In light of comments I received on blog posts, I may post one or two more (or just keep this going forever).
In the midst of moving to NYC, I have little time. However, religious phenomena are never far from my mind. I recently received a religious card. Now, I am grateful and happy to receive cards, especially considering it meant some one was thinking of me; so don't mistake this for ungratefulness. However, I am increasingly surprised that people choose to send their religious beleifs to others in this form. How strange it would be if I sent out Agnostic cards for events:
"Despite the fact that current evidence suggests there probably is no higher power, I still hold that perhaps one day evidence might suggest there is. Either way, we dont know....Happy Birthday!"
I feel as if this card would upset a Christian, who might respond with "this is ridiculous, we are chilren of the christian God!"
Will there ever be a time when people recognize that the essence of faith is doubt, not knowing? People are people, despite the fact that some were born in a place that affords them a different opinion on matters that cannot be proven. In this world of ever-colliding cultures, we should be cognizant of the differences in opinion we hold over things for which there is little evidence.
Then again, perhaps I am being overly critical of people wanting to share the joy they share in their personal faiths. This I understand, for the joy I find in evidence-based thinking is considerable.
May you find joy in your heart (now this sounds like a card...).
Monday, July 27, 2009
Monday, July 20, 2009
Winning the Lottery (On Leaving Haiti)
I am sitting at the PAP airport now, leaving Haiti. Kevin told me that this would a trip of a lifetime; it was. To briefly recap, the week here was absolutely nuts. I began taking all the Pap smears and HPV tissue samples from the clinic home with me so that I would have enough time to get all of the samples labeled, entered, organized, packaged and sent. It’s interesting, because at the clinic here so much rests on human relationships in order to get things done. An example: The new medical students interning for the summer came down recently. One of them is helping us with the HPV study in HIV positive women. My role in this project consists of many things: enrolling patients in a study, performing vaginal exams and collecting samples, assisting OB/GYN guys during colposcopies, taking inventory on materials and making sure we have everything, organizing and labeling all samples, making sure samples get sent to Cornell, etc. It sounds like a normal busy clinic/lab set up, but it is extremely hard to get anything done if people don’t know and like you. For instance, we ran out of slides (we take vaginal swabs and send them over to the micro lab for analysis). I sent one of the interns to get more covers, but people just told her they didn’t have any, etc. They didn’t know her well enough yet. I went back for the same thing. I greeted them, they all know me and joke with me in Creole, and then I asked for the slides. There was some discussion and eventually a guy I know popped out of his office and told me he would help me. We eventually found a lab that lent us some. The new intern has actually done a great job of walking around and making her face “known” so that she can get materials, etc. as well. It’s hard to explain unless you go through it. It’s extremely frustrating, but that’s just how it works there. Everything is based on relationships.
In the last week we had a big push to rescreen women from last year for HPV/lesions/cancers, etc. So each day for the last 2 weeks that I was in clinic we were in the exam rooms collecting samples. Of course, this made for GREAT clinical training for me, and the OB docs I worked with are awesome. One would stay as long as I was willing to see patients. He would even take us home if we missed our ride. This doesn’t sound like a big deal, but driving up to where we live in PAP is not easy. I digress. I was also enrolling patients in a different study with MORE samples and more paper work were required (and much more time). It was a huge mess but we got so many patients seen; more importantly we collected samples on projects that could lead to better treatment for HIV/HPV patients in Haiti and worldwide.
I skipped the last weekend at the beach and a few other things to get these samples finished up. It was a pain, but it worked out really well.
Then, I had a day or two to pack. Of course I got really sick one of my last days at the clinic (last Thursday). I actually was discussing a procedure with one of my OB mentors while I was performing it, and suddenly felt like I would pass out and puke right there between her legs. I had had major gallbladder attacks that morning and had hoped they would go away. This was something else. I felt sick. I looked up at him with my hands still on the speculum and brush and calmly said “I need you to finish this one.” He looked at me like any good mentor would and said “No, you can do this, you’ve done this many times, if it’s still bleeding you know what to do.” I looked at him again and said “I feel very sick, I really need you to do this.” He immediately grabbed the instruments, gave me the chair, and finished the exam standing up. He was great. He went and got me a shot of anti-nausea stuff and injected me and then got me a coke in case my blood sugar was low. I then developed had chills and flu-like body-aches. The problem was that I had patients scheduled for me to collect samples from the rest of that day (Thursday) and Friday, my last day. I HAD to see the patients. I had to rest for 30 minutes then finished the patients. I went home that day, got in my underwear, and slept til the next morning, on and off.
By the way, it is over 100 degrees F most of the time in our house right now. This means several things: 1) This is REALLY hot, especially considering that our ceiling fans don’t do much. Turn your heat on to about 90 to 100 degrees F and try to walk around inside for a bit, it’s awful. 2) In this heat my computer only works for about 30 minutes at a time. I’m serious; it then overheats and gets really choppy/freezes up. 3) I have taken to filling the bathtub with cold water and immersing myself in it for relief and to get my core temp down. 4) It doesn’t really cool down that much at night. Besides the fact that this is weird, it sucks.
I couldn’t eat anything all Thursday. Friday I felt better and managed to eat around lunchtime. Seems I had a 24-hour flu.
I started packing Fri night, but my friends had thrown me a wonderful going away party. My Haitian friend from the streets came, along with one of our guards. And of course, all the ex-pats I like. One of my very good friends here actually created the company that makes Rara bags. You HAVE to check these out and order some for people you know! These are wallets, bags, etc made from trash off the streets. She actually employs Haitians to sew these things. It's really remarkable. Check them out:
http://klynnstudio.com/RARA.html
This is a great cause and a cool gift. You can order one of these and it goes to a project that employs Haitians and helps clean up Haiti/is good for the environment! Order something!! At any rate, she showed up with one of the wallets as a gift for me. Also, both OB doctors I work with came, and one of them brought a Vase for me as a gift. A social worker I work with brought me a Haitian Vase/Case as a gift earlier in the day at the clinic too. During the party, I was drinking beer and talking creole with my Haitian friend and the security guard, and the security guard was telling me how he never gets to do this. When I asked him "do what", he said he never has had a beer with people he works “for.” I thought this quite unusual. He said in Haiti he is just in a different class – we wouldn’t party together. Maybe I live in my own little world, but I was telling him that in the states everyone is allowed to party with everyone if they want. We had a great time. I was moved that everyone came.
On my last day of work a good friend of mine at the clinic brought me a necklace. It was touching for several reasons. For one, I talk to her every day; she is a wonderful woman. She is a peer-counselor at the clinic. I found out later that she “grew up” around the clinic; she was a victim of mother-child HIV transmission. And this girl is awesome. She comes in every day that I have time and we practive English together. On my last day she made me close my eyes and put the necklace around my neck. I love it and was very moved by the gesture.
Today I left. I drove through PAP for the last time for now, but I think I’ll be back. In customs in Miami I got the opposite treatment as Haiti. In Haiti white means rich, and you’re treated well, as if you have lots of money. Of course, I have long hair and a beard. At customs in Miami I got asked some questions about how long I’ve been out of the country and then sent through the “agriculture” checking scanners. I have no idea what this is, but later in the airport a man came up to me and was like “Man, I saw that, that’s crap. I used to have a big beard and I’d get crap like that all the time.” We then went on to speak about Haiti and what I was doing. He then asked me, “Ok, I’m sorry if this is ignorant, but how can you work with those patients? Aren’t you scared you’ll get HIV?” I explained that even if I spilled HIV blood on my arm (which happened more than once during exams) it would be extremely hard to get it. In fact, I could take a needle out of an HIV-infected arm and stick it in mine, and the rate of transmission is still less than 1%. I explained all this and he was like “oh wow, that’s crazy; when I was in San Francisco I would cross on the other side of the street if someone looked gay or sketchy.” I then joked, “Well, if you‘re sleeping with your patients, it’s a different story!”
Finally, in Miami (I am at the airport typing this now), I tried to hop on a flight tonight to ATL instead of sitting in the airport all night to take the morning flight. I was told in Haiti that there was a flight tonight that was empty that I should get on. When I tried, the lady simply told me that she couldn’t do it; it was a rule - she can’t put me on a flight for a different day even if there are openings. I was confused and tried to work her with a smile, etc. But she was having none of it. I then realized I wasn’t in Haiti, things aren’t so heavily based on interactions here…Well, perhaps I just contrasted this with what happened as I left the PAP airport in Haiti: I have 4 bags, so I had to recruit bag-help at the airport. The men took me through to “business class” check in (skipping the big line for regular people). I told them that I was not business class, they were like, no worries, we got it. An American Airlines rep asked me if I was business class..I just said no. These guys grabbed him and talked to him and he just nodded and let me stay. Then they quickly checked me in, no worries. So I obviously tipped these guys well. It was an interesting situation.
So now I am back, the journey is over, for now. I wish I had some end all, be all advice, some wise words from six short months of experiences. I don’t. In fact, all I have is a mind full of memories, good and bad, difficult and fun. I learned more than I thought I would, about people, about life, about me, about the world. I also made better friends than I ever imagined I could in such a short time – friends I will have for life, Haitian and American.
Perhaps you don’t agree with everything I say; and if you don’t, I hope you show me evidence for where I have erred. Rational dissent is always welcomed. If nothing else, I hope you became more informed and stay informed. Appreciate where you are, what you have. And even if you can’t go see for yourself what these places are like in the world, read about them, try to understand them. Try to understand that while Haiti may be “the most dangerous country to travel to” on someone’s list due to kidnappings and violence, it’s also home to millions of people that were born there and are simply trying to make a good life. They’re just like you, just not so lucky. One of our drivers is about my father’s age. He has a family, he works hard, he speaks creole clearly and slowly so the Americans can understand him, and he is funny too. If he could speak English or my father Creole, I can picture them talking for hours about things, about life, about the good, about the bad. What do they have in common? Maybe not so much, maybe a lot. My dad never has to spin his wheels and do a 180 in the car because he runs into an angry mob charging at him; then again, he also probably doesn’t get a new crop of young foreigners coming into his workplace all excited to change the world every few months. But they both love their families, they both like to laugh, and they both are kind and hard working.
If you were to travel somewhere like Haiti you would likely meet someone like this; someone that makes you realize that despite what frustrations you have, despite what people say, despite how “bad” or “dangerous” a place it is, the majority of people are good. Maybe some bother you for money; is it so wrong that they are trying to get money to eat or send their kid to school? Others will bother you about their religion because you don’t believe what they do; is this so different from how you treat people that have a different belief system than you? But most will try to help you when you’re down, will smile when you joke, will greet you when you pass them. They might not understand why you would risk coming to their country right now, but they appreciate it, because they know the ease of life from which you come. And they appreciate your understanding that a few violent people don’t make everyone that is born there “bad.”
So in closing, appreciate the US, love the US. But please understand that you were lucky, you won the lottery. They didn't. Have compassion for your fellow humans. They're just like you, just not with a winning lottery number. Perhaps one day we can all win the lottery.
In the last week we had a big push to rescreen women from last year for HPV/lesions/cancers, etc. So each day for the last 2 weeks that I was in clinic we were in the exam rooms collecting samples. Of course, this made for GREAT clinical training for me, and the OB docs I worked with are awesome. One would stay as long as I was willing to see patients. He would even take us home if we missed our ride. This doesn’t sound like a big deal, but driving up to where we live in PAP is not easy. I digress. I was also enrolling patients in a different study with MORE samples and more paper work were required (and much more time). It was a huge mess but we got so many patients seen; more importantly we collected samples on projects that could lead to better treatment for HIV/HPV patients in Haiti and worldwide.
I skipped the last weekend at the beach and a few other things to get these samples finished up. It was a pain, but it worked out really well.
Then, I had a day or two to pack. Of course I got really sick one of my last days at the clinic (last Thursday). I actually was discussing a procedure with one of my OB mentors while I was performing it, and suddenly felt like I would pass out and puke right there between her legs. I had had major gallbladder attacks that morning and had hoped they would go away. This was something else. I felt sick. I looked up at him with my hands still on the speculum and brush and calmly said “I need you to finish this one.” He looked at me like any good mentor would and said “No, you can do this, you’ve done this many times, if it’s still bleeding you know what to do.” I looked at him again and said “I feel very sick, I really need you to do this.” He immediately grabbed the instruments, gave me the chair, and finished the exam standing up. He was great. He went and got me a shot of anti-nausea stuff and injected me and then got me a coke in case my blood sugar was low. I then developed had chills and flu-like body-aches. The problem was that I had patients scheduled for me to collect samples from the rest of that day (Thursday) and Friday, my last day. I HAD to see the patients. I had to rest for 30 minutes then finished the patients. I went home that day, got in my underwear, and slept til the next morning, on and off.
By the way, it is over 100 degrees F most of the time in our house right now. This means several things: 1) This is REALLY hot, especially considering that our ceiling fans don’t do much. Turn your heat on to about 90 to 100 degrees F and try to walk around inside for a bit, it’s awful. 2) In this heat my computer only works for about 30 minutes at a time. I’m serious; it then overheats and gets really choppy/freezes up. 3) I have taken to filling the bathtub with cold water and immersing myself in it for relief and to get my core temp down. 4) It doesn’t really cool down that much at night. Besides the fact that this is weird, it sucks.
I couldn’t eat anything all Thursday. Friday I felt better and managed to eat around lunchtime. Seems I had a 24-hour flu.
I started packing Fri night, but my friends had thrown me a wonderful going away party. My Haitian friend from the streets came, along with one of our guards. And of course, all the ex-pats I like. One of my very good friends here actually created the company that makes Rara bags. You HAVE to check these out and order some for people you know! These are wallets, bags, etc made from trash off the streets. She actually employs Haitians to sew these things. It's really remarkable. Check them out:
http://klynnstudio.com/RARA.html
This is a great cause and a cool gift. You can order one of these and it goes to a project that employs Haitians and helps clean up Haiti/is good for the environment! Order something!! At any rate, she showed up with one of the wallets as a gift for me. Also, both OB doctors I work with came, and one of them brought a Vase for me as a gift. A social worker I work with brought me a Haitian Vase/Case as a gift earlier in the day at the clinic too. During the party, I was drinking beer and talking creole with my Haitian friend and the security guard, and the security guard was telling me how he never gets to do this. When I asked him "do what", he said he never has had a beer with people he works “for.” I thought this quite unusual. He said in Haiti he is just in a different class – we wouldn’t party together. Maybe I live in my own little world, but I was telling him that in the states everyone is allowed to party with everyone if they want. We had a great time. I was moved that everyone came.
On my last day of work a good friend of mine at the clinic brought me a necklace. It was touching for several reasons. For one, I talk to her every day; she is a wonderful woman. She is a peer-counselor at the clinic. I found out later that she “grew up” around the clinic; she was a victim of mother-child HIV transmission. And this girl is awesome. She comes in every day that I have time and we practive English together. On my last day she made me close my eyes and put the necklace around my neck. I love it and was very moved by the gesture.
Today I left. I drove through PAP for the last time for now, but I think I’ll be back. In customs in Miami I got the opposite treatment as Haiti. In Haiti white means rich, and you’re treated well, as if you have lots of money. Of course, I have long hair and a beard. At customs in Miami I got asked some questions about how long I’ve been out of the country and then sent through the “agriculture” checking scanners. I have no idea what this is, but later in the airport a man came up to me and was like “Man, I saw that, that’s crap. I used to have a big beard and I’d get crap like that all the time.” We then went on to speak about Haiti and what I was doing. He then asked me, “Ok, I’m sorry if this is ignorant, but how can you work with those patients? Aren’t you scared you’ll get HIV?” I explained that even if I spilled HIV blood on my arm (which happened more than once during exams) it would be extremely hard to get it. In fact, I could take a needle out of an HIV-infected arm and stick it in mine, and the rate of transmission is still less than 1%. I explained all this and he was like “oh wow, that’s crazy; when I was in San Francisco I would cross on the other side of the street if someone looked gay or sketchy.” I then joked, “Well, if you‘re sleeping with your patients, it’s a different story!”
Finally, in Miami (I am at the airport typing this now), I tried to hop on a flight tonight to ATL instead of sitting in the airport all night to take the morning flight. I was told in Haiti that there was a flight tonight that was empty that I should get on. When I tried, the lady simply told me that she couldn’t do it; it was a rule - she can’t put me on a flight for a different day even if there are openings. I was confused and tried to work her with a smile, etc. But she was having none of it. I then realized I wasn’t in Haiti, things aren’t so heavily based on interactions here…Well, perhaps I just contrasted this with what happened as I left the PAP airport in Haiti: I have 4 bags, so I had to recruit bag-help at the airport. The men took me through to “business class” check in (skipping the big line for regular people). I told them that I was not business class, they were like, no worries, we got it. An American Airlines rep asked me if I was business class..I just said no. These guys grabbed him and talked to him and he just nodded and let me stay. Then they quickly checked me in, no worries. So I obviously tipped these guys well. It was an interesting situation.
So now I am back, the journey is over, for now. I wish I had some end all, be all advice, some wise words from six short months of experiences. I don’t. In fact, all I have is a mind full of memories, good and bad, difficult and fun. I learned more than I thought I would, about people, about life, about me, about the world. I also made better friends than I ever imagined I could in such a short time – friends I will have for life, Haitian and American.
Perhaps you don’t agree with everything I say; and if you don’t, I hope you show me evidence for where I have erred. Rational dissent is always welcomed. If nothing else, I hope you became more informed and stay informed. Appreciate where you are, what you have. And even if you can’t go see for yourself what these places are like in the world, read about them, try to understand them. Try to understand that while Haiti may be “the most dangerous country to travel to” on someone’s list due to kidnappings and violence, it’s also home to millions of people that were born there and are simply trying to make a good life. They’re just like you, just not so lucky. One of our drivers is about my father’s age. He has a family, he works hard, he speaks creole clearly and slowly so the Americans can understand him, and he is funny too. If he could speak English or my father Creole, I can picture them talking for hours about things, about life, about the good, about the bad. What do they have in common? Maybe not so much, maybe a lot. My dad never has to spin his wheels and do a 180 in the car because he runs into an angry mob charging at him; then again, he also probably doesn’t get a new crop of young foreigners coming into his workplace all excited to change the world every few months. But they both love their families, they both like to laugh, and they both are kind and hard working.
If you were to travel somewhere like Haiti you would likely meet someone like this; someone that makes you realize that despite what frustrations you have, despite what people say, despite how “bad” or “dangerous” a place it is, the majority of people are good. Maybe some bother you for money; is it so wrong that they are trying to get money to eat or send their kid to school? Others will bother you about their religion because you don’t believe what they do; is this so different from how you treat people that have a different belief system than you? But most will try to help you when you’re down, will smile when you joke, will greet you when you pass them. They might not understand why you would risk coming to their country right now, but they appreciate it, because they know the ease of life from which you come. And they appreciate your understanding that a few violent people don’t make everyone that is born there “bad.”
So in closing, appreciate the US, love the US. But please understand that you were lucky, you won the lottery. They didn't. Have compassion for your fellow humans. They're just like you, just not with a winning lottery number. Perhaps one day we can all win the lottery.
Saturday, July 11, 2009
This isn't good for anyone (On Medical Ethics)
A standard medical school interview question goes like this:
Q: A woman comes to you for an abortion. What do you do?
There are several ways to answer this. For example, you perform the procedure. More likely though, you would refer the patient to someone who could do the procedure (if you weren’t trained to do that). The other answer may be that you aren’t comfortable with it so you would refer them to another physician for it. These are "correct" answers. There is a wrong answer, however. That wrong answer goes something like this:
A: I think abortion is murder. Life begins at conception. I wouldn’t do it. Period. I would send the patient home to have the baby.
Prepare to get grilled. You will get grilled not necessarily on your views (although most educated people would be very curious about these black and white views – there is no nervous tissue for about 14 days post-fertilization, we can create a “fairly” viable embryo with no sperm (SCNT), we fertilize eggs and simply fail to implant many times during attempts to get pregnant (conception is only a part of life beginning), we fertilize many eggs during in vitro fertilization yet few seem to mind this, etc.), but rather you will get grilled on failing to provide your patient with adequate care. If you feel you cannot do the standard of care that is LEGAL and asked of you, then you are obliged to find that patient adequate care. If this isn’t how things worked, imagine the upheaval it would cause in medicine: Some right-wing neoconservative doctor doesn’t “believe” in evolution and he refuses to curb his over-prescribing of antibiotics, saying that nothing is evolving (of course, it’s hard to imagine people PRACTICING medicine that is based on evolution and not understanding it, but it happens). Superbugs continue to develop. Take it a step further, a doctor fails to give a young lady the HPV vaccine when she requests it because he feels she shouldn’t be having sex. He tells her to go home and not have sex. However, her religious system doesn't ban sex. Then she gets HPV-18, which is strongly linked to cervical cancer.
Just a short time ago these things were unconscionable.
I recently had a discussion with medical students here. I was horrified at what I found out I had missed in the states. President Bush signed new “conscience” rules in December of 2008 before leaving office. I could not believe what I read. In short, the new law allows a doctor to refuse a service because of a moral belief (I have no problem with this; just make the referral) AND not inform the patient of where to get care or that care is available. In other words, a physician can now legally wrap his morals into his care to a degree like never before. In other words, a woman can ask for the HPV vaccine and essentially told not only “no” but also not given a referall to anywhere else. In fact, the doctor is now ok to say no and explain why it is morally wrong to get it to the patient.
Is this what we want? Do we want someone trained to advise us on health issues spilling their morals into care that much? One could argue that all beliefs will affect that intimate doctor-patient relationship (and I agree), but where do we draw the line? Now a doctor can refuse a legal procedure, fail to refer you to someone else, and even counsel you on why he doesn’t do what you asked. So now what?
“That ethics policy, however, from the American College of Obstetricians and Gynecologists, had less to do with whether doctors should be willing to perform abortions or other potentially controversial services, and more to do with what they should do if they were unwilling to perform them (bold mine). In those cases, according to the policy, doctors should tell patients upfront and refer them to someone who is willing to provide the services.
Under the new regulations, however, such referrals will not be required.”
The AMA and various other medical societies opposed this action.
If you are like most people that will read this, you are a Christian and are so mainly because it is the religious story of your culture/people/family. No one argues about this.
But pretend you were some other religion that believed that there was no such thing as psychiatric illness. So when you see a patient that is severely depressed, rather than giving them the standard of care, you explain to them that you don’t believe it is right to take those drugs. You send them home. To me this is disgusting. Treat the patient or find someone who will – this is your JOB! If you find something about your job that doesn’t agree with your “morals”, then work to change it or quit. But do your job. Patients should be taken care of.
Or imagine you rush your son to the hospital, short of breath and weak. You find out his heart is failing and he needs a transplant. Imagine if there were a heart available but the doctor simply couldn’t bring himself to do the transplant – he considered the heart to be the “soul” of the person. Besides this not being correct, he now wouldn’t have to refer you to the surgeon who could do it, instead being likely to counsel you on how God has a plan (or the heart is the soul or anything else) and to say goodbye.
Or imagine that you’re seeing your physician about getting rid of syphilis; however, your physician feels that STIs are punishment for wrongdoing and refuses to provide care. Now he does not have to refer you to another physician for care. Now imagine that this is the only urologist within 50 miles. You are now out of options. You will not receive the standard of care for a disease that is easily curable. And that’s legal. (I think you now see the point; this crashes right into what really is legal, the standard of care, etc.)
The whole thing is an abomination.
Interestingly, I received an email out of the blue from a good friend of mine. She just wanted to share her strange story of late. She knew nothing of this law. She told me that suddenly upon returning to her usual OB/GYN this year she has had an incredible amount of trouble getting contraceptives. Insurance has denied the IUD, and her primary care doc suddenly is making it very difficult to obtain the pill. She was baffled.
One of her friends commented to her, "maybe their religious views are getting in the way of your care."
My friend went on to tell me that she couldn’t imagine her friend was right because she has been going to this doctor for years with no problems until this year. She knew nothing about this new law. I was upset. Here I am, now hearing about how it plays out with patients, unbeknownst to them! Her friend was right on target.
People that agree with this law (perhaps you?) agree with it because they think that their views are the views that their doctor will have. Just imagine for a second that he doesn’t share those views. Now he is free to deny you care that you may need. The issue isn’t with what the doctor does or doesn’t do; the issue is with what he does in the event he feels uncomfortable. Does he uphold some professional standard of care or not?My friend is currently searching for a new doctor. Interviewers for medical school must be scratching their heads; one of the most clear-cut ethical decisions a clinician can make is now being turned on its head, and not for the good. This isn’t good for anyone.
Q: A woman comes to you for an abortion. What do you do?
There are several ways to answer this. For example, you perform the procedure. More likely though, you would refer the patient to someone who could do the procedure (if you weren’t trained to do that). The other answer may be that you aren’t comfortable with it so you would refer them to another physician for it. These are "correct" answers. There is a wrong answer, however. That wrong answer goes something like this:
A: I think abortion is murder. Life begins at conception. I wouldn’t do it. Period. I would send the patient home to have the baby.
Prepare to get grilled. You will get grilled not necessarily on your views (although most educated people would be very curious about these black and white views – there is no nervous tissue for about 14 days post-fertilization, we can create a “fairly” viable embryo with no sperm (SCNT), we fertilize eggs and simply fail to implant many times during attempts to get pregnant (conception is only a part of life beginning), we fertilize many eggs during in vitro fertilization yet few seem to mind this, etc.), but rather you will get grilled on failing to provide your patient with adequate care. If you feel you cannot do the standard of care that is LEGAL and asked of you, then you are obliged to find that patient adequate care. If this isn’t how things worked, imagine the upheaval it would cause in medicine: Some right-wing neoconservative doctor doesn’t “believe” in evolution and he refuses to curb his over-prescribing of antibiotics, saying that nothing is evolving (of course, it’s hard to imagine people PRACTICING medicine that is based on evolution and not understanding it, but it happens). Superbugs continue to develop. Take it a step further, a doctor fails to give a young lady the HPV vaccine when she requests it because he feels she shouldn’t be having sex. He tells her to go home and not have sex. However, her religious system doesn't ban sex. Then she gets HPV-18, which is strongly linked to cervical cancer.
Just a short time ago these things were unconscionable.
I recently had a discussion with medical students here. I was horrified at what I found out I had missed in the states. President Bush signed new “conscience” rules in December of 2008 before leaving office. I could not believe what I read. In short, the new law allows a doctor to refuse a service because of a moral belief (I have no problem with this; just make the referral) AND not inform the patient of where to get care or that care is available. In other words, a physician can now legally wrap his morals into his care to a degree like never before. In other words, a woman can ask for the HPV vaccine and essentially told not only “no” but also not given a referall to anywhere else. In fact, the doctor is now ok to say no and explain why it is morally wrong to get it to the patient.
Is this what we want? Do we want someone trained to advise us on health issues spilling their morals into care that much? One could argue that all beliefs will affect that intimate doctor-patient relationship (and I agree), but where do we draw the line? Now a doctor can refuse a legal procedure, fail to refer you to someone else, and even counsel you on why he doesn’t do what you asked. So now what?
“That ethics policy, however, from the American College of Obstetricians and Gynecologists, had less to do with whether doctors should be willing to perform abortions or other potentially controversial services, and more to do with what they should do if they were unwilling to perform them (bold mine). In those cases, according to the policy, doctors should tell patients upfront and refer them to someone who is willing to provide the services.
Under the new regulations, however, such referrals will not be required.”
The AMA and various other medical societies opposed this action.
If you are like most people that will read this, you are a Christian and are so mainly because it is the religious story of your culture/people/family. No one argues about this.
But pretend you were some other religion that believed that there was no such thing as psychiatric illness. So when you see a patient that is severely depressed, rather than giving them the standard of care, you explain to them that you don’t believe it is right to take those drugs. You send them home. To me this is disgusting. Treat the patient or find someone who will – this is your JOB! If you find something about your job that doesn’t agree with your “morals”, then work to change it or quit. But do your job. Patients should be taken care of.
Or imagine you rush your son to the hospital, short of breath and weak. You find out his heart is failing and he needs a transplant. Imagine if there were a heart available but the doctor simply couldn’t bring himself to do the transplant – he considered the heart to be the “soul” of the person. Besides this not being correct, he now wouldn’t have to refer you to the surgeon who could do it, instead being likely to counsel you on how God has a plan (or the heart is the soul or anything else) and to say goodbye.
Or imagine that you’re seeing your physician about getting rid of syphilis; however, your physician feels that STIs are punishment for wrongdoing and refuses to provide care. Now he does not have to refer you to another physician for care. Now imagine that this is the only urologist within 50 miles. You are now out of options. You will not receive the standard of care for a disease that is easily curable. And that’s legal. (I think you now see the point; this crashes right into what really is legal, the standard of care, etc.)
The whole thing is an abomination.
Interestingly, I received an email out of the blue from a good friend of mine. She just wanted to share her strange story of late. She knew nothing of this law. She told me that suddenly upon returning to her usual OB/GYN this year she has had an incredible amount of trouble getting contraceptives. Insurance has denied the IUD, and her primary care doc suddenly is making it very difficult to obtain the pill. She was baffled.
One of her friends commented to her, "maybe their religious views are getting in the way of your care."
My friend went on to tell me that she couldn’t imagine her friend was right because she has been going to this doctor for years with no problems until this year. She knew nothing about this new law. I was upset. Here I am, now hearing about how it plays out with patients, unbeknownst to them! Her friend was right on target.
People that agree with this law (perhaps you?) agree with it because they think that their views are the views that their doctor will have. Just imagine for a second that he doesn’t share those views. Now he is free to deny you care that you may need. The issue isn’t with what the doctor does or doesn’t do; the issue is with what he does in the event he feels uncomfortable. Does he uphold some professional standard of care or not?My friend is currently searching for a new doctor. Interviewers for medical school must be scratching their heads; one of the most clear-cut ethical decisions a clinician can make is now being turned on its head, and not for the good. This isn’t good for anyone.
On Good Things
My last day of work in Haiti is this Friday. These last few weeks have been incredibly great. Busy, fun, and with a sense of belonging at the clinic. We are really in a big push to see as many patients as possible right now. As you probably know, my job is in the OB/GYN part of the clinic here. Within the larger study of examining when it is best to start ARV treatment, we are running another study looking at HPV in HIV positive women. Then within that there is another study looking at prostaglandin levels in women with and without cervical lesions. All this translates into me being very busy in the clinic, trying to coordinate patients coming, the appropriate paper work being ready (harder than you can imagine to get copies), examining patients, giving treatment, etc. It has been very hectic. Amidst this, though, I have realized how much I love about what I do here:
1) When I walk around the clinic I always run into coworkers who I horse around with and joke with in Creole ("bay odyens"). It has really become home to me in the last few months. It's helped that I’ve had to beg pretty much every lab here at some point to let us borrow supplies of some sort.
2) Our drivers are awesome. Sometimes we have a chance to stop and buy them all beer on the way home from work. It’s a good time. These guys could ignore us or whatever (they speak little if any English), but instead they are always upbeat and friendly, joking around with us in Creole about everything. They also cash checks for us and do other minor things that must be done. (And they put up with me when I insist we need to see another patient and we can't go yet.)
3) The two OB/GYN guys are work with are fantastic. One of them has on more than one occasion stayed well past 4:30 (6:30). This may not seem like much, but the labs shut down at 4-4:30 and everyone goes home. But this guy never complains; he just is like, “yeah, this is my job.” I am going to email the director of the clinic about him. He’s great.
4) The administration. They have been excellent. Despite not really knowing the director of the clinic, the secretaries/admin ladies have taken care of absolutely everything I could need. Any time I had a problem about a paycheck or anything else, they took care of it.
5) Locals. The locals where I live are wonderful. I am friends with a few guys here. I met them both the first week I arrived. While I work a lot here, whenever I can get out to the street to eat I do. My favorite is the lady around the corner who sells this big spicy plate of spaghetti for about a dollar. When I go out and sit in the dirt street/alley and eat, I always see the local guys I know. And they’re always really nice. I invited one of them to Mandy’s going away party; he speaks little English, but I think enough people spoke some creole there that it was “anfom.”
6) Plat de jour. I couldn’t leave this off! This is my daily lunch plate of rice, bean sauce, and meat. It is awesome, and it’s huge, and it costs 1.50 US. I love it.
7) Having no car but things being possibly available just around the corner.
8) Learning how much I know about seeing patients in the clinic, although I claim to know nothing about it. Although I complain about clinic, as I began to learn more and more Creole I began to understand patients more and was able to explain the drugs to them , the exams, how important it all is.
9) The ex-pat community and other foreigners. While I miss the lab desperately (turns out not everyone is concerned with “what the answer is”, but rather are concerned with looking good or appearing smart), I have enjoyed the other ex-pats I have met here. People from all over the world and even states. Being from the US-South is a unique thing here; especially considering that I am one of the most educated science people.
10) Haiti. This place is poor, many are uneducated, many are sick, and yet there are still smiles just a few feet away. While there are many things that bother me about this place, one thing about walking around here, especially as a “blan” is that you are always greeted. There are even some kids here that always say to me when I see them “Goodmorning!” It doesn’t even matter what time of day it is!
I am sure I will be back.
1) When I walk around the clinic I always run into coworkers who I horse around with and joke with in Creole ("bay odyens"). It has really become home to me in the last few months. It's helped that I’ve had to beg pretty much every lab here at some point to let us borrow supplies of some sort.
2) Our drivers are awesome. Sometimes we have a chance to stop and buy them all beer on the way home from work. It’s a good time. These guys could ignore us or whatever (they speak little if any English), but instead they are always upbeat and friendly, joking around with us in Creole about everything. They also cash checks for us and do other minor things that must be done. (And they put up with me when I insist we need to see another patient and we can't go yet.)
3) The two OB/GYN guys are work with are fantastic. One of them has on more than one occasion stayed well past 4:30 (6:30). This may not seem like much, but the labs shut down at 4-4:30 and everyone goes home. But this guy never complains; he just is like, “yeah, this is my job.” I am going to email the director of the clinic about him. He’s great.
4) The administration. They have been excellent. Despite not really knowing the director of the clinic, the secretaries/admin ladies have taken care of absolutely everything I could need. Any time I had a problem about a paycheck or anything else, they took care of it.
5) Locals. The locals where I live are wonderful. I am friends with a few guys here. I met them both the first week I arrived. While I work a lot here, whenever I can get out to the street to eat I do. My favorite is the lady around the corner who sells this big spicy plate of spaghetti for about a dollar. When I go out and sit in the dirt street/alley and eat, I always see the local guys I know. And they’re always really nice. I invited one of them to Mandy’s going away party; he speaks little English, but I think enough people spoke some creole there that it was “anfom.”
6) Plat de jour. I couldn’t leave this off! This is my daily lunch plate of rice, bean sauce, and meat. It is awesome, and it’s huge, and it costs 1.50 US. I love it.
7) Having no car but things being possibly available just around the corner.
8) Learning how much I know about seeing patients in the clinic, although I claim to know nothing about it. Although I complain about clinic, as I began to learn more and more Creole I began to understand patients more and was able to explain the drugs to them , the exams, how important it all is.
9) The ex-pat community and other foreigners. While I miss the lab desperately (turns out not everyone is concerned with “what the answer is”, but rather are concerned with looking good or appearing smart), I have enjoyed the other ex-pats I have met here. People from all over the world and even states. Being from the US-South is a unique thing here; especially considering that I am one of the most educated science people.
10) Haiti. This place is poor, many are uneducated, many are sick, and yet there are still smiles just a few feet away. While there are many things that bother me about this place, one thing about walking around here, especially as a “blan” is that you are always greeted. There are even some kids here that always say to me when I see them “Goodmorning!” It doesn’t even matter what time of day it is!
I am sure I will be back.
Friday, July 3, 2009
Fee for service (Drs. don't get paid to think)
Recently I was discussing how surgeons will tell you whether they think they should operate on you AND then get paid to operate, and I began thinking more and more about the concept of fee for service in medicine. I am disturbed by the fact that the same physician gets paid for performing a procedure, when they are the one that decided the procedure was needed. In other words, it would strike me as strange if I went to a painter who charges 500$ per room painted to ask him if I needed to repaint some rooms in my house. Wouldn’t it be strange if the SAME person decided 1) if you needed rooms painted, 2) told you that is what they do and they will do the service, and 3) they did it for a fee you didn’t really know about until later. In my view, I would like an independent consultant to determine the need for the paint (my family – “should we paint this room?”), a separate company to do the painting, and the price to be agreed upon before starting (and having the option of using a cheaper provider).
Because many of you are medical people, I am positive I am stepping on more than a few toes here. But aren’t we setting up physicians for unethical behavior when we pay them much more for doing procedures than thorough examinations, and we financially reward them for doing as many procedures as possible? If you are a cardiologist and you get paid 3,000$ per catheterization and 80$ for talking to a patient and doing a stress test, why would you NOT take any patient you could to the lab for a cath- Especially if the cath took less time. Now you can move patients through and make lots of money. And if you have a family money is a good thing. You’ll have a better chance of protecting your family in the case of emergencies and a better chance of providing a stimulating environment for children to grow up in. Also, having money will give you a better chance of sending them to study whatever they wish to pursue in life. Making a living is a good thing.
One problem is people don’t like to talk about money. But doctoring IS a profession, and a highly regarded one. Not only this, but the best of the best go into it, and part of this is that they are well-respected and adequately compensated for their considerable gifts, talents, and sacrifices. In my view, paying doctors less is not an option. As it is, they spend a lot of money and time in training during the best years of their lives. Many of the doctors who have devoted their lives to insane working hours could devote that time and energy in the business world and make MUCH more. But they don’t. Lowering income much will only lead to our beginning to lose some of the best and brightest.
But why must we reward doctors that do many so procedures and not necessarily needed/cost effective ones? Why can’t we figure out a way to salary doctors, so they are free to practice good medicine as they see fit? Why can’t we create a system in which the reward of good medicine is a higher salary? In other words, if you were rewarded at your engineering firm for the number of jobs you did, you would plow through them with little regard for quality. (Or with an adequate understanding of the “lowest level” work you can get away with legally. Of course, you would also be cognizant of your market and whether you may lose customers for this type of low level work. In medicine, you won’t lose customers because there is a shortage of doctors and few patients are given a choice as to which doctor they can see.) However, if the quality of your work was being analyzed, and your pay was determined by how good your work was, you would slow down and do your absolute best. Especially if this meant that your future salary would be in part determined by the quality of patient care you were giving.
Doctoring is set up now to encourage unethical behavior. Luckily, some of our most altruistic men and women become doctors and resist this temptation to practice bad medicine their whole career. The problem is the system. We need to fix it before we taint medicine forever. How far away are we from an expose on this topic that hits the New York Times and turns off a whole generation to scientifically-grounded medicine? How far away are we from the public distrusting everything about doctors due to something like this? We must fix it before someone fixes it for us. If you’re a doctor, I’m not sure why you are still reading this; shouldn’t you be doing a procedure?
Because many of you are medical people, I am positive I am stepping on more than a few toes here. But aren’t we setting up physicians for unethical behavior when we pay them much more for doing procedures than thorough examinations, and we financially reward them for doing as many procedures as possible? If you are a cardiologist and you get paid 3,000$ per catheterization and 80$ for talking to a patient and doing a stress test, why would you NOT take any patient you could to the lab for a cath- Especially if the cath took less time. Now you can move patients through and make lots of money. And if you have a family money is a good thing. You’ll have a better chance of protecting your family in the case of emergencies and a better chance of providing a stimulating environment for children to grow up in. Also, having money will give you a better chance of sending them to study whatever they wish to pursue in life. Making a living is a good thing.
One problem is people don’t like to talk about money. But doctoring IS a profession, and a highly regarded one. Not only this, but the best of the best go into it, and part of this is that they are well-respected and adequately compensated for their considerable gifts, talents, and sacrifices. In my view, paying doctors less is not an option. As it is, they spend a lot of money and time in training during the best years of their lives. Many of the doctors who have devoted their lives to insane working hours could devote that time and energy in the business world and make MUCH more. But they don’t. Lowering income much will only lead to our beginning to lose some of the best and brightest.
But why must we reward doctors that do many so procedures and not necessarily needed/cost effective ones? Why can’t we figure out a way to salary doctors, so they are free to practice good medicine as they see fit? Why can’t we create a system in which the reward of good medicine is a higher salary? In other words, if you were rewarded at your engineering firm for the number of jobs you did, you would plow through them with little regard for quality. (Or with an adequate understanding of the “lowest level” work you can get away with legally. Of course, you would also be cognizant of your market and whether you may lose customers for this type of low level work. In medicine, you won’t lose customers because there is a shortage of doctors and few patients are given a choice as to which doctor they can see.) However, if the quality of your work was being analyzed, and your pay was determined by how good your work was, you would slow down and do your absolute best. Especially if this meant that your future salary would be in part determined by the quality of patient care you were giving.
Doctoring is set up now to encourage unethical behavior. Luckily, some of our most altruistic men and women become doctors and resist this temptation to practice bad medicine their whole career. The problem is the system. We need to fix it before we taint medicine forever. How far away are we from an expose on this topic that hits the New York Times and turns off a whole generation to scientifically-grounded medicine? How far away are we from the public distrusting everything about doctors due to something like this? We must fix it before someone fixes it for us. If you’re a doctor, I’m not sure why you are still reading this; shouldn’t you be doing a procedure?
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