hiatus

Hemodynamics is on hiatus. Thanks for stopping by, though, and I am sure it will start back up at some point, in some form. In the meantime I share links and T-cell news at tcells.tumblr.com.

The mammal's brief moment of sorrow

Photo: Jacob in the movie Twilight, being a mammal.

Sometimes when we're leaving for work, the cat follows us to the door. As we go out, there's a glass-paned door that we shut between her and us. She will have been following us, looking up at us. Then there's a sad little moment. As we put our shoes on outside the door, she sits down on the floor on the inside, and then she stops looking at us and looks at some distant space on the floor a few feet away.

It's a moment we all recognize. This gesture, this way of experiencing a moment, this passing brief sad look, is something that cats and dogs do, and people do. We are all social mammals. And this little look-down-at-the-floor maneuver is something we do when we are feeling small, feeling that someone who we want to pay attention to us is no longer concerned with us.

I have felt that way at various times; we all have, right? Any teen movie is full of that look. So many times in my life, I've looked just like the cat looks when we leave for work. And if you had asked me at any such moment how I was feeling, I could have put words to it, likely embedded in the context of the particular moment. But I think there are a lot of things that we feel that are just mammalian. And this is one of them: it's a small melancholy moment of a social animal feeling alone. It is deep wiring, not in the sense of being a deeply-felt feeling, but in the sense of being some long-ago-evolved part of being a social mammal. It is some basic part of who we are, our animal selves, not our language and culture selves.

They've gone away and I'm still here. There's the floor. I'm alone here. A moment to absorb this. OK.

And then it passes: you look somewhere else, think about the next thing to take your mind to something else, comfort you: you turn to go find a little bit of food, or a blankie, or maybe a new email that might have arrived on your iPhone.

Eric Balderas is free, for a little while

Eric Balderas, a Harvard College sophomore studying molecular and cell biology, was recently granted a stay of deportation. Eric was picked up by immigration authorities after trying to use a Harvard ID card to get on a plane. His story is one of many arguments for the DREAM Act, which would enable undocumented young people, brought to the United States as children, to earn citizenship if they met a specific set of conditions (earning a high school diploma, college degree, or serving in the military). This would transform the lives of many members of our society, including some who matter very much to my family and me.

Around these parts, Harvard actually has a significant number of students in this situation, in part because it can offer full financial aid to young people who are not citizens or legal residents. But it is only a temporary refuge, as an article from the Crimson explains. The article puts particular focus on one Harvard student who is applying to medical school this year; I don't know when and whether she'll go, but I can only hope that she joins us in the hospitals and clinics, as a colleague who never has to doubt that she has a place here.

Here's a Crimson news video from earlier on in the saga, interviewing Eric Balderas.

why I walked

I admit I only signed up for the AIDS Walk because L, the HIV social worker in my clinic, was the captain of the team and intercepted me on the way to the hospital cafeteria with her strategically placed table.

And when I got to the walk this morning, many of our "Team Members" had evidently contented themselves with having raised a little bit or a lot of money--most didn't show up to our team meeting spot on the rainy morning of the actual walk. That's fine, really; our hospital employee team was a "Gold Team", and as a medicine resident from a rival hospital sheepishly noted, our hospital's team raised more money than that other bigger hospital's team did. Really, everyone who shows up and takes a tote bag and water and granola bars is probably just costing the AIDS Action Committee money--so maybe it's a favor to raise money and then bag the walk--there's even a category called "virtual walkers" to describe this strategy.

Still, it seemed like I was supposed to be there, so I went.

(continued below)







By mile 2 or 3 I'd separated from my fellow employees and could have easily hopped the T and gone home. Our hospital had done its bit--a community relations person had waved our sign around, we'd raised our money--and now it was time for the teams of the corporate sponsors, college charity groups, and AIDS non-profits and government agencies to finish the walk. Or so I thought for a moment. And then I started really making note of a small but persistent group of teams, each with their team t-shirts, made to memorialize a family member.

(continued below)












It was the 25th annual AIDS walk in Boston--they've been doing these things since 1985. A long time. Walking on my own, I was speeding up to get back to the finish line. I thought some about the morning teaching session I need to do on Wednesday--I think I'm going to do it about a patient of mine with AIDS.

As I walked, I noticed that the AIDS Walk had put up these little signs noting each year of the walk and events in AIDS history. I started doing AIDS work and volunteering in 1991, when I arrived in San Francisco. It was the red ribbon/Magic Johnson year, the signs reminded me--the year that AIDS most clearly became a part of mainstream culture. Sometimes I can be hard on myself about why it was I started then, when it was easier, and not in 1988, after I found out that my student government teacher had died, or in high school, in the mid-eighties, when passing out condoms would have been a radical act. (To ease up slightly on myself, it's true that I hadn't yet really had sex myself, so the gesture would have been a complicated one.) But then the next panel reminded me: that next year, 1992, was the year that AIDS became the biggest cause of death for young men in the United States. And in 1992, it only seemed like it was going to get worse.





1991-2010: I've been somehow involved in AIDS work almost all of those years, with a few small breaks for parts of my medical training. More than half the epidemic--in fact, now, about two-thirds of it, minus the very worst years. Next year will be 20 years, out of 30. I don't know what to say about that exactly. I could have stopped in 1997, since from 1991 to 1996 I said I would stop doing AIDS work and start doing something else "when the crisis is over" and when I said crisis I meant the kind of mass death that ended in San Francisco with highly active antiretroviral therapy.

But I didn't stop, though most of my friends who were also there for the crisis did. I'm still not sure why I didn't go do something else. For a brief moment in 1997, I almost went to work for an ad agency but I got another AIDS job instead, and I was relieved and knew I'd made the right choice. During a year in a lab, I found that I was depressed until I started volunteering for a needle exchange program.

No one I was super close to died or even got sick. There wasn't some big cathartic event, other than living in San Francisco in the early 1990s, that kept me going. I just kept thinking about AIDS because I kept thinking about AIDS, even though there would have been a lot of other alternative paths for me in which I probably could have done greater good for a greater number of people. So it's not like I'm claiming a moral high ground. I'm just observing the persistence of a theme. It is what it is.

Given that I have kept doing this work, kept connecting myself to this epidemic, I'm glad I got out in the drizzle and walked. Not for my hospital. And only partly because of the AIDS Action Committee--since the money raised was raised whether or not I walked, and they probably could have given my tote bag to encourage one of their nutrition clients to go to the farmer's market or something.

Mainly, I was glad to walk because those little clusters of families with their team t-shirts deserve to have lots of people around them when they gather together to remember someone now gone. It also gave me a couple of hours to think about how long this epidemic has kept pulling me back towards it, for reasons I don't entirely understand.

If you want to give some money to the AIDS Action Committee--they're good people. I know them personally because they're getting food and other services for one of my patients who's really sick, and a few years ago they got me down to the statehouse to help lobby for their (successful) effort to decriminalize syringes and make clean needles available in pharmacies in our state. They do a lot of other great stuff too. Here's the link to my AIDS Walk fundraising page.

And: thanks so much to that small but sweet group of friends and family who donated--it means a lot to me. It's true that because of your donations, I qualified for a tote bag; but more importantly, my patient will get some food. And trust me: he needs it.

Stop Obama's misguided global AIDS policy

Photo: Kaytee Riek, whose other photos of this recent demo can be found at kayteeriek.com

President Obama is making big mistakes on global AIDS. Click to read South African AIDS activist Zackie Achmat explaining why.

See also:

TakeANumber.org

New York Times

Zackie Achmat in New York, May 13 2010:

1996: protease inhibitors were confusing

For my zine, I wrote this; although my life changed in other ways shortly afterwards, and somehow that also meant that I stopped publishing my zine. Those were in the days before blogs, children; in the days of photocopiers when self-published writers had to go to the Leather Tongue video store and drop off five copies of the zine for the magazine rack, in hopes that there might be only two when they returned a month later.

Not long after this I ended up going to work for an HIV vaccine research group, which restored my sense of urgency. It also stalled the question of doctor or account planner (see previous 1996 post); then I learned immunology, did some needle exchange, and with much more excitement and no inertia, I decided to become a doctor.

October 14, 1996

At my job [at an HIV prevention agency in San Francisco] another person has quit; everyone seems disspirited and low. To some extent, that’s because of the particular politics of the agency: personnel absences, departures, events, personality changes, etc. But I’ve been wondering, on my return, whether there’s something deeper. The advent of the new drug treatments, and the incredible promise of the protease inhibitors, may have subliminally actually depressed people.

The idea that we are an important lifesaving effort is slowly losing focus; if people are staying alive with HIV, then we are disease prevention specialists, not the first line of defense in a community under siege. In itself, that would be great news, but unfortunately, no one knows for sure what the truth is.

How many people will really benefit from the protease inhibitors? The most optimistic school of thought has it that the protease inhibitors, if used for somewhere around the range of three years, might be able to help some people’s immune systems to entirely eliminate HIV from the body--in other words, that in a couple of years, we might have a partial cure blossoming in front of our eyes! Others are more skeptical and uncertain about the longterm prospects of the new drugs; if this group of people is more correct, we will only see people with AIDS die a couple of years later than they would have before.

So we can’t yet cheer the end of an era. On the other hand, the urgent language of our previous era is fading and cracking under the dim light of future prospects. We are left with no sure knowledge of our role, no clear sense of how important our work will be, and no overtly stated acknowledgement that things have changed. I am beginning to suspect that inertia is the result.

1996: what color was my parachute?

I was looking through old files for something else, and found this. Since you're reading this blog, you know what finally happened. Math was hard, but I stopped letting that stop me. I bought an algebra book, re-learned algebra and trigonometry, took science classes, went to medical school. Apparently What Color Is Your Parachute? knew what it was talking about. Maybe.

Also I had kind of forgotten how into REM I was back then.


Whenever someone asks me what I’m up to these days, I say, “Oh, trying to figure out what I’m doing with my life.” Then they chuckle. Heh heh. They’ve been there.

But were they ever really as desperate as I am now? Because I’ve turned not once, but twice to What Color Is Your Parachute? It’s maybe the most famous self-help book ever--so I must be in bad shape, right? The concept of the book is that if you follow its instructions, you’ll not only find just some job, but you’ll figure out exactly what your ideal job is and then get it. I’m a product of the culture that this book helped to create--it was first published a year after I was born. Maybe that’s why I hold on to the belief that it is actually possible to find an ideal job, a true calling, even outside of “Lottery Winner.”

A while ago, I was housesitting in a house so beautiful that I went out and bought twenty lottery tickets so maybe I could buy a house just like it. At least one of the beautiful house’s owners had read an early edition of What Color Is Your Parachute? which they still had laying around, marked up with notes. So, after my lottery tickets yielded no results, I sluffed my way through a few of the book’s career exercises. I came up with a plan, which was a pretty good plan except that it depended on some people who didn’t agree with it. After that, I managed to ignore my career woes for a while. Actually, I was sort of ignoring my career, period. My new boss, the smarty-pants bastard, eventually sat me down and told me that I’d better start shaping up. Which reminded me--oh yeah!--I still hadn’t figured out what I was doing with my life.

So--back to Parachute. This time I started in on informational interviews. A series of what-do-you-dos and how-do-you-like-its yielded a great deal of interesting information, not least of which was that if you sit people down and ask them about themselves, some of them don’t really want you to leave. Maybe ever. A couple of people told me I should be a doctor. Sounded cool, but difficult. I’m like that talking Barbie--math is hard. Plan B was a little more accessible: account planner at an ad firm. Until I realized that having Plan A as “Be a doctor” and Plan B as “Be an account planner” was a little too much like talking Barbie. I still really hadn’t figured it out.

So, back to the book. I started doing all the exercises, not just the few I didn’t find depressing. While I was writing a list of everything that I had ever learned, I was listening to an REM song and it occured to me that part of what bothers me most about submitting to the indignity of this kind of exercise is the overwhelming sense that most of my heroes never really did this. When REM were a bunch of students in Athens, GA, they just started playing music because they loved playing music, and then they started putting out singles and albums and videos, until they became the huge phenomenon they are today. I just can’t see that there would have been any career self-help books in the process.

From when I was fifteen to when I was twenty-four or so, I had a calling. I wanted to be a movie director and I wanted to make frequent interview appearances in oversized magazines and late night talk shows. But let’s not speak of those mistaken notions now. Let’s focus on the future: I need a new plan. I know that What Color Is Your Parachute? should help me find some reasonably satisfying direction, but I yearn for something more: a new calling, a new certainty that what I want is what I will be best at and enjoy the most and give the most to the world by doing. And also that it will be infinitely glamourous and make me famous and loved.

The problem is that this book, this Parachute is designed to move you away from obvious answers and convince you that, for instance, everything you like about being a movie director is actually fulfilled by being a freeway engineer. The idea is, obvious answers aren’t always the best answers. Sometimes you’d actually be happier designing freeways or selling plastics. But in the direction of obvious answers also lies the allure of glamour--of what everyone wants, or thinks they want. Diving with sincerity into a career self-help book is a sure sign that you’re giving up glamour. An important step, no doubt, but also, inevitably, a sort of depressing one. This isn’t going to be about your calling, the moment in Athens, Georgia where everyone realized you really had something. This is about settling down and going to work.

When you're done getting dressed, take the rooster to the front desk

Sue Lowden is a Republican running to capture Sen. Harry Reid's seat in Nevada. Recently she suggested that we should go back to the days when people paid their doctors directly, whether in money, or you know, if they didn't have the money right then, then maybe, barter, with, you know, like, chickens and stuff. That back-to-the-old-days nonsense is so phenomenally stupid, it nearly begged for someone to set up this site:

Prices of medical procedures in number of chickens.

Make sure to read the fine print to properly adhere to the plan's rules.

For big procedures, the site suggests possibly converting to cows.

On the other hand, teaching hospitals might consider accepting chicks in order to subsidize medical education--and to pay residents with. Residents, being mere doctors-in-training, should be paid in chicks rather than in chickens. This will also allow them to invest in their future. Once the chicks grow up, they can be used to pay off student loans.



The Democratic Senatorial Campaign Committee has a different plan available.

Unbelievably, after taking a week of jokes (Jay Leno: "But what if your doctor isn't Amish?"), she continued to promote this idea, in the tone of making a helpful suggestion for the folks at home.

Jamie Oliver, ABC's pop Alinsky

Photo: Jamie Oliver in Britain, where he transformed national school lunch policy.


Ms. Dr. Hemodynamics and I were having a little bit of TV time the other night, and Jamie Oliver was trying to convince the lunch ladies of West Virginia that cooking from scratch was a good idea, and railing against some state bureaucrat's affection for chocolate- and strawberry-flavored milk.

Surprisingly, we kept watching.

OK, so, admittedly, I've only seen one episode thus far--but still, I found myself surprisingly compelled by the episode I saw, as a template for health-oriented community organizing.

I have mixed feelings about the moral panic in progress about obesity. The term "obesity" has become so loaded with moral judgment that I've taken to showing people in my clinic the NHLBI BMI calculator while holding my hand over the category labels. I always explain that this is a continuum, and that it's my view that the terms "overweight" and "obese" are better understood as "higher risk" (for 25 to 29.9) and "even higher risk" (for over 30). I don't think that calling someone "obese" is that useful. And absolute weight numbers, especially around the high 20s/low 30s fairly "overweight"/slightly "obese" range that so many of my patients and I occupy, may be at least as important as proxies for other things--like cardiovascular fitness and nutrition--as problems in and of themselves.

But my own struggles with weight and fitness, and those of my patients, are for a different day. The genius of Jamie Oliver's show, at least the episode I saw, is that he doesn't waste a lot of time trying to persuade individuals to change their individual diets. He knows that they'll drink the chocolate milk if it's in front of them and they have a choice between that and regular milk. Who wouldn't? And if the chocolate milk isn't there, they won't drink it, because how would they?

Here are some other aspects of why Jamie Oliver showed himself to be a smart community organizer in the 45 minutes I watched him:

1. Big change comes from changing big systems. He knows that the leverage is in the structural intervention. Children in this town all eat lunch at school, so don't try to get them to bring their lunches. Change the school lunches. People at a work place eat food that's close to work, so don't ask them to drive to some place that has a salad bar two miles away: drive a food truck that serves salads and bison burgers up to the work place. Like smoking, a lot of food choices are made because of availability, proximity, habit--all things that can be affected by altering the physical and economic environment at least as easily as changing individual minds.

2. Individual beliefs matter. Conversely, he knows that structural interventions can only work if a large enough number of individuals support them. People who think eating better food and avoiding obesity is a good idea will appreciate the support that a structural intervention gives their personal goals. But if people don't understand the rationale behind the changes, they'll just be mad that there's no chocolate milk or french fries--they'll register a change, understand it as out of their control and leading to a result they don't like, and demand a change back to the old system.

3. Every individual matters. Anyone at any point in the process, from state bureaucrat to food supplier to principal to cook to teacher, can either advance or sabotage a project for change. Because of this, he also lets everyone know that when they are supporting change, they are instrumental in doing so. He lavishes praise on the smallest change. "Fantastic!" he raves, as if the low-level administrator who removes the chocolate milk for a day should win a MacArthur "genius" award. Even non-committal shine-on answers get a "great, great" from Jamie, as long as they're not frankly obstructive--though he doesn't take "maybe" for an answer, and goes back to trying to close the deal.

4. Follow the money. He understands that the approach he's recommending will cost more. He targets the town's biggest employer, which nicely is a hospital. He shows that they should have an interest in supporting his changes and relentlessly hits them up for money. (That in fact they may not have any particular economic interest in the changes he proposes is a sign of the utter perversity of the healthcare system, but that's another reality TV show.)


These four ideas are the basis for a lot of successful community organizing.

I'm not sure Jamie Oliver has got it all figured it out--most importantly, I'm not seeing him build a corps of organizers who will stick around to keep the pressure on. But maybe at the end of the show, the real point is not the people in that particular town--but the corps of organizers he might build from the millions of people who are watching him on Friday nights.

Miners die, again

The newspaper from Harlan, KY sends a reporter to the Montcoal mine disaster.

And though statistically, mining has become safer overall in recent years, that's in the context of technology that could make mining disasters entirely a thing of the past. Why aren't they a thing of the past? Here's a glimpse from In These Times, which makes me feel like

the more things change, the more they stay the same.

Stay the same

Stay the same

Stay the same, the same

Stay the same

Stay the same.

Berwick to run Medicare/Medicaid

Unless Republicans in the Senate manage to somehow find a way to sink the nomination, it looks like Don Berwick will be the new Medicare/Medicaid chief. I think that is actually big news. It suggests that in the next phase of healthcare reform, Obama's emphasis will be quality improvement--and likely, linking payment to quality outcomes.

Medicare has already started moving in that direction. And healthcare reform quietly includes some important tools to help it move farther. But this may suggest that Obama is going all in on changing payment structures.

Why do I say that? Because Berwick is the person who has probably best popularized the quality improvement movement within healthcare. Though he runs an institute and has evidently done a good job of it, he is primarily an evangelist, not an administrator. So you wouldn't choose him for a big job unless you thought the job required evangelism.

Yes, we did.

Nancy Pelosi knows how to count votes, and we all win.

This is a big deal.

It's not a great bill. But it's a lot better than no bill.

More soon. But I've got to mark the moment.

Repub's vow: no snitchin'

Someone called Stupak a "baby killer" on the Senate floor. (But... isn't a baby killer a guy who votes against the Children's Health Insurance Program? I must be confused.)

Campbell, initially suspected as the lawmaker who shouted the phrase, told reporters that he didn't say it and believed that it came from a member sitting a row behind him, where the Texas Republicans usually sit. Campbell said he heard "a Southern accent".

"The people who know won't give it up," Campbell told reporters.

He said the remark was "clear as a bell."

Michelle cheering for Sasha

From the White House:
"President Barack Obama, First Lady Michelle Obama, Vice President Joe Biden, and Dr. Jill Biden, react while watching Sasha Obama and Maisy Biden, the Vice President's granddaughter, play in a basketball game in Chevy Chase, Md., Feb. 27, 2010. (Official White House Photo by Pete Souza)"

If you thought talking smack about CAC scans got people mad...

The man who discovered PSA writes an op-ed piece arguing for scrapping it as a screening tool.

On NPR.org: "Overshooting Obama's Health"

New writing of mine, posted elsewhere (and broadcast on All Things Considered on 3/4/10):
"It doesn't take a CT scan to know that President Obama should keep exercising, watch his diet, and quit smoking. So deciding not to do a test like a coronary artery calcium CT scan isn't just about avoiding the financial cost of the test. If the results of the test won’t change what we recommend, then the patient is taking risks for data that won’t make a difference."

Black tar heroin coming to white people near you

Graph: Black tar heroin vs powder heroin, and HIV among injection drug users vs HIV among men who have sex with men, in a map of the US and Canada from Ciccarone and Bourgois 2003--click on the graph for a full-size picture.

Black tar heroin is moving east, says the LA Times, in this first part of a three part article I'll be reading over the next days, being moved by folks from Xalisco, Mexico. The strategy described in the LA Times article involves low-profile low-weaponry low-volume operations targeting white people who've been using prescription opiates, and moving small cheap quantities of black tar heroin as an alternative to Oxycontin and Percocet.

What will this mean for clinicians on the East Coast if the Xalisco teams and their ilk manage to continue moving black tar heroin eastward? UCSF researchers have hypothesized that the properties of black tar heroin itself contributed to less spread of HIV among West Coast heroin users because black tar heroin has to be boiled more; and remaining bits of gooey leftovers in syringes caused users to rinse their works more thoroughly, and to switch out needles more frequently. But black tar heroin also most likely means more bacterial soft tissue infections.

When I started as a pre-med in San Francisco, I volunteered on a healthcare for the homeless medical van. The van would stop and I would circle the surrounding blocks, telling everyone who looked homeless, "Outreach van, down there" and sending them to the nurse and the medical resident who were in the van. In addition to handing out socks and vitamins, a lot of what we did was abscess care. It seems kind of crazy and unthinkable in Boston, but almost inevitable in San Francisco at the time, that medical residents would be lancing and draining small abscesses in the back of an Econoline van. Better that than let some not entirely well-organized heroin addict wait for the bacteria to build up to bigger balls of pus (and attendant complications) until finally winding up in the San Francisco General Hospital emergency department.

At one point, the San Francisco Department of Public Health startedwhat became known as "the abscess task force" to try to deal with the huge number of soft tissue infections, most dramatically abscesses, but also necrotizing fasciitis, botulism, and other soft tissue badness. These problems can be linked to black tar heroin through greater amounts of intramuscular and subcutaneous injection. Black tar heroin users seem to do more shooting into muscle and skin-popping because black tar heroin users sclerose their veins faster. And the boiling of the tar (which Ciccone and Bourgois posit helps kill HIV virions) does not kill the spores of Clostridium species. That seems to mean greater vulnerability to tetanus, botulism, and gangrenous skin infections when the spores of C. tetani, C. botulinum, or C. pefringens get embedded in the tar and then shot into soft tissue.

As far as I can find, there has not been a direct comparison of bacterial infection rates among injection drug users by geography--but it looks like there is a natural experiment in the making, if someone is ready to track it. And, an opportunity to set up systems for early detection and treatment of soft tissue infections, before they begin to swamp new cities' healthcare systems the way they did in San Francisco.


Ciccarone D and Bourgois P, Explaining the geographical variation of HIV among injection drug users in the United States. Subst Use and Misuse 2003 December; 38(14): 2049–2063.

There'll always be a Texas: nurses prosecuted for reporting improper behavior by a physician

It's certainly possible that nurses might report a doctor to bosses or regulators just to be spiteful. But the system has to make reporting easy, and safe, to make sure that quality issues don't get missed. That's what makes it such a travesty to criminally prosecute nurses for reporting concerns about a doctor's conduct. It would be a travesty even if the nurses' concerns ultimately weren't legitimate. But it's especially egregious when what's being reported is, in fact, bad behavior--stuff like emailing patients to promote his own herbal supplements that he was selling on the side.

New York Times covers the case.
Texas Nurses Association offers updates and legal defense fund information.

And as a bonus, because the Internet is full of glory, and for your edification, are Amazon reviews submitted by the doctor in question, which may singlehandedly convince you that these nurses were truly noble fighters for healthcare quality.

Google is specifically full of glory, and yea, noble also, for it teaches that this same doctor donated $968 to Ron Paul, and is a Facebook fan of "Ladies of Liberty" which is an organization for libertarian ladies to get other ladies involved in libertarianism, and also is a fan of Leviticus diet tips; and that he also appears in a program on "God's Learning Channel" as a doctor who treats patients with Morgellon's Disease...

The VA feels different this year...

iPhone photo in the lobby of the West Roxbury VA hospital. Maybe it shouldn't, because it's the same hospital and the same patients--with a few more younger guys back from Iraq and Afghanistan than the last time I was here--but the president and retired General Shinseki (now the chief of the VA) make it feel a little different to walk in the door.

The Veterans Administration: the Linux of medical records

I just spent three weeks in our local Veterans Administration system. Mention "VA" to any group of doctors and you are sure to hear funny stories; a great many doctors have at least some of their medical training within VA hospitals, and those hospitals are full of characters among both their staff and their patients.

VA hospitals have various frustrating aspects you'd expect from a large federal bureaucracy. But they also share a common sense of purpose and community unusual in other hospitals. Because of their commitment to a particular group, they feel almost like massive community health centers, in which there is a sense of shared purpose built not on organizational advancement but on the welfare of the community which the organization serves. It's this part of the VA which makes it a great system.

Along the way, the VA has accomplished various things that other healthcare systems haven't. One possibly more broadly transformative innovation is VistA--the Veteran's Administration electronic health record software, now available as open source software for any organization that wants to use it. Revisiting VistA this last three weeks, I can testify: VistA really is the bomb-diggity.

I say this as someone who works in a hospital that regularly wins prizes and high rankings for its own electronic medical records and ordering systems. Our electronic medical record is easy to use and intuitive, the design has an Edward Tufte-style simplicity (though sadly without sparklines), and is full of useful features. I regularly use it as a selling point for medical students considering our hospital for residency. Having used various electronic medical records during my time as a medical student and in external rotations as a resident, I'd put our system against anyone's.

The VA's system is uglier-looking and harder to learn how to use. But even in three short weeks as a novice user, I found it quite powerful, especially when it allowed me to access veterans' health records scattered across various VA hospitals around the country. At the end of the day, any data storage system can only be as useful as the data it stores; when so many VA hospitals are linked, the software is more powerful partly because of the information it provides. And when I got past some of the difficulty in getting used to the program, some of the way it integrates information is actually more useful than the record system I use.

Most importantly, it is available as open-source software, which any medical organization anywhere can use. Its ordering system, once learned, is easily integrated into the rest of the record. I also liked its graphing features which allowed visual displays of prescriptions and lab values charted over time; many electronic medical records have this kind of feature, but somehow the VA's system works better than most to provide sensible x- and y-axes for the data which is being presented. Uploading radiologic images takes longer than I would have liked but this is likely a fixable problem.

The stimulus package of last year included a big bunch of money to support dissemination of electronic medical records. Spreading open-source VistA will likely be one of the cheapest ways to accomplish this. If I were a large healthcare system, I'd take this system and maybe put some extra money into building a more intuitive and lovely-looking graphical interface on top of it (the one in use at the VA is from 1997)--but I'd keep VistA.

doctor with a bomb

Above: Radovan Karadzic, psychiatrist and perpetrator of the Srebrenica massacre and other atrocities in Bosnia. Below: Ikuo Hayashi, a neurosurgeon and one of the perpetrators of the Tokyo subway sarin gas attack.


Yet another doctor has apparently joined the ranks of violent absolutists, as a Jordanian doctor working as a CIA informant turned out to be a double agent, and blew up CIA agents and a Jordanian intelligence agent. This particular man, having blown up a bunch of people who can reasonably be described as combatants, can't be said to be a terrorist as much as a kamikaze, but apparently in the cause of advancing jihadist and terrorist ideology. (Or so says the CIA; take that for what it's worth.)

Still, as Simon Wessely explained in the New England Journal of Medicine in his 2007 essay, "When doctors become terrorists", written just after seven doctors and a medical technician tried to blow up a bunch of stuff in Britain, doctors have been high achievers in the world of terrorism. Ayman Al-Zawahiri, a surgeon, is Al Qaeda's number two. Wessely also reviews the innovator of airplane hijackings in the late 1960s and early 1970s, a Tokyo sarin gas attacker, and one of the main perpetrators of war crimes in Bosnia, as well as those master clinicians of medical mass murder, the many doctors involved in Nazi Germany's atrocities. More recently there was Major Hasan, the US Army psychiatrist who killed 13 in a shooting spree in November, perhaps acting as a terrorist, perhaps acting just as an ordinary American lone gunman looking to rack up posterity points, but definitely doing a lot of damage in the process.

Various right-wing blogs have been pointing out the number of well-educated people in the ranks of Islamic jihadist terrorists, as a way of trying to smash the argument that jihadism comes from grievances of the oppressed. And honest members of the left can remember that past terrorism in the name of socialist or communist revolution also often came from well-educated and relatively privileged people. We need not diminish the tragedies of the oppressed to understand the difference between oppressed people's grievances and terrorist tactics.

Terrorists from lives of privilege are people who are inclined to make the actual grievances of oppressed people into abstractions; to respond to those abstractions with absolutist solutions; to divide the world into good and bad; and to believe that having a comprehensive analysis of a situation allows the justification of the sacrifice of a few for the good of the many. The poor and oppressed people may still be looking for an extra cow for the herd, or an end to drug dealers hanging out on the corner; their putative allies among the privileged, meanwhile, abstract those concrete goals into global policy aims, to be advanced by terror when simple non-violent political organizing is not possible or not sufficient.

Terrorism is not a war technique. Terrorism works because it attacks anonymous non-combatants, whose deaths become terrifying to all others because there is no rationale or particularity to the target beyond some vaguely defined group or national membership. To target these people--ordinary people--doctors are perfect perpetrators. We know a range of ordinary people well, often better than most well-educated people do; yet internally, at our worst, we hold ourselves apart from them.

It's hard to know the percentage of well-off and well-educated people within organizations like Al Qaeda or its affiliates. A blog post in Small Wars Journal--don't ask me how the Internet led me to that blog, because I don't really remember--suggests that our preconceptions about social class may blind intelligence efforts to the violent possibilities of the privileged. However common or uncommon the trustfundamentalist terrorist might be, when looking for the perpetrator of the next terrorist plot, perhaps we shouldn't be looking for people with nothing to lose because they never had it in the first place, but people who have nothing to lose because they want something other than material goods, and have the money to get it.

Some of the terrorists of tomorrow, whether jihadists or other murder-happy extremists, will be doctors. It's hard to know exactly what drives these people, and in most cases we'll probably never really know. But it's tempting, at least, to think there is a particular medical personality disorder type at risk. These are the people who will see their patients as diagnoses; and their targets as symbols. They will look past the sweetness contained in the human qualities of frailty and contradiction, and look instead for complete solutions to the imperfection of the world. They will believe in small elites with special knowledge. And then, magic bullets of medicine having failed them, they will turn to holy bombs.

Wessely S. When doctors become terrorists. NEJM 357;7 August 16, 2007
Haddick R. Do assumptions about class create a vulnerability to terror? Posted to blog Small Wars Journal.