Thou shalt hear a voice saying "this is the way, walk in it."

That's the Scripture passage I think about periodically when my my very bored, monotone sounding GPS system talks to me.

Her favorite phrases seem to be "recalculating" or "turn left" or "turn right" or "arriving at destination." I have often wondered what sort of adventure it would take to make her seem less bored. However, no matter how many wrong turns I make and regardless of the rate of speed I make them at, she always sounds very bored.

I felt a little foolish plunking down the money for the system several months ago. I feared that it would be some electronic gadget that would lie around collecting dust after minimal use. However, two months into my time in Houston, it has proven to be a lifesaver and has probably payed itself off in gas saved by not wandering aimlessly around this sprawling metropolis. It is quite phenomenal really. I can type in "post office," and it almost immediately lists the five nearest post offices.

Recently someone asked me how to get to one of the hospitals I have been to a number of times. I gave them a blank look and replied that I really had no idea... I just followed my GPS.

My only complaint is that it sometimes makes me do things that I think are downright cheating. For instance, I was in a traffic jam the other day, and it told me to get off at the next exit. I did so, thinking it had calculated some wonderful backroad plan for getting me to my destination. A la contre, it immediately got me back on the same highway at the next entrance, probably having gained me two car lengths by getting off and on the highway. However, she sounds bored even when executing such devious plots.

Can't we just call a duck a duck?

Have you ever wished that politicians could just honestly present realities? Two recent examples come to mind in which politicians say that our society can achieve mutually exclusive goals.

The first is the attempt to become more environmentally responsible while trying to stimulate the economy. Basically, consumerism involves the consumption of natural resources. The extraction and sale of these natural resources creates jobs which is great for the economy, however it is really lousy for the environment. So while "cash for clunkers" is great for the economy, it really is bad for the environment. The reality behind this debate is that people in the USA consume too much. As a country, we need to lower our standard of living to something that is sustainable.

The next example is the health care debate. Obama is promising to socialize health care while not decreasing people's current access to care and also not increasing the deficit or taxes as a result of doing it. That is sheer lunacy. The president also struggles with the facts of the debate. In a recent speech, he stated that we need to spend more money preventing and managing diabetes rather than paying a surgeon $50,000 to do a leg amputation for it. I agree about the prevention part, but disagree about the surgeon part. Surgeon's do not get paid even $1000 for an amputation. Furthermore, the fee they do receive for the amputation includes all of the care they provide to that patient for the 6 week postop period, they also have to pay office costs and malpractice costs out of that fee.

President Obama also said that we can save costs by using cheaper equally effective treatments. He gave this example. "If there is a blue pill that works just as good as the red pill, but costs half as much, we should use the blue pill." I agree. However, the problem is that often times the red pill works 20% better than the blue pill, but costs 3 times as much. Patients who are not paying for the pill themselves think they deserve the red pill.

Our healthcare system spends horrible sums of money on treatments that only very marginally improve outcomes. We also spend tonnes of money on people who are going to die in a matter of weeks no matter what you do. For example, Avastin is a drug used for chemotherapy in colon and rectal cancer. It was found to increase survival from 8 months on average to 10 months on average. Basically if you took the drug, you were on average going to live 2 months longer than someone who did not take the drug. That's great right? The problem is, that a course of chemotherapy with this drug costs $30,000. Another example is the terminally ill patient whose family has not accepted the fact that they are going to die imminently. The patient gets lots of blood transfusions, radiographic studies, blood cultures, antibiotics, and other meds all to very marginally delay what all of the healthcare providers know is an imminent death. However, Americans believe that they have a right to receive any medical test or intervention that might possibly be of any benefit no matter how miniscule regardless of their ability to pay. We already have socialized medicine. This is all just an argument about who is going to pay for it.

What currently happens in the healthcare system is that when you show up in an emergency room, that hospital is obligated to take care of you regardless of your ability to pay for it. It is like showing up in your local grocery store, declaring that you have no food whatsoever at home, and expecting them to load up your grocery cart with free groceries since no one can live without food.

What needs to happen in our healthcare system is an honest discussion. We all die. We need to be more comfortable with our individual mortality. We also need to decide at what level a treatment becomes prohibitively expensive. In other words, at what level does a treatment become so expensive that it is too expensive to be the standard of care?

I think the Democrats have been brave to tackle this minefield of an issue. The status quo cannot continue. However, I would really like to hear the president say that part of the answer to the healthcare issue is an acceptance that death eventually finds us all and that we cannot afford every invention that medical technology brings us. The benefits of a treatment need to be weighed against its cost.

Endings

The residency thing has gotten down to the last few weeks. Its sort of hard to imagine life in another place doing something else. I've been at my current address longer than anywhere I've lived in the last 16 years -- and I've liked it here. Chattanooga has been my favorite place to live since leaving northwestern Ontario. It has a sense of history, scenic beauty, and just plain old livability that I haven't found in the other places I've been.

I'll especially miss my coffee shop haunt -- Stone Cup. The people there are usually some sort of weird combination of anarchists/communists plotting the transformation of civilization by overthrowing it, church youth groups doing Bible studies and prayer meetings for all in the vicinity to hear, hippies just wanting a warm place in the sun, anemic looking academic types who are looking for a place to study, the gen-Xers looking for a cheap internet connection, and then all of the normal people like me. The anarchist/communist group is my favorite because they gave me a free bagel one night. I think the older members of the group are communists while the younger ones are anarchists. In addition to all of the folks that show up there, I like Stone Cup because it has a gorgeous view of the city -- the Tennessee river, the lighted walking bridge across the river, Coolidge Park and its carousel, the Hunter Museum, the Tennessee aquarium, and of course the Smoky Mountains.

Yep, Chattanooga has been a nice spot to park for a few years.

Islands colliding in the mist

I have spent the last three months on the "orange service." It is the service where we as residents are given the most autonomy in patient care. It has at times been a stretching experience and has at times been quite rewarding. There isn't anyone much more grateful than the patient who has had a colostomy reversed, a cancer removed, etc.

The tough part of the job is being the one to have "the talk" with the person you've just discovered has a cancer. Its especially difficult when the prognosis is clearly not amenable to intervention for cure. I've often thought that at some level that moment isn't fair to either doctor or patient. The people I deliver this sort of news to are people whom I have often not spent more than an hour with, at least where they were conscious. I have no idea who they are, what sort of life they have constructed, what their belief system is like, and cannot anticipate how they will handle the news. By the same token, the patient has no idea who I am, what my belief system is, and whether I feel comfortable with their displays of emotion. The terminal cancer talk, which can be one of the most devastating things anyone ever tells you, takes place between two utter strangers.

Some folks and their families degenerate into rather noisy, dramatic displays of emotion. Others are very matter of fact about the whole thing. Interestingly, people of faith are usually the most unreasonable about accepting a diagnosis of a terminal illness. We in communities of faith like to talk about how we have a reason beyond this life for living, how we are not afraid of death like nonbelievers, etc. However, I have seen these families torture their loved one with weeks or months of futile, agonizing care because "God is gonna heal momma." I remain baffled as to why many non-believers are more accepting of death than believers are. Is it that at some level they recognize it as a normal part of the life cycle? Is it that Christians somehow view God's purpose being one of protecting them from bad things, rather than their purpose being one of eternally worshipping God?

Send more catnip

I'm usually of the opinion that there is a reason why the ancient Egyptians worshipped cats, not dogs. I mean who would ever mistake a dog for a deity? They are known to eat their own feces after all!! To make matters worse, after eating something nasty, they want to lick your face. Definitely not a candidate for the false god list.

My cat is usually a well-mannered, well-behaved critter. However, this winter she has developed a bad habit that recently left me with a rather stiff neck. Cats have this passion for finding the warmest place on the premises and then parking themselves there.

I had been working on some documents on my computer for awhile, and decided to take the trash out. When I came back, my cat was sprawled comfortably across the computer keyboard, presumably for the heat generated by it.

Once I had kicked her off of my computer, I discovered that the screen now was presenting things upside down. I would have had to turn the screen 180 degrees to have the display back in the usual anatomic position. I figured fixing it wouldn't take very much time... I mean if a cat could figure out how to adjust the display so that she could read it while her head was upside down, it shouldn't be that hard. About an hour later, after trying every computer control screen on the system, I had a very stiff neck and still had an inverted image on my screen.

Fortunately, Al Gore invented the internet for us years ago, and I eventually googled fixing the upside down screen. It turns out toddlers have been pulling this trick for decades, and after reading the upside down advice on google, my screen was righted.

Now if I could only figure out how to keep the cat away from the computer. Yesterday she locked the keyboard. However, she was kind enough to leave the instruction panel displayed on how to unlock it. So if you get an email from my address asking for catnip, please disregard it.

Long time no post

Yeah, I've kind of been busy.

My life in Chattanooga is sort of on a downward slope now. I'm trying to get some of those remodelling projects done that I've been procrastinating about so that my house will sell. I've even started packing some stuff. The fact that I won't need that stuff for several months is a sign that it might be better served by being taken to the dumpster. Maybe my little sister was right though, stuff has feelings too.

Fortunately the real estate market in Chattanooga really hasn't declined at all. Property prices are pretty stable from where they were at a year ago. Hopefully that will hold until my place is sold.

I've found the economic politics of the last year to be very interesting. Both parties have missed the key point about the housing collapse... the problem was due to people consuming more than they were able to afford. People took on more debt than they were able to handle. The solution to this is to give banks gazillions of dollars, and then chastise them when they don't lend the same way to the same people who got us into this mess to start with. On a federal level, the consensus seems to be that the problem can be solved by the government spending massive amounts of money and thereby taking on massive amounts of debt. Wasn't it debt that created this problem in the first place? What ever happened to people trying to live within their means?

Recently someone commented to me that at least things can't get any worse. I was rather baffled that someone could say something like that, and asked them if they had ever been to Haiti. People feel entitled to our current way of life, and have no concept of what most of the people in the rest of the world live like. I'm sure that Obama will soon wave the magic wand that he promised to wield, and no one will ever have to work again, health care will be free for everyone, food will magically appear in the kitchens of all, and all of our cars will always be brand new.

How is that for a rant?

Hello 2009!!

I did something really exciting for New Year's Eve. I slept all night!

I know that such things as the New Year are arbitrary marks on the calendar, but they're good times for thinking about what has been and will be nonetheless. I've really enjoyed living in Chattanooga for the last 5 1/2 years. I'm also looking forward to moving on to what comes next in life. Hopefully nothing like Ike comes after us in Houston while I'm there.

The first 6 months of my chief resident year have flown by. I'll spend the next 3 months on the resident run service. It is the service on which residents have the most autonomy during residency. I feel ready for it. It is generally a fairly busy service, so I'm sure that I'll be ready for something different by the end of March. Tuesday's clinic apparently has 60 patients scheduled. It will be busy even if we have the normal number of cancellations/no-shows.

Hope that you have a blessed New Year.

Oh no, it happened again!!

Its unbelievable, it happened again!!

http://news.yahoo.com/s/ap/20081229/ap_on_re_us/obit_oldest_american_man;_ylt=AhckdBn_m.H.t4ReZvwWeHIDW7oF

Bail anyone?

After about 6 years or so of having an expired passport, I've decided to spend my afternoon tomorrow getting a new one. Now that the Bush presidency is coming to a close, I might just get by without too much hassle. My last passport is full of stamps to evil places such as Pakistan and Afghanistan. Hopefully no super-vigilant Bush minion will decide that I look like the terrorist sort. If they do, please come down to Guantanomo, or however you spell it, and bail me out.

P.S. Yes, I do start working in Houston in 2009, not 2008 as previously posted.

Staplers and such

This past Wednesday found me behind a desk with one of my fellow chief residents interviewing 20 applicants for our residency positions. It was a fun day. Having just completed a whole raft of interviews myself as a candidate, it was interesting to be the one doing the interviewing.

Wednesday was also an interesting day because it was the day that my own match for a fellowship position in colorectal surgery occurred. It was the most competitive match year for that sub-specialty in years, with 1/3 of people applying not obtaining a position. I was one of the fortunate 2/3's of applicants to obtain a spot, and was even more fortunate in that I obtained my first choice. So beginning in July of 2008, I will be a Houston resident. Whatever happens, at least I won't be cold.

Its sad to think of leaving Chattanooga. I've enjoyed living here and will miss the other residents and faculty whom I've come to know so well over the last 5 years.

The next 6 months will be busy ones with clinical work. I've also broken my pledge not to do more research and have embarked on one research project and one clinical case report, both of which will probably turn into journal articles somehow or another in the next 6 months. At least I won't be bored!!

Miracles

My oldest smallest sister is coming to visit my humble abode tomorrow. She will be stopping by as she passes through to Louisville, and will then stop by again and stay for a day or two on her way back to climes more temperate.

It is a very auspicious event, its not every day that I have the prilivege of hosting a visiting missionary. I expect to be regaled with stories of hungry cannibals, transformed savages, and miracles too amazing to describe.

Unfortunately, I've been working on a little miracle making of my own. You see, it has been nearly two years since I last hosted anyway in the aforementioned humble abode. Me not being here for much more time than it takes to boil some spaggetti, gobble it down, and then trundle off to bed makes for a rather untidy place. Not having had the motivation of facing social rejection due to the state of my humble abode, things have sort of accumulated.

Last night found me scraping away at the buildup of stuff inside the microwave. Tonight found me tidying up the guest room. Tomorrow will consist of throwing all of the remaining junk into the other room. I wouldn't want the visiting missionary to catch some awful malady after surviving for years as a poor, starving missionary.

Presidential Race

I'm glad for a lot of things, but mostly right now I'm just glad that the presidential race is over. I'm sick of it all after two years of coverage. Why can't we just do it like Canada and have a snap election that is over in a month or two?

I'm also glad that Obama won. I'm not sure that he'll make a better president than Bush, or that he will be better than McCain would have been. I don't think that all of the troops will be out of Iraq by the time he leaves office, and I don't think that he will magically solve economic problems brought on by people whose desires were bigger than their pocketbooks. No, I'm glad for one simple reason. I think that his win has meant a lot to many non-white Americans, and I'm glad for that.

His election has also raised some really interesting issues about race and our conceptions of it that prove that our society has done anything but move beyond racism, despite what the pundits would have you think. Both of my points on this are probably not politically correct, and have not been stated by the media that I have heard.

First of all, why is someone who is half white and half black called black? Especially when that person was not raised in a black community or black culture, if there is such a thing? The reason our society calls someone like that black, is because we have an almost Nazi conception of race when it comes to defining who is white. It is a pure-blood philosophy. If you are 3/4 white, and 1/4 black, you're still not white.

My second point is that racism works both ways. I have been to predominantly black neighborhoods where black cashiers have served black people behind me in line. That is racism. The same holds with elections. The media focused on whether there would be a "Bradley effect" in which non-black voters would not vote for Obama despite telling pollsters otherwise. Is it not just as racist for black voters to vote against McCain because he is white, as it is for white voters to vote against Obama because they says he's not?

The End of the Garden

The last couple of years I've had a wonderful time gardening during the summer. This summer I canned all sorts of tomato products and even canned some dill pickles. This year's garden if dying off, not due to weather yet, but rather due to the neglect of the gardener gone on various trips interviewing for fellowship spots around the country. Turns out that plants love water, and don't seem to do so well without it. Ahh well. It was fun while it lasted. Too bad that the academic year ends at the end of June. I'll be moving right in the middle of gardening season next year and won't be able to much horticulture I'm afraid.

Will work for gas.

On Monday I was in Atlanta for a fellowship interview. While I was there, I decided to check in on a good med school friend, Tejas Desai. It was really good to see him and his wife again. It had been about a year since I last saw them. He is finishing up a nephrology fellowship. They have a chosen a rather bad period of time to live in Atlanta. Last summer everyone in Atlanta was hoarding water because the reservoirs were almost empty. This summer everyone is hoarding gasoline if they can find any. The city looked like a scene from the 70's and the Iran oil crisis, except they forgot to use old cars. Any gas station with gasoline had a line of 10-20 cars waiting to fuel up. The situation is getting worse in Chattanooga as well. The last time I posted, half of the gas stations had fuel. Now only about one in 7 or 8 do, and they sell out quickly. Today I had to wait in line for the first time to buy gas. Its all just really bizarre.

Got Gas?

These be bizarre times. The banks are going bankrupt. The gas stations are all running on empty. Ever since Hurricane Ike, half of the local gas stations have no gasoline. The other half of stations that do have fuel have only one grade available. Its not just Chattanooga, either. Gas stations in Nashville and Atlanta are also apparently running on empty. Makes you wonder if them Old Order folks don't have it right after all. Makes you wonder where its all heading...

Chaos and Mayhem

I'm sure that all of you all are much better behaved than me, and never ever have evil impulses. Sometimes you wonder where in the world some ideas come from.

For instance, I was walking through the hospital the other day. My route took me through the pediatric hospital. There is a little library/play room for the kids there. There was a big sign on the door saying "Radio-a-thon" on the door, and a very prim, proper looking lady was talking into a microphone. I desperately wanted to pound on the windows, make faces through the glass, or even burst into the room screeching like a banshee. The very thought of it all gave me the sniggers for the rest of the day.

Then the other day, I was taking my garbage to the dumpster. My thoughts were on making enough noise when I got there so as not to startle the raccoon that normally is feasting in the dumpster that time of night. The aforementioned beast and I both had a very startling experience one dark night when we met. I had tossed my bag of garbage into the dumpster when I flying ball of fur came whizzing back at me. Anyway, I digress. As I said earlier, I was walking towards the dumpster thinking about the raccoon. I came up on a big fire engine parked in the street with its engine running. There were no firemen in the vehicle as they were all off somewhere in the vicinity doing firemen sorts of things. From deep in my childhood fascination with big red fire engines came this urge to climb into the drivers seat, flip on the sirens and lights, and go hurtling around town at 90 mph running all the lights.

Maybe I need some of that "xnax" that some of my patients talk about. (Known as xanax in dialects other than hill-billy.) Hill-billies also have high-needle or hyenal hernias instead of hiatal hernias. But that is unrelated to the general theme of sowing chaos and mayhem.