Race Matters.

Two weeks ago, I presented at conference  sponsored by the CDC, which focused on public health issues surrounding hemoglobinopathies - and of note sickle cell disease. On the last day of the conference, we were honored to have renowned family physician Dr. Camara Jones as the lunchtime keynote speaker. Her talk focused on the interplay between SCD outcomes and race. At the end of her talk, she presented the Gardner's Tale, an analogy I heard before at another one of her talks years ago while working on my MPH degree. The analogy originally appeared in the American Journal of Public Health some years ago, and I would very much encouraged that anyone who deals with issues of racial inequalities (i.e. Americans) should either take a peek at the video below, or read the pdf file*. In summary, Dr. Jones explains how the three levels of racism - institutional, personally-mediated and internalised - came to be in American society by likening Caucasian and African Americans to roses developed in varying quality of soil.

A Gardener's tale from Luis Manriquez on Vimeo.

And yes, I, too, stand in solidarity with those who seek justice for Trayvon Martin.

*Levels of racism: a theoretic framework and a gardener's tale. C P Jones Am J Public Health. 2000 August; 90(8): 1212–1215.

Family Medicine - Match Day 2012

So, I tried my hand at being uber-technologically sophisticated by writing, editing (somewhat), and then publishing a blogpost via my iPhone, on-the-go. Yeah, that didn't work. Also, for some reason I couldn't include hyperlinks (wait, do people still say hyperlinks these days - I feel like I haven't used that word since Yahoo was king). So, I am back to more traditional forms of blogging - MacBook Pro, physical keyboard, and a half-eaten afternoon bowl of oatmeal.

Anyway, a warm hearty congrats to the class of 2012 on their Match Day results. Let the revelry begin, I suppose. Rather unfortunately, interest in primary care seems to have stalled in that Family Medicine (the "only true primary care specialty") saw a very slight uptick in positions offered compared to last year. While some are celebrating, I still think that at this trajectory, such news does not bode well for the nation's interest in making up for the primary care physician shortage. WaPo writer, Sarah Kliff, surmises that recent spikes in interest may follow political trends (though, ignore the graphic)

Speaking of our nation's healthcare - Fareed Zakaria of CNN will be hosting a special segment on successful health-care systems around the world, at Sunday, 8pm. I will be watching, or rather waiting for, the hat-tip to primary care. Other successful western health-care systems seem to boast of a larger share of their physicians in primary care, compared to the US. Looking forward to the conversation this program may generate.

NEJM: Goal Directed Care, an alternative?

I have a feeling that if you end any argument with these eight words, "according to the New England Journal of Medicine," you've probably won half the battle. Spice it up with a little JAMA, you're literally there. And, oh man, mention your point of view was championed in the Lancet, set it and forget it - it's in the bag.

The Perspectives section of these week's NEJM features a number of views on the relationship between clinician and patient. One article in particular, caught my attention, "Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm." The argument is that the current model of health-care views success as achieving a number of objective parameters, such as decreased blood pressure, HbA1c within acceptable ranges, overall survival. While this may be an acceptable standard to apply to relatively uncomplicated patients, it is not suitable for patients with multiple comorbidities for whom achieving such measures may come at the cost of quality of life. Rather, they contend that outcomes should be more individually tailored and should instead be measured according to individual patient's goals - such  as, in the example they provide, a man with COPD, who simply wants to walk his granddaughter down the wedding aisle. In the table below, culled from the article (I hope I am not infringing on copyright, but I thought the following basically sums up the paper), the authors provide differences between traditional disease-specific outcomes and so-called goal-oriented outcomes.

From a personal standpoint - I am all for quality of life over quantity and I am sure there are many with multiple co-morbidities who would also agree. I also loathe the idea of cookie-cutter treatment approaches hastily applied to any one patient with a particular condition or specific set of lab results. An indispensable asset of a family physician - well, any physician - is the ability to engage in shared-decision making with patients, which requires and understanding of patients' goals.* I understand that at times, such goals may conflict with evidence-based treatment algorithms constructed for Patient X with condition Y.

However, the multiple co-morbidities crowd is not a monolith and some patients - and their clinician as well - may still prefer to evaluate clinical success by traditional measures such as mortality or encouraging trends in their lipid panel.  Also one must admit that even within individual specialties, care is being taken to adjust recommended outcomes according to functional status, age, co-morbidity, etc. For example, HbA1c ranges are generally adjusted for elderly patients, owing to increased risk of hypoglycemic spells - perhaps, not anyone's goal. Another example - invasive screening recommendations are relaxed for patients with limited life expectancies (think prostate biospsies in a 96-year-old). In addition, I think medical training today emphasizes the need the approach each patient as an individual with a unique set of needs and goals. Perhaps, I am a bit sheltered, but I see goal-directed patient care as a given at my institution.

I believe that over time, the "traditional model" has made attempts, perhaps, indirectly, to account for tough quality of life issues patients may face. Again, I cannot dismiss this "Perspective," and I believe that it provides the beginnings of an interesting conversation on how we measure outcomes as we go forward in this rapidly changing health care environment. However, I am not yet convinced that goal-directed outcomes is necessarily an alternative paradigm. Also, I was unclear as to whether the writers seek to create a sort of two-tier system, in which healthy patients are evaluated by evidence-based measures, and other, more complex patients, are not provided with such an option. I think there is a place for adapting the traditional outcomes model even further to include elements of goal directed care. For example, we can include, in evaluation measures patient's perception of quality of life, patient satisfaction with health care received, etc.

*3/17/12 Addendum: Going back to the comments on the actual article, many commented that goal-directed health-care, was, in essence, the family medicine paradigm. Perhaps I have been so immersed in the Family Medicine culture, so early in my training, that I assumed that most other physicians thought similarly.

Man: parts versus the whole

Just about heading off to bed and was reminded of a challenge I recently joined - the 21 Day Meditation Challenge hosted by the Chopra Center. I just started yesterday, though I signed up for it weeks ago at the suggestion of a fellow classmate.
Interestingly, the blurb for the first day's worth of meditation, entitled, "The Mind-Body Connection," addressed medical education:

Only a few decades ago, medical students were taught to view the body as a machine whose parts would inevitably break down until it could no longer be repaired. Today science is arriving at a radically different understanding: While the body appears to be material, it is really a field of energy and intelligence that is inextricably connected to the mind.
I agree that conceptually, we, as a profession have moved away from the model of the patient as a collection of parts, but practically, we are still beholden to the idea of doctor as a mechanic for humans. This is very much exemplified by the growing list of specialties and sub-specialisties, and interests within subspecialities. I credit this to the vast amount of new information we garner on literally a weekly, if not daily basis, of how individual parts of the body works. I do not fault this mode of thinking either, given the pace of new discoveries of how best to take care of various body systems. However, I believe that many a patient and his cast of physicians will admit that I times, we sometimes miss the forest for the trees (I believe that is the expression). Meaning that, in our quest to address individual systems and subsystems, we can forget the interconnectedness of such parts and how best to address the whole individual.

I do believe we are doing a better job at addressing the importance of the mind, both from an education, clinical practice, and research standpoint. The description of a human body as a "field of energy and intelligence" may be a bit too decorative for my liking, I am undoubtedly convinced about the prominence of the mind and its influence on clinical outcomes in some** cases.

**Oh yeah, I am so hedging my bets on that one.

an introduction, of sorts

Urrgh...I hate introductions, but I guess one is necessary before I hop into it.
Currently, I am a third year medical student from the East Coast who, if you can't tell, is interested in going into Family Medicine. Right now, it is 24 minutes past 12 midnight, so, yes, I am going to keep this as brief as possible. I have in the past forayed into the world of blogging, but, it was prior to going to medical school and as my interests evolved and steered towards Family Medicine, I thought it would be necessary to start afresh. At this point in time, I would prefer to remain anonymous, but I give it six months before my name, my mama's name and my next door neighbors' cat's name appear on this blog.

Choosing Family Medicine was a pretty long journey and even now, I would say that I am 85% settled on this decision. In a future post, perhaps after I write my personal statement, I will explain, in detail, how I got here. I think as I write and in the past, I have used the exercise of writing and blogging to clarify my goals and interests. The amount of written word dedicated to a particular topic is roughly proportional to my interests I figure.

For the most part, this post is a placeholder - a poor excuse for an introduction. It's more akin to staking a flag on this little piece of the web I founded - well, I'd like to think I have exclusive rights to it. I'd hate to make promises as to what will be featured on this site, but expect some part personal reflection, some part reference to articles, and some part my attempt to develop my health media chops. It's a work in progress, but hopefully, not for long. Welcome, I guess.

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