anything to anyone; a priestly compact prevailed. For better or worse, that compact barely survives now only in the businesses of law, psychiatry and religion.
Yet in the US, (by contrast to some foreign countries) the medical record itself still is openly or covertly considered property of the physician, hospital, or institution that compiles it. We recognize, inferentially at least, a patient’s right to limit sharing of the record with others; we obtain permission for that. So the record apparently partly belongs to the patient; yet ironically there is a reticence to share it easily with it’s putative part owner; we tend to require a written release, impose a charge, or dribble out a bit at a time.
Those who rudely overleap this barrier include—not yet the patient– but the lawyer with a subpoena, the insurance carrier, the government. In fact, for legal purposes there is an unlimited set of ancillary information scattered about: like phone call logs, testimony from staff or others, time clocks, charge cards, video surveillance, etc. Almost everything is potentially available to the court. Yet the basic question remains:
Whose Medical Record Is It?
But that’s a trick question; there are at least four distinct records:
- The record of diagnoses and test results that may support or weigh against a diagnosis, including consultant reports, procedures, and hospitalizations.
- The record of treatment, interventions, complications, and medications—including reactions—that may be important in the future.
- The record of visits, billing and payment.
- The clinicians’ partly subjective and written or recorded personal thinking about diagnosis and treatment
Only excepting the last, I suggest that all should be available immediately, on paper or on-line, to each individual patient, who thereafter has the option of making it available to any subsequent person, agency, or ‘provider’. This would:
- Encourage the patient to learn about, and participate in his own health care.
- Allow the patient, as co-owner of these records, to leapfrog some counterproductive HIPAA restrictions.
- Facilitate timely transfer of records, reducing delay and costly duplications.
It could be argued that even the clinician’s ‘observations and recorded thinking’ are already available to the patient indirectly when subpoenaed; therefore why withhold it in the first place? Wouldn’t the clinician be set on guard, and never write those thoughts down in the first place? Yes, perhaps: and what a loss that would be to physicians and patients—to medicine!
It should not be tolerable that NSA type capturing and surveillance of emails, phone calls, private conversations, etc. is necessary for the protection of people from bad folks, including US. At what cost? (I’m sorry Sir! Just kidding!)
The written or recorded thoughts of the clinician should remain private. To make them available in court would deny the 5th amendment right to avoid self-incrimination, would force testimony against oneself. Control of medical care may be justified by demand, but must not include control of clinician thinking. By paying for medical care, government acquires the right to control a physician’s training, income, prescriptions, diagnostic workup, treatment, hospital, and office… but not our thoughts about the care of any individual patient. Enough!
Carl Linnaus set forth in Systema Naturae (1735) three kingdoms, divided into classes, orders, families, genera, and species. Over time these were modified, and today cladistics is the most popular method for constructing phylogenies, not only from morphological data, but also from molecular. In the 1990s, the development of polymerase chain reaction suggested including more classifiable traits. Though computers made possible the searching and sorting of huge stores of data, cladistics is still the dominant method of phylogenetic classification in evolutionary biology.
Linnaeus also placed plants into 23 classes based roughly on their sexual organs; his taxonomy of minerals included 4 classes: petrae, minerae, fossilia, and vitamentra. While much of his first taxonomy survives, the latter two classifications have been relegated to history.
A distinctive feature of all living organisms is communication. Even plants communicate extracorporeally. I will here suggest a Linnaean taxonomy of communication; and for lack of a better name, call it Taxonomy of the MetaMind; I will argue that the advent of the net, www// and the browser made inevitable a new set of taxonomic features, derived of the natural history of communication.
For humans that taxonomic history begins with pictographs, and incrementally adds words, language, writing, books, printing, publishing—on and on— and now such refinements as those called email, browsing, self-publishing, fishing, hacking, NSA style surveillance, and live systems called Facebook, blogging, tweeting etc.
The problem now is that the information boiling in the sometimes befouled pot of facts and factoids makes it nearly impossible for any individual, alone, to search, assess, ingest and digest that whole e.stew.
Yet here Darwin raises his voice to claim that natural selection operates. He observes that small self selected groups of people have started to organize, with confidence that each will search, select with care, and share with respect. Elitist, or Aristotelian, Charles? Perhaps; but a closed and close association allows 50 or so like minded minds to communicate, almost live, and instantly, across the globe. The most vital feature of such a group is subjectivity within a voluntary, free and ideal association. No objective search program can bring to bear such a collection of selective subjective human judgments. No blog or e.magazine that lives on its volume of subscribers can, either.
I suggest that the aggregation of these selected and interconnected minds is a recent natural progression in the Taxonomy of the MetaMind. Space is limiting; but here are a couple of examples, courtesy of my daughter, who lives in the blogosphere, and is a member of several such groups.
1) A writer started a group composed of women authors who know– or know of–one another. Like cortex and cerebellum they may never have met, but they are interconnected. Granted, their group name is astutely based on the famous gaff of a WKWM (Well Known White Man) about women; but within days the it was oversubscribed, and remains a living example of metacorporeal interconnections. Others groups are sure to appear, though Darwin points out that only the fittest last.
2) pull up this subreddit:
It is # 23 on a list of anonymous comments at http://www.reddit.com/r/talesfrommedicine/
Now open the associated reddit, http://www.reddit.com/r/talesfrommedicine/ Scroll quickly through the other posts; I think you will agree that the med student subreddit, while comparatively long, is unique. How does anyone find such a morsel in the limitless net.stew without help from like minded colleagues? It’s almost impossible. Yet it happens often among a selected set of shared searches and finds typical of the newest addition to the Taxonomy of the MetaMind. There will be more.
Since Ancient Greece, western medicine has been associated with snakes,[i] so perhaps Medusa’s snake covered head, which when seen, turns people to stone, or ossifies them, is an apt metaphor for medicine today.
The unstated question for physicians is:
“ If Medicine is sick why don’t you heal it yourselves!’ The answer seems to be:
“Sorry. We can’t. Medicine is not a uniform or coherent profession, but many competing and isolated professions; each has looked at Medusa and become stone.
Government, in the role of a modern Perseus may:
1) Cut off the whole Gorgon head (immediate universal government single pay); or
2) Strangle one or several intertwined serpents at a time.
One toxic serpent is the failure of Primary Care. Even though a majority of physicians plan to enter that specialty at the start of training,far too few do so upon graduation. Their disillusionment is the result of ossified training favoring other specialties, and a realization that there is a mismatch between the demands and the value placed on primary care. To kill that snake we must attract and retain the best and the most idealistic students to primary care; and make their training more attractive, and more rational by:
I More rapid and practical medical training
II Inducements to practice Family Medicine
III Restoration of the Humanities in Medical training
IV Control of the Political Industrial Medical Cabal that drives outrageous costs
I Faster and more practical medical training:
This is not a new idea of course; in the Guild system a young apprentice learned by ‘see one do one’; the ‘master’ determines when the student was ready. The Hippocratic Oath reflects that guild system, requiring teachers and colleagues to hold professional secrets, and one another, sacred. In the USA today training for primary care is almost as long as many other specialties. It could easily be shortened. In the last century many accelerated physician training programs sprung up, most outside the US. I myself was in a U Minnesota accelerated 7 year college MD program devised in WWII– 3 pre med, 3 medicine, 1 internship.
In any event, 6 years of college before seeing a patient, and 9 years to complete a basic MD degree, is not necessary; neither is 12 or more post high school years before finishing Family Practice training. For any qualified student, we can provide for an MD degree 7 years after high school graduation: 3 college, med school, 3, internship 1, by:
1. Admitting students to med school who satisfactorily complete essential basic science in pre med: biology, bacteriology, medical anatomy and physiology, psychology, and biostatistics.(Thank god for software!) Students who had to recover from a poor high school experience, or pursued an interest in unrelated fields, might be given precede, in consideration of life lessons learned.
2. Beginning to evaluate and treat patients, under supervision, on the first day of med school.
3. Requiring that the last year of training be a general rotating internship (all specialties included);
4. Requiring this path be followed for all all medical students
II Inducements to Family Practice: We can:
- Offer to, but not require of all beginning med students, a fully subsidized path in Family Practice. This would be by way of a loan, cancelled after:
- 3 years Family Practice, in selected places, with tax free stipend equivalent to three times the average FP residency pay.
- For another 3 years thereafter, continuing that stipend, but also allowing private practice at the selected site. At any time after the first obligatory 3 year period, a subsidized Family Practice physician could elect to practice elsewhere, or apply for any specialty training.
III Resuscitation of the Humanities
What is subjective is generally foreign to medical training, but is elemental in life; one result is that too many physicians are deficient in the Humanities, and to a degree, dehumanized. Too often we:
Cannot or do not write or read well.
With the exception of medical literature, may not read at all.
Are unfamiliar with much of history, literature, music, and art.
Are too detached from patients and community.
Are ignorant of basic logic, philosophy, debate, and public speaking.
Finish training with little interest outside self interest.
While physicians are not alone in being dehumanized in a 21st century world, communication is more critical to medicine than most professions because:
# a deficiency in the humanities greatly reduces one’s ability to put the human condition in perspective;
# it leaves one less able to reject specious reasoning or ad hominem argument;
# it lessens our ability to appreciate the beauty and to hear the voice of every era, including our own;
# it limits our options as healers, listeners, advisors, parents, friends and lovers.
Therefore, I suggest at least four required upper division college humanities courses during the last 18 months of premed:
English literature; English Composition
World History; Philosophy or world Religion.
Suggested but optional: Speech, Music, Spanish
Adding these Humanities requirements for entry to medical school can both make graduates better physicians, and make a medical career more attractive and practical for students already well grounded in the humanities. More didactic material like Calculus, Physics, or Physical Chemistry, exists in the e.universe, where acquisition and sorting of material is a given; those skills can be added any time a specific medical career requires it because physicians, we hope, do not stop learning at graduation.
III Controlling the PIMC—Political Industrial Medical Cabal
Physicians, politicians, and the average voter,–none altogether ignorant and none altogether innocent–are groomed and seduced by the PIMC. (I use the term Cabal instead of Power because to use Power creates a problematic acronym.) Yet I do mean Power– the power of money, which is best considered an addictive drug. Physicians tend to practice in prescribed ways because the Cabal controls this drug: Money. We see it. We complain. We call for change. We want to be free, but wait for someone else to free us, fearing the pain of withdrawal. In short, we go about business as usual. What could be done?
The penultimate power in a democracy –while it survives–is the informed voter who actively participates in intense and intestine public debate. An encouraging fact is that this debate about medicine is now growing more active and informative every day. The most significant contribution that physicians can make is to participate actively, while listening carefully, as well as speaking carefully.
By contrast, the PIMC–the Cabal– exercises its right to plant sophisticated misleading or biased self serving material throughout the media: TV, magazines–both public and professional–, the net, and direct advertising. Physicians must call foul whenever media presentations are mired in self-interest. They must call out clearly, and determinedly, but with a civil tone. Screaming, playing The ‘Doctor’ card, or making demeaning remarks loses any debate.
There is a saying that ‘all politics is local’. A local medical society magazine is the members’ soapbox; their Hyde Park and Trafalgar Square. It is often their only ready forum. Physicians, to be effective must join the public debate both independently and within the profession. Essays and posit discussions in the medical society magazine generally reflect opinions of local docs; as such, they are far more interesting and believable,and more genuine, than collective or organizational voices alone. When physicians speak as individuals, even if what is said may be unwise, prove embarrassing, or be off the official text, it is still that individual’s opinion. Physicians must be involved, and Speak up. So must we all!