Wednesday, December 24, 2008


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.


Tuesday, December 16, 2008

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 image 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.

Sunset Over the Caribe...Never gets tiring! 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 least for a few weeks.

Monday, December 15, 2008

Physically Impossible

Although I did find a Jello shooter by the name, the laws imageof physics make it impossible. 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 imageand 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...

imageHere 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.

Sunday, December 14, 2008

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

imageI 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 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

Friday, December 12, 2008

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 imagemedicine 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?

Thursday, December 11, 2008

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...


Monday, December 8, 2008


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.



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 imagelike 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.

Sunday, December 7, 2008

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."

Saturday, December 6, 2008

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.

Friday, December 5, 2008

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.


Thursday, December 4, 2008

Tick, tick, tick

image 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...

Wednesday, December 3, 2008

Final Push to Finals

image 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. image

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!

Tuesday, December 2, 2008

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...