Sins of omission

Just had my "performance review" chat with my MICU attending, and he brought up something interesting I never really realized about myself - he noted that I tend to "go on whims, gut-feelings, etc." and that I am too gullible and not skeptical enough.

Odd he would mention that, because most people I know tell me the exact opposite - that I tend to argue everything and my coin-phrase should be "I'm not convinced".

In retrospect, I think what he's noticed is my tendency to believe what people tell me when it's about them - their feelings, events that lead up to their hospital admission, symptoms, etc. but when someone tries to tell me that "Drug X" works great against "Disease Z" I tend to resist strongly. As I reflect on why this might be, a few things come to mind.

1. I know that I lack a lot of social etiquette and empathy/sympathy (especially being able to read emotions/facial expressions). I'm not sure where this deficiency came from, but I think I tend to substitute instead what people tell me instead of what they show on their face. Ironic, indeed, as I'm usually the proponent for "show, don't tell". But when it comes to something that I cannot see, then I can only surmise based on what is told to me.

2. Back to the title of this post - why is it that I tend to believe what people tell me? I think it's because I've noted myself an aversion for telling falsehoods. No, it's not a noble thing, and I do "lie" many times, but for me it's almost always a lie of omission, not commission. I prefer to leave things out and let people draw their own (incorrect) conclusion, knowing that they would do so, because I guess it makes me feel blameless. In truth, I think it's because of my horrible experience as a 1st and 2nd grader where I made up huge fanciful stories with my friends and found that the lies just got bigger and harder to reconcile. I really think it was this experience that taught me it's far easier to let someone else "lie" for you (they do the reconciliation in their own minds). Thus, I feel I project these same ideas to the people I meet, and therefore am much more willing to believe that they say but guard against drawing any invalid conclusions from their statements.

3. When it comes to testing ideas of potency, efficacy, etc., however, I tend to be much more skeptical because I can then examine the data with my own eyes and draw my own conclusions. I usually prefer these types of exercises because I can do them at my own pace, on my own time whereas in conversation with another individual, I have to process and reply in real-time.

Much of this probably makes no sense whatsoever, but I think I learned something about myself yesterday...and have to learn to trust people less, I guess.

Vision insurance

As part of my healthcare package, I'm covered under a "Vision Plan." Unfortunately, as I found out recently, I believe this "Vision Coverage" is really not an insurance policy, but rather a scam to provide glasses to many people. Huh - isn't that insurance? Nope - and here's why. My glasses broke two days ago, so I needed a new pair. Luckily, my insurance plan allocates to me an eye exam every 2 years and a new pair of glasses. Great - my last exam was in September of 2006, so it's been far more than 2 years. Check. Now let's see my benefits: eye exam - $10 co-pay (fair enough), frame - $80 allowance, generous, lenses: standard plastic (CR39?) covered 100% - all else, you pay 100% retail. So, let's examine two hypothetical situations and see how things come out. Let's take Person A who has mild-to-moderate myopia and needs corrective lenses at say, -4.00 diopters. At this level, he could actually get around - albeit a bit clumsy - without glasses. So while he may wear these glasses all day (mostly out of convenience), it's not necessarily a required item for his activities of daily living. So I'd say these glasses are more of a "nice-to-have" item. While it's true $80 doesn't get you much of a frame, he could easily go with the standard CR39 lenses and it'll be covered entirely.

Now let's look at Person B who has severe myopia - say, -10 diopters. At these powers, the guy wouldn't be able to perform his activities of daily living without glasses, so the glasses become more of a required item, i.e. "need-to-have". Furthermore, at these powers, the use of CR39 isn't really recommended anymore due to the tremendous size and thickness required - higher index of refraction material are suggested. Once you get into these powers, you also will need anti-reflective coating to prevent glare from headlights, computer screens, etc. And oh - those $80 frames? Since the guy'll be wearing these frames at all waking hours out of necessity, a flimsy plastic or these new, fashionable thin metal frames won't do at all - they'll break much too easily. Of course, let's not forget anything other than the CR39 and you'll pay 100% retail. By the way, it's not just the lens material - at these powers, you'll need "custom resurfacing" and all sorts of other goodies - all extra, of course!

In short - the mild-to-moderate myope can get a functional pair of glasses for free, while the severely myopic will have to pay 100% retail. Let's also consider the actual cost - the CR39, as you might guess, is relatively inexpensive being plain plastic. Higher index of refraction materials - more expensive, and as you get higher and higher the costs rise faster.

So whom does this insurance policy serve? The large populace with mild-to-moderate myopia, and at a relatively cheap rate. Who gets screwed? The severe myopic who require inordinately expensive glasses. This would be the equivalent, in healthcare, for an insurance policy to cover annual check-ups and vitamins, but operations, prescription medications, etc. would be entirely the policy holder's responsibility. Sounds like an insurance company's wet-dream, doesn't it? Insure many people and you're only financial responsibility is small.

You've probably guessed by now I'm a severe myope. I measured out to -9.00 and -9.50 diopters. I also fly, so I like to have a pair of sunglasses handy so that I'm not blinded when flyingi nto the sun. But as I wear my glasses constantly (and frequently fall asleep with them on), I don't really want to get a second pair of prescription sunglasses.

My final choice/costs? I ended up having to spring for a $200 frame that's "bendable" (so hopefully it won't break when I sleep with them on and crush them, although my last pair was also bendable and they broke at the bridge after only slightly more than 2 years of wear). Then, I had to pay another $200 for polycarbonate lenses (higher index of refraction, although certainly not the highest possible, but it's also the most impact resistant and as a volunteer firefighter I also want to keep in mind the safety factor). Add another $100 or so for additional anti-reflective coatings, custom resurfacing, etc. and I did opt for a photochromic layer (Transitions - the lenses that change color according to UV exposure so that I won't need a separate pair of sunglasses) that costs another $50 or so. The total bill after a few discounts came out to nearly $500.

So that's my experience with health care insurance so far. I know of many people around me who wear glasses, typically in in the -2 to -4 diopter range, and they would've been fully covered. Even if they had not, it wouldn't have cost them $500 for a new pair of glasses.

Well, I guess life just isn't fair sometimes. No matter - hopefully these glasses will last at least another 2 years when I can repeat this whole process again, although at these rates it doesn't matter at all whether I have insurance or not. The exam fee itslf is normally waived at most places when you purchase a pair of glasses.

So on the bright side of things - I no longer have to care about the insurance details and find in-network providers. I'm on my own.

AWB Progress Report

I had made a decision to commute to work by bicycle earlier this month, and for which endeavor my All-Weather-Bicycle (AWB) project was born. I installed a front fender and a rear rack which also functioned as a fender. These items' importance I learned while riding through puddles and patches of wet mud, promptly ending up splattered with the same. At the suggestion of a friend, I then also purchased a pannier - basically a bag that sits on either side of the bicycle, in my case, mounted on the rear via the rear rack. So far things had been going well, although I was only able to test the bicycle in light rain conditions and wet surfaces (after a rain).

Tonight was my first test in riding under "inclement weather" conditions: night-time, heavy rain with winds 23mph gusting to 38mph, ambient temperature around 8C, visibility probably at 200 feet or so with my front LED light, and road conditions were wet with patches of deep (3-4") puddles of water.

I hit my first snag right off the bat when the bicycle hit a bump and the pannier slid forwards. There is a strap holding the sides of the pannier together at the rear (difficult to describe without words), and the forward motion then carried this strap into my rear wheel. This strap, oriented horizontally to my rear wheel, was then rapidly captured by the wheel and forced forwards. The bag, however, retained the strap aft (so-to-speak) and as a result my rear wheel instantly locked up. In the conditions described above, traveling at decent speed (15-20mph), I immediately began to fishtail and had to brake heavily on the front tires without exerting too much force so that I wouldn't be thrown off the bicycle.

After re-positioning the bag, I continued on my journey back home fighting the headwinds and trying to see (my visibility deterioriated at this point to <20 feet due to the water droplets forming on my glasses).

Another bump, another fish-tail. Dis-mount, re-position, re-mount, repeat. Bump. Fish-tail. Dis-mount, re-position, repeat. Hey - I'm getting good at this, but it's getting dicey. I'm going to be riding on the road soon (currently I'm on a dedicated bike path), and fish-tailing across the road in this condition with medium traffic wasn't my idea of a safe ride. So, I unlatched the rear strap in hopes of solving (temporarily) my problems. I could also see by now the multiple contortions the bag underwent as it was dragged by my rear wheel was deforming certain stiff members of the bag, designed for forming support. As a result, it was getting more and more likely to snag on my wheel.

Oh - and each time I rode through a deep puddle, the water would stream and cascade over my legs, into my shoes...

Luckily, the ride home was rather uneventful after unhooking the strap. Yes, it did rub against my rear wheel for the remainder of the ride, but I was able to pedal against the friction force.

On arrival at home, I was better able to re-evaluate my own personal condition. By "all-weather-bicycle", I meant a bicycle that I could ride to work, regardless of the weather condition, and arrive in a presentable fashion. Being a resident/intern, this would mean a shirt/tie and pants with white coat.

I realized now that I will need much more work on this concept. While the fenders and the rear rack did their work admirably, I ended up clean but thoroughly soaked. My gloves were so wet, I had to wring them out to dry. My feet/socks/shoes were soaked completely. My pants, too, were soaked. So were my underwear. The only thing that remained dry was my shirt, safely under my rain jacket.

Lessons learned:
1) I'll need rain pants, most likely, if I'm to arrive in a presentable manner
2) I'll need to engineer a better solution of mounting the rack/pannier to the bicycle
3) Maybe additional lighting
4) Someone needs to come up with windshield wipers for glasses...it's just not working well for me these days when I can't see out my glasses...

MR

A classmate and myself stepped into a crowded elevator at the hospital and asked if "MR" was pushed. At our hospital, there is no floor 13 (silly superstitions!), but a floor titled, "Medical Records" or MR where floor 13 normally would have been. It was already selected, but then suddenly a young man in a wheelchair loudly shouted, "MR! Mentally retarded!". Horrified, the two of us looked at each other and then back at the young man who did appear, outwardly, to perhaps have at most mild MR. My classmate was the first to open her mouth: "Or, medical records." His reply, "Mentally retarded!". I had no idea what to say. He seemed proud of this fact - the ability to decipher MR as mentally retarded. Someone else on the elevator finally spoke up and said something along the lines of "Now, Charles...." in a gentle admonishment.

I hate to say it, but I think I know what was going on. I've heard "MR" used quite a bit in the medical establishment, more particularly "MRCP" for mentally retarded, cerebral palsy. This kid must've figured out, over the course of time, to decipher MRCP.

I was ashamed, and I think many of us in the elevator were ashamed that day. It's not that using MRCP is bad or that we shouldn't speak of certain medical conditions, but sometimes we forget that there is a human being on the other side of the label.

I'm sorry that I failed to see him earlier.

How much would you pay to use an elevator?

A thought just occurred to me as I was taking the elevator up from the cafeteria. The door opened and nobody stepped in on a floor, and I thought that was such a waste of energy to stop and restart the elevator. I then wondered what kind of punitive mechanism could be setup to avoid such blatant waste of resources. Then I hit upon the current idea:

1) To request an elevator to stop at your floor, you must indicate which floor you wish to stop at (helpful for efficient movement of elevators) and not simply direction of travel, e.g. up/down, and pay a fee calculated in various methods (more details below).
2) As an alternative, stairs will always be available and remain free
3) Discounts/waivers can be given for physically impaired, i.e. handicapped, people
4) A display at every level indicating whether the elevator plans to stop and where it will stop. This way, you can ride for free if someone else has already paid, i.e. it's not a per-person fee, but rather a per-stop fee. This display/device should be integrated with the payment system to reduce cost of implementation.

Many variations on this common theme, but imagine the following setup:
1) At every floor is a computer-like device with a card reader. Swipe your card and select destination floor. A deduction is then made in your account (see rate table later) and an indication will appear that an elevator will stop on this floor and will then stop on your desired floor. If someone else has already paid for the elevator to stop on this floor and your desired (target) floor, then no deduction is made (it's free).
2) Rate table: A point system can be setup such that traveling one floor up or down is much more expensive that traveling multiple floors, and can even be devised to charge more for going down (encourages more people to take stairs at least down where it's not terribly physically demanding) versus up. A sample system might be: 10 points for going down 1 floor, 15 points for 2 floors, and 2 points for each additional floor, i.e. 3 floors would cost 17 points. Going up would be discounted by 1 point per floor, so 9 points for up 1 floor, 13 points for up 2 floors, and 14 points for 3 floors up.

Now, those with offices on the higher floors may cry foul because they are penalized for their office location. To that, I say - take the stairs, they're free! But if people really object, then provisions can be made such that they get an allowance of points as a function of their office location, e.g. those with offices on 15th floor (typical cost from 1st floor going up would be 25 points and going down would be 36 points so 2 round-trips would cost 121 points - good for coming in, out and back for lunch, and leaving) could get an allowance of 121 points per day.

One can also see that the rate structure can become very creative, including caps such that say, rides going up more than 8 floors or down more than 10 would be entirely free - it's reasonable use of the elevator at that point, I think. Or, you can have a reverse rate structure such that the going down 1 floor costs 10 points, 2 floors 9 points, etc. and then more than 10 floors you'd get for free. This type of rate structure is more conducive to encouraging people to walk rather than reflecting true energy/utility costs.

Of course - the final points-to-dollars conversion would have to be specified - not sure how much people are willing to pay in terms of dollars. And for the really lazy folks, you can always mimic the subway and offer "unlimited rides" for a high cost, but this would run counter to the idea of getting people to take the stairs.

The income derived from such an operation should be sufficient to pay off the initial investment, and then provide for continued maintenance of the elevator. Furthermore, as I indicated earlier, the relocation of the control panels from within the elevator to each floor immensely aids in the planning of the efficient movement of multiple elevators. Such a system has already been implemented in certain hotels (not fee-for-use, but people indicate which floor they desire and the screen directs them to a particular elevator to use). Once on the elevator, there are no buttons to push and the elevator will stop at the requested floor(s).

An interesting social experiment comes from this, too. Since you are paying per-stop and not per-person, it would be interesting to see a) who is willing to pay for a large group, and b) at what point will people simply take the stairs as opposed to pay for a group...

I would love to see this implemented somewhere..maybe someone else already has this idea?

Evolution and medicine

What I thought would've been an interesting discussion on evolution and medicine ended being a rather unconvincing argument about how certain disease gene(s) are more prevalent than expected. What I'd like to discuss more is how medicine is hindering evolution - people who normally would not have survived to reproduce now are thanks to the "miracles of medicine". I used to think that people who were "unlucky" and were involved in say, a traumatic accident, and "saved" by medicine wasn't really "cheating" evolution. But on subsequent thought, it's exactly those "unlucky" individuals that selective pressure works against. While there are always the flukes, it's very hard to distinguish between an accidental fluke and one made more likely by being "unfit" for the environment the organism found itself in. What about all the advances made in medicine, e.g. advanced neonatal technologies that is pushing back the shortest viable gestation? The nature of medicine is itself the anti-thesis of evolution through selective pressure - which brings me to the main point of this entry: Is medicine's obligation to the individual or society? As we continue to treat people, some with serious illness, and extend their longevity sufficiently long to impact fertility, we are in a sense preventing selective pressure from exerting its effects. I believe countries with socialized medicine have already faced this issue and have made conscious decisions, e.g. limiting the efforts of the healthcare industry based upon certain eligibility criteria. If the doctor's attention is patient oriented, then who's responsible for overseeing the physicians/healthcare industry to ensure that the social group as a whole benefits?

The difficult patient

We had an interesting discussion today about difficult patients. I didn't offer my experiences, but as I sat back and thought about it - I've had very few "difficult" patients. The only patient that came to mind was an obese 64 year old African American diabetic who's already had bilateral below-the-knee amputations - one due to trauma, and the other as a complication of his vascular disease likely from long-standing diabetes. His blood glucose control was extremely poor, often in the 200mg/dL range, and required intensive insulin therapy. In the meantime, he continued to sneak in food against the recommended diet, and often refused blood draws, finger sticks, and was otherwise a rather uncooperative patient. During his protracted hospital stay, he had an episode of altered mental status, likely a transient ischemic attack (TIA), and aspirated on some food. He then developed aspiration pneumonia, spiked fevers but never had a positive blood culture. Meanwhile, the surgeons were debating who's going to get first crack: neurosurgery who wanted to perform an endarectomy since his carotids were both >90% occluded (no surprise he's had strokes in the past), or the cardiothoracic surgeons who wanted to perform coronary artery bypass grafting. The reality of the situation was that neither team really wanted to touch him at all given his high risk factors. To make the situation worse, he refused to cooperate when the surgery PAs came over to see him and evaluate him for surgery.

After nearly 1 month in the hospital, he was finally discharged home - without any surgeries because that's what he decided. Listening to my friends' tales of "difficult" patients, I'd say I had a relatively easy case.