Void

The cleaning staff will fill the void of information when none is forthcoming. It's just amazing that smart leaders don't comprehend the damage done by unethical communication about jugular issues. And not saying anything at all is part of that formula for disaster. It leave a huge, gaping void that students and staff and the community will fill. I shouldn't hear from the staff about how they plan to survive the school's closing. I shouldn't hear from the store clerk that the government has been advised that the school is not going to be open very much longer. I shouldn't hear from a neighborhood child that she no longer aspires to got to medical school here because it is closing. The multiple of sources says we are not long for this place and I'm planning my exit so when it does fall, I'll have a contingency.

The sad part is that I'm one of the loyal. I'm doing my part to be supportive with my tuition and my verbiage, but it is increasingly difficult in a the environment of unethical communication. This has given me lots of time to contemplate what it is that we expect from our leadership that isn't forthcoming. It is fundamental to the relationship that the leadership here wants...ethical communication. We need to be shown some integrity, and respect and it is not there. It is the reason why we are seeing the exodus of quality leaders and teachers. Unethical communication threatens the quality of all communication and the well being of the university society. It's so simple to see, but difficult to deliver:

• truthfulness, accuracy, honesty
• tolerance of dissent to achieve informed and responsible decision making
• understanding and respect
• information that contributes to the well-being of students, faculty, their families and the university
• caring and mutual understanding
• elimination of distortion
• fairness and justice
• sharing information when facing significant choices
• respecting privacy and confidentiality

We have a tremendous void and it translates into distrust and fear. If this is how a company respects it's stakeholders, which students are, they can't survive...even if they wanted to. Just tell us, and let us make the decisions we need to make. I appeal to the leadership to start a different path NOW, before it's too late. If we are going under, and you know it, tell us, tell the staff, tell the faculty. There is no shame in honesty.

Deux "Pau", Una Mas

Ok, so I'm really confused between Hawaiian, French and Spanglish. Consider it part of the environment contribution to my breeding. But the sentiment should shine clear....2 down, one to go. Did ok on Physio, as confused as it was with multiple instructors, not really knowing what the other was doing. I have to credit the course director who was last minute tasked to keep the "stooges" in line and keep it all together. For the most part, it did stay together. A yeoman's job under the circumstances. And we actually learned a bit of physiology. Yet there were gaping holes left in the wake...missing elements that would be nice to know in the ER.  The good thing about missing elements is we'll get more in the coming terms. I'm not worried, and seemingly worry less and less as I progress.

So onward to the last one, putting a close on another term in the stair-step process of medical education. One more layer in the "cake".  Soon the details for actually bugging out of this tropical paradise will consume what little brain power I have left...at least for a few weeks.

Physically Impossible

Although I did find a Jello shooter by the name, the laws of physics make it impossible. Nothing...no entity on earth, can both SUCK and BLOW at the same time. The laws of nature and physics prevent both ingress and egress of air from any container of space at the same time. I believe that I have found the exception in biochemistry. 

This final, just recently put into my rear view mirror, and this class...while amazingly interesting, both sucked and blew. But I passed. Any addition of points for thrown out lousy questions, typos, English transliterations from Hindi, or pedantic miniscule details will be gravy but likely won't boost me over the threshold to the next highest grade. I have "passed" and in the new world of "pass/fail" this is the good side of the equation.

I actually liked this class, the content, and the instructor, but the content of this class must have been what Dr. Eugene Stead was thinking about when he noted how much "time and effort wasted" in teaching future physicians. If he were alive I'd call him to validate that. So much time spent on the effort.

I have passed though and won't have to tackle this aberrancy of physics again. I can safely state too that I will not in any immediate future run a biochemistry research facility. Thanks to God!

------------------------

"One act of pure love in saving life is greater than spending the whole of one’s time in religious offerings to the gods." - -Dhammapada

tick, tick

3 d, 14h, 23m til Winair....unless of course it is canceled or altered enough so I miss my connection. UGH!

Ye, I walk...

Here they are...FINALS at last. The culmination of another term of trying desperately to eat those 5 pancakes a day, EVERYDAY for almost 4 months. I have to admit, I tried and most days succeeded to do just that, but near the end, I am sick of pancakes and hopeful I can regurgitate enough of them to make the grade and earn the ticket to come back next term for more of the same. I know more about enzymes than anyone would care or want to know. I am filled with how many ways you can be "sick" from failed chemicals in the body. I think the term killed one or two of my chemicals. So off to the exam I go, hopeful, skeptical, joyful, tiredful, faithful, fearful...Ye, I walk thru the valley, in the shadow of the Quill, fearing no evil, but damn sure scared to death of missing a body part after this.

Shorter Hours, Less Error

Recommendations call for cutting back consecutive hours without sleep and providing more off days.

FLASHBACK! I had to laugh at the photo. In my rotations I often slept on the gurneys in empty rooms in the ER. It was "allowed" and assumed to be just "part of the training game." But is it right? Are we optimally being trained in this system?

The final report has been issued by the Institutes of Medicine (IOM). Residents, those physicians in training AFTER medical school, are too tired to to the work effectively and safely. This is even after the Graduate Medical Education Council implemented restrictions for resident hours about 5 years ago. Apparently it wasn't enough. The IOM concluded that tired residents are at increased risk of making serious errors in patient care.

Some comments/recommendations from IOM:

• limiting shifts with no sleep period to 16 hours
• 5 hours uninterrupted time/sleep after each 16
• increasing time off per month to 5 days without call
• restricting moonlighting hours
• One off call, uninterrupted day off per week
• increasing supervision by experienced physicians
• limiting patient loads
• scheduling overlap between shifts to make hand-offs (patient care responsibilities shifted from one resident to the one coming "on") more seamless
• providing transportation home for fatigued residents (correlation with increased wrecks?)
• hiring more residents and other providers
• providing additional residency funding
• improved monitoring of residency programs for compliance and tighter oversight

I can't say that I'm sad about not working long hours in residency, but I know how vigorously the medical education elite will argue against any changes that seemingly change the status quo, or increase costs. I shudder to think of how many things I did or didn't do in patient care because I was tired. This a "joke", a known, a given in medicine...you are going to get tired. But should it be? It is the belief of many I have worked with that tired residents (or any providers) don't learn better under these conditions and that this "fraternity hazing" system of residency should go away, perhaps even with a little push over the cliff into the abyss.

Source: "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," Institute of Medicine, 12-2-08

Right to Arm Bears

I heard an aside today about the need for biochemistry in medical school. I was fascinated at the story, but felt sorry for the individual who felt it useful to justify the class and content.  Too funny really. I was about bile and it's medicinal use.  And particularly focused on bear bile.

I knew that bears were being poached for their gall bladders but I had no idea of the value.  It's the Urso-deoxycholic acid (another application of biochemistry) that is sought. It's supposed to be good for joint pain, improving eyesight and to get rid of gallstones.  But $25 per teaspoon? Phenomenal!

Now I've not checked the facts, and it is hard to find evidence based practice guidelines, but apparently the value of UDCA has been shown and was listed as a medicine in the first official pharmacopoeia in the world, published in China in 659 AD. And apparently bears are a significant source of the bile that cures. There are even bile farms in east Asia where bears are drained of their bile thru surgically created "taps". Hot and cold running bile anyone? It is estimated that about 22,000 lbs of bile is produced in this was every year. There are 20-30 brands of farmed bear bile products including bile, tonics and wines on the market worldwide today.  At $25 per teaspoon, that's a $54 million market. Wow!

To no surprise this has spawned a huge illegal trade for bear bile and gall bladders including illegal hunting and farm raising. If there is a "cure" here, clearly more research is in order. I'm sure there is a frustrated biochemistry graduate student somewhere, trying to concoct the perfect substitute bear bile for market. Maybe I underestimated biochemistry?

It is Done...well almost

The term is almost over, the weather is wetter, and the profs are visibly fed up (smiling with glee really). Today was the last day of class officially and now the real study crunch begins. Most people can't keep a straight face about going home (automatic grin syndrome), or hide their exam stress. This was a tough term in so many ways, but it is coming to a close. The "sabbatical" break will be a good one, no matter what happens during it. So t-minus 3 days of study before the barrage of finals begins, and there is great relief in knowing that 2008 is almost over. But it does mean the "next term" and closer to the goal. In the meantime, I think I'm going to take up yoga, or shark fishing, or nude volcano downhill bike riding...

Finishing

Just because you finish a lecture, doesn't mean it's been taught or learned. Completion of a lecture, by a professor, is a ego filled event to say "I did it", in absence of the participation of the student.

Mistakes

Last month federal officials issued final regulations for implementing the Patient Safety and Quality Improvement Act of 2005. Going into effect on Jan. 19, 2009, the final rule:

* Allows physicians, hospitals and others in the health care system confidentially and voluntarily to report medical errors and other safety issues to patient safety organizations. The PSOs will analyze the data and identify trends that can inform patient safety improvement efforts.

* Keeps confidential any patient safety quality improvement reviews, deliberations and analyses reported to PSOs. Medical records, billing or discharge data, and any other patient or health professional information that exists outside of a patient safety evaluation system are not confidential or privileged.

* Prohibits health plans, regulatory agencies, licensing boards and government organizations that operate mandatory reporting systems from becoming PSOs. Such entities may serve as PSO parent organizations.

* Allows PSOs with parent organizations to share certain staff and computer network resources if they meet security, workload, ethics and other requirements.

* Requires PSOs to be engaged primarily in efforts to improve patient safety.

The airline industry is best at it. They set the curve for the reporting and analysis of accidents and errors. The medical world is cloaked in errors of the past never reported, fear, litigation, ego, and pride. But the pooling of information about error, and the analysis of confidential pools of such information is vital to finding the "cause" of error, and eliminating it. It's that simple.

All recent legislative efforts and discussion hinge on a voluntary, confidential, privileged reporting of safety information to groups called patient safety organizations (PSO). These PSOs are certified by the Agency for Healthcare Research and Quality, part of the Dept. of Health and Human Services and will serve as analysts for the data.  Information about error cannot come from legal discovery, and does not apply to medical records, billing or other records normally kept outside safety reporting systems.

Unfortunately, the need for voluntary participation will be an obstacle for PSOs trying to gather comprehensive data on medical errors and patient safety. Physicians and others involved in the management of healthcare aren't thrilled about reporting themselves, and are wary of "anonymous" labels. Is it really anonymous reporting?

AHRQ has certified 20 PSOs around the country.  Much like the National Transportation Safety Board does for the flight industry, the PSO plans to offer accident and event investigation, and that can't be a bad thing if it will stop one wrong leg from being amputated, or one death from accidental medication error.

Holland Rotations?

I've really been sheltered in my medical career. I was always led to believe that the U.S. medical system of care is one of the best in the world. While I see so many wonderful things about the system and working within in it, I recognize that there are other systems doing great things. The Dutch health services is one of those. The Dutch system of services is world known, mostly beyond the U.S., because of fourteen themes on which they differ from systems in other developed countries: A strong primary health care...For many years Dutch General Practitioners (GP's) are family doctors and gatekeeper before a patient enters a hospital. They have mostly a longstanding relation with their patients. The last years the GP's work more and more in multidisciplinary settings with practice nurses, psychologists, pharmacists and physical therapists. One thousand multidisciplinary health centers are in operation. But this Gatekeeper relationship is far more effective, cooperative and valuable than the gate keeper system as I know it. Strong patient unions...Since the eighties The Netherlands developed 200 patient organizations with about 600,000 members together. For nearly each disease a patient union exists. These "unions" are strong advocacy and watchdog groups for the major diseases and the patients who have those diseases. While "organizations" do exist in the U.S., these organizations in Holland play a far greater role in policy, procedures and funding. Centers for youth and family...The Dutch youth is very healthy and happy. However, there are four growing health problems amongst Dutch majorities and ethnic minorities: 1. a growing overweight in children; 2.  a growing number of children especially boys with ADHD and autism; 3. a growing number of children especially girls with depressed feelings; 4. an increase of violence at home  and sexual abuse of children. Disease management in mental health services...Since the nineties, in Holland many ambulatory mental health organizations and psychiatric hospitals merged. As a result thirty organizations now exist with an average of staff of more than 1000 professionals. They now all work with disease management programs per mental disorder, for instance for patients with depression, schizophrenic disorders, anxiety disorders and so on. Professional addiction care…Holland has in comparison to other European countries less soft and hard drugs users per 10.000 inhabitants. This year, the methadone programs were modernized and individualized. Most of the treatment is now evidence based. There are no perfect systems, but it was enlightening to read about the efforts of the Dutch and realize that there is more than one way to attack the issues we face in healthcare. I hope we do eventually end up with a comprehensive one payer system in the U.S., but moreover, I hope we stay focused on those core areas or themes that deserve the most attention now, so they don't eat up the most resources later. It's not impossible as some have suggested. „Onmogelijk betekent slechts dat u haven' t vond nog de oplossing." "Impossible only means that you haven't found the solution yet."

It Ain't NORMAL!

There is an opportunity here that allows the last term of basic sciences to be completed in the U.S.  There are many pros and cons.

At a going away dinner last night, some were gushing with the realization that they were going and leaving here forever, leaving this third world country for access to movies, drive thru burgers, and closer access to "home".

I don't think I will be availing myself to that opportunity. It's just not Normal.

Fear of PROF

"Fear" of God is described as a reverence.  It is a feeling merging awe and the motivation to perform in life.  Proverbs says, that “The fear of the LORD is the beginning of knowledge…”, and until we understand who God is, and develop a reverential fear of Him, we cannot have true wisdom.  Fear, awe, motivation, knowledge, wisdom...

No wonder my professors act and feel like Gods, particularly as we near final exams. 

The PROF is my shepherd; I shall not want much.  He maketh me to study into the wee hours of the morning. he leadeth me beside the blue Caribbean waters in search of knowledge and blue beads. He restoreth my grades: he leadeth me in the paths of intense memorization for memorization's sake. Yea, though I walk through the valley of the shadow of finals, I will fear no multiple choice question: for thou art with me; thy Powerpoint and thy laser pointer they comfort me. Thou preparest a table, an outline, reading assignments, and vast collections of knowledge before me in the presence of mine fellow students and grade curve adversaries: thou anointest my head with biochemistry, genetics, physiology, and throbbing; my laptop runneth over with content. Surely good grades, board scores, lofty residencies and healed patients shall follow me all the days of my life: and I will dwell in the house of the PROF for ever. AMEN.

Fear no final.

Tick, tick, tick

It is difficult to describe what happens, but seems that every conversation is focused on leaving, escaping, break,...everything beyond "the rock." I'm feeling it too, with the urge to be with really good family and friends (extension of Thanksgiving; I am REALLY blessed). But it is the clock mentality...x days till leaving...that is so pervasive. I don't want to wish my life away, but I have to admit, as much as I like it here, being in school, and living in the Caribbean...I'm yearning for a movie in a theater, a home cooked meal by my mom, a date to Coldstone, a daiquiri at the "deck", a long hot shower without fear of centipedes crawling up the drain, A/C instead of a chiller, clothes dried in a machine and washed in non-European soap suds, a drive thru burger hot off the "King" assembly line, a lake view from the patio, a big hug from a soccer player...

Final Push to Finals

As it is in life anywhere, you sometimes miss the beauty of your surroundings and the gifts in your life when you are so focused on the negative and the weariness of it all.  That state of weariness begins to creep into studies and living about this time each term. It's particularly acute given the long break to come, complete with the many holiday celebrations that await us. Time for family, friends and just being with people you love, and in places that are comfortably familiar. The conversations are completely focused on "when you leaving", "where you going" and statements of "I can't wait." It's been a long term for us with the changes in faculty, terrors of finances and school cutbacks, fears of the future, and worry. New cases of Dengue, a hurricane "hit" and assorted infrastructure challenges haven't made that any better.

But in all that challenges there are triumphs, and the times to enjoy the day and life in all the positives. That is certainly the case here. The school, for better or worse, is open, faculty are being hired again, services are being restored. Former basic science islanders are passing USMLE part 1 and moving to clinicals. Dutch accreditation is moving forward and hopefully will be a "full" reality shortly. I'm doing well in school and anticipate pulling out of this term in good shape academically. So, while the air and water around us is cooling for the Caribe winter, so does the air of trepidation that seemed to be the undercurrent of life here.

I could complain about what I've endured so far, but it's not been that bad. I'm less inclined to judge and condemn and more willing to just work with what is. Certainly not as bad as it could be as we hear about mayhem in India, and other significant crises around the world.  I can reflect and completely agree that what hasn't killed me strengthens me daily. I appreciate where I'm headed, see the goal..., so these "bumps" are really not an issue in the grand scheme. Some things I can control, others I cannot. And in the interim, there is always the underwater.

It is the most peaceful, contemplative place to be...down under. That is assuming your have enough air, and all your equipment works. Also assumes you don't get lost from the group and can find your way back to the boat. This past week, I had the chance to get away to the backside of the island, part I've never seen. And I was rewarded with an amazing few minutes with one of the largest turtles I've ever seen. I'm sure that they don't have to worry about testing, going to lecture and worrying about the things we worry about.  For those few minute, I could almost imagine I was one of them. And for that time, I didn't have to worry about those things either. Sweet!

Just wondering...

Had a wonderful hike this past weekend and ran into a few of our wondering flocks...just wondering a few things:

Who was the first person to look at a cow and say, 'I think I'll squeeze these pink dangly things here, and drink whatever comes out?"

Who was the first person to say, 'See that chicken there? I'm going to eat the next thing that comes out of it's rear end."

Why exactly were these donkeys following me?

Back to the books...

Thanks Giving

Thanks for LIFE. I get to walk out this morning, into the cool air, and see the work of God all around me.  4201 "kids" don't get to do that since they died in Iraq, and Afghanistan.  Holly McGeogh, 19 y/o died when her vehicle was hit by an explosive device in Kirkuk, Iraq (Photo: Holly & Mom).  

Thanks for health; the kind that sometimes is puzzling as people my age get sick or die. I shouldn't complain about the cool water temperature...I get to feel it.

Thanks for family and the love and support I feel from them every day.  I am blessed with both my parents, my brothers and their families and an extended family that surprises me daily with unconditional love. I can never repay the support I have felt from them, even when they didn't feel like it. I can only hope to do the same for them.

Thanks for food.  I never go to bed hungry. I never have to worry about where the next meal will come from or if it's really safe to eat. I have access to clean, drinkable water. The United Nations estimates that 1/2 of the worlds population has no access to clean water within a day's walk.

Thanks for shelter and clothing. I am covered from the elements and then some. Thanks for intelligence and good grades. Thanks for motivation, sanity, and foresight. Thanks for forgiveness.

When a sense of gratitude enters we allow memory of the thousands of fortunate moments and blessings in our lives.  It's not always easy, particularly with the bad habit tendency to remember the bad things.  Thanks giving should not be a one day event. It is a skill that must be practiced every single day of our lives.  It can be benefit throughout the year and rightfully should be.

I'm sorry that I won't be home for Thanksgiving and spend it those that I love. But I am so thankful no matter where I am or who I'm with.

EUREKA Moments!

The rush of studying medicine, or any science that takes more than one course, is those moments when information from one area, time or place "merges" with information from another area, time or place and becomes the consummate OMG moment.

It happens with increasing regularity for me as I merge 25 years of education, knowledge, information and experience together in this doctorate experience. I realize that the more I learn, the more I am able to see. The more I am able to see, the more different patterns of doing something becomes evident.

WHAT A RUSH!!

Tough Times

The reality is that the financial crisis in the U.S. is not isolated. It is a world-wide problem. The effects on small universities and economies like islands is dramatic. While the cost of fuel goes down here too, the cost of everything else is rising. There is almost constant talk from locals about the cost of everything from electricity to food. I don't doubt my rent is going to go up in the near future. Food cost is out of control.

I think schools in general, but particularly small schools, are being hit the hardest. The cost of doing business in utilities, rent, taxes, salaries, benefits and the like is going up, Incomes are going down and there is little if any money available for loans. It's a crunch being felt by small medical schools too. I think this place almost shut down at one point, but we have been assured that we are ok for now. Evidence of cost cutting is everywhere and there is a renewed sense of getting thru the most difficult period that this school has experienced since inception. It's not over though.

For the moment, it pays to just do the day to day, study diligently, focus on the end goal, and control those things I can...releasing the rest to the Gods (I choose Thor this month). Finals will be here soon, then a break to sort of recover...can't wait. For the moment, my attention is fixed on amino acid metabolism.

Case Based Learning

It's all the rage as an alternative method of teaching, and thus, learning. It has been advertised as the best of the best to have students learn to reason out problems and come up with solutions. But it is not an easy thing for teachers to do. It takes planning, and and understanding of the process. Most professors fail to recognize that and believe that it is something they "just know" because of their PhD, or teaching experience, or whatever. 

The skill is based on the concept that a discussion has to unfold among students with appropriate use of resources to ask about unknowns. In the proper execution of problem based learning, the professor is NOT one of those resources and is a "guide on the side" mentor of the process, NOT the authority or expert.

Managing Discussion and Debate Effectively

• The problem solving part (the "answer") must be delay long enough to clarify the facts, frame analysis, evaluate, make judgements, ascertain recommendations. This take TIME...minutes, days, weeks perhaps.
• It is imperative to shift points of view of the student (thru the problem or the mentor professor) to see things from the perspective of the anatomist, the physiologist, the pathologist etc. At this stage the student evaluates the case from those perspectives and compares the dynamics of the perspectives (after some research)
• Consideration of benefits/disadvantages of a position; for all sides. Again takes time to acquire the evidence based knowledge.
• Fully consider time, ethical, moral, other science, system, cost and risk/benefit issues.

After discussion, the process requires time to research the issues, discuss further, come back to class for clarification and guidance, and then further develop to final conclusion. This all takes guidance and TIME.

How Not to Teach with Cases:

• Have no clear goals other than arriving at an answer from an A thru E list.
• Don't know what you want to accomplish in the case, what facts, principles, viewpoints the students should cover.
• Provide little, if any, time to work thru the discussion.
• Provide no direction, guidance or resources.
• Do not allow class discussion to follow its own course.
• Provide instant answers to questions based on your inner depth of knowledge or your PhD dissertation.
• Don't provide enough class periods to discuss the case, and go off to do the literature searches, and research necessary for the next discussion.
• Don't mentor or encourage preparation before discussion and out of class prep time.
• Don't take time to get good at learning how to write, lead and execute a case based class.
• Just throw a case up on Powerpoint, and say "OK, discuss this among yourselves,"
• Expect miracles if you do the above...cause if any learning happens...it will be.

This process cannot be done in 2 minutes in class. This process should provide the framework for learning, not for creating additional stress...especially right before a huge exam. Why is it that professors believe that their science knowledge provides them the knowledge of teaching, particularly when the opposite is true? The arrogance is so palpable sometimes.  Teaching is actually a great role and responsibility than being a clinician, yet it is taken so lightly by so many.

Teaching is an unnatural process. It's not natural for most.  Teaching requires real attention to learning how to do it, and being open minded enough to learn how to do it...for the good of the student, and optimization of learning. In the end it will only help to create better providers and shift to teaching students how to be life long learners. Some of the nicest people, most accomplished professionals (doctors, scientists, etc) are the WORST teachers. But they never think so :)

You want to be a what?

Been a great "recovery" week after exams. Now the final push to finals for the term. Lots of stuff for sure on a cumulative (everything since the start of the term). but I've got some time. Catch up on errands for sure this weekend...

Very encouraging eh?  You have to be 1 chromosome short of a quadrisomy to want to go into a profession that half the people doing it want "out". And with a looming shortage and decent income, you would think that job security would be enticing. But no! The system is so broken, the strains so vast, the paperwork so onerous, the insurance situation so intolerable, that 1/2 of family physicians would LEAVE the practice of medicine if there was a suitable alternative.

For me, and the new generation of docs, it may be more a matter of creating a different practice world, not have expectations of the unpredictable future, and playing an active role in recreating the system that has been so revolting to so many who are doing it.

Reflections on Statia America Day

It really was a hoot being an American on Statia/America Day yesterday. To see 4 flags flying over the fort, including the American flag was exciting. To see the U.S. Coast Guard in Oranjestad Harbor was amazing.

Statia / America Day was celebrated in grand style on Sunday. It is amazing that St. Eustatius was the first "nation" on earth to acknowledge the independence of the United States in 1776 with a cannon "salute" to a passing U.S. warship way back when.

Early Sunday, uniformed troops marched to historical Fort Oranje in Oranjestad for the opening ceremony. Many dignitaries from Statia, other Netherlands Antilles islands, the U.S. and Holland witnessed the festivities.

The highlight of the Sunday program was a recreation of the now famous cannon exchange salute. It started with the first shots by the U.S. Coast Guard cutter. A return volley of shots rang out from the fort a short time later. I've never actually heard the gun fire from a Coast Guard vessel...a first for me.

The day wouldn't be complete without speeches from the various political dignitaries. This is a transition time for Statia as it goes Dutch once again, and the speeches reflected both the excitement and pure fear that is here. This is, for some, a huge step backward for Statia as they progressed closer to independence over the last 200 years. But becoming a "municipality" of the Netherlands makes Statia little more than a "city" of a larger, more dictatorial system called the Netherlands. While it's been "Dutch" for some time, as a protectorate of sorts, Statia was not really subject to the stringent processes and rules, and regs. Now they are.

Some some of the speeches were...defiant. They proclaimed a strength to resist the negative effects of the "motherland" Netherlands. The changes were enumerated by many....constitution, rules implementation, land purchases and transfers, budget reorganizations, etc. Statia wants the economics benefits of the new union, but they are very cautious about the effects of being part of a large, capitalist nation...Holland. One politician from the island proclaimed "Obama" as a battle cry, that anything is possible from a small island nation's people. The meaning was not lost.

This was then the last Statia / America Day where Statia is not fully integrated into Dutch society. Next year will likely be somewhat different and it will be interesting to watch over the next year. I'll be almost done with this phase of my education by then, but I'll leave with a sense of "Statia Pride" even if I don't really "belong" here.

Re-memoversary FL131

Beth; Born: February, 1977; Died: today, 2007

The mark of a life is in the imprint on those left behind. I can only imagine how Jorge feels now after losing his mate and friend, but those you coached, touched, supported, prompted, propped... hugged, we'll miss you Beth. In our mini breakthroughs and stands for what we believed you revealed parts of ourselves that can never be turned back over to "the nerd" again.

Your life was too short, but your work will live on forever in the lives you touched and the skid marks you left on some hearts.  You revealed that love, contrary to what most people think, is not a commodity to be saved, traded, or bargained for. It is available to all and how we all should "walk".  When looking up "walking in love" in the dictionary, it says, "See Beth". Many of us are where we are partially because of what you did for us.  We "barely knew anything" but you helped to clear up the fog a bit.

And I think I understand what you did now. Sometimes it's not why, but why not. Rest in the great peace and  you created in the short time you were here Beth.  You are missed and will never be forgotten.

Happy Dutch-American Heritage Day

Statia plays an important role in the history of Dutch-American relations. On November 16th, Dutch-American Heritage Day, 8 million Americans of Dutch descent celebrate their heritage and the contributions they and their ancestors have made to the economic, social, political, and cultural life of the United States.

The Dutch began relations with America in 1609, when Captain Henry Hudson of the Dutch East India Company sailed up the present-day Hudson River looking for a shorter route to Asia. Although Hudson did not find his route, Dutch traders began to exploit the riches of this wild country and in 1614 established Fort Nassau (near Albany), the second European settlement in America. A few years later, the Dutch Governor Peter Minuit bought Manhattan Island for 60 guilders, the famous $24 bargain.

A large portion of the eastern U.S., stretching from New Jersey and Delaware through New York and from Connecticut and Long Island to central eastern Pennsylvania, was settled by the Dutch in the early-1600s. The area was once known as New Netherland, and many places--Schuylkill, Catskill, Brooklyn, Staten Island, Harlem, Wall Street, Coney Island, to name but a few---trace their names from this Dutch period. Over the next two centuries, several waves of Dutch emigrants settled in the United States and, today, most Dutch-Americans are concentrated in ten states: New York, Michigan, California, Florida, Pennsylvania, Iowa, Washington, Texas, Ohio and Illinois.

Linked by traditions of intellectual and democratic freedom, the Netherlands became the first country in the world to recognize formal diplomatic relations with the United States in 1782. These relations have never been interrupted, and thus the Netherlands can boast the world's longest record of continuous friendly relations with the U.S. Benjamin Franklin once wrote: "In love of liberty and in the defense of it, Holland has been our example."

In the American War of Independence, the American revolutionary cause found both sympathy in and support from the Netherlands. In 1779, John Paul Jones wrote "The Dutch people are for us and for the war." In 1782, John Adams, the first U.S. envoy to the Netherlands, secured the first loan for Congress from three Amsterdam banks. Between 1780 and 1794 the Netherlands lent 30 million guilders to the U.S., a small amount by modern standards but at the time it equaled the entire foreign debt of the U.S. After the 1941 attack on Pearl Harbor, the Netherlands was one of the first countries to ally itself with the United States. The landings of the 82nd and 101st Airborne Divisions in the occupied Netherlands, which began the liberation of the Netherlands in September 1944, are still celebrated today.

Statia's Part: In November 1991 the U.S. Congress proclaimed November 16 as Dutch-American Heritage Day. November 16th was selected because on that day in 1776 Dutch forces on the Caribbean island of St. Eustatius returned the salute of the American brig-of-war "Andrew Doria," thereby making the Netherlands the first country to officially salute the flag of the newly-independent United States.

Alive and Well, Old

So if you've never been to school, as an older (politically correctly called "non-traditional" full time student, you just can't relate, but I'll try to paint the picture. The age gap is alive and well. Medical school is not hard, it's just a lot. And when you put together "a lot" with 20 some-things, you get stress. And when you are 20 something and you want to un-stress...it's usually a combination of eating, drinking, frivolity, nakedness (both public and private), sleeping and maybe some more drinking. I've been thru all those stages in the past but occasionally it's fun and bonding to get together with classmates during and after stress filled weeks of content being thrown at us (hoping it'll stick).

I've been wondering lately about all the invitations for dinners and get togethers that I'm not getting when the 20 some-things de-stress. Now I don't feel that I'm being excluded but have wondered about the dynamics (I've written about them before). It is different.  So I was talking to someone about it yesterday and said something about my perception of the gap. She (a verified 20 something) was very clear....

"Don't take this wrong or in a mean way, but would you want to party with someone older than your father?"

No I guess not. Leaves more time for study. But in my mind, I am 20 something.

CDC on Dengue

Outbreak Notice Update: Dengue, Tropical and Subtropical Regions - Updated: November 10, 2008

Dengue fever is the most common cause of fever in travelers returning from the Caribbean, Central America, and south central Asia. This disease is caused by a virus spread through the bites of infected mosquitoes. Many countries reported high numbers of dengue infections during 2007. This trend has continued in 2008, with large outbreaks reported in Brazil in March and April and an increase in cases reported in the Caribbean in October.

    * March 28, 2008: The Brazilian Ministry of Health reported a national total of 120,570 cases of dengue fever, including 647 cases of dengue hemorrhagic fever and 48 deaths.2
    * April 10, 2008: Health officials in Rio de Janeiro reported that 75,399 cases of dengue fever, including 80 deaths, have occurred over the past year.
    * November 5, 2008: Health officials in the Netherlands Antilles reported an increase in dengue cases on the islands of Saint Martin, Saba, and Curaçao in late 2008. More than 500 cases of dengue fever have been confirmed on Saint Martin and nine cases of dengue fever have been recorded in Saba. Saba officials say this is the largest number of dengue cases reported on the island in the past 30 years.

No vaccine is available to prevent dengue, and there is no specific medicine to cure dengue. Those who become ill with dengue fever can be given medicine to reduce fever, such as acetaminophen, and may need oral rehydration or intravenous fluids and, in severe cases, treatment to support their blood pressure.

Symptoms of dengue include

    * fever
    * severe headache
    * pain behind the eye
    * joint and muscle pain,
    * rash.

Sorta like I feel the week before exams...Watch the skeeters! And BTW, Florida has just been lucky...It's in the zone.

Dr. Pepper, Paging Dr. Pepper

I'm a pepper. Wouldn't you like to be a pepper too?

I'm not only a pepper, but I'm going to be Dr. Pepper!

I love pancakes, in moderation. One of my fave places to go at home is a pancake house I love. I heard a great analogy the other day (actually a You Tube Video) about medical school being like eating five pancakes a day, everyday. Some days you don't feel much like pancakes, but you have to eat them so you save them for tomorrow...and then you have to eat 10....and so on. The only problem is how many people can eat 5 pancakes a day, everyday?

Last push for exams. I'll never be ready. I've tried to eat my 5 pancakes a day, everyday for the term, and I'm barely able to swallow any more. I know I'll have to regurgitate all the pancakes I've eaten since the last exams next week, but I don't think they'll all come back. We'll see. Needless to say, I'm a little sick of eating pancakes.

Uncoupled Reaction

Thermogenisis...the ability of the body to create heat, in the absence of any. Humans have largely degraded this process over time with the use of heaters, clothing and such, but our animal brethren do it quite well. Think about the hibernating bear in the cold cave. The body senses the need for temperature increase secondary to regulation to keep the optimum temperature in the body for core physiologic processes. Temp drops, and the cells "scream" for increase in the heat (like banging on the pipes) to they can do their work of cell division, and protein synthesis (among others). The body kicks in with and "uncoupling" cascade that puts the normal processes of the cell on hold, to divert to the "brown fat" heat production machine...we using ADP for ATP energy, produce heat, and then "stop" when the cells have had enough. Thermogenin is the protein largely responsible for that action, but the system can also be triggered by dinitro substances, thyroxine, bilirubin and long chain fatty acids. What a mahvelous machine eh? Brown fat...who knew?

So why would I share such "interesting to me but useless to the rest of the world" information? It took 2 lectures, umpteen Powerpoint slides, and hours of intention to get me to that understanding. I've been short, but the number of steps to get to this point in the "reaction" is 20 or 30 or so, with lots of side steps in between. The minutia of medicine and body science. Far greater minds have determined the value, but I wish somebody in clinical medicine, at the front lines of headaches, nausea, cancer, and diabetes would tell me how does this make me a better physician? I've heard all the rationale about mechanisms for drugs and all, but those can be summarized in quick fashion for everyday use. It's about accumulation of more information for information sake, isn't it?

Worse, the time element that this takes away from really knowing what is important. We spent hours on this, and only 1 on EKG reading. Paramedics get more intensive EKG training (and thank God for mine). The real reaction in learning is:

Time + content = memory & recall

There probably is an enzyme involved to stimulate this reaction. Some, et. al. have suggested coffee, Red Bull, Twinkies, apples, Monster and other such substances are effect catalysts. I think the studies were biased and unfortunately written up by those taking the substance. However, there is a formula for effective memory and recall, assuming that all AcH and GABA neurons are firing correctly in the brain to allow learning and retention (the problem in Huntington's disease for instance..oh no! Do I have Huntingtons?...aside: While learning diseases processes, it is imperative that the learner rule out that he/she has that disease)

Manipulation of the raw materials of this reaction is also important. Modify time (spend to little or too much) and learning is modified. Manipulate content (make it too hard or too easy) and learning is modified. So the mix of right time, with right content (at the control of the "teacher" receptor) = optimal learning. I can manipulate the time, and there is NEVER enough. So it is truly up to the teacher. This is not it's his/her fault rhetoric, it's simply the truth. I don't believe that most teachers fully understand that roll...to distill content and thus delivery, to optimize the use of time (limited supply) in learning what we need. We CANT learn it all, so why try to deliver all?

I sometimes forgot this simple fact when I taught. I totally understand wanting to share all you know, but in the speed to deliver, there lies the fundamental problem with lectures in general, and lecturing too fast in order to jam in all the stuff. The problem is compounded given the geometric growth of the information database in medicine. It's simple too much to learn in two years. But do we have to? Is it necessary?

I am more appreciative everyday of scholars like Dr. Eugene Stead who suggested that medical school was so far off base that the problems we see in the clinical practice and the system at large, are largely predictable and of our own making. And it starts at the lecturer/learner level. And as long as we fill our classrooms with instructors of great knowledge, but of little ability to fully understand their role in manipulation (after full analysis and consideration) of the content arm of this reaction, the reaction will always yield what it continues to yield...in all it's glory.

Crisis!

Experts beyond the island call what is happening in the US family medicine specialty a "crisis." Recent "match" results show that of the 2654 family medicine residency slots available, 250 went completely unfilled (nobody in place in those slots for training). More importantly, only 48% of the "filled slots" were filled by graduates of US based medical schools. The rest, 52% of the 2404, were filled by graduates of international medical schools. Is there any wonder why offshore schools are booming? There is a need to be filled, and international medical grads are filling them. And this phenomenon is not just in the US. Those slots are likewise being filled in Australia, the UK, Canada and other westernized countries.

We are not turning out enough general practice physicians in the US for the future needs and not filling the slots of available training slots for the ones we are turning out. Crisis? Not sure. But certainly a challenge, and an opportunity....if I can get thru this term :)

To Netherlands or Not

We are sort of Dutch and sort of not. Most of the transitions on this island happened violently, but not this one. As I walk past the fort, I glance regularly at the flag poles to check where I'm living. Right now there are three flags there, but likely in the near future, there will be only two. I'm sure there will be great fanfare and some sadness, but at some point the flag of the Netherlands Antilles (we are one of the "stars" now) will likely come down leaving only the flag of Statia, and that of the Netherlands.

You can see and feel subtle signs of the transition coming. It likely is going to be a slow, drawn out, "island-time" process; well at least until the Dutch get really involved. After the discussion of Obama settles, locals are split on what might happen at that point. There is fear that the island will be too full of rules and regulations and lose it's outlaw mystique. Some welcome the infusion of European money, and possible development (including a possible resort). Some fear rapid rises in the cost of living (more than now??) and inflation. But one thing everyone can agree on, it will be different.

School is undergoing it's national (Dutch) accreditation site visit soon and the topic of value invariably comes up in conversation. I think the consensus there is, who knows. One thing most sure is it may open a gateway to European community rotations, residencies and employment. For some that is a real concern and issue. We shall see.

P.S. Word from a senior (year 4) Statia student about ready to graduate and get the coveted MD...he passed USMLE part II. It is now in my cross-hairs.

Just dreaming...

No reason...just dreaming. I know it can harden my arteries, encourage insulin resistance, boost polyp formation in the colon, and precipitate cholecystitis, but I'm willing to take the risk.

No Way!!

It's about 1300 miles away, but I can't believe that another storm, "Paloma", has evolved in the Caribe. Should be a Cat I by the time it hit's Cuba. I don't think we'll get anything here, but I feel pretty sorry for the soaked region that it is about to hit. They really have been brutalized this year. Our prayers...

OMG At Work

Most photographers take time to frame the shot, find a good location, eliminate the electrical wires :) LOL ...but this sunset was too good to pass, and the sun was setting quickly. Amazing, vibrant colors. Truly God at work!

Now what?

Ok, now start fixing the mess! Make the US a better place for our kids...

Post Pottery Booty Analysis

Arggghhhh! Avast mateys! All this treasure hunting on the west coast before and after my afternoon swims has yielded some interesting finds.  Photos got reviewed by our local expert.

Overall I got some refined earthwares:
-Creamware 1760s-70s
-Pearlware 1770s-1820s
-Tin Enamelware (often incorrectly called Delft) 1550s-present
-Canaryware 1760's

I got some Stonewares:
-Frechen (Bartman Jug) 1580s-1680s
-Fulham 1600s
-Dutch/German water/gin jugs 1700s

And some Coarse earthenwares
-Afro-Caribbeanware 1500-present
-Black glazed Earthenware 1730s-1760s

Not a bad haul for a part time beachcomber and archeologist. Pretty cool stuff got kicked up by the storm who shall not be named.  My searching will have to slow as the volume of molecular biology, genetics, biochem and physio begins to expand beyond the boundaries of my inner space.  But is was fun to think that one of my treks would yield the great treasures of pirates gone past. Blue glass was a great substitute.

Evidenced-Based Voting

אנא להצביע בעד הבחור השחור!

We can't take 8 more years. They tried, and failed.  Just look at the issues, and dissect the hype from the reality. The diagnosis and treatment is clear. Just use the historical past as the evidence. Calculate the mean, median, mode and standard deviation for the population the Republicans experimented on. Use the evidence.

FOUND ONE!

I almost didn't believe it. It isn't striking or particularly pretty.  The dot of color with the hole in it, rising above the large rocks, pale browns, tans, and blacks of the beach.  My eyes looked but my mind didn't quite register the reality. Thought is was another peace of blue pottery. I actually walked right by it, then paused, and walked backwards to look again.  It was in the most unsuspecting place. Like a friend told me, "no rhyme or reason." And with the seas constantly changing the coast since the storm, more are likely to "come up."

Like Hawaii, there is a Kamaaina (person of the land) thing that happens when you "connect" to the land through something native.  I believe now I am wired into the luck of the land of Statia.  One can only hope that it will help on future exams :)

Perspective

I am continually challenged by people. Isn't it amazing how selfish some people are? I love the specimen of human being that feels put out if they have to do something they don't want to do,  but is offended when you won't do what they want to do.

Bible Parable: There was once a girl who wanted to go snowboarding. She'd never done it and was intrigued by trying. So she decided to travel to a place with great snow to do it.  When she announced her intention to her traveling companions, they decided they didn't want to snowboard but encouraged her to go and enjoy the experience. They were happy for her adventurous spirit. She did go and became offended by the fact that her companions didn't want to go.

Later the companions decided to they wanted to go do something else, and asked the girl if she wanted to go. She did go, but in her mind became offended that is wasn't what she wanted to do. She wanted to do something else. She walked around angry the rest of the trip, and then stored away the painful experience to draw upon later. <end>

This specimen of human will now be "double" offended and "put out" in their own minds and begin building a case against others for why they don't want to be with you, or serve you graciously, or take care of you. They are unforgiving, cold hearted, selfish people inside, even though they may be light, cheery, smiling on the outside. This person is so put out by others beyond what they want to do and how they want to do it, and totally neglect the needs of others around them. Worse they judge others by that measure and see people who are flexible and serving in negative terms as "wishy washy" and "soft".

No it's not snowing in the Caribe, but that specimen of human being is alive and well here. In this "what about me" mentality, it rarely matters what other people do, it's never good enough and mostly "wrong". It is amazing how many of those people like that are attracted to medicine. And it's not just here. Recent events and contacts in my life just reminded me of how many there actually are in the field of medicine, pretending to serve others, when they are really just serving themselves.

I'm not trying to build a case for not being in this field. To the contrary, it motivates me to further explore those elements of myself that prevent me from really giving to others in this last part of my life and create a new reality for dealing with patients, staff, and colleagues. It is NOT about me, and never was or is. And it's not a cute "bunny" trait in others. It is totally opposite to empathy, sincerity, serving others and commitment to other in spite of how we "feel".  Living by those feelings is never reality, only the reality we invent.