The California Endowment

Last week, Dr. Anthony Iton, Senior VP of The California Endowment, told me I was "irrelevant." More specifically, he said that physicians alone could not alter worsening public health trends across our country without stepping outside the "I'm-only-going-to-treat-patients-and-do-research" box. Doctors can make a very big impact in the lives of individual patients, but we won't make a dent in the poor health statistics of  many U.S. communities unless we get at the root causes of these disparities (poverty, access to fresh produce and clean water, housing, community empowerment, etc.). Otherwise, physicians will continue to lose the war on health. Dr. Iton was the first of two people who told me I was irrelevant (the second was a tech guy in Silicon Valley who believes iPods will replace the need for doctors in a few years - Star Trek style. Yikes.).

So I was immediately defensive. Of course we can make a difference. Helping one more person control his blood pressure or maintain a normal blood sugar, taking out an appendix or putting in a new liver, all these things are incredibly important (and what iPod is going to be able to do that, huh?!). Of course I am relevant. I better be; I'm going to be spending the next ten years in training...

But what I slowly began to realize was that Dr. Iton was just better at explaining some of the feelings I've tried to describe as a third-year medical student: the sense of helplessness, the need to do more, that inability to provide care outside of the clinic. He was simply putting these emotions into words. He asked us why medicine needed to continue researching "misery" in our country, just so it can describe that misery in a slightly different way (and publish it). Stop describing the misery, and do something about it!

A very good predictor of life expectancy is how much control individuals feel they have over their own lives and circumstances. There has been much work on this topic as of late (including a professor here at the Kennedy School - see below). It is clear that a heightened sense of control directly correlates to lower levels of stress and increased longevity. It appears that this is true for communities as well. So while it is imperative that we treat patients on an individual level, we must also treat the ills of communities if we want to reverse some of these trends. At The California Endowment, Dr. Iton and his colleagues are doing just that. With their "Building Healthy Communities" plan, they are moving beyond the clinic, infusing $1 billion into neighborhoods across California to improve the social and economic well-being of these communities (you should read the whole article in the second reference below!).

"[In Acosta Plaza]...there are half a dozen convenience and liquor stores within walking distance but the nearest traditional grocery store is nearly 2 miles away. There’s a public park in the neighborhood, but it’s not considered safe to use after dark. So, it should be no surprise that residents of Acosta Plaza would have higher rates of obesity and diabetes than in other communities, have less access to preventive medicine, and are less likely to graduate high school. No matter how diligent every resident of Acosta Plaza is about their own health and the health of their families, they live in an environment that contributes to poor health. These factors affect the amount of violence in the community, the economic success of the local economy, the strain on the hospital emergency rooms in the area, and of course the overall well-being of the families who live there."

I've had a number of discussions with other CPL fellows about these issues, but Dr. Iton was able to put it all together for me. If I am going to be active in state and national health policy and/or be a physician leader, then the most fundamental question I need to be able to answer is, "What policies are going to make Americans healthier?" Obviously the answer is uber-complex, otherwise we would've fixed this broken system long ago. But this is why I came to the Kennedy School. I wanted to understand how other industries (business, government, education, public health) interact with medicine, and what can these industries inform and teach us moving forward? I think an hour and a half with Dr. Iton taught me more than all of my classes last semester combined in this regard.

This was just one inspirational talk out of 18 different meetings on the San Francisco Field Experience, but I hope it gives you a sense of how special this trip was. It has easily been the highlight of my time here at HKS, and I am still digesting all of its content. Again, I owe a thank you to Brooke King and Jen Firneno for all their hard work in planning and coordinating this trip, and a very special thanks to Glenn Dubin, the fellowship's founder, for without his support, none of this would be possible.


References

• Sherman GD, Lee JJ, Cuddy AJ, Renshon J, Oveis C, Gross JJ, Lerner JS. Leadership is associated with lower levels of stress. Proc Natl Acad Sci U S A. 2012 Oct 30;109(44):17903-7.
• The California Endowment. Health Happening in 14 Places.

San Francisco, CA

Every year the Fellows at the Center for Public Leadership engage in a policy "field experience." This occurs during a multi-day trip to one city in the U.S., where students have the opportunity to meet with top leaders and organizations across a variety of sectors and industries. The Fellows dialogue with local politicians, CEOs, and analysts, of whom quite a few are former HKS alumnae. The trip is meant to inspire, connect, and broaden our vision as we wade knee deep into the interweaving of the public and private sectors, experiencing how they interact with the community to promote positive social change. This year the Dubin Fellows and about 15 other HKS students flew to San Francisco, California, the Asheville of the west coast.

We met with 18 people/organizations in just three days. We ate unbelievably good food and sucked down multiple cups of coffee in order to prepare for the next activity (did I mention all expenses paid??). The trip was an absolute blast (mostly thanks to our incredible organizers, Jen Firneno and Brooke King!). Every group was inspirational. Briefly, I wanted to share with you some of the major highlights...

• La Cocina helps low-income food entrepreneurs grow their businesses with affordable kitchen space and organizational support. Their clientele are generally minority immigrant women who have had experience in the food service industry. Now they have a ballin' idea that they want to bestow on the American public. On Tuesday night we were served a three course meal by three of La Cocina's successful graduates. We started off with Alicia's Tomales Los Mayos ("My tamales are stuffed with love, and the best people are stuffed with my tamales!"), then ate authentic "onigilly" rice balls with Japanese fried chicken and delicious brussel sprouts, and finished with Tres Leches La Luna Cupcakes (I don't like sweets, but this was honestly the best dessert I've ever tried - so moist). We also learned a little bit about the people in the process, in between bites.
• IDEO is a design firm that takes a "human-centered" approach to helping public and private organizations grow and innovate. This firm is touted as one of the most creative and best organizations to work at in the country, and their office space demonstrates why. Bikes are hung on cables from the ceiling for daily personal storage, each employee works at a new desk every day, and the kitchen is always crowded. In the two hours we were there, we engaged in a brief exercise in design thinking, attempting to expand the public transportation system in SF in new innovative ways. I contributed to the group by offering helicopter bikes as a solution to this crisis.
• Delancey Street is a community that is completely made up of ex-convicts. Entirely. The typical individual who lives and works in this picturesque community, hand-built by the men and women themselves, has spent years in prison and a decade dependent on drugs. The minimum requirement is 2 years living within the organization, but the average person stays four. No doctors, no therapists, no staff. They learn by working hard every day, gaining the skills necessary to reenter society as a contributing craftsmen. The ex-cons run their own admissions process, and boast an incredibly low recidivism rate. Since there are no doctors, the mentally ill must find another place to rehabilitate.
• Gavin ("Norman Handsome") Newsom, former Mayor of SF and now Lieutenant Governor of California, was one of the first political advocates of the Freedom to Marry movement. About a decade ago, he began allowing homosexual couples to legally marry in the city of San Francisco, a measure which was later rescinded but which brought national attention to the issue. He spoke at length (and off the record) about his political career, so I cannot detail much of what he said. I will mention though that he gave us a unique inside look a the political process, both locally and nationally, and had an adequate number of chest hairs popping out of his "3-unbuttoned top buttons" dress shirt.
• Anthony Iton, MD JD MPH has more degrees than he knows what to do with (and you thought I was crazy with an extra year). He is the Senior VP of The California Endowment, and has a broad view of how to improve the health of all Americans. As has been shown in numerous research studies, the ability to have a sense of control in our own lives and the concept of hope for the future independently affect health and life expectancy. Dr. Iton seeks to empower communities that have lost the ability to represent themselves in our democracy, engaging with the poorest areas in California. He works to give community leaders the tools needed to build and develop their own land and resources. He was also concerned with the amount of bacon in our catered breakfast.
• Tesla Motors. My next car will be a Tesla. It was fun to end the trip with an electric car company that is looking to build the next big thing. Unlike Prius and other gas efficient vehicles, these are pure sports cars, yet entirely battery powered and not ugly. Their top model can go 400 miles without a charge, and won Motor Trend Car of the Year for 2013. Sign me up for no longer paying forty bucks at the pump!

These were just a few of the many groups from whom we learned. I have a notebook full of quotes to reflect on in the coming weeks.

My First Publication!

Dear Mr. Swendiman,

We are pleased to tell you that we have provisionally accepted your Medicine and the Arts (MATA) submission, "Between a Rock and a Hard Place," to Academic Medicine. Full acceptance for publication is contingent on journal staff receiving explicit written (e-mail) permission from you to reprint the original poetry, including a request for payment of $100 for reprinting the work. Once we receive this, you will be notified that your submission has been accepted, and we will process the payment...

BOOM!

A while ago, I published a blog post called Medicine in 55 Words. As a third-year, we had monthly "Art of Medicine" conferences, where students and seasoned attending physicians gathered over beer and chocolate, discussing the softer side of medicine, the work/life balance, and humanism. This contrasted with our usual meetings that were scientific and clinical in nature. Out of one gathering came a few short poems, describing medicine in 55 words or less. We were given this exercise in order to better reflect on moments during the year that had deeply affected us. Over the next few days, I tried to describe one of the most poignant moments of my short career to date, a case I scrubbed in on with Dr. Jennifer Hooker, a Pediatric Orthopedic Surgeon. I called it "Between a Rock and a Hard Place."


Between a Rock and a Hard Place
by Robert Swendiman

Operating Suite #9. We waited in silence for the pathologist to call.
A 15-month-old boy lay before us. Flaccid, sterile, powerless.
There were only two possibilities, given the X-ray and MRI.
We prayed it wasn't cancer.
"I only see blood, no abnormal cells. No cancer."
Sigh of relief. The diagnosis was child abuse.


When Dr. Meacham emailed us that MATA was calling for submissions, I immediately thought of this poem and the chance to further reflect, almost a year later. And so I began my first journal submission, in conjunction with my mentor, Dr. Robyn Latessa, who is now the Director of the Asheville Program. We wrote a brief tandem reflection on the challenges in medicine that students and veteran physicians face daily. The work will be published in the next couple months, and I look forward to providing y'all the link (I don't think I can reprint the commentary here, because they now own it)! It will be my first submission, as my one publication from my undergrad research doesn't really count - unless you count the number of mice my synthetic compounds must have killed, which was a lot.

I hope that the exercise of writing this blog in itself has improved my writing. It is obviously something I hope to continue as my career progresses. I also hope that "humanism" becomes a greater part of the medical curriculum. In the meantime, I didn't realize that you can get paid for submitting original works, so maybe I should quit my day job and become a poet/short story writer! My mother says not so fast...

I am back in Boston, and now off to San Francisco. More details on that next week.

Caye Caulker, Belize

I needed a vacation; there was no question. I'm not sure why, as this semester definitely hasn't been very taxing. Grades came back (the grades are posted, they posted grades!), and given that like 99% of students get B minuses or higher, it was very difficult to be worried. But I needed a vacation. So I went to Belize.

When Hurricane Ernesto hit in August, the cheapest option was to switch my ticket to Belize to January. So for a nominal fee, I sighed and accepted the fact that I would have to take another trip to Central America. Given that all I really wanted was a week for R&R, I decided to spend my entire time on Caye Caulker, an island off the coast known as the chill caye ("No Shirt, No Shoes, No Problem"). Here, the young lie on the beach, snorkel, smoke weed, and eat lobster. I did three of the above, leaving the pot smoking to rest of the island (and by rest of the island I mean everyone else on the island).

I got off the boat and wandered into my funky little hostel, Yuma's House Belize. For $13 a night, it was a great value. Dorms of only four, cold showers (which were lovely), and quiet time beginning at 11pm. The clientele was chill. There I met a couple of Americans ("Snacks" and "Biscuit") with whom I spent most of the first half of the trip. We played volleyball with the locals, ate Fran's lobster special (a large tail of lobster with butter sauce, rice, fresh veggies, chocolate cake, and a stiff rum drink for $12.50 - the chicken special was ten bucks), and played hours of spades. I read in the hammock on the dock, and watched the sunset. It was glorious.

The main reason I went to Belize originally was to dive. So I took a trek to the Blue Hole, one of Belize's natural wonders. There, tens of sharks circled beneath us as we marveled at the limestone walls and local biodiversity. A barracuda followed us from a distance, curious but wary, mouth slightly open to show us its sharp teeth. On the shallower dives we saw turtles grazing, moray eels, sting rays, and a plethora of colorful fish. On the way home, we paused to watch a group of four dolphins showing off, jumping and splashing in and out of our wake.

I ended the trip in the same fashion as I started. I met two more Americans, and we relaxed. We drank and watched the Redskins game (screw you, Seattle) and the BCS National Championship (ROLL TIDE). The morning before leaving, I was approached by a very nice (and high) gentleman who wondered if I wouldn't help him and his friends run cocaine into the country. I politely listened to his sales pitch, drinking my morning coffee on the beachfront. When I told him I wasn't interested in helping, he asked me for a "donation" to the cause (now that takes balls). I replied I think I'd rather spend my money on coffee, and he left disappointed but undeterred.

And so I returned to the real world, which is much colder than I remembered. A new year and a new semester is upon us. I can't help but think that swimming with sharks wasn't a bad way of getting it started.