Siguiéndole el juego a los vecinos del norte

Hoy domingo culminó la temporada de futrbol americano, con el encuentro entre los acereros de Pittsburg y los empacadores de Green Bay. Ganaron estos últimos pero lo increíble es como este tipo de eventos, que son finalmente estadounidenses, ponen a girar a una buena parte del planeta alrededor de ellos.

En México, la transmisión del "Súper tazón" genera enormes expectativas y ganancias entre algunos locales comerciales, como pueden ser bares y restaurantes. Desde luego, quienes transmiten estos eventos por televisión también se hacen de mucho dinero pues en plena transmisión "cuelan", por decirlo de alguna manera, a sus anunciantes locales. Obviamente habrá habido venta de camisetas de ambos equipos, ya sea en el terreno informal o en las casas especializadas en deportes. En fin, parece ser que esta fiesta, 100% norteamericana, nos llega como una gran ola y es imposible deshacerse de sus efectos.

Pero el asunto va más allá. Se sabe que los anuncios comerciales en un súper tazón son -curiosamente- un espectáculo extra, el cual la gente espera poder disfrutarlos cada vez que hay una pausa en el partido, y miren que hay muchas pausas en un encuentro de futbol americano profesional. Y ahora resulta que el modelo de negocios de la TV abierta, que simplemente nos obliga a ver los anuncios para no tener que pagar por la transmisión, se convierte en algo bizarro: ahora un nuevo protagonista, los anuncios de la televisión, son la estrella y hasta youtube tiene un canal para poder ver esa publicidad y votar, sí, votar para elegir cuál fue la mejor.

A mí siempre me ha quedado claro que los estadounidenses saben vender y que si por ellos fuera, podrían vender a su progenitora si eso les diera dividendos. Lo que llama mi atención es que a un espectáculo gringo, para gringos; un deporte con una infinidad de reglas, con todo la parafernalia mediática, en donde los vecinos del norte se solazan dando estadísticas de yardas recorridas, tacleadas, castigos, etcétera, nosotros le sigamos el juego que dictan los allende el río Bravo.

No me cabe duda que el Imperio está presente y nos invade cada vez que se le antoja. No necesita armas, ni balazos, ni derramar una gota de sangre. Impone sus gustos, sus modas, sus maneras de ver la vida a través de los medios electrónicos y además parece, que todo esto es tan cotidiano que ya ni siquiera nos lo preguntamos. Muy lamentable situación.

Poem: Delusions of Grandeur

I'm doing the evening monthly writing workshop at Stanford again and it's really fun. One of the prompts was to take a poem (shown below), cross out every other line, and then rewrite the poem filling in the alternate lines. (The next step is to cross out every other line - those of the original poem - and fill in the rest, thus creating a completely original poem). I'd never done this exercise before and it was quite fun. Here's the original poem:

Psychology Today
Darnell Arnoult

Have you ever had
delusions of grandeur?
I read all about it
in a magazine
on the coffee table
at Dr. Broadwell's office.

Have you ever thought
you were meant for
something special?
But you were afraid,
Afraid if you tried
you'd fail?
People
would think you
a fool?

You might risk
everything
only for
delusions of grandeur?

I have.
Thought that, I mean.

-
Delusions of Grandeur

It was one of those news stations, called
Delusions of Grandeur,
hounding and cannabilizing fear, horror.

In a magazine
there were six bullets. There were six bodies
at Dr. Broadwell's office.

Your heart stops at such headlines.
You were meant for
worrying -- her name isn't even Broadwell

but you were afraid
and opened the webpage anyway, because someday
you'd fail,

ignore and
would think you
caused it, did it, pulled triggers in outrage.

You might risk
a heart's wayward beat, a run of anxiety
only for

a moment to check the article.
I have.
Thought that, I mean.

Billing and the Review of Systems

Some parts of the current reimbursement system do not make sense to me. In particular, the "complexity" of an outpatient case is dependent on the number of "systems" checked. That is, regardless of what the patient comes in for, how we bill for that visit depends on whether we ask about all 14 organ systems. To be honest, I can't even think of what all these organ systems are, but in a complete 14-point review of systems, we ask about fevers and chills, nausea and vomiting, chest pain, shortness of breath, cough, weakness, urinary incontinence, swelling, muscle and joint aches, hearing changes, and a host of other particulars that likely do not affect the diagnosis or treatment of the patient at all. This is a bad way to do medicine; although we want to reward thoroughness, this is essentially saying that everyone should have everything checked on every visit, a mentality that pervades through American medicine as we order CT scans, ultrasounds, and MRIs with little justification, driving up health care costs. Furthermore, the clinical complexity of a case has nothing to do with this "review of systems." Indeed, most clinics maximize their billing potential by giving the patient a long checklist of symptoms so the doctor doesn't have to do this mundane laundry list. Attendings occasionally admonish me because I don't document in my note certain phrases to meet billing requirements. For example, family history can be essential in some diseases but irrelevant in others, and yet our billing schemes do not differentiate between the two (plus, I have blogged in the past about the utility of family history anyway). In any case, as a resident whose salary is fixed but whose role is to make the department money, trying to understand the quagmire of billing is intensely frustrating.

Pre-operative Clinic

All of the medicine residents have continuity clinic, a residency-long outpatient clinic where they see a panel of general medicine patients; they act as the longterm primary care physician or family doc. But a handful of us doing an internship in internal medicine are actually going into other specialties such as dermatology, neurology, or radiation oncology. I am going into anesthesiology next year. So it doesn't make all that much sense for us to have a primary care clinic, and indeed, because we're only here for a year, it isn't fair to patients. So instead of a continuity clinic, all of us "preliminary" interns have clinic in our specialty.

I work in pre-operative clinic which I really enjoy. The pre-operative clinic sees a huge volume of patients and it is run mostly by nurse practitioners supervised by an MD. It allows us to talk to the patient about anesthesia and answer their questions as well as make an assessment of the patient's pre-operative risk. It's a really educational experience. Although at first I focused on learning which medications to continue or stop and what elements of the exam are relevant, I'm now getting a sense of what medical problems are pertinent and important, and indeed, what issues might lead us to cancel a surgery. The directors are outstanding teachers and working in this clinic gives me a better insight into what to look out for next year.

Psyche

The word psyche comes from Greek meaning soul or butterfly. In fact, the insect appears on the coat of arms of Britain's Royal College of Psychiatrists.

It has been a long time since I've seen a patient admitted for a primary psychiatric diagnosis. We were consulted on a patient in a locked unit on a 5150 for a suicide attempt. She was a young type I diabetic with chronic fatigue who threatened to kill herself. She was involuntarily held for danger to self, and as the psychiatrists made their assessment, we were asked to help with insulin management. We kept her on her home dose, and she did well for a while. Then one day, she was about to eat lunch, got her prescribed insulin, and then purposefully refused to eat anything. Furthermore, she then barricaded the door so that none of the doctors or nurses could get in. They called a code on her and when they finally got to her, her fingerstick glucose was 30 and she had passed out.

We were caught off guard with this in-hospital suicide attempt. I'd seen one successful hospital suicide attempt as a student and it was awful. We then recommended that insulin be given after she ate her meal (routinely, it is given before a meal because the kinetics make more sense). But this reminded me how a very common hospital drug - insulin - can have deadly potential whether intentional or unintentional. It also reminded me of the precautions that we must take when working with someone with serious psychiatric illnesses.

Image from Wikipedia, shown under GNU Free Documentation License.

Cystic Fibrosis

Patients with cystic fibrosis are somewhat unique. At Stanford, a special cystic fibrosis service takes care of adults with the disease, but on endocrinology, we've consulted on several of these patients. They aren't on a resident medicine service because the educational value is limited; CF exacerbations are treated with a highly specialized selection of antibiotics, patients often stay for a while, and management of the disease, although it affects every organ, is similar in every patient. Furthermore, cystic fibrosis specialists offer the patient more directed care than a general internal medicine practitioner would.

Of most of the diseases I've seen, cystic fibrosis is one in which the patient always knows more than the medical student or resident. It's strange because there are many chronic illnesses - CHF, COPD, arthritis, anemia - which patients have for years but know nothing about. But for some reason, cystic fibrosis patients know everything about their disease. They are often young, Internet-savvy, and invested in understanding their genetic condition.

The image shown above (Creative Commons Attribution License, from Wikipedia) demonstrates "clubbing" of the fingernails, a very common finding in cystic fibrosis. Sometimes, physical exam findings like this are interesting and educational; indeed, as a medical student, I followed a cystic fibrosis patient and learned quite a bit from her. But overall, after consulting on several of these patients, I think it is most appropriate that they are on a non-resident cystic fibrosis service.

Bobby Fischer: el más grande...

Disfruta del ameno e instructivo estilo de Manuel López Michelone quien, durante tres noches nos hablará sobre la vida de Bobby Fischer y comentará algunas de las partidas de este grande entre los grandes.

Con base en su nuevo libro sobre Bobby Fischer, escrito en conjunto con el MF Silvio Pla, Michelone analizará las aportaciones que hizo el genio de Brooklin al ajedrez, extrayendo lo mejor de sus más de 700 partidas oficiales.

Inscríbete. Cupo limitado

Tres sesiones los días 9, 16 y 23 de febrero, de 19:30 a 21:00 hrs.

Cooperación personal: $300.00 por las tres fechas.

Lugar: Chessboutique, sucursal CU. Delfín Madrigal Núm. 60, 1er., piso, col. Pedregal de Santo Domingo, salida metro Universidad.

Inscripciones: Chessboutique CU ó Chessboutique Santa María. Tels. 55505858 ó 55418626.

He aquí el mapa aproximado de la sede de las pláticas: