Musical break: Senegal Fast Food

Listening to Manu Chao's new album on this rainy day off from the hospital, I went to his website and found this song ("Senegal Fast Food") he did with Amadou & Mariam--not on the new album, which like this song is both infectious and addictive. The plot of the video sneaks up on you, especially if (like me) you only get 1/10 or 1/15th of the French.

This I believe... (a few short posts in one)

I believe that:

* Scrubs is the most realistic medical television show of our era, and an informal but long-lasting and multi-city poll I've been taking of other medical students and residents suggests that many agree.

* Scrubs are the clothing of the hospital as factory floor--the hospital as a production process with teams of workers working together--and their persistence and popularity suggest that more and more healthcare workers see their work in roughly those terms.

* Ties should be eliminated from the work clothing of male doctors, and I used to think they would disappear because we would follow the "creative" sides of the business, research and technology worlds. But I have come to think that I will wear a tie for a long time to come, and so will most of my colleagues. But perhaps not mostly for the reasons of "respecting patients" that most of us will use to explain the choice. We will wear ties because part of what the doctor is offering is the power he will wield on your behalf. We will not admit the extent to which this power is an illusion, perhaps even a dangerous one.

* Women in medicine will continue to struggle to find the right outfit that expresses what it means to be a doctor, without clear rules and with much criticism for breaking unclear rules. Men in medicine should continue to struggle to find the right outfit that expresses what it means to be a doctor, but they will stick to clear rules and not give it enough thought. Transgendered people in medicine will be too cautious to innovate in the workplace.

* The trashy semiotics of medicine--the television shows, the clothes--are more important than they first seem. They are the visible signs of unspoken ideas of our culture.

White coats at protests? Maybe not.

Photo: Treatment Action Campaign and Student Global AIDS Campaign protesters at last year's International AIDS Conference, part of a coalition opposing Abbott Laboratories' approach to access to AIDS drugs.

I'm going to be taking part in a global day of action to condemn Abbott Laboratories for their attempt to block compulsory licensing of one of their AIDS drugs, known in the United States as Kaletra. This is an important medicine for people with AIDS, and Thailand wants to produce generic versions of it for impoverished people living with HIV and AIDS, who could not otherwise afford it.

The Bangkok Post has an editorial which lays out the legal issue from a Thai point of view. This one is pretty stark: Abbott is deliberately trying to roll back agreements about international trade rules, because the company doesn't like them.

There's more to say about Abbott, but I'll save that for now. In the meantime, I am now wrestling with a less important problem familiar to all 4 or 5 regular Hemodynamics readers, and a problem that afflicts all casual activists who only attend protests now and then: what to wear.

On its face, this is a silly thing to spend much time worrying over. But protests in the television age, and even more so in the digital image age, require careful attention to symbolism. And it turns out that as a future doctor I've got a lot of symbolism to think carefully about.

Medical students have often worn white coats to protests, as have doctors. This is a way of bringing professional credibility as a form of solidarity. But I've never done this, and though I thought about it earlier this evening, I don't think I will this time either.

This particular issue is fairly clear: when people don't get medicines to treat HIV, they often die of AIDS. Incredibly enough, and despite everything bad you can say about an organization like the World Trade Organization, nations around the world have agreed on ways that countries can make sure people get medicines. If you want to reap the benefits of global capitalism you should at least play by its very limited rules.

This message does not require a white coat for its credibility.

To say that you should listen to my views about intellectual property policy because I'm going to be a doctor would be absurd. After all, so many other doctors have been so egregiously wrong about this kind of issue that I would hate to encourage people to listen to doctors about patent policy. As far as the embroidery on my white coat, it says "Harvard Medical School" and it doesn't say my name. And I don't believe there's anything about my Harvard Medical School education that makes me any more equipped than any other reasonably well-informed person to express my opinion about Abbott's approach to intellectual property. All I know now that I didn't know before is the details of how people die from lack of medicines, and what happens to their various organ systems as they get more ill.

You could argue that wearing the white coat is a kind of threat to Abbott, along the lines of the anti-Abbott coalition's suggestions for doctors that they prescribe equivalent generics instead of Abbott products, refuse to talk to Abbott drug reps, and refuse to accept gifts from Abbott reps. But for me, this would not be sending the right message: whether or not Abbott cares about Thai people living with HIV and AIDS, I will prescribe generics when I can, I won't talk to drug reps, and I won't accept gifts. If I was the kind of doctor who was actually thoughtlessly prescribing unneeded overpriced brand name drugs and getting chummy with drug reps, I probably wouldn't be going to a protest at Abbott headquarters anyway.

Another entirely opposite direction would be the Treatment Action Campaign's "HIV Positive" t-shirt. But I've always felt that this shirt has a different meaning in the United States than it does in South Africa, and it definitely means something different when worn by groups of people which do not include many people living with HIV. In the US, the meaning of this shirt can be helpful but it can also be presumptuous; tomorrow, at least, I'm not taking this approach.

The only visual signal I might feel comfortable displaying is letting people know that I am a health worker--someone who makes it their life's work to care about the well-being of people who are sick. I'm uncertain about the political value of that gesture, but I think that at least it is a visual reminder that the protest is an issue of health, and survival, and not just an issue of market rules.

In other words, I've reduced my protest wardrobe to two alternatives: I can either dress as just me, a concerned citizen--or I can dress as a health worker. Considering the health worker option, I realized once again that if I take this route, I would not wear the clothes of the profession (the white coat), but of the hospital and all who work on its clinical floors: I would wear scrubs.

The doctors of The Sopranos

The Sopranos is a show about the frailty of mafiosi; because of this, it's a show about the power of medicine.

Tony Soprano's sessions with his psychiatrist frame the show by showing Tony's psychological frailty; in fact, the whole show started with Tony going to the psychiatrist because of panic attacks.

After a long struggle, Tony has basically given in to the psychotherapeutic approach to his own narrative. This week, Dr. Melfi asked, "Are you sure you aren't reading too much into this?" Tony replies, "I been comin' here for years. I know too much about the subconscious now."

Another running theme of the show has been the top bosses getting knocked down not by their enemies, but by their own physical frailty.

This week, New York boss Johnny Sack got bad news about his lung cancer, first from a specialist he flew to see, and then from a fellow inmate working as a hospital orderly. The orderly had been an oncologist, specializing in liver cancer, before shooting his wife and two others. "You saw Cohen?" the oncologist-orderly asks Sacks, flipping through Sack's chart when the prison doctor isn't looking. Sacks asks, you know him?

"I saw him talk once at an ASCO meeting." (That's American Society of Clinical Oncology to you, bub.)

The oncologist-turned-orderly is film director Sydney Pollack, who looks and acts exactly right for the role. I've seen a dozen internists who look and talk just like this guy. (Tony's psychiatrist's psychiatrist is played by film director Peter Bogdanovich, who does look like a psychiatrist.)

First Pollack's oncologist character tells Johnny Sack he should live longer than Dr Cohen has told him. Then, as the disease progresses, he says, "The aggressiveness. It surprises me. I've gotta concur with Cohen."

Johnny Sacks has brain metastases ("The headaches", he says, when Cohen tells him, recognizing the correlation of disease progression and symptoms); Phil Leotardo is still melancholy after his 5-vessel CABG; Tony had his long stay in the ICU.

And Paulie is super-proud of himself for "beating" prostate cancer. He thinks he's a badass for that; when Paulie proudly contrasts his survival to the death of Johnny Sacks, he thinks he's comparing like and like. Actually, comparing localized prostate cancer to metastatic lung cancer is like comparing Paulie Walnuts to Johnny Sack, seriousness-wise. (Though metastatic prostate cancer can be terribly painful and frighteningly lethal, localized prostate cancer is extremely common among older men, and more people die with it than of it.)

The feds make their mark from time to time, but they're mainly annoyances. On The Sopranos, the only people who are always more powerful than the mob–even in prison, there's an oncologist who tells Johnny Sack he's going to die–are doctors.

It makes sense. Doctors are probably the only people who can illuminate a mobster's deep psychological and physical frailty, and still have the mobster thank them for it. That's why a show that is about the frailty of mobsters needs doctors.

Postscript: I was struck by how Leroy Sievers, who's blogging about his cancer on NPR.org, saw this episode differently. He was struck by the episode (and a little bothered by it, despite his wishes not to be) because Johnny Sack's course was so realistic. I was impressed by that too, but I didn't think about it much. It just made sense. If they're going to show the underlings being shot to death, why not show the bosses die of cancer with the same realism? But the fact that the cancer part didn't bother me (while the gunshots still make me wince) probably just confirms that I've spent a lot of time in the hospital, and on oncology floors specifically. Johnny Sack's death seemed ordinary to me. I'm sure that's different from how I would have seen this three years ago.