Monday, December 14, 2009

My ideal outfit when I was four, now being actually worn.

Click for:

Coolest outfit ever.

I wanted a dress really bad at that age, and also I always loved Spiderman, and also, like him, I liked dinosaurs (he's holding one, and he's got a dinosaur book in the other hand), so, hey, I'm looking at this kid, and I'm saying,

Living the dream, young brother. Living the dream.

Sunday, December 6, 2009

Buy for the Borum

Paul Levy, the Beth Israel Deaconess Medical Center's CEO, is using his blog to publicize online auctions to support community health centers affiliated with the BIDMC. Right now there's an auction to support the Sidney Borum, Jr, Health Center. The Borum is dear to my heart, so let me take this moment to ask you to consider buying something... much of which remains at a considerable discount. (For instance, tickets to the Messiah at a fraction of their face value, which is how everyone likes their messiahs.)

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!"

Sunday, October 11, 2009

The marching bands of the radical left

At a bit after noon today, I heard some kind of big drum beat outside, and remembered--today was the day of the Honk! festival in which a bunch of radical leftist marching bands march down Massachusetts Avenue. They go from Somerville to Cambridge's Oktoberfest, a street festival with no particular political approach. Our apartment, near Mass Ave, is equidistant between the two points, and therefore ideally suited to notice the arrival of the Honk! parade.

What the Honk! festival lacks in polish--one band's website earnestly stated that it did not discriminate on the basis of musical ability, bless their hearts--it makes up for in enthusiasm and anarchic charm. As someone who grew up on the left, I was always viscerally bothered when people decided to go to protests and behave like a bunch of wierdos. But for all my normalcy since then, what have I accomplished politically? And despite recognizing that I have accomplished little in political terms, I am not a member of a ragged marching band with a dance troupe of slacker girls and gay boys doing cheerleader moves in front. So, in the end, I've had the worst of both worlds: I do not get to hang around and dance in the streets with a bunch of radical wierdos, because I'm not radical enough politically or culturally; but yet, I also do not get to enter the halls of power and really get things done, because, well, because of a lot of reasons.

The Honk! festival is a great community event, though, uniting Cambridge and Somerville in a Somerville confluence of radical leftist marching bands and a random Cambridge street festival. This allows the radical leftist marching bands to gather and play in different little pockets of fans and casual onlookers throughout Harvard Square; and also, presumably, allows the radical leftist marching bands to eat jerk chicken, vegetarian samosas, pad thai, caramel apples, and the other things that are served at the booths of any street fair in a big city.

Relevant to medicine? Well, there was a group called the "Pink Puffers"--a medical slang phrase indicating people with emphysema-predominant chronic obstructive lung disease, as opposed to bronchitis-predominant "blue bloaters".

By the looks of the Honk! festival, radical leftist marching bands can be found in many different places in the world; the Pink Puffers are from Italy.

Here, on YouTube already! are the Pink Puffers rocking Somerville in preparation for the festival, showing off their radical leftist marching band ways:

Representative videos from last year (we randomly bumped into the Honk! festival last year, too--it's in the neighborhood, and hard to miss once you hear it): here we have New York's Rude Mechanical Orchestra. This year they were standouts, playing this same song, "Matador", by Los Fabulosos Cadillacs, as they marched down the street.

Apparently "Push It" is also a favorite:

This does make me think that just as this emerging tradition among the radical left is doubtlessly fuelled by the many former marching band nerds who went on to read Gramsci and Emma Goldman in college, surely too the medical community also contains many former marching band nerds. The medical community's events would doubtlessly be more entertaining with medical marching bands as part of our professional and cultural tradition. I suspect the psychiatrists would blow everyone else out of the water, but I bet that infectious diseases has a lot of closet marching band geeks, and they could be contenders. And I'm sure surgical specialties, if combined, could roust up a fair number of brass players.

No, I don't see it coming any time soon. But, you never know.

Thursday, October 8, 2009

Our farmer

A member of our CSA, on our farm's Facebook page, laying out a week's small share on the counter, and sharing the photo with the world.

Today was the last day of the year to pick up produce from our farmer. Our farmer is an old punk rocker, now a single dad and farmer. His son (who is maybe 6?) was enthusiastically shilling the hen-of-the-woods mushrooms that our farmer was selling as an extra if we wanted to add it to our regular farm share: "It's fifteen dollars! You have to buy them!" No thank you, I said, bemused.

This last couple of pick-ups are extras beyond what we originally expected. We'd negotiated which of our two-out-of-three bonus sessions we'd attend, because we're going off on vacation soon, and getting married. He remembered this, and cut me off a hunk of hen-of-the-woods mushroom and said, "You're getting married, right?" Yep. "It's a gift." His son, still in salesman mode, shouted, "Fifteen dollars!" No, our farmer told him, it's a gift.

Our farmer has been frustrated and disappointed all season. Earlier this summer, the weather was so lousy that even our NPR station had started doing lengthy stories about the fact that it was raining; and we heard him on the radio talking about how the rainy weather had flooded out his corn. That was how we knew we were able to prepare ourselves for the disappointment of not getting any corn from our farmer later in the summer. We did get lots of good greens, though, and turnips, and radishes, and green beans, and cilantro, and kale, and some green tomatoes and some red ones. It was a tough year for our farmer. He was a little bitter, a little sad-seeming, and a lot apologetic at the end of the season.

But we were happy. It was our first season with a community supported agriculture program, and although it was apparently a bad year for our farmer, it made a tough summer a little sweeter to go get our produce from our farmer every week. Every Thursday we'd go to a corner about six blocks from our house, where he'd have a truck pulled into someone's driveway, handing out produce, often with some other guy who looked like he was probably an old punk rocker too. (Old punk rockers don't wear punk clothes any more. I'm not sure why old punk rockers look like they were once punk rockers, but there's a look. I think there are a lot of people in Narcotics Anonymous who look like that.)

"Large or small?" he'd ask when we approached--the two categories of shares. We had a small share for the two of us, so we'd hear instructions something like "One each of each of these, then a pound of the beans, and three peppers." We'd fill one of those reusable grocery bags with our loot for the week, and come home and have farm dinner--this year, very often roasted root vegetables and a salad, and then from the big store, maybe some turkey sausage or some chicken. Everything tasted great, and it was pleasing too: it was from our farmer.

There is no particular reason that all kinds of people couldn't have a farmer. Back in my hometown in California, there were Hmong families taking spots of empty land in poor neighborhoods, and farming the hell out of those little spots, suddenly bursting with green. They fed their own families, I'm sure; but with just a bit more land--knock down a couple foreclosed homes that aren't getting sold, till the land, and make a neighborhood farm--you could imagine these folks becoming neighborhood farmers, so that people would amble down the street and pick up the week's produce from their farmer.

I know from my dad--who's spent his life thinking about stuff like this, and in many ways dreaming of the day that ordinary people would be talking about going to their farmer like they talk about going to their doctor or their hair cutter--that there are all kinds of reasons this is harder than it sounds. Still, I'm kind of incredulous and pleased that by paying a sum up front that is almost certainly less than what we spent on produce last year over the same amount of time, we got great produce every week, from an old punk rocker who we can call our farmer.

Our farmer: there is something about these kinds of relationships that is different than the more fragmented retail marketplace, something that is important and good. It is how I want people to feel about having me as their doctor; I want them to see me in good times and bad. And even when they see that I'm frustrated with the insurance system, or apologetic that I'm running late, I want them to feel that I am their doctor, like I feel that my farmer is my farmer; and to feel like, at the end of the summer, they got a decent deal even in a bum year.

Friday, September 11, 2009

Joe Wilson's war

For all the fuss about Joe Wilson disrespecting Obama by shouting "You lie!" (to which, it can only be said, he never would have said that to a white president)--

the biggest crime is not disrespecting the president, but that he was doing so in the cause of trying to make sure some Guatemalan girl can't deliver her baby, and some Chinese guy can't get treatment for HIV infection, and some old Mexican lady is going to die for reasons regular medical care could have prevented.

And now, politicians are bending over backwards to say, Joe Wilson is disrespectful, but to his larger point, they only respond, please, fellow Americans, be assured, we won't be taking this love your neighbor thing too far.

Saturday, August 1, 2009

Night float

Our department chair decided at some point that the people on night float shifts--interns who cover the medicine patients overnight, and residents who admit new patients coming in after the regular teams have stopped admitting--should have a teaching session. And so we met this morning, all the night float residents and interns. I've been doing a pinch hitter sort of job, in which I do overnight medicine consults and also support the night float interns; next week I'll be doing admissions. The relationship among all of these people is an odd one. Except for me (because I spend a reasonable amount of time checking in with my early-in-the-year interns and backing them up in various medical crises), we are mostly working alone. But we see each other through the night, crossing paths in the hallways or sharing a workroom for an hour here or an hour there.

In our conference this morning, we started talking about a patient. It turned out she'd been admitted two days prior by one of the admitting residents. An ICU resident on call overnight came down to evaluate her when we thought she might go to the ICU, and spent a good long time afterwards thinking about the patient's situation. In a workroom, thinking aloud, getting excited about some ideas about the patient's situation, the ICU resident talked to another nightfloat resident, and had pitched her theory to a couple of us. One of the interns had been called a couple of times to go see her overnight, and I'd gone to back him up for some of the hairier calls, and I had helped arrange the patient's possible transfer to the ICU before we decided she was OK to stay on the regular medical floor.

In conference, then, the admitting resident presented the case, but the group started talking about it in an engaged and interested way, because so many of us had thought about the patient, cared for the patient, or heard about the patient already. I'd seen the admitting resident a couple of nights before and had talked about this patient even then, because the resident was excited about the admission. She wasn't too busy and with an interesting case to think about and read about, she got the chance to do real medicine instead of setting up a holding pattern to be handed off to the day team. I'd spent a long time thinking about the patient when I was trying to figure out whether she should go to the ICU. And the nightfloat intern had spent a lot of time seeing the patient because of multiple problems over several nights, trying to figure out which of the calls represented real crises and which ones didn't.

I was reminded of another time I was in the ICU and a patient came in with an unusual problem; within a couple of hours, cardiologists, pulmonologists, and oncologists had mobilized for procedures and studies, teams were passing the chart back and forth as they worked on plans and notes and recommendations, and people kept buzzing in and out of our MICU team rounds to give updates on the latest detail of the plan. A cardiology fellow showed up and so did an echo tech, and within an hour of us asking for the study, there was a detailed echocardiogram and an attending reading it. Someone else was planning for a biopsy. One consult team was calling another consult team to help work out details.

"This is when I love being at a teaching hospital," I said quietly to one of my fellow residents, as our intern was presenting data and we were watching out of the sides of our eyes as one of the consult teams was bustling about nearby. "These moments of this massive mobilization of expertise, all of these people with this insane amount of training, coming together for one sick person. It's beautiful."

Overnight, the hospital often seems like it's in a holding pattern. We try to keep people alive until care can be advanced during the day. So it was a surprise to me to find myself in conference with a little bit of that teaching hospital feeling: the feeling that there were all of these smart and engaged and caring people watching the progress of one sick patient and sometimes being a part of her care, wondering how it would turn out, wondering whether she would come to the unit or stay on the floor, wondering whether she'd get sicker or better, hoping for the best.

The senior admitting resident had come up with a long set of possibilities for what might explain the patient's symptoms, and ordered a bunch of tests right away to start sorting them out. The ICU resident was pitching an obscure diagnosis but one with some credibility; though I wasn't buying it, I had to give her props for zeroing in on a particularly striking lab value which I had skimmed over. I was pitching another theory, but at the same time telling the intern to cover for gram-negative infection, which was actually a counter-move to anticipate what could happen if I was wrong. The attending, writing a note in the morning when we emerged back onto the floor from our conference, thought we were all wrong, was stopping the antibiotics I'd told the intern to start, and had another theory entirely. But we all had opinions without certainty, which meant that we really listened to each other, and we all had a sense of suspense:

"Poor lady," said the attending, "I haven't seen a case like this for a while";

"I really think the team should start treating now, even without knowing everything!" opined the department chair;

"I know what you mean, but they could get in trouble with that in other ways," said the chief resident, deferential but firm;

and the intern, new to it all, was listening to the primary attending with eyes much brighter than his fatigue should have permitted, truly a part of this thing that we all had spent so much time working towards, and which he had finally just joined a few weeks before.

We felt ourselves to be a part of a community of highly trained people, late at night when others are asleep, part of the world of doctors as doctors themselves hope for and imagine it should be. A team of experts and people becoming experts, mobilizing, caring, theorizing, arguing; and at the same time, perhaps above all, walking briskly down the hall towards the patient's room after getting a page from the nurse about low blood pressure.

Saturday, July 11, 2009

Becoming the Fat Man.

Sleep-deprived and worried for my interns, I start spouting half-true or all-wrong or kind of right aphorisms as if I was aspiring to be the new Fat Man:

"All patients lie. All patients are crazy. And it is our job to love them anyway."

(Said to an intern who is tempted to believe everything his patients tell him, to his patients' potential detriment.)

A pair of nurses, overhearing this, do a double take and tighten up as they hear me start this, then visibly relax as I finish. One says, "You saved yourself with the last part there." I try to save myself a bit more: "Well, we all lie sometimes, even when we don't realize it, and we're all a little bit crazy, right?"

Still, I thought, Am I really the resident who blurts out cheap half-truths as if they were wisdom?

It is an inevitable temptation of power--even the minor power of a senior resident at the beginning of an intern's year--to start spouting bullshit. On reflection, I think I succumbed.

At the same time, I don't think it does any favors to patients to subscribe to a false humanism, some kind of big happy medical friendship bracelet of co-dependence between needy doctor and needy patient.

I got at what I was trying to say a little better a couple of days later, with the help of talking to Dr. Ms. Hemodynamics, who had more clear things to say about this problem, which I then said to an intern, with words something like this:

"It is inevitable that when we are feeling doubtful about ourselves as doctors, we want our patients to like us, because that makes us feel like we are good people. But it's not the point of being a doctor to have your patients like you. Your patients should come to trust you, and to respect your counsel, and value your role in their life. But liking you is beside the point, and it's dangerous to them for you to need that from them."

This I do believe.

To boil it down to a Fat Man-style law:

"It's not your job to have your patients like you. It's your job to love your patients enough not to care."

Friday, July 10, 2009

100% true dialogue from the wards

The attending, the senior resident, and the intern are sitting in the work area, discussing a patient. The senior resident, a bespectacled and bearded graduate of Harvard Medical School, is cautioning the intern on jumping to conclusions:

"I understand that you're taking the evidence and trying to see if it matches your theory. But actually, you want to do the opposite. You don't want to try to prove yourself right. In the philosophy of science, Karl Popper wrote about 'falsification'--the idea that you take your hypothesis and try to prove it wrong, until, failing to prove it wrong, you decide that it's the best theory for now."

The intern: "OK, yeah, I see your point."

The attending: "Karl Popper, huh? You've read Karl Popper?"

The resident: "No. But I've read about Karl Popper on Wikipedia."

Attending: Falls out laughing; retells the incident for laughs to another attending on rounds a couple of days later.

Resident: Laughs too; retells the incident on his blog a couple of days later.

Tuesday, June 16, 2009

Doctors, nurses, and medical students in Iran, June 16

Above: a video from YouTube, with the title
16 JUNE 2009 - Doctors and nurses are protesting in a major hospital in Tehran - Iran
with the following caption:

At 1:41 one of nurses is shouting "8 people died in this hospital last night". of them1 died by a headshot...which said that poor brave man shoted by sniper. at 1:35 you can see on that board which writen in persian "28 wounded...8 died"

Morning of 16 June...Rasoul Akram Hospital's doctors and nurses are protesting about what happened in the last night gunshots by Goverment's militia (basij) and police. 36 people shots By Gun 8 dies and 28 injured .

From Nico Pitney at the Huffington Post, an email from an Iranian medical student:


It's painful to watch what's happening.

I don't want anything to do with what has been said this far, as I neither have the strength nor the resilience to face all these unfathomable events.

I only want to speak about what I have witnessed. I am a medical student. There was chaos last night at the trauma section in one of our main hospitals. Although by decree, all riot-related injuries were supposed to be sent to military hospitals, all other hospitals were filled to the rim. Last night, nine people died at our hospital and another 28 had gunshot wounds. All hospital employees were crying till dawn. They (government) removed the dead bodies on back of trucks, before we were even able to get their names or other information. What can you even say to the people who don't even respect the dead. No one was allowed to speak to the wounded or get any information from them. This morning the faculty and the students protested by gathering at the lobby of the hospital where they were confronted by plain cloths anti-riot militia, who in turn closed off the hospital and imprisoned the staff. The extent of injuries are so grave, that despite being one of the most staffed emergency rooms, they've asked everyone to stay and help--I'm sure it will even be worst tonight.

What can anyone say in face of all these atrocities? What can you say to the family of the 13 year old boy who died from gunshots and whose dead body then disappeared?

This issue is not about cheating(election) anymore. This is not about stealing votes anymore. The issue is about a vast injustice inflected on the people. They've put a baton in the hand of every 13-14 year old to smash the faces of "the bunches who are less than dirt" (government is calling the people who are uprising dried-up torn and weeds) .

This is what sickens me from dealing with these issues. And from those who shut their eyes and close their ears and claim the riots are in opposition of the government and presidency!! No! The people's complaint is against the egregious injustices committed against the people.

Monday, June 15, 2009

The AMA doesn't speak for me

I've started a Facebook group:
"I'm a doctor, and the AMA doesn't speak for me"
I hope my colleagues will consider joining.

One of the group members linked to this article:
Abraham Verghese on the AMA

Monday, June 8, 2009

the future of the future

Wikimedia commons photo: Samuel Delany. NASA photo: Charles Bolden in 1992

Yesterday, I was registering the fact that President Obama has appointed Charles Bolden, an African American astronaut, to run NASA. I googled him, thinking about how it's not that incredible anymore to have black people go up in space, and that therefore it doesn't seem incredible that there's a black astronaut in charge of NASA. And then one article, which included various people gushing about Bolden, included a comment from his astronaut buddy Franklin Chang-Diaz, whose daughter is a Massachusetts politician with the same last name.

I don't want to dwell on the point, but "Franklin Chang-Diaz" used to not be an astronaut kind of name, nor a Boston politician name either. In fact, it is hard to know which would have seemed more improbable in 1950, or 1960, or even 1970.

I don't want to be the white guy who looks on in wondrous rapture about little victories of diversity as a way of ignoring inequality and discrimination. So let me pause and register that the world is still what it is; inequality still is the rule, not the exception. At the same time, the world is different than it used to be.

NASA made a decision, when it started the shuttle program, to change what astronauts looked like. Now, many years later, there are a fair number of black astronauts, women astronauts, astronauts from different parts of the world. Some of them are rising through the ranks. There are still plenty of white guy astronauts and white guys slapping each other five in Mission Control--the world hasn't changed so much--but it's different than Apollo.

This got me thinking about science fiction. I've mostly left the genre behind in my own reading over the last few years. My friend S. knows it better and is able to write about it more seriously. Still, from the reading I did in years past, I can say there are a few different versions of the society of space in science fiction. One of those versions comes from an often quietly utopian impulse, which involves more small-bore problems of dealing with difference, or of trying to make a better society, or of living in a different way than we now imagine. It does not describe utopias, but its broad imagination, its sense of possibility, is a form of utopianism. It is a way of saying, anything is possible. This genre uses science fiction as a way of stretching our imaginations about what could be. Some of the practitioners of this kind of science fiction, people like Octavia Butler or Samuel Delany, were African American, and the humans who inhabited their worlds were often of many colors, not to mention genders and sexual orientations. In fact, not at the time, but retrospectively, some people call them pioneers of Afrofuturism.

There is no immediate relationship between Samuel Delany, a gay man with a big unruly beard who now teaches creative writing at Temple, and Charles Bolden, a former Marine and astronaut, who will now run NASA. They are both black men who are interested in outer space, but then, so was Sun Ra. I can't really imagine Borden and Delany at the same event. And though there must be someone who knows them both, I don't think they travel in overlapping circles. They have outer space in common, sort of (though Samuel Delany does not even depend on that trope). But one of them is interested in imagining different planets as metaphors for different ways of living. The other is interested in specific real different planets as places we might drive a space ship to. Delany is wildly progressive; Bolden is not, at all.

When NASA chose its astronaut corps for the shuttle program, it did so for political reasons that were very much of the here and now. NASA understood then and understands now that its work can either seem like an inspiration, a bold project of building human capacity, a project on behalf of nothing smaller than humanity itself; or, alternatively, a wasteful boondoggle and gadget racket that has nothing to do with anyone's concrete problems. Choosing a diverse astronaut corps helped keep NASA looking like it was staying on the right side of that line. That has nothing to do with anything as edgy or visionary as Samuel Delany. Yet, if you would have written a science fiction story, in 1969, that imagined a black president and NASA chief, you would have placed yourself firmly in the left wing of the genre.

There are all sorts of possibilities come true lately, which I've been noticing simultaneously. Less lofty but maybe more spectacular: in my pocket, my iPhone seems more spectacular than a lot of gadgets I read about in science fiction books when I was a kid, exactly because it is an everyday device. Without any mythic resonance, an improbable-seeming thing I carry in my pocket, the iPhone is not a super phaser or a scanning diagnostic tool that instantly does my medical work for me. It's just a phone, a newspaper, a street map of the developed world, a global positioning device (the very existence of which is improbable, much less that it is in my pocket), a massive encyclopedia written by a global collective, a camera, some video games, a music player, a way to write people brief letters or read letters from others, and other things as well. And I put it in my pocket and carry it around! Every so often, we do make note of how incredible this seems. Perhaps I'm just getting older, and remember more and more time, more and more of my own history, that took place before we could take such things for granted.

Whether for the head of NASA, or my iPhone, the future is harder to accurately imagine than it first seems, and not just because you thought the phone/clock/navigational device would be a Dick Tracy-style watch and not some pocket version of the monoliths from 2001: A Space Odyssey. Once the future arrives it seems ordinary. To imagine the future puts a wondrous glow on it.

The future is not simply a time like other times; it is a time when anything is possible and therefore it is a time made up of a larger-than-appropriate proportion of our hopes and fears. When we find ourselves in the time that used to be the future, there is no such resonance. Some things are newly possible, others not possible anymore, and we simply find ourselves in a new set of circumstances. We fear and hope for new things. AT&T sends a bill for the iPhone minutes. The future is no longer the future.

But there is something about this year, and I know I'm not the only person to feel this way, that feels a bit more like science fiction than most years. The dull apocalyptic dread of the American economic empire in collapse; a black president with a Muslim name; iPhones in our pockets; gay marriage through all of New England but not in California or New York; a black astronaut in charge of NASA. Some Puerto Rican lady gets appointed to the Supreme Court and it is the exact person that the press has been predicting all along, which makes her appointment seem like an almost unadventurous boring political move by our president, who--we're almost used to it now--is a black man named Barack Obama. (Afrofuturism, indeed.) We take the internet for granted but we're still figuring out how to use it; we're also now used to things like dance music made entirely by computer programming; and we forget how extraordinary it is that in so many ways, from dumb television to crucial navigation, we depend on satellites orbiting the earth.

It's not future shock I feel; just a sense that the present is improbable, and thus, that the future must be even more so, for better, for worse, or, simply, for different. Really different. All possibilities remain possible. We are in a time that feels like the future even as it arrives. This year, more than most years, I find myself in the future, still catching up.

Friday, May 15, 2009

Sunday, May 3, 2009

another House of God

A very dear family member of mine, a secular Jew, had chest pain which led to a bunch of interventions. This led to me flying back home to California one recent weekend to see him in the hospital.

His primary care doctor's practice, and his HMO, use a hospital run by a Catholic healthcare network. It has excellent cardiac outcomes, says the Medicare data. So keeping in mind that quality should be measured by outcomes and not by tenure, I haven't pushed for him to go to the academic hospital in town. I think for most people these days, the religious affiliation of a hospital, or the former affiliation, is just kind of a quirky detail. A hospital is a hospital. The HMOs are more powerful than the church. The doctors and nurses matter more than the priests and the nuns.

As far as the doctors, I was frustrated by the hospitalist, who had a Muslim name, and reassured by the pulmonologist, who also had a Muslim name; and I liked the Chinese American cardiologist just fine too. (The experience reminded me that for patients and patients' families, doctors loom large because they are very rarely seen; and nurses loom large because they are always around.)

Their nurses are unionized, but order their scrubs from the same mail order catalogs that our nurses order them from, and probably drive the same kinds of minivans too. There were fewer young nurses with those kinda cooler scrub patterns, more nurse's union pins, more Filipina accents, no one saying "myocahdial infahction". In other words, the variations from my own hospital only emphasized that it too was a hospital above all else, much more than it was a Catholic institution.

But still, on Sunday, there was a prayer over the loudspeaker. "It goes on just long enough for you to start to get irritated, but stops right before you are about to go ballistic," another (definitely not Catholic) beloved family member observed. "They've clearly timed it very carefully."

My dear family member is back home, now back in the warm embrace of secular humanism. Phew.

The hospital focuses on cardiac care...

...but doesn't let you forget that for this hospital administration, there is a celestial nurse manager above all others.

My family didn't know that "S.O.B" stood for "short of breath" so they thought this clinical plan, written next to the bed by the nurse to explain the plan for the day, seemed out of character for the hospital.

Nightfloat pictures from my phone

From a few weeks ago when I was working nightfloat...

From top to bottom:
the hospital at night
and a sign put outside the rooms of patients on fall precautions.

Tuesday, March 24, 2009

Don't walk. Sit.

Above: employees of an Indiana health plan promote "breast cancer awareness" by wearing pink and making themselves into a ribbon. Below: from Rex Wockner at; the AIDS Coalition to Unleash Power in Chicago. AIDS activists demanded national healthcare, but mostly didn't figure out how to make common cause with other people with other illnesses.

Over at, a blog I've just started reading, the pseudonymous Mr. Cross urges us to consider not walking. Not going on breast cancer walks, Crohn's disease walks, polycystic kidney disease walks, etc, etc. Don't walk, he says:

To me, as a sick person, one of the worst aspects of these organizations is their aggressive insistence that the best way to help sick people is by funding for-cure research. That is a lie. Sick people face a lot of challenges, most of which cannot be deferred until a cure is found. If you’re sick, start talking about those challenges as you face them, and try asking for help.

If your concern is a specific person, get more involved in their life; ask them what you, specifically, can do to help them, specifically. For my friends who are sick, I make an effort to be there - to be available, to help them when they need it, maybe cook a meal or drive them to an appointment, but mostly to remain a presence in their lives. Look at the posters and the ads for these organizations: they’re clearly suggesting that sick people can only find community among their fellow-sufferers, as if our only hope to rejoin humanity is via the distant promise of a cure. That, of course, is false - and you can prove it false simply by refusing to be marginalized if you’re sick, or by being a friend to someone who is sick.

I hope you'll consider heading over there to read this essay in full.

One thing that Mr. Cross briefly considers is the origin of all of this walking, and of this marketing strategy. He traces it to breast cancer. My own read is that the breast cancer marketers (as opposed to breast cancer activists) got it from certain parts of the gay community's efforts to respond to AIDS in the 1980s. It seems to me that the Avon-sponsored pink ribbon element of the response to breast cancer must have looked quite closely at AIDS, then tried to find all of the elements of the successful response to AIDS that could be made completely banal.

There are always people in every disease organization who try to defy the vague sense of corporate uplift to have some relationship to the real lived experience of people with the disease. That's because the basic impulse of these organizations--try to work to stop diseases that make people suffer--is a genuinely decent one. But once they start taking sponsorships and decide to stop making tough political choices they will inevitably succumb to banality, because that is what they believe is required to make this kind of fundraising strategy work.

In the case of breast cancer, it is also partly a a story of how the practical innovations of feminism are often appropriated and then depoliticized. Barbara Ehrenreich has a brilliant description of her own reaction to the kitschification of breast cancer in a now-classic essay, Welcome to Cancerland. A brief excerpt of this essay, which merits reading by anyone who has felt a vague discomfort about pink ribbons but has never been able to say exactly why:

It is the very blandness of breast cancer, at least in mainstream perceptions, that makes it an attractive object of corporate charity and a way for companies to brand themselves friends of the middle-aged female market. With breast cancer, "there was no concern that you might actually turn off your audience because of the life style or sexual connotations that AIDS has," Amy Langer, director of the National Alliance of Breast Cancer Organizations, told the New York Times in 1996. 'That gives corporations a certain freedom and a certain relief in supporting the cause." Or as Cindy Pearson, director of the National Women's Health Network, the organizational progeny of the Women's Health Movement, puts it more caustically: "Breast cancer provides a way of doing something for women, without being feminist."

There have actually been plenty of AIDS versions of this kind of strategy--but that is for a longer post than this one.

Seeing the worst excesses of these ways of doing things, one would wonder, as Duncan Cross does, why anyone would want to do disease-specific activism of any kind. In the case of AIDS it was because of the very specific stigma associated with the disease. People with AIDS in the early 1980s died social deaths--people wrote them off as essentially dead before they were biologically dead, and ostracized them--unless they demanded a place both in their own communities and in the larger world. The medical community mostly avoided AIDS whenever it could and often responded poorly when they couldn't avoid it. And most leading researchers were uninterested in the problem; pharmaceutical companies had not yet jumped in because they couldn't see that there was going to be any significant market to be gained out of it. Organizing around their disease identity was built around a very specific and urgent political situation. And the urgency of AIDS activism came not only from the agenda of advocating for people with the disease, but also from trying to defend the communities that were under the threat of so many people dying.

The question is, does that situation exist anymore? Or is there more hope in people with different diagnoses banding together?

The disability rights movement in its modern form did not exist before the late 1960s and early 1970s. The seminal moment in the United States came in 1977 when the various disability organizations--organizations for the blind, the deaf, disabled veterans, and so on--came together to fight for implementation of Section 504 of the Rehabilitation Act of 1974. It was a relatively obscure piece of legislation but it made a huge difference in employment opportunities for people with disabilities, forced school systems to provide real education for a new generation of disabled people, and ultimately led the way to the Americans with Disabilities Act. A dramatic sit-in in San Francisco, including people with all kinds of disabilities, got the legislation passed and created the new face of the new, united, and militant disability rights movement. The movement saw a political opening--Jimmy Carter getting elected--and used it. ( Joseph Shapiro is a fantastic NPR reporter who has made disability his beat: his description of the 504 sit-in is here.) The key element of this movement and its success was the decision by many different disability constituencies to unite.

For people who need change because their own bodily circumstances require assistance from society and from the healthcare system, the history of AIDS activism and the disability rights movement show two things:

1. the credibility of your own circumstances can be a potent political weapon.
2. though that first central tactic can win victories, the largest and most enduring gains are won by tying your own circumstances to those of others.


I hope to write more about these two points, but in the meantime, here is an 18-minute documentary about the 504 protests that shows these two points in action. And below, a link to what the folks over at Breast Cancer Action are up to these days: their annual Think Before You Pink effort to end what they describe as "pinkwashing". ThinkBeforeYouPink.Org

The Power of 504:
part 1, followed by part 2

Thursday, March 19, 2009

God and intubation

One of my colleagues was the first author of this study. This is an underappreciated and understudied issue, which torments residents and nurses greatly: why do people end up choosing pointless treatments which will only minimally prolong life but substantially increase suffering? One of the answers appears to be associated with what my colleague and her co-authors describe as "positive religious coping"--i.e., seeking support from God--which appears to predict a choice to also favor aggressive treatment at the end of life.

Sunday, February 22, 2009

Only in Boston

Boston Globe story

There could be few moments that are more distinctly Bostonian than this one. By that, I don't mean that it couldn't happen anywhere else--it probably has already. Someone not from here might see a simple sweet sentimental moment. But there all kinds of undertones that make it distinct and local.

The combination of:
Harvard teaching hospital as one of the major industries in town+
building yet another medical building named after the former owner of the Red Sox (much memorialized, though also remembered as the last of the major league owners to start hiring black ballplayers) +
the medical building being built by members of Ironworkers Local 7 (the link gives you a list of names of union officers that tells you plenty about Boston construction union history, down to the South Boston location for the local) +
located across from another Harvard hospital trying to fend off a unionization campaign +
a nurse from the cancer clinic, married to one of those ironworkers...

in not only the gesture itself, but in its details, associations, and meanings, in its beauty and its underlying tensions, this is a nearly pure Boston moment.

Thursday, February 5, 2009

Pop culture round-up: kissing girls, black president, our goals in life

Pop music reflects social change and also rides it like a surfer on a wave, not in it, only on top of it, reflecting its contours, but using the wave for its own purposes.

The summer, with Barack Obama locking up the nomination, was full of hope and excitement. And two songs were on the charts that are worth looking back at now. They're going to define this last year in a funny kind of way, even though they're dumb songs--maybe because they're dumb songs.

Katy Perry will perform at the Grammy Awards this weekend, performing her song "I Kissed A Girl", which is simultaneously:
* one of the stupidest songs I've ever heard;
* one of the catchiest pop songs of last year, with a great guitar hook along with a great synthesizer bass throb underneath it;
* and, in its totally stupid way, maybe some small part of the decades-long process of queer liberation, in a "gateway drug" kind of way. For better or for worse there are cheerleaders in Texas singing along to this song, and you can make what you will of that.

The sentiment of the song--a straight girl tries on kissing girls because, hey, it's kinda cute and cool and why not?--was sort of dumb even fifteen years ago. Or, more precisely, in 1995, it was Jill Sobule's song "I Kissed a Girl". That song was folkier, a little more alterna, with smarter and more emotionally honest lyrics (the protagonist just had a marriage proposal from a guy and doesn't want to say yes, then goes and makes out with a friend of hers) and a pretty catchy melody of its own.

Still, it was a small little song in its lyrical ambitions and its musical sound. And ultimately, it was just as dumb as Katy Perry's song in its relationship to what it means to be a lesbian or an enduringly bisexual woman, someone who has to actually live queer instead of flirting with it.

More importantly, it had nowhere near as much pure pop power as 2008's "I Kissed a Girl". Sobule's variation on the theme was an alternative radio novelty song for coffeehouses and college girls; Katy Perry sings for all of America, though perhaps first and foremost for strippers. And presumably, for the coffeehouse college girls who work as strippers.

But the song is definitely for all of America's pop music fans; from the moment the first guitar attacks of the chorus start up (at 33 seconds into it, in true pop music factory production-line formula style), you know it's a big pop hit. It's perfectly designed. The lyrics could have been about a Toyota Corolla and that beat still would have rocked some dance floors.

The only reason I think this is oddly subversive--as opposed to just being a #1 hit song destined to be played in strip clubs for the next twenty years--is that CBS has now sponsored a contest for ordinary people to record their videos, you're supposed to vote on them, and the winner gets to perform with Katy Perry.

In other words, this song is about same-sex kissing and it is officially totally banal.

Here's the kind of contender you'd expect:

And then you realize, it's inevitable that this song would need to be lip-synched by a gay man.

(If you want this guy to be rocking with Katy Perry in her Grammy performance, as I do, vote here)

Just to give Jill Sobule her due, here she is with her song:

Speaking of pop culture, after the big Obama love-in, and a bit of an Obama let-down as his health policy point man turns out to be (surprise!) a huge ho, I'm trying to reclaim the Obama love by going through iTunes and looking at all the songs that reference this new moment.

This summer, somehow I wasn't listening to pop radio enough. Because I missed June 08's "My President", in which Young Jeezy, bless his soul, gets excited about the coming of a black president, with the following lyrics:

"My president is black
My Lambo's blue
I'll be god-damned if my rims ain't too"

The video involves Young Jeezy and some of his associates dancing around Mr. Jeezy's blue Lamborghini (which--god damn!--has blue rims) along with swelling inspirational movie-soundtrack strings and pictures of people marching, mobilizing, bringing a new day in politics. Also--hells yeah!--a blue Lamborghini with blue rims. And, John Lewis! Jumping up in the air! (As one music website puts it, "If all that's okay with John Lewis, it's okay with us.")

I think this song will turn out to be one of the smartest songs about the Obama age. is rocking it with "It's a New Day" in which he namechecks Harriet Tubman along with Lincoln, Kennedy and King: "The dreams that I've been dreaming have finally come true," he sings. (I hope the New York Times refers to him as Mr. am; I know I will, from now on). This is a very sincere song, and the sort of thing you can sing at the inauguration, which Mr. am did.

But Young Jeezy kind of had it nailed. The song is a combination of sentiments: I'm really excited about this amazing thing happening, and also, I'm the same knucklehead I always was, and really, what I've managed to accomplish is get a bunch of thugs to love me and give me enough money to buy myself a Lamborghini; but then, on the other hand, all things considered, it's a pretty great car.

Of course, hip-hop makes things bigger, blows up the parody until it's not even parody any more, and you're not sure when it's a joke and when it's just stupid. At the end of the song, Young Jeezy makes clear he knows it's a joke, kind of, when he starts listing black heroes, then tries to go back and give himself a role in black history, for being the first guy to drive a Lamborghini through his neighborhood. He's laughing and delivering the lines in a way that makes it clear he understands the comparatively smaller scale of this accomplishment, even though he himself is pretty proud of it.

In a remix, Jay-Z added on some more pointed lyrics, while also just adding in some comments about the color of his Porsche.

But though having a more direct political element changes the song, maybe Young Jeezy's June '08 song anticipates a more core American impulse that will doubtlessly persist. All the nobility of hope and change and a young black president inspires us. And at the same time, most of us are all just trying to live our own stupid lives, with our own self-centered goals, hoping the president manages to get the economy back to the point where we can start imagining not just getting by, but living large. In a hybrid, maybe, but--if he is truly a great president--it'll be a fast shiny blue turbo hybrid with 22-inch blue rims.

Here's Jay-Z and Young Jeezy at an inaugural party. On January 19th, the enthusiasm was sweeping over Young Jeezy, and he wasn't joking anymore--just really really psyched.

I don't want to forget the sincerity of this moment. And I don't want to shortchange the sincerity of the Texas cheerleader who's dancing around her room singing along with that Katy Perry song, thinking something different about what it means to kiss a girl than her predecessors might have. Like all of the best pop songs, these two songs are both dumb songs, but also get their momentum from reflecting a new moment, a new way of thinking, a new time in which these songs are allowed to exist as dumb songs, climbing the pop charts.

Hey! We've got a black president! I can kiss who I want to! It's a new day!

Pop music's insidious but undeniable power comes from being banal, stupid and meaningless, while at the same time, meaningful and sincere and in some way perceptive about who we are when we are young. Even if social change brings black presidents and queer love, those new elements are just the picture frame for more stable and eternal elements of American pop culture, dominating the pop charts since at least the middle of the last century. In this case, those elements are:
1. awesome cars; and
2. hot girls, as in:
being one
making out with one
genius! great bass line! love the guitar hook! sexy video!