Dutch Health Themes of Service

As I again intertwingle with the U.S. health care system, I realize how much I like the Dutch approach. The Dutch health services are world known in some circles because of their approach to care based on fourteen themes: Five general themes, nine themes related to special groups of patients and public health problems -

1. Competition - it can stimulate innovation without being a negative.
2. A strong primary health care - gatekeepers and longstanding relationships with patients
3. Transparent hospitals and other institutes
4. Strong patient unions advocating for the patient
5. Dissemination and implementation of successful experiments - Evidence in practice
6. Centers for youth and family - overweight, autism, ADHD, depression, violence, abuse
7. Safe hospitals with strict patient safety mgt systems
8. Integration of emergency services of ambulances, GP's and hospitals
9. Integrated care programs for chronic disease: DM, COPD, heart failure, stroke, cancer
10. Disease management in mental health services promoting recovery
11.One access to long term care
12.Flexible long term care
13.Professional addiction care
14.Legislation on medical end of live decisions with strict ethical systems

Anything even remotely successful must have strong leadership, allocated resources (taxes in the Dutch case), advocacy at all levels, and integration into new professional training. It's worth a look.

The Spill That Keeps on Giving

On Day 22 of the tragic oil spill from the drilling rig in the Gulf of Mexico.

Oil continues to pour into the Gulf from the undersea well at about 200,000 plus gallons per day. The pink, orange oil is now near the shore and has begun to wash up "balls" of oil on beaches, and a national wildlife refuge and nesting ground for sea birds. All sea wildlife is at risk. Shrimping may never recover.

And, there has been no success in stopping the flow of oil. It keeps on coming.

Beyond the direct effects of the oil, has anyone considered the effect of the nearly constant spraying with dispersant? Do we have any idea what the 1000's of gallons of dispersal solution can do to the environment and to human health?

What a tragedy.

Impulse

Why do we, at times, feel ourselves being compelled to improve ourselves, not only for our own sake but for the sake of a higher cause that we sense yet can barely see? What is that soft vibration that tugs on our hearts and beckons us to courageously leap beyond the small confines of the separate self sothat we can participate in the life-process in a much deeper and more
authentic way? - Andrew Cohen

Getting Closer

"It's not much longer". "You'll do fine". "You got this".

I know people are trying to help, encourage and insure my success, but they may be up for a fall. I know I don't have much longer. I'm watching the calender too. I've paid the fees, scheduled the date. But I don't know that I'll do fine, and certainly not sure if I got this. But I am hopeful...that people would just stop trying so hard to say the right thing when there may not be a right thing to say.

Onward into the dark night, the recesses of leukemias, anovulatory mechanisms, lung function, and tumor markers. I don't "got this" yet.

The Trek

It's really hard to get out of bed some days because I know that what faces me is another block of hours of study. I may be being hard on myself to do the best I can on this upcoming exam, but that's the beast that is medicine. I laugh inside when people say I'm "type A" or an overachiever or some such. Not sure I'd want a PA or physician or surgeon taking care of me who wasn't. But that internal motivation to succeed at this is none the less the thing that does actually get me out of bed. Although love for the study content, and for people, doesn't hurt.

I'm nearing the end of the first 1/2 of study with the exam some weeks away. I'm gaining confidence but still not performing up to the demands of my motivation. The mini eureka experience I have daily help, but I know that there is much to do, more to come. It is, like life, a day to day existence and discipline to keep mentally, spiritually and physically healthy while continuing the self motivated effort to ingest and retain as much of this elephant, these pancakes, as I can. Some day soon, I'll have to regurgitate it back, on cue.

I wish people wouldn't keep telling me that this is the hardest test in the world. Or that they wouldn't be doing this if they were me. Neither is good motivation. I get it.

USMLE Solo

Studying for USMLE Step 1 is a very lonely experience. While I see many others "doing it", still the highs and lows of study are lone and solo. The camaraderie of suffering thru class, while still painful, is somewhat blunted by the fact that there is a room full of people sharing the same experience. And while I know there are many 1000's of persons doing what I'm doing, it's hard to connect beyond it just being me vs. the ocean of content that is the mostly non-patient orientation of Step 1.

Drowning is NOT an option.

The Placebo Effect

"There is an effective treatment for your condition and the prospects for recovery are excellent"

Sometimes it's not what we do in medicine that matters, but how and what we say.

RESCUED!

They've seen us!!! We're RESCUED!

OOH "Out of Here"

All my bags are packed, I'm ready to go. I'm standin' here outside Winair. I hate to wake the goats up to say goodbye. But the dawn is breakin', it's early morn. The dog is waitin', he's barkin his horn. Already I'm so elated I could die. Cause I'm leaving on a prop plane, I don't know when I'll be back again...

This is it. Got my passport, and one-way ticket home. It's been a journey and a half, and I'm hopeful I've learned enough to make it to the next Step. But for now, it's travel and some welcome R & R before starting the push for boards and my date with destiny. Another long day, but I know the drill by now after 6 runs. Hopefully all the bags and flights are on time, and together. Can't wait to be home again.

Happy Kingdom Day

In the islands, there is only one thing more predictable than the weather... holidays! Today is 'Koninkrijksdag' or 'Kingdom Day'. it's a national holiday here and in the Netherlands and happens every December 15. It celebrates the signing of the Charter for the Kingdom of the Netherlands by

Queen Juliana on 15 December 1954. The charter deals with the relation between The
Netherlands and the overseas territories like the Netherlands Antilles (soon no longer to be in existence).

So today, nothing official can get done. I'm quite sure though that the green bottles will flow, and political conversation will spew. Or will the bottle spew, and conversation flow? As this place goes back to the kingdom, while most countries seek independence, the celebration will likely be the last one. In 2010, the last of the "overseas territories" will be gone, and all will either be back in the kingdom (not just a territory), or independent (like St. Maarten, Curacao, etc). This really is very historical but likely will not get the appreciation it deserves.

And I will continue to get ready to depart, also for the last time. Knowing that the next time I come to visit, if and when, I'll be entering a new place with more rules, regulations, organization, services, and taxes. It's bittersweet leaving now, but I'm a bit happy I won't have to live through the challenges that likely will be when the transition actually occurs.

So as we go back to the rule of the kingdom, Happy Kingdom Day!

Never Saw it Coming

"The toughest sacrifices are the ones we don't see coming. When that happens, when the battle chooses us, that's when the sacrifice can turn out to be more than we can bear."

Hard day. And I thought it was really out of my mind.

It never is, is it?

The Mind Protects

The mind has an amazing way of protecting us from the traumas of our lives. We experience great stresses and like the small animal injured in a fight, the mind squelches the event and moves us forward to new challenges and new risks. Such is the experience of the past few days and months.

The memories are becoming buffered by the action of the mind and everyone speaks of the "good times", and great friends, and wonderful experiences. But if you listen closely, you can hear the remnants of some of the trauma hidden by the artificial expressive aphasia imposed by the mind. For speaking the truth in many cases, while factual, only resurfaces the wounds. And while those truth traumas are really there, we have to thank the brain for doing it's handiwork.

Respect and Stuff

Coming to the 1/2 way point of this monster, I realize that I've learned so much since I hit the start all bright eyed and bushy tailed. Not that I'm any less bright and bushy (cuz I'm not), but I've had some sense knocked into me for sure. I'm so thankful for the wonderful mentors and teachers along the way here. They are the reason I came and stayed in spite of the processes that threatened to derail us.

I came on faith and the recommendations of my friends who graduated from here now directors, practicing docs, residents and interns. They said that the campus was filled with role models, respect for the students and a pathway to the goal I sought. So I came, and learned.

I've learned that respect is something that is earned, not demanded. I've learned that quality is created, not accidentally stumbled upon by filling up slides. I've learned that quality doesn't have to be packaged in a pretty building. I've learned that our students are some of he most tenacious, focused learners in spite of great adversity and forces willing to impede progress. I've learned that not all change is good change, and can be dangerous if not recognized as such. I've learned that often little things create the greatest footprint of impact and effect. I've learned that, at times, doing the right thing is just walking away.

In retrospective sum, I see the great things accomplished, but I'm sure that my brain is deliberately hiding from me the traumas we were subjects of. I appreciate the experience so far, my classmates and the opportunity. And I'm ready for the next phase of the learning and hopeful I didn't learn too much, or too little.

 

Cause the next "step" is coming....and it's a doozie!

Privacy

HIPAA Privacy Rule - protects the privacy of individually identifiable health information

I have to admit, I'm a novice when it comes to experiencing health care delivery beyond the borders of the U.S. So this Caribe healthcare experience has been truly "new" in many, many ways. But one of the most amazing to me, it the protection of privacy. To the extent possible, the providers do their best, but in a population of less than 5,000 where everyone knows everyone, is that really possible?

Further exacerbating the situation is the rather free flowing way that care is delivered and how patient privacy is protected, or not. One encounter truly summed that up for me the other day.

I am sitting with the doc in his private office. There are 3 doors entering the room from the hallway, the next door treatment room, and an adjacent patient room.

A patient walks in with another person and sits down near the physicians desk. I thought the other person was family or close friend. Au contraire! They hardly knew each other. It was the "next" patient in line, sharing the space. But it didn't seem to matter to the patient. Just then the door flies open and a nurse from the hospital, and the hospital administrator walk in. They engage the physician in a conversation about a patient and his family (by name) needing assistance. During the conversation, the nurse next door enters another door and announces that Mr. So and so is ready to see the doc in the treatment room. When the midwife walked in to consult the doc about Ms. such and such and her baby, a phone call engaged the doc in a conversation about Mr. Some and such coming back on island after seeing a specialist.

I looked around. There were 7 of us in the room, and the doc on the phone. Everyone heard everything about everybody. The patient, patiently awaited attention to be turned back on her and her headache.

HIPAA Privacy; apparently, just a formality.

Competent Culture

One of the buzz phrases of medical education has been the concept of "cultural competence." Loosely, cultural competence in health care services is the ability of individuals, and the systems they are a part of, to provide health care to patients with diverse values, beliefs and behaviors.

When I taught this class in an earlier life, I used the CLAS standards as the model for the behaviors that organizations and individual practitioners should use as a guide. Although the CLAS standards are primarily directed at health care organizations, individuals can use them as a guide to make their practice of medicine more culturally and linguistically accessible. This is becoming more and more important as populations become more blended with individuals of diverse backgrounds, religions, nationalities, races, sects and...most importantly...health care belief systems.

I cannot imagine a better place to learn the practice of culturally appropriate health care than where I am. I realized in clinic how far I've come to understand the Caribe culture, and language. First, most would say it's really English, but I say ney ney, ya? Iz der speak aw bra! (nothing to do with lingerie). Me bellie ben hurtz whir I coo coo (nothing to do with psych). Da water ist burn offa me git upa bed. After a few hundred patients, I'm actually beginning to understand most of it, but find myself totally baffled at times. I'm sure I have this deer in the headlights look when I nod as if I know all that is being said. I'm sure I laugh at the wrong times occasionally. The Caribe-English can be quick, choppy, rhotic, glottal, accented, sporadic with influences from Jamaica, Barbuda, Africa, Netherlands, the UK, France and Wales. Ah, but iz Stashia mon!

But then the culture falls away to the frank ills of this land. The charts stack up with the same chief complaints I hear in the U.S.: Diabetes, hypertension, obesity, poor nutrition, sexually transmitted diseases, teen pregnancy, cardiovascular disease, breast cancer, stroke, COPD, asthma, emphysema, flu, cataracts, glaucoma, melanoma and other cancers. Illness is a non-judgmental taker of life and health, without prejudice. Disease respects no boundaries or artificial segregation. It is truly equal opportunity. The subjective descriptions by the patient just sound a little different.

Cleared, the Sweetest Word

It's been a hectic last few weeks getting ready to complete basic sciences and move onward to the next phase of training. With all the gloom and doom discussions, and continuous drone about school, I'm ready to move onward, and not a moment too soon.  Lots of discussion about exams and such. It's such an inane conversation, truly an arbitrary system. Amazing how dogmatic people can get about this stuff. It's so contrived.

On that note, If large number of students are failing exams, that's not education...it's ego; teacher ego. Either the exam is too hard, or is poorly written. It is about ego creating an us vs. them mentality, adversarial instead of cooperative and mentoring. It is the creation of the antithesis to team work in healthcare. Students are not dumb, but teachers can be so vain and full of their position power that they succeed in seeing students as dumb, and working diligently to prove the point on exams...their only weapon in the great fight. Worse than having this environment is having it be supported by leadership. The greatest disappointment in school is when students recognize problems, and leadership is unable, or unwilling to move beyond "I know better" into "how can we make it better". There are no easy answers, but there are easy efforts. And in many cases, the effort and the process is more important than the reality.

Back on track...out of here. One of the last events of the process is getting away from the island, cleared of all "crimes and misdemeanors", bills, debts, cusses and discusses. It's basically a signature and pretty stamp scavenger hunt concocted by who knows who. But in a little less than two days I had my done and I was "cleared"...Cleared to leave without risk of being detained in some manner. What a sweet, sweet word. 

So I've officially (or mostly) survived this part of my education and learning (very different and sometimes mutually exclusive terms). I've navigated the right to move forward and onward to the next phase and for that I am grateful. As wonderful as parts of this experience has been, I'm very excited about getting off the rock and integrating back into some sense of civilization, sanity and clarity. Patient care soon, soon.

Well Packaged Fear

I've gone and done it. I've signed up for the first national  exam to practice medicine in the U.S. What a fear inducing process! It's all online and with a few simple clicks, it's done. $700 later, I look to the horizon for three months or so hence to sit down and take this beast on. I've got some time to prepare, but being the most important exam to date is daunting.

So what do I have to do now? Study. I need at least the national average 225 or so to be competitive for rotations and residency. I need to blow this thing out of the water if possible so I can compete against the twenty somethings for those coveted spots. I hope that I'm not putting too much pressure on myself, but I don't have a lot of second chances left in me.

For the moment, just keep swimming!

I Want to Teach When I Grow Up

I'd really like to teach again, at least one on one with an interested health care student. I miss the interaction and the cognition of the "ah ha" moments in others. I've missed seeing that here since it so rarely happens. And this sabbatical has really shown me a lot about good and bad teaching.

Good teaching is about passion, as well as reason. It's about motivating without coercion. It's about teaching others how to learn and making that lesson relevant, meaningful and memorable. It's about substance and treating students as consumers. It's about staying on top of the information you teach, and teaching relevant practical points over useless "I know more than you" knowledge. It's about bridging the gap between theory and practice. It's about listening, being responsive and questioning if necessary. It's about pushing students to excel with reasonable expectations while being human, and respecting the student. It's about not having a fixed agenda, being too rigid but instead being flexible, and fluid. It's not about "finishing" the material. It's a creative balance between being a dictator and being a pushover. It's about style, entertainment and still filled with substance. It means working the room and addressing every student directly in that room. It's about recognizing individual learning styles, and proficiencies and working to address them. It's about not taking yourself too seriously and a sense of humor. It's about caring, nurturing and devoting time...not just to test and presentation creation but to the student. It is supported by strong visionary leadership with a strong vision of what is appropriate and necessary.

Having had REALLY good teachers has been a great blessing and a great curse. I cherish the interactions and the learning, but despise the level of expectation it has created in me. I think I miss out on opportunities because of that prejudice and I don't think I'll be able to accept less than the quality I've come to expect in others, and myself.  One of the dangers of being an older dude with a history.

Missing It Already

I know I'm going to miss this experience at some level. I've enjoyed the overall environment and the people. This was a good choice, and I'm sure, heralds a wonderful future to the last part of my life. The learning has been wonderful, albeit difficult at times. The living has been challenging, while still inspiring.

Most of all I'll miss the natural beauty. It's part of my  soul, even before I got here, that I'm connected with nature around me. I love the water and the land. I appreciate it all. Best of all, it has been my sanity when there seemed to be none left. It's been my balance when the imbalances piled up. And I know, someday soon, I'll know how much I miss being here despite roaming animals, water shortages, absence of real culture or burgers, the mosquitos...

At some point we have to slow down, take stock and ready for the next day. That's what I've done here, and I hope that I can continue that work no matter what or who is around me.

The End is Nearly Near

Hard to believe that the end of this part, the first part, of training is nearly over. We are making preparation for leaving the rock and readying ourselves for taking the most important board of our careers to dates. I'm stunned at how quickly it feels we got here, but I relive the daily slog thru the 567 days in my mind regularly. But who's counting.

After taking the sample boards, and realizing how much we have to study for the next months before the national exam, we are finishing up our experience in the hospital. It's been great. I've really enjoyed watching the local physicians do their magic without the common conveniences I've come accustomed to appreciate. There is no x-ray, no ultrasound, no major labs, no surgery, no CT/MRI, and no EKG machine. Diagnostic is basically bedside combined with amazing low tech skills and lots of experience. It's not sophisticated, but it is magical in a way and a pleasure to watch.

We have engaged in some interesting discussions as well about what's coming with clinical rotations, and testing and such. Mostly I've enjoyed the discussions about the future and choosing a practice specialty. I'm particularly interested in that for my own sake and choosing a balance between practice and private life, while still providing a much needed, core service. I still envision being that "anything that walks  thru the door" doc in the hinterlands.

It is a very strange world in which we erupt into this phase of training and I am anxious to hear the pondering of our clinical faculty. The doctoring profession has been so mis- and devalued by what I've come to understand as "the business." It's not fashionable or profitable to be a general practitioner, yet it is our countries greatest need. I've seen an over emphasis on doing CPT coded procedures, and a sense that specialists are the only ones who know anything. Yet the patient centered "home" model where the doc knows the patient from "womb to tomb" seems to be what people want. But the finances, and legals get in the way. How to navigate that? I'm not sure, but hope to find out in the next two years.

My initial goal is to stay far afield of the financial conflicts that creep into our lives as new docs. I won't test or market products for drug or equipment companies and will scrutinize continuing medical education carefully, even though it's required. I'm not interested in serving the commercial interest Gods anymore. I recently turned down a steak dinner from a drug rep. Somewhere in this new world there is practice which is largely governed by patient advocacy, ethics and professional doctoring values in a private, not for profit realm of the wood. I'm moving thru cynicism and hopefully see clearly the "man behind the curtain." I'm sure it won't be a yellow brick road. 

But I am heartened when I see the docs here talking to patients at he beside, doing a classic Bates history and physical and actually making a sophisticated diagnosis without the high tech to depend on, or worrying about the lawyers in the hallway. There is something wonderful and pure about professional practice in the absence of profit, and a defensive posture, even if we can't get a chest x-ray.