Archive for the 'Uncategorized' category

The Mirror of Egelivirp

May 06 2015 Published by under Uncategorized

Click for source site

Click for source site

In one of the Harry Potter books, the protagonist (I won't say hero; I felt Hermione should have had top billing) finds a mirror. In it, he sees himself and his family. His friends do not see the same image, though. They see other things of their dreams.

Later, he finds out that he has found the Mirror of Erised, one that shows what the viewer most desires.

Desire, backwards as in a mirror, would be erised.

I believe we need a different mirror, The Mirror of Egelivirp.

(I will give you a minute to spell it out)

This mirror shows nothing like what you desire. It will show you things that you get through your privilege of birth, race, ethnicity, gender, etc.

One of my current frustrations involves explaining to white males how much they take for granted. Others in the world do not get the same respect or even the benefit of the doubt in many situations.

Being a lowly muggle, I cannot make this happen. I just hope someone at Hogwart's reads my blog. We could really use a whole bunch of these Mirrors of Egelivirp.

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The River of Knowledge

Apr 07 2015 Published by under Uncategorized

While at Experimental Biology, I wrote here about a number of presentations of interest. These studies revolved around cool animal models and very basic mechanisms of disease. None of them will result in a change in patient care in the next year (nor perhaps in the next 5 years). All of them are essential to advancing human health, because each is a drop of water in the river of science.

A river flows along, with new streams pouring into it all the time. All these bits of water run together, sometimes slowing to mix in eddies, other times tumbling over rapids and falls, producing a whole new arrangement of the molecules that make up the river. As new flows come together, the pattern of the river may change, its rate increasing. Sometimes a rockslide or a beaver provides an obstacle that stops flow, although ultimately the river will overcome a blockage.

In science, new facts and ideas constantly flow into the world, sometimes bumping into each other and mixing in unexpected ways. Sometimes a technical issue will prevent progress on an idea; at other times, a new tool will speed the flow and move the information flow forward faster.

The important part of the metaphor is that we have no idea what information will be the critical piece that solves a puzzle, just as we cannot call out a particular raindrop or snowflake as the one that overcomes the dam. If we want to make progress, we have to continue to study it all. Eventually, the critical pieces will fall into place.

That's why it's so important to study lots of different science, even if it appears to have no implications that we can use. Down the road, it may provide that critical information that revolutionizes our world. And we simply cannot know until it happens.

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One Week to Boston #ExpBio

Mar 20 2015 Published by under Uncategorized

This time next week I will be in an aircraft nearing the end of my first segment to Boston for Experimental Biology 2015 (#ExpBio is the official hashtag). I am beginning to plan my packing list, and the weather in the northeast is completely depressing.

At least the snow should be clearing...

At least the snow should be clearing...

At least the attendees will be warm, and the science will be hot!

I will once again be an official APS blogger, so expect to see lots of posts, tweets, and updates about the conference.

If you're there and you see me, say hello!


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They MOC Us

Jan 14 2015 Published by under Uncategorized

Maintenance of Certification (MOC) presents a challenge for me and others trained in my time frame. Before my class, physicians took exams after their post-graduate training and obtained life-long certification in their specialty. My class was the first to be issued time-limited certificates in Pediatrics. What has this meant over time as I have sub specialized and grown older?

A lot of money and pain. MOC has proved so tedious that The New England Journal of Medicine featured articles about the practice in its January 8 issue. One, Boarded to Death, was contributed by Paul S. Teirstein, MD, a physician whose petition to change the process has been signed by 19,000 doctors. 

Since I was in the first wave of time-limited physicians, I have a “historical” perspective on this issue. My initial exams in general pediatrics and pediatric nephrology both occurred in hotel ballrooms. Each cost about $1,000 plus time off of work and travel costs. 

General Pediatrics Recertification (Early 1990s)

In my first job I supervised residents on the inpatient pediatrics service each year. When I had to renew my certification, the process cost about $1,000 (similar to the original exam), but otherwise proved pleasing. The exam came on disks that I ran in my own computer. I had a time limit (in weeks) to complete it once I loaded it, but otherwise I could do as much research as I liked. The questions generally dealt with important clinical topics, and I received immediate feedback about the results. There were several things I learned through this process. Stuff not relevant to my life as a nephrologist had been published, and I had completely missed it! I pulled papers and looked stuff up! I learned a lot, and it was easy to fit into my life as an academic clinician-scientist starting up a lab. 

This format cost money and time, but overall I felt the process was rewarding and useful.  If they had stuck with this, I might still be certified in general pediatrics. Yup, it was that good.

First Pediatric Nephrology Recertification (2003)

By this point, the powers that be had decided that an open-source exam was not appropriate. No, we doctors needed a “high-stakes” exam. I had to find a testing center and take a supervised exam. This meant studying and taking off a day of work; lucky for us, most cities with an academic medical center will have a testing center. A few weeks after the exam, I received my score (passing!) and a summary of the question areas and my score for each category. My weakest area was transplantation; not exactly surprising, since other areas of nephrology have always interested me more.  

This format cost money and time. The proctored exam annoyed me; I could not take my jacket or purse into the exam room. Let’s face it, no doctor knows every fact that they need to know. However, the questions dealt with reasonable topics. Any competent nephrologist should be able to pass this exam.

General Pediatrics Recertification (Late 1990s)

The general exam now required a secure test center. As my new employer no longer required this certification, I opted out. I simply could not justify the cost of the exam, the cost and time off to take a review course (my only hope to pass), and the other annoyance of something not required. 

Next Pediatric Nephrology Recertification (2013)

By this time, recertification has grown into full-blown MOC. Once again, the cost was around $1,000 for a ten-year period. Requirements over that time included:

  • Maintaining valid, unrestricted state medical license (with its own requirements for continuing medical education hours)
  • Educational and quality improvement modules approved by the Board; these could also count for continuing medical education hours, but might conflict or duplicate other activities required elsewhere
  • Another exam at the testing center

 The medical license is pretty easy; if I don’t have that, being board certified is pretty useless. The educational module could be fulfilled by subscribing to a monthly Question and Answer publication sold by the Board (can you say more money). I enjoy this piece of the effort; I learn stuff. The quality improvement modules proved annoying. The ones relevant to my job duplicated efforts my employer had in place (prescription writing, hand washing, weight control). I got through the two required, but the process was generally useless. The cry about this part resulted in the Board agreeing to certify centers (more money) to produce their own modules. Finally, my exam this time included scanning with a metal detector. The questions seemed more esoteric than before, and when I got my letter, it told me I passed. No feedback on areas that might need improvement. Just a score and the cut-off.

The Future of MOC

Compared to Dr. Teirstein, my lot seems light. He is trying to maintain certification in several subspecialties. The time away from my other duties is less problematic for me, and the educational efforts supplement my other academic activities. When we arrange things so institutional quality projects can count for MOC, that part will also be less problematic.

The point many physicians have made regards the secure exam. Physicians simply do not have to remember information the way they once did. I can pull up drug information and other references on my smart phone in the exam room. If I did need to know which interleukin was secreted by a lymphocyte expressing certain markers (an actual question from my last exam; clinically relevant my ass), I can have the answer in about a minute. I am sure the person who wrote that one (a) studies the immune system and (b) considers it relevant, but I still do not know the answer. No one has yet died from this knowledge gap.

In addition to MOC, our institutions have placed further training burdens on physicians. Time here and there, even at no formal cost, adds up. I especially love reviewing fire safety on an annual basis. RACE never changes, you know.

Some form of ongoing education and certification requirements seem reasonable. I have seen some doctors who have not kept up, and it did affect patient care. However, the current system seems as much about income for the Board as it is about quality of care. We have to be able to make it less of a burden, or physicians will just go without it. And then it serves no purpose.

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Meaningless Use

Jan 12 2015 Published by under Uncategorized

Unfortunately, I have a prior engagement that prevents my participation in a TEDMED Hangout tomorrow. The topic is important: why do we not discuss socioeconomic and other social factors routinely when we know that these items influence health? As the website states:

We’ve all experienced a doctor visit. The physician measures your blood pressure, pulse, breathing, and temperature. They may ask about personal or family history of specific diseases or even inquire about eating or exercise habits. Rarely, however, do they ask about your income or education, access to healthy foods, the safety of your home, or the stability of your personal life. And yet, we know that 40 percent of one’s health is shaped by socioeconomic factors, and only 20 percent by clinical care.

The site implies that these factors could be another vital sign. I would not put them in that category (just as I would not have made pain a vital sign), but I do agree that we don’t think about these things enough. After all, how can my patients follow my advice when

  • The neighborhood may not be safe for outdoor activity that would help the child with weight control
  • The family can only get to a convenience store; if they pay for transportation to a grocer, they have no food money
  • The parent and patient cannot understand the instructions, even after discussion in clinic and reading the written stuff the electronic medical record prints out (meaningful use can be so meaningless)
  • The parent moves the family frequently because of an abusive ex, making support services difficult to maintain

As physicians, our training allows only the most superficial assessment of these issues. We need specialists in these social issues, people known as social workers! However, in the current reimbursement climate, these services often get cut. 

In a time when economic pressures force us to see patients in less and less time, we need to recognize the need for multidisciplinary more than ever. I hope that events like this one can get the conversation going. I also hope that the role of crushing poverty in bad health gets more attention.

One way or another, we all end up paying for these inequalities. 


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End of Vacation

Jan 07 2015 Published by under Uncategorized

Vacation officially ended on January 5, when our son drove back to the tundra and I went back to the office. The patient call backlog did not overwhelm me, and I feel pretty good about the job right now. 

My blogging spirit has not yet caught up with that “put your nose back on the grindstone” mood yet. I have found a couple of nephrology topics that I am reading about for the future. 

For now, I will wish everyone a prosperous new year. 

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Another New Year

Dec 31 2014 Published by under Uncategorized

2015 is almost upon us. I am still enjoying time with my son who is home from college. I am also beginning to work with my daughter to plan her upcoming wedding (FINALLY!!!!!).

Hope your New Year is happy and your resolutions attainable! Last year, I set out to finish my book. AND I DID IT!

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Travel Time: #AAMC14 and #KidneyWk14

Nov 04 2014 Published by under Uncategorized

It's that special time of year when two meetings overlap. This year, I get to come home for a bit and repack.

JetI head for Chicago this Thursday for the gathering of the Association of American Medical Colleges (#AAMC14). I fly back to OKC the following Tuesday, and then head to Philadelphia on Wednesday for Kidney Week, the annual meeting of the American Society of Nephrology (#KidneyWk14). I have a spread sheet going to make sure there is no critical wardrobe overlap. When I get home from meeting one, I want only to wash my underwear and then re-pack.

#AAMC14 includes a lot of people interested in career promotion in academic medicine. You may have heard about my book, The Promotion Game (if you haven't, then I have failed). I will be giving away some hard copies at that meeting. You can also win a free copy by signing up for email updates on the web site.

#KidneyWk14 will be a bit sad for me this year. It will mark the end of my editorship of ASN Kidney News. I have loved my 6 years as a magazine editor. Hell, it's that experience that got me involved in social media and blogging! You probably wouldn't be reading this now if I had not had that opportunity. It's time to move on and find new experiences. Who knows where I will go next?

I will likely post about events and presentation from these meetings over the next 11 days. Stay tuned!

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Big Surprise Coming

Sep 24 2014 Published by under Uncategorized

In the next couple of weeks I have a big surprise coming. It will explain my relative lack of posts lately.

In the meantime, I have to go to a wedding and take care of my patients.

Try to pee without me...

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What I Am Reading: Dystopian Future

Aug 21 2014 Published by under Uncategorized, What I'm Reading

CircleRemember reading 1984 in high school? Big Brother is watching you so you must conform to society's standards! The Circle tells the story of the genesis of an internet-age totalitarian society much like the one Orwell created.

I doubt that this one will make the jump to "literature that should be taught, but I might be wrong.

What is The Circle? Imagine that Google, Facebook, Twitter, Paypal, and every other major internet service were mashed up into one giant corporation. This company controls an online identity system that keeps people from participating anonymously or pseudonymously online. This led to complete internet civility (of course!). It also allowed more secure payment systems, even leading some to suggest that all cash be eliminated for Circle-based payments. Employees at the company propose new uses of The Circle to make life more pleasant and secure all the time. The one thing no one seems to do at The Circle is code or actually do computer stuff. Hmmmm.

The story focuses on Mae Holland, a new employee at The Circle. Through a friend who is in The Circle's inner circle, she secures an entry-level customer experience job that allows her to escape a mind-numbing position at a local utility company. The Circle resides on a California campus with all the bells and whistles we expect from an internet company: game rooms, free cafeterias, gardens, sports fields, the works. In addition, their seems to be multiple social events for employees every evening, some of which are mandatory. The campus also boasts beautiful dorms where employees can stay and give up life outside The Circle all together.

May starts out treating her employment like a job. As time goes on, she discovers that she is expected to participate in The Circle's ongoing social media (internal and external) as well as "extracurricular" activities or she will be viewed as "antisocial" and "not part of The Circle." May succeeds, and rises in her department, eventually resulting in 6 or 7 separate screens on her desk for various components of her work. Eventually, events occur that prod May to become "transparent." This means wearing a live web cam at all times so her life while awake becomes an open book. Nothing can be deleted from her video feed (even when she catches her parents having sex).

The leaders are intent on "Closing the Circle" which should make May ask some very critical questions. However, despite the obvious impending loss of freedom (and the reader screaming at her on the page), May seems disinclined to see anything but the rosy picture her supervisors paint. Even when someone brazenly spells it out for her, she fails to see the danger of the situation.

The use of tiles at the company echos parts of 1984. Instead of "Big Brother is Watching," we have "Secrets are Lies" and "Privacy is Theft."

We often look at totalitarian states and wonder how the regular people let this obviously bad government happen. This book tries to explain that, and does a reasonable job. I wish there had been a few more examples of resistance, other than an ex-boyfriend who I found generally unappealing. If anyone else has read this book, I would love to hear your thoughts in the comments.

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