At Least Insurance Is Unhappy

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The day that medical insurance execs and medical malpractice lawyers are screaming that their sky is falling, is the day that the U.S. has gotten serious about health care reform.

It sounds like half that equation is at least whining, so maybe some modicum of real reform is coming.

6 And A Cat

20090802241136After days of wishing and washing, we elected to subject ourselves to great risk…and added our cat to the mix of travelers to Germany.

We have never traveled to Europe with 4 children.  We’ve never moved to Europe with anyone.  So doing it with a cat – a mostly outdoor cat – brings some trepidation on top of the not insignificant amount of stress we’re already feeling.

Tonight I write this from our two-room hotel in SeaTac, WA within sight of the airport radar control tower.  The hotel is grungy and small and we’re all tired.  And we haven’t even left the ground yet.

For his part, the cat (name’s Mr. Elma, after the location where we was “rescued” by yours truly) has done rather well…so far.  He protested his soft cat-carrier on most of the drive up here from Olympia.  The carrier already looks a bit different after a solid hour of claws and teeth.

But once out of the carrier and hunting around the hotel, he settled down and if anything wants a bit more affection than normal.  We all love him because he is so mellow and self-sufficient.  He so far appears to be holding that course.  I do think that arriving here with cat in tow has, maybe, helped the kids maintain some sense of normalcy.

Tomorrow, however, is a new day.  He could freak, bust out of the carrier and maim an eyeball.  At least, this is the scenario that continually plays in my head.

All of the kids have handled this massive transition gracefully.  The two oldest had some tears tonight as things become real.  Really real.  We’re not going back to our beloved home.  Maybe ever.  One of the reasons we decided to go for this now was because while the kids do have some real friends…they aren’t the same kind of friendships people make in high school or college.  If you’re going to take kids away from their friends, now is the time to do it.  That said, they do have some sweet little friendships and the leaving is still hard.

Everybody (except, perhaps, for Mr. Elma) wants to see Germany, however.  Even El Nino, at 3, asks repeatedly when we will finally see “Doominee”.

Assuming no mishaps with the cat, the plane, the luggage (I’m checking my shorter surfboard…a little iffy) or the transportation, the answer to our youngest’s question should be, ‘tomorrow.’

Hard to believe.

Vanished and Forgotten

I spent the past two weeks working as a stand-in for a private practice family doctor in the tiny town of McCleary, Washington.

The stirringly beautiful enclave is better described as a village.  Calling it a ‘town’ implies a bit more hustle and bustle than actually goes on here.

Evergreen trees pepper the landscape, outnumbering cars ten to one.  Wooden cabins and simple churches with peeling paint line the single main road.  A generous census – throwing in some dogs and cats to pad the number – wouldn’t put the population over 2000.

But even here, in one of the most idyllic settings in all of rural America, something wicked this way…came.

lindseyOn a soft warm night typical for Western Washington this time of year, 10-year old Lindsey J. Baum disappeared while on a short walk home from her friend’s house.

She was last seen on June 26th around 9pm wearing a gray hoodie.  Lindsey should have made it home well before dark at this latitude in early summer.  But after weeks with no leads, authorities now assume the girl was abducted.

Each day as I worked in the small medical clinic, I overheard discussions about Lindsey.  Frequently, people decried the lack of “truly effective” sex offender laws.

The one running blog I found about the situation abounds with merciless criticism of those who allowed her to walk home alone.  The posts have an annoying, self-anointed authority and certitude about them, coupled with virtually zero compassion.

townMy criticism, however, focuses on the response of the outlying communities during this tragedy.

7 years ago, about this same time of year, a similar event occurred to a young girl not much older than Lindsey in Salt Lake City.  In that case, word of the abduction spread to every news outlet in the English-speaking world in a matter of hours.  Pictures of her were posted on websites and in newspapers in ever-widening circles, to include towns and cities hundreds of miles away.

Every day, this girl’s story stayed in public view.  News of her disappearance became a dull, throbbing headache to virtually the entire Western United States.

That girl, Elizabeth Smart, survived her ordeal and was returned to her parents fully 8 months after being led at knife-point from her own bedroom.  Her abductor was recognized by someone who had seen a picture of him on “America’s Most Wanted”.  Nearly a year after the incident, this girl’s abduction was still making top news stories.  Why?

The Smart family drove this process, true.  The parents had money, were excellent communicators and kept their wits about them in a horrific situation.

But they also commanded a small army of help. Literally thousands of people lined up to join the effort.  The Laura Recovery Center and other organizations dedicated to this type of tragedy joined the effort as well.

People worked continually to get the Smart family onto national news and talk shows.  Pictures of the victim and her suspected abductor appeared on Larry King Live and Oprah.  And, of course, the show that ultimately led to the break in the case managed to make the story seem relevant months after the incident occurred.

By contrast, Lindsey is yesterday’s news.  You can’t find a current story on her anywhere.  For all I know, she’s home watching Hannah Montana and pondering boyfriend proposals.

mapMcCleary is so tiny, its presence is rewarded with a dot only on maps with an unusual commitment to cartographic accuracy.  The community there can’t make much noise by themselves; certainly nothing to approach the caucophony of a galvanized rescue movement in the heart of upscale Salt Lake City.

The only paper that has carried regular updates about Lindsey is The Daily World, which covers sparsely-populated Grays Harbor County.  A little village like McCleary needs help.  It needs the media power of cities like Tacoma and Seattle, and even here in Olympia.

Yet daily checks of the Seattle Times reveal constant updates about Amanda Knox – a case involving a beautiful college student, sex, drugs and murder – deliciously entering year 3 of drama, but nothing about little Lindsey.  Here in the capital of Washington, The Olympian seems to have the memory of a golden retriever regarding this case, and we’re only 20 minutes down the road.

The Puget Sound region should be plastered with information about Lindsey Baum.  Every 3rd street light and telephone pole should have a Lindsey Baum flyer attached to it.  Every newspaper in the region should have a running narrative of the latest updates on her case next to their logos.  Every citizen from Port Angeles to Portland, from Westport to Boise should know the name, and the story, of Lindsey Baum.

This isn’t idealistic, hyper-passionate pontificating, either.  I distinctly remember stopping for a lay-over flight in Salt Lake City during the summer of 2002.  As we made our way from one flight to another, we could rightly have called the place “Elizabeth Smart International Airport.”  Thousands of fliers and posters papered halls, pillars, windows and doors everywhere we went.

I don’t think anything will change with tougher pedophilia and kidnapping laws.  I also do not think parents need to be more vigilant about this kind of thing.  Increasing either has too many unwanted side-effects.

CandleWhat needs to change is how our communities respond to such a horror.

The abduction of any of my 4 children is the singular fear of my life.  If it did happen to our family, I can only hope that hundreds, even thousands of concerned citizens would take up the burden to rescue that child.  Even if I lived in a forgotten small town off in the hills and away from the city lights.  Even if I was poor.  Even if divorced, uneducated, bad on camera, or just plain ugly.

The way to stop child abduction is to make it really, really hard to steal a child.  An army of awareness might save Lindsey Baum from this evil she faces.  Ignorance lets it flourish.

This Move, That Move

I”m writing this blog while perched on my toilet.

Nice image, huh?  If it’s any consolation, the lid is closed, and my pants are in place.  So, I’m not actually toileting. This is just the only place I could find to sit.

house2When we moved to Israel for medical school, we had no help from movers.  In retrospect, I can’t even imagine how we managed.  Every single, tiny detailed problem had to be taken care of by us.  There was nobody else.

This move (complicated by 3 more kids than our last international move) has professional movers doing all the major work for us.  Everything is paid for.  I’m sitting around blogging while they’re working.  The hardest part for me is that the only place I found to sit was on the toilet.

With some very occasional and sparse moments of stress, I can say that this move has been almost, just maybe…fun.  Fun?

It’s all about perspective, right?  The majority of our packing for Israel occurred in the 23 hours prior to our plane’s departure.  Seriously, our entire lives were barely even packed less than a day before we left the country for the first time.

So, we stayed up nearly the entire night, and left with over 20 boxes of junk – many still open and half-packed – that needed to be taken to the post office and mailed to us.  THAT idea cost us over 1000 bucks and tons of work for my hapless mother.  We didn’t get those boxes in Israel for nearly a half-year, so easily 80% of their contents were totally unnecessary.

house1Words fail me in describing the stress and expense of that move.  Probably the worst part, though, was that every single expense – down to the pack of gum we bought at the gas station on the way to the airport – was paid for on loans:

“Hello, sir.  That will be 38 cents.  Enjoy.  Oh, actually, you’ll pay about $12.50 for those 16 strips of minty chewing freshness since it’ll be about 40 years until you pay this off…assuming you don’t flunk out of med school or get killed by terrorists.  Did I mention to enjoy yourself?”

Retirement Ain’t So Great

As mentioned, I managed to complete residency.

That was a few weeks ago, and I haven’t stopped celebrating.

Minimal blogging.  No professional reading.  Lots of sleeping.  Ice cream pretty much whenever I want it…as if I’ve just had my tonsils removed.

I’ve gone surfing twice and will go again in a few days, after I buy the GREATEST BOARD EVER KNOWN TO MAN.

It’s a far-cry from a bohemian life of decadence – no absinthe, no scantily-clad pixies, no pleasure nymphs to speak of – but I don’t remember being this lax, this flatly averse to self-denial.

But, I have to say, after a week of this…workin’s cool.

I like needing to be somewhere in the morning.  I like having a schedule and trying to be efficient.  Mostly, I just like the purpose that a job provides.  With so many people out of work around the country, I can understand how hard it must be to deal with such a life change.  Aside from the financial instability (which I don’t have), just the dramatic shift itself must be really difficult to bear.

Lucky for me, I’m working some moonlighting shifts at nearby practices.  So, we’ll have enough money until I start a real job next month.  And I have quite a few things to keep me busy until then also, because my next job will be in Germany.  So preparing takes lots of energy.

But after even just a week away from the job, I can see that I’m too young to retire.  There’s lots of things I would change about my last job, and I’m not depressed since leaving or wishing to go back.  NOT AT ALL.  But I am looking forward to many of those intangible things that a daily job brings.  Some people are built to work.  In many ways, I guess that’s me.

The AMA – Trust At Your Own Risk

Adapted from an Op-Ed in today’s NYTimes by Nicolas Kristof

Some fun facts about the AMA (American Medical Association):

  • supported segregation
  • opposed President Harry Truman’s plans for national health insurance
  • backed tobacco
  • denounced Medicare
  • opposed President Bill Clinton’s health reform plan
  • probably represent less than 25% of practicing physicians, most of which are specialists who dearly want to protect incomes from $250,000/year to over a million per year

Here is their current position on a National Insurance system:

“The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

They might have been right about opposing Clinton’s freakish health care plan.  They should have shaped the medicare debate instead of obtusely opposing it, and you can be the judge on the whole segregation and tobacco thing.

I think for-profit medical insurance is morally wrong.  Insurers should not make more money than patients, and not doctors, either.  If you want to be available to help someone in a time of weakness and need…you shouldn’t make 20% returns on them until that time arises.

*Disclaimer:  The AMA is a putrid organization from the inside out (and hopefully will be obsolete in 10 years)…but they do have it right on tort reform.


I decided not long after I started this blog – quite some time ago now – to never apologize for not writing.  I’m a doctor.  Stuff comes up.

So, I haven’t blogged in awhile.  If you’re still one of the regulars, my thanks.

This latest distraction involved graduation from my residency program.  Or rather, not graduating…the specter of it, at least.  And while the problem is resolved…the emotions on my side still simmer with grim ebullience.

Arriving in the infuriatingly innocuous manner of many catastrophic announcements, I received the news recently that I had not spent a required week with an orthopedic surgeon during this last year of residency.  Setting up that week is one of what feels like 4 bujillion stipulations that lead to graduation.  I’d missed this one, and it was too late to change my schedule to fix it.

Through some fuse-burning mental gymnastics on my part, and some heroic situation-framing on my advisor’s part, the faculty of my program have just decided that I will, in fact, graduate with my class.  In essence, we found a workaround that keeps me on-track to finish with my peers in less that 4 weeks.

This experience however, reignited an old resentment in me that essentially boils down to oft-repeated theme in the “Jason Bourne” movie series about being required to give vastly more than expected when signing up.

The frank truth is that all the permutations of mid-level medical providers – from ARNP’s to PA’s to Dr. RN’s – have one thing in common…they’ve been subjected to roughly 1/3 the amount of training as I have.  Subsequently, they have 1/3 the debt, and probably have 1/3 the family problems, health problems, and 1/3 the incidents of depression, substance abuse and suicidality.

The result of that limited training?  They do the exact same job as me…and get paid about 80-90% what I will make.

Calculate how much money I lose in training when they’re out actually working, and I probably make less than your average P.A. over the course of a career.

I was so upset over this graduation snafu, that I rammed my fist through a wall in our house, and ended up driving hopelessly around the beaches of Washington until 7am this past weekend.  Then, thankfully, I got with the program and figured out a way to address the problem a little more professionally.

No, working an extra week after graduation wouldn’t be the end of the world.  But in so many ways I feel I’ve reached the end of my rope.  And, for lots of logistical reasons, another week of “work” would have really been tough on me and my family (and probably our walls).

I should mention that what I was deficient in – observing an ortho doc – falls into my category of ‘watching doctors be doctors’.  I’m not sure where anyone came up with the idea that people learn from this particular brand of education-theory rack-stretching, but frankly at my level if I don’t have responsibility, I don’t care.  If I don’t care…I don’t learn.

Watching doctors be doctors is  easily the least valuable learning experience I’ve had in my entire medical training…and residency is rife with this vacuous requirement.  I’m quite sure that the endless hours I’ve spent delivering Oscar-level performances of intellectual interest could be completely removed from my training and I would still be the same doctor I am today…just less poor because I would have started working at least 6 months sooner.  Maybe a whole year.

Simply put, I believe that my medical training is outmoded.  It’s destructively expensive.  If people can do my job with 1/3 the training, then I’m effectively over-qualified. 

The backside to this is that M.D.’s themselves will eventually become irrelevant in the marketplace because we’re just too expensive.  We spend so much money on school and inefficient training, that nobody can afford to pay off all of our debts.  How long will it take me to pay off the $330,000 I spent on my training?  How much more do I owe on that since I’ve piddled away another 3 years on training – watching orthopedic doctors and acting interested – while a number that big generated interest on itself?

I’m deeply grateful to my advisor especially in this case, because he presented my situation to our residency faculty in a light that was very favorable to me.  He is probably the reason I’m not in a padded room at the moment. I don’t really blame my residency program, either. 

The problem is the system:  tone-deaf, needlessly arduous, inefficently stubborn.  The mid-level system was created by smart people who realized that it just doen’t take this much to make a doctor.  You shouldn’t have to sell your soul for the honor and burden of taking care of sick people.

In the end, I approach graduation almost devoid of any elation at all.  Instead, I feel like I’m sitting in a field, blood and feces spilling into my lap from the mortal shotgun wound I’ve received to the gut, looking plaintively up at the shadow hovering over me – at my colleague and killer – and wondering aloud, “Look at this mess…look at what they make you give…”

Doctor Sells Insurance For His Own Procedures

**The following is another installment in an SW101 exclusive series entitled Medicine In America (MIA), covered by our crack journalist team scattered around the globe.**

TULSA, OK – “Just in case I screw something up,”  Dr. Jason Hines says, smiling, as he helps an elderly man sign a form and pay for his “procedure insurance.”

Dr. Hines, owner of New Day Family Medicine, a small group practice here, is one of a growing number of primary care doctors who are getting creative as they struggle to increase falling reimbursements.

“I got the idea from my very own Family Medicine Academy,”  Hines says excitedly, holding up a postcard with bold, red letters emblazoned across the top reading LAST CHANCE!  “They’ve been trying to get me to buy their life insurance policies for about 2 years.  This is the 14th ‘last chance’ notification I’ve gotten.

“Then it struck me!  Even the AAFP is getting in on insurance, why can’t I?  I mean, we can’t all be lawyers and dentists, right?  Gotta make the bucks somehow. ”

Dr. Hines’ fledgling business-within-a-business had a rough start.  “Nobody saw a need for it,”  he said.

Debbie Lawrence, one of the first patients to sign on, described her initial doubts.  “It seemed a little strange, you know?  I’ve already got insurance for my car, my house, for medical bills.  I even usually get that extra insurance for rented DVD’s.  But then, as the doctor described the procedure of removing a mole on my back, I saw this slight tremor…and then he read me the consent form!  Boy, it just seemed like the safest thing to do.”

“I had to figure out some way to promote things.”  Hines explained.  “The postcard idea was already taken by the AAFP, so I wanted to do something more creative.”

His solution was to enroll in an acting class at the local community college.

“Watch this!”  He said excitedly.  “I’ll just reach for this piece of paper, aaaaannd NOW, I’ll have this nearly-imperceptible tremor just before I pick it up.  See that?  We really worked on the subtle-but-obvious thing in class.”

Then he modified his legally-mandated consent form process.  “So, they make you blah, blah, blah about the risks and benefits of every procedure, right?  Well, I just figured I should capitalize on that.”

His consent form reads:

My signature is proof that I consent to the forthcoming procedure.  Procedures are dangerous.  Most are not proven to actually improve anyone’s health.  I understand that I risk serious pain, including but not limited to severe disfigurement such that my children and spouse might recognize me only by mannerisms.

Often, procedures of this kind result in lasting nerve damage, potentially to the genital area.  I understand and fully consent to an ambivalent and uninspired sex life from this point forward.

Bleeding is usually something that can be stopped.  If not, I am willing and happy to slowly dwindle into a shivering unconscious blackness from which I may never emerge.

I also agree to not underestimate the risk of infection.  I realize that flesh-eating bacteria exist everywhere, at all times, and are constantly attempting to gain access to my body.  I understand that should infection occur, I may wake up with parts of my body unexpectedly reduced to nothing more than exposed skeleton held together by rotting fascia.

“That’s the mellow one,”  Hines’ states matter-of-factly.  “I use it for wart removal and immunizations.”

After the slow start, business now is booming.  Dr. Hines calculated his acting class cost – “110 bucks a unit for a 3 unit class” – at $330, which he claimed on his income taxes as a business expense.  He sells insurance for any procedure in his office, usually at a cost of $25 to $350 per procedure.  “I’m thinking of adding waiting room insurance – you know, in case the roof collapses – but we haven’t worked that angle yet.”

What has been developed is the “Cabo” insurance package, which includes a special waiting room with palm fronds, seltzer water, a chaise lounge and soft music.  Aside from guaranteeing the procedure to be safe and “up to standards”, the patient also receives a massage at the conclusion.  “Sometimes, we’ll give their dog a massage also.” He said charitably.  “After signing my consent form, people are pretty keyed up.  I usually just throw the dog in for a reduced fee.”

The AAFP did not return calls for comment, but did release this statement,

The AAFP does not condone the practice of selling non-medical products within the environment of medicine.  We believe in assisting our doctors as they provide the best care possible for the entire family.  Just look at the success of primary care medicine in America over the past 30 years for evidence of our presence in Washington.

Although the insurance business does offer unbelievable profit margins and investment returns of nearly 50%, we strongly believe that individual doctors do not have the expertise to get into the business.  Individual family doctors should leave the big business and real financial gains to organizations that are qualified to actually make money.

Finally, although we typically keep information about doctors confidential, it should be mentioned that Dr. Hines appears appears to have let his board certification lapse.  He is soon to be rejected from our community as a “fellow” if he doesn’t pay his dues by cash, check or debit/credit.

“They can say whatever they want.”  Replies Hines.  “I got the idea from them.  The AAFP opened my eyes to the fact that there’s lots of ways to make money on the medical field, as long as you don’t waste much time actually practicing medicine.  I can’t believe it took me so long to figure it out.  I’m just glad I got in on the gig now, when the para-medical business is still in it’s Golden Age.”

Reader Q: My Med School

bgucloseI get lots of questions about my med school.  For those few not in The Know, I attended the Medical School for International Health.  The school is located in Israel, in the ancient town of Beer Sheva (you can find it in the Bible, dude…can you say something like THAT about Maple Acres, Kansas?).  The institution is Ben Gurion University.

The program focuses on providing medicine in an international context; particularly to the 3rd world.  The school is a collaboration project between BGU and Columbia University, so blokes like me have a reasonable shot of doing residencies in the U.S. after graduation (got my 1st choice in residency program).  

Anyway, emails come in from all over the world asking me about my experience there and soliciting my advice about going.  This latest query was so expansive and had such good questions, I figured that if I was going to go to the trouble of replying to it, I might as well post it as a blog so everyone could check it out:

My name is Bryan and I am an accepted MSIH student from Provo, UT headed to Israel in July.  Here are a few questions for you:  

What did your spouse and kids do while in Israel for the 3 years?  

They found all kinds of things to do.  Getting settled in Israel is quite a job compared to the U.S.  Everything is slower to accomplish, from records to mail to shopping, things just take lots of time.

That said, my wife and I had 2 children while in Israel, so that kept her busy in ways that older kids wouldn’t.  She also took a Hebrew class that provided lots of social interaction, friends and experiences in the culture.

Additionally, you will have WAAAY more time that you might expect.  The first year, you don’t even take an exam of any kind for 5 months.  Not one.  You just go to class.  Or don’t.  Depends on your learning style.  Then, when exam time does roll around, you are home studying most of the day.  I don’t know if that’s how it is at other med schools, but that’s the way we roll in the IS.

So, you won’t be gone as much as you probably envision.  And, the family will have more to do that you might think.

BGU from a distance:  Lots of dirt and dust...then, suddenly, CITY
BGU from a distance: Lots of dirt and dust...then, suddenly, CITY

Did your kids attend school at all?

Mine didn’t, but they easily could have.  I started the program with just one 2 year old girl, but we had 2 more by the time we left (like I said…you do have, *ahem* free time).  The oldest would have done fine in their preschools, called Gan (pronounced GONE, means garden).  

I would recommend it, especially if your kids want to learn Hebrew.  Like most European countries, education is a huge emphasis, so they’ll want your kid there EVERY day, all day.  Even preschool.  This was the hang-up for us.  Something M/W/F might have worked, but my wife wasn’t ready to ship our 3 year old off for full-time school, so we skipped it.

Did your kids and your spouse learn the language?


See comments above about wife.  Kids didn’t learn it (although for some reason, we ALL still regularly say ‘agvanot’, which means tomatoes).  I wish they had been a bit older, becuase then I would have insisted on school for them.

Did you have any Hebrew before MSIH, or did you buy a program like Rosetta Stone to get you started?

I had none, and sucked at it all the way through.  Figured out how to buy food pretty quick, though.  I bought a tape-series that supposedly was used by State Department people, but never even opened the box.  

The school provided a pretty good immersion class, but really you need to take the same Hebrew class that my wife took at night to actually learn the language.  The Israeli people (unlike many lame ethnocentric Americans like me) know English almost universally in addition to their native Hebrew.  So, they would rather work on their English with you than let you work on your Hebrew with them.  All of your classes are in English.  You actually don’t get as much exposure to the language as you might think.

Furthermore, on the wards, I’d say Hebrew is only spoken by about 60% of the patients.  Beer Sheva has to be one of the most nationally-diverse cities on the planet.  Walk down a typical medical ward, and you may hear anything from the Big Three:  Hebrew, Arabic and Russian, to many “lesser” languages of the area like English, Spanish, Bulgarian, Yiddish, Romanian, French and others.  Although Jewish in heritage, the people who immigrate to Israel come from nearly every country in the world.  Their primary language usually isn’t Hebrew.

If you truly want to learn the language – and the best reason to is so that you understand the ward doctors during your 3rd year – my recommendation is to go to Israel 2 months early and take a true immersion course.  This is how they do it for the new immigrants.  You live in a house with other immigrants and they DRILL the language into you.  You’ll have it forever after that.

Did you buy a car?


We did.  It was very expensive and a bad idea.  Getting all the paperwork for it took 3 solid days of sitting in offices all over the town of Beer Sheva.  Gas is spendy.  Insurance and licensing is more than in the states.  

We should have just used cabs instead.  They crawl all over the city all the time.  You never wait for them, and a trip anywhere in town is only 15 shekels, which is about 3 dollars. We calculated that we could take 60 one-way cab rides a month for the monthly cost of the car.  

Years out, I still talk to the guy on the left a few times a month.  He's starting a fellowship in pulmonary/critical care next month at Henry Ford in Detroit.
Years out, I still talk to the guy on the left a few times a month. He's starting a fellowship in pulmonary/critical care next month at Henry Ford in Detroit.

Right about that time, I got into a minor wreck;  we parked the car after that because we didn’t want to spend the money to fix it.  I watched with interest as teenagers slowly dismantled the thing on a semi-nightly basis over the ensuing months.  I ended up with a twisted metal creature that can only loosely be described as a “machine”.  They took everything.

“Oh well,”  my friend Brian consoled me one day.  “Just be happy that you probably made some high school kid’s senior year 10 times funnier as they systematically ripped your car apart every night.”

Do many students buy cars while there?

Nope.  Just the dumber ones.

How else can you get to the more remote sites like Masada, Dead Sea, Elat and the like? 

Rent cars.  Fairly easy.  Fairly cheap.  Pool with friends if you aren’t going with the fam.  We saw EVERYTHING in Israel in nice Skodas or Seats (see-aht) with power windows and A/C and no worries about breaking down.

You can also take the train, which is efficient and fun…except when its crowded and you’re crammed between 6 sweaty IDF soldiers with automatic rifles, some of which are pointed at you and your kids. 

Where did you do your residency and what specialty did you choose?

Olympia, WA.  Family medicine.  I felt then, and still feel, that my specialty is absolutely the best preparation for medical mission work.  

I have not once regretted my specialty choice or the residency program I chose.

Did you know of any MSIH grads applying to the handful of International Health Residency Programs?

None of my class applied, but this largely had to do with location, not competitiveness.  We wouldn’t have had a problem getting into those programs, in general.  U of Rochester had a good connection with our school and a few of our grads went there.  Their Intl Health cirriculum is fantastic (or was a few years ago when I was looking at them).

Is there any personal advice you think would be beneficial to me; advice that might not be included in the admissions packet?

Be flexible, don’t whine like an American.  Don’t expect anyone to care about you or your little worries.  Be a traveler.  Be observant and end your sentences with question marks rather that declarative periods at a ratio of at least 2:1.  

ipconflictRecognize that there is no answer to the Israel-Palestinian conflict.  Accept that you have no right to have any opinion on the issue until you can say honestly that you have deep friendships with BOTH an Israeli and a Palestinian.  Until then, try as hard as you can to shut up learn.

Travel, travel, travel as much as you possibly can.  Drive the country from end-to-end at least twice.  Stay at a Kibbutz or Moshav.  Swim in the waters of Gan Hashlosha and the Med.  Absolutely see the Golan Heights in the spring when curtains of flowing green grass are punctured by brilliant red Israeli poppies.  Try as many foods as you can and never turn down invitations to Shabbat, Passover, Rosh Hashanna or Succoth. 

Spend lots of time in Jerusalem – especially the Arab Quarter of the Old City – and try to hang out in the Armenian Tavern for dinner at least once.  See the Wall and the Dome on the same day.

The Golan
The Golan

Jump on chances to go to Europe, especially the eastern countries.  See Turkey, Jordan and at least the Sinai of Egypt.  Get certified in SCUBA in 3 days on the Gulf of Aquaba (look up a guy named Hamdi in Dahab if you are interested).  Consider your experience there a colossal failure if you miss out on many of these opportunities.

Pick up a cause that will build the school.  I started the literature and medicine class.  I think it’s a required class now, so if you hate it, you can thank me.  Pour part of your life into the school.  Put MSIH on the map in your own small (or big) way. 

Will every moment of your experience into the marrow of your soul; drink its precious nectar as if you never will again.  Because you won’t.

And pass your damn tests.

More Doctors?

Without really meaning to, I pounded out a totally serious blog about our health care system.  We all do it.  We all think we have the answers.  I know..this is no more than a hit off the crack-bong of American medical politics, but it shuuurrre feels good, man.  

There’s something so empowering about imagining my little ideas solving the ills of the world….

An interesting commentary about the perceived need for more doctors was posted recently at

In the article, 3 businessmen who run group called “Innosight” – an organization that attempts to help businesses be more efficient through innovative thinking – suggest that we have as many doctors as we need in the United States. 

Entitled “We Don’t Need More Doctors” – you can read the full article yourself – the authors present a sorta-new perspective on health care delivery in America.  Here’s a summary:

  • Current health reform plans are unlikely to break with the ways of the past.
  • Some advocate need for more doctors, but that’s actually not necessary
  • Nurses can provide quality care at low cost in clinics
  • This would free up doctors to do more complex work
  • Let’s look at some of their other points:

    All parents know the experience of worrying whether their child has an ear infection — treatment involves considerable pleading for a standby appointment at the doctor’s office, followed by a long wait, a 30-second visit with the doctor, and then a trip to the pharmacy for another long wait.

    Throw in the half-day of missed work and the stiff bill, and it becomes clear why many advocate the need for more doctors.

    Ouch.  Can’t really argue with that.  Our clinic has been putting lots of effort into “same day” appointments, and I know this is a push nationwide.  But still, the process is onerous.  Furthermore, a good majority of these cases don’t require treatment (ear infection is a good example).  So, add into all that waiting and effort, a “reassurance” from the doctor that things are fine and there’s nothing to do.

    However, a growing number of visits, incorporating quick and easily interpreted diagnostic tests and algorithm-driven care for conditions such as ear infections, sore throats and minor burns, can be handled better in nurse-run clinics.

    Algorithmic thinking.  I’ve lamented it many times before.  The less a person is trained, the more they rely on algorithms.  What is an algorithm?  It’s a recipie for care: “Does the patient have X?  If yes, do 123.  If no, do 123.”  Algorithms are the “Choose Your Own Adventure” of the medical world.  They provide efficient decision-making, but at the expense of good analysis. 

    Human beings, unlike the computers that generate algorithms, don’t fit well into specific enough categories for most “if/then” treatment plans.  Get yourself involved in any cardiac arrest code – where everyone is trained in ACLS, a completely algorithmic process – and you will see how poorly a care recipie works in the real world.  Furthermore, true thought and real experience provides better, safer and more efficient care over time.

    Nurse training is, by historical design, a non-analytical type of training.  Nurses are trained to react to data, not analyze it (exactly what algorithmic thinking is).  This feathers with analytical physician training perfectly, which is why the system has worked so well for generations.  Both types of thinking are equally important, equally intelligent, and both are required to provide the best care to a patient.

    To cheapen the process, we are now asking nurses to use reactive thinking to provide medical care.  Good care really should be provided through an analytical thought process, supported by reactive thinking (e.g. doc decides the patient needs a shot, nurse makes sure it gets done exactly right).  Remove either one, and inevitably the care suffers.  Even in primary care, medicine is no cookbook. 

    By moving more complex care from specialists to primary care providers, the payments will follow. These changes would make primary care more fulfilling and financially rewarding, while freeing up specialists to do even more complicated work that merits their additional training.

    The problem with specialists in the American healthcare system isn’t that they need to be “freed up”.  Most specialists are perfectly happy with their workloads.  The problem is that they are paid disproportionately, which then drives more med school graduates into those fields when we need more generalists anchoring the medical system.  I agree that additional training merits additional pay.  But not 10 TIMES what a generalist is paid. 

    Another big problem here is that procedures are paid at MUCH higher rates than office visits.  This biases the entire system toward interventions and procedures that cost a ton, are often not proven or helpful, and influence sound medical judgement.

    We don’t need to take patients away from specialists, we just need to pay them more reasonably and make payments for visits and counseling equivalent to procedures.

    We should embrace eHealth initiatives that enable virtual clinic visits and online house calls.

    I absolutely agree.  SO much good medicine can occur online.  To really work, however, solutions to HIPAA hyper-draconian privacy ensurances need to be relaxed.  Additionally, litigation risk needs to diminish so that doctors can make judgement calls without fear of major legal backlash.

    Furthermore, I’ll highly agree with the authors about e-medicine:  We need to move away from the “guild” mentality that has kept boundaries narrow and created regulatory, licensing and reimbursement obstacles to new models of health care delivery.

    Finally, they get it totally right when they sum their opinion with: Patients want correct diagnoses and effective therapies, but they also value accessibility, convenience, transparency, communication and their time and money — none of which have been priorities of the traditional health care model.

    In general I dislike health care reform discussions by non-healthcare providers. I’m a purist that way. I think the discussion should be between doctors and patients and nobody else. You can’t really know how to direct the work, unless you’ve been there doing it. But these guys get it pretty close to right on. Although I disagree with their central idea – that we need more nurses and not more doctors – in general their thinking is innovative and realistic. Maybe someone will listen.