Monday, April 28, 2008

Favorite run of the year

Saturday set the mark for my favorite run of 2008 so far. A 3-4 miler along Salt Creek Beach with my Dad. We glided down the big hill right when the sun was brilliantly blazing a red sunset, big and round over the horizon. We ran down to the beach front, right along the waters edge where the sand is hard and firm and easy on the knees. Did about 2 miles along the sand. Perfect temperature, nice breeze, good company. Not just my Dad, but a small pod of 5 dolphins that swam along at the same speed we were running. It may sound cliche, but it was magical, everything coming together, running, being home, feeling good, the breeze and 5 dolphins frolicking along side of us for a good 15 minutes made it surreal and incredible. One of the younger dolphins caught a few ways, two of them jumped out of the water, they were just playing while we ran along. One of those moments you won't forget for a very long time!

Wednesday, April 23, 2008

The Health Care Crisis

Health Care can be dwindled down into 3 basic parts: Cost, Quality, and Access. It is almost impossible to improve all three parts at the same time.

So far the media has focused on Cost and Access. Republicans yell about cost, Democrats rant about access. I think they are both important to the average American. My question is, what can we do now to improve our health care system for the long term? So we can improve all 3 aspects over time?

It's a tough question, no easy answers. Can focusing on quality and access to care lead to reduced costs in the long term? Will focusing on cost and quality lead to improved access in the end? How will technology play a factor in this triangle? Right now most assume that technology is increasing costs, but what if our innovations in the future lead to reduced costs? We have MRIs now, like the mega-computers of the 80s. Who is to say we won't have improved imaging technology in 15 years at much lower costs? This I believe, we are destined for. So, with this belief in mind, that technology will lead to lower costs of care in the future, I saw we don't worry about increased costs for now. I say that all these projections of the Health Care Sector taking up 40% of the GDP are wrong. Yes we do have some startling problems with an aging population and a fattening population, but I am seeing technology being the key to this, reducing physician visits, ER visits, making care accessible and affordable.

With this in mind, the government should own up, and take more of the costs off American's back. But we shouldn't worry about cost in the big scheme of things. Right now we need to focus on improving quality of care and access to quality of care first and foremost. This means we need a larger physician and health care provider pool and we need to really tackle quality. I don't have the time to go into quality of care right now. But lets just say that continuity of care would make for so much less duplicate and extra care that I think that would be a good place to start.

Friday, April 18, 2008

LA Homicide Report

I read an article today about the LA Homicide Report. It's a blog of all the victims of killings in LA over the past year written by an LA Times reporter. There have been over 800 murders in the past year in LA, in streets, homes, stores, driveways, alleys, cars, and parks. I know there are a lot of people in LA, 9.9 million according to the 2006 CA consensus. Oakland CA, a large city also prone to gangs, guns, and violence, had 115 homicides in 2007 with a population of 1.2 million....598 homicides Chicago with a population of 9.7 million...

I'm not putting in the effort to do a thorough examination of these numbers or the variables that contribute to them, it would be very interesting to look into this further. My main point is there are too many homicides! Just from scrolling through the LA blog, I would guess that majority of these homicides are from gunshots. To me, this is a serious problem, it is wrong to let this continue. But then again, it's not something I think about every day, personally, I've never known someone who was murdered, and to my knowledge I've never known a murderer. I don't know anything about the culture within these killings occur, I don't know the circumstances, the outcomes, or the reason for killing this people. What I do know is that if we could have better control of the use of arms in this country, we could dramatically reduce the number of people who die from them. Given the complexity of understanding why these homicides continue, why don't we just put a plug in the bottleneck? I understand the perverse cyclical thinking some people have, "If I can't get a gun I can't protect myself from those that do not give their guns in".
This is true, and this is why America and other developed countries with soft gun restrictions are in a predictament. But I really think it's the only way.

Tuesday, April 15, 2008

Ireland trip

For the past few months I've been debating whether I will go to Ireland this summer. For the most part, I've brushed the idea aside for several reasons. First off, I was blessed to go on an 11-day tour of Ireland with Grandma, Grandpa, my mom, and my sister in August of 2005. We stayed at Nora's in County Mayo, Grandpa, my mom and I successfully reached the summit of Croagh Patrick together. We also saw Dublin and Killarney. It was an extremely memorable and wonderful trip, I will never forget pushing Grandpa up the Holy summit that symbolizes so much of his spirituality and faith, nor will I forget Grandma's ability to know the oral history of every every village and street we visited, and how could I forget Abbey's ability to "Baa" in the car for 4 hours straight on the windy roads strewn with sheep on both sides. It was a trip of a lifetime--really, it was.

Regarding the upcoming trip, I've been in the mindset of, "I've done this before", "it's expensive", and as a new member of the work force (the sooner I'm back in school the better!), I put a high value on the limited resource that is known as "vacation days". There are other things playing into it as well, applications for medical school are rolling through in August, the new batch of interns could really use my help at that time, etc.

Recently, I came to the realization that I have not been putting enough value on what this trip really is about. It's not about "Ireland" per se, it's not about Grandpa's 80th birthday (his birthday is not even in August!), and it's not even about Abbey climbing Croagh Patrick. It's about family.

Honestly, how many opportunities do we have in life to travel together? Let alone as one big family to the place of our heritage? Many of those going on this trip I only have the chance to see at either weddings and funerals, wouldn't it be nice to get to know them more outside of these rather formal contexts? How awesome is it to have a chance to gather for the pure enjoyment of being a family? How many chances will there be in life to do something like this? What wonderful memories we'll be able to share for years to come? For some, this may sound a bit cliche, but really, how awesome of a chance. Looking at the big picture, instead of focusing on the immediate logistics, helped me to realize how fortunate I am to have this opportunity and how I should take full advantage of it. The logistical realities are still true and valid, but are so small in the big scheme of things.

This past year I've worked very closely with women diagnosed with breast cancer, some of which has been very serious disease. While this experience has increased my passion for medicine, it's also made me think about other things as well. If there is anything I've learned from talking with these women, it's the importance of priorities in life. It shouldn't take a life-threatening disease to reevaluate our priorities, to realize how we've been swept up in logistics, burdens, and constraints instead of doing what we truly we want to do. I talk with women who are facing a cancer that can't be cured, that has spread to their brains, their lungs, their bones, and I see what they want, what they cherish, what's really important at the end of the day. At the end of the day, it's all about family. We have our ambitions, our goals and passions, but we're social animals, we want to be there to create memories and experiences with our family and those we love...From this experience, I think it's important that we are constantly evaluating our purpose, our roles, our actions and how they play into the bigger picture, of what brings us happiness and what brings those we love happiness and satisfaction. To me, it doesn't matter if we go to Ireland or Death Valley, Ireland is a nice perk, but just getting together with so many relatives is a wonderful opportunity that I do not want to miss out on.

And, truth be told, someone's got to be there to photograph Grandpa when he's tied to a rope between Pat and Mike climbing up Croagh Patrick... :)

In the spirit of all things Irish, I'll close with the old Irishman's Philosophy...

There are only two things to worry about:
Either you are well or you are sick.
If you are sick,
Then there are only two things to worry about:
Either you will get well or you will die.
If you get well,
Then there are only two things to worry about:
Either you will go to heaven or hell.
If you go to heaven, there is nothing to worry about.
But if you go to hell,
You'll be so damn busy shaking
hands with friends
You won't have time to worry!

Wednesday, April 9, 2008

Olympic Torch Relay history

From the official Beijing Olympics website:

"The Torch Relay, as the opening of the Olympic celebration, was revived in the Berlin Olympiad in 1936 and since then the Torch Relay has preceded every Olympic Summer Games. Starting from Olympia and carried by the first runner, the young athlete Konstantinos Kondylis, the Flame traveled for the first time hand to hand until it reached the Berlin Olympic Stadium. Since, the Flame's magic has marked and has been identified with the beginning of the Games.

Olympiads that followed, the Torch Relay continued to play an important role, having been enriched with the characteristics and cultures of the host countries. The choice of the athlete who lights the Flame in the Olympic stadium is always symbolic to the host country."

I wonder why the Germans decided to revive the torch relay? According to a 2004 NY Times article, the Olympic Torch has some very modern motivations..

"Hitler, who admired the powerful imagery of Greek gods like Zeus, wanted his Games to promote his belief in Aryan supremacy. The torch relay, memorialized in Leni Riefenstahl's film, "Olympia," was part of Hitler's elaborate attempt to add myth, mystique and glamour to an Olympics intended to intimidate pre-World War II Europe. In Hitler's eyes, the torch symbolized the perfection and victory of the German nation."

My question is regarding the nature of symbols. The original symbol of the Olympic Torch in ancient Greece stood for the symbolic creation of the world, renewal and light. Hitler reclaimed the torch to symbolize Aryan dominance and world power. Since then, many claim that the nature of the 1936 games, largely due to the brilliance of Jesse Owens, reclaimed the symbol of the Olympics ( thus also the torch) as a place where all nations can compete equally and peacefully and come together promoting world peace through sportsmanship. This has been my feelings about the Olympics, a positive, global symbol of peace and good will. But what does the torch symbolize? Have we successfully taken back the symbol of the Olympic torch to be a benevolent symbol of the games? What symbolism does this year's torch bring? Through China's dogged refusal to adhere to basic human rights policies for their citizens and the citizens of Tibet, has the torch come to symbolize protection of a false truth? Is it more right to send police to protect the torch then to send police to China to protect those hurt by China's human rights abuses? In the spirit of the games, is it wrong for those to protest what they believe in? Was it wrong of the IOC to select China to host the games? Controversial yes, but was it wrong? Will it do more harm then good for the immediate future? For the long term?

If history is any indicator, the Chinese Olympics will ignite a flame on a global scale, bringing the blatant corruption of the Chinese government to stand on the world's stage. I think we are going to see retaliation on the part of the Chinese in the near future. In the long term, Hitler failed, Germany reformed, and I have hope that the Chinese Olympics will help reform China in the long term as well.

Tuesday, April 8, 2008

MRI report

My doctor called this afternoon with the MRI results of my knee. I have a cartilage divot behind the knee cap that is the cause of the knee locking cracking, From what Dr. Allen told me, arthroscopic surgery to shave the cartilage to make it level is the treatment for this.

I am not so sure about knee surgery, I've been running better then ever for the last month, and only 1 or 2 times out of the 67 miles I ran in March did I have to stop and pull up because of sharp pain. Would surgery, time off, and rehab be worth minimizing those 1 or 2 times a month? If this was August, when I couldn't run, had trouble walking at times, I would say yes 10/10 times, but now that I feel pretty good this option doesn't make sense to me.

Today I did an interval workout: 400m, 300, 200, 100, 100, 200, 300, 400 with 100m walks in between, at decent paces and felt fabulous, better then ever -better then last year at this time when I was training for track! Given this, the only reason I would consider doing the surgery would be if this divot would cause long-term damage to my knee (which I'll probably have regardless!)

Any thoughts or suggestions?

Monday, April 7, 2008

Medical Interpreters

I've had the fortune of working with several different medical interpreters at my job. Russian, Japenese, Cantonese and Mandarin speakers. I've come to respect their role for patients who do not speak english, it can be a tricky one. I wish I spoke a different language because I've very interested in learning what exactly changes through translation. I see the role of the medical interpreter to be one of complete translation, word for word, what the physician says to the patient. But given the variation in language this can't be true 100% of the time. My other respect for medical interpreters is derived from the fact that they work in all different types of health care settings, disease areas and spectrums. They must know so much medical terminology! This cross-work in different areas of medicine must give medical interpreters a very unique perspective on the health care system. I wonder if anyone has taken the time to ask them what they thought of how care is given in these different settings? What they thought could be done better?

Back to back 6 milers

I ran 6.3 miles yesterday and 6.5 miles today. Yesterday my pace was 8:05, today my pace was around 8:55, my quads a bit tired but other then that felt pretty darn good.

I think I'm at the point where my base is strong enough that I actually enjoy running more than 3 miles at one time. The onset of spring in San Francisco has really helped with my enthusiasm and motivation, the GG park is so fun to run through, so many people, so many flowers, birds, and other spring-like features!

Since Jan 1st I've now run 212.1 miles over the course of 2 days and 16 hours.

Friday, April 4, 2008

Insurance coverage for medical procedures

I have some questions about insurance coverage that I thought I'd throw into the blogosphere.
Who determines whether a certain medical procedure that reduces risk will be covered financially by the insurance company?

My question comes from issues surrounding prophylactic mastectomies (removing a breast even though it does not have cancer). Given the improvements in cosmetic outcomes of breast reconstrcution, many more women who have breast cancer in one breast are interested in having the opposite breast removed as well. In general, there is about a 10% chance of developing breast cancer in the opposite breast when you are diagnosed with breast cancer. Is this procedure paid for under this particular situation?

Another example: a 30 year old woman with a family history of breast cancer, her mother had it, her older sister had it, has recently tested positive for the BRCA1 gene, meaning that she has about an 85% chance of developing breast cancer in her life time. This woman wants bilateral prophylactic mastectomies. Will this be covered by insurance?

The core of my uncertainty with these two situations is that in neither case does the medical procedure "treat" a disease, it only reduces risk. My question is, at what risk reduction is this procedure considered appropriate? What if the risk of developing breast cancer is 5%? 15? 50? 90? And who has the authority to deem the "medical appropriateness" of this procedure? Let's say that one doctor deems that a particular woman has a 20% risk of breast cancer and this risk warrants a prophylactic mastectomy. What about financial coverage of this procedure? Will insurance companies listen to this physician's logic? Do insurance companies have their own formulas for what risks they are willing to take on (ie deny coverage) compared to what is "too risky" (ie they will pay to reduce the risk)?

In terms of what I think, I think that if a doctor has evidence in the medical literature to reduce risk by doing the procedure, and if the patient is highly risk averse, then the procedure should be covered--assuming that the risks of the procedure are minor compared to the risk potentially reduced.

This is also a situation where the grayness between evidence-based medicine and consumer-based medicine come into play. Let's say the doctor does not feel that the procedure would be a good decision, but the patient really wants the surgery. She doesn't care if the medical literature states that the mastectomy would minimally reduce her risk. Psychologically, she "wants the breast off", "doesn't want to lay awake in bed every night worry about it" etc. What's the role of the physician in this situation? To be consumer-based, to do the surgery because of the patient's desire. Or to be evidence-based and not perform the procedure? How does costs play into this decision? What would most doctors do in this situation? What ought doctors do? What would insurance companies do in this situation What ought insurance companies do?

Thursday, April 3, 2008

A life worth living

This may be my most revealing post yet...

I've been trying to write my personal statement for medical school (going nowhere by the way), and I've been thinking deeply about what draws me to the medical profession. Here are some of my thoughts.

To me, the essence of medicine is to help a person live a life worth living.
In a perfect world, we would not need physicians. We would not have sickness or disease. Each of us would be able to pursue our dreams and passions with full vigor. This is not the case. There is disease, there is cancer, there are eating disorders, diabetes, alzheimers. To me, the role of a physician is to do the best she can to help a person through a vulnerable time, help them navigate our health care system to obtain the highest and most comprehensive care possible. To help that person get back to their lives, contribute to their family, community, and society. The work of a physician is at the level of individual person, and a physician is morally bound to be fair, to be honest, to be thorough in her treatment of each individual she sees. I am drawn to this duty of a physician, to help each person I care for live a life most worthwhile for them, to treat all of the people I see with dignity and respect. This ground-level work of a physician is appealing to me at my most basic level, as a person of compassion, as a member of society myself, to help those around me when they are often left vulnerable.

A second aspect of medicine that appeals to my character is the need for strong leadership in the profession. The issues of medicine that interest me, continuity of care, disparities in care, costs of care, patient-centric care; are difficult problems facing the medical community, and it is my goal to pursue these problems as a physician. To me, leadership involves an ability to listen, a vision, and most importantly a strong inner moral compass. I think one of my most unique qualities is that I am willing to take on the responsibility of being a leader, and with that responsibility I have a very big respect for the power that comes with it. The idea of being in charge of a clinic, helping to improve all aspects of its systems, helping empower other health care providers, and most importantly, helping to empower and enable those who need our care, is exciting and invigorating to me...

to be continued.


Every day we take risks, we drive, we invest in the stock market, we apply for jobs, risky business life is eh?

The vernacular of medical oncology is risk. Local radiation is a treatment to reduce the risk of recurrence of the cancer in the breast Chemotherapy helps to reduce the risk of recurrence of cancer in other parts of the body, it also helps to improve 10 year survival rates. Hormonal therapy reduces risks in similar fashion if the tumor feeds off female hormones.

We know about the benefits of these therapies thanks to clinical trials that have randomized, quantified, stratified up the yinyang.

I think one of the hardest tasks of an oncologist is communicating the risk reduction of treatment to a patient. It's essential that the woman with breast cancer understands her options and understands the benefits of such options, but when the data is so complex, when the benefits are blurred, effectively communicating the concept of risk is crucial to ensure shared decision-making.

So far I've only discussed the risks reduced by treatments for breast cancer. To make things more tangled for treating breast cancer, there are also risks associated with the very same treatments that help fight the tumor. Radiating vital organs, Heart failure caused by adriamycin, uterine cancer from tamoxifen, you have the potential of getting ANOTHER cancer from an anti-cancer treatment. How dumbfounding! So here comes the second layer of risks and benefits for treating cancer. The oncologist and the patient have to weigh the benefits of treatment with the additional risks taken on due to such treatment. Here's a question, if someone told you that you could take a drug for 6 months, lose your hair, feel sick all the time, lose feeling in your fingers, have no energy, and this drug would improve reduce your risk of recurrence of cancer by 10%. But, this same drug comes with a risk of heart failure, say 4%. Getting complicated yet?

The tertiary level of complication is the basis of all of these numbers, where did all these numbers come from anyways? We know the answer: clinical trials. But the deeper questions are, what types of patients were on the trials? Were they your age? Were they your ethnicity? Were their tumors similiar to your tumors? Where they node-positive patients? Node-negative patients? How far along did they start the treatment? Did they take anything to prevent breast cancer in the first place? How successful was the local resection? What other treatments did they have? Talk about opening Pandora's Box...

Given this uncertainty, how are oncologists (or patients my gosh) supposed to make sense of all of this? That's my question, I still haven't figured out the answer. For oncologists, I know that years of training, of questioning and contributing to the medical literature, of immersing themselves in the controversies and successes of medical oncology, and treating a lot of patients can help. For patients, I think it comes down to the realization that at a certain point, you have to trust your physician's judgment, you have to believe in the efficacy of your treatment, and you have to have a lot of hope.