Buy These Books!

I must tell you, my readers, about two books you must absolutely rush out and buy now. Drop what you are doing. Go to your neighborhood bookstore, or visit the online book ordering website of your choice, and get these books.

Why am I so enthusiastic about these two books (which, incidentally, I have yet to read)? Well, it's because I am friends with the authors.

The first is called "Mortified: Love Is a Battlefield." This started as a show during which people go up on stage and read particularly embarrassing passages from their actual high school journals. This sounds like a spectacular idea (as I have gone back and reread some of my own angst-ridden journal entries from age 16 and they make me cringe). Anyways, they've collected some of the more humiliating journal entries into a book, and some of them come from my college roommate and good friend Kevin Wofsy.

The second book, for all you Francophones out there, is entitled "Carnet de Grossesse d'un Apprenti Papa", which I will loosely translate as "Handbook of Pregnancy for the First-Time Father". The author is Illich L'Henoret, who happens to be the husband of the head of my French lab, Sophie Saunier, at which I worked last year at Hopital Necker. Not surprisingly, both Sophie and her daughter (who was born just before I arrived in Paris) are two of the main characters, and I can't wait to practice my French by reading it.

What are you waiting for? Go, now, to the bookstore with thee!

Boston Museum of Fine Farts

The 10-year-old living inside me cannot resist the temptation to refer to the Boston Museum of Fine Arts, which we visited yesterday for the first time with some friends, as the Boston Museum of Fine Farts. So now that we've gotten that out of the way, I can show some pictures from our day at the museum.








Sophie gets exposed to some art, and likes it.

We went to the Museum with our friend Jamil (another Renal fellow) and his family, which includes his daughter who is about 2 months Sophie's junior. They were both quite well-behaved.Although apparently Sophie still has to learn the "Do Not Touch" rule while at museums.
Open wide.
Biblical painting depicting the 7th Egyptian plague, a rain of fire.A fleet of pointilist ships.
Man jumping from ceiling (don't worry, it's a sculpture).
Horsing around with Dad.

Snow Dialysis

We've been having another respectably-sized snowstorm here in the Boston area, so of course that meant I was safely home and about to chow down on some dinner when I was paged by the hospital (I was on-call last night) at around 9pm saying that there was a patient in the cardiac intensive care unit who needed emergent dialysis. After shoveling the car and driving extremely slow behind the trucks which plow & salt the streets, I made it to the hospital, threw a dialysis catheter in, and headed home. I took the opportunity to snap some snow photos

during the trip.

Corner of Chiswick Road & Commonwealth Avenue just outside my apartment.

It's coming down in buckets.

Arriving at Mass General Hospital at night, still bustling with business.

Picture of MGH Nursing Staff from 1909.

Picture of one of our dialysis machines. This particular one is nicknamed "Lurch" because of its apparent tendency to suddenly lurch forward while being moved, resulting in the plastic containers resting on top to go flying. I've been meaning to take a picture of "Lurch" for awhile since I've long thought it amusing that any dialysis machine would be named, and especially so after the Addams Family giant manservant.

And as extra-special Sophie Bonus Coverage, here's some video of Sophie motoring around in her brand new walker. Eat your hearts out, Mom & Dad. Next lesson: steering.

Islet Cell Transplantation

We discussed pancreatic islet cell transplantation at our Friday fellow's journal club today. It may sound kind of strange that a group of kidney doctors would be discussing the pancreas, but since the #1 cause of kidney failure in the United States is due to diabetes (a defect in insulin production, which occurs in the islet cells of the pancreas), it does actually have some relevance.

The procedure sounds like something out of science fiction. When a suitable donor dies, their pancreas is harvested, then treated with enzymes to break down the extracellular glue which holds the cells together. A big gamish of pancreatic tissue is then spun down in a centrifuge in order to isolate just the pancreatic islets. Then, the recipient (somebody with diabetes who hopes to be able to get off insulin) has the islet cells injected directly into their portal vein, the vein which carries blood to the liver. The islets lodge themselves within the portal venous system, set up shop, and, with a little luck, start pumping out insulin!

The technology is really just in its developing stages, and at this stage is still controversial. It only works about half the time, and requires the islet cell recipient to take multiple new medications, many of which may be quite toxic (often to the kidney--booo!) leading to a host of other medical problems which may be worse than having to inject insulin. So there's a lot of room for improvement, but also a lot of promise.

Medical Errors

One of my Attendings, a senior and respected nephrologist at Massachusetts General Hospital, went through the following calculation the other day with me. I'm paraphrasing:

"How many patient encounters have I had during my career as a physician? Well, let's say I see 25 patients in a day--that's a reasonable number and probably an underestimate. Let's also say I work 300 days a year--which is also a reasonable assumption. Already that's 7,500 patient encounters a year. Over the course of a 25-year career, that calculates out to an astounding 187,500 patient encounters.

"Now let's also say that I'm a competent physician, and I have a low error rate--let's say I only make an error in 0.1% which would be pretty exceptional--over the course of 25 years, that's still nearly 200 patients in which I screwed up."

The Best President's Day Ever

When I first heard that President's Day is an official holiday for the Massachusetts General Hospital, I was somewhat skeptical. Who celebrates President's Day? I was, quite frankly, almost embarrassed to take the day off (as I am not scheduled to be "on-call" today).

Well, I am embarrassed no longer. Today I will celebrate President's Day as I never have before. I need this day off desperately, as I was in the hospital 'til about 1:30am last night doing emergent dialysis on a patient with a potassium that was just a few decimal points shy of double digits (that's high). Yes, a significant portion of the day will probably spent in "nap time." But that's okay.

Happy President's Day, everyone!

Superman Wins Dunk Contest

I'm not sure what it was about last night's NBA Slam Dunk Contest, but I thoroughly enjoyed watching it. I was giggling and laughing the entire way through. Probably had something to do with the fact that I was a little slap-happy after a crazy day at work.

The winner was Dwight Howard, who pulled off this impressive, high-flying Super-Man Dunk. Not bad. However, in my opinion the highlight of the night was Minnesota Timberwolves guard Gerald Glass doing "The Birthday Cake" dunk (check out the link!) in which he positioned a cupcake on the edge of the rim, lit a candle on top, and proceded to blow out the candle as he was dunking. Totally hilarious. The judges didn't totally get it (they probably should have been allowed to see the dunk in slow-mo before voting) as it didn't get a very high score, but in my mind "The Birthday Cake" easily outranked "The Super-Man Dunk."

But that's just one man's opinion.

Breaking Down BWH versus MGH

I'm taking a different approach to being on-call over the weekend. Go with the flow. Don't worry, be happy. 10 new consults on a Saturday? No problemo.

The Brigham & Women's Hospital (BWH, located in Brookline) and the Massachusetts General Hospital (MGH, located in the Beacon Hill neighborhood of downtown Boston) are two of the premier medical centers in the world. Being located in the same city and both serving the Harvard Medical School, they are not surprisingly historic rivals (even though they are now officially both part of the same health care system, Partners).

I work at both hospitals, roughly 50% of the year at each place. How do the two cutting-edge medical centers compare with one another? I've rated them in a number of key categories. This is one man's opinion.

Category One: Ease of Chart-Finding.

Disadvantage: MGH. I spend a good chunk of my time wandering around the patient floors at MGH frantically looking for the green and gray charts each patient has which are essential for figuring out what's going on (good forbid we ask the patient, right?)

Category Two: Cafeteria Quality.

Disadvantage: BWH. This is a close one, as both are pretty nasty, as hospital cafeterias tend to be. The disadvantage goes to BWH for having an unimpressive selection of greasy food.

Category Three: Elevator Speed.

Disadvantage: BWH. Trying to get up to the top floors during the middle of the day at BWH can be a twenty-minute affair. Just painful.

Category Four: the 5pm Consult.

Disadvantage: MGH. Nothing can quite explain the demoralizing effect of the consult inexplicably called at 5pm, or the Dialysis patient who has missed his Saturday dialysis appointment and shows up in the ER late in the day, that must be seen before the end of the day. Perhaps it's the larger patient volume at MGH but this tends to happen a little more at MGH than at BWH.

There you have it, folks: MGH and BWH, the two Harvard-associated beacons of cutting-edge medical therapy in Boston, are on approximatyle equal footing when they are rigorously compared with respect to these all-important medical categories. (And if you think I'd honestly publicly state my preference for one hospital or another while still a fellow in this dual fellowship program...well, that just wouldn't be all that bright...)

Happy Valentine's '08

How did you spend your Valentine's Day this year?

I just spent a wonderful evening watching the latest episode of "Lost"' before a fine dinner while sipping some red wine. Pure hedonism.

Here's to a Happy Valentine's Day 2008.

Happy Girl

Sophie has been in an exuberant mood lately. It's refreshing to see somebody who is experiencing such unadultered happiness so frequently--often she is so happy she will simply waves her arms wildly in the air with glee. I consider myself a guy who is generally in a good mood on most days--but I don't get that happy. If only to be transported back into the body of a 7-month old, if only for a little bit.

Thoughts for the Day:

It's still too cold outside, especially waiting for the T to come at 5:30am.

I see one of the Chicago Cubs' players recently made a prediction during spring training that the team would win the World Series this year, the 100th Anniversary of their last World Series victory, in 1908. Doesn't bode well for the Cubbies this year...

I know in my heart that President's Day is not a real holiday--but I have never been so excited to celebrate it as this year, as I just found out I get a day off for President's Day--a welcome respite as I am slated to be on-call for the immediate preceding weekend.

Dialysis

This is a picture of the 1st dialysis machine, invented by the Dutch physician Willem Kolff in 1943-1945.

Up until this invention, the diagnosis of renal failure was synonymous with death. In fact, the first 16 patients that Dr. Kolff tried to dialyze went on to die. However, the 17th patient, a 67-year-old woman admitted to the hospital with acute kidney failure, was saved after a week-long treatment with the device, and went on to live an additional six years after her kidney function had returned to normal. Now there are about 375,000 patients in the U.S. alone who continue to survive based on the invention of dialysis.

I'm currently doing the Dialysis rotation at the Massachusetts General Hospital. Each day I help supervise the dialysis treatments of probably about 15 patients. I'll be the first to admit that there's a lot of problems with dialysis--but for many patients it's literally the difference between life and death.

Witch-Hunting

As a little excursion yesterday we drove up north about 45 minutes to visit Salem, MA, home of the infamous Salem Witch Trials of 1692. Despite it being home to one of the cheesiest and lamest museums I have ever visited, we had a fun time meandering around time seeing the historic sites and checking out the ice scultpure festival around town. Some pics:






Claire at the wharf with the schooner "Friendship" in the background.
Even though it may look cool from the outside, this museum is a total waste of $8.
Mural on the outside of the Salem Pirate Museum.
House of the Seven Gables, thought to be the inspiration for Nathaniel Hawthorne's 1851 novel.
What visit to Salem would be complete without a trip to "The Bunghole?"


Sophie & her grandparents unwind.

Grandma & Grandpa Visit!

Grandma Pat and Grandpa Rick are visiting Boston this weekend! Sophie is quite excited and we are currently planning on taking a driving trip up the Massachusetts shore heading towards Salem and possibly Ipswich, provided I can get my Dad to stop watching a stupid fishing show on T.V. and get ready. It's good to have everybody together again.

We also went out to dinner last night with one of our friends from Duluth, Nils, and his wife Lisa.

Have a good weekend, all!

Super Tuesday 2008

Random thoughts after an exhausting day at work:

Super Tuesday! I managed to escape from work for just long enough to cast my vote.

I gave my Renal Grand Rounds presentation on a case of cryoglobulinemia-induced kidney injury, and am glad I can check this box off on my ever-increasing "To Do" list.

My patient list has rapidly expanded to more than 30 patients. A whole lotta dialysis going on.

I think I've mentioned before that my year in France (during which I would watch American TV shows dubbed in French as an educational tool) left me totally addicted to the TV show "Lost." The premiere last Thursday was brilliant and leaves Losties like myself with a whole host of questions. My prediction? I still subscribe to the "Time Travel" theory. The "Oceanic Six" (probably Jack, Kate, Hurley, Ben, Sun and Jin) were somehow offered a deal to leave the island under the promise that they would not reveal the secrets of the island and in doing so abandoning their other island-mates, an action which causes them to become profoundly unhappy and guilty. The last season of the show will involve them figuring out a way to get back onto the island. I'm nearly inspired enough to buy a Hurley action figure at some point.

Laure et Sophie

Here's a picture of Sophie (looking much older than she actually is, in my opinion) and Aunt Laure in Paris from last week!

The Boston community seemed a little hung-over and grumpy today, no doubt due to the giant let-down of their Super Bowl loss to New York last night. I saw the game last night with some friends; it was kind of a dull game up until the 4th quarter. I think of the 4 Super Bowls the Patriots have played in recently, this is the only one I was openly rooting for them to win...and consequently the only one in which they lost. Coincidence?

How Nate Would Fix U.S. Health Care

I'm not running for President in 2008 but have been thinking a lot about how royally f'ed up the U.S. health care system currently is. Although I do enjoy helping people deal with their kidney disease on a day-to-day basis and can point to numerous instances of success, there are certain cases I am involved with duI'ring which I can't help shake the feeling that I am also helping propagate this ridiculous health care system which is not sustainable in its current form.

Three things I would do to improve the system:

1. Universal Medical Records. I have talked about this on my blog before. One computer information system for everybody. Eliminate paper charting. This would save oodles of dough and improve communication between doctors, resulting in less duplication of expensive medical tests and overall better clinical care. I heard Hillary Clinton speaking about moving towards a universal medical records system recently and I couldn't agree more.

2. Limit care in medically futile situations. One of the reasons our medical costs are so astronomical is that our resources are allocated so poorly. Specifically, we are spending too much money on patients with advanced medical illnesses in a misguided attempt to prolong their lifespan at the expense of a reasonable quality of life, and too little on preventable disease. I can point to numerous examples of this since starting my renal fellowship, the most obvious one being an elderly man who underwent a heart valve replacement surgery and had a very difficult post-operative course which involved, among other things, kidney failure and low blood pressure requiring him to be hooked up to a special dialysis machine which was running 24 hours a day and required the presence of a single nurse to be with this patient at all times. He was on this kidney machine every day, 24 hours a day, for a period approaching 4 months before he expired. I feel guilty when I think about (a) the suffering this patient likely endured over this extended period of time, and (b) the amount of vaccines, antihypertensive agents, and pediatric checkups which could have been paid for with this single individuals' medical bills.

I think most physicians involved in this case probably felt that this had gone on for too long, but for whatever reasons, these concerns were not voiced until the very end. Why did this happen? Some of the fault lies with us doctors: there is a culture of not giving up at any costs, which in a sense is noble, but at the same time our degree of medical sophistication has evolved to the point where we need to realize that just because we can do something for a patient doesn't necessarily mean that it is appropriate. Second, our country has moved too far towards giving the patient decision-making autonomy and away from the traditional paternalistic model during which the physician makes the "best decision" for a patient. This is accomplished in the transplant community--there are only so many liver transplants to go around, for instance, and it is up to a panel of physicians and other health care providers to decide who is eligible and who is not--because the organ supply is seen as a limited resource. At some point, high-priced medical procedures should also be categorized as "limited resources" since our medical funding is not unlimited. Finally, I think another reasons doctors are reluctant to limit outrageous medical spending in helpless medical cases is that they are concerned about the possibility of a lawsuit which could destroy their medical career, resulting in the current practice of "defensive medicine" in which many unnecessary tests are ordered. Which leads me to my next point:

3. Put a cap on medical lawsuits. I agree that we must preserve the right for patients to sue doctors for gross negligence--I would be nieve if I stated that all doctors are altruistic and cannot be held accountable for obvious mistakes such as sawing off the wrong leg or missing an obvious diagnosis of a treatable cancer. However, for the most part doctors are a hard-working bunch who sacrifice a great deal of personal time in order to help achieve a good outcome for their patients, and it really bothers me to see "good samaritans" such as these to be scape-goated and sued. Furthermore, million-dollar lawsuits results in driving up malpractice rates for doctors and health care insurance premium for patients. If there were a "cap" on the amount somebody could sue for, this might help limit these expenses. I know it is impossible to put a value on human life, but at the same time such large sums of money are a huge burden to society.

So there you have it. Three easy-as-pie steps to fix the U.S. health care system.

On a lighter note, GO PATS. They play in the Super Bowl in about an hour.

Here is the all-too-short list of professional sports teams who have won a championship while I was living in that city:

1987 Minnesota Twins
1991 Minnesota Twins
2000 St. Louis Rams
2007 Boston Red Sox
2007 New England Patriots?

Welcome Back Sophie & Claire

I'm feeling much better after that 24-hour flu bug fortunately. And hopefully recharging the batteries with this wonderful Super Bowl weekend off.

Welcome back to Sophie & Claire, they had been in France for the week for Claire's job. It's good to have them back, and Sophie's learned a few new tricks during her absence, including some cool new lip-smacking noises and the beginnings of what I genuinely believe is a purposeful hand-wave. Let's face it, our kid's a total genius.