You ever wonder how your physicians are paid? The first thing an immigrant to the US complains of after agonizing over the evil exchange rate regime that forces him to spend a buck fifty on a bottle of Coca Cola when he could get three bottles for that much in his country is the fact nothing is what it appears here. Only at the register do you find out your $1.50 coke actually is $1.60 with sales tax. But what really grinds our gears in the early goings is tipping. Yup, that 15-20% gratuity that says if you do not have fourteen bucks, do not go to a restaurant for a twelve dollar meal.
Tipping is annoying because it makes an otherwise simple matter complicated; it leaves the customer to determine the waiter’s salary. Why can’t the restaurateurs pay their employees and include the cost in the price of my meal? I presume this all started in some good faith—people showing their appreciation and societal status by leaving money for good service, an admirable incentive system.
But the times it seems, have changed. Tipping is now a given. Thus, even though my cab driver offers no help with luggage and is on his phone all trip, I still give him the 20% tip to elicit his only words (thank you) to me. It got me thinking about physician reimbursement. In the traditional system, physicians and hospitals are reimbursed a specific amount for providing care for a disease or condition. There isn’t much of a measure of the quality of that care involved in the payment system. The patient is left to decide which physician is better through available ratings and some other measures of outcome like surgical complications. Critics argue there is thus little incentive to improve upon current practices. Of course most doctors are not callous and most hospitals continue to find ways of providing better care for the patient. But would financial incentives push them along faster?
Earlier in this decade, there was a lot of talk about pay for performance. It was pretty much a tipping system. You provide me with medical care; I pay you depending on the quality of that care. There was some uptake but the system had its problems. Just how do you measure the impact of a physician’s actions on a complex entity like the human being? The consensus, as it now stands, is to withhold payment if processes of care (e.g. a specific question) were not followed. This is a rather cumbersome process contributing to more paperwork for doctors and less time to spend on patients.
Getting around the measurement problem partially, Medicare, the federal health insurance program ruled it would no longer cover costs for “preventable” conditions like hospital acquired infections. This made the cost of mistakes visible to hospitals and ensured they would innovate. Of course a cynic can argue how exactly a preventable condition will be ascertained but we will leave that for another discussion. It is a positive step towards inspiring even greater commitment to quality care from care providers. But it cannot end here.
Personally, I prefer a modified process analysis approach—two levels of payments; insurers to hospitals and hospitals to physicians. On the former level, using weights based on the mix of patients, a hospital can be paid based on its overall outcomes. Hospitals can then pass these on to physicians by paying for adherence to pre-determined best practices but rewarding initiative. This is not an argument for standardized care per se but a way to reward innovation.
Physicians can vie for peer respect and financial reward by coming up with improvements (which then become best practices) to existing best practices. The problem with pay for performance is not that it is a bad idea. It is that physicians are not empowered in the system. The only people who can determine where the problems with care exist, are the people on the frontlines. By incentivizing healthcare providers to reward physician quality improvements, healthcare payers can help lower costs and improve care. Of course this whole argument is based on the premise that physicians are at least partly motivated by money. In Ghana, then, we might want to think of a move from guaranteeing all to only a percentage of doctors’ salaries.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Saturday, October 30, 2010
Friday, September 17, 2010
Healthcare (Monkey?) Business
With the recent financial meltdown and the apparent non-repentance of the industry even in the face of the severe backlash that has accompanied the tax-funded support of its institutions, one might say it is foolhardy to mention business and health in the same sentence let alone propose their marriage but that is exactly what I have set out to do.
Let's examine what a business is. In its simplest form, it is a purposeful activity. As one scales up discrete units are added until it takes on the complexity of a behemoth enterprise working towards a particular goal. In our contemporary world, this has come to mean turning a profit; the bigger, the better. Turning a profit instead of a loss (negative profit in normal parlance) has been the primary motivation of most businesses—create some value at a cost, try to capture part of that value by receiving a price, and hope that the fraction of value you capture is greater than your cost. One can do this either by creating or praying for a high price and/or keeping costs down.
In the medical field and in many other realms, the idea of business is seen as evil. This has been based on a long history of financial malpractice, questionable trade practices and lack of corporate commitment to society. A particular criticism is the ruthless efficiency with which the business world goes about, well, business. It is the one thing the common man hates about business; the lack of emotions in making personnel decisions, the drastic shedding of human resources when productivity falls and the quest to extract more and more such productivity from labor while keeping the wages down make companies appear uncaring and downright callous. This perception is worsened when profits are used for top brass bonuses. So why would anyone want this for medicine?
Medicine is usually seen as a benevolent, humanity-based endeavor geared towards providing that most basic of human needs, health. And that it is. It also, costs money and recently, exponentially increasing amounts of it. Suggestions for funding it abound and are outside the scope of this article. Regardless of how funding is provided or who provides it however, a basic equation must balance; cost must equal revenue. Consider a hospital which violates this rule. It would in time be unable to support its operations and the services it provides and will ultimately end up bankrupt depriving society of a necessary good.
One can argue that hospitals must not have profit as an incentive. However, they must still meet their costs. This just means they have a target profit of zero dollars as revenues are just enough to pay for expenses. Since many people will pay anything to maintain good health however, the incentive for hospitals to reign in cost is rather weak. To counter this, there are numerous reforms that limit reimbursement rates for healthcare providers. So let us assume prices and revenues remain constant. Then the only way to break even is to decrease cost. How does one do this? By becoming efficient.
Consider how long you have to wait in the emergency room before you see a doctor, are admitted or discharged home. How many times a day do you get stuck with needles for lab tests? What are the best distributions of work hours for your doctors to ensure they are available to take care of you and are alert/awake while doing it? What is the best means of physician-physician-patient communication/information system to ensure the best care for you? How do you design workspaces to minimize medical errors/accidents? In my Technology and Operations Management class in business school, I have already begun to learn about how people, resources and information flow through a system. The goal, of course, is that ruthless efficiency we talked about earlier; finding the bottlenecks and improving them, decreasing waste and increasing yield.
If there is one thing there is a general consensus on, it is that there is a lot of waste and organizational inefficiency in healthcare. An application of the concepts of business to healthcare organizations (which are inherently businesses by our definition above) will go a long way to saving money and decreasing the cost of care. The principles that underlie business are not intrinsically evil. They have just been used so often in the pursuit of individual goals that society frowns on. But they can be used for good too. Ruthless process efficiency, brewed in the context of compassionate care, can save costs while increasing the quality we deliver to our patients. Rather than swear off them, then, let’s apply business tools conscientiously for the general good. Society’s appreciation can then trickle down to the care providers who sacrifice for it. As one of my professors said, no one is begrudged for capturing value they create.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Let's examine what a business is. In its simplest form, it is a purposeful activity. As one scales up discrete units are added until it takes on the complexity of a behemoth enterprise working towards a particular goal. In our contemporary world, this has come to mean turning a profit; the bigger, the better. Turning a profit instead of a loss (negative profit in normal parlance) has been the primary motivation of most businesses—create some value at a cost, try to capture part of that value by receiving a price, and hope that the fraction of value you capture is greater than your cost. One can do this either by creating or praying for a high price and/or keeping costs down.
In the medical field and in many other realms, the idea of business is seen as evil. This has been based on a long history of financial malpractice, questionable trade practices and lack of corporate commitment to society. A particular criticism is the ruthless efficiency with which the business world goes about, well, business. It is the one thing the common man hates about business; the lack of emotions in making personnel decisions, the drastic shedding of human resources when productivity falls and the quest to extract more and more such productivity from labor while keeping the wages down make companies appear uncaring and downright callous. This perception is worsened when profits are used for top brass bonuses. So why would anyone want this for medicine?
Medicine is usually seen as a benevolent, humanity-based endeavor geared towards providing that most basic of human needs, health. And that it is. It also, costs money and recently, exponentially increasing amounts of it. Suggestions for funding it abound and are outside the scope of this article. Regardless of how funding is provided or who provides it however, a basic equation must balance; cost must equal revenue. Consider a hospital which violates this rule. It would in time be unable to support its operations and the services it provides and will ultimately end up bankrupt depriving society of a necessary good.
One can argue that hospitals must not have profit as an incentive. However, they must still meet their costs. This just means they have a target profit of zero dollars as revenues are just enough to pay for expenses. Since many people will pay anything to maintain good health however, the incentive for hospitals to reign in cost is rather weak. To counter this, there are numerous reforms that limit reimbursement rates for healthcare providers. So let us assume prices and revenues remain constant. Then the only way to break even is to decrease cost. How does one do this? By becoming efficient.
Consider how long you have to wait in the emergency room before you see a doctor, are admitted or discharged home. How many times a day do you get stuck with needles for lab tests? What are the best distributions of work hours for your doctors to ensure they are available to take care of you and are alert/awake while doing it? What is the best means of physician-physician-patient communication/information system to ensure the best care for you? How do you design workspaces to minimize medical errors/accidents? In my Technology and Operations Management class in business school, I have already begun to learn about how people, resources and information flow through a system. The goal, of course, is that ruthless efficiency we talked about earlier; finding the bottlenecks and improving them, decreasing waste and increasing yield.
If there is one thing there is a general consensus on, it is that there is a lot of waste and organizational inefficiency in healthcare. An application of the concepts of business to healthcare organizations (which are inherently businesses by our definition above) will go a long way to saving money and decreasing the cost of care. The principles that underlie business are not intrinsically evil. They have just been used so often in the pursuit of individual goals that society frowns on. But they can be used for good too. Ruthless process efficiency, brewed in the context of compassionate care, can save costs while increasing the quality we deliver to our patients. Rather than swear off them, then, let’s apply business tools conscientiously for the general good. Society’s appreciation can then trickle down to the care providers who sacrifice for it. As one of my professors said, no one is begrudged for capturing value they create.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Monday, August 16, 2010
“If you can read this, thank a teacher”
“A courage which looks easy and yet is rare; the courage of a teacher repeating day after day the same lessons - the least rewarded of all forms of courage” – Honore de Balzac
If you attended school in Ghana, West Africa, or I daresay any African country, you have probably been lashed/received corporal punishment. I remember all six teachers who ever lashed me; two of course being my parents. I never cried. I was a big boy. I was close a few times though—my classmates at Mfantsipim can tell you about one. But these traumatic experiences do not form the basis of my memories. I can tell you the names of at least 90% of my teachers so far from Ms. Amenyui through Mr. Azasoo, Frimpong, Collins Aguzey, “Harriso wo yɛ tall”, “Adorable – Paul Adu Kumi, “Coomson aka Fuck”, “Baffoeman, Yeboaman, “Borlɛɛ”, “Karishika/Matriculation”, “Duncanman aka “The Son of Man”, “Aboa Apɔnkye” to “Duoduman”.
From Louis Baffoe intoning “you are mad!” because I screwed up a mathematical calculation to Aboa Apɔnkye teaching us temperature was the sixth sense and that HIV stood for “Highly Infections Virus” (it stands for Human Immunodeficiency Virus by the way), there are many unique stories by which we remember our teachers. I recall Mr. Kusi forcing us to buy his useless pamphlets, Karishika skipping English periods while trying to induce our paying her for extra classes and Borlɛɛ’s tag line “as for you Edo, you are a baaaaaaaaaaaad boy” anytime I went for an exeat (signed permission to leave school) for the town of Cape Coast. I also remember Yeboahman allowing me to attend his high-cost but effective extra classes in Physics for free, Baffoeman lending me his Math texts for study, “Adorable” buying me an English-French dictionary, and Duoduman screening World Cup matches at his house. What I’m saying is my development as an individual and my success as a student has been entirely due to my teachers. Same could be said for the larger majority of my friends. So why are they paid so little?
I was a rebel growing up – at home that is. In school, I was always an angel, well, with the teachers anyways. Maybe it was fear of corporal punishment. Whatever, it worked. In my village, teachers wielded extraordinary power that extended to time outside school. A parent could request punishment of kids for some wrong committed at home. When teachers decreed that funerals were no place for children, it meant you did not want to be seen at a funeral by a teacher or, God forbid, the headmaster. And you did not want them to catch you doing something wrong outside of school. Teachers were our moral compasses, our role models, our number one fans, our most severe critics and our fiercest supporters.
There were inspections on Monday mornings for cleanliness – white socks, washed and pressed uniform, hair cut short, fingernails clipped, teeth brushed, it was a beauty. And this was outside of the fact they were actually doing teaching in the classrooms. When I was practicing my cursives in the sand under the big Neem tree in Dabala, it was a teacher who held my hands. And it was a teacher who taught me about “Air Pressure” and how I could turn a glass of water upside down with covering as flimsy as a cardboard and it wouldn’t spill.
The most widely heard saying in Ghana regarding teachers, however, remained “a teacher’s reward is in heaven”. But is it? I have been wondering about how society judges the value of different services. In Ghana, we were of the view that the US valued its teachers more and that they were among the highest earners in the country. How wrong we were! Teachers earn a pittance here and, it seems, everywhere else. How can that be? I do not know much about the requirements for teaching in the US but at least in my country, this usually involves attending a three-year Teacher Training College, a tertiary institution. The admission criteria for these schools are less stringent than for four year universities which meant they became places for students who did not make the college grade. One can then boost her pay grade, albeit marginally, by attending a “mature” students degree course in university although most look at this as an escape from teaching. Rather than fault this set-up, however, I fault the human condition.
Society as a whole is obsessed with education and the level of education achieved resulting in pay levels increasing as you achieve higher and higher levels of education even if your degree is as useless as Latin outside of the catholic church. No, I am not arguing against education. Ask my family, it’s the only thing I seem to offer them when we speak—go back to school, get another degree and the like. But shouldn’t the future value of a person’s work be indicated in their remuneration?
A profession which seems to be at the extreme end of this value-based remuneration is medicine where doctors are paid large amounts of money for barely keeping a patient alive. Even here, primary care doctors who save the system hills of money by preventing complications before they arise earn the least pay. What influences the value of a man’s work seems steeped more in how immediate the results are than what the actual contribution to society over time is of his work.
We are blinded by the college graduates who generate millions sometimes doing mind-numbing work on Wall Street so we pay them in loads and cap it all by giving some CEOs significant portions of GDP even when companies fail. But we are unable to foresee the fact that we would have a society of illiterates and no professionals without the teacher. Imagine a society without doctors, lawyers, businessmen, farmers, historians, technicians, to mention a few. We’d be back in the ice age in no time.
Supply and demand and the curse of Adam Smith continue to numb us into decreasing the reward of teachers because, well, they are easily replaceable. They are, of course. But is this enough to keep their pay low? Imagine waking up each day, writing the same teaching plans albeit modified for the characteristics of the class that year, standing in front of students and repeating the same information over and over again. And most of them do it faithfully and cheerfully, knowing the only reward they have is hearing of their students who made it. And the only way they could ever be rich, at least in Ghana, is go into politics and become parliamentarians.
So even though it is not teachers’ day today, shout outs to all my teachers, past and present. Part of your rewards are in heaven all right but the larger part is in our pockets as a society and especially, in those of our politicians. I pray one day it is returned to you.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
If you attended school in Ghana, West Africa, or I daresay any African country, you have probably been lashed/received corporal punishment. I remember all six teachers who ever lashed me; two of course being my parents. I never cried. I was a big boy. I was close a few times though—my classmates at Mfantsipim can tell you about one. But these traumatic experiences do not form the basis of my memories. I can tell you the names of at least 90% of my teachers so far from Ms. Amenyui through Mr. Azasoo, Frimpong, Collins Aguzey, “Harriso wo yɛ tall”, “Adorable – Paul Adu Kumi, “Coomson aka Fuck”, “Baffoeman, Yeboaman, “Borlɛɛ”, “Karishika/Matriculation”, “Duncanman aka “The Son of Man”, “Aboa Apɔnkye” to “Duoduman”.
From Louis Baffoe intoning “you are mad!” because I screwed up a mathematical calculation to Aboa Apɔnkye teaching us temperature was the sixth sense and that HIV stood for “Highly Infections Virus” (it stands for Human Immunodeficiency Virus by the way), there are many unique stories by which we remember our teachers. I recall Mr. Kusi forcing us to buy his useless pamphlets, Karishika skipping English periods while trying to induce our paying her for extra classes and Borlɛɛ’s tag line “as for you Edo, you are a baaaaaaaaaaaad boy” anytime I went for an exeat (signed permission to leave school) for the town of Cape Coast. I also remember Yeboahman allowing me to attend his high-cost but effective extra classes in Physics for free, Baffoeman lending me his Math texts for study, “Adorable” buying me an English-French dictionary, and Duoduman screening World Cup matches at his house. What I’m saying is my development as an individual and my success as a student has been entirely due to my teachers. Same could be said for the larger majority of my friends. So why are they paid so little?
I was a rebel growing up – at home that is. In school, I was always an angel, well, with the teachers anyways. Maybe it was fear of corporal punishment. Whatever, it worked. In my village, teachers wielded extraordinary power that extended to time outside school. A parent could request punishment of kids for some wrong committed at home. When teachers decreed that funerals were no place for children, it meant you did not want to be seen at a funeral by a teacher or, God forbid, the headmaster. And you did not want them to catch you doing something wrong outside of school. Teachers were our moral compasses, our role models, our number one fans, our most severe critics and our fiercest supporters.
There were inspections on Monday mornings for cleanliness – white socks, washed and pressed uniform, hair cut short, fingernails clipped, teeth brushed, it was a beauty. And this was outside of the fact they were actually doing teaching in the classrooms. When I was practicing my cursives in the sand under the big Neem tree in Dabala, it was a teacher who held my hands. And it was a teacher who taught me about “Air Pressure” and how I could turn a glass of water upside down with covering as flimsy as a cardboard and it wouldn’t spill.
The most widely heard saying in Ghana regarding teachers, however, remained “a teacher’s reward is in heaven”. But is it? I have been wondering about how society judges the value of different services. In Ghana, we were of the view that the US valued its teachers more and that they were among the highest earners in the country. How wrong we were! Teachers earn a pittance here and, it seems, everywhere else. How can that be? I do not know much about the requirements for teaching in the US but at least in my country, this usually involves attending a three-year Teacher Training College, a tertiary institution. The admission criteria for these schools are less stringent than for four year universities which meant they became places for students who did not make the college grade. One can then boost her pay grade, albeit marginally, by attending a “mature” students degree course in university although most look at this as an escape from teaching. Rather than fault this set-up, however, I fault the human condition.
Society as a whole is obsessed with education and the level of education achieved resulting in pay levels increasing as you achieve higher and higher levels of education even if your degree is as useless as Latin outside of the catholic church. No, I am not arguing against education. Ask my family, it’s the only thing I seem to offer them when we speak—go back to school, get another degree and the like. But shouldn’t the future value of a person’s work be indicated in their remuneration?
A profession which seems to be at the extreme end of this value-based remuneration is medicine where doctors are paid large amounts of money for barely keeping a patient alive. Even here, primary care doctors who save the system hills of money by preventing complications before they arise earn the least pay. What influences the value of a man’s work seems steeped more in how immediate the results are than what the actual contribution to society over time is of his work.
We are blinded by the college graduates who generate millions sometimes doing mind-numbing work on Wall Street so we pay them in loads and cap it all by giving some CEOs significant portions of GDP even when companies fail. But we are unable to foresee the fact that we would have a society of illiterates and no professionals without the teacher. Imagine a society without doctors, lawyers, businessmen, farmers, historians, technicians, to mention a few. We’d be back in the ice age in no time.
Supply and demand and the curse of Adam Smith continue to numb us into decreasing the reward of teachers because, well, they are easily replaceable. They are, of course. But is this enough to keep their pay low? Imagine waking up each day, writing the same teaching plans albeit modified for the characteristics of the class that year, standing in front of students and repeating the same information over and over again. And most of them do it faithfully and cheerfully, knowing the only reward they have is hearing of their students who made it. And the only way they could ever be rich, at least in Ghana, is go into politics and become parliamentarians.
So even though it is not teachers’ day today, shout outs to all my teachers, past and present. Part of your rewards are in heaven all right but the larger part is in our pockets as a society and especially, in those of our politicians. I pray one day it is returned to you.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Saturday, August 7, 2010
The Politics of Recycling
One said to Confucius: “Why are ye not in power, Sir?”
The Master answered: “What does the book say of a good son? 'An always dutiful son, who is a friend to his brothers, showeth the way to rule.' This also is to rule. What need to be in power?”
(Confucius, Confucius. The Sayings of Confucius. Hayes Barton Press, 478 B.C.).
Tuesday, November 3, 1992: Do you remember where you were? I do. I was 7yrs old, in Class 3. It was the first presidential election of the Fourth Republic of Ghana. It was 13 years in the making. 11 since Junior Jesus, Chairman Rawlings had completed his second coup d’etat. The election results would come to live in infamy as “The Stolen Verdict” but those were remarkable times to be alive. Oh yes, that evening, I was playing football on the little volleyball court adjacent the perpetually uncompleted Evangelical Presbyterian Church building in Dabala. This was the Volta Region. This was the World Bank…for the National Democratic Congress that is. It was the stronghold of the party formed by the newest “democrat” on the block; the soon to be President Rawlings.
The NDC had run a particularly shrewd campaign. There was the catchy “No retreat, no surrender. No curve, no bend. Straight to victory. NDC, Akatamanso” which blared from loudspeakers mounted on the newly minted Toyota pick-ups. Then there was the play on people’s superstition with fishermen suddenly catching crabs with the distinctive colors and umbrella of the NDC indelibly imprinted on their backs. The rumours spread like a harmattan fire; God and the gods had anointed the NDC. Thus when there was a funeral held behind the Post Office with a coffin for the elephant of the New Patriotic Party, it seemed only appropriate. The elephant had it coming. And that day when we all stopped play for a moment and shouted after the rickety old lady, tottering to the old JSS campus to put thumb to paper, to vote for Rawlings, we were only repeating the refrain so often sang--what I had heard from my grandfather’s Sanyo radio for 7 years, Chairman Rawlings…, Chairman Rawlings…, Chairman Rawlings. That,….and nothing else.
But this is not some trip-down-memory-lane piece. This is about a remarkable aspect of the political landscape of Ghana and of the many parties in our multi-party, very African Democracy. It is that long before the developed world started the green revolution, before the “pure water” sachets would dance freely in the putrid waters of the Korle Lagoon we were recycling. See in 1992, I heard of Rawlings, Adu Boahen, Limann, Arkaah, Mills, Mahama, even Kufuor. 18 years on and these same names ring out. Some, may they rest in peace, have since passed on. But as these parties proclaim allegiance to the Nkrumahs and Busias, so their leaders continuously descend directly from these dead presidents or the people around them. Welcome to the world of dynasties. Welcome to Political Recycling.
As I write this, Nana Addo Dankwa Akufo-Addo, the incessant chatterbox with the affected slang twang has been elected the flag bearer of the NPP beating virtually the same field he did the last time round. He is the son of Edward Akufo-Addo, member of The Big Six, and later president of Ghana in the Busia administration. Junior lost the last presidential elections as flag bearer for the NPP. But as surely as current President Atta Mills was elected again and again by the NDC in spite of losing two straight elections, so it seems, the NPP is recycling its limited resources. There is of course something to be said for brand and name recognition; it is arguably a major reason Mills won the last election. And within a party, loyalists at the top will push to get their candidate in place, helped by the specter of incumbency and inertia of the masses. So the recycling continues and the same trash gets put out over and over again.
But at what point is recycled material unusable? My dad used to say that the useful span for a man to implement his vision is at most 10 years. He is of course no expert but one would be hard pressed to find a politician who has ideas to last the first week of office let alone one hundred and twenty moons. So why do they keep coming back? My sister says it is because every rich man’s dream in Ghana is to be president. It is the ultimate status symbol. And since there really are no qualification requirements, anybody from the high school drop-out, Rawlings, through the non-practicing lawyer Kufuor to Akufo-Addo and the heart surgeon Frimpong Boateng with management lessons learned at the Korle-Bu Teaching Hospital can up and stand for the presidency. How one runs a country with absolutely no understanding of basic economics, surrounded by people practicing the economics of Adam Smith's time, is baffling to say the least. But alas, politics is a popularity contest and the lawyers are the best at painting black white so they inevitably rise to the top. It is worth noting that Akufo-Addo's wikipedia page and other biographies state he was called to the English Bar (Middle Temple). However, my search of the internet has no mention of a law school and his name cannot be found here.*
But even if this is our lot, even if we are eternally cursed with the same political parties going through our government like a revolving door, even if our state coffers have become like a street walker, screwed at every turn by the NDC, the NPP and once more by the NDC for the go around, must it be by the same men? Does neither the NPP nor NDC have any new blood? Are there no young women or men in the folds of these parties who can radically rethink our progress as a nation? Why does the old guard not step aside? Surely a lesson or two learnt in defeat can show the younguns the way to rule?
This nation deserves a better bunch of the criminals, ahem, politicians (apologies to The Dark Knight). Today, it is Akufo-Addo. Tomorrow, it will either be the ineffectual Mills or Nana Konadu Agyeman Rawlings, wife of ex-chairman, sorry, ex-president Rawlings. From the twenty years of Rawlings through the fourteen and counting of Mills and the thirteen since Akufo-Addo junior has been in parliament, the years have grown no kinder to our leaders. Wisdom, it seems, does not come with age. Their ten years are over; their visions depleted. And what is left are the depleted shells, dazed and confused and shouting the hollow promises of addicts looking for their next fix. We need, indeed we demand a viable alternative; for party, for president and for parliamentarian. Because if there is one arena where going green is bad for business, it is that of politics. Let’s keep the recycling to the environment. God Bless Our Homeland Ghana.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
* It has since the publishing of this article been shown, through some fine piece of investigation by Dzidzorli Agbleze, that Nana Akufo-Addo did pass Part II of the transitional Trinity Term Bar Final Exam and was invited to the Middle Temple of the Inns of Courts. His name can be found in the published list of examination successes in "The Times", Friday July 2, 1971. As of today, the law school he attended is still unknown.
The Master answered: “What does the book say of a good son? 'An always dutiful son, who is a friend to his brothers, showeth the way to rule.' This also is to rule. What need to be in power?”
(Confucius, Confucius. The Sayings of Confucius. Hayes Barton Press, 478 B.C.).
Tuesday, November 3, 1992: Do you remember where you were? I do. I was 7yrs old, in Class 3. It was the first presidential election of the Fourth Republic of Ghana. It was 13 years in the making. 11 since Junior Jesus, Chairman Rawlings had completed his second coup d’etat. The election results would come to live in infamy as “The Stolen Verdict” but those were remarkable times to be alive. Oh yes, that evening, I was playing football on the little volleyball court adjacent the perpetually uncompleted Evangelical Presbyterian Church building in Dabala. This was the Volta Region. This was the World Bank…for the National Democratic Congress that is. It was the stronghold of the party formed by the newest “democrat” on the block; the soon to be President Rawlings.
The NDC had run a particularly shrewd campaign. There was the catchy “No retreat, no surrender. No curve, no bend. Straight to victory. NDC, Akatamanso” which blared from loudspeakers mounted on the newly minted Toyota pick-ups. Then there was the play on people’s superstition with fishermen suddenly catching crabs with the distinctive colors and umbrella of the NDC indelibly imprinted on their backs. The rumours spread like a harmattan fire; God and the gods had anointed the NDC. Thus when there was a funeral held behind the Post Office with a coffin for the elephant of the New Patriotic Party, it seemed only appropriate. The elephant had it coming. And that day when we all stopped play for a moment and shouted after the rickety old lady, tottering to the old JSS campus to put thumb to paper, to vote for Rawlings, we were only repeating the refrain so often sang--what I had heard from my grandfather’s Sanyo radio for 7 years, Chairman Rawlings…, Chairman Rawlings…, Chairman Rawlings. That,….and nothing else.
But this is not some trip-down-memory-lane piece. This is about a remarkable aspect of the political landscape of Ghana and of the many parties in our multi-party, very African Democracy. It is that long before the developed world started the green revolution, before the “pure water” sachets would dance freely in the putrid waters of the Korle Lagoon we were recycling. See in 1992, I heard of Rawlings, Adu Boahen, Limann, Arkaah, Mills, Mahama, even Kufuor. 18 years on and these same names ring out. Some, may they rest in peace, have since passed on. But as these parties proclaim allegiance to the Nkrumahs and Busias, so their leaders continuously descend directly from these dead presidents or the people around them. Welcome to the world of dynasties. Welcome to Political Recycling.
As I write this, Nana Addo Dankwa Akufo-Addo, the incessant chatterbox with the affected slang twang has been elected the flag bearer of the NPP beating virtually the same field he did the last time round. He is the son of Edward Akufo-Addo, member of The Big Six, and later president of Ghana in the Busia administration. Junior lost the last presidential elections as flag bearer for the NPP. But as surely as current President Atta Mills was elected again and again by the NDC in spite of losing two straight elections, so it seems, the NPP is recycling its limited resources. There is of course something to be said for brand and name recognition; it is arguably a major reason Mills won the last election. And within a party, loyalists at the top will push to get their candidate in place, helped by the specter of incumbency and inertia of the masses. So the recycling continues and the same trash gets put out over and over again.
But at what point is recycled material unusable? My dad used to say that the useful span for a man to implement his vision is at most 10 years. He is of course no expert but one would be hard pressed to find a politician who has ideas to last the first week of office let alone one hundred and twenty moons. So why do they keep coming back? My sister says it is because every rich man’s dream in Ghana is to be president. It is the ultimate status symbol. And since there really are no qualification requirements, anybody from the high school drop-out, Rawlings, through the non-practicing lawyer Kufuor to Akufo-Addo and the heart surgeon Frimpong Boateng with management lessons learned at the Korle-Bu Teaching Hospital can up and stand for the presidency. How one runs a country with absolutely no understanding of basic economics, surrounded by people practicing the economics of Adam Smith's time, is baffling to say the least. But alas, politics is a popularity contest and the lawyers are the best at painting black white so they inevitably rise to the top. It is worth noting that Akufo-Addo's wikipedia page and other biographies state he was called to the English Bar (Middle Temple). However, my search of the internet has no mention of a law school and his name cannot be found here.*
But even if this is our lot, even if we are eternally cursed with the same political parties going through our government like a revolving door, even if our state coffers have become like a street walker, screwed at every turn by the NDC, the NPP and once more by the NDC for the go around, must it be by the same men? Does neither the NPP nor NDC have any new blood? Are there no young women or men in the folds of these parties who can radically rethink our progress as a nation? Why does the old guard not step aside? Surely a lesson or two learnt in defeat can show the younguns the way to rule?
This nation deserves a better bunch of the criminals, ahem, politicians (apologies to The Dark Knight). Today, it is Akufo-Addo. Tomorrow, it will either be the ineffectual Mills or Nana Konadu Agyeman Rawlings, wife of ex-chairman, sorry, ex-president Rawlings. From the twenty years of Rawlings through the fourteen and counting of Mills and the thirteen since Akufo-Addo junior has been in parliament, the years have grown no kinder to our leaders. Wisdom, it seems, does not come with age. Their ten years are over; their visions depleted. And what is left are the depleted shells, dazed and confused and shouting the hollow promises of addicts looking for their next fix. We need, indeed we demand a viable alternative; for party, for president and for parliamentarian. Because if there is one arena where going green is bad for business, it is that of politics. Let’s keep the recycling to the environment. God Bless Our Homeland Ghana.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
* It has since the publishing of this article been shown, through some fine piece of investigation by Dzidzorli Agbleze, that Nana Akufo-Addo did pass Part II of the transitional Trinity Term Bar Final Exam and was invited to the Middle Temple of the Inns of Courts. His name can be found in the published list of examination successes in "The Times", Friday July 2, 1971. As of today, the law school he attended is still unknown.
Saturday, July 17, 2010
Exams should be banned...but since they wont be, this is how I prep for them.
Hey, wasup, how're yall doing? A couple of months ago, a friend who has more illusions about me than me Mom asked me to write out how I prepare for exams. Since I am preparing for another tedious exam anyways, I figured why not. Then a study partner took a look and said put it on facebook so I put it on my blog. Now before you read this, I want to put out the disclaimer that these are my thoughts, this is my modus operandi. These are observations that I have made on my study habits and patterns and may or may not work for you. As usual, it is important that you find your personal style and work with it. This is a general theme that you can vary as you wish. Oh, it also makes liberal use of the pronoun "you". Forgive me. So..
1. Set a target score.
2. Give yourself time – Do not over-estimate your abilities. Afford yourself as much time as you can to study for the exam. This should take into account the fact that you are likely to burn out at some point and will need a few days rest before you begin again. Pace yourself appropriately so you remain interested in what you study. And set aside days of the week (it can be a night per week) when you can relax, with no studying and stick to them.
3. Study hard – There are two stages of studying, intense studying and review.
i) Months before your exam, study hard and study detailed material. This period is for understanding the fundamental concepts of the field, the threads that run through every other topic. You can then build upon that as you go. Begin memorizing factoids if these are needed in your exam so you can go through the cycle a couple of times before the exam. At this point, read the concepts you are more likely to remember; the ones that are easier to take in. If you are stumped by a concept, an advanced concept or one which is not essential to further studying, write it down and move on. This is the time to experiment with study habits. Work with one at a time. If it does not work, switch to another. Do not be married to one study habit but do not also follow all and sundry’s suggestions. Choose the book that works best for you and the study materials that do and stick to them. Switching between things gets you confused and nowhere.
ii) Review stage – this depends on the amount of material you need to cover for your exam. Again, pacing and realism on time needed is the most important factor. This is not the time for detailed reading. This time is for you to glance over material to make sure they are at the forefront of your mind going into the exam. You are unlikely to remember everything in detail but you will have an idea about most things. Towards the end of your review period, you should plan a time when you read and memorize the concepts you were stumped by in the study period. These can be chewed, poured, and forgotten after day of exam.
4. Keep a routine – the brain works best when it knows exactly what it needs to do at a particular time. Maintain exact study times, keep a good sleep hygiene/protocol – go to sleep at set times, go through the same routines before sleep, keep a 30min block when you do nothing but relax before sleep. In the weeks before your exam, do practice exams at the exact time of and of similar duration as your actual test. In this, try to simulate as much of the test day as possible – preparations, sleep and all that.
5. Two nights before the test day, wrap up your readings, go to sleep on schedule. This is particularly important as sleep deficits will generally catch up with you in 48hrs. This is probably the day to take a quick look again at all those hard things you never could get your head around
6. The day before the exam – this works differently for different people. Some prefer to look again over some high yield material, keep the brain going. Others prefer to take this day off and do activities they enjoy like read, shop etc. Do not watch TV or spend hours behind a computer. They will put your brain to sleep. If you haven’t already, take this day to visit the test center and plot your transportation details. Get all the documents you need ready, put your food, drink, calculator, money for transportation, pens, pencils, all logistics in one bag. Needless to say, get a good amount of sleep. Through this whole study period, it is advisable to maintain at least 8hrs of sleep per night. Do not change your schedule in the final week and certainly not on the last two days. More sleep in those days will only make you groggy on the day of the exam. Less sleep will make you high.
Throughout this period, it is important that you continue to exercise and engage in other activities that refresh you and get your mind outside of books. They are not only healthy for mind and body, they decrease your stress levels and you don’t want to be stressed at this time.
On the day of exam – sometimes it doesn’t come quickly enough; other times you want it to stay away.
- give yourself more than enough time to get to test center
- Choose/ask for a quiet area of the exam room.
- bring earplugs. You will likely need them
- For food, eat a good breakfast, lunch should not be heavy. The advice generally given is to bring dried fruits like raisins and nuts instead of sugary energy drinks which can make you crash really fast, and carbohydrates which will make you sleep.
Before the exam – PRAY
During the exam,
- As soon as you sit down, write down the formulae and other memory aids you will not remember and do not erase them. When a formula you do not know is given to you or you derive it on one question, write it down. Do not erase drawings you use for one question. You might need them later.
- Read the instructions carefully. You miss points if you do not answer the question being asked.
- Read the question at the end of the preamble/blurb to guide you on what you should be looking for in the preamble.
- Formulate your answer before you look at the options you have. Reason through the scenario and apply the concepts you have learnt.
- Even if you know the answer, humor me and read through all the options
- Do not get tripped by answers that are too obvious
- Do not get tripped by answers that are too complicated
- If an answer does not sound right to you, it’s probably wrong.
- Go with your instinct. Memory is fickle and the associations between concepts tenuous. You are more likely to reason yourself out of a correct answer than into a correct one.
- If a question is too hard, guess and move on. Most exams do not penalize for guessing (the SAT does) and this might be an experimental question anyway.
- If you have no idea about a question, use process of elimination. Cross out the answers you know cannot be right. Then guess on whatever’s left.
- On mathematical questions, if are asked to find x, plug the options in if that’s easier. There should only be one that fits. Remember plug and play.
- If you have no idea about a question or the options, choose an option you are familiar with or have vaguely heard of rather than one you have never encountered.
- Work deliberately, work fast, pace yourself. Do not spend too much time on one question. All questions are worth the same points on most exams. Computer Adaptive tests like the GMAT are different so read about the tests so you can strategize.
- Between sections, take a moment to breath. Do not carry baggage over from one session to the other.
- Thou shalt not panic. One question or run of questions will not ruin your exam. Breathe easy. I mean literally breathe. Look off from your question paper, think of the happiness at the end of the test. Then, continue.
At the end of the exam, pray, thank your God, get out of there and move on with life. Do not believe there will be a profound sense of relief/happiness. There, most likely, will not be but that is normal. Move on. Enjoy life and don’t think of the results until they return.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
1. Set a target score.
2. Give yourself time – Do not over-estimate your abilities. Afford yourself as much time as you can to study for the exam. This should take into account the fact that you are likely to burn out at some point and will need a few days rest before you begin again. Pace yourself appropriately so you remain interested in what you study. And set aside days of the week (it can be a night per week) when you can relax, with no studying and stick to them.
3. Study hard – There are two stages of studying, intense studying and review.
i) Months before your exam, study hard and study detailed material. This period is for understanding the fundamental concepts of the field, the threads that run through every other topic. You can then build upon that as you go. Begin memorizing factoids if these are needed in your exam so you can go through the cycle a couple of times before the exam. At this point, read the concepts you are more likely to remember; the ones that are easier to take in. If you are stumped by a concept, an advanced concept or one which is not essential to further studying, write it down and move on. This is the time to experiment with study habits. Work with one at a time. If it does not work, switch to another. Do not be married to one study habit but do not also follow all and sundry’s suggestions. Choose the book that works best for you and the study materials that do and stick to them. Switching between things gets you confused and nowhere.
ii) Review stage – this depends on the amount of material you need to cover for your exam. Again, pacing and realism on time needed is the most important factor. This is not the time for detailed reading. This time is for you to glance over material to make sure they are at the forefront of your mind going into the exam. You are unlikely to remember everything in detail but you will have an idea about most things. Towards the end of your review period, you should plan a time when you read and memorize the concepts you were stumped by in the study period. These can be chewed, poured, and forgotten after day of exam.
4. Keep a routine – the brain works best when it knows exactly what it needs to do at a particular time. Maintain exact study times, keep a good sleep hygiene/protocol – go to sleep at set times, go through the same routines before sleep, keep a 30min block when you do nothing but relax before sleep. In the weeks before your exam, do practice exams at the exact time of and of similar duration as your actual test. In this, try to simulate as much of the test day as possible – preparations, sleep and all that.
5. Two nights before the test day, wrap up your readings, go to sleep on schedule. This is particularly important as sleep deficits will generally catch up with you in 48hrs. This is probably the day to take a quick look again at all those hard things you never could get your head around
6. The day before the exam – this works differently for different people. Some prefer to look again over some high yield material, keep the brain going. Others prefer to take this day off and do activities they enjoy like read, shop etc. Do not watch TV or spend hours behind a computer. They will put your brain to sleep. If you haven’t already, take this day to visit the test center and plot your transportation details. Get all the documents you need ready, put your food, drink, calculator, money for transportation, pens, pencils, all logistics in one bag. Needless to say, get a good amount of sleep. Through this whole study period, it is advisable to maintain at least 8hrs of sleep per night. Do not change your schedule in the final week and certainly not on the last two days. More sleep in those days will only make you groggy on the day of the exam. Less sleep will make you high.
Throughout this period, it is important that you continue to exercise and engage in other activities that refresh you and get your mind outside of books. They are not only healthy for mind and body, they decrease your stress levels and you don’t want to be stressed at this time.
On the day of exam – sometimes it doesn’t come quickly enough; other times you want it to stay away.
- give yourself more than enough time to get to test center
- Choose/ask for a quiet area of the exam room.
- bring earplugs. You will likely need them
- For food, eat a good breakfast, lunch should not be heavy. The advice generally given is to bring dried fruits like raisins and nuts instead of sugary energy drinks which can make you crash really fast, and carbohydrates which will make you sleep.
Before the exam – PRAY
During the exam,
- As soon as you sit down, write down the formulae and other memory aids you will not remember and do not erase them. When a formula you do not know is given to you or you derive it on one question, write it down. Do not erase drawings you use for one question. You might need them later.
- Read the instructions carefully. You miss points if you do not answer the question being asked.
- Read the question at the end of the preamble/blurb to guide you on what you should be looking for in the preamble.
- Formulate your answer before you look at the options you have. Reason through the scenario and apply the concepts you have learnt.
- Even if you know the answer, humor me and read through all the options
- Do not get tripped by answers that are too obvious
- Do not get tripped by answers that are too complicated
- If an answer does not sound right to you, it’s probably wrong.
- Go with your instinct. Memory is fickle and the associations between concepts tenuous. You are more likely to reason yourself out of a correct answer than into a correct one.
- If a question is too hard, guess and move on. Most exams do not penalize for guessing (the SAT does) and this might be an experimental question anyway.
- If you have no idea about a question, use process of elimination. Cross out the answers you know cannot be right. Then guess on whatever’s left.
- On mathematical questions, if are asked to find x, plug the options in if that’s easier. There should only be one that fits. Remember plug and play.
- If you have no idea about a question or the options, choose an option you are familiar with or have vaguely heard of rather than one you have never encountered.
- Work deliberately, work fast, pace yourself. Do not spend too much time on one question. All questions are worth the same points on most exams. Computer Adaptive tests like the GMAT are different so read about the tests so you can strategize.
- Between sections, take a moment to breath. Do not carry baggage over from one session to the other.
- Thou shalt not panic. One question or run of questions will not ruin your exam. Breathe easy. I mean literally breathe. Look off from your question paper, think of the happiness at the end of the test. Then, continue.
At the end of the exam, pray, thank your God, get out of there and move on with life. Do not believe there will be a profound sense of relief/happiness. There, most likely, will not be but that is normal. Move on. Enjoy life and don’t think of the results until they return.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Monday, May 31, 2010
Up on a hill
Up on a hill
- garland of crop and flower as neck,
the Eagle dwells
House of twigs and thorns
her rounded iron beaks
make into feather beds for her young.
I remember!
Young birds thrown gently over rocky cliff
Forced to fly
with wings not dry
Mother soars above—eyes watching
Sharp!
Glides in, gentle breeze
lest we break.
Rock-solid span
soft, comfortable, sure!
Unlike the rockier death to which we plunge
our dance
of life and death
Can I ever marry?
Would my heart anyone else love?
A taste of you
is the first drop of rain
that teases the parched, broken land
that is the landscape of my heart
whispering of the louder downpour
blood through venous cracks
giving life—and mending
I thirst some more!
Nurture the new plant—green
head high, stem straight without a bend
Give the adult strength
to make its food
Independence!!
So what locks my jaws—strangles me
prevents me from telling
I sing your love
speak my love
for you on your hill
The world hears, its heart listens, feels
The ear that’s valued the most
becomes the island
wondering, feeling, wondering
About a son’s love
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
- garland of crop and flower as neck,
the Eagle dwells
House of twigs and thorns
her rounded iron beaks
make into feather beds for her young.
I remember!
Young birds thrown gently over rocky cliff
Forced to fly
with wings not dry
Mother soars above—eyes watching
Sharp!
Glides in, gentle breeze
lest we break.
Rock-solid span
soft, comfortable, sure!
Unlike the rockier death to which we plunge
our dance
of life and death
Can I ever marry?
Would my heart anyone else love?
A taste of you
is the first drop of rain
that teases the parched, broken land
that is the landscape of my heart
whispering of the louder downpour
blood through venous cracks
giving life—and mending
I thirst some more!
Nurture the new plant—green
head high, stem straight without a bend
Give the adult strength
to make its food
Independence!!
So what locks my jaws—strangles me
prevents me from telling
I sing your love
speak my love
for you on your hill
The world hears, its heart listens, feels
The ear that’s valued the most
becomes the island
wondering, feeling, wondering
About a son’s love
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Tuesday, May 11, 2010
Musings from my time away – Akpa evelia (second part)
Hi, my name is Akpa evelia. If you have not read Akpa gbator, it may be difficult for you to know me. But if you are brave anyway, here goes ...
Next up were Neurology, Psychiatry and Radiology. Neurology was a large field with many unknowns but it made a lot of sense to me. In many ways, it was logical. Like 1+1 = 2 and very rarely was it something else. It could be summarized in deficits or excesses. Deficits naturally were the easiest to see as in strokes when someone suddenly cannot use an arm or cannot feel temperature differences or touch on a part of the body. Reasoning through the losses and what normal function is, one can usually pinpoint which region of the nervous system the problem lies, something called “localizing the lesion”.
Excesses are much more difficult to notice. For example, when does an old lady who suddenly becomes hypersexual and happy come to attention or when does someone with repeated vocal ticks and a propensity to burst out in curse words realize it is Tourette’s syndrome? Much has been achieved in the medicine of the nervous system but a lot still needs to be done and I found it difficult to come to terms with the futility of a lot of it. We could determine what the problem was in most cases. We could not always treat them. One of my patients died with us knowing neither what caused his problem nor how to definitively treat him.
The most important thing I found in Psychiatry is we all have mental problems to an extent and if you dig below the surface, you could very easily come up with a diagnosis of yourself. It is also not for me. Radiologists are some of the smartest people in the medical field and not only because they make the best lifestyle decision of us all. The breadth of differential diagnoses they have to know is beyond belief and they know more than just the names, they know the pathophysiology and they know the best management practices. They are everyman’s doctors with no direct patients.
The best, and the reason I have been incognito for the past 3 months, was saved for last. Surgery was the light at the end of my proverbial third year tunnel. Since I was a child, I have wanted to be a surgeon. The simple idea of getting into a person’s body, fixing a problem and closing up like nothing had happened in the first place was just amazing to me. It is as good as instant gratification goes. As I grew, I got more and more excited about the heart. I saw a heart come back to life after being stopped for surgery and oh my! It was poetry in motion. But I jump forward. Let me rewind for a second.
My surgery experience ran the gamut from an attending telling me she would “take away [my] scissors if [I] cut like [I] did again” and duly taking it away on the next cut then not saying a word to me for the rest of the day’s surgeries outside of sending me to get her camera for a picture of an interesting pathology, through opening the six pack muscle to enter the abdominal cavity to resecting a lipoma, replacing a hip and suturing multiple incisions closed. Through all this, I never did tire of cutting into human skin…for good, of course.
I would have to say as a pre-clinical student, I thought watching a surgery was incredibly boring. I did not understand a lot of the pathophysiology, I did not know much about the procedures and in many cases, I could not even see what was going on. However, once I got into my third year and started putting together the link between pathology and physiology, it was easier to think through what procedures were going on, how the problem would be approached, why surgery was indicated in the first place and most importantly, the anatomy of the situation. In addition to this, I started looking at how surgeons exposed problem areas, how they were holding instruments and what instruments they were calling for during various parts of the surgery. And of course I thought through what the anesthesiologist was doing.
Let me tell you a typical day. I woke up at 4am, got to work by about 5am to pre-round on all patients on the team. This involved getting their vital signs, fluids in and out and for my patients, reading through the consult notes from the previous night, checking out on events overnight and writing a preliminary plan of action for the day. I was lucky to have another student, “Goose” to my “Iceman”, on the team and we could very easily divide and conquer. I felt the sting when he moved on to another service. We rendezvoused at 5:50am with the Intern and then rounded with the Senior (Boss – he hates it and this is the last time I will call him that) at 6am. Then we did “gravity rounds”; starting with the patient on the topmost floor and ending down on the surgical floor. Our role as we saw it as students was to get the patient charts, do dressing changes, get pimped (tested on multiple surgical and non-surgical knowledge) and in general make the morning a smooth and enjoyable one for our team.
7am saw us in rounds where we went through the trauma admissions of the previous night and the cases for the day and then we were off to the operating room of which you have heard enough. Suffice it to say, there was a totem pole and we were at the bottom of it. Our work mostly involved transferring the patient onto and off the OR bed, transporting them to the post-anesthesia care unit and in-between, cutting stitches and retracting other organs out of the way so the surgeons could get a better view of what they were doing and if we were so fortunate, getting further pimping. And NEVER contaminating the field.
And here-in lay the bane of the medical student’s OR existence. The circulation nurse. Yes I have been lucky to have the best of them. The ones looking out for you and the ones who were only vested in your success, helping you maneuver the OR adroitly. Yes I have also had the worst including those who invented more and more ingenious ways to charge you with being “contaminated”. You remember that totem pole in the OR? The circulation nurse, see, is on top of it. They are the people tasked with setting up the operation room, getting things and people moving and overall, making the operation a success. And they take their work seriously. If you are ever in an OR, make sure you have had your orientation and know who they are. Ask what you can do to help, get the temperature of the situation and act accordingly. One source that helped me with this is found here. Seriously though, a lot of them are very nice people who are more than happy to teach you and you should learn from them.
Back to the time line. Between cases, we checked on our patients “post-op” to ensure we did not screw up that physiology or the other anatomy. Then it was off to didactic lectures at 1pm during which we ate lunch. The rest of the day was spent either in cases, managing the patients on the floor or answering consult requests. We sign out to the night team at 6pm and go home to begin in another few hours. For the medical student, that meant dinner, and hitting the books for however long you spirit or body could take. Then sleep beckoned and before long, the annoying alarm goes off and you are back again.
As far as my personal experience, it was awesome. I have to say these were the most brutally honest people I have ever worked with and that was refreshing even if it meant there were harsh critiques half the time and I felt worthless the other half. I had, most of the time, teams with doctors who were committed to the philosophy of education and challenged my thinking, knowledge base and surgical skills. They also gave me a lot of responsibilities during cases, handing me large parts of the simpler cases and making me experience first hand, the art and science of what the French call Chirurgie. It is a time I will always cherish and most of the people will be remembered by me through my career. Above all, what made surgery great for me, and what keeps me excited about it, is seeing the problems in peoples’ bodies with my eyes and then seeing them solved. As one Senior said to me after we witnessed a ventricular fibrillation, “internal medicine doctors can only read about this in books”.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Next up were Neurology, Psychiatry and Radiology. Neurology was a large field with many unknowns but it made a lot of sense to me. In many ways, it was logical. Like 1+1 = 2 and very rarely was it something else. It could be summarized in deficits or excesses. Deficits naturally were the easiest to see as in strokes when someone suddenly cannot use an arm or cannot feel temperature differences or touch on a part of the body. Reasoning through the losses and what normal function is, one can usually pinpoint which region of the nervous system the problem lies, something called “localizing the lesion”.
Excesses are much more difficult to notice. For example, when does an old lady who suddenly becomes hypersexual and happy come to attention or when does someone with repeated vocal ticks and a propensity to burst out in curse words realize it is Tourette’s syndrome? Much has been achieved in the medicine of the nervous system but a lot still needs to be done and I found it difficult to come to terms with the futility of a lot of it. We could determine what the problem was in most cases. We could not always treat them. One of my patients died with us knowing neither what caused his problem nor how to definitively treat him.
The most important thing I found in Psychiatry is we all have mental problems to an extent and if you dig below the surface, you could very easily come up with a diagnosis of yourself. It is also not for me. Radiologists are some of the smartest people in the medical field and not only because they make the best lifestyle decision of us all. The breadth of differential diagnoses they have to know is beyond belief and they know more than just the names, they know the pathophysiology and they know the best management practices. They are everyman’s doctors with no direct patients.
The best, and the reason I have been incognito for the past 3 months, was saved for last. Surgery was the light at the end of my proverbial third year tunnel. Since I was a child, I have wanted to be a surgeon. The simple idea of getting into a person’s body, fixing a problem and closing up like nothing had happened in the first place was just amazing to me. It is as good as instant gratification goes. As I grew, I got more and more excited about the heart. I saw a heart come back to life after being stopped for surgery and oh my! It was poetry in motion. But I jump forward. Let me rewind for a second.
My surgery experience ran the gamut from an attending telling me she would “take away [my] scissors if [I] cut like [I] did again” and duly taking it away on the next cut then not saying a word to me for the rest of the day’s surgeries outside of sending me to get her camera for a picture of an interesting pathology, through opening the six pack muscle to enter the abdominal cavity to resecting a lipoma, replacing a hip and suturing multiple incisions closed. Through all this, I never did tire of cutting into human skin…for good, of course.
I would have to say as a pre-clinical student, I thought watching a surgery was incredibly boring. I did not understand a lot of the pathophysiology, I did not know much about the procedures and in many cases, I could not even see what was going on. However, once I got into my third year and started putting together the link between pathology and physiology, it was easier to think through what procedures were going on, how the problem would be approached, why surgery was indicated in the first place and most importantly, the anatomy of the situation. In addition to this, I started looking at how surgeons exposed problem areas, how they were holding instruments and what instruments they were calling for during various parts of the surgery. And of course I thought through what the anesthesiologist was doing.
Let me tell you a typical day. I woke up at 4am, got to work by about 5am to pre-round on all patients on the team. This involved getting their vital signs, fluids in and out and for my patients, reading through the consult notes from the previous night, checking out on events overnight and writing a preliminary plan of action for the day. I was lucky to have another student, “Goose” to my “Iceman”, on the team and we could very easily divide and conquer. I felt the sting when he moved on to another service. We rendezvoused at 5:50am with the Intern and then rounded with the Senior (Boss – he hates it and this is the last time I will call him that) at 6am. Then we did “gravity rounds”; starting with the patient on the topmost floor and ending down on the surgical floor. Our role as we saw it as students was to get the patient charts, do dressing changes, get pimped (tested on multiple surgical and non-surgical knowledge) and in general make the morning a smooth and enjoyable one for our team.
7am saw us in rounds where we went through the trauma admissions of the previous night and the cases for the day and then we were off to the operating room of which you have heard enough. Suffice it to say, there was a totem pole and we were at the bottom of it. Our work mostly involved transferring the patient onto and off the OR bed, transporting them to the post-anesthesia care unit and in-between, cutting stitches and retracting other organs out of the way so the surgeons could get a better view of what they were doing and if we were so fortunate, getting further pimping. And NEVER contaminating the field.
And here-in lay the bane of the medical student’s OR existence. The circulation nurse. Yes I have been lucky to have the best of them. The ones looking out for you and the ones who were only vested in your success, helping you maneuver the OR adroitly. Yes I have also had the worst including those who invented more and more ingenious ways to charge you with being “contaminated”. You remember that totem pole in the OR? The circulation nurse, see, is on top of it. They are the people tasked with setting up the operation room, getting things and people moving and overall, making the operation a success. And they take their work seriously. If you are ever in an OR, make sure you have had your orientation and know who they are. Ask what you can do to help, get the temperature of the situation and act accordingly. One source that helped me with this is found here. Seriously though, a lot of them are very nice people who are more than happy to teach you and you should learn from them.
Back to the time line. Between cases, we checked on our patients “post-op” to ensure we did not screw up that physiology or the other anatomy. Then it was off to didactic lectures at 1pm during which we ate lunch. The rest of the day was spent either in cases, managing the patients on the floor or answering consult requests. We sign out to the night team at 6pm and go home to begin in another few hours. For the medical student, that meant dinner, and hitting the books for however long you spirit or body could take. Then sleep beckoned and before long, the annoying alarm goes off and you are back again.
As far as my personal experience, it was awesome. I have to say these were the most brutally honest people I have ever worked with and that was refreshing even if it meant there were harsh critiques half the time and I felt worthless the other half. I had, most of the time, teams with doctors who were committed to the philosophy of education and challenged my thinking, knowledge base and surgical skills. They also gave me a lot of responsibilities during cases, handing me large parts of the simpler cases and making me experience first hand, the art and science of what the French call Chirurgie. It is a time I will always cherish and most of the people will be remembered by me through my career. Above all, what made surgery great for me, and what keeps me excited about it, is seeing the problems in peoples’ bodies with my eyes and then seeing them solved. As one Senior said to me after we witnessed a ventricular fibrillation, “internal medicine doctors can only read about this in books”.
Prime
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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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