Physician, heal thyself

"Physician, heal thyself" Luke 4: 23

My professional goal is to assist the human body in healing itself. Be it through medication, lifestyle changes, surgery or other interventions, my efforts are for people to live better, healthier lives. I have spent 11 years since I graduated from High School working toward this, with at least another 4 to go. The vast majority of my waking hours are spent caring for others. It is truly one of my passions.

And yet.

We spend so little time caring four ourselves. It is our own doing. There is no question that there are not enough doctors to truly see the patients who need medical care. There is a supply/demand mismatch, and we created this. With restrictions on the number of new medical students every year, as well as restrictions on the number of residents who match, we are ensuring there will always be a significant demand for our services.

Likewise, rigorous entry requirements, significant time and financial investments also put limits on the number who apply. With a population that is growing significantly faster than the number of doctors, there will be no shortage of work for those who pursue medicine as a career.

And this job security is the very thing that hinders our own self-care.

Though time has passed, the memory of my kidney stone is still fresh. Yet even more clear is the realization that I did it to myself. See, the stone hit on my last day of three continuous months on the Trauma service. Three months of 14+ hour days, 6-7 days a week, with 1-3 30 hour shifts per week thrown in for good measure takes its toll on the body. Add to that the fact that all day long you are running: to the Trauma bay to run the traumas, to the ER to see surgery consults, to any and every floor and clinic in the hospital to see consults, dealing with and organizing transfers from smaller hospitals, to the OR. Most days, the first time I had anything to drink, let alone to eat was at 7 pm or later when I finally sat down to have some dinner.

Fact: That is not conducive to being healthy. This is only compounded by the paucity of time available to exercise. We try to fit it in when we can. Often the choice is between one more precious hour of sleep, one hour of actually seeing your family before they head off to bed, or getting in that workout. It isn't hard to guess that the workout often loses.

How do we reconcile this seeming hypocrisy?

I wish I knew. I refuse to try to justify it. I know we need to work long hours to get the work done. I recognize that medicine is a rather unforgiving career, and has a history that is much worse than its present. But that doesn't excuse the self-abuse. I told my daughter that it has probably been at least 13 years since I could honestly say I wasn't tired. Most of that has been due to my efforts to get where I am today. That isn't healthy, and it isn't sustainable.

Yet the winds of change are blowing. A new generation of us are entering the profession. A generation who believe that a well balanced physician, who cares for him/herself, who has at least a little time to nurture a family or friendships, is better equipped to really connect to his patients and care for them as human beings.

Not as diagnoses.

I could care less

In the written language, there are few phrases that irritate me more than this: "I could care less."

Why does it irritate me so? Because it makes no sense. It is often used in place of the original phrase (penned by the British) of "I couldn't care less." This statement works. It makes sense. When I say it I mean exactly that: I care so little about [insert particular comment/rant/article/person here] that I actually could not care less. That is to say, on my care-o-meter I am officially at or below zero.

So where did the illogical derivative come from? Well, leave it up to us good old Americans to take something that actually makes sense, and turn it around so that it doesn't. But this raises the question: What happened to the negative? Perhaps some sarcastic punk wanted to really emphasize his/her apathy when he/she said to his/her equally stoned mate "Dude/ette, like I could care less." Now, that makes sense. The person is, in a sarcastic manner, emphasizing that he/she is totally apathetic. Sounds like a reasonable language permutation to me.

In the ensuing years, though, this phrase was repeated again and again, by ignoramuses (my own personal bias there) until it actually came to resemble a proper use of language. Now, there are plenty of places discussing this improper use of the phrase. I link because I care. The point that some (not all) of these references clearly make is that, in the spoken language, vocal inflection can lend meaning to the phrase "I could care less." Delivery can emphasize the sarcasm the speaker may have intended.

However, the written word cannot. I have previously evangelized that all written communication on the internet should have 'sarcastic green', a vile color that is used to warn the unsuspecting reader that the offensively colored words are meant to be sarcastic. Think of the confusion this would clear up. Lamentably, this idea has not gained widespread acceptance, and we, the readers, are forced to infer (often from barely literate writers) what passes as sarcasm. In the end, failure ensues, ideas are miscommunicated and a visual diarrhea of smileys is used in an effort to smooth things over.

My personal bias (again) is simply this: Most people who write and say that they "could care less" are simply stupid. They aren't trying to be witty or sarcastic. They are ignorant, and haven't given thought to just how silly it sounds/reads when they say/write "I could care less." Perhaps I should give them the benefit of the doubt.

Unfortunately, most bloggers haven't given me a good reason to. In the end, as evidence by the fact that I wrote this article, I actually could care less.

iPod and Nike+: A Match Made in Heaven

A while ago I wrote an article I titled: iPod and Nike, a match made in marketing. It isn't a long article, but in short, I slammed the idea as nothing more than a lame gimmick to get people to buy more stuff. I even went so far as to say "I wouldn't be interested at all."

Two years later I have to say the following: Not only is it a gimmick, it is the coolest freaking gimmick in the world.

I said I didn't see new runners being motivated by this scheme. WRONG. I also said I didn't see current runners getting into it either. Again, WRONG. A friend of mine mentioned that he had picked this up and was really enjoying his first foray into the world of running. The more we talked, the more intrigued I was by the idea. There was, however, one problem: I only have a 30 gig hard drive based iPod. The system only works with the Nano (they don't want to encourage people to jostle their hard drive around and then call them when it stops working).

Wait, what I meant to say was I only had a 30 gig iPod. Being the sucker I am, I now also have a 3G black 8 gig Nano. I now also have the Nike+ sport pack. This morning I plugged it in, put on my new Nike+ shocks shoes and fired up some good tunes (a little Testament at 5 am). I told the iPod I wanted to run for 30 minutes, then hit start. Then I started running. Well, okay, jogging. Calling it running is a bit unfair to, well, running.

After five minutes a voice calmly let me know I had been going for five minutes. I pushed the select button and that same voice told me how long I had been running, how far I had gone, what my current pace was. Once it was all over it told me how far I had gone, how many calories I had burned (calculated pretty well based on your weight which you enter), and what my average pace was.

I then plugged my iPod into my computer and all that information was uploaded to my Nikeplus.com page. On my Nike+ page I now have goals. I also joined a competition for beginning runners: the first to run 50 miles. I might not win, but heck, I might. And if I don't, I have something to work towards.

Overall, I love it. Sure, I can see that it is a gimmick. But I actually see it as a very motivating gimmick.

NIN and the Future of Music

Years ago a little program revolutionized the music world. Its name was Napster.

Napster wasn't the first way to find music on the internet. Usenet and IRC had been around for years. However, both of those solutions required a bit of tech-know-how to use and were not accessible to the mainstream user. Enter Napster. A clean, easy to understand interface and instant access for millions of people (many of them college students) to begin sharing and downloading music was born.

Along came Metallica and the RIAA.

Sure, they weren't the only ones, but they became the most vocal. Lawsuits ensued, the service was shut down, the RIAA declared victory and then realized that, just like Obi-Wan Kenobi, "If you strike [it] down, [it] shall become more powerful than you can possibly imagine."

Dozens of alternatives to Napster sprung up in the wake of the ruling. Audio Galaxy, Scour Exchange, Soulseek and others filled the gaps. As these were all services with centralized servers, a new generation of peer to peer programs appeared, without centralized servers, allowing true direct peer to peer connection to download, such as Gnutella, eDonkey, and Kazaa. As the RIAA continues to kick against the pricks, new ways to find music in the internet continue to flourish.

This article has nothing to do with the legality or morality of downloading music. Let's just establish that here and now.

What I find most disconcerting is the "head in the sand" attitude that the RIAA as a whole, and many artists and labels seem to have about downloading. Digital music is not just the future of music, it is the present as well. Apple has made itself a household name based on the premise that people want to be able to have access to lots of music, all the time. This can only happen with digital music. Heck, my very nice (at the time I got it) Sony Discman has been buried in a drawer of mine for over 2 years now. And this certainly isn't because I don't love music.

The truth, as I see it, is you cannot win out against downloading. It has proliferated since the RIAA decided to crusade against it, and shows no signs of slowing down. Intelligent artists and labels should be using it to help themselves, instead of insisting it is going to lead to the ruin of music as we know it.

Sadly, very few of them are doing just that. Yet there are pioneers.

Radiohead released their album In Rainbows to the internet last October, allowing people to pick their own price. While the figures have not been widely released, there is no question that Radiohead did well with their effort. Saul Williams released his third album in digital format, allowing people to download for free or for $5. While not a rousing success, it is worth noting that nearly 30,000 people have payed the $5 to purchase the album (released in Nov 2007) as compared to the 30,000 who have purchased his previous release since 2004.

But the most overwhelming success is that of Trent Reznor. The mastermind behind Nine Inch Nails, Reznor has very publicly spoken out against the recording industry and, after his release of Year Zero in 2007, severed all ties with his label and declared his forthcoming material would be self-published and released. In the beginning of March 2008, Ghosts I-VI was released. Ghost I was available free for download to anyone who wanted. If you wanted to download the other 3 albums, all that was asked was $5. If you wanted more than that (physical media, collector's sets), there were plenty of options.

Think about that for a minute. $5 for 36 songs. Each of the downloaded tracks had unique album art embedded in the tag, was at a high quality, and was ready to be loaded into iTunes (or your digital jukebox of choice: foobar2000 for me) and loaded onto your digital device. No DRM, no need to authorize your computer to play the song (iTunes, I'm looking sternly in your direction), and no limit to the type of player you could play it on. Want to burn them to a CD? Go for it. No problem. But how did this work out for Reznor? All we have are the first week's figures: Reznor took home $1.6 million in sales and scored 781,917 total transactions.

Does this include everyone who downloaded the album? Of course not. There are probably many more who downloaded the album for free from some other source. But can anyone call that a failure? I think not. And now, two months later, Reznor has again spit in the face of the RIAA and released The Slip. Another full album, this one is free in a variety of formats that will appeal to the most casual listener or to the most hard-core audiophile (24/96 WAV format is much higher quality than you could even get on a physical CD). Again, each track has unique album art embedded in the tag, the download comes with a .pdf file of the albums booklet. Physical copies will be available in a couple of months as well. According to Trent "this one is on me."

Why do this? In the first place, NIN is in that upper echelon of bands that could pull this off. There needs to be a certain, dedicated fan base who will, out of loyalty and love for the music, support the artist. The beauty of it, though, is that now Trent Reznor has complete control over his music. He controls the quality of what is available for download on the net, he certainly gains new fans as this album is spread around and talked about (heck, I would never have said I was a NIN fan, but here I am devoting time and energy to talk about Reznor). He has no middle man sucking him dry, telling him how and what to do. He has no contractual obligations to fulfill. The music remains just that: music. It no longer becomes muddied by the turbulent waters of large record labels and pompous, self-serving executives. The connection between artist and fan becomes that much more real, that much more pure.

Trent Reznor has embraced the new medium. He is quietly revolutionizing the way music reaches the ears of the audience. Let's only hope other artists will follow his lead.

The Deconstruction of American Idol

Now in its seventh season, there is now doubt that American Idol is a powerhouse in American entertainment. Week after week, it is the most watched show on television. Millions call in to keep their favorite contestant in the show. Millions are donated to help a worthy cause. And numerous careers have been launched thanks to this little singing competition. One of the aspects that makes American Idol fun is the feeling of participation that the viewer has. We, the audience, have the power to call a phone number (as many times as we want in the 2 hour block) and do our part to support our favorites. Part of this excitement is that the show is "live", at least for those of us here on the East Coast (I've never watched it elsewhere, so I don't know how they pull it off). However, nagging the show over the years have been suggestions that it is somehow "rigged", that the results are, at the very least, manipulated by the producers through the judges and the host. As best as I can tell, though, these have never been more than vague suggestions. Rumors and whisperings. Nothing more. Until now, perhaps. Thanks to somewhat spacey judge, Paula Abdul, there have been no shortage of "Huh?" moments over the years. She has what I like to refer to as verbal diarrhea. She just sort of talks, and talks, and you hope that something coherent comes out of the mess she just spewed all over the place. Last night, though, was the most surreal moment I have witnessed. Here is the set-up: Each contestant was to sing two songs. Host RyanSeacrest made it clear they would be pressed for time and the judges were to only comment and critique after both songs had been sung. Each contestant performed their first song and, in what appeared to be a somewhat impromptu moment, Ryan has all five come out on stage and asks the judges to quickly comment on the songs so far. Randy and Simon were their normal selves. But in the middle of them we have thetrain wreck that is Paula Abdul. She first starts to comment on Jason Castro's (forgettable) first song. After a quick comment she then continues, "The second song, I felt like your usual charm wasn't...it was missing for me, it kind of left me a little empty. And the two songs made me feel like you're not fighting hard enough to get into the top four.'' What? Randy leans over and reminds her that Jason only sang one song and she acts dumbfounded. She says she thought he sang twice, then comes up with some line that she was confusing her notes with David Cook, who sang second. Only she then says that David was fantastic. Hmmm, something doesn't add up here. So, the question becomes; What was Paula talking about? As I see it, there are only two possibilities. On the one hand, she already had notes from the rehearsal and she was just going to stick to those, no matter what happened with the actual "live" performance, or on the other, she had prepared before hand the type of critique she was going to offer based on what the producers wanted to see happen. Either option seems pretty underhanded to me. The second option, well, that is nefarious enough I don't even have to discuss it further. But even the first seems wrong to me. If this is supposed to be live, and we, the American audience, are expected to judge the contestants on the live performance, what business do the judges have not doing the same? To maintain the integrity of the competition, the judges should be commenting on exactly the performance I just saw. Commentary on a previous performance, that could have been much better or much worse than the one seen on TV gives the judges an opportunity to artificially manipulate the audience. In the end, I find it quite disingenuous.

Another holiday away from home

I knew, going in to medicine, that there would be holidays that I missed, ones I just couldn't be there for. In the (not quite) 2 years I have had the initials MD after my name, this has been true on more than one occasion. Here is a brief list:

• Valentine's 2007
• My Anniversary 2006
• New Year's Eve and Day 06-07 and 07-08
• Easter 2007 and 2008

Not to mention some Memorial Days, and a few other minor holidays. However, I have been home for both Thanksgiving Days and Christmas Days the past two years. Honestly, I really can't complain. Being gone is just sort of part and parcel for the job. However, what really has impacted me is just how amazing my family has been about all of this. Today, again, my children heard their friends talking about their Easter Egg hunt, without being able to talk about their own. But they don't utter a single complaint. Birthday celebrations have had to be adjusted a day or so here and there. Other celebrations have been bumped as Daddy had to go to the hospital. But they don't seem to care. I'm sure that, at some level, they do care. I am sure it is tough at times. However, they deal with it with amazing grace and poise. They actually seem to see it as exciting that they have theirs the day after (or before, as the case may be). Most of us know (all of us should know) that there will be similar sacrifices. And our families should know this as well. But talking about it is one thing, actually starting residency and living it is another. Now, a few years in to it, I can say that, like having children, no one can tell you what it will be like. Sometimes families struggle with this. And while it hasn't always been easy on us, I am humbled to realize just how supportive my family has been through this all. They are pretty amazing.

I passed!

Please refer to the previous post to fully understand my excitement. It is sufficient to say that I passed my stone. Hooray. I just have some vague lingering discomfort in my back, but nothing like it was. Thank goodness. Carry on.

A healthy dose of empathy

The time quickly approaches. I really only have a few months left as a General Surgery resident. Then I make the transition to Urology resident. To be quite honest, I am incredibly excited. Not only am I incredibly tired of General Surgery, I look forward to focusing my time and energy on what I will be practising for the rest of my life. But yesterday I gained a whole new ability to empathize with my future patients. It was about 8:45 in the morning. I was working on writing some transfer orders for one of our patients. Getting ready to move her out of the ICU, I sat down at the desk with a pile of forms (we can't seem to do anything without forms) and started to write. Then it hit me. Pain. Pain like nothing I have ever experienced. In my right flank. It radiated down, around the side and to my left groin. Maybe that is too much information. Oh well, there it is. I couldn't sit still. Walking hurt, sitting hurt. Anything I did hurt. I knew exactly what it was. I had a kidney stone. I paged the chief resident on our service and told him I thought I had a stone. After I told him my symptoms he agreed. Time to go to the ER. About 30-40 minutes had passed and it was just getting worse. I walked down to the ER, hobbling a bit, and went to the check in desk. They gave me a funny look, here I was, in my scrubs and white coat, embroidered with "Peter J Jones MD" right there on the front. The triage nurse called my name and immediately looked at me with a quizical look. "What are you doing here?" she asked. Yeah, we know each other. See, the General Surgery resident is in the ER a lot. Seeing consults, running traumas, etc. They get to know us pretty well. "I think I have a stone," I told her. I mentioned the symptoms and she took me right to a room. I won't lie, they took really good care of me. Sort of that "care for our own" attitude. The nurse was in immediately, and IV was in my arm along with 30 mg of Toradol. They even went and got me a mobile IV pole, since I just couldn't stand to sit still. A few minutes passed, things were getting worse and I called the nurse back in. "I'm ready for the morphine," I said. He pulled the syringe out of his pocket and I had 4 mg of morphine on board. Holy crap, that is good stuff. I didn't get a buzz (I don't think you really can when you are in real pain), but I felt a lot better. All this happened before the ER doc had even seen me. Honestly, the nurses and aides were great. I gave them a urine sample, and within minutes I was on the table of the CT scanner. I walked back to my room (walking was still preferable to holding still) and grabbed a C.O.W. (computer on wheels), logged in to the medical record system, and pulled up my own CT scan. Maybe there is some HIPAA violation in there. Frankly, I didn't care. I just wanted to know if there truly was a stone or not. As I scroll down the scan, I spot one. A little 2-3 mm white kidney stone. But there was one problem. This was in the upper pole of my left kidney, no the right, where the pain was. I look over at the right side and notice that the right renal pelvis is dilated. So is the right ureter. That means there is something further down the line. I keep scrolling through the scan and sure enough, there it is. Another 2-3 mm stone in the right junction of the ureter and the bladder. Great. Well, at least I knew why I hurt so bad. At least I knew it was real. A few more doses of morphine, a prescription for ibuprofen (the 800 mg tablets) and some Percocet, and a couple of liters of IV fluid later and I was headed home. The pain continued, off and on the rest of the day and into the night. As it is right now, the pain is better, but I still haven't caught that little bugger in my strainer. I have puked a couple of times (first time since High School), and didn't really sleep at all last night. Hopefully tonight will be better. At least I don't hurt nearly as bad. Next time I have a patient with a kidney stone, now I can truly empathize with them. I suppose that is good. Right?

Christmas photo follies

As some of you should know by now, we decided to just use a picture of our little ones for our Christmas card this year. It was fast, easy and we thought they turned out well. But getting one photo that was decent enough to use, well, that was not fast or easy.

Alex would only smile for a split second, Jessica wasn't feeling well, and tried her hardest to muster a smile, but it just didn't work. And Aubrey, well, she is just Aubrey. You never quite know what you are going to get with her.

In the end, we managed to salvage one that was decent enough. Jessica still has a bit of a grimace, but she is trying.

Merry Christmas everyone!

Chuck: Our new favorite show

Years ago, I started watching Alias. My wife sat down and we were both immediately engrossed. It became our weekly show, the one we would set time aside to watch together. And if one of us couldn't be there we either taped it (in the old days), or (confession here) downloaded the episode. It was a lot of fun. We knew that, every week, we had that time set aside for a little escapism. Our enjoyment of this activity waned a bit during the third season (our least favorite), but we stuck through. After Alias went off the air, we were sort of in a void. There just wasn't anything that we both wanted to watch. My wife fell in love with Gilmore Girls, and is still enjoying catching up on past seasons on DVD. I would see the occasional episode, and while I found much of the dialog witty, it didn't really draw me. We sort of started watching Lost at the beginning of the second season. But, to be honest, it started to get a bit too weird for us. For the most part, we have not really watched too much TV together since that time. Not a huge loss, as there are better things we can do with our time. Still, we missed having a show that we sat down to watch together every week. We tried with Heroes last season, and while I enjoyed it, it was too dark for my wife's taste (and this season is too directionless and, well, just bad). Enter Chuck. I happened to catch the pilot episode and found it quite enjoyable. It managed to straddle numerous different styles. On the one hand you have an action/spy show. Similar to Alias, the main character has to hide his spy life from his friends and family. Yet the show also mixes in well the geekiness (or nerdiness) of the main character and his friends. It manages to balance humor with action nicely. To be honest, it is a very pleasant breath of fresh air. The cast is great. Each one is likable and believable (relatively) in his/her role. The interplay between the characters is handled well, not too heavy handed, but again with just enough tongue-in-cheek to keep you smiling. We have been catching up on some past episodes we missed, and are, unashamedly, big fans of this new show. The news that it was picked up for a full season (and possibly a second-it is hard to tell for sure due to the writer's strike) came as welcome news. At least thus far, they have managed to make it work well. And for the other nerds that may be watching, there are ample nerd and geek references (subtle for the most part) that keep me on my toes, watching for them. It is a lot of fun to have something that my wife and I both look forward to watching again.