Sex, Drugs, and Public Health

July 3, 2012

Med School Culture Shock II

Filed under: Uncategorized — cbmosher @ 4:44 am

So I dove into what should have been an exhilarating exploration of the world’s Second Oldest Profession, but was, because of this thing hanging over me, a blur of classes, labs, and library hours. I always avoided the Dean’s office, constantly fearing a call or note from the little bald man, transmitting a lethal pain as does the vagus nerve, when it conducts to the brain, news of the death of your mutilated heart.

In the evenings, I read my day’s notes, outlined them, re-read them, then underlined the important parts (that is, every line). I sunk into sleep when my eyelid muscles no longer had the endurance to remain open.

In sleep, dreams were intertwined with nightmares. I see my father, shaving at the mirror. He turns to me.

His eyes say, in my silent dream, what I always believe I’d heard years before: “you need to watch over your mother for a few days. I have to go into the hospital for a little test.”

Even in sleep, I feel my gut spasm at the words “a little test.”

Behind the swirling curtains of another dream, I stand at my father’s bedside in a room of white walls, white sheets, white food on a white tray served by an albino nurse.

“I’m fine,” my father smiles at me. “I’ll be home tomorrow. They’re taking real good care of me here.”

I was dedicated, from that day, to being a performer of such miracles for others. A restorer of indestructible and indespensible fathers, when their bodies betray them.

But hovering above each dream scene was the dark gossamer threat of my Draft Board Damocles, my Report for Active Duty date one day closer.

I awoke, all my muscles sore from the constant tension, to face another day, already hopelessly behind in my studying.

II. Our Body

The classical moment in a new Med Student’s life is when he (or she – more on that later) is introduced to his cadaver. My father had told me about how my grandfather acquired his. With a shovel, apparently. At midnight. With a couple of other new Med Students watching for the police while he and his lab partner dug as fast as they could.

In New York in the late 1960’s it was much more civilized. Those who had donated their bodies to science before their demise hung, in a chilled room, suspended with ice tongs by their ear holes. The school’s technician removed them, placed them on tables, and covered them with plastic sheets. Then he leaned into a corner of the lab to watch as new students slowly pulled back the sheet with all the bravery they could fake smeared across their faces.

“There’s something wrong with his skin,” I blurted.

“Her skin,” one of my dissecting partners corrected.

“No breasts,” I corrected him.

“Mastectomies,” he pointed to the dual scars with his steel dissecting probe.

“It’s the chemical that preserves them,” Tom, our not-a-hair-out-of-place Ivy League third partner said. “It turns the skin brownish.”

“Maybe it’s natural,” our fourth partner offered. “Like she’s maybe Puerto Rican or Jamaican or something. Anyone know her name?”

“We aren’t told their real names,” Mr. Professor-of-Medicine-to-be with perfect hair pontificated. “So we’ll have to name her ourselves.”

“Let’s not,” I suggested. “Wow. Look at all the scars on her abdomen. Hope the surgeon left enough parts for us to find.”

And my chest swelled with a familiar sadness as a vision of JFK, his brain all scrambled within a shattered skull, replaced our cadaver for a moment. Another father lost.

No one at our table gasped or puked; all the day’s entertainment was three tables over. Next to the table where four women, their books open, were already identifying anatomic points on their cadaver. Over at the table where the college football player and three other guys had yuked it up loudly, obnoxiously, before they pulled back the plastic sheet. Three of them were now staring at the body of the football player. Three guys in white coats at a Medical School, looking down at their passed-out acquaintance, unsure what to do. We sure had a lot to learn.

May 6, 2012

Med School Culture Shock

Filed under: Uncategorized — cbmosher @ 8:35 pm

I.       The Auditorium

“Look to your left,” the little man said to us from behind the podium. Twin snakes wound their way up the front of the podium toward him.

“Look to your right,” he continued his command.

All 128 of us swiveled our heads obediently, even though we knew what his third line would be.  It was legendary and we’d all heard it many times.  He would say: “One of the three of you will not graduate and become a doctor.”

The real message, of course, which neither the Dean at the podium nor any of us in this Med School auditorium would say aloud was: work harder than you’ve ever worked before.  Sacrifice sleep for study. Sacrifice your social lives.  Sacrifice your marriages. Give your fellow students wrong answers.  Fear the professors and their grade giving.  Learn not just the human body, but the entire medical library.  And be able to regurgitate it in its entirety, on command.

But he was cute about it, this Dean.  After all, he had heard the famous saying, too.  He changed the third line:

“All three of you should graduate and become physicians…”

It should have been a relief, but he wasn’t finished.

“…as long as you work harder than you’ve ever worked before, and learn everything we have to teach you.”

He smiled beneath his bald little head, above the brass snakes entwining the brass staff of Caduceus on the podium, and awaited our applause.  He heard only silence.  Our hands were frozen in terror.  The underlying message, after all, had not changed.

We congregated outside the auditorium, as soon as we’d been released.

“Hi, I’m John.”

I responded to the stranger with my name. 

John added with a toothy smile, “believe me, I’m going to make it to graduation.”

I felt a powerful urge to be honest, but instead I just added, “Yep.  Me too. I’m gonna be an Internist. Like Kildare.”

We almost had a moment of optimism there, the two of us.  Then a tall guy with an intensity burning to the verge of homicidal maniac leaned into our conversation.

“You two don’t know what you’re talking about.”

“And you do?” chirped John.

“Yeah,” he pinned us to the wall with his eyes.  “I do.  I was here last year.  Right here.  First year student and – ”

“Well,” I interrupted him, “You’re here this year too, so you made it just fine.”

“Think so?” he hissed.  “I’m not a second year student.  I‘m a first year student.  Again.  Along with eight others.  They flunked us in Physiology Lab and we’re repeating.” He bore in deeper with his eyes.  “You only get one repeat.  The sword of Guillotine – Dr. Guillotine – is hanging over our necks.  Yours, too.”

“Damocles,” I corrected him because it made me feel better somehow.  “Sword of Damocles.”

“Well,” chirped John with a broad smile.  “Good luck this year.  We’ll see you in the study hall.”

The tall guy slunk away, into the milling group.

It was autumn in New York.  Beyond the dark paneled walls of the century-old Med School, trees were bursting into yellow and red and orange across the Avenue in Central Park.

“Come on,” John offered, “Let’s take a walk before classes start.  Exercise is good.”

“Thanks, but I have to do some business in the Dean’s office.  Catch you after lunch.”

When the Dean’s secretary said, “You may go in now,” I laid a letter on his desk for him, then sat in the chair, trembling as he read it.

“Hum-m,” he murmured as he read it.  “Looks like you’ve been drafted.  This is an order to report for Active Duty.”

“In ten days! They told me I’d be deferred,” I tried to say without wailing.  “Told me the physical this summer was ‘just a formality’.  Promised me they wouldn’t draft me.  They knew I was accepted into Med School.”

“Okay.  Okay.  Calm down.  I’ll write them a letter.”

 “I don’t mind going some day, but I’m worth more to them as a doctor.  If they pull me out now, I don’t know if I’ll ever get back to Med School.”

“I’ll take care of it,” he smiled beneath his little bald head. “You’ll get your deferment back.  I’ve got four other letters to write.”

”Four others?  Same issue?”

“Yep.”

“They tried to draft four other guys out of Med School?”

“Yep.”

“But if I’d gotten a ‘Report for Active Duty’ date just a week earlier, before school began, I’d have been gone.”

“Yep.”

“They lied to me!”

“Calm down.  They have quotas to fill. You’ve got other things to worry about now.  Study hard.”

So I left it to him. Not because I was overflowing with confidence in him, but because I knew I couldn’t do anything to change that letter which hung, Damocles-like, just inches above my entire future.

                                                                                              ( to be continued)

March 21, 2012

The Act Goes to Court

Filed under: Uncategorized — cbmosher @ 2:03 am

For some reason, the way the U.S. funds medical/health care is thru insurance policies. This is not the way it’s done in many other developed countries, and is inherently inefficient.

Inefficient because insurance companies operate for profit. All money deferred to profit and executive salaries is money not spent on health care.

And, as most physicians know, insurance companies put up lots of barriers to keep (or delay) patients from getting tests and treatment the doctor recommends. That is, obviously, good for their bottom line.

But what it means is that, rather than insurance companies providing health care to their insured – they frequently have powerful financial incentives to NOT provide expensive services.

However, politics in the U.S. is strongly biased against a major shift from
insurance to “Single Payer” (i.e. the government pays for everyone’s health care as it now does with Medi-Care).

Therefore, the Affordable Care Act is a complex law aimed at accomplishing the following:

A. Leave those who already have insurance alone

B. Help those who have no insurance or who are trying to buy
“individual” insurance (not group plan insurance)

Why did we need a law for this? Because obtaining individual policies is very difficult currently for many people due to insurance company activities like these:

– May deny a policy to someone with pre-existing
condition
(i.e. those who need it most)

– May yank coverage if someone’s health care is getting expensive

– May set premiums so high (especially on those with pre-existing
conditions or risk factors) that it’s practically not available

– May put annual dollar limits on benefits paid out of policy.

II. Timelines: There are a lot of them. We’ve passed several and more aspects of the law will be implemented from now thru 2018. Here are just some:

2013          Feds will pay for more Preventive services without insurance co-pay

2014         People will be able to buy insurance on Exchanges, instead of individual policies (where people have historically been
gouged).

Those who earn under 133% of poverty (around $23,000
for a four person household) will be eligible for Medi-Caide.

Insurance plans will no longer be able to refuse coverage for pre-existing conditions (i.e. deny insurance to those who need it most)

Insurance plans will no longer be able to put annual dollar limits on policies

People without insurance will be required to obtain it (this will drive down insurance costs since healthy people will be in the pool, and will take the burden of care off taxpayers who now end up paying many bills of this without insurance)

2015           Increase in federal funds into Children’s Health Insurance Program.

2018           Insurance companies that are still gouging people will have to pay higher               taxes

III. How has the Act already effected people?

A. Children under age 26 may now remain on parent’s insurance. 
This will help young adults, struggling to get started.

B. Seniors whose drug bills are high and who hit the “donut hole” will receive federal rebates and discounts to help.

C. People on Medi-Care (mostly seniors) are now able to get preventive services like mammograms and cancer screenings free.

D. Many more children are now covered thru Medi-Caide and CHIP.

E. When states have their “Exchanges” set up, people who currently can’t afford insurance will be able to do so.

IV. Conclusion:

Over the past ten years or so, fewer jobs have offered health insurance benefits, so there’s a trend that’s increasing the number of families without coverage.

The Act takes aim at Insurance Companies which have historically denied coverage to those who need it most, dropped coverage at will, balked at providing services ordered by physicians, and set premiums so high that it’s practically unobtainable for many.

We have a model of this Act – Massachusetts’ approach. So far, it seems to be working well and not breaking the bank

Speaking of funding, here’s how the Affordable Care Act gets funded:

A. Insurance companies must provide health coverage to everyone not otherwise covered.

B. Those without insurance must buy it (unless they’re financially unable). This drives the cost of insurance down by including the healthy

C. Low income families will be subsidized

D. New revenues on pharmaceutical companies, indoor tanning parlors, “Cadillac” insurance, and those on Medi-Care with incomes over $200,000 will help offset increased costs.

March 2, 2012

Armed

Filed under: Uncategorized — cbmosher @ 6:19 am

He came in for a physical, that’s all. Applying for a job. And it should have been simple: he was in his mid-twenties, trim, athletic. When he smiled, the muscles of his face revealed that the rest of his muscles would be well toned, too.

But even before he undressed, the jagged scar on his arm snagged my eyes. It gouged its way from his biceps down to near his wrist like the Colorado tears through the rocks of Arizona. Some places thin and presumably deep, other places thick, wide, a bundle of scar tissue knotting together the halves of his arm.

So, of course, I asked. I can get away with asking, what with the stethoscope dangling from my neck and all.

Me and three buddies, he began, we went up to Humboldt to surf. Great beach there with good waves. Not monsters, but challenging, you know?

It’s off the road quite a ways. Half an hour of slow driving over a cow pasture to the cliff where you can climb down.

Humboldt, you know, the water is cold and always stirred up. Kinda brown. Not much visibility. But the rollers were perfect that day. Fucking perfect.

I was into the water before my buddies had zipped their wetsuits. I wanted to catch the first big one.

He hit me while I was still paddling out, and pulled me down by my arm. I think he wanted to drown me first. My leg was dragging my board down behind me – I felt like I was being torn in half. I figured out right away what it was and knew I had, like, a 90% chance of being dead in a minute. And that pissed me off.

So, with my right hand, I felt around for his eye. Somewhere on that sandpaper head, I found it. And I started digging. Like my life, you know, depended on it.

Deep. I would have dug with my thumb to that bastard’s brain, if I could have. My thumb squeezed that gelatinous ball in its socket. I aimed my fingernail straight in, and pushed until I felt it explode, and my thumb fell deep into the puddle of goo oozing from his socket.

He spit me out.

The rest I don’t remember too good. Air. That felt good. A few heaving breaths of air. Then I yelled for my friends. They tell me I was thrashing in the “Red Sea.” Ha, ha. Very funny. Assholes.

They tell me they wondered if they were supposed to put a tourniquet on to stop the gush of blood. But they didn’t know what a tourniquet was, so they didn’t.

They tell me I was going unconscious as they dragged me up the cliff. They tell me they drove so fast over that pasture that the truck was airborne half the time. They tell me the doctor in the little one-horse hospital thought I was dead when they dragged me in, just dripping blood, no longer gushing it. No blood pressure to gush with, they said.

The doctor, they tell me, said the only reason I was still alive was ‘cause I was young. ‘Course, I know better. It’s because somewhere out there, some Son of a Bitch fish is trying to hunt seals with a patch over one eye.

January 25, 2012

Dr. Pannikatakus

Filed under: Uncategorized — cbmosher @ 6:19 am

Guest editorial by World – famous psychiatrist to physicians, Dr. Pannikatakus

I hear from physicians what, to no one else, they tell. Their secrets. Their fantasies. Their failures. Their sick little ideas.

 

 

Case # 69

“I was sent,” he snarls, this doctor. He is not a physician, I learn, but a surgeon. In this country, they license them the same. “Physician AND Surgeon” says the license. It’s confusing. But I digress.

“Ordered to come here,” he spews. “For the Public Health. Three sessions. So let’s get it over with, and you write to the Authorities that I came, and we’ll be done. Understand?”

“You are,” I say calmly toward his face, so flushed and hot I see steam rising from his sweat, “accustomed to giving orders, no?”

“Damn right. I’m a – ”

“Sit down, please,” I interrupt him. “On the couch. In this office, the orders I give.”

“It all started,” he begins, eventually, after a few more exchanges where, to him I make clear who is boss, “in the hospital. Late. Midnight, I think. I’d just finished an emergency torsion of the testicle, and was in the cafeteria, getting coffee from the machine. You know, for the drive home.

“The place was deserted. Except for this one guy. He was pushing an I.V. pole, his ass flapping in the breeze.”

“Asses can flap?” I blurt.

“The gown,” his eyes rise up and roll like exasperation. “The gown flaps. Don’t interrupt me. So, just as he’s passing me, he collapses. I look around for a doctor. An anesthesiologist. Even just an Intern. Hell, I’d have taken an E R nurse – if she was cute. But no one. The place was like a morgue with dispensing machines. This guy drools some saliva on the floor and his I.V. line pulls over the pole.

“Shit ! I think. Now I’ve gotta see if I remember any of that CPR crap. You know, this is not like on the table in the O.R.”

“No,” I say to fill the brief silence. “It is not like that. Continue.”

“So, he’s not breathing. No pulse. It’s – what do you guys call it? Cardiac arrest. So I can’t do CPR alone there until the 7 A.M. shift comes in, can I?”

“You said you don’t know CPR, did you not?”

“Well, there was that problem, too. So anyway. No way to call someone. Hours until someone might stumble by. So I get this brainstorm.”

Oh, oh, I think.

“Brilliant idea. Which makes sense ‘cause I’m a brilliant surgeon, you know.”

“Continue,” I say during the silence he creates, waiting, I assume, for applause.

“Anyway, I slice open his chest, reach in, massage his heart and, Boom! He wakes up!”

“Good,” I say. “You save his life.”

“Not yet. Every time I take my hand out, it stops again and his brain goes back to sleep. I need help, but there’s no one around. So, here’s the really brilliant part – – – .”

Another silence.

“Continue,” is all I say.

“And do you think he appreciates my brilliance? That I saved his life? No. After he recovers, he goes and gets a lawyer and sues me for mental torture or some such. Reports me to the licensing Board. So here I am.”

“Tell me,” I say, into the silence, “tell me your greater story of this brilliant idea.”

“I squeeze his heart until he wakes up again, then I take his right hand, put it down into his chest, around his heart, and I tell him to squeeze. Once a second. I tell him I’m going to get the E.R. doctor. And I warn him not to stop squeezing, or he’ll black out and die.”

“What did he say?” I ask.

“Say? He said what I told him to say. He said ‘thank you, Doctor’.”

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