Needed to share this song

I really like this song

and wish the B.E.P. would make a music video of it

It rained all day in Cleveland today

and I felt rather out of place wearing my brown dress, with my silk scarf.

I came home and packed, for what feels like the umpteenth time in my life. It was strange to see what I had accumulated and had not during the past four years. My books I can still not let go, though I am giving away some medical books that the internet has since replaced. I threw away some photos and memorabilia from friends in the past - sad to see them go, but new keepsakes and loves need their room in both space and the heart. I anticipate feeling a twinge of sadness when my apartment looks empty again, prepped and sterilized for the next new tenant.

I have been reading Patti Smith's "Just Kids." Her sense of memory resonates with me. I know how vivid it all can be. Some things never quite leave you. I wonder if, in time, I, too, will extrapolate the great quiet messages that accompany our strongest memories, and how my feelings will change.

I think I shall take up writing again. Too much goes by and gets lost in the frenzy of intern year. Just a few snippets a day. Just like I did in high school. That's my therapy to myself.

I would like to...

... write sestinas
... stop thinking about certain people at inopportune times
... go for long walks along the canal
... enjoy the sun and friends before med school ends

Detox

My cup is too full.

I don't care what nerve says....

I think this is pretty damn good!

"Hysteric"

It's a pretty good one, and ideal for those end of years. If only the Yeah Yeah Yeahs had made a video of it!

An Admonition: "While there's life, there's hope." (Cicero)

I feel split between two selves.

One: content and proud to feel useful to the world, beers on 2nd floor white-washed balconies, private dance-a-thons with the ipod on at 2 am, blissful in running, flirtation and smiles, balanced and respected.

The other: restless and disappointed, fucked up erotic dreams about people whom I never had much love for in the past, crying the average 2 hrs a week, angry and avoidant, full of poor coping mechanisms.

This is how I have felt since my teens, and age - while having dulled my initial emotions - has not mitigated this. I wonder if I am both of these personas, and if I always will be. Or is one the real me and the other the abberation? And if so, which is which?

the new year comes

... and we are all moving on in this elusive life.

Thoughts on the Inteview Trail

A Prayer: May the good forces that be prevent this post in any way from preventing me from attaining the residency of my dreams.

I've been on the interview trail this month and the last, and it's been something of a jarring experience.

For one, I really hate the process of interviewing. It is so difficult to explain yourself to someone - and to make them love you - in 15 to 30 minutes. What do you focus on? Your personality? Your potential? What if there is a dichotomy between who you are at work and who you are at home? What if you haven't worked out the balance yet (which I haven't)? How can I possibly feel comfortable telling a stranger all of these things when I am too private to tell some of my best friends this?? The solution, of course, is just to present a facade of yourself, something cut and dry, pretty and pressed - and that's why I hate it.

Being on the interview trail, and having little to talk about during the socials besides things related to medicine, also makes me realize - as my friend Ravi says - how NOT FUN we've all become. According to Ravi, the things that used to be fun - the things that other people do - seem trite to him now. To me, it's something even worse - it's not the activities themselves that seem trite, but the excitement of my friends towards these activities. Drinking, flirting, being "artsy" - I find myself getting annoyed with people taking pleasure in these things, and especially if they are proud to be labeled good drinkers, flirts, or artists. I can't relate, and feel, as Andre Gide describes in The Immoralist, "dull, sad, inept, both boring and bored."

When did I become this horrible person? Lacking pleasure in life, convinced that I know more miseries than others, unable to relate? I feel that I need to reconnect with the world, but I simultaneously intuit that this feat cannot be accomplished until I take the proper time to change my own mindset first. I need to feel at peace, I need to get rid of baggage, and I need to be productive and creative again.

Steph might scoff at me for this. Did I learn NOTHING from Loneliness? The alienated and bereft must reach out to others in order to fix themselves. And perhaps she is correct. I still remember the immense gratitude I felt when the random old lady in Long Island recognized my unhappy face and tried to make chitchat with me while I waited for my (late) taxi cab in the bitter cold. I feel bad that I never thanked her. Working other people in, though, is an issue of time, of which I have precious little and obviously I still need work on time management.

There is too much to correct for me to even bother making New Year Resolutions this year.

A Sestina

This lovely piece was found in my bathroom, placed there by my sister. For more about Peter Cole, the author, see here.

"Improvisation on Lines by Isaac the Blind"

Only by sucking, not by knowing,
can the subtle essence by conveyed -
sap of the word and the world's flowing

that raises the scent of the almond blossoming,
and yellows the bulbul in the olive's jade.
Only by sucking, not by knowing.

The grass and the oxalis by the pines growing
are luminous in us - petal and blade -
as sap of the word and the world's flowing;

a flicker rising from embers glowing;
light trapped in the tree's sweet braid
of what it was sucking. Not by knowing

is the amber honey of persimmon drawn in.
An anemone piercing the clover persuades me -
sap of the word and the world is flowing

across separation, through wisdom's bestowing,
and in that persuasion choices are made:
But only by sucking, not by knowing
that sap of the word through the world is flowing.

Today in useful studies

"Falling TV Deaths Remain Concern Amid LCD Fad"

Quick, somebody get the government to take away all old TVs! FOR THE CHILDREN!

New ACOG Cervical Cancer Guidelines and NE Interviews

New cervical cancer screening guidelines have been put forth by ACOG. Some highlights;

• Cervical cancer screening should begin at age 21 regardless of age at onset of sexual activity.
  
• Cervical cytology screening from age 21 to 29 is recommended every 2 years but should be more frequent in women who are HIV-positive, are immunosuppressed, were exposed in utero to diethylstilbestrol, or have been treated for cervical intraepithelial neoplasia (CIN) 2, 3 or cervical cancer.
  
• Women aged 30 or older who have three consecutive negative screens and who do not fit the above criteria for more-frequent screening may be tested every 3 years. Co-testing with cervical cytology and high-risk HPV typing is also appropriate; if both tests are negative, rescreening in 3 years is warranted.
  
• Cervical cancer screening is unnecessary in women who have undergone hysterectomies for benign disease and who have no histories of CIN.
  
• Discontinuation of screening after age 65 or 70 is reasonable in women with 3 or more negative consecutive tests and no cervical abnormalities during the previous decade.
  
• Women with histories of CIN 2, 3 or cancer should undergo annual screening for 20 years after treatment.
  
• HPV vaccination does not change these recommendations.

I'm publishing this post partially so I will remember these new guidelines as well.

Meanwhile, I'm having a lot of fun on the interview trail, even if it is somewhat exhausting. Walked around Rockefeller Center with some friends today, and it was nice that they came out, even if they were sick. About to watch a movie and eat Chinese take-out with old friends - it's nice to relieve college as an adult :-)

Wild Things

What was most powerful about the movie was the accuracy with which it portrayed the angry powerlessness of youth. Where it missed was in thinking that young adults (which was definitely what it was aimed at) would still think "Don't be selfish" is a profound lesson. Yeah, we know already. We're Catherine Keener, not Max Records.

Dorelan is the best!!

I have the sweetest roomie EVER!!

There must always be a reason

Unless there is a direct cost to US taxpayers from elective cosmetic surgery paid for out of pocket, I don't agree with a tax on plastic surgery.

****
WASHINGTON (AFP) – Americans opting to have surgery to suck out fat, grow or shrink breasts, shape their nose or banish wrinkles may pay for a health care overhaul that was unveiled by US Senate Democrats.

The White House-backed plan would impose a five-percent tax on elective cosmetic surgery that is estimated to raise an estimated 5.8 billion dollars over 10 years towards the 849-billion-dollar plan.

The measure exempts plastic surgery done to remedy a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.

Individuals who seek purely elective procedures, which are typically paid for directly out of patients' pockets, would have to pay the new tax starting in January 2010.

The global economic recession has not dented US demand for cosmetic surgery procedures, which were up three percent in 2008 to 12.1 million procedures, according to the American Society of Plastic Surgeons.

But breast augmentations were down 12 percent from 2007, to 307,230, while wrinkle-banishing Botox injections were up eight percent to just over five million procedures.

The legislation does not exempt US lawmakers.

Today in the life....

Today, the Obama administration reports that over $98 million dollars of taxpayer dollars was improperly used in 2009. In particular, it notes improper payment rates of 7.8 percent and 15.4 percent in the Medicare fee for service and Advantage programs, respectively. While no one contests that Medicare and Medicaid has poor mechanisms in place for filtering out waste and fraud, I think it's important to point out that a lot of these "improper" payments is defined as such by lack of proper documentation. Anyone who works in healthcare can give testimonial as to how burdensome and confusing government documentation is, and I have to wonder how much of this money was truly improperly spent, or merely appears to be because busy healthcare workers don't have the time to fill out the reams of government paperwork required for simple indicated procedures.

Also, the Augusta Chronicle reports that applications to the Medical College of Georgia are 4 percent higher than last year, outpacing the 0.1-percent national increase. Not surprising considering that, despite astronomical tuition increases from 2006 to present, MCG still remains a competitively priced medical school with decent residency admit numbers. Alumni truly cast a wide net, as evidenced by the Chair of my residency interview today graduating from MCG.

Finally, I am finally back in GA after an exhausting and eventful two months! Here is the song that's been getting me through the past few days...

From the Healthcare Economist

Health Reform Bill Passes in the House: Who wins and who loses?

November 9, 2009

A Health Reform Bill passed in the House despite declining support among the American people. The Kaiser Family Foundation has a nice summary of what is included in the bill. Today, I will review who wins and who loses from different aspects of the bill.

Individual Mandate.

• Winners: High cost individuals. Premiums (may) decline if younger, healthier individuals are forced to buy insurance and the insurance companies. This will only decrease premiums, however, if insurance companies can’t charge lower rates to these healthier individuals.
• Losers: Those who don’t want health insurance or can’t afford it. All individuals will have to pay a penalty if they do not buy “acceptable health coverage.” Low-income families are exempt from this requirement.

Employer funding requirements.

• Winners: Requiring employers to pay for health insurance simply means that individuals will see lower wages in the long run. The big winner here is big business. They already provide health insurance for their employees. Small company competitors however
• Losers: Health insurance is more expensive for small companies. Making them pay for health insurance will drive up their costs and force them to cut wages more than big businesses will. This may make working at a small firm less attractive, especially for younger employees. However, the smallest companies are exempt from this requirement and the government will provide subsidies to cover some health insurance cost initially.

Expand Medicaid to all individuals with incomes below 150% of the Federal Poverty line (FPL).

• Winners: Lower middle class individuals who are now covered by Medicaid who were not in the past.
• Losers: Taxpayers.

Require CHIP enrollees with incomes above 150% FPL to obtain coverage through the Health Insurance Exchange.

• This depends on how well the Health Insurance Exchange works. If it is an efficient system, poor children could get better coverage and the taxpayer bill could decrease. Or poor children could get worse coverage and the taxpayer bill could increase.

Subsidies to individuals with incomes below 400% of the FPL to to obtain coverage through the Health Insurance Exchange.

• Winners: Middle class families not eligible for Medicaid who now will received subsidized insurance.
• Losers: Taxpayers not eligible for the subsidy.

Reinsurance program for individuals aged 55-64.

• Winners: Employees of this age bracket. They will be more attractive to employ since their health care costs will be capped.
• Losers: Taxpayers not aged 55-64.

Tax of 5.4% on individuals with modified adjusted gross income exceeding $500,000 ($1m for families).

• Winners: Individuals getting subsidies, expanded public programs, etc.
• Losers: The Rich.

The Public Option and the Health Insurance Exchange.

• Here, the devil is in the details. If the Public Option provides superior health care at lower cost, everyone wins (except private insurance companies). If the public option provides superior health care but runs a deficit every year, consumers will win while taxpayers and private insurance companies will lose. If the public option loses money and provides low quality care, everyone loses except for government employees now hired to run the public option. Similarly, the health insurance exchange may provide more choice to consumers, a standardized benefit package so the consumers can price shop, or it may reduce insurance choice by limiting the products insurers can offer.

Savings from Medicare and Medicaid

• Winners: If the savings come from reduced waste, Medicare enrollees will benefit (fewer unnecessary procedures will increase their health) as will the taxpayers. However, if the savings come from cuts to necessary services, Medicare enrollees will be harmed.
• Losers: Doctors and hospitals. Cuts to Medicare mean that doctors and hospitals will get less money. If the cuts are from waste, only inefficient doctors will see their earnings hurt. If the cuts come from necessary care, then good and bad doctors will see their incomes fall.

Fascinating!

but also reminds me a bit of the beginning of I Am Legend :-)

New gene therapy halts 2 boys' rare brain disease

By LAURAN NEERGAARD, AP Medical Writer Lauran Neergaard, Ap Medical Writer – Thu Nov 5, 5:12 pm ET

WASHINGTON – French scientists mixed gene therapy and bone marrow transplants in two boys to seemingly halt a brain disease that can kill by adolescence. The surprise ingredient: They disabled the HIV virus so it couldn't cause AIDS, and then used it to carry in the healthy new gene.

The experiment marks the first time researchers have tried that long-contemplated step in people — and the first effective gene therapy against a severe brain disease, said lead researcher Dr. Patrick Aubourg of the University Paris-Descartes.

Although it's a small, first-step study, it has "exciting implications" for other blood and immune disorders that had been feared beyond gene therapy's reach, said Dr. Kenneth Cornetta, president of the American Society of Gene and Cell Therapy.

"This study shows the power of combining gene therapy and cell therapy," added Cornetta, whose own lab at Indiana University has long researched how to safely develop gene delivery using lentiviruses, HIV's family.

The research was published in Friday's edition of the journal Science.

In 20 years of gene therapy research, there have been few home runs and some headline-making setbacks — including a risk of leukemia caused by otherwise successful gene therapy for another rare disorder, "bubble boy disease." That's a risk that specialists hope a lentivirus-based gene therapy will eliminate.

Best known from the movie "Lorenzo's Oil", adrenoleukodystrophy, or ALD, is a rare genetic disease that, in its most devastating form, destroys the coating of nerve fibers in boys' brains. Without that coating, called myelin, the neurological system breaks down. The disease typically strikes between the ages of four and 10, leading to blindness, deafness, dementia and loss of muscle control, and killing them within a few years.

Bone marrow transplants can halt ALD by letting new myelin-forming stem cells take root. But it's difficult to find a matching marrow donor, and the transplant itself is very risky.

So what if stem cells from the boys' own bone marrow could be genetically corrected, eliminating the ALD mutation? To do that, Aubourg's team had to overcome a technical hurdle: Gene therapy works when scientists harness deliver a healthy new gene by attaching to a virus that can harmlessly infect cells. But none of today's so-called gene therapy "vectors" could penetrate enough of the stem cells needed for an ALD treatment to work.

Unlike most viruses, HIV can penetrate stem cells, and it sticks permanently. So Aubourg's team removed the genetic parts of HIV that make it dangerous, leaving basically a scaffolding to carry the new therapeutic gene.

Then they culled stem cells from two 7-year-old boys in the early stages of ALD, and mixed in the healthy gene. The boys underwent bone marrow-destroying chemotherapy and then had their genetically corrected stem cells reinserted.

Two years later, the boys have shown no sign of worsening brain damage and are functioning well with 15 percent of their blood cells producing the healthy protein, said Aubourg, who plans to test the experimental procedure in more patients. An advocacy group, the Stop ALD Foundation, is working to raise money for a similar U.S. study.

Fertility, Family Planning, and Female Social Progress

Key excerpts from a fascinating Economist article about the dropping global fertility rate:

"The move to replacement-level fertility is one of the most dramatic social changes in history. It manifested itself in the violent demonstrations by students against their clerical rulers in Iran this year. It almost certainly contributed to the rising numbers of middle-class voters who backed the incumbent governments of Indonesia and India. It shows up in rural Malaysia in richer, emptier villages surrounded by mechanised farms. And everywhere, it is changing traditional family life by enabling women to work and children to be educated."

"Indonesia’s Family Life Survey showed that, on average, each birth reduced by a fifth the likelihood that a woman would have a job—lowering household income and pushing some families into poverty. So smaller families made middle-class status more likely. Between 1974 and 1996, Bangladesh turned a district called Matlab into a giant demographic experiment: some villages and households got family planning, others did not. According to one study of the results, fertility in the areas that received help declined by around 15% more than in those that did not. And over the two decades of the experiment, indicators of the well-being of women and their children—health, earnings, household assets and so on—were all higher in the villages that got the planning."

"A surprising amount is known about how many children parents want, thanks to a series of surveys by the Demographic and Health Surveys programme. The picture it paints is of huge numbers of unplanned pregnancies. In Brazil, for example, the wanted fertility rate in 1996 (the most recent year available) was 1.8; the actual fertility rate then was 2.5. In India the wanted rate in 2006 was 1.9, the actual one, 2.7. In Ghana the figures for 2003 were 3.7 and 4.4... One study in 2002 estimated that as many as a quarter of all pregnancies in developing countries in the 1990s were unintended. Yet another found that more African women say they want to use contraceptives but cannot get them (25m) than actually use them (18m). Unmet demand in turn implies that fertility in some countries could be even lower than it actually is if more family planning were available."

"Another big reason why fertility is falling: the spread of female education. Go back to the countries where fertility has fallen fastest and you will find remarkable literacy programmes. As early as 1962, for example, 80% of young women in Mauritius could read and write. In Iran in 1976, only 10% of rural women aged 20 to 24 were literate. Now that share is 91%, and Iran not only has one of the best-educated populations in the Middle East but the one in which men and women have the most equal educational chances. Iranian girls aged 15-19 have roughly the same number of years of schooling as boys do. Educated women are more likely to go out to work, more likely to demand contraception and less likely to want large families."

Looking at these facts, how can you possibly argue against family planning unless you just don't care as much about the lives of the living as your own personal principles?