52 Posts Left...

It is hard to believe this is the fourth time I've reread my first post. Today is the four-year anniversary (hence the "linen and silk" shoes pictured left - Wikipedia says a four-year anniversary gift should be something made of linen and silk) of my first acceptance to medical school. Each year I go back and relive my December 26th experience in Chapel Hill, NC - my first taste of the years to come. I still get chills when I read it, remembering the anticipation, joy, and relief like it was yesterday. Inspired by my sister's blog as a PeaceCorps Volunteer in Ukraine, I decided I would start my own literary journey, which soon turned into weekly posts that I promised myself to continue until the end of medical school. And today it seems surreal to announce that I only have 52 posts left.

Obviously (if you do the math) 52 posts doesn't take me all the way to the end of school. That's because, over the course of the spring semester, I will transition this blog to something bigger and better (waaaaay more details on this to follow in the coming months!). For now I will just say I am looking forward to continuing this personal journey for one more year, and I am excited to continue writing about my final experiences as a student.

In the coming year I hope to diversify the posts a bit more. I am going to ask my family members (yes, that means you! - Mom, Dad, Shelley) to each write a blogpost. My mother has dutifully edited this journal for the past four years, and I want her to detail her own take on the experience (and then I can edit her writing for a change!). Shelley was my inspiration, and Pops needs to comment on how pumped he is that I will actually have a real job before the age of 30 (knock on wood). I would like one or more of my preceptors to write a post, and maybe I will throw in few other guest bloggers in the process. It is going to be a good year.

As another December ends, I also must look back on my three New Year's Resolutions for 2012: first, learn to cook something. That one was mission accomplished. I also was able to reach my second goal, taking a year to study Public Policy. The third one I am going to have to fudge; I really wanted to "go somewhere crazy" in 2012 (I really wanted to go to SE Asia). I did make it to Costa Rica, and on January 1st I will head to Belize, but I wouldn't call either place "crazy" (the more Americans you find somewhere, the less crazy it actually is). Add them together and you get a pretty daggum good vacay though.

Resolutions for next year? I think I will pass. I have some personal ones, but I can say I would like to continue to learn how to cook. However, I'd really like to have a real job! That resolution, though, will have to wait until 52 posts from now...

Happy New Year!

Lots and Lots o' White Men

Earlier this fall, I had the opportunity to attend the 97th Annual Clinical Congress of the American College of Surgeons. It's the meeting of the bigwigs. Surgeons from across the country travel to Chicago to attend top-notch skill sessions, expert panels, and lectures on leading research. Speakers feature the premiere innovators and investigators in their specialties. As a medical student, I attended interview training sessions and resident panels. I also made sure I took the opportunity to take a step back and soak in the entire experience. I wrote down some of my first impressions...

Impression #1 - There are a lot of white men here.

I've spoken quite a bit about the importance of mentorship on this blog, specifically about how mentors have shaped my career trajectory. I can honestly say that I'm not sure I would've chosen General Surgery without the skilled and caring surgeons I worked with in Asheville and Linville, NC. I certainly wouldn't have considered rural surgery without briefly living the craft, getting to know surgeons who have worked in a rural area for 10+ years and then moved back into academia. I cannot stress how important it has been that people like me are already doing what I want to do. With this knowledge, I believe I can accomplish as much as they have, and even push the boundaries.

Aspiring leaders want to know that their dreams are reachable. First, they must have access to the necessary resources (e.g. students of low socioeconomic status must have the educational and financial means to even get to medical school). Second, they want to see someone who has come from their position... and succeeded. Politics aside, it is no longer a question whether an African-American can be the President of the United States. We now have a black Commander and Chief. It is no longer a distant dream of possibility; the path has been forged. Resources and mentorship: our youth need both to succeed.

So why is this an issue in medicine? I've focused quite a bit on rural disparities. One quarter of the US population lives in a rural area, yet only one out of every ten physicians work there. This population is in dire need of primary care physicians and general surgeons. Studies have shown that women are more likely than men to go into primary care and minority medical students are more likely to care for underserved and indigent populations. Yet only 6.3% of the American physician workforce is black. Women are only a third of the physician workforce.

Of course, in 1970, only one-tenth of all physicians were women, so great strides have been made. But the progress is slow, and often the leadership lacks diversity. I guess this is to be expected, since the more experienced clinicians trained at a time when the medical profession was almost exclusively white men. And their mentors were probably white men, and their mentors were white men. To change this we need to work on access to resources, and make sure there is an increasingly diverse group of mentors. In both regards, medicine can (and will) improve. Just an observation.

Of course, I am another white man. So I guess I'm not helping the statistics :).

Helplessness

(Update: for a wonderfully written article on this, click here to read the Huffington Post article.)

Today marked another unbelievable tragedy in American history. Twenty-seven are dead in Newtown, CT. Twenty of them were elementary school students. The school ran kindergarten through fourth grade. The principal was murdered. The school psychologist murdered. Dozens of children executed. I've heard that word, "executed," used quite a bit day, and it is only appropriate. Almost zero injuries, only death.

I've written quite a bit about the helplessness that medical students begin to feel in their third year. We enter as first-years expecting to ameliorate suffering in our patients. This profession is a golden opportunity to improve the health and lives of our fellow human beings. The doctor is an all-powerful being. Rarely do we think that we are going to fail, we are going to make mistakes, and we are going to fall short. We imagine our power to be much greater than it actually is. However, third year is a real wake-up call. As we spend more time in clinical medicine, many struggle with the limits of our knowledge and capabilities. Not just the knowledge that we lack as third-years, but the capabilities that we will always lack. I cannot ensure that my patients take their medications or quit smoking. I cannot guarantee they will have food on the table, and a roof over their heads. I cannot always safeguard a child from the trauma of physical abuse, or the tragedy of a mass execution. The guns used in the massacre today were legally registered to the perpetrator's mother. A pediatrician can talk about gun safety in the household, but cannot ensure it.

I don't know much about gun laws, but I do know we don't take mental health seriously enough in this country. We have no problem understanding disease processes that we can see: the flu causes fever, diarrhea, and vomiting. These are easy, physical symptoms that we can identify, and we understand the need for medical intervention. We even develop annual vaccines so we can avoid this illness. Diseases of the brain, however, these are more difficult to comprehend and more difficult to prevent. Interventions for these illnesses often do not receive the same amount of funding or support. The public doesn't equate diseases of the mind and diseases of the body. But they are one and the same. The mind is the body, and the body is the mind. The aggregate of the mental health of our populace is our country's health.

I wish I knew how to ensure that a tragedy like this will never happen again. Yet again I feel helpless, but I also feel a responsibility to try. Like medical training, it is our duty to learn as much as we can and do our best for others, even if we fail. I've enjoyed many subspecialties during my training, but few more than Pediatric Surgery. Watching TV today certainly made me wonder whether I could have handled being the surgeon on-call when those two children rolled into the Emergency Room. I want to think I could have, and that I would have been at my absolute best. If that is the road I take, perhaps that is my part. Or my part will be advocacy. Or something else. All I know is that the statement "this is an inevitability of our culture" is not acceptable. We can be better.

I moved my flight up a couple days, so I will be flying home to DC tomorrow. I will hug my parents a little harder when I return home.

WHEN MY PARENTS WANT TO KNOW WHAT I'M DOING AT SCHOOL

Recently, I have been obsessed with tumblrs. Ever since I found out that my Mom knew about "pinterest" before me, I've been making sure I'm up on my e-culture. Tumblrs are not new, but I certainly have enjoyed this one over the past week or so. It speaks to me. It's mostly nerdy lab stuff (I've spent my fair share in the lab, so I love it), but once in a while it hits on grad school in general. I wasted an hour on it procrastinating before the Thanksgiving break, continually hitting the "random" button for fresh jokes. I like this Napoleon Dynamite one specifically, because during the Labor Day weekend football game at UNC this year, my Dad had to ask one of my friends (who is getting a "real" dual degree, aka an MD/MBA), what I was doing up in Boston...

WHATEVER I FEEL LIKE, DAD! GOSH!

Sometimes, though, it is tough to know exactly what I'm doing here. I have had a couple friends, who are now fourth year med students, travel through the Boston area on the interview trail. It is awesome to hear their excitement (and sometimes weariness) about the process, and the anticipation as Match Day approaches. Most people have November and December off to interview, speed-dating all over the country at prospective programs. In many ways, I'm jealous.

I know I'm not ready to "settle down" yet (aka buy a house, pop out a few kids), but I'm definitely ready to "settle in." I would love to call one place "home." For the next year and a half, I will live five months in Boston, two in Asheville, one in a rural part of NC, two or three back here in Cambridge, then a few months jumping around DC/Boston/Chapel Hill, finally settling down Chapel Hill for a 3-4 months before moving in June 2014 permanently (wherever that might be!). The move/drive from Asheville to Boston was exhausting enough; just thinking about this itinerary makes me what to sell all my possessions so I don't have to store or move them.

Laptop, carry-on, and a free checked bag. Thanks, Delta.

Every once in a while I have to ask myself, "Am I really about to take 'end-of-the-semester' exams again (and again)? Am I really taking an undergrad level Intro to Economics class? Are people really pulling all-nighters for reasons other than call or a real job?

I keep telling myself there's a light at the end of the tunnel. A couple days in Chapel Hill to see Ronnie and meet with the Surgery department, then Christmas, then a week on an island off the coast of Belize (gloriously by myself), and then I face 2013 with a whole lot of medicine in my future. I will be reenergized and amped to start studying before my Family Medicine rotation in June, and so ready to be back in the OR and on the interview trail myself!

Time flies. Just not during exams. Come on Xmas break!

Rotini with Summer Garden Vegetables

No, I'm not giving up medicine for a career as a chef, but one of my New Year's Resolutions was to learn how to cook. So, here I will show you what I've learned. Blake started me off with The Best 30-Minute Recipe cookbook, and at this point I've probably learned about 30-35 new dishes. Earlier this year I started you off with one of my favorite recipes, and now I will close November with another one of my new "go-to" dinners. I like this one because it is one of the few veggie plates that I really enjoy. There's no substitute for sausage, but if you need meat that bad, I'm sure it can be added. Below are my additions to this excellent summer dish (or spring, or fall, or winter)...

Ingredients

• 4 tablespoons extra-virgin olive oil
• 2 zucchini, halved lengthwise and sliced crosswise 1/2 inch thick
• 2 yellow squash, halved lengthwise and sliced crosswise 1/2 inch thick (the recipe calls for carrots, but I like squash better!)
• 1 pint cherry (or grape) tomatoes, halved
• 1 onion, minced
• 3 tablespoons tomato paste
• 3 garlic cloves, minced
• 1/2 teaspoon red pepper flakes
• 1 1/2 cups low-sodium chicken broth
• 1/2 pound rotini
• 1/4 cup minced fresh basil
• Copious amounts of freshly grated parmesan cheese (just to make sure it's not a vegan dish)
• Salt and pepper

First, boil water for pasta, then heat 1 tablespoon of oil in 12-inch skillet over high heat until shimmering. Add zucchini, squash, and 1/4 teaspoon of salt, and cook until browned, about 5 minutes. Stir in tomatoes and heat through, about 1 minute. Transfer mixture to bowl and set aside.

Add rotini and 1 tablespoon of salt to boiling water and cook until al dente.

Add 2 more tablespoons of oil to skillet and return to medium heat. Add onion and 1/4 teaspoon of salt,  cook until softened, about 5-6 minutes. Stir in tomato paste for 30 seconds to coat. Add garlic and red pepper flakes, stirring for an additional 30 seconds. Stir in broth, scraping up any browned bits, and simmer until slightly thickened, about 1 minute. Remove skillet from heat, cover, and set aside.

Toss pasta with vegetables and sauce, adding basil and remaining 1 tablespoon of oil. Season with salt and pepper. Serve hot, add grated parmesan cheese as desired.

A feast for three!

Stop Supersizing, Massachusetts

In the second edition of our "Guest Blogger" series, one of my colleagues, Dhruv Khullar, continues the conversation concerning the New York Soda Ban. While I tried to address the moral implications of such a law and its inherent paternalism, Dhruv highlights the science behind the legislation. Dhruv is a fourth year medical student at Yale University, and an MPP candidate at the Kennedy School. He is also a Zuckerman Fellow at the Center of Public Leadership here at Harvard.

When you train to become a doctor at a time when more than 50 percent of the population is overweight, your eyes start playing tricks on you. You compare your clinic notes with the appearance of your patients, and words like “severely overweight” and “moderately obese” just don’t seem to fit. These words imply some deviation from a norm – but these states are the norm. You accept historic rates of obesity as the default – because for this generation, they are.

The passage of New York City’s controversial soda ban last month has reignited debates about how to address the nation’s obesity epidemic. The New York City law restricts the sale of sugary beverages in containers larger than 16 ounces in movie theaters, fast-food restaurants, sporting arenas, and other food establishments regulated by the city. Exempt from the ban are beverages sold in convenience and grocery stores, as well as fruit juices, diet sodas, and dairy-based drinks. Massachusetts would do well to consider a similar proposal.

Massachusetts has a history of trend-setting health initiatives that have resulted in a well-insured and (relatively) healthy populace, but even here obesity has taken a disturbing toll. The obesity rate in Massachusetts has doubled in the past 15 years, leading to large increases in associated conditions like diabetes, heart disease, and hypertension. Rates of childhood obesity have nearly tripled in the past three decades. And a recent study by Trust for America's Health and the Robert Wood Johnson Foundation estimates that by 2030, half of all adults in Massachusetts will be obese.

The size of American waistlines has grown in concert with the size of American sodas. In the 1950s, the largest soda sold at McDonald’s was 7 ounces. Today, a “child size” is 12. The default “small” at most fast-food restaurants is now 16 ounces, and health-conscious Subway offers only 21-, 32-, and 44-ounce options. Regal Cinemas boasts a 54-ounce large with a whopping 175 grams of sugar. That’s more than 40 teaspoons. Free refills. All in all, the average soda in the United States is 6 times larger than it was 50 years ago, and the average American is 26 pounds heavier.

So is a soda ban the cure for our obesity epidemic? Of course not.

Our current epidemic is a complex, multifaceted problem that developed over the course of decades. There is no silver bullet. But there is good reason to believe that bans such as New York City’s are a bold step in the right direction. Soda is the single greatest source of added sugar in the American diet and consumption has tripled since the 1970s. Adolescents today consume up to 15 percent of their calories everyday from sugary beverages and fruit juices. And liquid calories seem to be processed differently from those in solid foods so people don’t feel as full after drinking calories as they do after eating them.

But the true value of a large soda ban is not in limiting the number of nutrition-less calories Americans gulp down at movie theaters and fast-food joints. After all, people are not restricted to buying just one soda – if you want to buy two (or three or four) sodas, that’s your prerogative. Heck, stick a straw in a 2-Liter and be on your merry way. No, the ban’s true significance comes from thrusting the issue of portion sizes squarely into the public consciousness. It comes from forcing individuals to make active choices to consume more, rather than reflexively accepting stealthily and steadily swelling dimensions of food and drink. It comes from taking the first step toward resetting our cultural defaults.

The portion size of almost everything has increased over the past several decades. With profit margins of up to 90% on products like sugary beverages, it’s not hard to see why. The result is that we find ourselves in a food environment that strongly encourages vast overconsumption of unhealthy foods.

This overconsumption has serious consequences – both for the health of our population and the health of our medical system. Obesity-related diseases cost the healthcare system an estimated $147 billion every year, and account for about 10 percent of all medical costs. Obese individuals spend 42% more on healthcare than do people in a normal weight range. Massachusetts recently sent a strong message about controlling medical costs with its first-in-the-nation health-spending cap, which seeks to limit overall health spending so it grows no faster than the state economy. But this cap must be accompanied by a larger conversation about obesity and disease prevention if it’s going to be effective. We can’t cap our massive spending until we start capping our massive sodas.

Psychological Safety - Why "Asheville" Works

Over the last few months, I have reflected at length about my experience as a medical student in the "integrated clerkship" or "Asheville" model. For those of you new to this concept, the idea is that medical students in their 3rd year learn the basics of clinical medicine in a radically different format from the norm. In the "traditional" model, student-doctors rotate through different fields of medicine in "blocks." For example, they may spend 8 full weeks in Internal Medicine, 8 weeks in Surgery, 4 weeks in Neurology, 4 weeks in Family Medicine, etc. Students get a taste of each of these core clerkships to help them decide which specialty they will pursue. In this curriculum, students often work with many different "attending" physicians (docs at the top of the hierarchy), fellows, residents, interns, and other medical students as they rotate through their clerkships.

The Asheville model transforms the way medicine is taught to budding clinicians. Instead of block scheduling, students do all their clerkships at the same time. They generally work in the outpatient (out-of-hospital) setting, one-on-one with the same attending physicians for an entire year. This may mean working half-days in each clinic; for example, Monday mornings in Family Medicine, Monday afternoons in Neurology, Tuesday mornings in Pediatrics, etc. Space is blocked off to see certain "longitudinal" patients in the hospital and in other clinics. These patients are seen many times throughout the year, and provide an opportunity for the student to become truly invested in the health care of other human beings over an entire year. Students generally begin their year with a few weeks in the hospital in order to garner "inpatient" experience.

Some believe this model of teaching offers a better environment in which to learn, because it humanizes medicine with intimate patient contact. I certainly felt this was the case. My experience was very different from that of my colleagues in the traditional model. Instead of me watching the intern watch the residents watch the fellows watch the attending in action, I was partnered with my attending physician, not as an equal, but as someone who was expected to perform in tandem at a high level. Such a close relationship can be daunting at first, but over time the sense of team is palpable. Attending - Student - Patient. Published data now exists (as well as yet-to-be-published data) suggesting that this type of learning is extremely positive for both students and faculty.

But, why?

I have often pondered this question. Why did I feel so invested in my patients, and why did I feel like I was really part of a team? How did these close relationships with attendings affect how I learned? I am starting to find some answers whilst studying leadership. One idea that has caught my attention is Dr. Amy Edmonson's concept of "psychological safety," and how it affects learning environments in teams.

Roughly, psychological safety "describes individuals' perceptions regarding the consequences of interpersonal risks in their work environment." Team members often worry they will be thought of as ignorant or incompetent if they speak up or make mistakes (e.g., the medical student who asks a "dumb" question may get a lower grade). In a psychologically safe environment, however, asking for help is encouraged, and reporting mistakes is a way to learn, not a route to punishment. Here, mistakes lead to learning and speaking up leads to innovation. Institutions that have psychologically safe environments succeed. In hospitals, this can mean the difference between a nurse who thinks a medication dose is inappropriate, but administers it anyway for fear of being wrong, and one who double-checks with the physician to make sure the dose is correct. Medical errors are unfortunately all too common, and patients often find themselves at the mercy of these mistakes.

Dr. Edmonson breaks down work environments into four different "zones," each with different characteristics based on levels of psychological safety and accountability.

• Low Psychological Safety + Low Accountability = Apathy Zone
• High Psychological Safety + Low Accountability = Comfort Zone
• Low Psychological Safety + High Accountability = Anxiety Zone
• High Psychological Safety + High Accountability = Learning Zone

The second I saw this table in her book, Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy, a light bulb went on in my head. Third year medical students fit very well into these categories. Most medical students would undoubtedly perceive their environment as high accountability. Thus, they would find themselves either in the Anxiety Zone or Learning Zone (or some may find themselves in the Apathy Zone during a particularly awful rotation), depending upon whether their environment is one of high or low psychological safety. To maximize clinical education, one would hope that students find themselves in the Learning Zone environment with high psychological safety, as this should be the most effective teaching environment.

As a student of the integrated model, I cannot speak too much to traditional learning and its level of psychological safety; however, the hierarchical structure of the traditional medical team model has had some difficulties in this area (and its shortcomings are well-documented). I can, though, attest to why the integrated model helps students find themselves in the Learning Zone. I think there are three reasons why this model promotes a psychologically safe environment: 1) medical students work with the same attending throughout their clerkship, 2) students work with that attending for an entire year instead of just a few weeks, and 3) students often find themselves one-on-one with these attendings, providing numerous opportunities to build strong relationships and a sense of "team." This relationship for some may start out in Anxiety Zone, but it often quickly moves to a psychologically safe environment as the two parties become more comfortable with one another.

As an example, one of my favorite clerkships last year was Family Medicine. It was a clerkship I enjoyed, and in which I excelled. Every Monday morning I worked in this clinic from 8am to 12pm, first seeing a patient by myself, then again in conjunction with my attending. Right off the bat, every mistake became a learning opportunity or a "teaching point." Expectations were clear. I was a third year medical student so mistakes were anticipated. But, I was expected to learn from my mistakes and get better (high accountability). From a grading perspective, I didn't worry about "messing up." If I was unsure whether I heard a heart murmur or "crackles" in the lungs, I told my attending. I knew I would have many opportunities during the year to listen to hearts, and my grade wouldn't be affected by asking questions. I wasn't worried about being seen as "ignorant" or "incompetent" (high psychological safety). Looking back, I spent all my time in the Learning Zone.

I suspect there are many reasons why the integrated clerkship model is such a successful learning experience, and I don't believe creating an environment of psychological safety is a panacea for improving medical education across the board. I do have a sneaky suspicion, though, that fostering a Learning Zone environment would go a very long way toward that goal. I hope to study this concept further, both in medical education and in Surgery. I would be interested in your thoughts and comments.

References

• Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.
• Edmonson, Amy. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. Jossey-Bass, 2012.

Really Really Missing Medicine

As the year has progressed, I am reminded daily why I went to medical school: I miss taking care of people. While I have enjoyed aspects of taking a year off to study public policy, there are many times when I agonize about not seeing patients and having all the knowledge I built up over the past three years slowly slip away. Some of my colleagues are starting to interview for residency slots, and all my closest friends stayed in North Carolina this year. With Thanksgiving around the corner, I have been trying to keep everything in perspective. Every time this "gap" year starts to get me down, I try to remind myself how fortunate I am to be in school, to be a future doctor, and be bestowed such wonderful opportunities. But in truth, it has been a difficult year.

The year has been much like my gap year after undergrad. There are many parallels. Although I was not writing about my journey via social media, I was journaling frequently. That "super-senior" year came with an identity crisis. I could no longer define myself as a swimmer or a student, but I didn't have a vocation either. I was working at Starbucks, while my friends had moved on to graduate schools and investment banking. I was questioning who I was and where was I going. I learned that what I thought was hard-work was going to be barely passing if I wanted to be a doctor, and I had to take a crash course in honesty. In reflection, I don't look fondly upon that year, but I do understand its importance for personal growth. I learned a lot about myself, and I realized I had a lot of growing up to do.

This year has been similar. I thought taking time off to study public policy and leadership would answer many of my questions; instead it has engendered even more. I am currently reading a book called True North by Bill George, former CEO of MedTronic and professor at the Harvard Business School. In the introduction, he lays out what he believes should be one of the most important questions any leader must ask himself or herself, "What is the purpose of my leadership?" It is this question that I have struggled with all year. There are many things I am passionate about, and numerous fields I could see myself delving deep into. I love the ethics of health care. I love leadership in medicine. I have found writing cathartic. I have relished my time in rural care, as well as pediatric surgery. I like certain types of research, but I can't stand the bureaucracy. As one of my friends in school recently quipped, "It sounds like you love academics, but hate academia." Perhaps there is some truth to that statement. I feel like I have so many passions that are pulling me in different directions, I just don't know where to begin.

And I feel like I'm ready to take the reigns on a passion and run with it.

The question of whether I see myself as part of the academic world is an interesting one. As one of my former mentors recently told me, "My dad's an academic, my mother's an academic, and my sister's an academic. Every time I question why I don't live in that world, I just spend an afternoon with them and I am easily reminded." Throughout my short medical career I have very much understood that sentiment. But at the same time I have realized that do some of the things I want to do in medicine, I may need that support structure. It is exhausting to think about sometimes, and I need to do a better job living in the present, not the future.

Later in True North, Bill George reminds the reader, "The hardest person you will ever have to lead is yourself." At all points in our careers, this remains true. However, I am finding that now this is particularly apt. Perhaps that path will become clearer in the next few years...

A Case for Rural Care

(this was a piece that I wrote that was accepted to the Bulletin of the American College of Surgeons; I will post a link here when it is published)

The CLASS Act and Long-Term Care

TO: Senator Kay Hagan (D-NC)
FROM: Robert Swendiman, MD MPP
DATE: October 26, 2012
RE: Demise of the Community Living Assistance Services and Supports (CLASS) Act

The CLASS Act program was an effort within the Affordable Care Act (ACA) to address the rising costs of long term care (LTC) for seniors and young workers with disabilities. Ultimately, the Obama Administration halted its implementation due to concerns regarding its fiscal sustainability. Unfortunately, in this political climate, new federal efforts to address LTC spending are likely to meet a similar end.

Financing Long-Term Care. As the cost of long-term medical care rises, both for public programs and individuals, lawmakers have sought ways to alleviate this financial burden. Medicaid now finances over 60% of this $208 billion annual price tag, and individuals pay about one-fifth of costs out-of-pocket. Approximately two-thirds of seniors will need some type of LTC in their lifetime, with services ranging from intermittent care in one’s private residence, to full-time observation in a nursing home or skilled facility. Given that fewer than 10% of all individuals 55 and older have private insurance policies for LTC, the CLASS Act was meant to serve as a voluntary, national insurance program that could attend to this growing financial risk.

With the goal of ensuring financial and personal independence for those with functional limitations in their daily activities, the CLASS program would offer all working individuals 18 and older the opportunity to purchase the LTC insurance, given a minimum yearly income of $1,200. Enrollees could collect a minimum of $50 as a daily benefit for LTC, which is about one-third the average daily benefit provided by similar insurance programs today. Premiums would be set based on 75-year cost projections to ensure solvency, and advocacy/counseling services would be established to aid individuals in LTC decision-making.

CLASS Program Limitations and its Demise. Due to a five-year vesting period, Congressional Budget Office (CBO) and the Centers for Medicare and Medicaid Services estimated that initial 10-year deficit savings would be $70 billion and $38 billion, respectively, though this trend would reverse in the ensuing years. However, the program’s sustainability was ultimately called into question, mainly due to the guarantee issue requirement and voluntary nature of the program. The concern was that patients who most needed the benefits would opt-in, and healthier patients would opt-out, also known as “adverse selection.” This, combined with the perceived modest benefit of the program, led the Secretary of Health and Human Services to send a letter to Congress, stating that the Administration did not see a viable path forward for implementation of the CLASS program at this time, and that implementation efforts would be halted.

“Fixing” CLASS. Thus, in addressing the question of paying for LTC through a federal program, the flaws that buried the CLASS program would have to be addressed:

• Adverse Selection – It is vital to the program that those with pre-existing medical conditions are included, but is it possible to ensure that enough young and healthy individuals enroll to spread the risk? While some have suggested a universal mandate to purchase LTC insurance, this produces obvious political challenges.
• Incentivizing Enrollment – Designing the program to require employees to “opt-out” would increase enrollment, but how would employers be incentivized to purchase this insurance? Without employer buy-in enrollment would remain low, as CBO already projects, estimating a 3% national participation rate.
• Financing and Modest Benefits – The Secretary estimated that monthly premiums would rise to just under $400 a month, a figure that is unaffordable, especially given such a meager daily benefit ($50).

There have been a number of small tweaks proffered in order to revive the CLASS program, though implementation would be extremely difficult given the current political climate. Despite the President’s reelection, 51% of Americans still desire repeal of the ACA, with the individual mandate remaining exceedingly controversial. A mandate for LTC insurance has been proposed to account for adverse selection, but cost and popularity would likely hinder enactment. The income requirement could be raised to $12,000 in order to lower premiums; however, this would likely exclude many of the working-disabled, a key demographic target of the CLASS program, thus limiting access. The daily payout could be increased, while the duration of eligible benefits limited, but this poses similar concerns. Without a mandate, CLASS is unlikely to seriously address the LTC issues this country faces.

Next Steps. Given barriers to implementing a program like CLASS, one must seek other viable options to improve access to LTC. Two such solutions to consider would be 1) creating a private insurance market for LTC under the Medicare program, much like Medicare Part D for prescription drug coverage. This again would be a voluntary system, but one that could potentially obtain more visibility and better buy-in, especially with seniors. 2) Allow individuals to use a small portion of their Social Security benefits to purchase LTC insurance in the private market. Coupling LTC insurance with Social Security may allow better planning for future health needs. However, cost and access remain unknown considerations in both of these proposals.


References

• U.S. Congressional Research Service. Community Living Assistance Services and Supports Provisions in the Patient Protection and Affordable Care Act (R40842; February 15, 2012), by Janemarie Mulvey and Kristen J. Colello. Text in: LexisNexis® Congressional Research Digital Collection. Accessed: November 5, 2012.
• H. Stephen Kaye, Charlene Harrington, and Michell P. LaPlante. Long-Term Care: Who Gets It, Who Provides It, Who Pays, and How Much? Health Affairs, 29, no.1 (2010):11-21.
• Terence Ng, Charlene Harrington, and Martin Kitchener. Medicare and Medicaid In Long-Term Care. Health Affairs, no. 1 (2010):22-28.
• Howard Gleckman. Requiem for the CLASS Act. Health Affairs, 30, no. 12 (2011):2231-4.

Lifting Weights 101 - Get It Together, Harvard

I'm taking up a new cause. I've decided to petition all the schools here at Harvard to require "Lifting Weights 101: How to not look like a weightlifting virgin." Inspired by the upcoming election, I have decided to make phone calls, canvass local businesses, yell and scream in the Quad, and run my own TV ads. The amount of idiocy and general douchebaggery in the weight rooms here has been absolutely atrocious. First of all, the student gyms here are abysmally tiny (of course no one knows about the Business school gym - us "normies" aren't allowed). Sure, there are 100 ellipticals lining the walls, but if you can work out your Differential Equations homework while "faux-running," you aren't working out. Where are the squat racks? Why do I have to weight an hour to bench press (pun intended)?! I would love to say that I'm going to raise enough money to build new facilities here, but I can't. However, in the meantime I will require all undergrads and graduate students to learn a few basic lessons about gym etiquette.

Here are the Top 10 lessons Harvard students should take away. People who lift at the law school gym and the MAC, this is for you:

1. The weights should be EQUAL on BOTH SIDES of the bar. I'm leading with a very crucial learning point here, so pay attention. I recently watched someone bench pressing (if you can call it that) with a 35 lbs. plate on one side, and a five and a 25 lbs. plate on the other. 35 does not equal 30, people. Where do I start with how piss poor this is? First of all, it immediately proves that Harvard is not accepting the "best and brightest." Admissions committees here must be sure to screen out such individuals, perhaps on the campus tour through the gym facilities (as Kelly knows, I use lifting knowledge as part of my screening test for women... Harvard could learning something from this). Anything less is a disgrace to the institution. Furthermore, be advised that a 45 plate on one side, and a 25, 10, and a 10 on the other is ALSO NOT THE SAME! PUT EQUAL WEIGHTS ON BOTH SIDES. Goodness gracious.
2. Don't wear a hat on the premises. You look like a douche.
3. Rack your daggum weights! Okay, I shouldn't have to spend half my time scouting machines and racks that aren't in use. You put weights on when you start, then you take them off when you're done. If you just leave them there, other people think you are still doing that exercise. Don't be that guy (or girl). Rack 'em and stack 'em, like Willie. No one wants to be the one who has to take off your two and a halves from the bar. It's just annoying.
4. Couples lifting is sketchy at best; holding hands makes patrons vomit. Working out is sacred time. Throw on your music, get lean, and get mean. The gym is not a movie theater, a hotel room, or the back of a Chevy, i.e. no hanky-panky. Twice I have spotted couples canoodling (sp?) between sets, and that is not okay. And, "I don't use tongue" is not an excuse. If I have to say this again, someone is getting slapped.
5. Headbands are for people who can pro-bench ONLY. If you don't know what pro-benching is, don't even think about throwing on your LeBron band. At the NFL Scouting Combine, they have the athletes see how many times they can bench 225 lbs. That's the bar with two 45 lbs. plates on either side. If you can't lift this (let along a 45 lbs. plate by itself), again, please don't try to make any fashion statements.
6. You don't need anything to make the bar "softer" when you squat. No towels, no other contraptions. Squatting with the bar on your shoulders doesn't hurt. If it does, you either squat with Ray Lewis weight or (more likely) you just need to suck it up.
7. I'm 6'5'' 200 lbs., I SHOULD NOT LOOK LIKE A WEIGHTLIFTING GOD. At Carolina, I'm puny. At Harvard, I'm Arnold Schwarzenegger. Milk is for babies. When you grow up, you have to drink beer. Just saying that I shouldn't be the one writing this blog.
8. Don't ever tell me you don't know how to "spot." I know you have your iPhone on you, because God forbid you would miss a journal publication whilst working out. Ask Siri what it means to "spot."
9. Never lift in a button-down dress shirt. Really?! #PaulRyanWearsUnderArmor #SoShouldYou
10. If you don't know what you are doing, hire a personal trainer. There's an awesome dude whom I see all the time in the weight room who looks like Leonard from the Big Bang Theory. He doesn't know what he's doing, but instead of making the many egregious mistakes above, he is using the available athletic trainers to help him beef up and win over the lady-folk. Every time I see him, it brings tears of joy to my eyes. This is the kind of common sense that is needed in these dark times.

Heed my wrath. Now go and prosper.

Early Liver Transplantation in Acute Alcoholic Hepatitis

More than 16,000 Americans are waiting for a liver transplant, according to federal data from the Organ Procurement and Transplant Network. Only 6,000 organs are available a year and nearly 2,000 people will die waiting for one to become available. Should an alcoholic who is likely to die from liver cirrhosis in the immediate future be allowed an early transplant (i.e. prior to the required six months of abstinence), if she is commits to abstinence from alcohol and has family support to help keep her promise, even as thousands of others who have not abused their bodies with alcohol or drugs await a new liver?

We first must agree that there are circumstances in which human beings deserve a second chance. Mistakes are made, and we ought to have the opportunity to learn from them. If the mistake is egregious enough, we, as a society, invoke laws requiring restitution and punishment. When found guilty in a court of law, a criminal may pay a fine, provide community service, or spend time in prison (or sometimes a combination of all three). Only then can the person return to society as a free citizen. A former criminal may also be subject to a period of probation, during which the individual must prove she can adhere to the rules of society without recidivism.

There are also circumstances in which society determines that a criminal does not deserve a second chance to be a free citizen. In these cases, the criminal may be banished from society permanently, sentenced to prison for life or put to death. These offenses almost always involve intense violation of someone else’s bodily integrity, not one’s own. Applying this dichotomy, if one views alcoholism as a “crime” that involves “fault,” it is certainly not worthy of complete condemnation; alcoholics deserve a second chance.

Sometimes, that second chance at life is a liver transplant. If so, should all alcoholics not abide by some form of "penance," i.e., evidence of abstinence from alcohol, in order to be eligible for a transplant? In fact, the United States transplant system already includes this requirement. Patients must abstain for at least six months before they can receive a new liver. These six months are the required justification to become a "free citizen" again, and be accorded the same rights as other persons to "life, liberty, and the pursuit of happiness." Some will argue that despite this six month penance, despite the probation, reformed alcoholics still deserve to be treated as second class citizens in terms of priority for liver transplantation. It is their fault, so they should wait behind those who have not ravaged their bodies with alcohol.

While this argument may “comport with basic intuitions about fairness” (Wikler, 110), society generally discards the notion that personal fault should play a role in medical treatment. The medical community, in particular, has rejected this idea of “priority” based on fault entirely, believing that all patients deserve medical treatment regardless of whether or not they may have caused their own illness. Imagine an Emergency Room where physicians prioritize patient care in terms of “fault” instead of “need.” A doctor would be obligated to treat a patient with warts before an individual who is bleeding to death from a skiing accident. While the latter person had arguably knowingly engaged in a dangerous sport, can a lack of immediate treatment truly be justified? Few would argue so.

Some scholars also argue that social injustices account for many health injustices, and thus society cannot be completely exculpated. Daniel Wikler presents this view eloquently in Personal and Social Responsibility for Health, and it is worth noting that the belief that alcoholics are completely at fault for their illness is shaky at best. There are too many genetic and societal factors that contribute to this disease. Without a clear concept of “fault,” it follows that “need” is the only justifiable means of priority, despite limited resources.

Unfortunately with liver disease, sometimes six months of abstinence is a death sentence in itself. Patients with severe alcoholic hepatitis may deteriorate over days and weeks, not months. So if we agree that these patients are morally justified in obtaining a new liver after six months of abstinence, what of their dire prognosis? I believe there are two requirements for providing a new liver without strict adherence to the six month rule. The first deals with “intent.” The patient must state her intention to become or remain abstinent. If the opposite were true, the patient would never actually have completed the required penance in the first place. Therefore, a new liver would not have been transplanted, and would not be justified.

I would further argue that this patient population (those who are alcoholics, have less than six months to live, and swear abstinence) should be studied in terms of rates of recidivism. If 100% of these patients typically fall back into alcoholism post-surgery, then one could argue that early transplantation is not morally justified. However, if patients who meet these criteria are found to have similar rates of recidivism to those who were able to abstain for six months, there is no question that early transplantation would be moral justifiable. There is current evidence to support this argument. Thus, with the caveats of “intent” and that it would be prudent to study the population at hand, our patient with acute alcoholic hepatitis deserves a new liver.


References

• Wikler, Daniel. “Personal and Social Responsibility for Health.” Public Health, Ethics, and Equity. Eds: Sudhir Anand, Fabienne Peter, Amartya Sen. New York: Oxford University Press, 2004. 109-134.
• Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365(19):1790-800.
• Brown RS Jr. Transplantation for alcoholic hepatitis—time to rethink the 6-month “rule.” N Engl J Med. 2011; 365(19):1836-8.

Story of Self

Tonight at our leadership workshop I was asked, "Why are you here?" It's the theme of this year, repeated over and over, because it is so easy to forget. I could get lost studying statistics and economics, going out in the city, and doing what some people refer to as "the n-word" (aka "networking" - the dirty word you should never use when talking about what you are doing here at Harvard...). But tonight I was pushed further. It is not enough to say, "I am here to learn how I can be an effective public servant. I'm here to learn, and I'm here to lead." Well, why? Why do you want to be a public servant? And why do you want to lead? In response, I often refer to the quote that I leave at the bottom of my emails:

The moral test of government is how it treats its people in the dawn of life, the children, in the twilight of life, the aged, and in the shadows of life, the sick the needy and the handicapped.

Is that not enough? Can't I tell you story after story about patients I've met and how they have affected how I view the world? It's not. It's not because I could've had these experiences, developed these relationships, viewed the world differently, and still not thought that we need to do more. Still not thought that policy changes can be made for the greater good, and I have a responsibility to be part of that change. So again, I am asked, why am I here? Why did I go to medical school, and why am I interested in public service?

After I got home, the first thing I did was call my parents. I needed a debrief. Why am I here?! Someone please tell me a story from my childhood that in some way embodies the values that I believe in today. Where was my life changed? As my parents sit on speakerphone listening to me babble and push back, I keep thinking that I don't have a story. I didn't grow up in poverty, work my way out, and feel like I needed to go back and make a difference in my community. I didn't struggle most of my life with being gay, growing up in a society that doesn't accept me for who I am. I didn't have to learn English as a second language. I'm a white male from the suburbs who went to a high school with a golf course on campus.

I got off the phone with my parents and looked at the screen. We talked for over 43 minutes. My first thought was, "Those are the only two people in the world who would drop everything and listen to my quarter-life crisis." My grandmother would as well, but unfortunately she is no longer with us. And as I was thinking about these three individuals, what they have (and would) sacrifice for me, I realized I had a story.

When I was 17 years old, I had an opportunity that I wish every child could have as well. During a high school retreat, I received a packet of letters. These letters were from the people who cared about me in my life. Some were from friends and mentors, some from distant relatives, but there were a few that meant much more. A few letters that still bring tears to my eyes, even just thinking about them. Three letters in particular, all of which have had a lasting impact.

Tonight I reread those letters. It has been a number of years since I have gone back and poured over them, but I always remember the kindness, love, and hope they embody. Much in these letters is private, but there are a few quotes that I do want to share. So again I ask myself...

Why am I here? My mother writes, "We hope in our hearts that you will come to know certain things when you become a man: that you will know in order to gain respect from others, you must give them respect; that you will realize it is not whether you control others that matters, but whether they choose to follow your leadership... that you know all the money in the world can never buy back your good name if you have disgraced it; and that you will understand you can expect many people to treat you worse than you treat them, but you can never expect anyone to treat you better than you treat them."

Why am I here? My father writes, "Now we wish we could prepare the world for you, but we can't, so we have to prepare you for the world. We want to provide you with the tools you will need to cope with the challenges of the fast-paced, demanding, and all too amoral world waiting for you. When you think about it, your appearance came near the end of a century that saw immeasurable evil and cruelty. It was a century that ended any illusion that there is a limit to the atrocities of which human beings are capable. But that wasn't your century; your century is that of the twenty-first... To your generation comes the burden of the past, but also in your generation lies the hope of the future. And the future will depend in large measure on the character of the men and women growing up now, as you are."

Why am I here? My grandmother writes on a theme that I will never forget. It is the one quote in life that I will hold with me until I die. I can literally hear her words, both spoken and written. "Rob, with great power comes great responsibility. 'To whom much is given, of him much shall be required' - Luke 12:48."

There is so much more I could share, and in so many ways I have failed these letters. But I, like my parents, haven't given up hope. So what is my story? My story is built on the values my parents taught me. They are the values that are at the core of the passages above. Hope. Love. Respect. Sacrifice. Courage. There are many ideologies in this world, but when I see patients who are disabled, poor, marginalized, or silenced in a world that does not allow them to speak, for me I hear their story. How I intertwine my story into their narrative is with the values that my family have tried to instill in me.

My story is to hope. To hope that our generation can overcome the poverty and hate that holds humankind back. My story is to love. To love every person like they are my mother, my father, my grandmother. My story is to respect. To respect those without a voice, and to be their voice when the time comes. My story must be to sacrifice. To sacrifice my time and energy for something greater than myself. My story is to have courage. The courage to accept the things I cannot change, change the things I can, and the wisdom to know the difference.

That is my story. That is why I am here.

Understanding the Ryan Medicare Plan

TO: Senator Richard Burr (R-NC)
FROM: Robert Swendiman, MD MPP
DATE: September 28, 2012
RE: The Path to Prosperity Plan

While your joint proposal with Senator Coburn (R-OK) and Representative Ryan’s “Path to Prosperity” are both constructed around the concept of premium support for Medicare beneficiaries, there are key differences that warrant your consideration. Rep. Ryan’s plan places hard limits on future Medicare expenditures, by means of fixed annual caps on spending, which may expose seniors to higher out-of-pocket medical bills over time. The Path to Prosperity also raises the age of Medicare eligibility gradually over the next two decades. These effects should be weighed carefully in light of financial risk to current and future Medicare enrollees.

Cost Containment. Rep. Ryan's plan allows private insurance companies to compete with traditional fee-for-service (FFS) Medicare, mitigating cost growth through competition. The Path to Prosperity also establishes a new “Medicare Exchange,” overseen by the Centers for Medicare and Medicaid Services, where seniors can choose among a range of insurance plans (with traditional Medicare included as a choice). In the Exchange, the second lowest bid will determine the exact amount of federal premium support to individuals, estimated at about $7,500 per person in 2023. All plans must offer actuarially equivalent benefits to traditional FFS Medicare, though it is important to note that these benefits will not necessarily be the same. Individuals who choose higher cost plans will have to pay the difference in premiums, and those who pick the lowest cost option will receive a rebate.

In contrast to your proposal, the Seniors’ Choice Act, Rep. Ryan would limit the annual per capita premium support to match growth of nominal (adjusted for inflation) GDP plus 0.5%. If premiums rise faster than this rate, seniors will have to cover the excess expenses out-of-pocket (with some adjustment for income). This lower cap contributed to the loss of the bipartisan support of Senator Ron Wyden (D-OR), because it shifts more costs to seniors in the future. He had originally cosponsored a similar plan with Rep. Ryan, employing a 1% cap. In March, the Congressional Budget Office (CBO) evaluated Rep. Ryan's proposal against current predictions of Medicare spending. Using its “extended alternative fiscal scenario,” which more accurately predicts the political climate than an evaluation with no changes in current law, CBO estimated that traditional Medicare expenditures would increase from 3.25% of GDP today to 7.25% by 2050. In comparison, Rep. Ryan’s proposal would cut 2050 spending projections by a third, with Medicare representing only 4.75% of GDP.

With passage of the Affordable Care Act (ACA) in 2010, the Medicare Board of Trustees estimated an extension of the Medicare Trust Fund’s solvency from 2016 to 2024. Repeal of ACA, as proposed by Rep. Ryan, would reverse these dates; however, his plan would provide significant long term savings, and few believe Medicare would ever be allowed to “go broke” in the short run.

Financial Risk to Seniors. The primary concern with these hard caps on federal subsidies is that premiums will rise faster than nominal GDP plus 0.5%. Over the past few decades, the annual cost of health insurance per capita has risen approximately 2% per year faster than GDP growth. While competition within the Exchange and incentives for diminished utilization would help private plans lower costs, CBO in 2011 predicted that this scheme would still raise out-of-pocket costs for seniors over time. This is true for two reasons: first, private insurance plans have higher administrative costs and provider payment rates compared to traditional Medicare; and second, the federal premium support will grow proportionally smaller as medical inflation continues to surge.

CBO admits that its predictions contain significant uncertainties, and partisanship has steered the rhetoric concerning the merits and limitations of this approach. However, one thing is clear: with rapidly rising costs, along with fiscal uncertainties that surround the health care industry in general, the potential risk of cost-shifting medical expenses to seniors is real. This hard limit on spending is the fundamental difference between your Seniors’ Choice Act and Rep. Ryan’s Path to Prosperity.

Access to Care. Both your proposal and Rep. Ryan's plan would increase the Medicare eligibility age to 67, although the latter takes a more gradual approach. Medicare beneficiaries who are eligible prior to 2023 would remain in traditional FFS Medicare. Starting that year, the Medicare eligibility age would increase by two months each year until it reaches age 67 in 2034. CBO analysis projects that raising the Medicare age would cut total Medical spending in 2035 from five percent of GDP to 4.7%, a net savings of about $150 billion. However, many unemployed seniors would bear the cost of insurance themselves in those last two years, likely finding themselves either paying for expensive plans in the individual insurance market, or uninsured.

The Bottom Line. Like many current proposals, Rep. Ryan’s plan does little to change the underlying drivers of rising costs in the health care industry. The Path to Prosperity does, however, have a very strong emphasis on reducing federal Medicare expenditures, though it appears to expose seniors to more out-of-pocket costs in the future. These issues should be considered simultaneously when weighing support for this plan.

Breaking Down the New York Soda Ban

In my Ethics and Political Philosophy class, I had the opportunity to contemplate the following prompt... Recently, New York City made international headlines by banning sodas and other sugary drinks larger than 16 oz. from being sold in restaurants, on the street, etc. Can this sort of paternalism be justified in terms of political morality? Take a stand and defend it.

While pundits debate whether the now famous “soda ban” will improve the general health of the New York City citizenry, the merits of this law are defensible without employing arguments regarding social harm. With over a third of Americans categorized as obese, this legislation encourages residents to make health-conscious decisions regarding their diet (albeit in an unapologetic fashion). However, for this clear example of state paternalism to be justified, it must satisfy several conditions: the choice must be inherently “irrational;” there must be a demonstrated lack of information present; true choice must not be limited; and the state’s restriction must prevent serious and irrevocable harm.

We must first agree that choosing to become morbidly obese would be irrational. This is by no means an argument of aesthetics, but rather one of self-preservation. Research has proven that obesity is directly linked to high blood pressure, diabetes, heart disease, etc., and most Americans do not find these debilitating conditions desirable. These diseases are extremely costly, and they severely impair an individual’s quality of life. Excessive consumption of high-caloric beverages is a major contributor to the obesity crisis. Soda is not the only form of “empty calories,” but it is an obvious target for improving public health. As a physician in training, I was taught numerous ways of counseling patients about weight loss. First trick of the trade? Eliminate “liquid sugar,” which patients can do without changing the foods they eat. The proof? An extra-large Coca Cola from McDonalds is about one fifth of a person’s recommended daily caloric intake.

Some say, “Everyone knows sodas are bad for you.” I would suggest that advocates of this statement spend a few days in a family doctor’s office, where they will see just how wrong this assertion is. There is much confusion about how diet can affect our health, and even more denial about seemingly straightforward scientific data. But there are also structural reasons for the lack of good information about healthy choices. In the present case, the “default” size of sugary drink options at fast food chains is often 20 ounces. This is promoted as “normal,” and generally there are no choices smaller in the value meal. Such a marketing strategy immediately biases the consumer towards making an irrational decision; a “normal” person does not need over 200 calories in a drink at each meal (in the 1950s, the only drink size McDonalds offered was 7 ounces… have our bodily needs changed that much?!). While the soda ban does add a new limitation, consumers were already limited by their default options. Under the new soda ban law, consumers will have to make an active choice to opt out of the healthier option, back to the unhealthy, former status quo.

Yet, even if excessive consumption is irrational, and even if consumers have all the information needed to make an educated decision, isn’t how much soda I drink still my choice? Absolutely, and it is imperative to understand that consumers’ fundamental choices have not changed. At establishments affected by the soda ban, a citizen who wishes to drink 40 ounces of soda will still be able to purchase 40 ounces of soda (by purchasing two 20 ounce drinks). True, the transactional cost may rise, but choice has not been limited; the purchaser’s options have simply changed. In addition, large sodas will still be sold in grocery stores, vending machines, and at any institution that does not receive a health grade. Dairy drinks, fruit drinks, and alcoholic beverages will be, for all intents and purposes, spared. And the size of “diet” drinks will not be regulated in any capacity.

Some argue this legislation will not curb obesity rates in New York City. However, whether or not the ban works does not affect the original justification. Others argue that this ban sets a dangerous precedent. If the size of soda cups should be regulated, why not the ban sale of any burger over half a pound? Or ban the purchase of more than a hundred French fries at a time? I understand this concern, but this argument misses the point of the New York City legislation. Our country needs to be having this conversation. Obesity is killing this nation, both financially (in terms of health costs) and literally. New York City is not banning the consumer from drinking 600 calories; the law simply empowers consumers to ask themselves, should I drink 600 calories? We can still answer an emphatic “Yes.” But so long as people choose irrationally, one can argue that public policy can and should foster positive and educated decision-making. This law is not a limit on personal freedom; it provides a forum in which Americans can make healthier choices. The soda ban does this while still tipping its hat to political morality.


(see conditions as described by Thompson in Political Ethics and Public Office and Thaler and Sunstein in Libertarian Paternalism is not an Oxymoron)

Guest Blogger - Dr. Stephen Buie

Dr. Stephen Buie is a Psychiatrist at the Pisgah Institute in Asheville, NC, who was invited to speak to this year's class of first year medical students at UNC during their White Coat Ceremony. He graduated from UNC-Chapel Hill undergrad, as well as the medical school, and now works as the Psychiatry clerkship director in Asheville for the longitudinal clerkship. He was my mentor last year, and will be my first "guest blogger." Enjoy!

When you see a white coat, what is your first thought? To you as a medical student you might think I can't wait 'til I get one of those! The white coat signifies reaching your goal to be a physician. A long white coat means that you have become faculty! Oh my! I'm not going to talk about what Freud would say about the long coat vs. the short coat.

When your patient sees a white coat, what is their first thought? It might cause enough anxiety to raise their blood pressure, causing the white coat syndrome. In my specialty, psychiatry, it is the men in the white coats who are coming to take you away!

So, why do physicians wear white coats? When I was asked to give this talk, it occurred to me that I had no idea where the white coats came from. As I first started reading about it, the answer appeared to be that doctors began wearing white laboratory coats to appear more scientific.

Doctors in the 1800s were struggling to establish credibility in the eyes of the public. There were not many effective treatments available and often the doctor's role was one of informing the patient and family what condition the patient suffered from and what the likely course of illness would be. They provided assistance when possible and comfort as they could, but many times they were limited in what they could do and sometimes their interventions made things even worse. But, as I read more about it, a much more interesting story emerged.

Until the late 1800s, physicians wore black clothing, which was pretty much what all the men wore in those days. They cared for their patients and performed surgery in the same type of clothes they wore out on the streets. Surgeons in those days wore dark surgical frock coats. A dirty surgical coat was seen as a sign of the surgeon's experience. They allowed blood and pus to accumulate on their clothing and would not wash or change coats day to day or from dissecting lab to operating theater. They thought the emission of pus from a wound was a good sign that the dead tissue was being carried out of the wound. The smell that accompanied their dirty frock coats was referred to as "that good old surgical smell."

On your program there is a painting by Thomas Eakins entitled The Gross Clinic with all the surgeons and students wearing dark clothes. Gross was not a description of how bad it smelled or even what the patient's mother is thinking over behind the surgeon as she sees her son operated on.

Rather, Samuel D. Gross was the name of the surgeon standing there, bloody scalpel in bare hand, holding forth to the operating theater full of students watching with rapt attention. Those are your professional forebears from 1875. Dr. Gross was the Chair of Surgery at the Jefferson Medical College in Philadelphia and one of the most eminent surgeons in this country. The patient had osteomyelitis of his femur. For the parents, that is a bacterial infection in his thigh bone and is very difficult to cure, even in these days of antibiotics.

In England, a quiet revolution had been under way for about ten years before this painting. A young surgeon named Joseph Lister read the writings of Louis Pasteur describing how bacteria cause putrefaction of wine and beer.

Lister had the realization that bacteria could also cause putrefaction in surgical wounds. He began using a solution of carbolic acid to sterilize his surgical equipment, to wash his hands prior to operating and even to spray on the wound itself. He studied the rates of postoperative infections and survival and published a series of five papers in Lancet from March to July of 1867. His fame spread and surgeons in Britain and Europe began adopting his techniques that saved lives and reduced post surgical infections.

His approach was not so widely accepted in the US. In fact, Dr. Gross invited Dr. Lister to come to the United States to lecture in order to refute his claims about the antiseptic technique.

Lister came to present at the International Medical Congress which was held in Philadelphia in 1876. The congress met as part of the Centennial Anniversary of the signing of the Declaration of Independence.

Lister came and gave a three hour discourse on his methods and outcomes. The American audience was not impressed. The president of the International Congress was quoted as saying, "Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called (antiseptic) treatment of Professor Lister."

There was one enterprising young man who attended that lecture and saw an opportunity. Robert Wood Johnson of the future company Johnson and Johnson decided to develop and mass produce sterile sponges and dressings and other surgical supplies based on what he heard Lister present that day. He later published a book titled Modern Methods of Antiseptic Wound Treatment which was the first handbook of sterile technique published in this county. Of course in the spirit of free enterprise there was a complete listing of Johnson and Johnson products in the back of the book.

The American surgical establishment persisted in their ways for the next several years until their beliefs were rocked by a national tragedy, the assassination of a president.

James Garfield was elected president in 1880. He was considered by many to be the finest orator of his age. He was a progressive man, advocating for the end of the patronage system in government and for the full equality of slaves freed by the civil war.

Only 4 months after he took office, the president was shot in the back by a delusional assassin. The bullet fractured the 11th and 12th ribs, fractured a vertebra without damaging the spine and came to rest deep inside the left side of his back.

Unfortunately for the President and for the nation, the surgical team who cared for him had not adopted Lister's antiseptic technique. Within an hour of the shot, they were probing the wound with unwashed fingers and silver probes trying to find the bullet to remove it. They introduced bacteria into the wound with every procedure. The President lived for 80 days after the shooting and finally died of overwhelming infection. Autopsy revealed multiple pus-filled cavities. The presiding surgeon, Willard Bliss, refused to accept the findings of the autopsy, insisting that the President died of a broken back. Several prominent physicians of the day believed that the medical care he received killed the president, rather than the gunshot wound.

The public outcry following Garfield's death gave new credence to young physicians who had been advocating for Lister's antiseptic technique. As part of this movement toward the antiseptic approach, surgeons began wearing white surgical garb. The second painting by Eakins, The Agnew Clinic, was painted in 1889, 14 years after The Gross Clinic. The distinguished gentleman to the left, Dr. Hayes Agnew, was a professor of surgery at the University of Pennsylvania. The sterile instruments are stored in a container you can see between Dr. Agnew and the surgical team. In an interesting twist of fate, Dr. Agnew was one of the surgeons assisting in the care of President Garfield after he was shot.

Following Garfield's death and the public outcry about his medical care the antiseptic technique became widely accepted. In 1888, Johnson and Johnson published Modern Methods of Antiseptic Wound Treatment, which helped revolutionize wound care in this country. Two authors of the book: Dr. Hayes Agnew and Samuel W. Gross, son of Samuel D. Gross of the Gross Clinic painting.

So, what do we learn from this brief history?

Lister's research bridged laboratory and clinical science. He took the findings from Pasteur's basic research and applied them in the surgical suite to the benefit of countless patients. His studies helped begin a more scientifically based era of medicine. As physicians developed more scientifically based treatments the white coat became a symbol of our profession. But we must keep in mind both the light and the dark sides of that symbol. The same drive for excellence that has led to you sitting here, beginning your medical school education, can lead to a false sense of knowing more than you really do. It can lead you to feel superior. It can lead to a mind closed to new information. Dr. Gross was one of the leading surgeons of his time and was responsible for many surgical innovations, but he was unable to see past his own beliefs about the truth and so was unable to accept Lister's findings. So, the first lesson is to remain humble in your knowledge. Remain truly a scientist, always willing to test your hypotheses and holding no truth to be sacred.

A second lesson is that science guides us, but does not rule us. Objectivity and reliance on science can be carried too far. Our randomized, double blinded, placebo controlled studies can't cover all of the situations you see in a clinical practice. You will always have to make judgments about the individual who is sitting in front of you. You have to be comfortable making decisions based on probability rather than certainty.

When we say the word antiseptic, what do we think of? For those of us in the medical profession, we think of cleanliness and decreased infection rates. In our general culture antiseptic also has the negative connotations of being sterile, unfeeling, cold, analytical, and aloof. We can become so enamored of our scientific knowledge; so focused on the mechanisms of disease that we lose sight of the human beings we are treating. So strong is the pull of scientific fact and desire for certainty that it is almost impossible for this not to happen.

Often, the emotional side of the work we do is painful and we retreat behind our white coats of scientific certainty. Patients are reduced to their medical conditions so you don't have to feel their suffering. You find yourself thinking of the MI in the heart tower or the ALS on neurology. So, we must act with science as our foundation, but remember that in its practice, medicine is an art.

Which leads me to the third lesson, which is about compassion. If you get to really know your patients as people, you will be have more compassion for them. If you think about how you would talk about one of your family members in the hospital, you would never refer to them by their diagnosis. It wouldn't even occur to you to do so.

I imagine that you are all compassionate individuals and that compassion was one of your motivations for entering medical school. But at this point, yours is an abstract, untested compassion. Patients sometimes are angry, frightened, drunk, high, belligerent, and physically aggressive. They may curse you, spit on you, walk out on you, throw up on you and perhaps worst of all, refuse to follow your recommendations.

Medical training is exhausting so you often have little emotional reserve yourself. Yet, you are expected to be friendly and caring at all times. In the worst cases we let our emotional reactions cloud our judgment and affect our care of those patients.

Sarcastic comments are made about the patient who came in to the emergency department with a suicide attempt or about the massively obese woman who is hypertensive and diabetic and who just won't lose weight. Or the opiate addict who comes in asking for pain medications.

As a student you will hear residents and attendings make humorous, sarcastic and sometimes cruel comments about patients. Every year at the beginning of the year we hear our third year students in Asheville talk with shock about how patients are talked about in rounds at the hospital. Now granted, they start the year on surgery and Ob-Gyn, so that biases the sample, but we all have talked that way at some point in our training or later when we are stressed or frustrated.

It is much better to channel your feelings into sarcasm than to let it effect your care, but I encourage you to see this as a phase you will go through but grow out of. You grow out of it by increasing your ability to feel compassion.

In my experience, compassion is perhaps one of the more difficult skills to learn. Some people are easy to feel compassion for, but feeling compassion for your difficult patients often does not come easily. I am convinced that compassion is a skill that can be developed along with the skills of taking a history and performing a physical exam or a mental status exam.

When you find yourself angry or resentful with a patient and wanting to make a sarcastic remark about someone, acknowledge that within yourself. Practice not saying anything about a patient that you wouldn't say straight to their face. Learn as much about them as you can within the limits of your time with them. One thing I've noticed among the senior teachers of the medical students is that they are much less likely to engage in this sort of banter. My experience is that after you get to know patients over several years and understand the reasons behind their behaviors you feel much less judgmental toward them. Once you have had that experience with a few hundred patients you reach a point where you are less judgmental even from the beginning of your relationship with a new patient.

So, when you put on your white coat, let it remind you to be humble in your knowledge; scientific but artful; and to be compassionate toward even your most difficult patients.

I wish all of you the best in moving forward with your careers in this wonderful, amazing profession that you have chosen and look forward to meeting some of you in Asheville in another couple of years.

Why Am I Here?

I have occasionally asked myself this very question over the past few weeks. Mostly, I need to ask myself this because my entire year here is about perspective. In what ways can medicine improve and how can other disciplines inform me to be part of that change? It is easy to get lost in the non-medical grind (ambling around a new city or studying for tests that seem to have little application to a patient’s gouty feet), but the classes and extracurricular activities here do relate back to medicine quite well. It’s just up to me to find those connections and run with them. So, for the fall semester, these are the core classes filling up my weekdays…

• MLD 101: Strategy, Structure, and Leadership. Easily one of my favorite courses, every Tuesday morning I enjoy a jambalaya of leadership development. The class is almost 100% case-based, with very little true lecture to get in the way of the practical application of topics. One day we practiced negotiating a deal to buy property from a national coffee chain threatening to block the ocean view of our “homely” Bed and Breakfast, and then this week we’re organizing T-shirt drives for the homeless.
• DPI 201: The Responsibilities of Public Action. An introduction to political philosophy, this course gives me the opportunity to reflect on how government and health care intermingle, and what the ethical implications of this relationship are. Most rewarding will be the writing I get to do throughout the course. I will be blogging here about the rights of government via paternalism in health care, whether or not health care is a “right,” and personal responsibility in patient care. Awesomely, our professor wants us to write our papers in the format of blog posts (can we say fate?), and the class will actually set up its own blog in the process. I will post all my arguments here (the first will be on the New York soda ban in a few weeks).
• API 201: Quantitative Analysis and Empirical Methods. Intro to statistics. If I didn’t love sensitivity and specificity as a second year med student, it’s time to start. This class will greatly enhance my ability to assess the medical literature and design research projects. Other than that, it’s just more math…
• API 101: Markets and Market Failure. This is a fancy-shmancy course title that really means I’m taking Econ 101… again. Given that I almost failed this class in college, I am here for redemption. As a second semester freshman in college, I showed up to the first class and the last class, and then took the final for 100% of my grade (results = poor). Mom and Dad, I am happy to report I have only missed ONE Economics class since the start of school, and that’s because I was at a conference in Chicago (finally a legitimate excuse). My only defense of my actions in college was that I thought the 9 o’clock start time infringed on my rights as an 18 year old. It did.
• SUP 500: Introduction to Health Policy. Fantastic course so far, taught by two health policy experts with a lot of DC clout. I’ll write three memos this year, and I’ll post them all. More to come on this course as it progresses. This is obviously the most applicable to my medical training.
• The Center of Public Leadership. With the Dubin Fellowship, every Wednesday night we sit amongst the other scholars to work on leadership development and personal growth. So far our experience has been unreal, and it has confirmed my decision to come to Kennedy. We’ve had public speaking workshops, speeches by eminent leaders in different fields, and of course, bacon-wrapped scallops, lobster, and corn-on-the-cob at David Gergen’s house on the Cape. This week I will be leading a medical ethics case conference for the Dubins, as each of us has an opportunity throughout the year to learn from each person’s life and area of interest (the case I will present actually was posted earlier on this blog - Ethics Committee). We also meditate once a month.

It has been a whirlwind tour so far, and additional extracurriculars will keep me busy. I look forward also to working as a member of the Advisory Council for Rural Surgery (through the American College of Surgeons) for my thesis work (more to come on that as well). I can tell already that the year will go by waaay too quickly.