Saturday, September 29, 2007

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....

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

Wednesday, September 26, 2007

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.

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.

Tuesday, September 25, 2007

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

Monday, September 24, 2007

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?

Thursday, September 20, 2007

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:

Monday, September 17, 2007

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
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

Thursday, September 06, 2007

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.

Saturday, September 01, 2007

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

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.