Intra-Uterine Parasite

Week 11

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Week 9

Google Calendar Sync on 3G

You can sync your Google Calendar back and forth with the 3G with three easy steps.

1. Follow my directions below to jailbreak your 3G
2. Download the "Google Apps" in Cydia and then reboot your 3G
3. Download Nemus Sync in Installer

*don't use Nueva Sync -- there is no point to use a third party server that proxies an actual sync. Nemus Sync flows much more smoothly

Jailbreaking with Firmware 2.1

A couple of things:

1. I think it is easier to use QuickPwn instead of WinPwn now to jailbreak the 3G on a PC. I used WinPwn the first time mainly because they came out with the ability to jailbreak on Firmware 2.02 first. Now, however, QuickPwn allows you to jailbreak with the latest firmware update (2.1). Plus, it is easier - you simply upgrade the firmware using iTunes, then run QuickPwn. It isn't necessary to build an IPSW file like in WinPwn.

2. To use QuickPwn to jailbreak an iPhone using firmware 2.1, follow these instructions
a. Use iTunes Version 8 to upgrade to firmware 2.1
b. Download Firmware 2.1 seperately
c. Download QuickPwn
d. Put QuickPwn and Firmware 2.1 in the same folder
e. Run QuickPwn and Follow the instructions

*quickpwn doesn't upgrade your firmware, it just jailbreaks it.

Links
1. iDevTeam blog post about 2.1

iPhone Mods - tips and tricks

I have been playing with my iPhone 3G a lot lately and having a lot of fun figuring some useful mods out. This reminds me of early computer days in terms of user-end changes and experimentation. Anyway, all of these ideas are stolen from other sites and just synthesized here in my logic - which is at the level of a retarded 3rd grader.

How to Sync Your iPhone on Multiple Computers (e.g. your desktop and laptop)

1. Download the free programUltraEdit

2. Find your itunes library

3. Locate the file "iTunes Music Library.xml"

3. Open the file with any text editor (e.g. notepad or UltraEdit)

4. Find the entry between the tags that follows "Library Persistent ID". The entry will be a long alpha-numeric entry.

5. Copy the entry down exactly on a piece of paper.

6. Close the file.

7. Make sure itunes is not running

8. On the other machine you want to sync with (e.g. laptop or work computer), open the file "iTunes Music Library.xml" in a text editor and, again, find the entry between the tags that follows "Library Persistent ID". The entry will again be a long alpha-numeric string of 16 characters.

9. Copy the entry down exactly on a piece of paper.

10. Now, replace that entry with the entry you copied in step 5 - don't change anything else. The new entry should also be 16 characters and match that on your first computer.

11. Use UltraEdit Hex Editor to open the file "Tunes Music Library.itl" (or "iTunes Music Library" on a Mac).
12. Select "find and replace" from the edit menu -- make sure Hex matching is selected, not ASCII
13. In "Find", enter the ID you wrote down in step 5. In "Replace", enter the ID you copied down in Step 9.
14. Choose "Replace All"
15. Save file and close it

How To Jailbreak Your Iphone

1. Download WINPWN 2.5

2. Download Firmware 2.0.2 IPSW

3. Plug in iPhone to USB

4. Power off iphone

5. Run WinPWN 2.5

6. Select the 2.0.2 Firware file when prompted

7. Follow steps to put iphone in DFU mode

8. WINPWN will shop up on iPhone with message to restore custom IPSW

9. Hold SHIFT button and push the restore button in iTunes

10. You will be prompted to select your IPSW

11. Select the ISPW you must built (it will be called something like “Custom_2.0.2” and will likely be in My Documents

How To Tether Your 3G (using your iPhone to get your laptop on the internet)

1. Jailbreak your Iphone

2. Download 3Proxy in Cydia

3. Download Terminal in Cydia

4. Create an “ad-hoc” network by right clicking on the two computers in the bottom right hand corner of XP or Vista

5. In the first box of the create ad-hoc dialog, type in anything you want for the network name. I named mine “3G Net”

6. In the second menu, select, “No Security/Open Access”

7. Create Network

8. You will temporarily lose your internet access as your laptop starts the ad-hoc network and leaves the wireless you were on

9. Now go to your Iphone

10. Go to Settings à Wi-Fi and your newly created Ad-Hoc Network should be listed there

11. Join that network

12. Now you need to write your new IP Address down for your Iphone by clicking on the blue dot to the right of the network name in settings

13. Write the IP Address down, you will need it in a moment

14. Now go to the “Terminal” program on the 3G

15. Type in “socks”

16. Nothing will seem to happen, but it does

17. Hit the home key

18. Go to Safari and then type in a URL (e.g. http://www.google.com)

19. Your Iphone won’t be able to get on the web through the Ad-hoc and will automatically switch to 3G but it will keep the ad-hoc network running in the background

20. Now go to your laptop and open up Firefox

21. Go to Tools à Options àNetwork à Settings

22. Click “manual proxy configuration”

23. On the last line that says SOCKS Host, type in the Iphone IP address you wrote down earlier

24. Type in 1080 for the port to the right

25. Click ok

26. In the URL of firefox, type in “about:config”

27. On the Filter line, type “socks”

28. Click on network.proxy.socks_remote_dns

29. This will change the value from “false” to “true”

30. In the URL box, type in a URL (e.g. http://www.google.com) and you should be good to GO!!!!

31. If you need more help, go to

a. http://cre.ations.net/blog/post/how-to-tether-your-iphone-3g-and-browse-the-web-using-your-3g-co

How to get NES ROMs on your Iphone

1. Download WinSCP on your home computer or laptop

a. It’s free at

i. http://winscp.net/download/winscp416setup.exe

2. On your iPhone, go to Cydia – you will need three programs

a. WifiToggle

b. OpenSSH

c. NES

3. Connect your 3G to a WiFi network

4. Get IP Address of the iPhone (Settings à Wifi à blue button on the right)

5. Disconnect the phone from the Wifi Network

6. Go back to WinSCP and type in the iPhone IP Address in the “Host Name” field

7. Type in “root” as the username and “alpine” as the password but DO NOT try to connect yet

8. Go to the iphone and hit “Toggle Wifi”

9. This will enable the WiFi and give a message that says “Enabling in 3 seconds” and then disappear when you join

10. Right when the message disappears, or just before, hit “Join/Connect” on WinSCP

11. The timing is important – otherwise the iPhone security features will load up and not allow you to connect

12. If you connect successfully a file explorer screen will come up with the iphone on the right side

13. Now you are ready for ROMs

14. ROMs can be placed in …..

a. You might need to create a directory called “NES”

15. To find ROMs, you need a torrent programs, like uTorrent

a. http://download.utorrent.com/1.8/utorrent.exe

16. Go to http://www.mininova.org and search for NES games

17. You can usually find all the ROMs as one zipped file

18. Download the file using uTorrent

19. Now you just drag and drop the files using WinSCP from your computer to the correct folder on the iPhone

How to Create Ringtones

1. First, you need to go to Control Panel à Appearance and Personalization à Folder Options à Show Hidden Files and Folders à and make sure that “hide extensions for known file types” is NOT selected

2. Go to itunes and select the song you want (if using itunes, you can’t do this with a song purchased through itunes).

3. Right click on the song and select “Get Info”

4. Put in the start and stop time of the ring tone you want to create in the dialog box (max = 40 seconds)

5. Select “OK”

6. Now, right click on the file and go to “Convert Selection to AAC” and click on this

7. Itunes will do some magic and the new file will appear

8. Right click on the file and select “display in Windows Explorer”

9. Find the file in Windows Explorer

10. Make sure that the file has the “m4a” extension – if not, see step 1

11. Select the file and right click on it and select “rename”

12. Rename the file from whatever.m4a to whatever.m44

13. You should get a message from windows telling you that this will be an unstable file. That’s good. If you don’t get the message, see step 1.

14. Go back to itunes and add the file into the library

15. Now sync or drag the file into ringtones

References and Software

1. How To Sync Your iPhone to multiple computers

2. UltraEdit

3. WinPWN 2.5

4.IPSW Files (Firmware)

5. iCafe

6. i dev team

7. Sleepers

Real Estate: Like a fun game for grown-ups

We have a house under contract here at 2540 West Maryland Avenue 33629 and closing is on July 2!





Buying a house so far has been a neat experience - especially because I was looking for location, price and equity more than granite counter tops, hardwood floors, and a jacuzzi style bath tub (can put all that in later).

Anyway, it looks like the hunt paid off and we were able to get a town home under contract two blocks west of Bayshore and just north of Bay to Bay. This is 2 miles from my work and about 2 miles for my wife as well. Plus we are less than a mile from shops and restaurants in Hyde Park.

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click on image for larger view of layout

click on image for larger view of layout

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We offered 28% less than their asking price and 20% less than any comparable house had sold for in the area. Originally, the property was listed at 240K. At that price, the home sat on the market for 80 days until the price was slashed to 199K. Then the home sat again for another 5 days until I came along.

At 199K, the house was at $148/sqft. In that area of 33629, especially compared to other very nearby townhomes, nothing really goes for less than $160/sqft. So, in reality, a house in relatively good shape (clean and well maintained, but out-dated) was already a good deal at 199K. Nonetheless, Money magazine (05/2008, 06/2008) predicts a continued decline in Tampa home prices. In addition, this house was offered by a seller who put no money/work into the home just before placing it on the market and had their mortgage 90% paid. In other words, they stood to walk with some money even if the price dipped. In addition, the sellers are in their late 70s and don't even live in-state at this time. The daughter is having to travel back and forth between Atlanta to deal with issues related to the house.

I took all of this into consideration when coming up with an offer of $126/sqft (170K).


We also asked seller to pay all closing costs (above the estimated fees and up to 6% of purchase price) and include a home warranty. The sellers had already offered to pay buyer's agent fees (it was on the face sheet) but we even increased that by $250 in the offer contract. In other words, I was trying to give the sellers things to negotiate before they went back to the price. My goal was to get the house at the offered price and walk into equity. I fully expected the seller to cut the amount of closing costs and cut the warranty. I also expected some movement on the price.

Let me say, I was pleasantly surprised when my agent called a few hours before the offer deadline to say that the sellers had essentially accepted EVERYTHING we asked for in the purchase offer. The only changes -- they found a cheaper warranty company and didn't want to increase my agents fees by $250 (no biggie though because there is plenty left in closing costs that can go to that). My agent definitely should get all the fees he can out of this because he has been great. We met last night at 10pm - as soon as he received the contract signed from the seller - to finalize the purchase offer. So, if you need a house you should definitely get in touch with Rob Wilson (rob@askrobaboutrealestate.com). Oh, and an aside, Rob used to run Ink19 - the music magazine from the 1990s that we lived by for planning Florida road trips to see bands play in the pre-internet era.

Let me give a plug to my lending company, Compass Bank. If you are looking for a Doctor's Loan Home Mortgage, this is the place to go. Specifically, get in touch with the mortgage broker Drew Daniels (drew.daniels@compassbank.com). I know there are few others out there (BOA, Suntrust, Tower) but Drew was able to still get 100% financing at a time when others were starting to have difficulty making that work. Plus, no PMI and I'm able to buy points to decrease the interest rate with the left over money at close. That parts kinda cool because I'm essentially getting a check from the seller to buy their house.

Well, no problems so far - now comes the inspection, appraisal and the joy of finding Home Owner's Insurance in Florida (a market where no one sells it any more thanks to the multi-Hurricane year in 2004).


One of the best things about the house is it's built in security and privacy. The garage and privacy fence are essentially all you can see/reach from the street and the garage can be used as the major entryway for residents.


After you come through the garage/fence, you enter the front patio. Notice the white door - what is not shown here (but is shown on the hand drawn figure above) is that this door goes into a small entryway that then has yet another door to enter the home itself.



This is the main living room after you walk in the front door - the front door is over in the left hand corner and this is taking from inside the room looking to the front.



The stairs are right in front of you when you walk in the door.


After you pass through the living room, there is a hallway with a bathroom on your left and a utility closet/pantry on your right.


Then you move into the dining room with the kitchen on your left


This is taken from the far part of the dining room, looking back towards the front of the house (kitchen on right and living room is down the hallway which has the bathroom and pantry).



One thing that is great about the place is it's size and the potential with that size. This room follows the dining room and is at the back of the house. It's large at 12X12 and was used as the TV Room/Family Room in the old home. We will likely use the front room as our main common area and forgo a formal living room (that never seems to get used anyway when people have one). This room will likely become a study or extra bedroom at some point.
There is a door on the left wall that goes to the outside back yard/patio.


There are 2 bedrooms upstairs, each is the same size. Each has a huge walk in closet. The windows have a view of the back patio in one bedroom and the front patio in the other. All of the blinds are nice wood blinds - no vinyl cheap mini blinds anywhere. Plus there are hurricane shutters (that's what the weird crank is on the left of the window).

They share this weird bathroom seen in the next picture:

The bathroom is really the only major house flaw. From one bedroom, there is an alcove (no door) that has a sink. Next to the sink is a door leading to the main part of the bathroom with toilet and bathtub/shower. Then there is another door that leads to another sink and toilet and is connected to the other bedroom. Yep, it's odd.


This patio is begging for a hot tub - don't you think? And the best part is the light maintenance that is required with the simple patio blocks and landscaping - no big yard but still a (fairly private) space outdoors.


This is taken from the corner of the backyard (where there is a little gate out to the ally) and looking at the back of the house.

USF COM c/o 2008 Video

I'm trying to use some of my off time this month and next to get back into wakeboarding and wakeskating a little bit. However, I've discovered some other cool sports that I didn't know about previously. Namely, wakesurfing and toe-in surfing using a jet ski to get past the break. More stuff to try....This documentary on wakesurfing is excellent and the huge waves on the toe-in surfing are incredible.

Wakesurfing

John McCain

Not going to vote for the Senator but still got a great opportunity get up close to McCain yesterday at Moffitt. I was a tool for the "young" face of health care along with about 10 of my med school colleagues as well as some other associated USF Health people (nursing students, a few attendings, etc). Still didn't figure out what's going on with the left face/neck area.....

I'm three rows behind McCain - the blue shirt floating in the background of the large woman with black hair on Sen. McCain's left side.

Video Here:
http://www.myfoxtampabay.com/myfox/pages/News/Politics/Detail;jsessionid=39A9020C22E62A3FFB2CC5E52280B57F?contentId=6420366&version=2&locale=EN-US&layoutCode=VSTY&pageId=3.14.1&sflg=1

Real American!

The original photos in this video were taken circa 2001 (look the young Dr. Rockathon!). It has taken me about 7 years to get around to putting them together as a video. Fortunately, my procrastination paid off and there are some great new images that were integrated in with the originals. So, turn your volume UP and watch (the whole thing for some twists). Enjoy.

Match Day!

Yesterday was an exciting day as I matched into my top choice for residency training in emergency medicine at the University of South Florida/Tampa General Hospital. I know many of you are aware that this was an important goal that allows me to train in a great program with excellent faculty, opportunities and resources (and a brand new ED!). It also allows Christy and I to stay in Tampa. I’m looking forward to these next three years of residency training as a physician.



Below are some related links regarding match day.

USF Health profiled me on their main page (second story):
http://hscweb3.hsc.usf.edu/health/now/?p=412


The Tampa Tribune also covered Match Day:
http://www2.tbo.com/content/2008/mar/20/anxious-usf-medical-school-graduates-get-residency/?news-breaking
Photos from the Trib
http://snap.tbo.com/pages/gallery.php?gallery=324168

In addition, the St. Pete Times conducted an interview with me that should appear Saturday (assuming it doesn’t get bumped for real news).

http://picasaweb.google.com/alivinghominid/Matchday

My AHEC Talk

I'm giving the following talk as part of National AHEC Week (see below)

http://hscweb3.hsc.usf.edu/health/now/?p=414

The Case for Single-Payer, Universal Health Care in the United States

Jason W. Wilson, MSIV

National AHEC Week 2008 (March 24th-28th)
USF AHEC luncheon Tuesday, March 25
Noon - 1:00pm / MDC 1097
Open Invitation to All USF Health

To mark the start of National AHEC week on Tuesday, March 25 USF’s Area Health Education Center (AHEC) Program will host a luncheon & presentation entitled "The Case for a Single-Payer Universal Health Care in the United States". The thought provoking presentation will be delivered by medical student Jason Wilson, President of the Class of 2008.

"In order to resolve health disparities, we must focus on possible systematic and structural origins of outcome differences," states Wilson, a fourth year medical student. "A major area where we see large disparities between populations and individuals in this country is in access to health care services. Unfortunately, access is often limited due to lack of health insurance or inadequate coverage. Equal access won’t solve all of our health care problems, but certainly we can address many AHEC goals by working towards better policy and economic structure."

College of Medicine’s Class of 2008 President, Jason Wilson, and Cynthia Selleck, Program Director of USF AHEC and President of National AHEC Organization.

USF’s AHEC Program Director is also the President of the National AHEC Organization. Cynthia Selleck, DSN, ARNP, says AHECs plays an important role in the workforce development, training and education component of the nation’s health care safety net programs. "AHECs focus on improving the quality, geographic distribution and diversity of the primary care healthcare workforce and eliminating the disparities in our nation’s healthcare system." There are 54 AHEC programs throughout 47 states operating 208 centers in rural and medically underserved areas.

The March 24th luncheon on the campus of USF Health is open to all, with food provided by Gulfcoast North AHEC.

A Closer Look at USF AHEC and the national organization…

The University of South Florida AHEC was created in 1993 and has placed thousands of medical, nursing, public health and other health professions students in medically underserved and community-based sites to provide health care during clinical training rotations.

Congress established National AHEC Week in 2006 as an opportunity to recognize AHEC’s valuable contributions in the recruitment, retention, education and training of health professionals in medically underserved areas.

The College Cost Reduction and EMTALA

Linking Title IV of the College Cost Reduction and Access Act to EMTALA.

The benefits of the Public Sector loan forgiveness clause.

Recently, current medical students and residents received a scare after the passage of HR 2669 – The College Cost Reduction and Access Act. As many now know, the language in the bill would have ended the so-called 20/220 debt-to-income rule that allows most residents to receive economic deferment status of federal loan repayment during postgraduate training. It is possible to qualify for the 20/220 pathway if an individual’s debt burden is greater than 20% of income and if their debt to income ratio is less than 220% of the federal poverty level for a two person household. Any resident with $100,000 of federal loans (2/3s of all medical school graduates) would qualify for the deferment during all three or four years of post-graduate training.

Instead, the CCRAA would have implemented an income-sensitive repayment plan. There is an important difference between deferment and forbearance in regards to delaying repayment and many residents would have had to seek forbearance during their training. Deferment means that subsidized student loans will continue to be subsidized during the deferment period. When the CCRAA passed, 20/220 pathway to deferment looked to be out the window. Furthermore, the income-sensitive repayment plan proposed a cap on borrower’s repayments at 15% of their income with a minimum of $4,200 per year. This would result in approximately a payment of $350 per month beginning in 2009 and given residents and unwelcome choice between this large monthly bill or the accumulation of interest.

Here is the problem with that in comparison to the old plan: If you pay $350 per month during 3 years of residency ($12,600 over 36 months) you have essentially just taken a pay cut of about $4,000 per year and you will still owe the same on your loans as you would have under the old deferment model that paid the interest for you. Why? Assuming you have the maximum aggregate subsidized loan, you will only be touching the interest during that 36 month period – the interest that would have been paid by the government in the deferment model. Thus, residency salaries essentially decrease by $4K.

Fortunately, while the CCRAA did pass, the 20/220 rule was NOT eliminated thanks to hard work by the AAMC, AMA and AMSA. You can help ensure that the 20/220 stays intact by supporting S. 2303 and visiting www.ama-assn.org/go/cola for more information.

So, now that the fear of monetary loss has subsided, is there anything good about the CCRAA? Does it have any impact on EM or medicine more broadly? Well, indirectly the answer is “yes”, more directly, the answer is “maybe”. Let’s take a look at the CCRAA and explore some ways I think that the bill’s language might allow improvements in our own discipline by putting this law in the context of other federal legislature such as EMTALA (or at the very least brings in to question some areas of EMTALA that could be improved by further advocacy).

First of all, the CCRAA does some very important things that should be commended: the law increases the amount of a federal Pell grant by almost $1100 by 2012 and establishes a $4,000 a year grant for future teachers. For those of us in or near repayment, the new bill also decreases Stafford loan interest rates to 6.8% if disbursed between 2006 and 2008. Eventually, interest rates will be 3.4% for loans disbursed in 2012. The new law also increases grant funding through College Access Challenge Grants for underserved student populations. In addition, specific funds are disbursed to minority serving institutions.

While all of these aspects of the CCRAA are laudable, I would like to turn our focus to Title IV of the legislation. This part of the CCRA discusses loan forgiveness and outlines a program to increase public service employment among new graduates. More specifically, the portion of the bill allows for full Federal Direct Loan forgiveness after 120 months of income sensitive payments occurring simultaneously with 120 months of public service employment. Borrowers who have FFEL or other federal loans could consolidate/reconsolidate their loans under the Direct Loan program to qualify.

So, what qualifies as a “public service job”? Well, let’s look at the language of HR 2669. The CCRAA defines a public service job as follows:

A full-time job in emergency management, government, military service, public safety, law enforcement, public health, public education (including early childhood education), social work in a public child or family service agency, public interest law services (including prosecution or public defense or legal advocacy in low-income communities at a nonprofit organization), public child care, public service for individuals with disabilities, public service for the elderly, public library sciences, school-based library sciences and other school-based services, or at an organization that is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under section 501(a) of such Code; or Teaching as a full-time faculty member at a Tribal College or University as defined in section 316(b) and other faculty teaching in high-needs areas, as determined by the Secretary.

Is “EM physician” a public service job? I would argue that the answer to this question is “yes” for two reasons.

1. The language of the bill specifically states that those with a full-time job in emergency management are considered public service employees. Certainly, an EM Physicians manages patient services, an emergency department, as well as broader aspects of emergency care (including EMS and disaster planning). These are all components of the job duties found in emergency medicine physician positions.

2. Federal mandates to treat all comers defined by EMTALA specifically link emergency medicine services to public service. The ED is often the last resort for patient care in our current health care setting. There is a legal and ethical responsibility to treat every patient that enters our doors and this responsibility is taken up by EM physicians when other fields refuse. This treatment, however, does not come with any guarantees for reimbursement nor are we protected from litigation resulting from undesired outcomes. The services we provide to the community and the risks of increasing our legal exposure during difficult cases suggest that we provide a public-service as a full time job. Thus, EM physicians should be eligible to qualify for the loan forgiveness provision.

When the CCRAA was passed this year, no one envisioned the potential burden to current and future medical residents. This was an unintentional consequence and, once it was pointed out, was quickly resolved. Now, we are left we a CCRAA that will likely be modified to make the 20/220 pathway permanent. Therefore, we can turn our attention to positive aspects of the CCRAA. We have invested heavily into higher education in this country. The interest on our student loans will finance education in this country for the next generation. Thus, as heavily invested shareholders, we have a stake and claim to an associated piece of legislature that affects the economic and monetary rewards of that system. The recognition of EM physician as a public service job will lead to some relief from a heavy loan debt for many young members of this field.

The issue of funding in relationship to EMTALA can be taken a step further (and outside the context of the CCRAA). This debate reminds us that, while we are obligated to treat all-comers to the ED, there is no guarantee of monetary reimbursement associated with that responsibility. Whether we work through the language in the CCRAA or not, we must continue to advocate progress in the current structure of EMTALA. More specifically, until funding and exposure issues are resolved, we will continue to fail at resolving the problems laid out in the 2006 IOM report on emergency medicine. The on-call shortage is inherently linked to this issue and, in the current context of medico-legal liability, it is up to us to find creative approaches at raising awareness to the problems that exist within emergency medicine. If that means using a new law as a tool for advocacy, so be it.

gay marriage amendment isn't just about gay marriage

The Florida4Marriage group has 587,000 signatures out of the 600,000 required to force an amendment on the 2008 ballot banning gay marriage. Aside from the irony of the group's name (kind of like the "clean air act"), notice also the timing. Doing this in 2008 - a presidential election year - is simply a good bait and switch tactic.

The Republican presidential candidate will not be strong enough to bring swarms of voters to the polls, but an intense hatred of homosexuals should certainly do the trick. And hey, while there, why not go ahead and vote for Rudy/Romney/Fred

Tampa Tribune Story

Apple 3rd Generation (3G) Nano -- How to get TV Out setup

Bottom Line:

1. If you have a TV/DVR or Cable Box with composite video (3 RCA inputs - red, white, yellow), you need the Apple Composite Video Cable.

2. If you have TV(HDTV)/DVR or Cable Box with component video (5 RCA inputs red, blue, green + 2 audio inputs), you need the Apple Component Video Cable.

*The Apple Universal Dock is not required for this setup but does allow you to use a remote control.

Okay - here is how I figured this out after much tinkering and a few trips to my local apple store. This was written as I was doing things, so some aspects are resolved with the notes above.

First, let me note that the problem is mostly related to those who have composite, not component video. Meaning, if you only have composite video input (just the yellow RCA input jack with the red and white audio inputs) instead of component video, then things seem a little more difficult. Let me explain.

If you have a more fancy-schmancy receiver such as HDTV or some DVR boxes (but not mine from Brighthouse), then you will likely have the red,blue green inputs. If you have the component video input, along with stereo input (a red and white input jack), then all you need is the new apple component video cable . This can be plugged in directly to your ipod and your receiver and you should be good to go.

Now, if you only have composite video (the red, white, and yellow inputs), you will need another route. Okay, first of all you will need the apple composite video cable and you *might* need the apple universal dock as well. I will explain why I say *might* below.

Alright, here's the problem I ran into though. My local apple store didn't have the apple composite video cable - they only had the third party version made by monster (the itv link cable ). So, I bought that cable and went home, hooked it up to my ipod and to my yellow,red, white inputs on my DVR. Of course, I set the settings on the Ipod to TV out, selected a video and then hit play. What I got was an ugly picture of a 30 pin cable on my Ipod screen and the message that "TV Out is selected Please connect output cable". Grrrrr....

I then went back to the apple store and picked up the universal dock . I went back home, put my ipod on the dock and stuck the monster cable into the back and hit play again. Okay, now some progress. The video showed up on the TV screen and looked pretty good (like a DVD). BUT.....NO SOUND! I double checked the cables, everything was in the right place.

Frustrated, I took the Ipod off the dock, with the video still playing, and plugged the monster cable directly into the ipod -- booo-yah! Sound and video and no error message!!!

So, here's the really weird thing - I have to do this EACH time I play a video. If I try to play a video with the monster plug directly in the back of the ipod, i get the error message. If I play the video with the Ipod in the dock, NO SOUND. Instead, I have to start each video with the monster cable plugged into the dock and the apple on the dock. Then, after it's playing, I have to take the ipod off the dock and plug it in directly to the monster cable. Weird, but it works.

Now, my plan is to order the apple composite cable and see if it works better than the monster cable. Plus, I wonder if you can bypass the dock with the actual apple cable since I really don't know what the actual role of the dock is in the process since my technique is jury-rigged.

Okay, the final thing I will say is that the old way of doing this - with a 1/8" cable plugged into the line out of the ipod or the dock, no longer works at all. In other words, don't buy this apple ipod AV cable - it's useless with the new nano

Well, I hope this rant helps someone who is having the same problem - and if anyone knows a way for me to do this with less rigging, please do let me know. Thanks.

**Update -
My Apple Composite video cable arrived today via FedEx. I plugged it in directly to the Nano and to my input on the DVR. Everything worked great first try - none of the rigging described above with the itv link cable by monster (that's going back to the apple store today). Only small glitch is that the sounds is a bit low and requires the TV/stereo receiver to be turned way up - but everything else is fine.

http://docs.info.apple.com/article.html?artnum=300233

Legislation in Support of Emergency Medicine

There are 3 bills that have lingered in congress without a vote that would greatly increase funding to emergency medicine, address issues outlined in the 2006 Institute of Medicine report on EM, and help deal with shortages in on-call specialists and lack of access to EDs for patients. Here, I will briefly go through the language in those bills and talk a little bit about their potential impact on practice.

1. HR 3875 (S 2750):
Access to Emergency Medical Services Act
This bill is sponsored by Rep. Barton Gordon, a democrat from Tennessee (and people claim dems are friendly towards medicine!). As of 1/1/2007, there were 47 co-sponsors of the bill - 23 democrats, 24 republicans. The bill was referred to the House Energy and Commerce and then to the Subcommittee on Health. Unfortunately, the bill didn't make it out of committee and died two years after it was introduced. Furthermore, the attempt to move past a subcommittee on the Access to Emergency Medical Services Act has been ongoing since 1995 (the 104th congress). It is imperative that this bill receives broader support and is reintroduced in a future session of congress.

Federal legislation (Emergency Medicine Treatment and Liability Act -- EMTALA) dictates which patients must be treated in an ED, regardless of funding status. However, the mandate to treat legislation, while morally right, is not correlated with any increased federal funding or immunity from liability. Thus, it is difficult for hospital EDs to meet the requirements of EMTALA financially. Furthermore, the IOM has discussed the clear crisis in on-call specialists available to EDs. This crisis is partially due to fear of no reimbursement and exposure to liability with unknown patients by specialists. Finally, EDs are overcrowded. This is often due, not to the level of business in the actual ED, but, instead, to the number of beds filled throughout the entire hospital.

The Access to Emergency to Emergency Medical Services Act would solve many of those problems by amending the Public Health Services Act to include EDs as members of the Public Health Service in regards to liability and exposure, providing a separate and limited fund for any such claims.

In addition, the act would amend Medicare (Title 18 of the SS act) to increase funding for ED services for Medicare patients. This is critical. The Medicare sustained growth rate (SGR) formula is noted to be flawed as it does not increase proportionately with other health care costs and inflation. Cuts to SGR have been approved but kept from taking place at the last minute each year. This is an ad-hoc funding method. New legislation would outline protected, increased, funding of ED services to Medicare patients.

The Act also adds incentive payments to hospitals that admit patients to the floor in a timely manner, thus, creating an economic benefit for the hospital to ease ED overcrowding.

This is a bill that makes sense for patient safety and physician employment.


References
1. EM News - EPs, Nurses lobby congress for Overcrowding Relief
2. Govtrack.US HR 3875


2. S. 3606 This bill was originally sponsored by Democrat Jeff Bingaman, New Mexico and two other democrat co-sponsors. The bill echoes a portion of the more inclusive Access to Emergency Services Act discussed above. S. 3606 specifically links EMTALA and funding issues to a proposed amendment to Title 18 of SS act and away from the flawed SGR designed by CMS (Center for Medicare and Medicaid Services). Effectively, this would raise payments for ED services by 10% for medicare and medicaid patients. This bill has been referred to as the SOS Act of 2006 (Save our Safety Net)

References
1. TeamHealth Advocacy Center

3. Health Courts I have posted a number of times in the past about my support for a Federal Health Courts system to decrease physician liability, frivolous lawsuits, and the lack of real access to malpractice benefits for true victims are poor health care. You can read the latest update on this blog by clicking here.

4. HR 676 -- United States National Health Insurance Act/Expanded and Improved Medicare for All Act
-Sponsored by John Conyers, MI -- 85 cosponsers (1/3 of the Democrats in Congress
-Introduced in 2005
-in the Subcommittee on Health
Thomas Summary on HR 676

Alternatives/Paths to Single-Payer Healthcare

I support a complete overhaul of health care spending that includes shifting administrative costs associated with the dissolution of multiple payers, the money from costly premiums, and the generated revenue from allowing the Bush tax cuts to expire in 2010, into a single-payer health care system that keeps corporations from dictating the type of care my patients receive (care synonymous for "medical losses" in the lingo of the HMO).

There is a broad recognition that our health care funding system has failed, mostly brought upon by the realization that even middle-class workers with "good" health insurance are being bankrupted by high costs and denied coverage. This epidemic of underfunding (even with high costs to employers and workers for premiums) is likely to go further than the epidemic of unfunded (close to 60 billion) people in this country.

In addition, my vision of a real single-payer system is integrated into a number of other economic reforms and increases in social insurance. Since it is unlikely for all those necessary reforms to occur in this conservative/corporate climate, it is necessary to find other ways to put America on a path to universal health coverage.

On the even of the 2008 elections, we can already see that health coverage and health care spending will play an important role. Republicans such as Mitt Romney have designed semi-progressive models in their platform and past experiences (as governor of Massachusetts) that do serve as some improvement. In addition, all of the Democratic candidates for President have offered some form of health care reform (although only Denis Kucinich has proposed a true version of universal health care).

The major problem with the Obama, Edwards, and Clinton plans is that insurance is still tied to employers. This allows - forces - employers to seek the cheapest, not the best coverage. In addition, tax subsidies to employers for offering health care, combined with the tax-free status of a health care benefit to an employee, do not allow us to collect appropriate revenues that could lead to a more broad restructuring of health care. And, of course, this does nothing to correct the flaw in a model of health care that puts patients and physicians against HMOs since those groups have two very different groups (improving patient health vs. increasing profits by denying coverage). One of the worst aspects of the Democratic health care proposals is that, by setting a mandate that everyone must have insurance, the candidates have essentially said "You must have health care. Now, go out and buy it! Good Luck!"

Having acknowledged these flaws in the potential reforms, there are also some positive aspects of these plans that move us much closer to 100% health care coverage (and 100% reimbursement for the physician). A mixed-model approach can put the pieces in order to -- eventually -- get us to true single-payer universal health care while maintaining - or even decreasing - current per capita spending.

This path is best presented by Paul Krugman who outlines 4 components of the current proposals that may reduce costs and might lead to increased and adequate funding.
These 4 components are community rating, subsidies for low-income families, mandated coverage, and public-private competition.

The idea of community rating allows us to move past the "Go out and buy some health care - Good luck trying to afford it!" aspect of current policy. How? Currently, insurance companies try to minimize loss by first screening out any person with risk factors for health problems, or charing them exorbitant premiums (they also minimize loss by denying coverage once a person is accepted for underwriting). Anyway, the community rating (which is already in place in New York) prohibits health insurance companies from charging different premiums to different people. Some models of community rating also prohibit denial of coverage if there is any penetration of that company within a given community.

Next, subsidies exist in the form of medicare and medicaid. These programs can be slowly expanded (lowering the age for medicare eligibility and increasing the % of poverty to quality for medicaid).

Community rating and subsidies create a lower burden for low and middle income workers in the context of mandated coverage. However, public-private competition (laid out best in John Edwards health care reform proposals) might go furthest to eventually creating a true single payer health care system.

To understand why public-private competition may lead to a lower spending burden per capita on health care, it is first necessary to understand the differences in administrative costs between govt programs and corporate health care. More specifically, Medicare/Medicaid provides health care to a large number of Americans and operates with a 2-3% administrative cost. On the other hand, health care spending associated private insurance companies, as a whole, operate around 15% administrative costs. In Canada, the percent of administrative costs as a total of all health care spending is under 5%. Thus, the elimination of multiple private insurance companies and the consolidation of spending into a single agency could, effectively, reduce administrative fees from 15% of health care spending to 2-3% of health care spending.

Furthermore, if govt programs can operate with lower overhead/admin costs they can also operate with lower premiums and costs to patients. Therefore, if patients are allowed to chose between the govt plan and the private plan, they will likely chose the cheaper plan (assuming it offers the same level of coverage). The govt plan is likely to be cheaper and this will, in effect, out compete the private plan. In addition, some have proposed caps on % of health care spending per capita that can be made up by premiums. Thus, if premiums were capped, this might also limit a profit making company's ability to bring in an adequate margin.

The ideas for health care reform are out there and many of them, while not perfect, are quite good. If the house and senate Democrat majority is retained and one of the leading Democrat candidates are elected in 2008, there is a real chance that some type of broad change will take place in health care spending.

As Krugman points out, there was also a good chance for this to occur in 1993 with Clinton health care reform proposal. However, the failure of the Hillary Clinton health care plan and the beginning of the dot.com era in the context of increased economic growth, allowed the urgency of universal health care to fall further and further away from public concern. Plus, total health care spending did stop rising for a brief period in the early-mid 90s. Now, however, we are again seeing drastic rises in health care spending as %GDP (now over %16), an increase in unfunded/underfunded individuals, and no clear economic boom insight. Even though unemployment rates are indeed low, the existence of employer based health care has decreased drastically. Thus, the next 10 years are critical for the direction of health care spending in this country and for the possibility of escaping a true health care crisis that has already begun.

If you haven't read Krugman's work yet, you should. Even though the writing is a little sloppy and the writing is double spaced, the basic argument is sound (that we need a new new deal with universal health care at the center combined with increased taxes on high income earners in order to redistribute wealth and decrease inequality by growing a middle class). I just wish he would have had a better editor - there are missing commas after transition words and plenty of independent clauses simply smashed together with dependent clauses during long run-on sentences (like the ones you see in this blog!). Anyway, Krugman is not the most camera friendly person or best orator. His writing is reflective of those two things. However, his logic is strong and his vision should be commended.

Paul Krugman. The Conscience of a Liberal. 2007.

Shifting Demographics: A quantitative assesment of ED patient visits in a hypothetical setting of universal health coverage

ABSTRACT

INTRO: How would universal health coverage change the volume of patient visits, the acuity of encounters, and the structure of residency training in a typical academic ED? To put this question another way, if the current structure of health care funding in the United States is partially responsible for the growth of academic emergency medicine and residency training, how will changes to that funding system impact medical education within the field? In order to enter the national debate regarding access to health services, emergency medicine must understand the current relationship between visit acuity and funding and the potential changes to that relationship given various specific funding policy initiatives. If patient volume and acuity is partially responsible for the increase in the number of EM residency training positions over time, what would the impact on medical education be if that volume and acuity shifts? Is there any reason to expect any shifts in the context of universal health coverage?

MATERIALS/METHODS: This is a retrospective case control study using a computer software database program to conduct a chart review of a large urban hospital ED associated with a university. First, the distribution of visit acuity is described for funded and unfunded patients over a 1 year period. Next, the null hypothesis that there is no difference in those distributions is tested. Finally, multiple regression analysis is used to test the hypothesis that funding status explains the variation in visit acuity and examines how much of the variation in the acuity distributions can be explained by funding status or other variables such as age and race. Finally, these results are discussed in the context of potential new healthcare spending initiatives to address questions of possible changes in patient volume and acuity within an academic ED.

RESULTS:

DISCUSSION: EM has a legal and ethical mandate to treat underfunded and uninsured patients. Therefore, we have unique insight into how health policies affect patients. Thus, we have an obligation to enter the national health care debate.

INTRODUCTION
The goal of this paper is to address the following question: How would universal health coverage change the volume of patient visits, the acuity of encounters, and the structure of residency training in a typical academic ED? To put this question another way, if the current structure of health care funding in the United States is partially responsible for the growth of academic emergency medicine and residency training, how will changes to that funding system impact medical education within the field?

Emergency departments are designed to provide life saving care at all hours of the day and night. However, in reality, many patient encounters are for non-emergent health problems. Numerous hypotheses have been posited to account for this phenomenon and some have suggested that these non-emergent visits likely result from a lack of ambulatory care and underfunding of health coverage in some patient populations (Haywood et al., 1991; Rask et al., 1998; O’Brien et al., 1997). This paper examines the link between the increase in non-emergent ED patient encounters and the number of EM residency training programs. Furthermore, changes to sociopolitical policies and health care affect the demographics of patient visits to the ED. Here, the potential changes that might be expected within some variant of universal health coverage are quantitatively considered.

Past research has focused on differences in the epidemiology and demographic characteristics of frequent versus infrequent users of the ED and a number of researchers have tested hypotheses relating to funding as a causative agent in such differences. In a 2001 study conducted in Sweden by Hansagi et al., the authors found that frequent users of ED services were also frequent users of ambulatory services. The conclusion was that universal coverage does not reduce ED visits. Other studies in Europe have shown similar results regarding the epidemiology of frequent ED users in universal coverage systems (Byrne et al., 2003). However, this conclusion cannot be extrapolated to the United States because many of our patients have no other access to services and we do not know what the ED would like in Sweden sans universal care.

A similar type of study was carried out by Byrne and colleagues in 2003 within a mixed-funding environment (an ED in Massachusetts) and similar results were found regarding the correlation between high frequency ED visits and high frequency outpatient visits. However, these studies have not addressed the types of ED visits that took place or the possible effects of funding changes on those ED visits. In other words, past studies have examined some of the variables within a health services model, but have not examined how those variables co-vary when another variable in that model is changed. Thus, it is critical to explore issues of patient funding, potential changes in coverage, and their estimated effects, on our current system of emergency medicine. In order to enter the national debate regarding access to health services, emergency medicine must understand the current relationship between visit acuity and funding and the potential changes to that relationship given various specific funding policy initiatives. The assumption of this paper is that majority opinion regards the current funding model to be in crisis and that a solution is necessary. Some type of change will arrive and that change might impact the structure of ED visits.

BACKGROUND
Emergency medicine is a growing field. This year, three new allopathic residency training programs have begun accepting new applicants (Florida Emergency Medicine Physicians, Oklahoma State, and UTMB-Galveston) and a number of other programs have increased the allotment of new residents for the subsequent year.

The field of EM was born approximately 40 years ago with the founding of ACEP in 1968 and the subsequent movement toward board specialty status. Herbert Flessa started the first EM residency training program at the University of Cincinnati with Bruce Janiak as the first resident in 1970. By 1975, there were 31 residency programs (http://www.emra.org). In 2001, there were 124 allopathic sites (Lathrop et al., 2001) and AMA-FREIDA lists 141 allopathic EM residency training programs as of October 2007. Furthermore, there were 4,957 approved training spots according to the ACGME in the 2003-2004 season. However, EM, like all fields of medicine, is affected by sociopolitical policies and changes. In the ED, the demographics of our patient encounters may be most reflective of shifting lifestyle choices or social-epidemiological risk factors more so than anywhere else in medicine.

On the eve of the 2008 elections, a number of candidates have outlined some form of mandatory universal health coverage. Furthermore, the recent presidential veto to expand S-CHIP has renewed the debate regarding a broader universal health care system in the United States for both children and adults. While health care expenditures continue to rise as a percent of our GDP, health outcomes have not improved substantially. Many health care professionals now accept the fact that change is necessary to insure solvency and better care for our patients.

In order to remain ahead of potential shifts in health policy, it is important to consider how such changes to coverage and patient funding might affect the volume and types of patient encounters in the ED. Our field is still relatively young and has not yet witnessed multiple shifts in policy and political cycles. It is critical to examine potential scenarios and affects of those scenarios on the field of residency training and medical education in emergency medicine.

The 2006 IOM report on EM notes that, over the past decade, the number of emergency rooms has decreased while the number of ED visits has increased. During this same period, the overall number of training positions has also increased. The volume of patient visits is not the only variable that accounts for the growth of our field. Certainly the spread of the requirement that hospitals staff EDs with ABEM certified physicians has also created a shortage of well-trained doctors that is likely to persist for some time, even if residency training continues to expand. However, it is important to consider all variables that lead to growth of a particular industry and, surely, patient volume must be one of those factors that provides a basis for increasing the total number of EM residency positions. The question is, to what extent does volume matter and, more importantly, is there even any reason to expect a volume decline in the context of improved patient funding and better access to primary care? The goals of this paper are to elucidate the relationships between funding, volume, and acuity of patients visiting a typical academic ED in order to provide more insight into how the field might change a future scenario with 100% access to ambulatory physicians and preventive services.

MATERIALS AND METHODS
In order to answer questions regarding changes to the distribution of visit types and volume, it is necessary to first examine descriptive data for a typical academic ED in an urban setting under the current model of coverage. What is the distribution of acuity in ED visits among insured patients? What is the distribution of acuity in ED visits among unfunded patients?

Next, I will test the null hypothesis that there is no difference in these distributions. If the null hypothesis if false, a prediction is that, if unfunded patients seek ED care for primary health concerns, the distribution should be right skewed (towards lower acuity visits with Level 4 and Level 5 triage designations)*. However, it is also possible that unfunded patients will have a left-skewed distribution toward lower acuity visits if (1) they rely on the ED for ambulatory care at roughly the same volume as the normal population visits primary care physicians and (2) if the occurrence of high acuity visits is infrequent, or at least equal to that of the funded group so as to not inflate the mean due to ordinal numbers of higher magnitude. If there is a right-shift distribution in the unfunded patients, how does this represent the overall distribution of ED visits in a given year?

If there is a statistically significant difference between funded and unfunded low-acuity visits, that difference may represent a pool of patients that would seek care with a primary care physician if funding were equal between the two groups. If this pool of patients is lost, what would the impact be on the ED in terms of lost patient encounters, teaching experiences, residency training and medical education? In other words, how much primary care/ambulatory care do we really see in the ED and how much of that would likely be lost if all patients could visit a primary care physician?

Finally, it is important to examine the state of EM and the demographics of patient encounters within academic EDs in other countries that have different types of funding models. For example, the demographics of an academic ED in Canada or other industrialized democracies may provide some insight into expected changes within our own departments.

This is a retrospective case control study using a computer software database program to conduct a chart review of a large urban hospital ED associated with a university. X number of patients will be identified that had no existing funding on presentation. Next, X number of control patients will be identified who have some source of funding (private insurance, Medicare, Medicaid, other state or local agency coverage – such as the Hillsborough County Health Care Plan). [Or should I look at all cases over a given time period – e.g. 6 months, 1 year, etc – depends on how easy it is to pull out info from the database??]. The cases and controls will be assigned a unique identifier. Given the retrospective and anonymous nature of this study, a request for informed consent was [will be] approved by the USF IRB and other aspects of the study were done with appropriate review. [will this likely receive exemption from the IRB people?]

The cases and controls will be compared to ensure that any observed differences in acuity level are explained by variation in funding status, as opposed to age, race, or sex. Thus, a chi-square analysis is conducted between the two groups for each of those three variables. Any significant differences in the groups will be addressed and controlled for in further statistical analyses (i.e. age and/or race may predict funding status and -- especially age -- may also predict level of acuity of a given ED visit).

For the cases and the controls, the level of acuity will be assigned a number from 1-5 based on the initial triage assessment [or should I base this on the discharge ICD-9 code and correlate that to acuity???]. Statistical analysis is used to test the hypothesis that there is no difference in the distribution of acuity level between groups. If there is a difference in acuity level, the hypothesis that the difference is explained by funding status will be further explored.

To test the hypothesis that there is no difference in the distributions of acuity level in the funded and unfunded group, a two-tailed T-test is employed. If statistically significant at p < style=""> Finally, an odds ratio can be calculated for the likelihood of a high acuity visit [Level 4 and 5?] between the unfunded and funded groups. A 95% CI is calculated for the odds ratio. An odds ratio is useful because the results of the ratio calculation can go in either direction and still provide relevant data. In other words, is it more likely that an unfunded patient relies on the ED for all primary care, thus, comes in for a wider range of ED visits with a likely lower mean-acuity score? Or, is it possible that the unfunded patient only uses the ED in a catastrophic event, simply living without medical care for most health concerns?

RESULTS

DISCUSSION
Leadership is seeing problems before they exist and knowing possible answers to questions that have not been asked. EM is a unique position to see the impact of our country’s healthcare policies first hand. Through federal legislation (EMTALA) and the words of our current president (“they can just go to the ER [if they don’t have health insurance]”) we are also the safety net for the underfunded and uninsured. Thus, we have an ethical mandate to play some role in the national health care spending debate.

Currently, we are nowhere near universal health coverage in this country. However, as our patients continue to suffer, vulnerable to the vetoes and philosophical debates of legislation, we must be willing to discuss realistic approaches to improving patient care. If our overall goal is to improve the health of our patients and keep them out of the ED, it is critical to understand the projected impacts of a wide range of potential solutions and improvements to our current healthcare crisis. While the idea of keeping customers away may seem to be a paradoxically positive outcome in the business of EM, this is balanced by the prospect of 100% reimbursement rates in the context of future health care spending policies.

References

1. http://www.emra.org
2. http://www.acgme.org/acWebsite/CMS/resPopData_specialty03-04.pdf
3. http://www.cjaonline.net/Communities/FL_Hillsborough.htm
4. Hayward RA, Bernard AM, Freeman HE, et al. Regular source of ambulatory care and access to health services. Am J Public Health. 1991;81:434-438.
5. O’Brien GM, Stein MD, Zierler S, et al. Use of the ED as a regular source of care: associate factors beyond lack of health insurance. Ann Emerg Med. 1997;30:286-291.
6. Rask KJ, Williams MV, McNagny SE, et al. Ambulatory health care use by patients in a public hospital emergency department. J Gen Intern Med. 1998;13:614-620.
7. IOM. Hospital based emergency care – at the breaking point. 2006.

Notes
* However, this is complicated by the possibility that unfunded patients waiting to seek care may present with more high acuity complaints due to delay in care.

**In Hillsborough County, there is an award-winning and nationally recognized comprehensive health care plan for indigent members of the community. Up to 28,000 residents are eligible for this plan at up to 100% poverty level. The plan emphasizes preventative services, early intervention, health education, and the coordination of health and social service. Thus, enrollment previous to recorded ED visit will be considered “funded” for this paper. However, enrollment during ED visit will be considered “unfunded” even if retroactive funding covers the particular visit since that patient would not have benefited from the primary care inherent to the plan previous to the ED visit.

***If there are more than funded vs. unfunded (e.g. underfunded) – conduct a trend analysis to examine the relationship between acuity and level of funding

The "Green New Deal" - a call to lead in renewable energy

I don't agree with Thomas Freidman about everything, but I do think he is getting smarter and further away from his support of the Iraq War. Friedman basically gets his argument right in "The World Is Flat" that there is a growing global middle class causing a crush on resources (I also think it's unfair to label him a neoliberal since he doesn't support unregulated capitalism).

I also think that our nation and our generation is waiting for a broad vision regarding renewable energy. Anyway, here is a video with Friedman explaining his idea and call for such leadership.

Thomas Friedman Video "The Power of Green"

If anyone has any idea how to embed NY Times videos on the blog, please let me know.

blogging you blogging us - ACEP in Seattle

I'm currently up in Seattle for the big Emergency Medicine conference. On Monday, I was sitting in the lobby next to Sanjay Gupta as he banged away on his PDA/smart phone. A little bit later, I checked his blog and a post had appeared regarding an article that is presented at this meetings regarding the safe use of tasers by police (which is a whole other issue for a whole other blog post). The post is attributed to one of his staffers, but who knows.

We are staying at the Ramada Inn (thank you USF College of Medicine) in the middle of the financial district -- the same area that was hosted the WTO in 1999 and, of course, was home to the massive street demonstrations that same year.


The Ramada is on the corner of 5th avenue and Blanchard Street. The video above is a webcam from 4th avenue and Pike - just a few blocks away. The ACEP convention that I am attending is at 6th avenue and Pike. Things look clean and sterile (but admittedly very nice - nice city) today in front of the Washington State Convention Center.

William Easterly vs. Jeff Sachs - A question of treatment threshold and dose response

Professor Sachs is well known for his advocacy to increase federal aid to poor countries, while also canceling debt in many areas. Furthermore, Sachs advocates meeting the funding goals outlined in the Monterrey Consensus that calls for rich countries to give 0.7% of GNP. If the countries involved were to meet this funding level, Sachs argues that the Millennium Development Goals to end poverty by 2015 would be met. Unfortunately, only a small number of countries have reached the 0.7% level and the U.S. and UK are not among those.

While the U.S. did pledge to meet the 0.7% bar, the country is currently no where near this level of giving. However, the U.S. has expanded - nearly tripled - it's international aid donation during the Bush administration compared to the 1990s. However, at 0.23%, that still puts the U.S. well below the 0.7% benchmark. Jeff Sachs points out that this is only $0.23 of every $100 of income and only $0.70 is needed.

Easterly, an economist at NYU, is a long-time intellectual opponent of Prof. Sachs. In numerous articles and books, Easterly has criticized Sachs for his support of foreign aid, the Millennium Development Goals and the current state of international aid organizations. One of Easterly's comment critiques is that international aid has not been effective -- over the past 50 years, aid has increased exponentially but rates of poverty have also gone up throughout the world - specifically in those areas that receive the most aid. He makes many good observations for why this might be and also outlines important ways to improve the delivery and efficacy of foreign aid. However, his call to stop increasing foreign aid because it doesn't work is completely misguided.

In medicine, drugs have a window of efficient action called the Therapeutic Index. This window is the range of doses that - at minimum - allow the drug to affect the given pathology and -- at the top of the range -- the maximum dose that will not produce increased morbidity/mortality due to adverse reactions or drug side effects.

In terms of international aid, we are under the therapeutic index. Thus, Easterly is perfectly correct in his claims that increases in aid have not let to reduction in poverty. However, it is a fallacy to assume that further increases in aid will not lead to a dose-response once we surpass some threshold (namely 0.7% of collective GNP from donor countries). Until that benchmark is met, Easterly's argument is moot.

Finally, Easterly does have two ideas that should be integrated into the arena of development economics. Namely, incentives and accountability. People work harder and produce more when they have incentives - usually monetary gain. The distributors of international aid need incentives to optimize the results of every donated dollar. Finally, we do need accountability as well. Both Easterly and Sachs note that the majority of aid, in the past, has not reached the appropriate people due to corruption by top-level officials in aid countries. This has to stop if we are going to get a return on our aid dollars. But the approaches of Easterly and Sachs do not need to remain mutually exclusive.

Easterly seems nervous that Sachs is calling for a top-down, centralized approach to government when the truth is that Sachs is actually in support of a market economy within the framework of appropriate wealth distribution in the vein of - as he calls them - Nordic economies (namely Finland, Denmark, and Sweden).

An update on Health Courts

An alternative to jury based malpractice decisions and a potential solution to the malpractice crisis

The Health Care Blog has posted an interesting audio file updating us on Health Courts via a discussion with Professor Mello from the Harvard School of Public Health. Definitely worth a listen.

If you have been reading my blog for a while, you may remember a discussion of a bipartisan bill which proposed a Federal Health Court System. I couched that discussion in terms of, at that time, recent 2004 elections which added to health-related amendments to the Florida state constitution. If you are interested in those amendments or the context of the original discussion, read the post here.

Otherwise, here is an excerpt of my original discussion that is limited to a summary of the Health Courts Proposal:

"....only 2% of patients injured by negligent care ever file a malpractice claim and the current malpractice system only compensates 1 in 14 people. These low odds and the lack of precedent cause attorneys to adopt a strategy of swamping the courts with malpractice claims, 4 out of 5 of which are found to be invalid. A system of standards for awards and for care would greatly reduce frivolous suits and would allow attorneys, patients, and physicians to modify their practices and behavior accordingly.

There is a solution to these problems that would be in complete alignment with Amendment 3 and Amendment 8. The Progressive Policy Institute, among others, proposes a system of health courts for liability claims and written standards of liability settlement that would function similar to the workers compensation claims process operated by the Board of Labor.

The most striking and revolutionary changes that would follow the health court system would be a shift from designating blame to a particular physician into assigning a process of blame to a team, group, or institution. Furthermore, and maybe most controversial, the system would end jury awards for malpractice and would rely on written standards to dispense benefits.

The basic tenants of the Progressive Policy Institute proposed Health Court system include (1) replacing civil courts with health courts to hear liability claims (similar to specialized tax courts), (2)creating a written standard of accelerated compensation events (ACEs) of common medical mistakes and errors (e.g. bleeding after colon surgery requiring an additional surgery) that would detail a benefit schedule that could be included with lost wages and direct economic damages, (3) ability for patients to directly file liability claims with the health care provider or hospital, (4) a local board that would review injury claims and determine if they meet ACE designation or if they require further judafication, (5) a system of state and federal health care boards with mixed funding at each level, (6) the establishment of additional ACEs and benefit standards determined by written case law (7) experts will be paid and obtained by the court and board, not by the attorneys from either side, (8)the ability to monitor truly negligent hospitals and institutions over time and (9) use of evidence based medicine to establish a standards board for practicing physicians.

The benefits of this system are that physicians will have a clear idea of what constitutes malpractice and liable behavior because their will be a written set of standards developed from court rulings. This will decrease overall health care expenses by decreasing the practice of “defensive medicine” which is common among physicians (an over abundance of tests are ordered to cover liability). Furthermore, all patients will have access and ability to pursue injury claims in a similar manner in which they already pursue worker’s compensation claims. In addition, the hiring of experts by the court will reduce attorney fees significantly making it easier for low-income individuals to obtain representation. Also, juries should not be in the business of deciding law, they should be focused on deciding fact. However, the unclear precedents in current malpractice suits make it so that the jury focuses their efforts on deciding law since there are no clear standards of care. It is quite possible that two people suffering identical injuries will receive very different awards simply based on the jury they receive. A physician faces the same fate at the mercy of an assembled jury. Health Courts remove juries from these decisions and allow clear expectations and standards to develop over time.

The Progressive Policy Institute has also outlined a number of potential objections to this system. The objections will likely come from attorneys for two reasons – (1) citizens have the right to a jury trial and (2) malpractice attorneys could suffer decreased compensation and less demand for services. However, the workers compensation model is ideal for demonstrating that it is possible to settle liability claims without a jury. Furthermore, if only 2% of malpractice injury claims are pursued at present, and only 1 in 14 of those receive an award, attorneys may be able to find compensation simply by the increased frequency of malpractice cases they will be able to take on.

One other potential problem is that large jury awards have been significant for increasing reform in other industries. For example, tobacco lawsuits resulted in billions of dollars in jury awards that threatened tobacco companies and resulted in significant modifications within their industry and an increase in positive health outcomes among the community. However, the large jury awards are not useful in altering physician behavior or hospital practices. Since there are no clear standards in place, it is not possible that a systematic practice of negligent and liable behavior is occurring. In other words, there is no behavior to deter by these awards. As a matter of fact, the large awards are linked to increased health care costs due to the practice of defensive medicine and high insurance rates.

........By enacting a short-term 1% increase in malpractice premiums, a much larger decrease could be expected in the following years. The 1% increase can be used to set up a state Health court, as well as local boards that create ACEs and review claims. Once the system is launched, necessary attorney fees will drastically decrease as neutral experts are hired by the state, not the legal team. In this scenario, injured claimants would certainly recover 30%, or more, of their first $250,000 in non-economic damages. Furthermore, a state board would be created with the ability to monitor negligence and malpractice among individual physicians and hospitals...... It is possible that even with the significant reduction in attorney’s fees and the elimination of unfair jury awards, malpractice premiums may not decrease. At that point, the state should explore insurance reform, similar to the MIRCA in California to ensure that we maintain a population of specialist physicians in the state. In the immediate future, a state Health Court would allow us to address numerous problems now posed to us by the liability crisis. Furthermore, we would create the necessary infrastructure that goes beyond putting a band-aid on a gushing wound, allowing us to plan for adequate delivery of health care services now and in the future."

Links
1. My original post about health courts and new Florida law
2. Professor Michelle Mello, Harvard School of Public Health, Audio File
3. Progressive Policy Institute Article on Health Courts
4. Common Good Explanation of Health Courts

everything in moderation

I think it's funny that Naomi Klein's new book calls for a "mixed-economy" - which I agree with in principle (a mix of free markets with strong support for govt social programs and regulation). But there is also a reactionary feel to her work - such as her criticism of people like Prof. Jeffrey Sachs.

I like what Klein is saying in her book but I like the policy and goals of people like Sachs even more. If I wasn't moderate about my intake of information and opinion/perspective formation, these two things would NOT be able to co-exist. Why? Klein calls Sachs "The New Shock Doctor" in response to his radical economic policies in Bolivia and in Poland in the 1980s.

More importantly though, Sachs has an outlined goal to END poverty - he has steps to take and is working on the Millennium Project with the UN, and with his own Earth Institute at Columbia University, to carry out those steps.

The point is not whether this will work or not, the point is that Sachs has a vision for change , the education to formulate real steps and ideas, and the influence/power/experience to actually carry out many of those propositions.

Why spend so much time criticizing someone who wants to find ways for local economies to meet financial independence through the creation of their own infrastructures? In the Sachs model, populations become less dependent on the U.S. - something you would think Klein would be in favor of? But, in the uni-lens view of "shock"/in the reactionary vein, it is difficult for the author to see this - even though it sounds like she is advocating moderate approaches that would support other ideas about economic progress in her push for "mixed economies". The NYU economist William Easterly has a much more serious rebuke to Sachs' ideas. However, his training and his acceptance of many basic tenants laid out by Sachs make his review more serious than that of Klein.

Blinded by ideology -- something that scared me about the left when I was younger and something that keeps me much more independent now (whether I align 90% of the time or not). More on all of this later, when I give more detailed discussion of Sachs and Klein - or moreover (and more fair, since Klein isn't an economist) - to Sachs and Easterly.

Bridge Clinic - USF Free Clinic

Congrats to Sam, Omar, Shelby and Waldo. More importantly, congratulations to the USF area population. They now have some refuge during our country's continuing health care crisis.

My colleagues' hard work to open the Bridge Clinic in the USF area has paid off. The clinic has the full support of Dean Klasko and is up and running as a student-run continuity clinic (supervised by attendings) with the ability to make specialty referrals, provide lab testing and other services - such as physical therapy.

Channel 10 did a recent story that you can view by following the link below:

http://www.tampabays10.com/video/player.aspx?aid=48866&sid=64484

The Bridge Clinic

The Inkwood Penalty: Are locally owned businesses worth the tax?

Tampa doesn't have a very large market of independently-owned businesses that carry things I consume. One of the few that does have stuff I want is Inkwood Books on the corner of Armenia Avenue and Platt Street in South Tampa.

The small bookstore became popular when I was a high school student at Plant in the mid-90s during an era predating amazon.com - the store was the place to go for english lit books throughout the school.

As I got older, and the non-fiction market grew, I turned to Inkwood more because it simply was the best place to go in hopes of actually locating a new book that I wanted to read. While Amazon was prevalent by the late 90s, always carried what you wanted, and almost always cheaper - instant gratification could not be found online. Thus, local bookstores did - and still do - win out when I wanted/needed a new tome.

However, Borders began to expand their selection in the late 90s -- stocking their shelves with more "independent" and "small" publishers. Thus, the choice between the mega seller and Inkwood became less clear cut.

In addition, the social attraction to Borders over Inkwood also became clear as a college student and grad student looking for a place to take up space. Coffee, couches, music are all good ways to pack customers into a store and keep them there until they buy a book.

Furthermore, new books at Borders sell for about 25% off the list price. A select handful of new books each month sell for 20% off the list price at Inkwood. Therefore, in many cases, shopping at Inkwood results in paying a penalty and receiving less goods (no coffee, couches, music) for a higher dollar figure.

In addition, if you sign up online for Borders Membership Rewards club, you receive a coupon every Friday for for 20-30% off any item in the store. You can print out as many coupons as you want - there is no limit on hitting the print button and no link to your exact account (to be more clear, I'm sure Borders would prefer you to come in and buy infinite products at 20-30% off then no product or 1 only product).
Furthermore, every time you buy something at Borders, you get another coupon for 20-30% off anything in the store, allowing you to keep the purchasing cycle alive ad nauseam.

Essentially, you can find everything at Borders that you can at Inkwood (plus a whole lot more stuff you don't really want to find). You can also get it cheaper with more hours in the day to get there(Borders is open until 11pm everyday, Inkwood is open as late as 9pm only 1 time in the week).

If price and convenience were the sole factors, certainly Inkwood would be out of business (at least out of the direct retail business - maybe they would subsist instead only with contracts/deals with local schools). So why are they still in business? More importantly, why did I go there this weekend and pay $13 more (30%) for a book I could have also purchased at Borders, less than 1.5 miles away? What makes a consumer willing to spend such an exorbitant penalty?

Branding. Inkwood has a prius in the parking lot. Inkwood carries a wide range of books but certainly has all the liberal non-fiction and the small-press fictional literature that is hot in the Democracy Now!, NPR, McSweeney's circles. Inkwood is an independently-owned local business with a connection to other independent news sources, radio stations, and stores within the community.

The bottom line for me is that I almost feel as "duped" by buying within my brand - feeling some intangible need to support local business. Moral economics?

I buy a lot of books and I'm not convinced that conscious consumerism is really worth such a high economic penalty. I suppose one way to look at it would be - Who can do more with the extra dollars? The local business you are supporting or you --the individual? Well, if that's how you look at it, then I would say that the answer is dependent on what percentage of income we are talking about. Until I'm an attending physician, $13 - potentially over $100 per month - is still a decent chunk of change on a med student or resident's salary with a teacher for a wife who doesn't exactly rake in the millions.

At this point (and maybe at any point) I could probably "do more" with the excess dollars by purchasing more books at a cheaper price. Wouldn't this scenario lead to larger support of the publishing industry as a whole by supporting a larger group of people then just one store? Not too mention, increased knowledge acquisition by me and a better return on my money at every purchasing event (comfort of borders, etc).

Inkwood does do a service that should afford some extra price of their products - they bring in many authors for book discussions. I would be open to the argument that this service offsets the services provided by Borders of comfy confines. Only problem is, Inkwood rarely brings in the folks I want them too. Thus, this happens to be a matter of personal taste and I can't feel guilty about neglecting the store on that point. For example, this weekend I bought a book by Naomi Klein (The Shock Doctrine). The author is currently on tour but not coming anywhere near Inkwood. Perhaps if the author was going to speak at the store I would have no problem paying the extra $13 for my copy of her work?

I think my conclusion, for now anyway, is that " The Inkwood Penalty" is one that I just can't pay - especially when you know you are getting less material return for your dollar.

Now, if Inkwood wants to start honoring those competitor coupons I get each week, maybe, just maybe, we could talk.

T-mobile or T-rex?

The dinosaur of wireless companies and the ridiculous expense/luxury-tax on true wireless internet (not yet obtainable to even a tech-savvy consumer).

For some time, I have been curious about using upgrading my existing T-mobile service into the world of full wireless internet. hahaha - this was a thought in futility as I, instead, learned all about the outdated infrastructure of T-mobile and the high price of all wireless companies in the realm of broadband access.


1. Currently, T-mobile has only an EDGE network which runs at about 90 -135 kbps. Almost every other major carrier sports a 3G network, allowing speeds around 300 kbps.

2. There are rumors that a 3G T-mobile network is now ready for launch sometime in the near future. However, it is apparently on a different frequency then current phones (1900 mhz instead of the more common 1700 and 2100 mhz [european]) so new phones/PDAs will need to be created before it can work with mobile devices. Plus, there is no exact launch date yet. The slow down may be due to some government related entanglement involved in freeing up the 1900 mhz frequency according to this article.

3. The new T-mobile combo phone/PDA (the T-mobile Wing - see video review here) is really not a great improvement over the 2005 T-mobile MDA ( video review here) that I currently have. The new Wing does have Windows Mobile 6 (which is itself apparently not a great improvement either) but no real upgrade in processor speed (201 mhz vs. 195 mhz), SDRAM (both 64 mb) or onboard flash memory (128mb in both). Most of the improvements seem to be in things I don't really care much about - nicer design, better color, square keys on keyboard, and a bigger menu button. Plus, the camera went up to 2.0 megapixels with an 8X zoom - whoope-dee-f*in-do....it's still a crappy plastic lens and a crappy camera that should only be used in odd situations (spy photos while looking busy at work!) or emergencies (you get in a car accident with no camera handy, etc).

4. I would like to make the transition to full wireless company networking - e.g. get rid of the cable modem if possible to obtain non-801 dependent wireless access.

5. My options are to stay with T-mobile and move around the network like a dinosaur with arthritis or to eventually make a switch to another company when our current T-mobile contract expires at the beginning of may.

6. I will first consider the options to stay with T-mobile in hopes that 3G shows up by May but will also examine networking possibilities with AT&T/Verizon/Sprint since they seem to be far far ahead in that arena. Especially AT&T which has produced the exceptional 8525 phone/PDA combo that definitely outperforms the T-mobile Wing and will be adding Windows Mobile 6 later this year.

7. I only consider Windows Mobile OS-based in this review. I have a personal preference for this type of phone, which are also usually designed with the slide-out QWERTY keyboards. No Palm Treo models are considered.

8. What am I looking at here? The ability to convert our house to non-cable modem internet access on the 2 laptops and having a fast and efficient PDA/phone for work.

9. T-MOBILE
a. T-Mobile Wing: Price w/contract renewal = $300
b. 2 Sony Ericcson Laptop Network Card s = $150/card = $300 (listed as $199 on web, but phone rep verified $150 price)
c. Internet Access Price per month = $50/laptop X 2 ($100/month for, essentially, dial-up speed!)
d. 2 Year Total Cost = $3000

10. AT&T
a. 8525 Smartphone: Price with contract = $350
b. 2 AT&T Laptop Connect Cards: Free with 2 year contract (AT&T also offers ability to use your smartphone as a modem to get to the 3G network)
c. Laptop Connect/Data Connect Internet Access Price Per Month = $60/laptop with 1 $5/month discount for a voice plan ($115/month)
d. 2 year total cost = $3110

11. SPRINT
a. Spring Mogul by HTC Smartphone: Price with contract = $300
b. 2 Sprint PX-500 Network Cards: $10/card with 2 year contract = $20
c. Unlimited Broadband Mobile Connection Plan = $60/laptop X 2 = $120/month
d. 2 year total cost = $3200

12. VERIZON
a. Verizon XV6700 Smartphone: Price with contract = $300 (slightly outdated, Mobile 5.0, plans for new one?)
b. Verizon PC5750 PC Card: Price with Contract = Free
c. Unlimited Data Plan = $60/laptop X 2 = $120/month
d. 2 Year Total Cost = $3180

10. Additional Costs OVER Existing Roadrunner Cable Modem Service
a. Do not need to include cost of T-mobile Wing -- if no changes were being made to internet service, I would still buy a wing (excluded = $300) - so this is not really an extra cost.
i. The adjusted cost over 2 years with that considered-credit then is as follows
T-mobile = $3000 - $300 = $2700
AT&T = $3110 - $300 = $2810
Spring = $3200 - $300 = $2900
VERIZON = $3180 - $300 = $2880
b. Roadrunner Cost Per Month
i. Currently have Digital Combo Package = Cable + Roadrunner = $79/month
ii. Digital Cable Alone is $60/month
iii. Thus, the Roadrunner incurred cost = $19/month
iv. We would keep basic cable if we canceled the internet, thus, our bill would only derease by approximately $22/month (when taxes are included)
v. The savings of 2 years of this service decrease = $22 X 24 = $528
c. The additional cost after 2 years of cellular-company based wireless is
i. T-Mobile = $2700 - $528 = $2172
ii. AT&T = $2810 - $528 = $2282
iii. SPRINT = $2900 - $528 = $2372
iv. VERIZON = $2880 - $528 = $2352

11. 2 Year Costs PER Laptop
a. T-mobile: Network Card $150 + Internet Access $50/month ($1200) = $1350 - $528 = $830
b. AT&T = Internet Access $55/month ($1320) - $528 = $792
c. SPRINT = Network Card $10 + Internet Access $60/month ($1320) = $1330 - $528 = $802
d. VERIZON = Internet Access $60/month ($1440) - $528 = $912

11. CONCLUSION
In May, I will likely just "upgrade" (not much of an upgrade) from my current T-mobile MDA to the T-mobile Wing - mostly for mechanical reasons (my MDA takes a daily beating and it is starting to show). With two computers, you just pay way too much for the internet access - essentially paying more than double what it's probably worth. Anyway, with one computer, things are a little more attractive (as low as a $792 luxury fee to have this service if you go with AT&T).

With more than one computer and still high prices, another 2 years as a T-mobile customer is likely (will go to 10th year of T-mobile at that point I believe). I'm not happy that this company hasn't made infrastructure upgrades and I'm even more unhappy that the cost of true wireless seems ridiculous compared to the traditional cable modem/wireless router/hit up paneras approach I currently employ. My guess is that this may be cheaper and easier in a few other countries out there.

more people who disagree.....

so, here are some more arguments from other people who disagree with my perspective regarding the Lee Bollinger intro of the Iranian president....

http://blogs.zmag.org/node/3226

The Conflation of our Era

This is an excellent excerpt from a longer article on Hunffington Post

If the quintessential symbol of the American character in World War II was Rosie The Riveter, the poster for the Bush Wars has to be that of an SUV driver receiving a tax break while sucking down enough Saudi oil to drive to a mall where he's expected to buy lead-tainted crapola manufactured overseas -- a yellow ribbon hypocrite magnet dangling just above his exhaust pipe and several inches from a fading W04 sticker. The caption: "The Bush Patriot Says: 'I'm On It, Mr. President!'

go to the post here

Flight of the Conchords - The Humans are Dead

Men's Health Advocates Doctor Shopping!

In a troubling column by Men's Health writer Adam Baer, the author describes his recent one year search seeking a diagnosis for a puzzling set of symptoms. The author was a Hodgkin's Lymphoma patient as an adolescent. As a 29 year old man, the author began experiencing some vague neurological complaints but no focal neurological deficits. Anyway, he presented to his PCP and the physician did the appropriate work to rule out any serious complications of his previous lymphoma as well as any new, acute and organic health problems.

After ordering blood work and appropriate imaging no explanation was found for the symptoms. The physician, completely appropriately, asked the patient to follow up in 6 months. This is where things fell apart and the likely anxiety from the patient's past diagnosis likely took over better reasoning.

The patient, unsatisfied with his physician's management plan, began to doctor shop. After receiving the same response from doctors in his area, he branched out. Over the year, the patient traveled the country seeking a "definitive diagnosis". After one year of this, the patient did find an explanation (at least partly) for his symptoms and started treatment. Thus, the author concludes, that it is important to "doctor shop". Yikes.

The basic problem with this is that the original physician would have likely gotten to an appropriate diagnosis at follow up - likely quicker than 1 year and certainly much cheaper than the cost of traveling the country. Without developing a relationship with a primary care physician, it is impossible to know a patient's baseline health status and to follow changes over time.

The other disappointing aspect of this article is that it short-shifts a more important point - namely that adolescents and young men do have poor relationships with physicians and are certainly under-served populations leading us to miss rare but serious disease in those groups.

Anyway, I wrote a reply to Men's Health regarding the article that follows below. We will see if they publish it in some form.

LETTER TO MEN'S HEALTH
As a soon to be physician (I graduate medical school in May) and a young man, I read the recent article by Adam Baer (October 2007, pp. 106-111) with much interest. The article noted the difficulties all young men face with finding adequate health care and the special situation of Mr. Baer that involved dealing with a serious medical issue as an adolescent and adult. However, there is some very troubling advice offered in this article that I would like to address.

First of all, I will commend Mr. Baer on noting a very real problem – lack of satisfactory coverage in adolescent and young adult populations. Certainly we, as health care professionals, do need to work harder in addressing preventive health and illness in those groups. As the author points out, even young healthy people sometimes get very sick.

The problem is that, when Mr. Baer noticed changes to his health, he was unwilling to work with one physician to solve the puzzling symptoms he brought to the clinic. His first physician acted appropriately by ruling out an immediate life threatening condition and asking the patient to follow up to evaluate any further changes.

Apparently, the author was not satisfied with this conclusion and proceeded to travel around the country from doctor to doctor. It is true that one year later the patient did, indeed, receive a diagnosis. However, if the author would have developed a relationship with a physician, appropriate follow up may have led to a quicker, and certainly cheaper, realization of the diagnosis.

The author encourages readers to doctor shop until you receive a definitive diagnosis. This advice does not help us get any closer of solving the original, very real, problem that the author first described – namely, that young men need to develop a relationship with one primary provider so that a long term relationship will lead the physician and patient to appropriately explore any changes in health.

Bollinger the shill?

1. The overwhelming response by liberals is that Bollinger played the shill during his introduction, playing into the hands of the conservative agenda and making a case for a war with Iran.

2. Here is where I part company then, I suppose. Just because "right" happens to correspond with conservatives doesn't make it not right anymore. What Bollinger did was still, in my mind, exactly the type of frank talk needed right now on university campuses. The foreign policy leaders need to exhibit more etiquette, but our academic institutions do not.

To read those who disagree with me, go to:

Byron Williams, Huffington Post

President Lee Bollinger

[scroll down past this post for the Andre Meyers/UF Taser Incident entry]

Well, on the same day I wrote an entry calling for more real-life social disruption, I think we got some yesterday afternoon. I'm sure it's because of this blog, right? right?

I was at U of Michigan during the tenure of Lee Bollinger. He left when his alma mater, Columbia University came calling and was replaced by Mary Sue Coleman. Well, I never really had an opinion about Mr. Bollinger until today. Now, he will forever have my respect for his engagement of President/Lunatic Ahmadinejad during an official welcome and introduction before a speech/rambling diatribe by the Iranian "leader".

It is so rare to see people in prominent positions speaking so frankly and so passionately in a direct and antagonistic manner. This is what our academic bastions of free speech should be doing right now and Mr. Bollinger is leading that cause with his manner of speech. Wow. This is the grown up version of the taser incident. Only, President Bollinger's position allowed him to cause important social disruption without a physically violent result unlike we, unfortunately, see result for many workers, poor immigrants/citizens, and, of course, Andrew Meyer.

Finally, my current medical school and university - USF - is certainly on the rise both academically (some top ranked programs in the medical school and on main campus, research 1 status, increased research dollars flowing in) and in national prominence (hello #18 AP and USA Today Football Ranking). But, can you imagine hosting such a controversial figure at the Sun Dome? Can you imagine President Genshaft delivering the message that was given by Bollinger? Can you imagine anyone caring if she did?

Nope, nope, and nope. We're getting there Bulls, but we still have a long way to go before we are nationally and internationally relevant on the big time stage of academia. I've been a part of the USF community as an undergrad in the mid-late 90s and came back in 2004 to a much improved place for medical school. I can see myself as a faculty member at this place in the future but I'm not sure if I can honestly see us ever taking a place on the world stage that places like my alma mater U of Michigan and Mr. Bollinger's current Columbia University certainly exhibit.

Anyway, if you somehow missed it, or just enjoy watching the intro again and again, follow this link:

Andrew Meyer

Please read this whole post before making any assumptions about my interpretation of the recent arrest of Andrew Meyer at the John Kerry event on the UF campus.

1. Talking about the UF taser incident on a blog is, indeed, a large part of why the very non-virtual incident needed to happen to begin with and a huge part of the overall problem with the current trend of "social activism".

2. My hypocrisy is going to be alleviated by the fact that from the ages of 15-22 years old I do have a record of non-virtual activism/conscientious objection that took place in the real world and not on the internet. Amazingly I was never tasered - this is probably because I remember in 1996 that the very idea of a police taser was the punchline at the end of an early Daily Show episode, not an actual weapon carried by cops.

3. The kid who got tasered seems like a real asshole. He has a website dedicated to making himself famous - which, in his future line of work, I can appreciate the need for some vanity. Thus, on it's own, I think I could let that slide. I mean, many of us do have blogs, myspace pages, and family web sites - a page collecting early professional work of a wannabe isn't too vain in context. He also has an irksome email address though (famouswriter@....) and apparently had a track record of writing poorly researched articles aimed at angering the UF student body.

4. It seems pretty obvious the kid was being disruptive, speaking out of turn, and flailing about in front of a current veteran senator and past presidential candidate. Surely, the guy should have been kicked out of the event, right?

5. Yes, he should have been kicked out of the event. At the same time he should never have been tasered. I mean, come on, no matter how much a dorky kid bounces around, 4 or 5 burly cops should be able to handle the situation without much problem. Furthermore, a taser is not a weapon to dismiss lightly. In medicine, we learn the pathophysiology of many diseases that cause much less morbidity and mortality than the 61 deaths reported last year as a result of a police taser.

But now, let's take the argument one step further......

6. We need more assholes like Mr. Meyer. We need more people who purposely set out to cause disruption. We need more people to start flailing about right now.

Especially our 21 year olds on college campuses who don't yet have that weight of real-deal adulthood bearing down on their shoulders with wives and kids and careers always resisting their actions much more strongly than any police taser.

There are millions of blogs like mine and places to go to voice every protest to every speech, every politician and every action in the country. There are TV channels dedicated to every viewpoint.

Does this translate to any change, to any action? Well, if a social faux-pas is committed, than, yes, I will allow that youtube-ostracism does change careers (Howard Dean, Sen. Allen, and Larry Craig).

But how about social justice? The most recent examples of large scale youth movement in the U.S. is probably the WTO protests in Seattle - well before the Web 2.0 revolution. Just after this was the Gore 2000 Washington marches - again, before Web 2.0

I would argue that - if these events took place now - real world action would be eroded by virtual protest. I would offer that the lack of daily large scale protests against the Iraq war are partly due to the prevalence of virtual protest which is doing much more than disseminating information equally. It is eroding a collective nationwide response to injustice.

7. Comedy is an excellent weapon and tool to cope with life but right now we are using comedy to alleviate middle-class guilt. The popularity of The Daily Show and The Colbert Report (both excellent programs) demonstrates that people do have problems with the Iraq War and President Bush (both frequent topics on these 2 programs) - otherwise, free market economics wouldn't allow those shows to focus on such issues repeatedly. But this current trend of comedy, and the shared popularity of these themes in our collective conscious, makes us impotent to do anything more than watch and laugh as the world passes by. This is clearly made evident by the quick response to that already-famous line "Don't Tase me, Bro!". Buy your T-shirt now!!!

Although, at least Comedy Central's Mr. Colbert did call for his viewers to stop blogging, stop watching and follow Mr. Meyer's lead.

8. Web 2.0 promised to change the world, and, indeed, it has. But is this the change we had in mind when we envisioned equal information access?

health care hillary

hillary joined john edwards and mitt romney in crafting a "universal" health care plan.

problem is, the plans all have two things in common that keeps them from being truly revolutionary --

1. they are employer based health care plans
2. they are managed by private businesses that seek to increase profits not health

until we move away from these two things we will never have real change.

the worst part about all of this is that people get caught up on labels they don't understand. for instance, consider these two points:

1. people get all worked up about "socialized" medicine but if you say "universal" health care people are at least willing to talk

2. people have no idea how close we are to socialized medicine already and how well it actually does work -- medicare/medicaid/hillsborough county health care plan and the VA are great examples

well, i'm going to the physician's for national health care leadership conference on November 2 to learn more and work harder for a real alternative. in the meantime, i'm done apologizing to my colleagues for my support of health coverage for every person in this country.

the bottom line is that it is time to find a way to make it work - every other democratic, industrialized country handles this - we're the best country in the world, so why can't we?

now, just convince health care professionals that their salaries won't drop to minimum wage and we won't have to drive old beat up chevy's when the day comes that our patients can afford to see us and we can treat our patients based on medical decisions (of course that is half stuck in the muck of CYA medicine as well) not ways that maximize HMO profits.

Here is the Physician for a National Health Care Plan response to Clinton's plan:

http://www.pnhp.org/news/2007/september/hillary_clintons_a.php

The Journal Project

Back in the grad school days, keeping up with the literature was critical to keeping your cred on the anthro streets....okay, there are probably no anthro streets, but, nonetheless, it's important...

anyway, in med school, the literature is still important but not nearly as crucial to your academic life. That's because, as a med student, you are more responsible for the background information than the foreground information and creative research questions. It's still necessary to just get a hold of the huge amount of human disease and illness in all aspects of pathophysiology, pharmacology, etc.

However, now that I'm about to make the transition from med student to residency, my life will become more similar to my like as a PhD candidate with a true obligation to make some type of research contribution and certainly to understand the relevant advances within my field/fields of interest -- emergency medicine, global health and applied medical anthropology...

So, having said that, it is simply NOT possible to keep up with all the articles and journals that you should keep up with - you can't read everything while still keeping up with your normal clinical duties and maintaining some type of life. I heard a recent stat that you would have to read 18 articles a day to stay up to date in just one discipline of medicine.

Now, there are some great tools in medicine that I didn't have at Michigan to help with this task. For instance, Journal Watch monitors, collects, and summarizes the important journal articles in a field of your choosing for a monthly price. Furthermore, the conferences in medicine are not solely devoted to presenting new research - they also have time for interactive sessions to review past literature so you can just sit for a few hours in a dark room and get up to date by osmosis.

These are all advances I'm planning on using. In addition though, I do think it's important to make an effort to read a least a fraction of the important publications. Thus, I've chosen 10 journals that span the breadth of my professional interests, collected their publication dates and made a schedule to keep myself aware, up to date, and hopefully sufficiently read-up on their contents. Right now, I've got a list of 9 and for two weeks now, I'm doing pretty well with keeping up - not reading everything, but at least the abstracts of the articles that have only tangential relevance....

1. New England Journal of Medicine
2. JAMA
3. Annals of Emergency Medicine -- ACEP
4. Journal of Emergency Medicine -- AAEM
5. Academic Emergency Medicine -- SAEM
6. Journal of Trauma
7. Human Nature
8. Current Anthropology
9. Evolutionary Anthropology
10. Health Affairs

prelude/intro to "the summer of sharks and beaches"

In the middle of the twentieth century, philosophers often used fiction writing as a tool to explore epistemological questions. The novel became the vehicle for Camus and Sartre to deliver an existentialist platform. In many plays, (such as "Waiting for Godot" as well works by Sartre and others) various themes were explored by using appropriate plots and characters to work through logical constructions in an entertaining manner. This approach is not as popular today, or at least is not widely accepted academically, and thus, is not as well known by readers exploring contemporary issues in philosophy. The use of fiction allowed past writers to entertain themselves and their readers, likely leading to better penetration of their ideas to a broad audience.

In today's publishing market, a plethora of non-fiction titles dominates the landscape of empirical knowledge acquisition. Unfortunately, the sheer volume of these titles and the limited time nature of their relevance, makes it impossible to keep up with anything but the most specific sub-sub-specialty areas of our interests. Many theoretical arguments in popular non-fiction are based on current events and are written by policy experts, journalists, or scientists within the specific topic field. The advantage of this approach is that the average reader does have ACCESS to more information than ever. However, the disadvantage of this is that access may not translate well to knowledge or individual growth for the reader. The reader likely can not keep up with all of the titles, can not explore titles in all fields and is accessing data and hypotheses that may already be irrelevant at the time of publication or reading.

The merit of literary fiction, on the other hand, rests in the timeless lessons delivered to us through the character development and plot. Through fiction, a reader can construct a broad empirical foundation of knowledge acquisition. In other words, they can learn how to think and how to realize their own perspective of the world and of information. By exploring the "theory of knowledge" outlined in a story by a fiction author, the reader might, if astute and appropriately reflective, construct their own "theory of knowledge" that they can use in all areas and topics they encounter.

In this manuscript, I have attempted to return to fiction as a tool to convey an underlying philosophical construct. My hope is that, at the very least, this approach will deliver and engaging story with characters that are emotionally significant for the reader. At best, this approach will help me work though an idea I continue to develop through my own reading, observations, research, and experiences. This work is not meant to introduce an overarching, perfectly reasoned, philosophical theory that has been applied to any serious academic rigor or testing. Instead, this work is meant to take advantage of a tool (fiction) to scratch the surface of an important idea. In other words, nothing earth shattering is likely to be found in these pages and the way you view the world may not drastically change. However, I do hope to introduce a hypothesis, a nagging little observation, into your life through the development of my characters and the construction of the subsequent story.

More specifically, the goal of this manuscript - this story - is to explore the viability of using fiction writing to discuss probability, randomness, and how we use information to make decisions. As alluded to earlier, this topic has been explored recently in popular non-fiction. Malcolm Gladwell's work (Blink and The Tipping Point) brings difficult mathematical concepts regarding probability and decision to a broader audience by using a broader language in his writing. Furthermore, Steven Levitt (Freakonomics) has also been able to write about statistical patterns in a very appealing way. However, while these authors have indeed done an excellent job exploring those topics, they are, nevertheless, non-fiction. It is my belief that this genre has the limits outlined above and that an approach to those topics through literary fiction is needed to provide an appropriate complement. Only through this approach of duality can we hope to disseminate important ideas to all interested readers.

This is not to say that my ideas are identical to those in earlier non-fiction works. They are similar but focused on a different theme. Here, in this story, my goal is to explore how we acquire knowledge, how that knowledge affects our decision making process, and whether or not increased knowledge leads to better decision making. Is it knowledge, timing, or experience that leads to the best outcomes in our own life? Can we retrospectively evaluate this conflict by looking at our past decisions, or are we too biased by likely overstating the positive outcomes with a more clear picture in our minds eye regarding what went into those decisions?

My basic premise is that the most important decisions we make will be made fairly quickly - in a small window of time. Maybe we do nothing - we let the window pass by due to lack of preparation or readiness. This is a decision in itself. How do we evaluate the unknown and how do we rank and weigh the available information we do have? Does that information even help? How much of the outcome is simply chance and given the same scenario again, who is isn't to say that the same decision would have a negative result? How do we know the result that we think is positive, is successful, doesn't actually represent the wrong decision between two options - would the other choice have turned out better?

In addition, it may seem that our options, our choices, are infinite. But they are not. While the decision trees are, indeed, close to infinite and likely distributed continuously, the individual decisions we make themselves are actually quite confined within a given set of choices. This set of choices might actually be where our past work of knowledge acquisition and idea development comes into play. In other words, our experiences and education might not help us actually make the right decision given a set of choices. Instead, our experiences and education might be responsible for something even more a priori and important - the underlying set of choices from which he have to select. Thus, I argue in this story, that every time we make a choice, we are - at some level - aware of the elements of our choice set and have purposely (at least through proximate mechanisms) acted to construct that choice set. However, it is unlikely that, given our limits to predict the future, we have any ability to pull the "best" element out of that set in terms of having a positive impact on our remaining life.

Certainly these are themes that could be explored rigorously in an academic mathematical or statistical program. What is probably obvious, however, is that I am neither a mathematician or a statistician. Instead, I am a soon to be physician-anthropologist and, thus, I have chosen to approach these problems using a tool I appreciate and find most applicable to my own personal and professional life - a novel.

This manuscript is a work in progress - while all of the chapters have been drafted, much work still remains in integrating the appropriate questions raised here in this introduction. Furthermore, much editing still remains to improve the writing, plot and dialog. My plan is to intermittently use my blog to work through those areas of the manuscript where I continue to have difficulty.

west palm drift dive

we had a great, but short, dive today in west palm beach - 2 wrecks during a drift dive of about 80 feet. Saw 2 hawksbill turtles and a goliath grouper. great visibility, lots of life with a ton of diversity. check out the pictures on the picassa album at

http://picasaweb.google.com/alivinghominid/West_palm

ideas about the PACEMD Oaxaca Project

1. Some NGOs believe that improving maternal mortality and reproductive health can lead to better access to contraceptives and reproductive planning, as well as an eventual delay in the beginning of the reproductive period. Ideally, this delay would decrease overall fertility and would lead to economic and social advances. However, my question is whether this is a testable assumption. Do NGO funded programs designed to increase reproductive health actually lead to decreased fertility and the desired advances? How can we measure such a claim?

2. The premise of life-history theory is that species must make trade-offs in available resources and thus, there is likely some ideal level of fecundity which correlates to the highest possible fertility of a reproducing female. How do programs that are explicitly designed to decrease fertility become adopted into human groups that maintain traditional practices aimed at increasing inclusive fitness by maximizing quantity of viable offspring?

3. What is the current demographic characteristic of the southern Mexico region? What pattern do we see in this region and are changes to this pattern likely to follow in the coming decades? Is a demographic transition occurring within this group? Does such a transition make adoption of a model that improves reproductive health more likely?

4. Is a training program organized by "outsiders" sustainable? Can sustainability be maximized by making use of a few key target individuals within the culture of interest? Will using those individuals allow the program goals to proliferate without a continued presence of the "outside" entity?

5. Recently, an emerging field within the confines of emergency medicine has grown in popularity. Fellowships in "international medicine" can now be found at multiple graduate medical programs. However, the underlying goals and methodology within these programs is not clear. If this field is too survive and contribute to medicine and other disciplines, an overarching purpose should arise. What type of implications does this program have for the future of the emerging field of "international medicine"?

6. There are multiple fields in other disciplines that address global health questions and examine the impact of system changes worldwide. For example, medical anthropology looks at how cultures integrate and respond to various models of health and illness while applied anthropology often focuses on ways to improve health by designing and examining programs grounded in public health principles. Of course, public health and social epidemiology also examine the risk factors of individuals and groups in regards to their health status. Medicine has not played a large academic role in these questions and has, instead, focused on providing short term care to a small amount of individuals in need during a given point in time (i.e. medical missions). An integration of these disciplines may lie within the new field of international medicine.

thanks sam

samantha died last week of complications from lymphoma - she was close to 10 years old and the best dog ever

obesity as a contagious disease

great article today in NEJM that is right at the intersection of human behavioral ecology and medicine - Christakis and Fowler analyze a social network and make an argument that obesity spreads horizontally throughout....
ah, if only i would have thought of a project like that while at michigan!

http://content.nejm.org/cgi/content/full/357/4/370

adiós mexico

Dollmaker in San Miguel de Allende

Teotihuácan

We left San Miguel on Friday morning July 6 and headed back to Mexico City for one last day. After arriving at the Central del Norte, we went straight to the bus marked "Pirámides" and started the 1 hour trip out to Teotihuácan - a perfect last day activity for Mexico.

As you probably know, this is one of the best archaeological sites in the world, with most of the buildings and pyramids still standing even though the site was deserted by the Aztecs years before the Spanish discovered Mexico. These sites near Mexico City are important because they represent the habitation of the area for thousands and thousands of years as the focal point for the population.
Plus, Pyramid of the Sun is the 3rd largest Pyramid in the world and, to Kryste's dismay, you can climb to the very top of it - sometimes even with the assistance of a handrail!

Anyway, here are some pictures of the site:

i dunno know

More posts coming soon...

more mexico and keys scuba posts coming soon.....

Dolores Hidalgo

Dolores Hidalgo may be the ugliest city in the world, or at least in Mexico...or at least in the state of Guanajuato...

Dolores Hidalgo is located about 30 miles north of San Miguel de Allende....about a 1 hour bus ride each way with no first class available (so while cheap - about $2 - also slow with many stops)....




The town can best be described as the land of exotic ice cream flavors (cerveza, avocado, cheese, etc), the bean market, and cheap pottery/ceramics. Oh, it's also the cradle of independence in Mexico as it is the sight of where Hidalgo started the march to San Miguel in the beginning of the revolution against the Spanish. You can read more about the history of Hidalgo and Mexican independence here.

Unfortunately, even with that claim to fame, there is not much in the way of historic or tourism interests here and the natural beauty of the town is lacking. The major historic site is the Hidalgo church and museum in the main plaza area.





Nonetheless, I did work in the ER here and found that it was worth the 1 hour bus ride each way from San Miguel in comparison to the other hospital site I was at. This is because there are medical students from the University of Leon at the facility, and, thus, the attendings here are a little more comfortable and acquainted with the role of a medical student.

Furthermore, Kryste and I did make a day trip out to DH to find hand painted plates for the house - which we did at won of the many many pottery/ceramic stores up and down the main strip of Dolores Hidalgo.


Of course, we couldn't leave without some strange ice cream flavors as well....

America!

I've been meaning to write this post for some time now - and what better time than July 4th for this topic?

First of all -- yes, I do realize that Mexico is in "America" - but having said that, let me assure you that when someone here says "American" - they are referring to a person or style from the U.S.

OK - now that I've given my blurb, let me get to my post.



There is an area of town, a strip mall really, that we call "America". Why? Because if you didn't know you were in Mexico - if you just saw the picture or landed from a space adventure in this strip plaza - you would think you were in Novi, Michigan or Carollwood, Florida - any suburban plaza in the U.S.

America is pretty close to Atascadero (our neighborhood) and has (1) a very modern, large Grocery store, (2)A megaplex movie theater with movies in English and Spanish, (3)A Sushi restaurant --yep... (4)A coffee shop - with a name in English (5) A McDonalds coming soon and (5)A number of clothing boutiques selling American style clothes at American prices (600 frickin pesos for a dress, come on!).

Anyway, we visit America about once a week - on America Day (aka Saturday or Sunday)...generally on America Day, we sit at the coffee shop and study Spanish, eat dinner at one the Sushi place or the Sports themed Mexican Restaurant and then head over to a movie at the megaplex - Ocean's 13, Fantastic 4 - all the stuff you would expect at home - plus the Spanish subtitles do help with the learning - really. It's nice to hit up the Gigante on the way home to grab all the groceries that we could live with but wouldn't want to live without for 4 weeks (but Cous-cous and Ivory soap are rare commodities - even lacking at the Gigante).

This place is apparently brand new - within the last 6 months. The construction was meant with a lot of - understandable - resistance from the local community. Plus, I don't think that it is just land availability or a coincidence that the plaza is very close to the upper class white part of town.

Nonetheless, America makes a good diversion and a nice place to study/take a break from the trip 1 time a week - but anything more would be nauseatingly to similar to home.








Amazingly, the community has been very successful in keeping out big business - or at least tacky construction - within the heart of the town. Not even a Starbucks here. But there are a few places I will post about later......

The Markets in San Miguel de Allende

Mexico is a land of markets. In Mexico City there are countless markets - in San Miguel de Allende, the finite number of markets and their ability to actually be counted - is just a function of the relatively smaller size of this city.

Nonetheless, there are a lot of markets here.

First of all, you have the Mercado Ignacío Ramirez and the virtually linked Mercado de Artesanías. This is the major market in the center of town and is located just North, off of the Plaza Civica which is across the street from PACEMD.



The upper red thumbtack is the end of the artist market, the middle red thumbtack is the beginning of the vegetable/fruit market.




This is the market we visit almost everyday - to buy vegetables, fruit, chicken, and in other small things we need for dinner or for the day. Things are fresh and cheap in this market - plus there is nothing hidden like in the Grocery Store. For example, Kryste stumbled upon a truck full of cow carcasses today parked just outside the entrance, complete with skulls and bones. In addition, next to the chicken breasts were the left over chicken heads to use for broth. Still a fun place to go and just no comparison in terms of freshness to a Publix/Kroegers, etc.




In addition to the food market, the Artist/Craft market seems to stretch endlessly - moving via a series of stalls from building to building.







Now, don't think this is the only major market. Only 1-2 miles west at the corner of San Rafeal and Guadalupe is another major market -- Mercado de San Juan de Dios. This market has similar items to the big market described previously but is also the place to go for clothes and household materials - think Target/Walmart with a series of stand alone stalls instead of aisles. The stalls stretch out of the building and run for blocks north all the way to the corner of Insurgentes - essentially almost linking this market with the Mercado de Artesanías discussed briefly above.



The far left thumbtack (far west) is the San Jose Market. PaceMD is Yellow and the other market previously described is marked by the two diagonal red thumbtacks.

Okay, that's the two major markets that are always present but in addition, there are some rotating markets as well.

First of all there is the Tuesday Market which is in between the large modern grocery store in the plaza we refer to as "America" (more on that in another post) and our neighborhood - Atascadero.



The location of the Tuesday Market is the second red thumbtack from the bottom.
You can tell two things from this GoogleEarth image -- (1)It's not a Tuesday, because the area would be packed and (2) This is before the strip mall - America - had been built (no office depot yet).


I would describe the Tuesday market as something akin to a U.S. Flea Market, although I can't really see what the difference is between the cheap goods - shoes, pirated DVDs, pets, etc - sold at this market compared to the San Jose market - but people who live insist that there is, indeed, a difference. One of the strangest things to me about this market is how crowded it is - on a Tuesday morning - not a holiday.








Those are the markets you can find on the map. But, it seems like a market appears every other week in the Civic Plaza (for example, this week is the book fair and two weeks ago was the campos craft fair -- crafts from the surrounding areas). If not in the Plaza Civica, then in the mostly American run Instito Allende (this week there is a craft fair and there was also one on the weekend of Los Locos).

Plaza de Toros

The Corrida itself is just not for me - bullfights are kinda gruesome. But, here in Mexico and most Latin-American/Spanish areas of the world, the bullfight is considered a ritualized art form and any aspects of cruelty imply are not culturally recognized. Well, maybe if the bull didn't have to be drug out of the cage before the fight due its fear of the toreo and the crowd, maybe then I could buy all the guy-risking-his-life hoopla. As it stands, it seems more like an overblown way to kill a bull with some added entertainment. Now, the running of the bulls here in September (or of course the large running of the bulls in Spain) IS something I would like to see someday..

Having said all this, I do like the excitement surrounding the meere mention of a bullfight and the artwork is very nice as well. Thus, I thought it would definitely be worth checking out Plaza de Toros here in San Miguel just to see the arena and maybe some associated art/architecture. If there was a bullfight here, I would probably even go hang out around the Plaza just to see the buzz and maybe score some cheap prints or something - but there isn't one in town until late July.

Anyway, we walked over to the spot on the map that had the stadium drawn and marked. Then we walked around the block and back around again - never finding the actual Plaza. Keep in mind this a pretty large place - easily spotted first on the Google Earth and tourist maps of San Miguel - how could we not find it?

Turns out, the whole block has a huge wall built around it and the arena is simply not observable from the street. Finally we found one relatively small door that opens on the day of a bullfight and was worn with old fliers announcing upcoming events. I don't see how they contains something so big behind a wall....but they do.

These walls and are actually very common here - it's not infrequent that you will be walking down the street and someone will open a tiny door and when you glance in, a large space is revealed - maybe a school or a soccer field.

the only sign of the large Plaza from the street....

W.A.S.P International Convention? Nope, ¡just the Biblioteca Publica!

The Biblioteca Publica in San Miguel de Allende is located just west of the Plaza Civica. It's in a really ugly yellow building but it makes a nice place to study as it is just a short walk across the plaza from the PACEMD/MedSpanish building. Thus, we spend a decent amount of time there.

The nice thing about the place is that it's got a huge outdoor patio with a coffee shop and cafe. Plus, there is a movie theater off the courtyard (Santa Ana Theater) that plays independent films 2Xs per day for 50 pesos a person. In addition, it's one of the few locations around town that has free wireless internet (also check the Instituto Allende on Ancha de San Antonio).

There are a few annoying things about the place as well.
First, if you visit the library you should go knowing that this is an English language collection - the second largest biblioteca de ingles en la país.
In addition, it's the gathering spot of all the U.S. and European people who have moved here or relocated for a long period of time - so it's going to feel like you are back home...but an even more annoying version of back home. This is a back home filled with ping-pong ball people just bouncing through life and flopping into San Miguel. Also not a place to go to hear Spanish. So, just know those things going in and if you can get past that, the library isn't a bad place to study and get cheap food/coffee.

Upstairs from the library is the headquarters of the English weekly, Atención.

http://www.atencionsanmiguel.org/links/bibliotecasma.html

La Biblioteca is indicated with the central red thumbtack, pacemd with the yellow and the house with the red marker to the far right (east)

Mexican Pharmacies

One of the more interesting things here in Mexico is the number of drugs available without a prescription - basically everything that is not on the our controlled substances list can be bought by anyone at any pharmacy.

This means that antibiotics, heart medicines, diabetes pills, and other common chronic drug regimens can be purchased during a trip to the market. No benzos or opiods but plenty of other medications to allow people here to deal with many problems on their own.

Of course, this also means that medications are a lot cheaper here (except for some of the big gun antibiotics). For example, I can purchase my month long supply of allegra for less than $20. Many U.S. health insurance companies won't even cover Allegra these days due to the availability of the similar (but for me and many others, less effective) Claritin over the counter. Anyway, the old Blood pressure meds and DM regimens are certainly cheaper, as are the old generation and generic antibiotics.

The good thing about this system is that people with very little money can treat common conditions much more easily. It's not too hard for a women to figure to use a sulfa to tx her urinary tract infections if she gets them a couple of times, or if her sister/mom etc has had them as well. Same goes for mom's treating ear infections with some amoxicillin. The problem of course is that many things are mistreated and of course there is less preventive medicine in this model.

For example, in the emergency room this week I saw a women who tried to treat a bladder infection with an antibiotic that only covers gram + organisms (most bladder infections are a different type of bacteria). So, the infection spread to her kidneys. Since she was pregnant, this became a relatively serious infection likely requiring hospitalization and IV antibiotics (at least in the U.S).

Of course this would throw the economics of medicine in the states out of control as well if these drugs were over the counter - think of all the office visits for med refills and relatively common prescriptions/common problems. Anyway, the argument, of course, that those of us trained in medicine in the U.S. would make is that while it is more costly to have these frequent office visits, it is also the only way to rule out more serious problems and keep up with immunizations and other necessary prevention/health maintenance issues.

Anyway, arguments aside, I will enjoy my $15 Allegra while I'm here, my ability to grab some antibiotics to keep away the Monteczuma's Revenge, and other simple stuff that even with my level of training, I can select the appropriate medicine for treatment. Different world.

Night time in San Miguel de Allende

This is a busy place at night - especially Thursday - Saturday (but certainly any night one can find places to dance, places to just hang out, or movies at the library or the mega cinema by gigante (he-gone-te)....anyway, the all-purpose hang out is at the Jardin in the center of the Principal Plaza. Every night features mariachi bands, tourists, and locals just sitting on the benches eating the fresh fruit pelatos (Popsicles)