Register at the AMSA National Conference or by contacting our chiefs “Harbor FM Chiefs” <harborfmchiefs@gmail.com>,

Saturday, March 13, 10:30 am – 1:30 pm
Off-site
Environmental Justice on the Streets: A Tour of South Central Los Angeles

Join a limited number of fellow attendees for a Saturday morning tour of south central Los Angeles with residents and local community organizers from the Harbor UCLA Family Practice program.  Hear how environment, community, and health are intricately interwoven.  Learn best practices about street medicine and health justice!  The tour will take participants to visit Harbor hospital’s catchment area, the poorest and most underserved sections of Los Angeles.

Note: Space is limited.  Advance registration required

From knee-high pink stockings and spandex to Michael Jackson’s famous white glove, the atmosphere was vibrant and ebullient at the massive downtown Kansas City Convention Center. Add to the mix The Spazmatics, an 80’s cover band, and what you’ve got is one serious tribute to all things 80’s. Welcome to the first day of the 2009 AAFP National Conference for Residents and Students! What could’ve been mistaken as an 80’s convention filled with fanatic Breakfast Club devotees was instead the orientation/registration day to our annual conference. As Los Angeles natives, we, of course, dressed the part, and donned white gloves and sunglasses of our own. The outfit was low-budget, extremely easy to put together, and very well received – a testament to our collective creative stretch unbound by our limited means.

Students who made the trek to Kansas City caught a glimpse of a day in the life of a family medicine resident. Roughly 1,600 of this country’s finest primary care supporters were on hand to inaugurate this year’s recruiting season and to whet the appetite of prospective family physicians. They got to hear all about what would be in store for our specialty in the future.

Here’s the breakdown: approximately 700 medical students and 850 residents were registered participants. More than 300 residency programs were represented in the Exhibition Hall where colorful poster displays lined the aisles sectioned by state.

Booth 628, which belonged to our residency, Harbor UCLA Family Medicine, was located across from an email station in the heart of California row and boasted a tall, seamless blue and yellow cornucopia of goodness – information about different programs, services, fellowships, and unique curriculum that we had to offer. The traffic through our booth was almost as busy as the traffic back home in Los Angeles. Tons of eager students, mostly 2^nd to 4^th years, and even current residents and faculty members, strolled by to see and hear what all the buzz was about.

It was exhilarating to see the prospective candidates so animated, yet so technical and calculating in terms of the questions they brought forth. Yes, it was really an interview for us to see if we fit their bill. Regardless, I was extremely delighted to be surrounded by future family physicians. Our well-represented contingent consisted of my fellow residents – Dr. Evelyn Akinsanmi (R3) & Dr. Tipu Khan (R2), the chief residents – Dr. Dawn Mautner (R4) & Dr. Munish Bakshi (R4), an attending – Dr. Suganya Karuppana (who, by the way, scored a Spazmatics T-shirt and is probably their biggest fan now), and our very own Residency Program Director – Dr. Daniel Castro.

Dr. Castro, who participated in a panel of educators and spoke at a session entitled, “Applying to Residency: From Application to Interview,” was a great example and representative of our program. It’s tough not to pick up on Dr. Castro’s passion for helping the underserved. And after hearing the dynamic speaker, students were all abuzz looking to converse with the Big Kahuna.

But he’s not the only one who is passionate about such a cause. That’s exactly what we’re all about. Our mission is to help the underprivileged and be a patient advocate – working to empower the communities in need. We are the creatively maladjusted individuals who make-do with the limited resources and the non-existent, yet hopefully soon-to-be public option, that Los Angeles County alone offers to those without resources. That’s what makes our residency so unique.

So, if you’re interested in joining our program, well, we say HURRY UP and APPLY!!! The revolution is here and with reform just a step away, it couldn’t be a more exciting time to become a Harbor UCLA Family Medicine resident. For more information, please contact our chief residents at harborfmchiefs@gmail.com or contact our program coordinator Mari Morse at harborfp@aol.com or call 310-534-6221. Happy Hunting and we hope you’ll consider us as a destination on your interview trail!

Los Angeles Burrito Project started when a few friends in the bike community decided to do something to change the world: hand out free burritos to homeless folks in downtown. After toasting tortillas on gas stove, I toss warmed flour shells to my friends. They scoop rice, beans, and salsa to form delicious burritos. These beauties would sell for $5 a pop, neatly wrapped in aluminum foil rolls. We layer them into our bike messenger bags by the dozens alongside water bottles.

Four teams of riders head out to distribute water and burritos. “Buurrrrritos! Aaaaguaa! Waaateer!” our calls echo in the glowing night vacant roads. From tents, plastic lined cardboard boxes, lifting baseball hats off eyes, hundreds emerge hungry, thirsty. “Oh its Wednesday again?” people ask unwrapping dinner. The Burrito Project hasn’t missed a Wednesday night distribution since January 2006.

“The Burrito Project has changed the way we all interact,” my bike messenger friend informs me. “We used to be hassled riding through these streets. I used to not acknowledge homeless folks and just ride right past.  Now we have a different relationship. I wish I didn’t have to see the same people living in these conditions weeks after weeks. Since we started handing out Burritos the streets have changed for the better for all of us.”

Working in a county hospital in South Los Angeles, I doctor on the frontlines of poverty, homelessness, drug abuse, and mental health. Patient by patient, one by one, disease by disease, we are the healers of last resort. Our emergency room always in “surge capacity,” the special designation occurs when a hundred of patients wait in boredom and desperation for medical attention. My patients on Thursday could easily be some of the same people I handed a burrito on Wednsday. Its not enough.

From the hospital, I bike north on Vermont Avenue twenty miles to reach my house in Koreatown. This terrain stretches forth miles and miles of medically underserved neighborhoods. If I weren’t a doctor, I would be a bike mechanic, I think to myself. I live a fantasy-alternative life, pondering who I would be if I didn’t decide to be a doctor. What would I be doing right now, at 3 AM if I weren’t an intern? I’d be sleeping at home, my hipster bikes hanging from the ceiling. Some people think I’m crazy for biking. In Los Angeles. Twenty miles.  After working 30 hours. Biking links my alternate identity to my reality. The Burrito Project affirms both.

My friend Emily Ramsey brought me to my first night with Burrito Project. She’s a rad nurse at UCLA and board member of the Bike Kitchen a nonprofit in Koreatown dedicated to teaching youth how to fix bikes. We find ourselves talking equal parts bike geek and medical geek. “What would it take for us to put together a mobile clinic on bikes?” I ask her,”What would our top 10 medications be?” I vote antibiotics for wound infections. Emily believes some sort of pain medication.

Later, I accost one of my co-residents in Family Medicine in the elevator. She used to be a one-woman walking free clinic. “Lets see, you should carry meds for hypertension, infection, pain, diabetes…” The Burrito Project is an all volunteer run project, funded by passing around a can before our ride. You are welcome to ride with me Wednesday, I’ll be there unless I’m on call. We’re half serious about the new and improved Burrito with side serving of Primary Health Care Project.

Neither our emergency room, nor our Burritos will cure our community. But until we decide to invest comprehensively in our city’s health, both will have to make do.

———

Rebecca is an intern at Harbor UCLA Family Medicine who believes that our burritos & our bikes are our bombs. She is a proud single mom to Zev age 10 who is too smart for his own good. Reach her at revolution.is.medicine@gmail.com

Given our commitment to vulnerable and underserved populations, it was no surprise to see Harbor Family Med residents and faculty making public our mandate for health reform. A seething, volatile crowd of thousands listened intently to the panel where Rep. Adam Schiff and others discussed options for reworking our broken health care system. Rowdy opponents of reform were met and even superseded by health care reform advocates, as we joined those supporting reform.

When we walked toward the crowd in our white coats, heads snapped around to watch us approach. We were greeted by people we didn’t know, over and over again: “We’re so glad you are here,” and “thank you for coming.” Interviewers with entourages turned their news cameras on us, asking what was important about health reform and how we would respond to the accusations of socialism perpetrated by those fearful of change. One woman touched my sleeve and said, “Doctor, what’s the right answer?”

People often don’t trust politicians. Who do they trust?

They trust their doctors.

This moment in history is our time, our opportunity and our responsibility to use the unique power of our perspective and education on behalf of our patients.

See you at the next Town Hall Meeting.

Dawn Mautner, MD
Chief Resident
Harbor-UCLA Family Medicine

The former seems blatantly lacking the story quoted below.

Every neophyte is owed the opportunity to be taught so long as the teacher recognizes her imperative to teach. Especially in a hospital in July.

New Docs on the Block

According to medical lore, July is the worst time to be hospitalized because that’s when inexperienced med students start clinical training. But is summer really riskier for patients?

A month into Sandeep Jauhar’s medical internship at a prominent teaching hospital in New York City, he was asked to drain fluid from the belly of a patient who was HIV-positive. “I was trying to get out of the hospital to keep a dinner appointment,” he recalls. “I was sort of rushing. I heard a snap and there was all this fluid leaking all over the floor.” Jauher’s gloves were too small, he hadn’t assembled the tubes for the blood correctly, he was new, he was inexperienced and nobody was watching. “[The patient] was totally oblivious to the disaster, but it was a mess,” he says. “These are the mistakes that new, green interns can make.”

According to conventional wisdom, a patient’s chances of encountering a mistake-prone rookie like Jauhar go way up in the summer. That’s because July 1 is the start of the academic year for medical schools: In teaching hospitals around the country, medical students will replace interns, interns will replace residents and residents will move on to fellowships or to become full doctors.

This crucial and sometimes perilous training period can be incredibly difficult for medical students. As Jauhar writes in his recent book, “Intern, A Doctor’s Initiation,” incoming doctors are not only practicing on patients for the first time, they’re also learning the often Byzantine workings of their respective hospitals, new technical language, new procedures and the tedious, yet critical, ways to fill out paperwork. All this learning is packed into 80-hour workweeks and overnight shifts in a busy hospital environment—a far cry from the academic environment they might be coming from. But is it really riskier to go into a teaching hospital during those first few weeks of intern training? Or is the “July phenomenon” a medical myth?

Finish reading at New Docs on the Block

~casey

The Summer Project has different components:

• Mentorship at all levels
• Health Fairs within the Wilmington Community
• Public Health & Poverty Medicine Lectures
• Research Project on Children of Wilmington Access to Healthcare
• Teen Peer Health Education
• Clinical Experience
• Community Health Talks

The students involved were extremely motivated to get things going. The undergrads and med students were an amazing group. Each had great strengths – to many to list – but the most impressive was how quickly they bonded with the high school students and placed these teens in critical roles in the Summer Project. It’s amazing what can happen without trying to force things, especially when people care to make a difference in others’ lives.

The Residents at first were on the outside looking in. We joined the group late because of our scheduled rotations. I remember talking to the residents and wonder what our role would be – the students had everything covered. Lucky for us, we had a new idea to introduce to the group. We created and modified various lectures to teach A Teen Peer Health Education class for the high school students. The goal for the Peer Health was to educate them in health, cultural, and social issues that affect their daily lives while providing them the confidence to teach the information to fellow teens. What made these lectures unique was we moved away from the standard lecture style format incorporated fun, interactive, and confidential exercises. The various topics covered were: Sex, Sexuality, Reproduction, STIs, HIV/AIDS, Cultural Awareness, and LGBT Issues. We also took field trips to watch Michael Moore’s Movie, Sicko and the Japanese-American Museum.

As the Summer Project continued we successfully had 2 Health Fairs in the underserved community of Wilmington, CA. The entire planning and execution of the fair was done by the students, while Residents and Attending assisted when needed. Over 500 people participated in health screenings such as Diabetes, HTN, Depression, Substance Abuse; some received mammograms, echocardiograms, and dental care. In addition, the program focused on door to door interviews for a research project looking at Children’s Access to Healthcare, Asthma and Obesity. These interviews were primarily conducted by the students in Spanish. The data analysis are ongoing but we are sure that the asthma rates in the Wilmington, CA 1.5-2.0 times the Los Angeles County rate – not surprising to some given the Port of Los Angeles resides in Wilmington.

The entire Summer Project culminated in a Health Summit held at the Banning High School Auditorium. The Summit gave the students the opportunity to analyze and present the various findings and activities of the Summer Project. Given its importance, the information presented at the Summit was broadcasted locally on various television networks (ABC, Univision, & KTLA) and written about in local newspapers. One of the proudest moments was watching several high school students be interviewed by local television reporters in regards to why Healthcare is a right for all individuals and express what they gained from participating in the Summer Project.

It may not be everyday that we see a small group of individuals make a difference but the Summer of 2007 sure did remind me that it is still possible if you try.

Lesson #1 – Hold it like a football

It was my very first night on call at Cal OB. As expected the OB triage was booming as well as the contractions on the L/D deck. The two of us, interns were doing our usual monitoring of laboring patients. I had spoken to my senior resident and mentioned that I officially never delivered a baby. He was very supported, taught me the techniques and mentioned he would be there to help. As the night went on, things became busier. I had just finished my hourly check on my patient and suddenly heard, “IS THERE A DOCTOR ON THE FLOOR!” Of course I hesitated but then realized I was the ONLY ONE. “Quick, this lady is crowning and the baby is about to fall out,” the nurse said. As I race into the room I had a few seconds to gown up and put gloves on. I frantically asked the staff to call in my Senior – he was to assist me with my first delivery. Unfortunately, someone forgot to tell the baby to wait. As the baby was going through its cardinal motions, I felt every emotion you can imagine – scared was the most dominant. Luckily, I saw to gloved hands enter the field. It was my Senior! As I looked over at him and back at the baby he leaned in to utter those famous two sentences…“Have you ever played football? Then hold it like one and don’t drop it.” The following words after that were…“you fumble it, we are dead.” Needless to say I maintained a good handle of the baby/football. I congratulated mom, grandma, and dad. Grandma mentioned it was her daughter’s first child and with all that emotion running through me, I uttered, “It was my first time too.” Grandma replied, “I noticed.”

Lesson #2 – Protection is key

Another sleepless night on call and many deliveries later…I was doing my usual rounding on my laboring patients. I had spoken to my senior regarding rupturing my patient’s water bag. We discussed her progress and he agreed that I should proceed. Without any problem I performed the procedure and noted amniotic fluid flowing out. As time went on my patient and her contractions were progressing nicely. The staff had asked me to assist in teaching mom how to push during delivery. I agreed, and positioned myself with a sterile glove at the edge of the bed. As I proceed to talk with the patient and examine her, the nurse mentioned that she had ruptured her membranes again. I thought nothing of it at the time since it was possible that the patient may have developed a fore-bag. At this point the cervix had completely dilated, contractions were every 2 minutes, and the baby felt engaged. We proceeded with the trial of pushing. As we began to count off her pushing, in slow motion I saw a WAAAVE of FLUUUID heading my direction. As I felt this warm, gooeey mess cover my body, I managed to only turn my head to the side and close my mouth…Everything came to a screeching halt – pushing stopped, nurses stopped, contractions stopped. I got up covered in my slimy mess and asked for a change of clothes and ordered the mom to stop pushing till I was done cleaning up. I went quickly into the bathroom and changed, came out with a smile and said, “Let’s put on some protection and have this baby.”

Shipra and I were invited by Dr. Juan Manuel, a local physician we have close contact with, and Mere, a “promator” (community health worker), to travel to a Zapatista community in the hills of Chiapas. This, in short, is what we did:
- Meet Juan Manuel and Mere in front of Hospital San Carlos at 8am.
- Travel by “collectivo” (shared van) from Altamirano through valleys and cloud forest to Ocosingo
- Traverse bustling market, carniceria, and shops in Ocosingo
- Eat tamales and atole (milk and corn drink) for breakfast
- Leave Ocosingo by “combi” (covered truck), and speak at length with Juan Manuel about Mexican history and history of the Zapatista movement
- Pass military checkpoint, no hassle
- Arrive at Municipio Autónoma Olga Isabel, a large Zapatista enclave
- Met many Tzetzal “coordinadoras”, indigenous women from many pueblos in the area who lead and organize around the movement. They lead the Zapatista “communidades en resistencia” (communities in resistance). They speak Tzetzal, an indigenous dialect, and little Spanish, making introductions difficult.
- With Mere, ride “combi” up bumpy dirt road to trail head and hike uphill through jungle and pine forests. Dodge a black snake. Stunning valley views.
- Arrive at Campanawiitz, a small indigenous village of several wood, tin-roofed, dirt-floored huts.
- Mere and Solomon, local promator, administer vaccinations in Solomon’s home as Shipra and I entertain the children with hand puppets and silly faces. Children and adults curious of us. Farm animals abound – chicks, dogs, a pig. Small black and white TV, decorations with tricolores (Mexico’s red, white, and green) and with health education posters made by Solomon. Solomon’s wife cooks lunch in adjacent hut, the air thick with the fire’s smoke.
- Lunch with Mere and Solomon of homemade corn tortillas, rice and black beans.
- Shipra and I examine Solomon’s sister pregnant at 38 weeks (baby’s heart sounds perfect, head down) and father suffering from osteoarthritis, we think.
- Hike back to dirt road along a ridge with valley views, through corn and bean fields and several cows grazing.
- Ride combi filled with lumber back to Olga Isabel where we speak with several Swiss human rights workers invited there to witness the Zapatista struggle as observers. We watch a DVD on the Zapatista movement. It begins to rain.
- Take short combi ride through the night to Chilón, a nearby town, where we sleep at the gorgeous home of Nely, a “partera” (midwife) and friend of Juan Manuel.
- Eat heuvos rancheros and Juan Manuel sees a patient as Shipra and I explore the fantastic hilltop views of Chilón.
- Return to Olga Isabel. Juan Manuel sees patients at Clínica Autónoma Municipal, Shipra helps the women bake bread, I chat with the men and shoot basketball. It is a warm, sunny day.
- Two more combi rides: one from Olga Isabel to Ocosingo (2 military stops this time, no issues) and then from Ocosingo to Altamirano and home.
- Happily home and grateful for the incredible experience, we eat, shower (after 2 days), and go to sleep.

The pathology and variety of disease seen out here in rural Mexico is not as surprising as is the ability to practice modern, mainstream medicine, of course with limitations, in a place where one’d expect very very little of anything. I am grateful to the Sisters of Hospital San Carlos and those generous folk, physician or otherwise, who’ve come before me and helped bring this, and my experience in it, into reality. I marvel at diagnosing and treating relatively common ailments at least as I’ve been working in the pediatric ward here: bronquiolitis, neumonia, trauma, abscesos y celulitis, recien nacidos eutroficos y hipotroficos (full term and premie newborn babies). In a place where I expected close to nothing, I’ve found so much. Mexico is a land of plenty and of wealth, but of various sorts you might not anticipate.

My first patient was Jose Maria, a charming 3½ year-old boy. He had been admitted 5 days prior to my arrival with a hugely swollen, red and painful right pinna, the conch shell-shaped, floppy outer portion of the ear. He had been seen at an outside clinic and received antibiotics to no avail. What could have certainly been a simple outer ear or skin infection had developed into a serious infection of his ear cartilage – perichondritis (pericondritis en Espanol – See, Spanish no es tan dificil!). This condition can be very challenging to treat given the nature of the tissue itself: cartilage has very little blood flowing through it, and blood carries, among other precious things, antibiotics. If you’ve ever had your ear or nose pierced, you’d notice how while it may hurt like all heck, it bleeds very little (Big ol’ nerve endings, teeny lil’ blood vessels). That said, perichondritis requires up to 2 weeks of intravenous antibiotic, one that can eradicate, among other more common skin bacteria, a nasty little bugger called Pseudomonas, a common organism in this condition. Jose was started on an anti-Pseudomonal medication – Ceftazidime – plus another called Gentamicin for its synergistic effects with other antibiotics. Here, in a rural Mexican hospital, Jose was receiving exactly the treatment regimen he’d be receiving in any American hospital. Fascinating.

As with many things here, though, aside from maybe thunderstorms and black beans and rice, resources are limited. As one might expect, powerful, specialized antibiotics such as Ceftazidime are in short supply. Thus, after 7 days of treatment, Jose Maria consumed into his tiny vessels the entire hospital supply of the ear-saving serum. We continued the other antibiotic and since he made such great clinical improvement throughout his stay, we let him go home early to enjoy his family and his new and improved ear.

Jose Maria on the mend

Jose’s improvement and cheery mood leant for a more treasured and therapeutic plan: the bond of doctor and patient. Jose is a sweet, smiling young boy as you can see. I lucked out as I got to him as he was feeling better so I reaped the dividends of another’s poking and prodding. We joked, played, shared coloring time and he and his family were kind enough to sit for these pictures.

Ready for home

Originally uploaded by daprovocateur

Funny, aside from a few technological gaps in his care, of important but not of critical value, I could imagine the same scenario playing out in the States.

You’ve seen her image before: a dark round face. a stout but solid frame. Her body cocooned by colors of all kinds: a patchwork of red and gold stripes, bright green and blue hues, beads and other shiny accents. You may recognize her from the cover of a magazine, maybe National Geographic, or your favorite cable travel channel, but never would you ever expect her to enter your world, to see her and her many children in tow strolling your sidewalk or perusing the aisle of your local grocery. Never in a million years.

Now, flip the image.

She’s seen you too: your shape, your tone, your presence but never with her own eyes. Maybe in the TV set she passes on the way to market. Maybe in the dingy black and white of an old newspaper she once caught glance of. But never in front of her face.

Today, though, she sees me and I see her. We don’t stare but a glace is enough to know I don’t belong here. I interrupt her reality as though I’ve fallen from the sky (in actuality, I have). I am a head taller than most men she knows. Skin shades lighter than anyone she’s ever seen. Bespeckled and clothed like an alien to her world, which I am. If only to borrow her thoughts and her eyes for just a moment: Who is this person? Where does he come from? What is he doing here?

I wonder the same about her.

And we continue to wonder, for today anyway, and to guess. To speculate, perhaps even to fear, unless the museum glass shatters…with a word, a nod, or a smile…and we cease to be anthropologic specimens to one another and become human, in this moment: neighbors.

Harbor Family Medicine heads to Kansas City!

Only one thing can beat that, and that’s having the chance to meet dozens of enthusiastic, engaging medical students from all over the country ready to take on health care and transform family medicine.

Even while we physicians and residents grumble and lament over a crumbling health care system, inefficiencies, inequalities and stagnation in health and medicine, medical students can reignite our idealism and passions for change. Below is an account I wrote from last year’s AAFP Resident and Student Conference that details just what I mean. I’m happy to finally have the chance to share it!

Every year medical schools around the world graduate young physicians eager to continue the beautiful struggle. It is a pleasure to watch them work and to work with them. We owe it to them to help keep their (and our) dreams alive.

~Casey

Title: The future of Family Medicine is bright, I gotta wear dark-rimmed glasses
Subtitle: Report from the AAFP Resident and Student National Conference, Kansas City, MO 8/2 – 8/5/06

I’ve been known shine about the joys of working with med students. After all, I was one for 4 years and worked exclusively with them for 5, now going on 6. What is it about working with med students? Why is it SO darn fun? Maybe it’s their energy, their idealism, their readiness to take action and make change as we as docs struggle to keep from melting away.

Well, I went on and on and on about this all weekend at the AAFP Resident and Student Conference. How could I not? We’d been chatting it up with only the most stellar med students and soon-to-be family docs out there, and to Jose and Linda, my dear fellow resident recruiters, it became quickly apparent that I had had my share of acquaintances there at the conference, thanks to AMSA. I was being recognized somehow. Few times by face – maybe a talk I’d given at their school. A lecture I’d hosted. More often it was the email address that gave me away.

We had reached a lull on Friday afternoon in the exhibit hall and the Harbor crew was chatting it up about all potentials we’d met when from around the corner and at high speeds comes zipping Justin from Vermont. He’s hard to miss: Stylish and slender even in his V-neck undershirt (the kind I could only get away with wearing, well, as an undershirt or when paired with black dress socks and Ray-Bans, a la Tom Cruise in Risky Business). His scruff and dark-rimmed glasses reminiscent of Elvis Costello though he really doesn’t look a thing like Elvis Costello but name someone with dark-rimmed glasses who doesn’t recall Elvis Costello. Physical attributes aside, what draws one to Justin is his energy: pure, creative, and infectious. With the speed at which he approximated our booth, I knew he was up to something – something big – and that I was in for trouble…

“Hey, Casey” he greeted me, grinning, and we exchanged a hearty soul grip and the guy’s guy half-hug. “Dude, do you know anything about these resolutions?” Not knowing the AAFP political process a lick, I didn’t. Yup, Justin was up to something…again. “Dude,” I cautioned, “what are you up to?” I grinned back. Whatever Justin was up to, I knew I wanted to be a part. Of course, he had decided that for me already. “Dude, check it out.” He handed me 2 sheets of paper. I noticed my name etched in xerox. I didn’t recall putting my name on anything. “I wrote these two resolutions and introduced them this morning.” I was in for it. “They need a resident sponsor to get into the resident congress. I didn’t think you’d mind. You don’t right?”

Of course I didn’t mind. Actually, Justin had read my mind from the night earlier. On flipping through the conference schedule when we arrived, I noted the Resident and Student Congresses. I had missed the session on writing and introducing resolutions but I recalled it from last year when our own Harbor graduate Dr. Fred Kim made AAFP news in his testimony supporting a closer eye on and narrower practices of drug reps and residents in academic medical centers. I gave brief thought to standing on Fred’s mighty shoulders and continuing the fight against Big Pharma…but I was tired. I was there to talk with prospectives, give my support to Harbor and to Family Medicine, not to stir up AAFP like I had in my AMSA days. This wasn’t AMSA, after all. I as in unfamiliar territory. I was an unknown and the last thing I intended was to get caught up in it, tarnish the good Harbor name, and wear myself out on the back & forth of the Big Pharma debate.

Justin had cut straight through the B.S. that I had piled high up around me, and the spark of action had been set. I thanked my friend: “Justin, dude, you are the MAN!

(for some reason, perhaps his laid-back style, his Vermont-cum-Southern Cal vernacular, I’m compelled to say “Dude” around Justin more than usual. Go figure.)

I can’t believe you pulled this off.” He had been out checking the KC music scene late the night before and at some point he’d drafted and printed these two great resolutions, one encouraging alternatives to accepting drug company free samples as the solution to our patients’ need for meds, and a second to restrict access of drug reps and their marketing practices at academic medical centers, including residencies and medical schools. 2 great approaches to limit the influence of biased marketing practices and advertising on patient care. 2 great stances, I agreed, the Academy could support to ensure excellence and integrity in medical education and practice. I chuckled and glanced at Justin again. “Dude, I’m so in.” I didn’t need to read the resolutions to know I supported them and that I’d speak out for them. Justin had done the tough part: he pushed himself, put pen to paper and started the machine. My standing up and speaking was the easy part. “Where, Justin? When?” The kid was on top of it. Me, I could hardly remember being booted from the exhibit hall later that day. “Dude, no sweat. I’ll give you a call with all the info. But check it, I gotta run and get these out.” From his bundle of papers peeked a stack of green half-sheets. “Dude, what are those?” “No, check it out. Surveys.” Not to be outdone by his own butt-kicking activism, he had managed to produce a 5 question survey on what policies the 200+ residencies in attendance had on residents interacting with drug reps. The kid was en fuego. He handed me a survey, said “Dude, Ill call you in a few” and sped off down the carpeted aisle, distributing surveys, a dust cloud at his heels.

Well, Justin’s hard work came through. We pulled it off and as a result the Resident and Student Congresses of the AAFP voiced strong policies against the relentless marketing influences of Big Pharma.

It might have been my name that made it onto the website, but it was a medical student’s drive and focus that put me there.

We set up our display booth this afternoon, which was quite fun, we’re pretty excited about it. We’ll have video from our residents and screenshots of this blog and our wiki (resident-driven collaborative learning/reflecting) on two laptops at our booth.

The freebies here are interesting. There are some really fun ones, like the program that brought the portable popcorn maker and another program that brought a smoothie machine. Some of us think it’s little disappointing to see so many pharmaceutical companies’ huge display booths — very expensive and schmancy ones at that — set up among the family med residency booths. We’re not quite sure what the purpose of them is…

More reporting back from the conference later…
-anjali

There is at least one other of us at Harbor using biodiesel. Another uses compressed natural gas (and she wants just 5 mo’ minutes of sleep – hint hint). Several – I count 5 – use hybrid gas/electric engines including Su’s ever-recognizable Prius. So I KNOW at least a few of us are taking action on our wasteful use of the Earth’s precious resources, and I’m CERTAIN that we all are at least somewhat concerned. So, below I’ve posted a upcoming conference in LA on biofuels.

You all know that a few of us family med residents have been involved in the diabetes chronic care collaborative with Drs. Snyder and Cheng. We’ve been trying to provide intensive and attentive care (including testing, treatment, education, and self-management) to our most out-of-control (OOC) diabetic patients. As the Resident Clinic Director (aka “RCD”) for the last month (a required and worthwhile rotation as a 3rd year resident), I’ve been on the front line of patient care at the Family Health Center. Here’s an example from today’s RCD experience that shows what we’re up to.

* Please email me if you’re interested in participating in the chronic care collaborative!*

One of our nurses, Mahdi, alerted me to a patient with fasting blood sugar 256. (This is something you have to address in the few spare minutes you have while RCD between triaging urgent care patient, writing for med refills, and putting out the occasional fire (ie someone with chest pain, residents swamped with clinic, etc) that erupts in the waiting room. It’s fun, actually.) This 66 year old Latina lady with her daughter at her side explained that she’s NEVER been in control of her diabetes in the 15 years she’s had it. Her last Hemoglobin A1c in 1/07 was 9.8% (far above her goal of 7%). Her home sugars run 200 to 400. She’s been seen only a couple of times here, but already her meds are maxed out: metformin 2500mg a day (about max dose), pioglitazone [Actos] 30, glipizide 20 bid (max). So, fair doctor, what do you do?!

Obviously her oral meds aren’t doing it. Your choices are: increase the Actos to 45 a day (max dose)? Start a 4th agent – acarbose, Januvia? All of the above? Start insulin? Take a second: based on what you know about this lady’s diabetic control, how can you best help her?

Well, a little bit more of the story helps. First, she and her daughter are asking for insulin. That doesn’t happen too often (many of our patients fear that insulin causes blindness, amputation, etc – Educate patients, people!), but when someone has a chronic, debilitating condition that isn’t helped with maxed oral meds, she knows that only insulin can help her. Smart lady. Fortunately she’s been given insulin in the past so knows the routine. I start her on NPH 10 units (she’s thin, so 10 is a good start. If she’s obese, I might start 16 units) before bed and counsel her on increasing the dose every 3 days by 2 units if her AM fasting sugars are >130. Both she and her daughter understand, but adjusting insulin like this is tough for newbies; she might need more counseling in the future…

What else do I do? She’s already on 3 orals hypoglycemics. Not having her chart nor knowing her history, I wonder: What else is she taking? carvedilol, lasix, losartan, simvastatin, warfarin – the ingredients of a cardiac patient. Turns out she has CHF and a prosthetic mitral valve. Question: Should she continue Actos? For one, it’s not helping as it is and increasing it to 45mg probably wont help either. Second, many speculate that the heart failure dangers of rosiglitazone [Avandia] may be a class effect, so right now we can’t be sure that pioglitazone [Actos] wont lead to failure also. Especially in this patient who a) isn’t helped with Actos and b) has a history of CHF, we may be doing MORE harm than good giving her Actos even IF she had had A1c improvement. So, I discontinue it.

How about the glipizide? She is on a hefty dose of this sulfonylurea which, on its own and especially when given with insulin, can induce hypoglycemia. So I D/C that too.

I keep her on the metformin at the same dose to continue her peripheral insulin sensitization and inhibit gluconeogenesis, but not after checking her creatinine first to make sure it’s <1.5 and she’s not at risk for lactic acidosis.

Why this email and why this case? Many of our patients are languishing with out-of-control diabetes on the same stale regimen they’ve been on for months or even years. Don’t be afraid to start ramping up therapy more rapidly. We are working on clinic infrastructure improvements to make doing this easier. Secondly, I, for one, will start discussing insulin therapy with all of my diabetics, even those on less-than-max oral therapy. Bringing up insulin early and in the context of physiology (insulin therapy can be simply explained, after all, as just hormone supplementation) may help patients understand their disease as well as dispel some of the myths and fears around insulin use. SubQ injections are, after all, a lot less scary than foot ulcers, amputations and blindness. Finally but most importantly, don’t forget to be a family doctor and see the patient as a whole. What is her understanding of her disease? What does she want from her visit? What other co-morbidities does she have that would change therapy or clinical course? Protocols are tremendously helpful, but they aren’t for everyone. Treat the person, not the disease.

Fortunately she has follow-up here at clinic with her primary doc on July 24, less than a week away, and I’m curious to see how well her sugars are controlled but more so to see how well she and her family take to her new treatment regimen. I think they and I will be happy with the outcome.

~Casey

cross-posted at:
the Life of KirkHart

Over the course of three days recently, I had 23 head-to-toe physicals from 23 second-year students at the Georgetown School of Medicine. I was the first person these would-be doctors had ever fully examined on their own. Some were shaking so violently when they approached me with their otoscopes—the pointed device for looking in the ear—that I feared an imminent lobotomy. Some were certain about the location of my organs, but were stymied by the mechanics of my hospital gown and drape. And a few were so polished and confident that they could be dropped midseason into Grey’s Anatomy.

Georgetown allowed me to be a “standardized patient”—that is, a trained person who is paid $15 an hour to be poked and prodded by inexperienced fingers, so that med students can learn communication and examination skills before they are sicced on actual sick people…

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. “So, do you pick someone you like, or someone you don’t like?” he recalled. “Either way, it’s lose-lose.”

Now there are standardized patients trained for genital duty (they’re called GUTAs, for genitourinary teaching associates), but I signed up for something less invasive. Mine was the simplest possible assignment. I was to sit on the edge of a padded table in one of those awful, flapping hospital gowns, in a room equipped with recording devices in the ceiling. Each doctor had 30 minutes to conduct a standard head-to-toe physical: from my vital signs, to my nerve function, to my reflexes, etc. Then I was to go to a computer and check off whether they’d done all 45 parts of the exam (“Palpated for fremitus,” “Auscultated carotids”), and write my comments on their bedside manner…

Oh, it gets better. Check out the rest of her piece. Any thoughts on this concept of standardized patients? Any embarassing stories folks have to share?

A [pharmaceutical] representative can quickly access a breakdown of pharmaceuticals prescribed by any physician on a handheld computer, enabling that representative to deliver a tailored marketing pitch to physicians selected for their current prescribing habits.

…

How do pharmaceutical companies obtain such detailed prescribing data? Currently, retail pharmacies sell de-identified patient prescription records with limited physician identifiers to data intermediaries known as health information organizations (HIOs). By purchasing a comprehensive database of U.S. physicians from the American Medical Association (AMA), HIOs can link individual physicians to prescription records by using identifiers common to the pharmacy databases and the AMA database, such as a physician’s U.S. Drug Enforcement Agency and medical license numbers. They also can track a physician’s demographic and practice characteristics. The HIOs build prescribing profiles on the basis of these linked databases and sell them to pharmaceutical companies, which use the profiles to identify sales targets and plan detailing visits.

This practice continues unabated, much to the financial benefit of Big Pharma and the AMA, despite physicians’ disapproval:

Many physicians believe that using prescribing profiles in commercial marketing crosses a line of acceptability. A Kaiser Family Foundation survey found that only 60% of physicians were aware that drug companies have access to physician-specific prescribing data. When they were told of the practice, 74% disapproved. A physician survey commissioned by the AMA found similar levels of awareness (77%) and disapproval (66%). Anecdotes also confirm the survey findings, with one physician recently commenting, “It makes me feel like a rat in a maze when they put little nibblets in front of me to see if I’ll prescribe their drug”.

This is yet another staggering example of the ubiquitous presence of Big Pharma within and throughout medicine. With every prescription written, with every life-saving medication dispensed, with every sacred patient-physician relationship affirmed, Big Pharma is watching. For a more visual interpretation, click here.

There is a place for business and there is a place for privacy. Between patient and physician, there is no place for Pharma.

The above quotes excerpt from Prescriber Profiling: Time to Call It Quits, David Grande, MD, MPA, Annals of Internal Medicine, 15 May 2007, Volume 146 Issue 10, Pages 751-752

Well, aside from its blue, breezy skies, its cute boutique shops and restaurants, and it being the beachside home to a number of our residents, Redondo Beach is the ONLY beach in LA County that is NOT SMOKE-FREE. For you visual learners, look here. Hermosa beach? Smoke-free. Santa Monica beach? Smoke-free. Venice beach? Smoke-free (though I’m not sure exactly what kind of smoke we’re talking about).

Cigarette butts on the beach recently got the attention of Rick Dickert, meteorologist for FOX 11 morning news and Good Day L.A., Redondo Beach resident and surfer:

From Rick Dickert’s blog
Ash Tray of the Bay
Apr 18, 2007

My home town…Something I am not too proud of. That’s right..Redondo Beach is the ONLY coastal city of the Santa Monica Bay that does NOT have a non-smoking ban…I collect more cigarette butts than any other item when I participate in beach clean-ups in Redondo.
Rick Dickert
Ash Tray of the Bay Resident

My response:

Apr 26, 2007
Rick, thanks for using your public voice to bring attention to this important issue.

I’m a physician, I work in Torrance, and I see the awful effects of smoking everyday: in my ex-smoker patients with heart and lung disease, in children with asthma caused by SECOND HAND SMOKE, and when I run the beach in Redondo, only to gasp through a cloud of sooty smoke.

Now, we the people need you, Rick, to take your voice, and the support of your viewers, to the Redondo Beach City Council to finally put an end to smoking in our public areas including the beach AND the pier.

Redondo Beach, the last and ONLY beach in LA County to permit smoking. Shame on US for not demanding our leaders take action.

Attend the next City Council meeting – http://www.redondo.org/cals/default.asp

Contact your councilperson directly. They work for YOU! – http://www.redondo.org/depts/council/default.asp

We have to take responsibility for ourselves in leading healthy lives. We know the right thing to do, but tobacco smoking is an addiction, a disease. We also have to care for each other and our community.

Make Redondo Beach smoke-free.

~Casey KirkHart, D.O.
Family Physician

Want to get more involved? I’m on a two-week public health elective that places me in the LA County Tobacco Control and Prevention Program policy unit and led me to a regular meeting of the South Bay Clean Beaches Coalition. There are always looking for support, especially from physicians, Redondo Beach residents, concerned citizens or all of the above (that’s you!).

Get in touch with me or drop a line to Joan Waddell @ joan@ncaddsb.com. She’s the program director of the Coalition and leading the effort to make all Southland beaches smoke-free.

NO-BUTTS can work for our smoking patients. NO-BUTTS can work for Redondo Beach too.

~Casey

Use this time to tear up the old contracts, Henrikson told his young writers, who listened to him as if he were a guru. “People die never getting to know who they are,” he went on. He read them a Rumi poem, written in the 13th century, called “Ali, the Fighter,” in which Ali prepares to vanquish a foe who, in a last fit of anger, spits in his face. Ali pauses, sees a younger version of himself in his foe, and helps him up.

Of all the kids in the room, only Mario seemed old enough to be world-weary and wise. He’d already revisited his past — It’s not a life-style, It is a death-style — and wanted to move on. He called his poem “Better Days,” and read it as if he were ready to graduate.

Now I’m looking forward to

The better days

Where I don’t have to steal

For me to buy a meal

Or run around like a menace

Looking for an enemy to kill

“You’re a man now,” Henrikson told him when he was done. “You’re 18, and you’re an old soul.”

And that’s not unusual. “I see a difference in the kids who go through the program,” said Craig Levy, director of Camp Kilpatrick, which is next door to Miller. “It exposes them to things they don’t know well, like reading, writing and expressing themselves in public. They come out of it with a little less slang, and speaking more like young men.”

More of Henrikson and others’ work is detailed on their organization’s website, Street Poets, Inc. They do a lot of violence-prevention themed poetry, sessions with youth in juvenile centers, and performances in public, and they’re based in Los Angeles. There’s a beautiful poem written on the left side of the website, written by a 21 year old boy man.

This is somewhat similar to what two of the faculty members in our Department of Family Medicine (Dr. Puvvula and Dr Granados) do many sunday mornings — talk with kids in LA Juvenile Hall, support them, encourage creative outlets. And Father Greg Boyle created Homeboy Industries in 1992 to help transform the lives of ex-gang members through a variety of personal development and community building programs (that’s also where we — family medicine residents! — are trained to remove tattoos with a yag laser for ex-gang members who are making changes in their lives). All of this is so beautiful, and these methods are much more humane and long-lasting in their ability to make positive change than the negative ways of prison and negative reinforcement.

And thanks to Andy Hilbert for the tip, who blogs about education, the LA Unified School District, teachers, and other related issues.

8/30/06 In clinic, lots of abdominal pain, fibroids, neurocysticercosis, prenatal care. What to do with a positive brucella antibody from an outside lab? Who ordered it? The woman is well, without complaints.

9/2/06 Post-call. I’ve learned a new word: keraunographic markings. The characteristic pattern lightning leaves on skin. A seventeen-year-old girl was struck by lightning. I’ve never dealt with this before. Quick consultation with the books: the girl’s story matches nearly word for word. Loss of consciousness, transient swelling of the legs. Her hair is burned where she was struck. Terrified. Her seventy-year-old grandmother, who weighs marginally more than a healthy nine-year-old American child, is speechless, and I am grateful she was not struck herself. I don’t think she would have survived.

Later that night, an 18-year-old girl I’m convinced has congenital hypothyroidism comes in, hugely distended. A plain film reveals loops of colon 12 centimeters in diameter. At 11:30 pm, I call the surgeon, an insomniac who had finally fallen asleep, and feel guilty for waking him. I’m wondering: ascaris? Volvulus? Adhesions? The next day, he operates, and it’s a megacolon of unknown etiology. I marvel at the care her father gives her. She cannot communicate, first walked at the age of 13, and only on her good days. He holds her, carries her, whispers encouragement. He sleeps at her bedside, on the floor, like many family members at Hosp. San Carlos.

9/6/06 We fell, one by one, to the “venganza de Moctezuma.” The case of traveller’s diarrhea that hit Mark made its rounds through half the team. We blamed fruit, water, our own underchallenged immune systems. A few doses of Cipro later, we were back on our feet.

The two weeks passed quickly. From the distant vantage point of our supremely overweight nation, it’s hard to believe that people can be so malnourished, that their illnesses can be so ignored.