I remember in medical school being taught the difference between sympathy and empathy - a lot of people tend to use them as synonyms. In my line of work, when you empathize with someone, it means that you can feel what they are feeling. For example, if they have some type of cancer, and you've had that exact type of cancer, you can feel something similar to what they must be going through and you "empathize." If you feel sympathy for someone, then it's more that you understand, or try to understand as best you can, what the person is going through but you may not feel or have not felt that way yourself. In my opinion, it's very difficult to empathize with someone unless you've gone through a very similar process or situation that they're going through.
Having said all this, I highly empathize right now with all the 9 month pregnant ladies out there who like to deliver soon. :)
Friday, May 31, 2013
Thursday, May 30, 2013
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Wednesday, May 29, 2013
Dinner with the big wigs
So intake this morning was a little surprising – my team had 3 patients die over the weekend – one 77 year-old with metastatic adenocarcinoma, which wasn’t too surprising. But the other two were young, 30 and 42, with mental status changes, that I thought were going to live! It was a little difficult to take – I was not expecting it, and I had poured so much work into them to try and make them better. Some of these patients you know are going to die, so it’s not worth 3 hours of your time to try and diagnose or treat them. But these two I thought were going to make it. I guess that’s the way it is here… Nothing much happened today though. I thought we might pick up a huge number of patients since Boipelo was on call Saturday, but we only picked up 3 or 4.
Tonight we went out for dinner again, this time at Tendani’s house – she used to be an MO, and was leaps and bounds better than the other MO’s, so got recruited to run IDCC, which is the Infection Disease Clinic at Princess Marina Hospital – it mostly takes care of patients with HIV and AIDS. However, she is rarely ever there anymore as she now is very involved in PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief). Her dad is the Minister of Finance inBotswana , arguably the 3rd most important person in Botswana
There were some very interesting people at the dinner. The entire Penn team had been invited, and she had invited a lot of PEPFAR people as well. I had very interesting conversations with a few different people – one was the son of a prior president and he told us a lot of stuff aboutBotswana Botswana
Tonight we went out for dinner again, this time at Tendani’s house – she used to be an MO, and was leaps and bounds better than the other MO’s, so got recruited to run IDCC, which is the Infection Disease Clinic at Princess Marina Hospital – it mostly takes care of patients with HIV and AIDS. However, she is rarely ever there anymore as she now is very involved in PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief). Her dad is the Minister of Finance in
There were some very interesting people at the dinner. The entire Penn team had been invited, and she had invited a lot of PEPFAR people as well. I had very interesting conversations with a few different people – one was the son of a prior president and he told us a lot of stuff about
Monday, May 27, 2013
Family
Around this time of year I suppose tons of people are thinking about family, and usually with family. I'm really lucky to have a great one, and just as lucky to be marrying into another great one.
Here's my family back in Sacramento:
And here is the family I'm marrying into - with twins in the family it is pretty much impossible to get everyone together at the same time for a group shot, but here are a few pictures of them separately:
I am super lucky to have two such wonderful families... but sometimes I wish I could be close in distance to both at the same time. I'm on the east coast right now, and there's a good chance I will be staying here for quite a long time, and my mom, dad, brother and sister are all still in California - I definitely miss them.
And get this - this Christmas was the first time they met! Not everyone - that would have been pretty difficult, but Carol (Pete's mom) came over to California to meet my family. It went pretty much as expected, which was wonderfully.
Everyone got along very well, and we had a great Christmas. In fact, I'm still humming Christmas songs, much to Pete's chagrin, I'm sure. :)
Here's my family back in Sacramento:
And here is the family I'm marrying into - with twins in the family it is pretty much impossible to get everyone together at the same time for a group shot, but here are a few pictures of them separately:
I am super lucky to have two such wonderful families... but sometimes I wish I could be close in distance to both at the same time. I'm on the east coast right now, and there's a good chance I will be staying here for quite a long time, and my mom, dad, brother and sister are all still in California - I definitely miss them.
And get this - this Christmas was the first time they met! Not everyone - that would have been pretty difficult, but Carol (Pete's mom) came over to California to meet my family. It went pretty much as expected, which was wonderfully.
Everyone got along very well, and we had a great Christmas. In fact, I'm still humming Christmas songs, much to Pete's chagrin, I'm sure. :)
Sunday, May 26, 2013
Frustrations with giving medical care
I'm sure there are a many frustrating things during intern year, and I'm sure I will blog about quite a few of them. Here's one.
There are so many patients in the hospital who fight with you about their care. You're trying to do something for them which will make them better, and they don't want to go through with it. And I'm not talking about interventions that are risky, or have lots of side effects, or ones that we're not sure about or ones that don't matter that much. Sometimes they're life-saving interventions! Here's my example from intern year:
I had a patient who had a horrible infection - she needed IV antibiotics. She wasn't about to die just yet, but if she didn't get the IV antibiotics soon, she would get horribly sick. And we know this because we see it happen all the time. Sometimes we don't even know people have infections in the hospital yet until they're horribly sick - we got lucky and managed to catch this patient before they got to this point. She tried to refuse the IV antibiotics! She said vitamins or herbs might do just as well. Ridiculous. She also had made some really bad medical decisions that had got her in this situation in the first place. I spent close to an hour talking her into, first, letting us put an IV in her arm, and then second, getting the IV antibiotics. What if I had said, fine, don't get the IV then. She would have gotten seriously sick! But of course, I spend more than an hour arguing for her, and she got the IV and the IV antibiotics, which probably saved her life.
The problem is that it's very difficult for doctors to say something like oh well, it's your call, go ahead and die to a patient. First of all, they genuinely believe in the therapy and believe that they're right. Secondly, if they didn't try their absolute hardest to argue with the patient for their own good, doctors would be held liable. It's very frustrating, but I think we're stuck with it.
There are so many patients in the hospital who fight with you about their care. You're trying to do something for them which will make them better, and they don't want to go through with it. And I'm not talking about interventions that are risky, or have lots of side effects, or ones that we're not sure about or ones that don't matter that much. Sometimes they're life-saving interventions! Here's my example from intern year:
I had a patient who had a horrible infection - she needed IV antibiotics. She wasn't about to die just yet, but if she didn't get the IV antibiotics soon, she would get horribly sick. And we know this because we see it happen all the time. Sometimes we don't even know people have infections in the hospital yet until they're horribly sick - we got lucky and managed to catch this patient before they got to this point. She tried to refuse the IV antibiotics! She said vitamins or herbs might do just as well. Ridiculous. She also had made some really bad medical decisions that had got her in this situation in the first place. I spent close to an hour talking her into, first, letting us put an IV in her arm, and then second, getting the IV antibiotics. What if I had said, fine, don't get the IV then. She would have gotten seriously sick! But of course, I spend more than an hour arguing for her, and she got the IV and the IV antibiotics, which probably saved her life.
The problem is that it's very difficult for doctors to say something like oh well, it's your call, go ahead and die to a patient. First of all, they genuinely believe in the therapy and believe that they're right. Secondly, if they didn't try their absolute hardest to argue with the patient for their own good, doctors would be held liable. It's very frustrating, but I think we're stuck with it.
Saturday, May 25, 2013
God and medicine
I'm not particularly religious, but I know many patients and doctors are. Although I don't believe in the same thing they do, I feel that I have plenty of respect for their beliefs and don't usually have a problem with it. However, I have a small pet peeve about something I hear a lot of patients say. It's not a big deal, really it isn't, but I dislike it when there's a test or therapy patients don't want to take and they say "it's in God's hands." I completely respect patients' wishes (and sometimes agree with them) when they don't want to take something or do something - it's their right. However, I have a problem with them using God as an excuse. I'd rather them tell me they just don't want to do it, even if it's against all logic, than use what I call the God excuse.
For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.
But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.
For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.
But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.
Friday, May 24, 2013
Prisoners as Patients
We were on call today and miraculously got no patients!!!! It’s the first time ever! I was pretty excited. :)
I’d like to mention a special subset of patients we have at Princess Marina – the prisoners. There is a prison near Gabs (which we actually saw on the way to the Kalahari) that often sends prisoners to us for medical treatment. There is a small clinic within the prison but I think they can only treat patients to a very limited degree – so for very sick prisoners, they send them to PMH, shackled at the ankles, along with at least one prison guard.
You never really find out what these prisoners were jailed for. Boipelo and Maggie (another MO) told us that it’s mostly small things, like theft, but occasionally there are murders (usually crimes of passion, or as they say, “passion killings”) and rapes. Sometimes if a prisoner comes with two prison guards, I think that they must have committed some more offensive crime. But we treat them all the same. They stay shackled with these old-fashioned metal chain shackles, and anywhere they go, a prison guard goes with them. Some of them are relatively healthy and walk around everywhere, while others are incredibly sick and stay in bed all the time – it’s interesting because they stay shackled no matter what, even if they’re too sick to move!
Most of the prisoners are pretty sick by the time by the time they come to PMH. I think the prison clinic does everything it can to help them and then sends them to the hospital only when absolutely necessary. There probably is a huge incentive to fake illness – PMH is like a vacation for these guys. They get mattresses, decent food, and they can even have visitors at PMH!
A high percentage of the prisoners are foreigners, especially Zimbabwean. It’s actually a big problem because foreigners don’t get the same medical treatment that Motswana prisoners do. Because they aren’t citizens, they can’t get CTs without paying (and it’s expensive!), and they can’t get free HIV or TB medications. One patient I had was diagnosed with HIV in prison a few months ago, and is starting to get these complications from AIDS. These are mostly due to opportunistic infections, like Cryptococcus, or TB, and if you get them, it’s a sign that your CD4 count is pretty low and you need to start HIV medications as soon as possible. If this patient could just start taking HIV medications, then it would be ok, his immune system would recover enough for him to fight off the infections on his own. But since he’s a foreigner, he can’t get the free medications fromBotswana Zimbabwe
I’d like to mention a special subset of patients we have at Princess Marina – the prisoners. There is a prison near Gabs (which we actually saw on the way to the Kalahari) that often sends prisoners to us for medical treatment. There is a small clinic within the prison but I think they can only treat patients to a very limited degree – so for very sick prisoners, they send them to PMH, shackled at the ankles, along with at least one prison guard.
You never really find out what these prisoners were jailed for. Boipelo and Maggie (another MO) told us that it’s mostly small things, like theft, but occasionally there are murders (usually crimes of passion, or as they say, “passion killings”) and rapes. Sometimes if a prisoner comes with two prison guards, I think that they must have committed some more offensive crime. But we treat them all the same. They stay shackled with these old-fashioned metal chain shackles, and anywhere they go, a prison guard goes with them. Some of them are relatively healthy and walk around everywhere, while others are incredibly sick and stay in bed all the time – it’s interesting because they stay shackled no matter what, even if they’re too sick to move!
Most of the prisoners are pretty sick by the time by the time they come to PMH. I think the prison clinic does everything it can to help them and then sends them to the hospital only when absolutely necessary. There probably is a huge incentive to fake illness – PMH is like a vacation for these guys. They get mattresses, decent food, and they can even have visitors at PMH!
A high percentage of the prisoners are foreigners, especially Zimbabwean. It’s actually a big problem because foreigners don’t get the same medical treatment that Motswana prisoners do. Because they aren’t citizens, they can’t get CTs without paying (and it’s expensive!), and they can’t get free HIV or TB medications. One patient I had was diagnosed with HIV in prison a few months ago, and is starting to get these complications from AIDS. These are mostly due to opportunistic infections, like Cryptococcus, or TB, and if you get them, it’s a sign that your CD4 count is pretty low and you need to start HIV medications as soon as possible. If this patient could just start taking HIV medications, then it would be ok, his immune system would recover enough for him to fight off the infections on his own. But since he’s a foreigner, he can’t get the free medications from
Wednesday, May 22, 2013
Getting sick
Since getting here, almost everyone has gotten sick. There seem to be two different things going around, but maybe it’s a variation of the same bug. One illness has people with upper respiratory symptoms – congestion, cough, runny nose, fatigue etc. The other one seems to be fever, chills, GI symptoms with vomiting and diarrhea. I’ve been extremely lucky so far – I haven’t gotten sick yet. Neither has Lisa or Josh. I’m pretty sure it’ll happen, but I just hope it’s not over the weekend. And I hope I get the first one rather than the later one.
Drug Dinners
In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."
I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.
The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.
On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.
I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.
All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...
I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.
The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.
On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.
I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.
All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...
Sunday, May 19, 2013
Camping in the Kalahari!
We went camping in the Kalahari this weekend! Joanne, Amy, Jeremy and I went with Johannes (Jo), a guide that works with Tim. It took us 3-4 hours to get there, we had lunch at the campsite, and set up our lion-proof tents. We were staying in Khutse game reserve, which is connected, or adjacent to, the huge Central Kalahari Game Reserve (CKGR) – the largest game reserve in We had a huge lunch – quiche, salad, other things – and then went on our first game drive.
We saw a few funny things, but no huge game. We did see this huge flock of vultures near the air strip – very impressive. Of course, we saw many springbok and steembok, some oryx gazelle, these cute ground squirrels that ran fast everywhere and use their tail to shade themselves. And we saw a ton of birds – the lilac-crested roller, hornbills, some weavers, and the kgori (or kori) bustard (which we were saying bastard the entire time) – apparently it’s largest flying bird in the world. We also collected some firewood and saw a beautiful sunset! Here are just a few pictures of the things we saw:
Vultures
Ground squirrel
hornbill
kgori bustardAfter we got back, Jo made dinner. It’s funny – there were 3 Jo’s on this trip so it was very confusing when Jeremy or Amy tried to talk to one of us. They would say Jo, and three heads would turn. Dinner was delicious – we had steak, garlic bread, and green beans with pap. And we also had chocolate cake for dessert. We sat around the campfire for a while,
and eventually crawled into our tents. I slept with Amy, Jeremy slept alone, and Jo(anne) slept with Jo(hannes). J We were a little afraid of lions – they often go right into the campsite at night although they stay away from humans for the most part. So I didn’t make it out to the drop toilets all night because I was so worried! I think that was a good decision because apparently campsite 5, which was right next to us, had a lion visit them!We went on another relatively uneventful game drive the next morning after breakfast, and Jo took us to a relocated village of the San-people (they’re also called bushmen, which is derogative, or Basarwa, also derogative since it literally translates to “stick-people”). I thought it was the most interesting part of the trip, but it’s a pretty sad story. I’ll talk more about it in the next blog entry. After visiting the San-village, we stopped at the Khutse Lodge, which is right on the border of the Khutse Game Reserve, for a light lunch of sandwiches and salad. We were there for a couple of hourse, so we went swimming in their pool to cool off, and then drove home. Even though we didn’t see any big game, it was still a great experience, and I’m totally glad I went. It was so quiet and beautiful out there. I think it was a good preview of what our safari will be like…
Saturday, May 18, 2013
Being a health care professional in bad economic times
One good thing (of many, I think) of being a doctor during bad economic times - you pretty much are guaranteed a job. Especially in this day and age, with more and more people living longer and longer, people will always need doctors and nurses, and other health care professionals. In fact, there's an increasing demand for them. I'm sure salaries may go down, and people may have to work (even) longer hours and care for more patients in a shorter amount of time, but at least they're usually not at danger for losing their jobs. At the worst, people may have to relocate or take less-than-ideal jobs or situations in order to keep their incomes flowing in.
It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.
It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.
Thursday, May 16, 2013
Transfer of Care
At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.
As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.
However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.
As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.
However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.
Tuesday, May 14, 2013
the genetics of race
When I was in high school, I got into a debate at school. I said that if different races were separated long enough to evolve different skin colors, then other things could have evolved differently too. For example, blacks are stereotypically thought of as good athletes. Asians are thought of as good at math. I know this is really oversimplifying it, but it's certainly possible that over time, blacks developed a "strong muscle" gene (or set of genes) or maybe a "hand-eye coordination gene" and Asians developed a "math" gene (or set of genes). I'm not saying that's what happened... it's just what is possible.
I was watching a TV show (I think it was Without a Trace) and although I'm sure nobody really picked up on it, there was this one part that I think really made this statement. In this episode, there was this white kid who disappeared, partly because he was having an identity crisis. His mother was white and the father who raised him with his mother was white, and the kid looked white, but his father was black, and he just found that out. In one of the flashback scenes, they show the kid when he really young, and he's talking to his adopted father, saying that he doesn't "feel right". I'm not getting the words completely right, but he basically says that he feels different from his father and all the other (white) kids - they don't like the same things, act the same way, or even look the same. And after the flashback, the father says about his adopted son, "he always knew" (that he was different).
Now at first glance, this doesn't seem to mean much. But actually, what's it's saying is that even though there was no difference in skin color for this kid, there were other characteristics - facial or other body features, personality, attitudes, etc. - that made him feel different. And then he finds out he's half-black. The point is that this one scene in the show is suggesting that there may be other differences to race than skin color (whether genetic or otherwise). It's interesting to me that this was brought up, albeit in a very subtle way, on TV, while in reality, it's something that society as a whole isn't really ready to talk about yet.
I was watching a TV show (I think it was Without a Trace) and although I'm sure nobody really picked up on it, there was this one part that I think really made this statement. In this episode, there was this white kid who disappeared, partly because he was having an identity crisis. His mother was white and the father who raised him with his mother was white, and the kid looked white, but his father was black, and he just found that out. In one of the flashback scenes, they show the kid when he really young, and he's talking to his adopted father, saying that he doesn't "feel right". I'm not getting the words completely right, but he basically says that he feels different from his father and all the other (white) kids - they don't like the same things, act the same way, or even look the same. And after the flashback, the father says about his adopted son, "he always knew" (that he was different).
Now at first glance, this doesn't seem to mean much. But actually, what's it's saying is that even though there was no difference in skin color for this kid, there were other characteristics - facial or other body features, personality, attitudes, etc. - that made him feel different. And then he finds out he's half-black. The point is that this one scene in the show is suggesting that there may be other differences to race than skin color (whether genetic or otherwise). It's interesting to me that this was brought up, albeit in a very subtle way, on TV, while in reality, it's something that society as a whole isn't really ready to talk about yet.
Sunday, May 12, 2013
HIV/AIDS: A Very Short Introduction (Very Short Introductions)
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Amazon.com Review
HIV/AIDS: Questions for Consideration and Discussion
To what extent do you feel that there is a moral obligation on rich countries to help respond to HIV and AIDS in the developing world? The HIV epidemics in Europe and America are driven by different dynamics compared to those in sub-Saharan Africa. Why do you think this is the case? If you were in charge of responding to HIV and AIDS in the developing world--would you put your money into treatment or prevention? What percentages would you allocate? AIDS is often seen as one of the first diseases of globalization. Do you think it is? What have we learnt in responding to HIV and AIDS that may have implications for other global diseases? Can legislation help prevent the spread of HIV?Very Short Introductions - General Series - Series - Academic ... Oxford University Press UK - dictionaries, educational, academic, and scholarly books, journals, and online products AEGiS Welcome to AEGiS: AFTER 30 LONG YEARS, AEGiS is undergoing a re-birth. The site is still under construction as we migrate data into the new more efficient database ... HIV/AIDS - Wikipedia, the free encyclopedia Human immunodeficiency virus infection / acquired immunodeficiency syndrome (HIV/AIDS) is a disease of the human immune system caused by infection with human ... Solution for AIDS HIV & Cancer - Bucks here on HubPages Since AIDs and HIV have been around, there always seems to be a twist as to how it began and why it cant be cured. What is AIDs ? Is it man made, a designer virus, or ... Transcript: HIV/AIDS Prevention and Care Among Migrant and ... Comprehensive, up-to-date information on HIV/AIDS treatment, prevention, and policy from the University of California San Francisco HIV & AIDS Information from AVERT.org Detailed worldwide HIV/AIDS information focusing on regional and global responses to the epidemic. Avert.org also provides HIV and AIDS facts, advice and sex ... AIDS This page defines Acquired Immune Deficiency Syndrome (AIDS) as well as explaining how AIDS is linked to HIV including the stages between HIV infection and the ... Introduction to HIV/AIDS - YouTube Becky Kuhn, M.D., co-founder of Global Lifeworks, covers critical basic information about HIV and AIDS. HIV is a virus that causes the disease AIDS, which ...
Saturday, May 11, 2013
Mokolodi Game Reserve
Today we went to Mokolodi game reserve, which is just 20-30 minutes away, still really a part of Gaborone. It’s not nearly as wild as Tau, but it was still pretty fun. It’s probably 
about 1.5 times the size of center city in Philadelphia, and it’s a little more zoo-like than Tau. The animals are still wild, but they are tamer, and there aren’t as many predators. They don’t have any lions, and they only have 4 elephants. On our game drive, we of course saw tons of game, but our guide was not nearly as good as Hein from a week ago. She tended to blaze past the animals and recite memorized bits of trivia about the animals. I didn’t get the sense that she knew a whole lot about the animals other then the stuff the game reserve probably gave them to memorize. Nevertheless, it was pretty cool.
We saw tons of kudu and other deer-like animals, likely springbok and steembok. We also saw
this baby rhino with its mother, which I took a million pictures of. I think Aaron and Jacob (Pete’s nephews) will love this picture – I can’t wait to email it to them! We also came upon this giraffe just by the side of the trail munching on a tree. This was very cool, since I’d never seen a giraffe so up close before. We also got to see their 
4 elephants – they had one male and 3 females. The male one was definitely bigger than the rest, but was chained, and they had a staff of about 3 people watching over the 
elephants, I guess to make sure everything stayed okay as people came by in the safari vehicles to gawk at them. It was a little sad, actually. Although it was super impressive – they came within an arms reach away, and they (rather angrily, I thought) started ripping to shreds this massive tree right next to us. They were reaching above our heads to the branches and pulling them down! It was amazing! And we got close-up views of their tusks and their mouths, and just how strong their tusks and legs can be. Pretty scary, actually.
Finally, one of the highlights of the trip was that I got to pet a cheetah! There were two male cheetahs that were in this large fenced enclosure. Apparently their mother died when they were very young, and the only way they were able to survive was being bottle fed by humans. So they got used to humans at a young age – although they’re still somewhat wild. So now, they feed them every day at 2pm, and around 3 or 4pm, they’ll bring a small group of tourists in to their fenced enclosure to pet them! I wasn’t going to do it at first. It was an extra P100 to pet the cheetah, and I was just going to watch other people do it. But in the end I figured, eh, it’s an extra $16 and I don’t want to walk away from this regretting not going to pet the cheetah, even if it is super touristy. :) However, I think Phil put it in a pretty funny way: “why would I pay an extra $16 to go get my hand bitten off?” I thought that was hilarious, but maybe you had to be there.
So it wasn’t quite as I expected. For some reason I had in my head the idea that we would be petting the cheetah through a fence, or that there would be a trainer there holding them or calming
them or something while we petted the cheetah. Not so. Our guide unlocked a gate to let us into the first fenced enclosure (sort of like a foyer), and then unlocked another gate to let us into the second fenced enclosure, which was large, and was where the cheetahs were. The cheetahs were prowling around, and eventually lay down in the shade of some bush. We went over to them, and the guide said to go up one by one, and avoid petting the paws and the tail. She went up first and petted the cheetah, and then we all did it. One cheetah was feeling feisty I guess and didn’t want to be petted, so we petted the other one.
There were these two Indian guys on our safari who I swear deserved to be eaten. They were so intent on taking pictures and everything that they seemed to forget that this was a CHEETAH. They were kinda like that the entire trip – almost jumping out of the jeep to take pictures, and being totally touristy. I mean, I know I’m also a tourist, but they were a little obnoxious. Anyways, during the cheetah petting, we were mostly petting one cheetah because the other one was a little grumpy. The two Indian guys kept on almost stepping on that cheetah’s tail because they were too busy taking pictures of them petting the other one. And the one that we were petting, they petted it too hard or something, because it took a swipe at one of the Indian guys. I’m sure it was just a little annoyed and doing the equivalent of batting a fly away (if he had really wanted to hurt the guy or attack him, I’m sure the cheetah would have), but the Indian guy didn’t seem to realize it! He dodged backwards, but then went back for more petting! Then the cheetah reared its head, and looked at the guy, who finally seemed to get the picture.
Anyways, it was a fun trip overall. We hung out in the Mokolodi restaurant for a while afterwards, drinking some beer. It’s supposed to be one of the best, or maybe the best, restaurant in Gabs. I think they changed chefs recently though, so I’m not sure how it’s supposed to be now. I know that some of the Caucasian doctors go there for special dinners. They also apparently have more exotic things on the menu, such as kudu, and their steaks are supposed to be amazing. I wanted to eat there for dinner, but I think some of the other people either didn’t want to eat out or wanted to go home. It’s expensive by Gabs standards, but definitely not by American standards – it’s probably about P80-120 for an entrée (which is about $15-$20), and drinks are relatively inexpensive. But that’s okay. I’ll try kudu eventually.
Speaking of kudu, while we were sitting out there on the restaurant terrace, they had set out some grass for animals to come and eat, and we saw a few warthogs and a lot of kudu. This family of kudu seemed to come up – one male
and several females. Then we saw another male kudu a hundred feet behind, who seemed a little hesistant to come forward, probably because of the first male already there feeding. Eventually he came up, and we thought they were going to fight! They lowered their heads and met horns softly several times, but didn’t end up fighting or anything. I think it was a way of greeting each other or making sure everything is okay. It was pretty impressive and I got a few good shots of them greeting each other with their horns.
about 1.5 times the size of center city in Philadelphia, and it’s a little more zoo-like than Tau. The animals are still wild, but they are tamer, and there aren’t as many predators. They don’t have any lions, and they only have 4 elephants. On our game drive, we of course saw tons of game, but our guide was not nearly as good as Hein from a week ago. She tended to blaze past the animals and recite memorized bits of trivia about the animals. I didn’t get the sense that she knew a whole lot about the animals other then the stuff the game reserve probably gave them to memorize. Nevertheless, it was pretty cool.We saw tons of kudu and other deer-like animals, likely springbok and steembok. We also saw
this baby rhino with its mother, which I took a million pictures of. I think Aaron and Jacob (Pete’s nephews) will love this picture – I can’t wait to email it to them! We also came upon this giraffe just by the side of the trail munching on a tree. This was very cool, since I’d never seen a giraffe so up close before. We also got to see their 
4 elephants – they had one male and 3 females. The male one was definitely bigger than the rest, but was chained, and they had a staff of about 3 people watching over the 
elephants, I guess to make sure everything stayed okay as people came by in the safari vehicles to gawk at them. It was a little sad, actually. Although it was super impressive – they came within an arms reach away, and they (rather angrily, I thought) started ripping to shreds this massive tree right next to us. They were reaching above our heads to the branches and pulling them down! It was amazing! And we got close-up views of their tusks and their mouths, and just how strong their tusks and legs can be. Pretty scary, actually.Finally, one of the highlights of the trip was that I got to pet a cheetah! There were two male cheetahs that were in this large fenced enclosure. Apparently their mother died when they were very young, and the only way they were able to survive was being bottle fed by humans. So they got used to humans at a young age – although they’re still somewhat wild. So now, they feed them every day at 2pm, and around 3 or 4pm, they’ll bring a small group of tourists in to their fenced enclosure to pet them! I wasn’t going to do it at first. It was an extra P100 to pet the cheetah, and I was just going to watch other people do it. But in the end I figured, eh, it’s an extra $16 and I don’t want to walk away from this regretting not going to pet the cheetah, even if it is super touristy. :) However, I think Phil put it in a pretty funny way: “why would I pay an extra $16 to go get my hand bitten off?” I thought that was hilarious, but maybe you had to be there.
So it wasn’t quite as I expected. For some reason I had in my head the idea that we would be petting the cheetah through a fence, or that there would be a trainer there holding them or calming
them or something while we petted the cheetah. Not so. Our guide unlocked a gate to let us into the first fenced enclosure (sort of like a foyer), and then unlocked another gate to let us into the second fenced enclosure, which was large, and was where the cheetahs were. The cheetahs were prowling around, and eventually lay down in the shade of some bush. We went over to them, and the guide said to go up one by one, and avoid petting the paws and the tail. She went up first and petted the cheetah, and then we all did it. One cheetah was feeling feisty I guess and didn’t want to be petted, so we petted the other one.There were these two Indian guys on our safari who I swear deserved to be eaten. They were so intent on taking pictures and everything that they seemed to forget that this was a CHEETAH. They were kinda like that the entire trip – almost jumping out of the jeep to take pictures, and being totally touristy. I mean, I know I’m also a tourist, but they were a little obnoxious. Anyways, during the cheetah petting, we were mostly petting one cheetah because the other one was a little grumpy. The two Indian guys kept on almost stepping on that cheetah’s tail because they were too busy taking pictures of them petting the other one. And the one that we were petting, they petted it too hard or something, because it took a swipe at one of the Indian guys. I’m sure it was just a little annoyed and doing the equivalent of batting a fly away (if he had really wanted to hurt the guy or attack him, I’m sure the cheetah would have), but the Indian guy didn’t seem to realize it! He dodged backwards, but then went back for more petting! Then the cheetah reared its head, and looked at the guy, who finally seemed to get the picture.
Anyways, it was a fun trip overall. We hung out in the Mokolodi restaurant for a while afterwards, drinking some beer. It’s supposed to be one of the best, or maybe the best, restaurant in Gabs. I think they changed chefs recently though, so I’m not sure how it’s supposed to be now. I know that some of the Caucasian doctors go there for special dinners. They also apparently have more exotic things on the menu, such as kudu, and their steaks are supposed to be amazing. I wanted to eat there for dinner, but I think some of the other people either didn’t want to eat out or wanted to go home. It’s expensive by Gabs standards, but definitely not by American standards – it’s probably about P80-120 for an entrée (which is about $15-$20), and drinks are relatively inexpensive. But that’s okay. I’ll try kudu eventually.
Speaking of kudu, while we were sitting out there on the restaurant terrace, they had set out some grass for animals to come and eat, and we saw a few warthogs and a lot of kudu. This family of kudu seemed to come up – one male
and several females. Then we saw another male kudu a hundred feet behind, who seemed a little hesistant to come forward, probably because of the first male already there feeding. Eventually he came up, and we thought they were going to fight! They lowered their heads and met horns softly several times, but didn’t end up fighting or anything. I think it was a way of greeting each other or making sure everything is okay. It was pretty impressive and I got a few good shots of them greeting each other with their horns.Friday, May 10, 2013
The Making of the Lubangs
I just got married!
We had a crazy 3 weeks, starting with my graduation. You'd think this would be a bigger deal since I spent 9 years trying to get this diploma, but it got a bit eclipsed with the wedding. But it was still a good time - my parents came into town, as did Pete's mom. We had a nice dinner that night, and the next night, my parents through a big banquet dinner for me and my friends. It was so nice of everyone to come!
That next week we spent getting ready for our wedding, which takes way more time than you might think. I can't even remember what I was doing anymore, but every day was super busy doing super important wedding stuff. Plus we were picking people up from train stations and airports and my brother his girlfriend, and my sister and her boyfriend were staying with us.
The wedding itself was so much fun for us! We started with photos to get them out of the way,
and then it was on to the ceremony. My brother Bruce was our officiant, with Karen, my sister, as my maid of honor, and Ben, Pete's brother, was his best man. We had Ben's two twin sons, Jacob and Aaron, as our ring bearers. During the rehearsal they were so cute, in their tuxes carrying the ring pillows. I wish I could have seen it myself, but I hear during the actual ceremony, they did great! And of course, there are probably a bazillion pictures documenting their cuteness. :)
Bruce did an awe job as the officiant. I'm lucky he let me read a draft of his talk the day before, because when I read it I was bawling, and that probably would not have been the best thing to do during the ceremony. He made it very personalized for Pete and I, which was great. You know those parts of ceremonies where you almost fall asleep? Well completely objectively-speaking, there were none of those parts during our ceremony. I for one, did not fall asleep. :) Tons of people came up to us afterwards though and told us what a wonderful job Bruce did. There were even a few requests for Bruce at other weddings!
Afterwards came the cocktail hour. We holed ourselves up in our private room for 30 minutes or so then stepped outside for some socializing. The private room was great - family members came in to see us, we played with the twins for a bit, and we even had our own food! I didn't have many of them, but people said the appetizers were great. We had a table with lox and whitefish and bagel fixings, a table of cheeses, olives, and crackers, as well as an assortment of butlered hors d'ouvres brought around to guests: shrimp tempura, wild mushroom phyllo, scallops wrapped in bacon, coconut chicken, beef tenderloin with eggplant, asparagus with goat cheese, peking duck rolls, and crab cakes. And, of course, it was open bar.
Time went so fast! Before we knew it, it was time to go into the reception hall. Bruce went in and was announced first, followed by my parents (Phillip and Catherine Jang) and Pete's mom (Carol Lubetsky). Then we were announced as Mr. and Mrs. Lubang! It was such an amazing feeling to go into that room with everyone cheering and applauding. After our entrance, we went right into our first dance. I know this is what everyone wants to see, so here, courtesy of Jen (my sister-in-law, Ben's wife, and mother of Jacob and Aaron), is a video of our first dance on youtube. We had it choreographed to Let's Get it Started, by the Black Eyed Peas.
The first dance led right into the hora, which was the best idea ever because all the energy from that was transferred into the hora. I've never been lifted or pumped in a chair before, but it's great!! I can't believe they even got my parents up there. And everyone said my dad looked so good in his yarmulke. :) After that, there we had toasts from Ben, Catherine (and Phillip) and Carol. And then we started dinner! Even though we didn't get to eat too much of it, everyone told us the food was so good! I think it was just as good as when we tried it at the tasting dinner. Just because food is my thing, this is what the guests were served:
Appetizers:
Butternut squash soup (delicious!!!)
Caesar salad
Main entree: Guests had a choice of
(1) sweet potato-encrusted NY strip steak grilled medium rare with roasted potatoes and julienned vegetables,
(2) chicken olympia (seared European chicken breast topped with sauteed spinach, roasted red peppers, and feta cheese in a lemon-thyme sauce) with garlic mashed potatoes and julienned vegetables, or
(3) a vegetarian option that I -believe- consisted of tortellini. I guess this shows how much we cared about the vegetarian entree... :)
Kids got something like chicken fingers and fries.
Dessert: wedding cake! (with coffee or tea) The wedding cake was a layer of vanilla and a layer of chocolate, separated by a coffee ganache and a raspberry layer. The wedding cake was awesome - we got it from Dough Main Bakery. Pete keeps talking about how he wants to order another cake from them. :)
The rest of the wedding was fantastic! We had a father-daughter and mother-son dance, which ended up with all of us dancing together. We did cake cutting and a few more pictures. We talked to so many people, although not nearly as many as I wanted to. At some point we tried to make it around to all the tables, but we probably didn't even get to half of them! I felt really bad about not talking to some people, so I figured it out... the entire reception was 5 hours, but we spent half of the cocktail hour alone, then there were the different dances. Also cake cutting, toasts, etc. - so there were really only about 3 hours to socialize. If you divide that by the number of guests, each guest would only get a little more than a minute! So if I talk to someone for 5 minutes, I shaft 3 to 4 other people! So no wonder I didn't get to talk to everyone - I'm justified by math. And yes, this is pretty nerdy. :)
It was a wonderful day and I think it set the tone for a wonderful life.
We had a crazy 3 weeks, starting with my graduation. You'd think this would be a bigger deal since I spent 9 years trying to get this diploma, but it got a bit eclipsed with the wedding. But it was still a good time - my parents came into town, as did Pete's mom. We had a nice dinner that night, and the next night, my parents through a big banquet dinner for me and my friends. It was so nice of everyone to come!That next week we spent getting ready for our wedding, which takes way more time than you might think. I can't even remember what I was doing anymore, but every day was super busy doing super important wedding stuff. Plus we were picking people up from train stations and airports and my brother his girlfriend, and my sister and her boyfriend were staying with us.
The wedding itself was so much fun for us! We started with photos to get them out of the way,
and then it was on to the ceremony. My brother Bruce was our officiant, with Karen, my sister, as my maid of honor, and Ben, Pete's brother, was his best man. We had Ben's two twin sons, Jacob and Aaron, as our ring bearers. During the rehearsal they were so cute, in their tuxes carrying the ring pillows. I wish I could have seen it myself, but I hear during the actual ceremony, they did great! And of course, there are probably a bazillion pictures documenting their cuteness. :)Bruce did an awe job as the officiant. I'm lucky he let me read a draft of his talk the day before, because when I read it I was bawling, and that probably would not have been the best thing to do during the ceremony. He made it very personalized for Pete and I, which was great. You know those parts of ceremonies where you almost fall asleep? Well completely objectively-speaking, there were none of those parts during our ceremony. I for one, did not fall asleep. :) Tons of people came up to us afterwards though and told us what a wonderful job Bruce did. There were even a few requests for Bruce at other weddings!
Afterwards came the cocktail hour. We holed ourselves up in our private room for 30 minutes or so then stepped outside for some socializing. The private room was great - family members came in to see us, we played with the twins for a bit, and we even had our own food! I didn't have many of them, but people said the appetizers were great. We had a table with lox and whitefish and bagel fixings, a table of cheeses, olives, and crackers, as well as an assortment of butlered hors d'ouvres brought around to guests: shrimp tempura, wild mushroom phyllo, scallops wrapped in bacon, coconut chicken, beef tenderloin with eggplant, asparagus with goat cheese, peking duck rolls, and crab cakes. And, of course, it was open bar.
Time went so fast! Before we knew it, it was time to go into the reception hall. Bruce went in and was announced first, followed by my parents (Phillip and Catherine Jang) and Pete's mom (Carol Lubetsky). Then we were announced as Mr. and Mrs. Lubang! It was such an amazing feeling to go into that room with everyone cheering and applauding. After our entrance, we went right into our first dance. I know this is what everyone wants to see, so here, courtesy of Jen (my sister-in-law, Ben's wife, and mother of Jacob and Aaron), is a video of our first dance on youtube. We had it choreographed to Let's Get it Started, by the Black Eyed Peas.
The first dance led right into the hora, which was the best idea ever because all the energy from that was transferred into the hora. I've never been lifted or pumped in a chair before, but it's great!! I can't believe they even got my parents up there. And everyone said my dad looked so good in his yarmulke. :) After that, there we had toasts from Ben, Catherine (and Phillip) and Carol. And then we started dinner! Even though we didn't get to eat too much of it, everyone told us the food was so good! I think it was just as good as when we tried it at the tasting dinner. Just because food is my thing, this is what the guests were served:
Appetizers:
Butternut squash soup (delicious!!!)
Caesar salad
Main entree: Guests had a choice of
(1) sweet potato-encrusted NY strip steak grilled medium rare with roasted potatoes and julienned vegetables,
(2) chicken olympia (seared European chicken breast topped with sauteed spinach, roasted red peppers, and feta cheese in a lemon-thyme sauce) with garlic mashed potatoes and julienned vegetables, or
(3) a vegetarian option that I -believe- consisted of tortellini. I guess this shows how much we cared about the vegetarian entree... :)
Kids got something like chicken fingers and fries.
Dessert: wedding cake! (with coffee or tea) The wedding cake was a layer of vanilla and a layer of chocolate, separated by a coffee ganache and a raspberry layer. The wedding cake was awesome - we got it from Dough Main Bakery. Pete keeps talking about how he wants to order another cake from them. :)
The rest of the wedding was fantastic! We had a father-daughter and mother-son dance, which ended up with all of us dancing together. We did cake cutting and a few more pictures. We talked to so many people, although not nearly as many as I wanted to. At some point we tried to make it around to all the tables, but we probably didn't even get to half of them! I felt really bad about not talking to some people, so I figured it out... the entire reception was 5 hours, but we spent half of the cocktail hour alone, then there were the different dances. Also cake cutting, toasts, etc. - so there were really only about 3 hours to socialize. If you divide that by the number of guests, each guest would only get a little more than a minute! So if I talk to someone for 5 minutes, I shaft 3 to 4 other people! So no wonder I didn't get to talk to everyone - I'm justified by math. And yes, this is pretty nerdy. :)
It was a wonderful day and I think it set the tone for a wonderful life.
Thursday, May 9, 2013
Wednesday, May 8, 2013
The absurdity of the airline industry
I've been traveling a lot over the last year and I've had to spend a lot of time in airports. Of course, everyone has gripes about traveling. But lately I feel it's been getting absurd. Take a story that my mom told me.
My parents had to be in Boston for a wedding, so I arranged all their travel plans for them - their flights, the rental car, hotel, etc. My parents aren't poor, so instead of going for the cheapest flight, which is usually a red-eye or leaves at an insane hour, I book a reasonable return flight for them going from Boston to Sacramento, which leaves at something like 9am in the morning, has an hour and a half layover, and makes it to Sacramento around 2pm. About a month later, I get an email notice from this un-named airline (but which rhymes with Smelta) telling me that their flight has been changed. Not only does the flight now leave at 7am, but now there are -two- layovers, one of which is 30 minutes long (yeah right, my parents would never make that), and now they don't get home until 6pm at night (9pm EST). This is important because they need rest. My dad is asleep usually by 9pm, and moreover, they were picking up more family at the Sacramento airport the next day from China, Taiwan, and Hong Kong to show them a good time in ol' Sacramento. Anyways, so I call, raise hell, and eventually they rebook my parents - they still have to leave at 7am, but now they only have one layover (45 minutes, still tight), and get back to Sacramento around 1pm.
So the day of their return flight, my mom calls me around 11am. Of course, I'm assuming that it's during their layover, but noooo. My parents made it to the airport around 5:45am - a good hour and 15 minutes before their flight takes off. I would have thought that at 7am, probably the first flight of the morning, this would have been plenty of time. Unbeknownst to them, Smelta apparently has around 7 or 8 flights leaving all at 7am from Logan International. The lines were horrendous and since everyone was in the same boat, they were not letting anybody skip ahead to make flights. My parents finally make it past security with a couple minutes to spare and my mom makes a run for it - my dad was a little slower since he had to put shoes back on and he's old, so he has to sit for that, and tie his shoes and everything. My mom actually makes it to the gate, it was still open, and they were letting in 4 more people. She pleads with the woman and says her husband is coming up right behind her. The gate woman says sorry, it's too late, and closes the doors. Literally a minute later my dad comes running up as well, and she wouldn't open the door for them even though the other people had just gone through and probably were still in line on the bridgeway to get it their seats. It was 7:01am.
How ridiculous is that? Do you know how many times I've been kept waiting by airlines? Not even for weather reasons. For cleaning reasons, mechanical reasons, reasons not explained to us, the customers. These delays have over my lifetime probably cost me days and days of time. If I said, oops, sorry, you were a minute late, I'm not paying - how do you think they would take that? Probably not well.
My parents had to be in Boston for a wedding, so I arranged all their travel plans for them - their flights, the rental car, hotel, etc. My parents aren't poor, so instead of going for the cheapest flight, which is usually a red-eye or leaves at an insane hour, I book a reasonable return flight for them going from Boston to Sacramento, which leaves at something like 9am in the morning, has an hour and a half layover, and makes it to Sacramento around 2pm. About a month later, I get an email notice from this un-named airline (but which rhymes with Smelta) telling me that their flight has been changed. Not only does the flight now leave at 7am, but now there are -two- layovers, one of which is 30 minutes long (yeah right, my parents would never make that), and now they don't get home until 6pm at night (9pm EST). This is important because they need rest. My dad is asleep usually by 9pm, and moreover, they were picking up more family at the Sacramento airport the next day from China, Taiwan, and Hong Kong to show them a good time in ol' Sacramento. Anyways, so I call, raise hell, and eventually they rebook my parents - they still have to leave at 7am, but now they only have one layover (45 minutes, still tight), and get back to Sacramento around 1pm.
So the day of their return flight, my mom calls me around 11am. Of course, I'm assuming that it's during their layover, but noooo. My parents made it to the airport around 5:45am - a good hour and 15 minutes before their flight takes off. I would have thought that at 7am, probably the first flight of the morning, this would have been plenty of time. Unbeknownst to them, Smelta apparently has around 7 or 8 flights leaving all at 7am from Logan International. The lines were horrendous and since everyone was in the same boat, they were not letting anybody skip ahead to make flights. My parents finally make it past security with a couple minutes to spare and my mom makes a run for it - my dad was a little slower since he had to put shoes back on and he's old, so he has to sit for that, and tie his shoes and everything. My mom actually makes it to the gate, it was still open, and they were letting in 4 more people. She pleads with the woman and says her husband is coming up right behind her. The gate woman says sorry, it's too late, and closes the doors. Literally a minute later my dad comes running up as well, and she wouldn't open the door for them even though the other people had just gone through and probably were still in line on the bridgeway to get it their seats. It was 7:01am.
How ridiculous is that? Do you know how many times I've been kept waiting by airlines? Not even for weather reasons. For cleaning reasons, mechanical reasons, reasons not explained to us, the customers. These delays have over my lifetime probably cost me days and days of time. If I said, oops, sorry, you were a minute late, I'm not paying - how do you think they would take that? Probably not well.
Tuesday, May 7, 2013
Doctoring Online
This is a very interesting concept. It's a service that allows you to mostly connect with your doctor online through video chat, IM, and email after an initial face-to-face office visit. I think it's a great idea for simple problems that people have that can be diagnosed over the phone or email. I think it breaks apart when a patient comes in with more complex problems or health issues, making a good physical exam necessary. Then you need an actual doctor's appointment, just like with any other private practice.
Sunday, May 5, 2013
Patient Rights
Informed consent. It's a long history, but informed consent came about when patients started asking for more autonomy in their patient care and the term "patient rights" came into being. I'm all for patient rights and autonomy and it's definitely the right direction for patients to go towards. Of course, there has to be a limit to what a doctor can or has to do, and this article does an excellent summary of listing and explaining common myths about informed consent:
http://archinte.ama-assn.org/cgi/content/abstract/156/22/2521
Let me summarize.
Myth 1: A signed consent form is informed consent. Just because somebody signs a piece of paper saying they understand all the risks and potential complications of a procedure doesn't mean that they understood everything you tried to tell them, or everything that's on that piece of paper. Some of those consent forms are pages and pages long and full of jargon, so that could actually confuse someone more than it helps.
Myth 2: Informed consent is a medical miranda warning. There's more to informed consent then tell patients all the risks of a particular procedure or action. You also need to tell patients about options, potential outcomes, etc.
Myth 3: Informed consent requires that physicians operate a medical cafeteria. For a given problem, there might be 20 different ways of going about treating it or solving it. A doctor doesn't actually need to present all 20 ways - in fact, this usually confuses the patient! The doctor only needs to (and should) present a couple of the methods (usually what the doctor thinks is best) to the patient and information about the different methods. And physicians can still give advice - the goal is just to not be paternalistic. In fact, patients often ask for advice ("what would you do if you were me") in addition to the information and welcome it. Doctors don't have to just sit back and let the patient choose out of all the options with only factual information.
Myth 4: Patients must be told everything about the treatment. This is certainly not legally required, and if doctors did this, it could take hours. Ethically and legally, a doctor should tell a patient everything a "normal" patient would want to know, and then of course, ask if the patient has any questions. A doctor cannot and should not be sued or deemed a bad doctor because he failed to disclose an aspect of the treatment that is very rare or that the common patient wouldn't care to know at the beginning.
Myth 5: Patients need full disclosure about treatment only if they consent. Theoretically, patients need to know about important things before they consent if they are trying to choose between options.
Myth 6: Patients cannot give informed consent because they cannot understand complex medical information. While a patient might not be able to remember or recall everything that was explained in the office, during that office visit, they will probably understand everything well enough to make a decision. Secondly, things need to be simplified in a way that patients can understand things. If a patient is incapacitated or incompetent in a way that makes them unable to make decisions for themselves, then there needs to be a surrogate decision maker.
Myth 7: Patients must be given information whether they want it or not. It is certainly within a patient's right to not participate in decisions affecting their health care - they may leave it up to a family member, or even their doctor. The doctor shouldn't force a patient to listen to them if the patient truly wants to give up this right.
Myth 8: Information may be withheld if it will cause the patient to refuse treatment. In no instance is it right to withhold health information from the patient about him or herself.
I think this article is great, because often doctors feel they have to tell the patient too much, or there are doctors not telling patients enough. Conversely, there are patients who expect things that doctors aren't obligated to give. Of course if they ask, it is usually given, but just because a doctor doesn't give it, doesn't mean they're a bad doctor. The article basically explains to both doctors and patients what is expected of them during an office visit, and that's been a relatively murky issue for quite a while - at least in my mind.
http://archinte.ama-assn.org/cgi/content/abstract/156/22/2521
Let me summarize.
Myth 1: A signed consent form is informed consent. Just because somebody signs a piece of paper saying they understand all the risks and potential complications of a procedure doesn't mean that they understood everything you tried to tell them, or everything that's on that piece of paper. Some of those consent forms are pages and pages long and full of jargon, so that could actually confuse someone more than it helps.
Myth 2: Informed consent is a medical miranda warning. There's more to informed consent then tell patients all the risks of a particular procedure or action. You also need to tell patients about options, potential outcomes, etc.
Myth 3: Informed consent requires that physicians operate a medical cafeteria. For a given problem, there might be 20 different ways of going about treating it or solving it. A doctor doesn't actually need to present all 20 ways - in fact, this usually confuses the patient! The doctor only needs to (and should) present a couple of the methods (usually what the doctor thinks is best) to the patient and information about the different methods. And physicians can still give advice - the goal is just to not be paternalistic. In fact, patients often ask for advice ("what would you do if you were me") in addition to the information and welcome it. Doctors don't have to just sit back and let the patient choose out of all the options with only factual information.
Myth 4: Patients must be told everything about the treatment. This is certainly not legally required, and if doctors did this, it could take hours. Ethically and legally, a doctor should tell a patient everything a "normal" patient would want to know, and then of course, ask if the patient has any questions. A doctor cannot and should not be sued or deemed a bad doctor because he failed to disclose an aspect of the treatment that is very rare or that the common patient wouldn't care to know at the beginning.
Myth 5: Patients need full disclosure about treatment only if they consent. Theoretically, patients need to know about important things before they consent if they are trying to choose between options.
Myth 6: Patients cannot give informed consent because they cannot understand complex medical information. While a patient might not be able to remember or recall everything that was explained in the office, during that office visit, they will probably understand everything well enough to make a decision. Secondly, things need to be simplified in a way that patients can understand things. If a patient is incapacitated or incompetent in a way that makes them unable to make decisions for themselves, then there needs to be a surrogate decision maker.
Myth 7: Patients must be given information whether they want it or not. It is certainly within a patient's right to not participate in decisions affecting their health care - they may leave it up to a family member, or even their doctor. The doctor shouldn't force a patient to listen to them if the patient truly wants to give up this right.
Myth 8: Information may be withheld if it will cause the patient to refuse treatment. In no instance is it right to withhold health information from the patient about him or herself.
I think this article is great, because often doctors feel they have to tell the patient too much, or there are doctors not telling patients enough. Conversely, there are patients who expect things that doctors aren't obligated to give. Of course if they ask, it is usually given, but just because a doctor doesn't give it, doesn't mean they're a bad doctor. The article basically explains to both doctors and patients what is expected of them during an office visit, and that's been a relatively murky issue for quite a while - at least in my mind.
Christmas at the Hospital
I think Christmas is probably my favorite holiday of the year. Despite having to spend it overnight at the hospital this year, for whatever reason, I was still in pretty good spirits. There was Christmas music playing on the radio, people are generally in pretty good moods (although there were definitely some sour faces at the hospital), and it's a relatively quiet night at the hospital - I think I got 6 hours of sleep on call, which is absolutely amazing! I played some poker with some other residents, we ordered some Chinese food (the only thing open on Christmas day), and just hung out.
However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.
Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.
However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.
Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.
Friday, May 3, 2013
2012 Medical Management of HIV Infection
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Thursday, May 2, 2013
Steps involved in medical care
I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.
A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).
At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).
Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).
After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).
Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.
As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.
The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.
A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).
At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).
Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).
After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).
Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.
As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.
The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.
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