Monday, April 30, 2012
Particularly, what stood out to me the most in Gawande's Better was his suggestion to ask patients new and genuine questions, which was one of his 5 concluding suggestions to physicians at the end of the book. I think this is a really helpful and valuable suggestion that can be utilized in a variety of different realms when practicing medicine and can lead to better diagnoses and better treatments. In one sense it sort of echoes back to How Doctors Think in that in complicated cases it's helpful to set aside old records and look at a case with a clean slate in order to avoid making the same wrong diagnosis over and over again. It can also help doctors to get to know a patient better in a short amount of time by asking questions that really give a sense of what the person is going through, instead of skimming the surface of a patient's records and not getting any valuable information out of them. In addition, asking new questions can put a research-like spin on new cases in that a doctor can treat each new case like a puzzle that they are trying to solve instead of slipping into a routine which can become mundane and cause doctors to miss important clues that would lead them to the right diagnosis.
In addition to this perspective, Gawande explores the work of physicians from the battlefields of Iraq to overcrowded Indian hospitals, and this provides a compelling landscape of how healthcare is delivered in a variety of conditions. Gawande's efforts to compare his Western practice against these different approaches indicates what I believe is a wonderful devotion towards self-development. In class today we discussed how modern medicine is fundamentally about manipulating within very narrow margins, and I believe that having such self-critical skills is absolutely essential to being an effective physician. This reiterates one of the broad themes of the book - the importance of diligence across the board - not only in order to be a competent health delivering machine, but to evolve communication skills, and to be able to navigate the uncertainty that is inherent in the practice. And in the end, that is how I believe Gawande frames his book; it is a testament to his self-development as a doctor. In his conclusion he puts forth five open-ended steps which are really geared towards critical self-development: (1) to ask unscripted, genuine questions to patients, (2) to avoid complaining, (3) to count something, critically study your practice, (4) to write your thoughts, and (5) to change and evolve the way you work. As such, Gwande's book reads more like a self-help book rather than a tangible to treatise to improve the system.
In Atul Gawande's book Better, Gawande stresses the importance of diligence in medicine. In order to illustrate this point, he profiles a recent campaign to "mop-up" polio from southern India through a large scale vaccination. I found this extreme case of diligence to be very provoking because of the great lengths these doctors had to go through to administer vaccines to a large number of children in the area. Among other logistical problems, doctors had to overcome illiteracy and compliance issues in order to execute the vaccination. For example, vocal announcements had to be made in order to spread news of the program to those locals who were illiterate.
The issue which I found the most interesting was compliance. I found it surprising that circulating rumors implying immoral intentions of the physicians were a signficicant obstacle. In this particular case, there was a rumor that the vaccine was going to cause infertility. Of course, parents were not going to allow vaccinations of their children if they believed such a rumor. How could a problem as widespread and intangible as a rumor be solved?
I thought the particular WHO doctor in this situation, Pankaj Bhatnagar, had an extremely reasonable approach towards such compliance issues. When Pankaj was confronted with a woman who did not consent to the vaccination of her children, he was not persistent or violent. In fact, when Pankaj's colleague started yelling at the woman, Pankaj instantly stopped him and explained that such an attitude would only enforce any negative rumors about the vaccine that were already circulating.
I thought this was a good way to approach diligence in this situation. Pankaj demonstrated that the achievement of diligence is not about obsessing over small tasks, but rather being persistent in trying to achieve a larger goal.
Thursday, April 26, 2012
He also states that "physicians might not want to develop or adopt guidelines out of fear of liability consequences," (111). This statement is reasonable to me because it would be damaging to any physicians career if they agree to these guidelines and then come across a case where they can't follow them as strictly as they are set and the patient makes a complaint. Even if it is not directly the doctors fault, they were just working out of experience or trying to think out of the box, the can be severely punished. There are so many rules and regulations that these doctors have to follow it is like they are being held back by a certain "red tape," because a lot of things are already determined for them like how they allocate their resources to which department, rules to limit the clientele, etc. According to the book, some people view all of these third party external reinforcements of the hospitals and practices as unprofessional and an autonomous way to run a profession.
Tuesday, April 24, 2012
Monday, April 23, 2012
Wednesday, April 18, 2012
Diamond goes extensively into the different cultures and societies that were building at different points in time. One of the early societies he starts to analyze are tte Native Americans in the Fertile Crescent and people of New Guinea. These people were extremely important to us today because they helped domesticate animals and were the first ones to hunt and gather which helped the human population survive in times where there was little technology. On page 160 there is a outline of the domesticated animals at the time on different countries. He goes on to state that "This very unequal distribution of wild ancestral species among the continents became an important reason why Eurasians, rather than peoples of other continents, were the ones to end up with guns, germs, and steel," (Diamond 161, 162). I feel that this quote, besides having the title in it, encompasses a lot of what Diamond is trying to achieve in this book. He wants to find out why certain countries and continents ended up like they did. Why some of them had advanced supplies and advanced crops while others lagged behind. He also wants to know what fueled these differences and why some places did not ever catch up.
Some countries learned to domesticate and use nature to their advantages, like Europe, much quicker than other countries did. In his chapter called "Necessity's Mother" Diamond starts to talk about the first developments of human technologies and he also states that Europe and Russian countries were the first to succeed in these areas, such as ceramics, printing, and anatomy. In fact, Europe was the country in the lead in all aspects, including science and population in general, according to the chart on page 263 even into the 1990s. One of the reasons Diamond states for disparities between the Native Americans and the European societies was the food production differences. While Europe had protein- rich cereals and advanced tools to farm the Native Americans and some other countries did not. Ultimately, Diamond is examining why human societies such as these , that were all in communication with each other, developed completely and utterly differently.
In his afterword, Diamond states "My main conclusion was that societies developed differently on different continents because of differences in continental environments, not in human biology. Advanced technology, centralized political organization,...could emerge only in dense sedentary populations capable of accumulating food surpluses," (Diamond 426). Diamond wants the take away of this book to be that societies develop accordingly depending on the resources at hand, and these can make or break a society as a whole. He might not have used the most concise and precise way to do this. however he provided an extreme amount of details that are beneficial in understanding how societies came to be today.
Tuesday, April 17, 2012
Monday, April 16, 2012
I found that several of the points in Jared Diamond’s Guns, Germs and Steel were either given substantial evidence or minimal. For example, his description of how plants and animals were domesticated was very thorough. However, I found his argument about why certain societies are innovative versus those that are conservative insufficient. For one thing, I wish his list of factors for what leads to different degrees of receptivity across societies were more universal norms rather than descriptions of time periods. For example, for economic factors, I wish he would have made a stronger institutional case such as emphasizing the importance of liberal institutions for innovation. While he certainly makes the point that patent protection exists in the Modern West and that its lack of discourages innovation in China, I think he could have made a stronger case from a broader historical standpoint rather than using such narrow evidence. But my biggest issue was his lack of describing what led certain societies to be conservative and shy away from embracing new technology versus those that are innovative and readily adapt new technology. I found his explanation left something to be desired. I don’t believe his anecdotal evidence can necessarily be applied to all of human history. He uses the example of two tribes in New Guinea: one, the Chimbu who he indicates is innovative and readily embrace its introduction to new technology, and the other the Daribi who he describes as “briefly looked at [the first helicopter] and just went back to what they had been doing” (252). So his evidence provides a good explanation of what they did, but it doesn’t address why. Are their larger social differences between the two? Do the two tribes have essentially the same structure or do they vary greatly? From my understanding, he makes it seem as if it is a random process by which societies are innovative or conservative rather than being the product of their social environment. While I realize this isn't a sociological text, I wish he had provided more social explanations.
Thursday, April 12, 2012
All in all, I think there needs to be some reform within the medical field of how things are carried out. I feel that they can reduce the amount of errors that students and interns make by having more guided training, and a lot less hierarchy. The need that interns feel to claw their way to the top probably does not help their concentrationo n their patients. Additionally, I think there needs to be a better way of assigning interns in hte first place. I feel that a lot of the errors they make come from the fact that hey are seeing tons of different patients a day and paper work is being filled out everywhere and it is very disorganized because there are time constraints. Since they do not really know what they are doing I think interns should only focus on a few patients at a time but work with them full out, and work on their charts and paperwork and medications as well. I think that not enough credit is given to them having come out of medical school with that hugh encyclopedia in their head and attendings and residents do not give them the chance to fully show their knowledge. These reforms would most definitely increase the quality of patient care and that is the ultimate goal of health care professionals.
Tuesday, April 10, 2012
Monday, April 9, 2012
In the amended appendix of the second edition of Forgive and Remember, Bosk includes two stories that he had purposefully omitted from the previous edition. Both omissions relate back to the idea of the social construction of medical errors, as he states, “Each blunted the interpretation, analysis, and critique of surgical training and professional socialization, shop-floor ethics, and professional social control embedded in the ethnographic account” (217). These are all very important concepts and the two omitted stories add a great amount of depth to their understanding. The first omission occurs in Chapter 5, where Bosk illustrated the influence attending surgeon’s judgments of the residents’ performance on their careers, exploring the differences between the four types of errors. An entirely new context is added to this chapter because the resident he describes, Dr. Jones, is a woman and not a man as originally stated. Not only was Jones a woman, but she was the sole woman out of all of the residents Bosk observed. Bosk claims that he made this change in order to protect the subjects’ confidentiality and anonymity, but the analysis of the observation changes completely when the gender changes. Jones’ experience as the only woman in a hostile, patriarchal environment may have very well played a huge role in determining her behavior and her subsequent dismissal. The influence that sexism may have had on what others deemed to be her errors is a narrative that encourages a very important discussion regarding male domination, gender identity, and its influence on the medical profession.
The second omission that Bosk made involved the attending surgeon, Dr. Arthur. What Bosk did not mention in the earlier edition was that Dr. Arthur, who believed that residency was a “stress test” and that recreating “battlefield conditions” were critical for developing excellence, would rountinely make incredibly demeaning and racist remarks. This relates to his analysis of the resident Dr. John Carter, who Bosk now believes was baited and ended up leaving the program due to his resistance to the hostile environment created by Dr. Arthur rather than due to his own personal attributes. Both of these omissions are important to Bosk’s work because they add important perspectives to the analysis of medical errors. They add to the discourse as they clearly illustrate how the application of quasi-normative standards can undermine the fairness of the normative standards of medical training. As Bosk states, “We need to ask ourselves: how many voices have we allowed to speak and how many hidden presumptions have we questioned.”
Apparently WebMD has admitted connections to pharmaceuticals and other health related companies. The website has biases towards certain medication and advertises various medications openly throughout their site. Kinda interesting no?
This is my second reading of Jerome Groopman's How Doctors Think and I believe the book serves its purpose well, demonstrating the difficult decisions and bioethical issues faced by physicians. On a slight negative note, I have always thought that while Dr. Groopman does a fair job identifying problems, he offers few concrete suggestions for reform. For example, while he does make a number of suggestions on how physicians can think more clearly (think outside the box, questions gut instinct, etc), he does not offer a concrete program for improving the diagnostic skills and thought processes of physicians in the US. His only idea for improving training seems to be to push clinicians to ask themselves the above questions more frequently. Given the success of the book, you would have thought the guy would come up with some original solutions to ethical and professional issues.
But while this shortcoming does provide a certain degree of post-reading dissatisfaction, Groopman manages to demonstrate how some physicians fail while others succeed, and raises some important questions around the profession. Americans have a various ideas on what they expect from their physicians, as demonstrated in class discussions. It is impossible to expect any sort of perfect competence from doctors, but I believe it is essential for all physicians to exhibit a strong inclination for self-development. The field of medicine will always be messy and complicated, both in terms of ethics and practicing effective medicine. It is pinnacle for physicians to be able to develop a personal philosophy around delivering effective and efficient care, alongside a permanent grasp of medical knowledge. Without constantly developing a strong, positive moral agreement and maintaining clear communication with patients, it becomes very easy for physicians to become unsatisfying with the challenges of their job. There is no silver bullet for the issues of medicine, and this is the reason for Groopman’s omission. Most of the changes that would positively contribute to patient care need to happen among the psyches of individual physicians, constantly reevaluating the care they provide and not being stuck with their egos.
Sunday, April 8, 2012
Despite my extreme distaste for Forgive and Remember: Managing Medical Failure, I thought Bosk’s discussion about the “Varieties of Normal Action” and the accompanying grid of expectations and outcomes (pg. 116-120) to be were interesting and worth more detail, particularly Cell 4, expected failure. Here, doctors face the difficult situation of knowing that medical intervention will most likely be unsuccessful, but needing to care for their patients in the most ethical and humane way possible. I stumbled across this New York Times article from 1990 that touches on the same idea: http://www.nytimes.com/1990/05/15/science/the-doctor-s-world-despite-many-shifts-oath-as-old-as-apollo-endures-in-medicine.html?src=pm. In a nutshell, the Hippocratic oath, a list of axioms repeated by new doctors that essentially mean they will do no harm, has been phased out in the medical school setting and there’s a question of the validity of its origins. According to the article, it’s quite possible the Hippocratic oath (and accordingly, medical ethics) are not studied in medical school at all, which is detrimental to patients, and that the oath has paternalistic roots that don’t honor a patient’s wishes and hold the doctor above all others. It’s an interesting read, and encompasses bits of our discussions about How Doctors Think, medical ethics and our current reading.
Wednesday, April 4, 2012
However, I do feel as if there are problems with the ways in which medical schools are teaching their students. He explained that in medical school when they saw patients during rounds, they would be "led through a calm, deliberate, and linear analysis of the clinical information," (Groopman 34). Even on the first night of being out of the medical school and into the hospital on his own, Groopman learned that "thinking was inseparable from acting," (Groopman 35). Nobody can truly be prepared to what can happen to a patient when they are not working under an instructor. Groopman was dealing with a patient, William Morgan, just having a normal conversation with him when his blood pressure started falling and his breathing turned abnormal and he had to idea what to do. He was getting flustered and frenzied, because obviously he had never dealt with an experience like this. This is one thing that medical schools will teach you in textbooks and writings but how do you know how to really deal with it when you face it in real life? This is definitely a flawed system because all the medical students have to rely on is that encyclopedia in their heads or index cards that they carry around with them. However, textbook definitions of diagnoses and procedures is not always how it goes with patients.
Despite the flaws of medical schools, I never realized all the different problems and things that doctors had to go through when evaluating patients. I mean, obviously I knew that being a doctor would be no cake walk, which is why only the smartest people can become one, but I never realized the extent of it until this book. For example, even when a doctor thinks they have the right answer, all the right symptoms pointing to one disease and everything, they should create a list in the back of their minds of other possibilities that it could be. The doctor cannot ask patients questions in certain ways, and there can always be misunderstandings between patients and doctors. For example, he described the pediatrician that had a regular patient that left because she thought she was being racially profiled as having dirty blood, when in fact it was just a diagnosis that her blood had been contaminated while being tested and she completely misunderstood, but left to find a new doctor anyway. Doctors have to do their best, most complete job under heavy time constraints, Groopman described it as spinning plates with people distracting you and always asking you for something at the same time. In that sense, doctors have to be able to have very good divided attention. As we discussed in lecture, there are tons of qualities that people look for in doctors, and knowledge is not even one of the top ones,, and great doctors have to encompass all of these, even after going through a flawed medical school system!