Thursday, February 19, 2015


I had a great weekend in Amsterdam! I met up with a couple Northwestern med students who are doing a radiology rotation in Berlin. Airbnb was clutch once again. The canal boat tour was nice, but I am glad I took the time to see the house where Anne Frank and her family lived in hiding. Powerful stuff. Europeans are quite lucky they can travel to so many countries with different cultures and rich histories in a 2-3 hour plane ride.
Standing on the "Amsterdam" sign

This week I went back to medicine and picked up from where I left off. 4 new medical students started mid-week so it has been nice getting to know them.
Amsterdam waffles with chocolate

Some observations:
-While helping Serghei, the intern, with orders, I noticed that next to each item is a price for the test. Given that the cost of healthcare is an issue in all countries, not just the US, it was interesting to see this approach as a possible way to make residents and faculty aware. I know it is something I've read about as a method to try in the US, but have not seen it implemented. Does it work? When we were putting in orders, the focus, understandably, was on the patient and the right tests to order given her problems. However, on rounds, cost is something that has come up several times. Specifically, does the cost of a certain intervention/procedure/test lead to better outcomes for the patient. While I value the discussion, I wonder if there is a broader set of guidelines given by the hospital or a certain committee. I think listing prices can change a person from ordering a specific lab test if the price differences are egregious. It, more importantly, brings the issue to the limelight. End-of-life care is very expensive no matter the country. An attempt to target this issue via the Affordable Care Act was touted in some media outlets as "death panels." Politics aside, the issue of cost is tied to our views on mortality. Some studies have shown that among doctors, less intervention is preferred regarding end-of-life care while the lay population advocates more for an aggressive approach. Is this difference because we see the futility of certain interventions or procedures while a lay person does not have that perspective? Or does our American cultural views on death and dying see dying as yet another disease with a variety of interventions that require aggressive management? I think it is a mix of both among other things. Interestingly, can cost be so prohibitive a factor as to change a culture psyche regarding an issue as personal as death? In other words, if costs continue to rise and more pressure is placed on less intervention, can we, as an American society, shift our views on death and dying in order to cope with the fact that less intervention is the only approach? Many questions on this topic with no clear right answer. However, I feel it is important to start now given that elderly populations around the world continue to grow.

Amsterdam canals at night
-Many patients on our service are above 80 years old. While I noticed it the first week, it became more apparent to me now. For many, given the underlying conditions and current mental status, there is not much we can do for them long-term. I've seen CHF, stroke, and pneumonia among a few other things, but I wonder are younger patients with acute disease processes are handled by specialist services? I say this because, while on cardiac MR, the cardiologist mentioned a few cases of viral myocarditis recently admitted from the ED. Did the patient go straight to them or did a medicine service create a note and then consult cards? The other possibility is that the time of year is such that the elderly population is disproportionately more affected right now. On one hand, specialist services could have more control over the full course of the patient rather than just as a consult. However, the flipside is that teaching cases are taken away from the medicine service and thus they see a narrow set of pathologies. Some investigation to do on my part.

-On another note, I've gotten much better at ABGs (gasometria) while on service. ABGs and EKGs are done by the residents and many patients need these tests. As with other topics above, there are two sides to the issue. On one hand, residents gain experience and comfort doing procedures that are vital in critical care situations. On the other, the time spent doing these procedures can take away from time spent learning more about a patient or reading about disease management. I know there is a phlebotomy nurse and there might be an EKG tech, both who could do their respective tests.

View along the Duoro river
-Lastly, I wanted to touch on the issue of global health again. Dr. Basto and I had a great talk last Friday about it especially the work done by Hospital Sao Joao in Africa in ex-Portuguese colonies. Clearly, there are many challenges and the work can be deflating if years spent building partnerships and providing clinical teaching go nowhere. Also, if doctors from these countries are brought to Portugal to train, there is a risk of them staying forever since the situation they are coming from is worse. Interesting, Dr. Basto mentioned how charitable donations to governments can easily go into the wrong hands and can sometimes be a crutch that countries have come to anticipate. This got me thinking, can we do more harm through intervention and charitable donation? The earthquake in Haiti  is a great example where people feel this is true. Excessive intervention by NGOs and various donations have not gotten the country far since 2010. In addition, many within the country have gotten accustomed to the financial support of the donations. NGOs can sometimes fail to involve a country's own citizens in creating change leaving a country crippled by various, unaligned changes from differing NGOs. Obviously, global health outreach is a difficult process. From my various experiences, it seems that it really comes down to the context, which defines the intervention and method through which it is hopefully accomplished.

That's a wrap. Only one week left! Time flies. 

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