Winter 2007
Editorial: Endangered species
Danse macabre: Poverty, social status, and health Disparities in health status and in life expectancy are striking features of the American health landscape, and of the landscapes of other developed countries as well. To some extent these differences can be related to variations in the incidence of disease, access to health care, health-adverse personal habits, violence, and other factors, but deep societal forces appear to be important determinants as well, and in fact may, in many instances, be primary. Socioeconomic status is prominent among these, and has been tied not only to life expectancy but to health trajectory across the lifespan in a variety of studies over more than 150 years, despite changes in health care systems and disease patterns, and in the fact of deepening understanding of the biology of disease and the effectiveness of clinical interventions. Similarly, education, gender, race and other individual characteristics have powerful health impacts. The mechanisms whereby poverty and social status and other group or individual pressures translate into shorter and sicker lives present a rich set of considerations bearing on vulnerability to disease, mechanisms of adaptation to social and environmental circumstances, and psychosocial issues.
Six decades of progress and chanage in hospital medicine, 1974–2007 Two common cases, myocardial infarction and gastrointestinal bleeding, are presented in 1947 and re-presented in 2006. The differing hospital courses illustrate the astonishing advances in diagnosis, treatment, and outcome of these common illnesses over the past nearly six decades. These remarkable achievements at academic medical centers have coincided with—and are somewhat directly connected to—a decline in the doctor-patient relationship for house staff.
Saturday night in Mariposa The summer before entering medical school, the author spent four weeks training as an Emergency Medical Technician (EMT) and Wilderness First Responder (WFR) in Mariposa, California, outside the Yosemite Valley. On the Saturday night following the first week of training, an incident tests the limits of the author’s skills and initiates him into the realities of caring for the critically ill. This is a non-fiction account of a student’s first awkward step into the medical profession.
Cole Porter's orthopaedic odyssey When Cole Porter was 46 and at the height of his career, he sustained bilateral open leg fractures in a horseback riding accident. These injuries occurred before the availability of intravenous antibiotics and modern techniques of fracture management. Cole developed the dreaded complication of chronic osteomyelitis with a draining sinus that plagued him for 21 years. Scarcely a day went by that he was not in pain. He underwent at least 33 operations in a futile attempt to get the bones to heal and eradicate the infection. The osteomyelitis was so severe that in 1958 his right leg was amputated above the knee. The amputation prolonged his life for almost six years but completely terminated his creativity.
Trauma on trauma: Lessons from the tsunami and civil conflict in Sri Lanka As three surgeons on a post-tsunami relief mission to northeast Sri Lanka in March 2005, we encountered resilient communities struggling to rebuild from great natural devastation. Even beyond the immediate effects of the tsunami, the longstanding civil conflict in this region has had profound effects on the health and well-being of the civilian population. Common obstacles to health services delivery in a conflict zone are identified, including critical manpower shortages and deficiencies in infrastructure and supplies which have compromised access to care for civilians who have been displaced multiple times. Appropriate mental health interventions given the local socio-cultural context of the disaster and conflict in Sri Lanka are also called into question. Physicians can play an important role in fostering peace-building through advocacy in areas affected by conflict. Voluntarism need not be reserved only in response to the latest world disaster.
Knowing my body This personal essay describes the conflict within a bulimic medical student. The student’s knowledge of the anatomy and physiology of the human body is contrasted with her disordered thinking and behavior as she binges and purges. This essay explores the themes of the opposition of knowledge and emotion and the discrepancy between the exterior surface of a medical student and her internal mental illness.
Matching blindness elimination efforts to health-seeking behavior Blindness due to the opacity of cataracts is completely avoidable by virtue of a very cost effective surgery. However, in the developing world where 90% of blind people reside, cataracts still remain the most significant cause of blindness. Interestingly, despite a desperate need for aid, curative resources remain remarkably underutilized even when available. The nature of this counter-intuitive inefficiency is dissected in the paper, revealing that psychosocial dimensions act as grossly under-appreciated barriers to eye care. A resolution to this problem is suggested, whereby, an integration with widely exploited traditional services would result in both greater numerical success in eliminating cataract blindness and a higher quality of care.
The tradition of the gold-headed cane In the late 17th and 18th century, physicians in London enjoyed a life of prosperity and influence as elite members of society. A cane, topped by a flashy knob of gold, served as their professional badge and as an essential dress accessory, much as the stethoscope later became the symbol. The passage of a cane from an older to a younger physician, a symbolic act that showed high regard and affection, became a common practice. This tradition was imaginatively captured in “The Gold-Headed Cane,” published in 1827 by William Macmichael. In this book, the cane speaks as the author recounting its observations as it journeys from the hand of one eminent physician to five others until it is permanently deposited in the closet of the Royal College of Physicians. In doing so, the cane provides an accounting of the composite ideal characteristics of a physician preceding the example of William Osler. Cushing, in “The Life of Sir William Osler,” considered Osler to be a “twentieth century edition of these six men rolled into one.” Because of the charming and enduring appeal of the book, its unreserved admiration for the highest qualities of a physician, and the hoary tradition that it represents, a presentation gold-headed cane has lived on as a distinguished award given to an outstanding student or physician as well as to others in North America though, perhaps surprisingly, not in England.
Of hospital advertising truths, half truths, and the academic medical center Direct-to-consumer advertising by academic medical centers (AMCs) is an increasingly used approach to compete for patients. Prior to the rise of managed care, AMCs’ competitive efforts were directed primarily toward persuading physicians in private practice to refer patients to their hospitals and clinics. Potential patients were never viewed as influencing hospital choice. No one disputes that academic centers have an obligation to succeed financially. But aiming ads at healthy consumers through print and broadcast media to increase business is new, and it entails risks. Moreover, if empowered and informed consumerism is the goal, it cannot be achieved through sound bytes in advertisements. If AMCs want to have an impact in competing for patients, they need to take a hard look at themselves. Commentary: Of truths, half truths, and less than half truths on the road to health
POETRY To the end of her life A Visit to Apollo's Temple Warm nights in Oaxaca A Rigid Mind Sprouts No New Crops Sentinel Node The Code Scan Trauma
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