Wednesday, November 25, 2009


Originally written earlier this month, and originally posted late November while dated "November 1" --now dated 11/25 to reflect the order in which it was posted.

Ms. Dr. Hemodynamics and I got married a few weeks ago, and then went on a honeymoon. So my faithful reader(s) will be unsurprised to find that the thing I want to write about on my return is, of course, local production and the evolution of service economies. To those finding this blog with some hope of reading about medicine, I promise that this discussion, after passing through Marie Antoinette, water buffalo, goat cheese, and wine, will lead us back to medicine.

I'm not writing about the wedding and honeymoon part, dear reader(s), because though it was very lovely, it was also private, and I'm not one of those bloggers. But, for all you sentimentalists--and who is my Hemodynamic reader(ship) if not sentimental fool(s)?--a bit of our honeymoon will appear below.

* * *

I wrote a little while ago about our farmer from whom we purchased a Community Supported Agriculture share this summer. We loved having a specific guy, Steve the Farmer, provide us with our spring and summer produce, even though (or perhaps because) sometimes Steve the Farmer's operation is a mess, his corn gets flooded, we don't get any corn, and he worries about losing the farm. Every small farm is like that, at least sometimes, so we know that buying into a farm means buying into the uncertainty of farming. And also, some really delicious produce and a connection to the process of growing it.

Ms. Dr. Hemodynamics and I are confirmed urbanites, but we like going and seeing where food is made. Last year, almost exactly a year ago, we went on a road trip to Montreal, stopping for a couple of stops to sample the goods and view the workings of a couple of small Vermont cheese producers. The Vermont Agency of Agriculture has put together a "Vermont Cheese Trail" which is more conceptual than actual: when you call these places on the phone they are often not able to accept visitors, and sometimes even seem befuddled by the question. But we found a couple of cheese farms, beyond bigger tourist-targeted operations like Cabot, who would let us visit. This included a farm that raised water buffalo to make the real deal Italian-style mozzarella di bufala (now apparently moving the herd and operations to Quebec, per an updated web site), and even more lovely, a small goat farm and cheese-making operation run by a former employee of Cambridge cheese mecca Formaggio Kitchen and his wife, called Twig Farm.

At Twig Farm, we learned about goats and goat social hierarchies, saw where the cheese gets made, and the basement of the Twig Farm family house where the cheese is aged. We started to understand what it takes to make delicious cheese like the kind of cheeses we buy at Formaggio Kitchen. And we grew more fond of the cheese itself in a way we do not when we just go to Formaggio Kitchen's deli counter and jostle with the well-heeled Cantabridgians who try to cut ahead of us in line to get their prosciutto before we get our cheese. We bought Twig Farm t-shirts and a bunch of Twig Farm cheese. It was delicious, and precious to us not only for being delicious, and for being two pounds of gourmet expensive cheese which we got from the source, but for being the cheese from a herd of goats and a little family of cheesemakers who we had met and spent time with.

A couple of hours after we returned from that road trip to Vermont and Montreal, our apartment building caught fire, and when we were able to get back into our water-damaged apartment, moving the cheese out of the fridge and into safety was one of the first things we did. And we still wear our Twig Farm t-shirts with great affection and loyalty, even after just meeting the Twig farmers for a couple of hours.

(continued below the pictures)

* * *

Photos: Twig Farm goats being milked by Michael Lee of Twig Farm; groups of the goats get into this milking area via one door. As he milked, Mr. Lee explained the complex goat hierarchy, in which the chief goat and her lieutenants are the first group to get in the door from outside to get milked (and eat yummy snacks while being milked), with the head goat going into the first position. This means more snacks for complex reasons having to do with the order in which Mr. Lee does the milking and snack replenishing. A former queen goat had been deposed last year, and if our memory serves us, she is the one looking at the camera in the picture of the goats eating, below, now in a later milking group, abandoned by her former lieutenants, but still (from this picture, at least), clearly possessing qualities of curiousity and leadership. Once finished with milking, the group of goats files out, leaving through a second door which leads to the other side of a fence, with the last one in the group being urged out by Mr. Lee's helpful push. Below that: Ms. Dr. Hemodynamics and I remain big fans of the Twig Farm t-shirts we bought on our visit; this is mine, worn while visiting a local orchard to pick our own apples, a much older and more developed New England agricultural tourism tradition. Last two photos: A water buffalo cow, and a water buffalo calf, at the mozzarella farm.

* * *

We went to France for our honeymoon, and we discovered some changes since our last visits there, before we knew each other. France now has big box stores, and more and more chains. These were not only McDonald's, which serves a more French menu than it used to, and Starbucks, which was dotted throughout Paris, but also French chains, with food prepared in some central assembly center and trucked out to the stores. I remember that there was an earlier time in which this sort of thing seemed shocking to French people and those who loved them (like the part of the movie Perfumed Nightmare, where the narrator proclaims, "Liberte! egalite! fraternite! supermarchet!"), but it's now part of the landscape in a permanent way.

It seemed during this visit that France has now more fully entered a stage of rationalization, automation, and modernization of the service industry, in which many of the past quaint details of small shops and producers are overcome by the same factors that make box stores and chains attractive and competitive elsewhere.

But even when we went to buy cheese in the little cheese store, there was not a focus on who made the cheese, but instead, where it was from and what kind it was. When there are traditional ways of doing things, I guess, customers assume that one of the traditional products is like that of another; or perhaps, the consumers are focused on their trust for the shopkeeper's taste.

We actually had a Twig Farm sort of experience when a friend of ours arranged some wine tastings for us. One of the appointments she made was at a small winery, run by a married couple who left their jobs with a corporation that runs big box stores in Europe and elsewhere. They started making lovely wine from a small vineyard. We loved their winery as much as we loved Twig Farm, and we liked their wine as much as we liked Twig Farm cheese. We bought a cheap bag in a crummy Paris luggage store just so we could put our extra clothes in it to make room for extra bottles of wine in our suitcases.

The winemakers' personal trajectory seemed almost like the evolution of our era's service economy in general. They went from box stores to their little winery. But this is a romantic adventure, not a transformation of the actual economy of wine. The emphasis on small personal producers, once a feature only of pre-industrial economies, is now a feature of a romance of local and artisanal products.

The economy sacrifices small-scale pre-automation production for efficiency, gets agribusiness and box stores, and then one part of the market starts romanticizing the small local producers. I don't want to diminish those producers; I believe in Steve the Farmer, and Twig Farm, and all the other small producers with whom I have relationships. I believe in what they do, and I want more people to be able to do what they do.

But then there was Marie Antoinette's country village at Versailles. There, in a tucked-away corner of the most insane royal estate this side of the Taj Mahal, she imagined herself as some kind of rural peasant. She had a little herd of sheep, and beautifully arranged little plots of vegetables. Marie Antoinette probably got a bum rap in all kinds of ways--there were much bigger villains in the pre-Revolution order of things--but we know that this kind of romanticism is not how we want to relate to the project of growing food.

Of course, Twig Farm and Steve the Farmer are not Marie Antoinette. They are real farmers, they work hard, they get their hands dirty, and their operations are arranged for the creation of pleasing products, not for the pretense of the pleasure of production. But unless we are thoughtful about it, there can be a little bit of the queen's farm in those of us who support the industrial service economy, but romanticize the pre-industrial way of doing things.

Every time we shop in a big chain store, or buy food shipped from some other hemisphere of the world, we are making it more difficult for small producers and sellers who make personal products to sell to other people. We make the relationships of small markets and high quality more difficult. This actually has the paradoxical effect of increasing the romantic value of small farms, and the difficulty of actually running a small farm. In other words, the mass production of food is itself what creates the small high-cost market of special and personally-made food. We value Twig Farm partly because of the co-existing massive industrial project of creating and distributing mass-produced cheese. The contrast makes Twig Farm what it is.

To put this another way, the American service economy is so industrialized and hyper-efficient, that it has made personal production romantic enough to make money.

In 17th century France, peasants labored on over-farmed soil controlled by large landholders, taxed by the church, with lean years meaning famine, fear, death from hunger. Meanwhile, the queen delighted in the quaint project of harvesting a tiny crop of perfect grapes, or commanding a small herd of perfect sheep to amble across a perfect meadow. Both of these projects had something to do with agriculture, but little to do with each other.

Many of us are aware of this problem in our modern lives, and try to make compromises with it. The effort to sell us on a compromise becomes a goal of marketing for chains like Whole Foods. When they highlight local producers and particular high-quality low-volume products, they help us feel that the convenience of Whole Foods is a reasonable compromise, even if it is a giant supermarket chain run by a libertarian guy whose views on health reform run counter to those of many of his customers.

It would matter to me if Steve the Farmer was mean to his kid (he's not, he seems to have a nice relationship with his kid, and I like that), or if Twig Farm was run by insufferable snobs who spent all their time expressing disdain for people who eat cheddar. But I know that Whole Foods is a large chain, a corporate enterprise. It is not a farmer's market. I don't like the CEO, but I can maybe get a little more local produce there; the produce that isn't local might be at least organic, which is better for the people working in the fields far away; and I can buy delicious cheese made locally or made in my old local cheese zone of Northern California.

* * *

I'm no agricultural theorist, and one reason I've actually been thinking about all of this in a more than idle way is because of the evolution of the service economy of medicine.

Medicine, particularly primary care medicine, is retail business. Customers come in, they get served, they leave. Medicine is its own distinct industry; and yet, it is also part of the service economy. Most of us, when we think of the doctor we want, imagine a medical equivalent of Steve the Farmer or Michael Lee of Twig Farm--someone who is somehow apart from the hyper-industrial underpinnings of the actual larger healthcare system, someone who in fact runs counter to that system.

The personal relationship in medicine is a near-necessity, and this is why we have not sacrificed it as easily as we long ago sacrificed making food ourselves, and then sacrificed having relationships with people who make our food. But our desire to have a personal relationship with a doctor means that the medical system is an awkward blend of types of service economy. It is one part an old-style pre-modern service economy, and the other part, a highly industrialized and automated up-to-date service economy.

In my big hospital, going to work in the morning in a massive medical area with not only my hospital, but others, and lots of laboratory and clinic buildings as well, I am always aware of medicine as an industrial process. I work in a hospital which is making a niche in the local and academic medical marketplace by emphasizing "quality", which in medicine has become the shorthand for a movement which emphasizes process, reliability, systems engineering. It emphasizes rationalizing and industrializing the processes of medicine. It is a descendant of Fordism; it more explicitly borrows from Toyota.

I believe in this way of thinking about medicine. But at the same time, I know that embracing Toyota medicine means that I'm not making goat cheese. I'm not bringing a truck full of vegetables to a corner in Somerville, where my little son runs around trying to get my customers to buy the special mushrooms. I'm joining a big store, a big factory.

That means there is an irony in my life. At the same time I believe in standardization, in streamlining processes, in building guidelines and common ways of doing things, I also want to make my own special kind of goat cheese. I want my patients to think of me as someone unique and special. I want to think of myself that way.

And so, the rhetoric of doctors and patients is full of mutually-agreeable untruths. Whether in the politics of healthcare reform, or in our personal relationships of the clinic, we like to emphasize that there are large dark forces that want to embed our relationship within some kind of bureaucratic industrial process, when all we want is small-scale goat cheese. Any system survives because it plays useful functions. In our current insurance system, we enjoy having a scapegoat. The insurance company becomes the holder of all our anxiety and anger, the faceless formless evil which absorbs all blame and pays all bills.

Doctors who nourish sentimentalism within an industrial medical economy will emphasize the humanism and kindness of particular doctors, rather than the systems that make humanism and kindness possible or impossible. Yet it is the system that matters within a massive rationalized Fordist/Toyota-cized infrastructure. The infrastructure supports relationships or doesn't. Pretend that medicine is mainly about a single doctor and a single patient, and you risk building Marie Antoinette's clinic.

Tuesday, November 24, 2009

Monkeys in a cage

Watching a patient in an altered mental state sit in a bed, I realized that if my patient were a monkey, and my relationship with my patient were governed by a laboratory's animal care and use committee, I would be cited or censured for not providing enough activities for my lab monkey. But there is no one to cite me. So my patient sits in a room, isolated, a TV on in the corner, a sad lonely primate.

Friday, November 20, 2009

Coding ET

[I tried to embed scenes from the movie from YouTube. Of course these have been removed due to copyright violation. But probably if you look it up, someone else will have posted it.]

I was at home on my own, watching TV post-call after an ICU shift. Nothing was on, and I landed on the middle of "ET: The Extra-Terrestrial". Before you know it, government agents are surrounding the family home; soon, as ET gets sicker and sicker, a medical team starts coding ET.

When I watched this movie as a kid, I saw it through the child's eyes, and the government agents were totally terrifying. Now I see the physicians among them as basically benign, though surely misguided: in trying to save ET's life; they're running a by-the-book Advanced Cardiac Life Support code algorithm.

Apparently, there were real emergency medicine physicians involved in this scene, and although some things have changed in the way we run the same algorithm now (betrylium? huh?; and what is with those lousy chest compressions?), much is the same. You could argue with the technique: a light-hearted series of letters in an emergency medicine journal at the time went over the code. One pointed out, for instance, that ET had 6 beers earlier in the movie, and this might have induced hypoglycemia given his small size; another pointed out that perhaps an overdose of endorphins related to ET's abandonment on earth meant that he could have benefited from naloxone.

A letter in Annals of Emergency Medicine defended the scene: "As one of the physicians responsible for resuscitating ET in Steven Spielberg's movie, ET, The Extra-Terrestrial, I read with great interest the letter in your August 1983 issue entitled, "Use of Naloxone in CPR" (August 1983;12: 519-520). In that letter Drs Wasserberger and Ordog suggested that the resuscitation effort of ET might have benefited from the use of 'high-dose opiate antagonists.' I would like to inform my colleagues in emergency medicine that ET received every drug known to our specialty in our resuscitation attempt. Unfortunately, many of the drugs used, the correct dosages administered, and the procedures performed on ET were destined for the cutting-room floor of the editing department...

"I am pleased that our efforts did not go unnoticed by those with knowledge to judge and evaluate the scene. Although the process of editing changed the details and order of the events in the scene, we hope the flavor of the management of a true cardiac arrest came through on the screen." (A. Lampone, Ann Emerg Med 2 February 1984)

The emotional punch of the scene of ED being coded comes because the scene does look like a real code. Because it looks like a real code, it also looks like a form of madness in the emotional context of the children's relationship to ET. Nearby, (not shown in the excerpt above) little Elliott, who feels what ET feels, shouts, "You're killing him! You're killing him!" And poor little Drew Barrymore, then a small child, is flinching and crying as she watches the code team apply shocks to ET's chest.

Elliott is not upset because they're not giving Narcan to ET, or because the chest compressions are too weak and too slow by today's standards. He's upset because the process of coding ET seems barbaric; and totally beside the point. Most of the audience, I'm sure, identifies with Elliott. I can't help but identify with the doctors; and yet, I also recognize the emotional resonance of the scene from the Elliott point of view. There are plenty of times when we start moving forward with some high-intensity intervention, coding someone because that's our job, putting a line inside someone, whatever it is--and at the same time inside of us, some little Elliott is screaming, "Stop! Stop! Please stop!"