Photo from Mount Royal, Frisco, Colorado.

"Children are fascinated by the ordinary and can spend timeless moments watching sunlight play with dust. Their restlessness they learn from you. It is you who are thinking of there when you are here. It is you who thinks of then instead of now. Stop. Let your children become the teachers and you the student" - William Martin

Monday, 6 January 2014

Johns Hopkins

Allow me to lash out for a second- against the culture of non-learning. Against the culture of social media, which values in your face half truths above teaching and learning.

I had an outstanding English teacher at UW-Madison who said “Every time you write something, ask yourself why you are writing it and what your audience will get from reading it”. That principle has stuck with me. Sometimes I forget it, but I probably think of it on average once a day.

Don’t get me wrong, you don’t need to explain the Pythagorean Theorem every time you write, or anything scientific, mathematical, tangible or practical. Maybe it is a feeling, way of thinking or explaining something in a way that most people don’t, because your viewpoint is different. Or maybe it just sounds really good.

Today, I interviewed at Johns Hopkins for a residency position. To a "young" physician, this just kind of seems like a big deal. Johns Hopkins is the biggest name in medicine in the United States and arguably in the world. Why? (and if they really are THAT great, why did they offer ME an interview?)

So Johns. You know who he is, right? Good old Johnny Johns Hopkins. Up until today, I had thought that there were two doctors: Dr. Johns and Dr. Hopkins. Nope. One guy: Mr. Johns Hopkins. Nice first name, isn't it? (embarrassing, I didn't know this, right?).

He was born in 1795.

He was the owner of (among many, many other things) the Baltimore and Ohio (B&O) Railroad (of Monopoly fame) and the game Monopoly may in fact be based on his life (this is at least my theory) - and this is Christian's favorite board game right now. He (Johns) won the game, you could say. And he was the quintessential self-made man. But what made Johnny Johns so special was he gave all of his money away to good causes. He was a Quaker and this was an important tenant of his faith. This other important part was he could not marry his cousin, even though she was the only woman he ever loved, so he never had kids (which of course may or may not have anythingto do with his faith). Anyway, the money he gave to start Johns Hopkins University and Hospital was "by all accounts, the largest philanthropic bequest ever made to an American education institution" (nice quote from Wikipedia, with no source).

But then there was this guy from Ontario named William Osler. And it is THIS guy who made  the Johns Hopkins School of Medicine so famous (or was it Harvey Cushing who wrote William's biography? - you know, the first guy to stick a knife into a living person's brain with the intent of curing them). Osler established what is the modern day "residency" training in medicine, where young physicians in training sleep at the hospital - "round" on patients (his term). Basically he had this revolutionary idea that one could learn what a patient's disease and diganosis were by talking to them and looking at them. My favorite quote of his is "listen to your patient, he is telling you the diagnosis". It seems so inane that this is my favorite quote of his when it is so freaking obvious- but guess what? Doctors don't do this anymore. 

And so, I felt today, in some way, that medicine is coming full circle. Where innovation is not necessarily about the amazing 128 slice CT scan, but learning to listen and examine so health care dollars can be saved and people can be saved of cancer-causing radiation, among other burdens of modern medicine.

Yeah, I was asked today how I thought health care costs could be cut. Being asked this question said a lot (of good things) about Johns Hopkins. I said two things 1. holistic medicine: diagnosis made though history and physical and treatments that are non-harmful, based on unbiased research (not funded by drug companies). For example, acupuncture can work better than opioids. It is the drug companies who manufacture opioids that have beendriving physicians and the public to believe otherwise.

2. Health comes through living in a healthy society. If America wants to cut health care costs, exercise needs to be a part of daily life (walking, biking to work), healthy food needs to be affordable for everyone and poverty needs to be reduced.

And that's why Johns Hopkins is STILL cool. Because they are leaders, wanting to initiate change that works. And they are affiliated with the National Institutes of Health- the best funding source for non-biased research in the US; where money comes from public funds. 

And why is it that Americans are so gosh darn opposed to giving tax money going to these public funds? To research, health care, reducing poverty, creating safe bike lanes, etc. etc?? 

But I am sugar-coating my experience for no apparent reason other than "it sounds good". The applicants: we are all dang tired. It is common knowledge among Physical Medicine and Rehab applicants that you need to interview with at least 10 programs to be guaranteed to "match" anywhere. It is crazy. The specialty has become super competitive in the last two years And we're all standing there thinking "just tell us how often we're on call, how hard our work will be and what the exact work hours will be and oh- if we'll like living in Baltimore". You know, we are all just humans of course.

And I hate travelling to all of these interviews even though I learn so much about the speciality of PM&R as well as medicine in the United States - and I want to make an educated choice about where I train. I miss being with the kids and SR. When SR encouraged me to apply to PM&R, I didn't know if I could do it- enter this world again, but I miss clinical medicine and the pursuit of knowledge, change and ideas - and mostly patient care- so much. It really suits me. The path to stay-at-home momness is paved in the US. It's practical and affordable. But I'm used to the Danish model by now where no familes can afford stay-at-home momness.

So why not stay Denmark, right? Well, if I get specialty training in the US, I will be able to work in both the US and Europe, but not vice versa. There is also no dedicated field of PM&R in Denmark.

Oh, by the way, I have a new job in Denmark in the Department of Clinical Biochemistry! That's why I'll be going back in two weeks. If Denmark offered double citizenship, life would be a lot easier and SR and I wouldn't need to live this double country life all the time just to meet the requirements of our residency permits-- get with the double-citizenship program, Denmark.

BTW - the above blog post is what happens when I am stuck waiting at BWI airport for a 3 hour delayed plane to Minneapolis.

But look at the design yourself salad I got at the said Baltimore airport!

and the salad's point of view.
The statue at the entrance to Johns Hopkins hospital. See, I thought it was Jesus because of the sandals, but I guess it is actually God. There was a teenager standing there writing a long message that started with "Dear God" in a large, guilded book as we applicants walked by.

Oh, if you are interested in follow-up from my last post about health issues in the endurance athlete, I am doing a podcast with Elevation Trail on Tuesday about the topic! I'll let you know when it is out. In the meantime, go to the link for some outstanding listening: (I highly recommend the episodes with Jill Homer and Rob Krar).

And I have never enjoyed winter so much. The cold is pristine and the running gorgeous.Thank you Leslie Semler for an "I will kick your ass, SeaLegsGirl" run at Hartley Park. SR and I have also been hitting the x-c ski trails basically every other day. Suddenly winter is my favorite season. Yay, Duluth.
Song for running in the cold: Harrison Ford by SSLYBY (Someone Still Loves You, Boris Yeltsin)

"Pretty eyes, you don't have to be good"

30 comments:

ScottyD said...

Glad you decided to do the podcast. I emailed Gary right after reading your healthcare post & told him they need to have you on. Very interesting & can't wait for the podcast.

Good luck with the interviews!

Fast Bastard - World's Fastest Hematologist said...

I like your comment on safe bike lanes. Americans don't enjoy sitting in idling cars all day; it's just that there is rarely an alternative.

Many Danes and Dutch ride their bikes, not for excercise but for transportation. Copenhagen and Amsterdam have decided to make it faster and easier to bike than to drive, so that's what people do. Bikers aren't envirohippies there. They ride their bikes for the same reason people drive mini-vans here: it's convenient. That 10-minute bike ride to the library or grocery store is worth a lot health.

Duluth is a good bike city by american standards. The Lakewalk trail goes for 7 miles along the lake and through town.

But. Whenever the trail crosses a road, there is a stop sign - on the bike trail! Again, it's a question of what is more convenient. Should we not encourage riding bikes over driving cars? The irony is that all cars stop anyway, because American drivers tend to be so courteous. So both the bike and car stop, leading to a sense that the bike is a traffic anomaly that requires cessation of all movement.

The Munger trail is a beautiful, paved state bike trail. To ride on it costs a small fee, while driving on Minnesota's many roads is free. Again, it sends a bad signal, that driving is the norm and biking is for excercise and frivolous enjoyment. Look at the trailhead in summer: people drive their cars, with the bikes strapped onto carriers, to get to the trailhead. We have done that, too. Why? Because it's convenient, that's why.

Anonymous said...

I like the second part of your answer a lot. But...acupuncture? As far as I know, most studies in decent journals conclude that any effect is a placebo effect:
http://www.ncbi.nlm.nih.gov/pubmed?orig_db=PubMed&cmd=Search&term=259%5Bvolume%5D+AND+2%5Bissue%5D+AND+125%5Bpage%5D+AND+2006%5Bpdat%5D

When my friend was doing research for his climbing injuries book, he also found a study that showed acupuncture working better when performed by a Chinese man than by a non-Chinese person! All I'm saying is, the placebo effect might be better than nothing, but I'm not sure it's time yet to start recommending acupuncture over opiates.

See you guys tomorrow? I did get sick though (bronchitis) so if you want me to stay home, I understand...

p.s. SR, a fee for using the Munger Trail? Maybe technically there is one, but I don't know of anyone who has ever paid.

Alicia

Olga King said...

Your life is totally nuts. And were you trying to tell me to sleep more?? :) Best of luck with all, thanks for the informative post, and I hope we bump into each other somehow this year (or next?).

sea legs girl said...

Alright Alicia, NOW you really got my attention. Since there has been SO much overwhelming evidence (from many high quality randomized controlled trials) that acupuncture works for many, many things- including pain, where it has been shown to be equal or superior in treatment of some types of pain including some cancer pain to opioids. I am happy you brought it up, though because is it a common misconception that it is placebo? Interestingly one of the docs who interviewed me yesterday is an acupuncturist who uses it for pain control. If you were intimately familiar with the side effects and long-term effects of opioids, you would do/prefer the same. Here is a long summary from the National Cancer Institute of all the trials done on acupuncture for cancer-related problems. It is very long and comprehensive. Enjoy! and we look forward to Tuesday night! http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional/page5

BTW having myself received acupuncture as pain control during labor, I can testify to the fact that it is NOT just placebo. But of course all the above studies in the link are much more convincing.

sea legs girl said...

Scotty- thank you so much for connecting Gary & Tim with me! I was wondering how Tim ever stumbled across my blog when he wrote to me!

sea legs girl said...

FB, the weirdest was when I was in Orange County, CA, on a gorgeous day and everyone was looking at me from their cars like I was some sort of homeless freak because I was using the sidewalk. If only sidewalks were as profitable as cars in the US, then the tables would turn for the better.

Unknown said...

Actually the statue is Jesus. Christians believe that there are 3 persons in one God: The Father, the Son (Jesus) and the Holy Spirit. So, you're right! It is a statue of God :)

sea legs girl said...

Olga, I sleep over 8 hours ever night,almost without exception! I never sacrifice that for anything, well except for screaming child.

sea legs girl said...

Anon, I am just not used to people addressing statues of Jesus as "God", but I know what you mean. I used to be a Sunday School teacher in a Methodist church so I am familiar with the Father, The Son and The Holy Spirit. Baltimore happens to have THE most beautiful Methodist Church I have ever seen. Are you familiar with Mount Vernon Place: http://commons.wikimedia.org/wiki/File:Mount_Vernon_Place_United_Methodist_Church,_Baltimore,_MD.jpg

Fast Bastard - World's Fastest Hematologist said...

Alicia, maybe I am wrong about the Munger trail. In Wisconsin, there is a fee to ride on the state bike trails.

However. One could extend the argument to state parks. Even in progressive Minnesota, they charge an entry fee. Why should it cost money to go for a hike, when driving on multi-million dollar scenic highways is free?
.

amy said...

This wasn't really the key point in the blog, but I thought I would point it out regardless. Biking popularity, acceptance, and accommodation for it varies very widely from area to area within the US. Just so as to not make a sweeping generalization that "America" does not accommodate bike lanes. There are many cities that have put a lot of time/money/research into becoming bike friendly. But I live in Portland, and what happens here isn't necessarily very typical of other places in the US.

Fast Bastard - World's Fastest Hematologist said...

Amy, don't get me wrong. Minnesota is very progressive and bike-friendly. Minneapolis is often up there competing with Portland for best cycling town in America. Madison, WI, is very nice, too. There is nothing wrong with Duluth, actually, except maybe the crazy hills.

Everything is relative, of course, and everything has to start somewhere. I love the bike lanes and trails of Minnesota, but at the same time I firmly believe every single street should have a protected, curbed bike lane. Every mall and grocery store should have right-of-way bike lanes and sidewalks connected to them.

It's simple. Until it's easier and faster to ride a bike, car culture will be the norm. I repeat: people in Amsterdam or Copenhagen are not political activists saving the environment by riding their bikes. They do it because the bike lanes are 15 feet wide and car traffic is barely moving.








Olga King said...

We're forgetting Europe is all about biking because the cities are small and overpopulated, and they can't accommodate cars. They came up with smart-car type of design because of parking limits. Russia uses public transportation because it's insane to drive there and park as well. Not to mention the affordability of cars vs other means. Also, when we get mad at America as a whole that is driving big cars, remember, lots of that America is farmland, and farmers a) need trucks to transport shit, b) simply need any car to sometimes even get to the mailbox (yet along neighbor, grocery store, or said farm), and since a) they might as well get the bigger car. No, it does not excuse all those SUV's owned by city dwellers, and I am with you on that one. But even if I had bike lanes with curbs, I'd not bike - personally, I am petrified of biking anywhere besides wide dirt road with no turns or other humans in any capacity. Nothing will change that, I tried. I do take a bus though - but I have to drive to the bus stop first. That's called suburbia.
Tracy, 8 hrs - I am impressed! I am now on a week's roll of 7.5 - and for the life of me that's all I can find! And that's because I cut an hour run and a shower out.

sea legs girl said...

Amy, just have to say that is a good point because different states prioritize money differently and most money is at the state level for that. I would also venture to say that Portland inhabitants are more healthy on average than for example Atlanta or Houston inhabitants, which may be cause or effect, but they feed off each other. New York is a good example of an American city that is European by necessity since it is so big. There people are actually quite healthy because they mostly walk and bike (at least on Manhattan).

sea legs girl said...

Amy, just have to say that is a good point because different states prioritize money differently and most money is at the state level for that. I would also venture to say that Portland inhabitants are more healthy on average than for example Atlanta or Houston inhabitants, which may be cause or effect, but they feed off each other. New York is a good example of an American city that is European by necessity since it is so big. There people are actually quite healthy because they mostly walk and bike (at least on Manhattan). But unfortunately Manhattan doesn't put a lot of money into safe bike lanes! Anyway, it is a cheap, good way to encourage health and cut health care costs to discourage driving, but when there is no money in it up front, I wonder if it will happen.

sea legs girl said...

Olga, I am quite obsessive about my sleep. Surprise, surprise.

Anonymous said...

Okay Tracy, we are going to have a lot to talk about!

1. Did you see the conclusions on the study I linked to? It was a roundup of the research on acupuncture. It found that (a) The majority of studies using devices to help control for placebo effect fails to show effects beyond a placebo response, although (b) Some findings are encouraging. *Some* encouraging findings would certainly not be enough for me to conclude that it's only a misconception that acupuncture works by placebo effect!

2. I don't think your link supports what you're saying. First of all, there were only THREE randomized, controlled studies about cancer pain. Second, out of those three, two were from China, which may or may not involve some bias (I only say that based on the enormous volumes of acupuncture studies that come out of China and the fact that they're all at least slightly positive, which doesn't match at all with the other research. Personally that makes me think there is some kind of bias going on.). Third, out of those three studies, two of them were also using opioids or other analgesics in combination with the acupuncture. Fourth, your National Cancer Institute link itself talks about the methodological weaknesses of these studies.

And finally, the bottom line for me, the clinical study with the absolute best result for acupuncture showed an "equal to or better" effect as opioids. And that was the ONLY clinical study with that result. So I don't think there's any way you can make a leap from that to "it's a misconception that acupuncture works only by placebo effect." At the very best you could say that there is some, limited evidence that acupuncture could be worth trying in conjunction with other treatments.

4. Yes, I am very aware of the side effects of opioids. But the balancing of side effects v. efficacy for them is a totally different issue to whether acupuncture works. There's no point abandoning opioids for another treatment if that treatment doesn't work.

5. This will undoubtedly get you typing in a fury:
http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html
:)

Alicia

sea legs girl said...

Alicia, I like how you are looking at it critically. Please note that there are not 3, but 6 randomized controlled trials with level one evidence that acupuncture is superior to some kind of therapy and some, very importantly have a control with "sham" acupuncture so the concern about non-inferiority to placebo is removed. If that isn't enough evidence for you to at least think "hmmm, maybe we should study this further with high quality studies" since the US is really the ONLY country that uses opioids to such a huge extent, then you are also in the hands of the drug companies and big industries that rule this country. WHY do you believe that opioids work so well for non-terminal pain? What is your evidence for this? And what are the risks and side-effects that go along with THEIR use? (yes, by the way, I clicked on the link you sent - the first one, I didn't read the second because it was from a non-academic source, and the conclusion in my mind was, there should be more research into acupuncture and that was in 2006 and I agree, but there have been new studies since then. Also, the fact it is acupuncture extremely effective for nausea and vomiting (vs. sham acupucture placebo) has to catch your attention. It works, I've seen it in others and experienced it myself too many times to count.

sea legs girl said...

Alicia, the additional three studies are under treatment of cancer treatment-related pain.

And so I totally agree there need to be higher quality and additional studies so it is clear exactly when and how acupuncture is most appropriate for treatment of pain. I think it is wrong based on the fact that some studies are conflicting to just say "it is all placebo". There is also no evidence that the effect is just "all placebo". A high quality dental pain study also found acupucture was superior to sham acupuncture placebo. Lao L, Bergman S, Hamilton GR, et al. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Archives of Otolaryngology—Head & Neck Surgery. 1999;125(5):567–572. It would be WRONG to ignore it as a treatment modality when there are so few risks.

Anonymous said...

I put that second link in there partly because I figured the title would wind you up, but actually it is written by a physician and is well-referenced. He discusses the poor quality of the Chinese studies and the low numbers of patients involved in most studies. One of the studies with a larger number of patients was a 2004 University of Heidelberg study of "postoperative nausea and vomiting (PONV) in women who underwent breast or gynecologic surgery. The study involved 220 women who received either acupuncture or the sham procedure at the acupuncture point "Pericardium 6" on the inside of the forearm. No significant difference in PONV or antivomiting medication use was found between the two groups or between the people who received treatment before anesthesia was induced and those who received it while anesthetized." Streitberger K and others. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: A randomised placebo-controlled patient and observer blind trial. Anesthesia 59:142-149, 2004.

Apparently that study did find evidence supporting the reduction of vomiting through acupuncture, but the authors noted that this might be due to having studied multiple outcomes.

The anti-emetic use looks the most promising to me of any of these, but then again with an antiemetic context the "normal" drugs don't have as nasty side effects as opioids, so the benefit of using acupuncture would also be less.

I never said I thought opioids worked so well--I have no opinion on that since I've never looked into it, although I have to say from personal experience I didn't find them all that effective. BUT the important difference from my perspective is that there is a clear, scientifically-sound explanation for how opioids work. So, I give them a higher level of starting credibility than I would to something like acupuncture, which *currently* has no scientific explanation ("normalizing your qi" doesn't cut it in my book!). That's not to say that we simply haven't figured out how acupuncture works (and I'm open to the possibility of that in the future), but as things currently stand, they don't appear to have overcome their initially poor starting credibility. Like I said before, your link only has one study showing an equal-to-or-better result on cancer pain than opioids alone. And, that study was published in the Journal of Traditional Chinese Medicine.

I also don't agree that there is no risk. Aside from the conflicting studies about the degree of risk of adverse effects, virtually everyone has limited money to treat a health problem, and EVERYONE has limited time. Patients need a recommendation of something that will be the best use of that time, or at the very least they need the information that acupuncture's efficacy is at best questionable and that they might want to do their own balancing of whether or not it's worth it to them. It just seems totally irresponsible to take a couple of limited studies with largely inconclusive results (never mind the studies with negative results) and say "it works! you don't need opioids!" In fact, I feel my own blog post coming on...

No doubt we will continue this tonight!! Elsa and Rodrigo said to tell you thank you so much for the invitation but they are also both sick and they want to stay home and try to sleep it off. If you still are willing to brave my germs, see you at 6.

Alicia

Jill Homer said...

I had to comment on the statue. It's the same replica of the Christus that the LDS Church uses at their Temple Square Display in SLC.

http://en.wikipedia.org/wiki/Christus_(statue)

It originated in Denmark. From a Mormon's point of view it does not represent God. Mormon's believe absolutely that Jesus and God are separate physical beings; it's part of the core of their doctrine. But they wanted to better show the rest of the world that they were Christians, so they adopted a well-known Christ statue as representation in what effectively serves as the SLC Mormon museum.

I look forward to your Elevation Trail interview! I enjoy that podcast but admit I only have listened to a handful of them. Generally I do not like to be "talked at," don't even listen to NPR all that much for that reason, and prefer to digest my information and entertainment through reading. The ongoing podcast trend somewhat disappoints me; I wish more people would write. :)

sea legs girl said...

Jill, that is fascinating info about the statue. I should say, it really is gorgeous (and enormous) in person. And one can't appreciate in this picture the 4 floors of balconies in a circle above Jesus, then I guess it is. Amazing it orginated in Denmark. What is the story there? I think of Momonism as originating in the US. How did Denmark get involved?

I know what you mean about podcasts vs. writing, but when one has a long car ride, podcasts sure are great. Seriously I loved the podcast with you. You are an exceptional story teller in written and spoken word.

sea legs girl said...

Alicia, we will continue this conversation tonight. 8-)

Dale Nesbitt said...

The podcast is out now. :)

Jill Homer said...

I meant the statue was carved in Denmark, in the 19th century, and I think still resides at a cathedral in Copenhagen. Mormonism originated in upstate New York and traveled west with the pioneers. It spread to other countries through missionary work.

I had to comment on your photo because it sparked so many memories. I was actually quite religious as a child and had a particularly strong visceral reaction during my family's visits to this statue at times. If you look closely you'll see there are scars carved into his hands that are supposed to represented where nails were driven through during the crucifixion. Once at about age 9 or 10 I had this spark of realization about his hands, and I remember feeling overcome by sadness. Interesting what childhood experiences become most memorable and affecting. My strong emotional ties to religion began to slough off as soon as I was old enough to begin questioning the logic of all of the doctrine I clung to as a confused child. I admit, though, that sometimes I miss the certainty of blind faith.

Anyway, I was wondering if you are making your way to the Bay Area soon. I'm sure you will be crazy busy, but if you have any time, send me a message and perhaps we can go out for a short trail run.

Anonymous said...

Okay it's probably too late for Jill to see this, but I just had a memory that there is some connection between Denmark and the Mormons. I can't remember exactly what it is, but I remember finding that out after being curious about why everyone in the small town in Utah where I go climbing (a bit south of Salt Lake City) had a Danish last name.

Alicia

Anonymous said...

I realized that instead of getting Jill to take the trouble to tell me about it, I could google:) So yeah, there are a surprising number of Danish Mormons:

http://www.uen.org/utah_history_encyclopedia/d/DANISH_IMMIGRATION.html

Alicia

Ana-Maria RunTriLive said...

I enjoyed the exchange on acupuncture vs opioids for pain. As a psychologist who specializes in pain management both clinically and through research, I have to draw attention to mind body therapies that combine mindfulness meditations with cognitive behavioral and acceptance based strategies. These treatments are efficacious, cheap and have no side effects. Opioids are overprescribed, at least for musculoskeletal pain, and the issue of tolerance is a huge problem (though if i have terminal cancer, please give me lots of opioids!). My understanding (though I have not checked the literature lately) is that acupuncture works because it relaxes the body; I don't think we need needles to relax the body. Of course, my contention goes against the quick fix american mindset (sorry for stereotyping); typically people prefer to take a pill of have someone do something to them (acupuncture), rather than do something themselves such as learn mind body techniques.

kathleen said...

Oh man. I get so mad about the no sidewalk thing sometimes. It would be so much easier to run, literally run to the store. But, I don't particularly care to die just yet so I drive. What fascinates me is how much easier it was to run or bike or walk everywhere in a city but now that we are out here. Way out near the Pennsylvania Amish with all this space, there are no sidewalks. The only grocery store is a super Walmart so I guess It fits. At least in summer, there's a farmers market for a few hours each week I can walk to. Don't get me started on the disconnect between all these organic farms that sell their stuff 2 hours away and everyone here buying food at Walmart. Maybe its the poverty level here?