Another Problem for Puerto Rico

(by whizbang) Jul 01 2015

My recent meeting included a session with the Deans of Puerto Rico's four medical colleges. As we discussed diversity and inclusion, they presented an unexpected issue. Because Puerto Rico is a US territory, its medical schools are accredited by the same groups as those on the mainland. Their students must take the MCAT, National Boards, and Specialty Boards that mainland students do.

These exams are only offered in English.

That means only truly bilingual students can hope to get into medical school and eventually qualify to practice. For the urban population and wealthier people, this is not a huge problem. For the bulk of the island, that level of English fluency is difficult. Medical school thus becomes primarily an upper-class option, perhaps even more so than on the mainland United States.

Then, if you have that sort of fluency, training on the continent provides more options than the island. Once you move to train, it becomes tempting to stay, leading to major brain drain for Puerto Rico.

My school's problems seem less weighty now.


By the way, San Juan is a lovely city. You can visit the Caribbean without a passport. All of your appliances, including your cell phone, will work. OK, some Verizon customers had issues with voice calls, but my AT&T phone worked just fine. No plug adapters required. There's history, tropical beauty, and the ocean. You will eat more rice, beans, and plantains that you imagined possible, but the food is delicious. So is the rum.

So go; you can thank me later.



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What I Am Reading: #GDIGFA Edition

(by whizbang) Jun 26 2015

One of the plenary sessions at this meeting demonstrated the utility of Whole Brain(R) thinking.

Now, I assumed that I tried to use my whole brain most of the time, so I got the book, The Whole Brain Business Book, and read it en route to Puerto Rico. This model overlaps with a lot of other approaches to how we humans perceive the world, but it can provide a useful new frame for the problem.



Four aspects of human pattern preference occupy each quadrant of the diagram. The upper left thrives on logic and facts. The bottom left craves order and process. The lower right focuses on the human-emotional facet of things. The upper right is creative and big-picture. Many, if not most, people have a dominant quadrant. This doesn’t mean that we cannot appreciate the other perspectives; they just come less easily to us.

Many people have more than one quadrant that is relatively strong. The two upper quadrants are often found in inventors, scientists, and other creative yet data-driven types. The bottom half of the diagram, with its order and emotion, often finds professions like nursing supervisors. Those who favor the left side rely on facts, logic,and order, while those on the right tend to be idealistic.

As I read this book, I thought about the pharma booths I saw at recent clinical meetings. Ad agencies certainly know how to pull all of these perspectives into the show. Each booth featured big images, most often people living good lives with their disease (because of this drug, naturally). If not a patient image, some other emotionally charged picture appeared; fish out of water seem to be favored by pulmonary products. A tag line also dominates the big stuff, often with a message appealing to those D (upper right) quadrant folks: “Imagine a world without disease X.” Less prominent, but still big enough to catch the eye, are diagrams and graphs showing study results about the drug to start pulling in the left side of the diagram; after all, you have to get them close enough to take the reprints and package inserts that have the details they need to change their practice!

Like all models, this one cannot solve every problem of interpersonal communications. It explains a lot, if you let it. And Ann Herrmann-Nehdi put on a rollicking work-shop this morning where we all learned a lot.


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(by whizbang) Jun 19 2015

logo-aamc.gif-dataI have finally dug into the latest AAMC dataset on the status of women in academic medicine. The website AWEnow (Academic Women for Equality Now) will be featuring these updates over the coming weeks. Today I posted the overall scores for the nation.

Good news: The overall share of women in leadership has increased over 4 years (3 datasets).

Bad news: At this rate, I will be 94 when women hold half the leadership positions in academical centers.

Go see my pretty graph here!

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How To Fix Youth Hydration

(by whizbang) Jun 12 2015

This week a story about inadequate hydration in US youth has gotten a fair amount of press. As a pediatric kidney doctor, I end up seeing these kids in my clinic, most often for stones. Getting these kids to drink enough liquid to keep calcium from getting together with other stuff to form crystals and rocks is tough. The biggest barriers come from the schools!

The first problem is lack of access to fluid. There are water fountains in the halls, but kids often do not like to drink from them. Also, a mouthful of water every hour or two is far less than most of these children need. We have a stock letter we send to schools allowing our patients to carry water bottles to class.

ToiletLoveThe next issue involves bathrooms. Carmines' law of physiology states, "You drink, you pee, you don't, you die." Our stock school note also asks schools to let our patients use the bathroom when they need to go. Too many schools have really short transition times between classes that do not give students time to use the restroom. Teachers can also be reluctant to allow their pupils to wander about the school unsupervised, even when pursuing a noble activity like urination.

My final issue also involves bathrooms. Too many students tell me that they do not want to go to the bathroom at school. They are often dirty, unpleasant, and sometimes unsafe. If we want our kids to drink enough fluid, then we need facilities where they can "recycle" that liquid. These facilities should be ones we would use ourselves, and not just in an emergency situation.

We evolved on the savannah where access to liquid was often unpredictable, so our kidneys can conserve water well, without immediate damage. Long-term effects of concentrating urine may occur, but kidney stones are a clear, early result. This is more than a matter of telling our offspring to drink more. It's a matter of making them able and willing to pee more.

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Getting Loud and Angry

(by whizbang) Jun 10 2015

I remember when Acquired Immune Deficiency Syndrome (AIDS) first appeared as a case report in the 1970s. This mysterious illness shared epidemiological features with hepatitis B and some other disorders that made a virus the likely culprit. Eventually we discovered HIV and a number of drugs that have turned this former death sentence into a chronic manageable disease. Magic Johnson has been living with HIV for almost 25 years now! The cure is still out of reach, but what progress in 37 years, from “we have a syndrome” to a chronic disease.

How did this happen? We threw a ton of money at AIDS/HIV. Why did we designate so much funding to a disease that the mainstream had little to fear? At risk and affected people knew how to make some noise. Organizations like ACT UP lobbied and protested. Entertainers and politicians showed support with red ribbons.

Funds at the NIH got earmarked. Not all of that money led straight to scientific advances, but with that much moola driving things, things got done. It was almost like the space-shot of the 1980s.

Once upon a time, kidney disease had vocal advocates. When dialysis first became a practical treatment, it was performed on the floor of congress to get kidney failure treatment covered by the newly formed Medicare program.

Unfortunately, since those early days of yore, the focus for kidney disease has been on reducing costs, not improving treatments. Sure, we have incremental changes in equipment for dialysis and new ways to prevent transplant rejection, but really novel stuff? Not exactly.

We also have contracting funding for kidney disease research, Partly this is because chronic kidney disease disproportionately affects the poor, minorities, and other disenfranchised people. Even high profile patients like Alonzo Mourning and Sarah Hyland have failed to motivate congress.

We need more visibility for kidney disease. We need loud and even angry patients demanding research funding so that we can have cures. Dialysis works fairly well, but we can make it better with more research. Transplant is even better, but it is not a cure. We also do not have enough kidneys for every patient, and there are some diseases that repeatedly attack the new kidney, making dialysis the only option. While Medicare covers dialysis for most patients, it may not allow the optimal prescription for everyone. It also cuts off transplant immunosuppression coverage after a couple of years, making patients choose between their medications and other expenses.

In other words, despite our progress, we do not have kidney disease figured out by a long shot. Our patients, friends, and loved ones deserve better. We need to demand it, loudly and, perhaps, with some anger.

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A Doctor Deals: Thoughts from #2015ADA

(by whizbang) Jun 08 2015

Boston revere 220x175

As usual for this time of year, I am at the annual scientific sessions of the American Diabetes Association. For four days I have been hobnobbing with others interested in diabetic nephropathy, learning about new stuff, and hanging out with my spouse in Boston.

This year brought a new perspective. I am now living with diabetes myself.

The diagnosis provided no big surprise. My fasting glucose levels had been “impaired” for about 10 years, a clear indicator that this could happen. I would start a diet, compulsively recording every bite and calorie I ate. This resulted in a few pounds coming off, but as soon as I failed to track food, it came right back. I had generally resigned myself to plus sizes for the rest of my life.

A few months back I established care with a new doctor. Basic lab work showed a somewhat higher glucose than before. Oops. I got back on the wagon to try and fix that by my next labs. I had some additional motivation as well. My daughter got engaged at Christmas, and I really wanted to drop some tonnage before taking family photos. I thought I would get it all fixed.

Unfortunately, I failed. Or at least my pancreas did. My HbA1c, a measure of the amount of hemoglobin with glucose glommed onto it, was 6.8%. Anything above 6.5% means you have diabetes.

Knowing stuff like this does not help

Knowing stuff like this does not help

My brain spent a few minutes in denial. Perhaps if I got more aggressive and lost some more weight, this would go away…? Luckily, I had put on my big girl panties and dealt with it by the time the doctor came in to discuss my next steps.

So this was my first year attending the diabetes meetings as a doctor, a scientist, and a patient living with the disease. In the near future I will write more about dealing with diabetes. It's especially sobering when you know stuff about your pathology...


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Our Private Wild Kingdom

(by whizbang) Jun 01 2015

Nature and science are everywhere, even in a civilized front yard. In addition to the usual insects and lizards, my spouse encountered a shy copperhead and a small turtle while spreading mulch around our front shrubs yesterday. His scariest encounter was with a mallard hen. We saw her walking around the yard earlier, but as he moved toward the front door she flew out of the bushes at him.

We soon learned why:


This lucky duck feathered her nest of ten eggs right outside our dining room window, a mere 5 feet from our front entry. When she sits on the nest, she is really difficult to see. I thought the duck and eggs were gone this morning!

We will keep an eye on progress and update when things happen!

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For Dottie (And Me)

(by whizbang) May 30 2015

Microbiome research makes headlines often, especially when folks start talking about "fecal transplants" (yup, eating shit). There's a whole microscopic world living in our guts that influences all sorts of things about us. We have only just begun to explore this fascinating area of research.

Now a group is raising money to document the feline microbiome, a Kickstarter project dubbed the Kittybiome. For various amounts of money you can sponsor study of a shelter cat, your own cat, or even other goodies. My friend Michelle Banks, an artist who specializes in science-inspired designs, is creating a Kittybiome scarf. Given the lovely silk items I have previously purchased from her site, I decided to kick in enough to study a shelter cat and buy the scarf.

Dottie Hinson Lane

Dottie Hinson Lane

Why am I doing this (besides my need desire for another scarf)? The little lady in the photo is my inspiration. Dottie Hinson Lane, named for the Geena Davis character in A League of Their Own, has suffered from a diarrheal illness this year. Cat diarrhea is at least as annoying as diarrhea in your offspring. The more we learn about the cat gut, the better as far as I am concerned.

We have Dottie's symptoms controlled at the moment. I still want us to learn more about what goes on in those feline guts.

You should consider supporting this project as well; if nothing else, you can score a cool scarf!

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My Week In Review

(by whizbang) May 29 2015

I have been treating inpatients this week and dealing with a particularly annoying virus that someone gave me last week. I am exhausted and sore from coughing.

Neither of these stopped the calendar. I still gave Grand Rounds on Wednesday, discussing the past and current recommendations for screening urinalysis in children in the US. I have my presentation on SlideShare, and I'm embedding it below. Enjoy the flow!

Have a good weekend. I look forward to thinking about something besides my own mucus next week!

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Better Late Than Never: Book Review

(by whizbang) May 15 2015

I reviewed Connection: Hollywood Storytelling Meets Critical Thinking by Randy Olson, Dorie Barton, and Brian Palermo (Prairie Starfish Productions, Los Angeles, 2013) a while back for a newsletter. As the newsletter changed, this review got bumped out several times and seems less relevant right now. However, I still like it! Using the structures recommended for communications in the book to summarize its messages really brought home to me the utility of the methods.

CoverRandy Olson definitely marches to the beat of a different drummer. After becoming a tenured professor, he left for film school at the University of Southern California. What could lead someone to follow this path? He became distressed at the inability of scientists and others who know facts to communicate those to the public, particularly in the area of climate science and evolution. He made some films and wrote his first book, Don’t Be Such a Scientist: Talking Substance in an Age of Style (Island Press 2009) to try and give logical, fact-listing academics some guidance. His ongoing quest to improve our communication skills led to collaboration with others involved with film work, producing this 2013 book.

This volume provides a frame work for storytelling. Think about the last movie trailer you saw. With a short bit of image and words the makers had to tell you about the movie and make you want to see it. If they can learn to boil a two-hour film into a 1 minute trailer packing a punch that makes you want to pay to go to the theater, then we can use these techniques to sell our information to patients and others.

The first component of the framework is a word. What is your message in a single word? This sounds easy, but I found this the trickiest part of the technique. I actually did this part of the exercise last. For an example, I used this structure to review this book. The obvious words include communication, connection, and story. After crafting the rest of the framework, I picked influence. The real goal here goes beyond merely transmitting information; we want to drive people to action, be it changing their health habits or accepting the reality of evolution. Others may pick a somewhat different word, but I stand by my choice.

The second component requires creating a sentence, using the construct “and, but, and therefore (ABT).” For Connection, I created this:

Scientists know a lot of facts that can help people and they need to educate the public, but they often have trouble getting their message understood, accepted, and remembered; therefore, they need to read this book to turn facts and figures into stories that compel behavior changes.

Finally, a more detailed paragraph can be constructed using a logline technique. All story narratives can be boiled down to 9 steps:

  1. In an ordinary world
  2. A flawed hero gets life upended when
  3. A catalytic even happens
  4. After taking stock
  5. The hero commits to action
  6. The stakes get raised
  7. The hero must learn the lesson
  8. To stop the antagonist
  9. So the hero can achieve their goal

Dorie Barton deconstructs Star Wars using this technique. You can fit any story into this structure, even documentaries. I have summarized Randy Olson’s biography using this technique:

A scientist wonders why students accept things they see in movies as reality, even when shown evidence that these things are wrong in the real world. He gets his life upended when he heads to film school to figure out why movies have more impact than scientific fact. After some course work, he realizes that humans are hard-wired for stories, especially those with emotional impact. He begins making films with classic narrative structure. Soon he realizes that all academics need these skills, and all of them cannot go to film school. Alone he cannot give them the skills they need to get their messages heard and remembered. In order to spread the word, he teams up with others who do script writing and acting. They start workshops to teach these storytelling skills. Then they write a book so more scholars learn to get their message out there the right way, the way that will influence people.

In addition to these models (Word-Sentence-Paragraph; And-But-Therefore; and the Logline), the live workshops put on by the group feature some improvisation exercises and actual storytelling. Brian Palermo acts and performs stand-up comedy; he gets to be “the fun instructor” in this group. I would love to participate in one of these live events, but for now I have settled for the book and the apps. Oh, yes, there are apps for Android and iOS devices that let you fill out these templates and then email your results. This work gave me a great starting draft for the material above.

Humans are wired for stories. We remember the narrative events and the emotional reactions to them far more readily than a series of facts. These techniques may help us have more impact in clinics and classrooms if we adapt them.

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