Michael Vick

Michael Vick should be allowed to play in the NFL right now. He has paid his debt. He has a right to ply his trade, immediately. The team that takes him will be rewarded in the stands. I can't think of one person who would not attend a game because of this conviction. Leave the guy alone. Let him do his work.

Healthcare reform

I am interested to know: how many doctors are willing to take a pay cut to ensure universal coverage? I'm not going to lie, at this point, end of medical school, I'm not willing to take a pay cut to cover everyone if it just means being told by bureaucrats what to do. Here is the nightmare I am thinking of: child comes in with signs of an intracrnaial mass. Do a CT scan. Its negative. Some posterior fossa tumors can't be seen with CT scan; you need an MRI. Some public good study says it is not worth it to scan every negative CT scan with an additional MRI. Can't get the MRI approved. You can see how the rest of it goes. Ugh.

Medical school is long and hard, and doctors work hard to take care of people. It is difficult to be entering a profession that is being reviled and assaulted.

Libraries

When I am in a library, I feel like a thief. YOU MEAN EVERYTHING IN HERE IS FREE? And, most books have diminishing returns and you dont want to keep them, particularly current events books. So you rent them. For free. It is the best public instiution in the US of A. The library and the post office. Reading (learning something) and posting a letter (going somewhere). These are probably the only two things the government does well. I am trying to think of another. Hmmm. I'll think for a little longer. What does the government do well? Hand out passports. I think they do well at handing out passports, which is, of course, related to the post office.

And, the Simpsons are on the stamp this month. I thought they would be more expensive - a fundraiser for kids with disease or something. I was prepared to pay more. Nope. Available for the egregious price of 44 centavos. each I recall 19 cents apiece. At least they are cool; no stagecoaches or crocheted hearts from a dying museum in Council Bluffs, Iowa. I am dangerously close to buying a stash and tucking them away somewhere. Dangerously close to starting a stamp collection.

Re-branding Food Stamps: A Roadmap from High-Speed Agribusiness Toll Road to Targeted, Restricted, and Healthy Food Bridge

Abstract

More Americans are utilizing federal funds to subsidize food purchasing than ever before. Over 30 million people use the food stamp program, recently re-named Supplemental Nutrition Assistance Program (SNAP). This program was established in the 1930s to be temporary, to address hunger, and to distribute excess food surplus. The program ended in 1943 and was permanently revived by Lyndon Johnson in the 1960s in an effort to eliminate poverty as part of the Great Society.

Fortunately, we no longer live in a world where hunger is the prevailing threat to human health, and the SNAP program as originally intended could be phased out. However, several entrenched interests ranging from non-profits to agribusiness have a strong interest in seeing the program continue, so abolishment is unlikely in the near future. SNAP and other food programs continue to operate with limited controls on the nature of purchases and the amount of time individuals may receive services. Unfortunately, SNAP as it exists expands the American waistline, permits permanent reliance on government aid, and feeds illness with unhealthy foods. Policy makers must take a realistic view of the program as it stands and adopt sharp modifications to contract its reach and mitigate the negative consequences of SNAP. Given the unlikelihood of abolishment, the program must be recast as a food program with a twin mission of calorie supplementation and provision of food to improve health.

In the modern era, obesity due to excess calories drives illness in poor communities, and the SNAP program has failed to adapt to modern food environments. The program operates with few restrictions on purchases, and high-calorie, low-nutrient foodstuffs can easily supersede the mission of putting nutritious, healthy food into American homes. Under current policy, food stamps can be used to buy anything that is considered ‘food’ excluding hot, prepared items. As a result, a person or family that relies on SNAP is free to buy chips, soda, cake, and bacon to feed their family. A cartful of Ramen noodles, Twizzlers, ice cream, and Pop-Tarts can freely be charged to the United States Department of Agriculture (USDA) under current SNAP guidelines. The consequence of unrestricted purchasing is the utilization of government resources to feed the obesity epidemic. The government often then purchases healthcare for the hypertension, diabetes, heart attacks, strokes, cancer, and myriad other health conditions that are the consequence of poor diet. Also, SNAP recipients often draw on several food assistance programs at once, resulting in over-apportioning of calories and resources. SNAP recipients can stay on the program forever; there is no time limit to dependence on SNAP.

While the stated mission of the SNAP program is to ‘help low-income people buy the food they need for good health’, a realistic assessment of the program will demonstrate that any food most often equals unhealthy food. The lack of food purchase restrictions may give comfort to policymakers loathe to pare the ‘rights’ of people on public assistance programs; I propose that people should not be guaranteed full access to the marketplace of options under government assistance terms. No child has ever starved due to a lack of cake or soda.

A proposal to restrict food stamp purchases will alarm food manufacturers that sell billions of dollars in cheap, unhealthy food to citizens on food assistance programs; I propose these manufacturers respond to the market demand and shift their product offerings towards healthier fare, develop their markets elsewhere, or seek to capture the unrestricted dollars that people spend on consumable goods. Others critics will fret that healthy food is too expensive, but, when held to closer scrutiny, this claim falls apart. SNAP allotments for families of 3 or more are higher than the average working family spends on food in the course of a month.

Of course, restriction of SNAP purchases is not a cure-all for the nutrition challenges facing poor communities, but will provide a strong signal from policy makers that the well-established links between unhealthy food choices and disease are being incorporated into food assistance programs to improve their outcomes. Also, education on healthy eating must be emphasized, and the lack of access to healthy food in poor communities must be addressed by the development of innovative business models to aggregate demand for high quality fare in poor communities.

Healthcare providers and policy makers are failing to make a dent in the obesity problem that threatens to, for the first time, cut short the lifespan of the next generation. There is an opportunity to start at the top – at the source of funding- to set a strong course for rational changes to SNAP policy that results in fewer costs, healthier purchasing, and improved health outcome for SNAP recipients. This policy change can serve as a specific, quantifiable touchstone in a matrix of food policy reforms in the next several years.

Introduction and History of the Food Stamp Program

The food stamp program was initially founded to address supply and demand problems during the Great Depression. City people could not afford food, and several farm products were in surplus. Subsidized vouchers could be redeemed for specific food items available via the federal Agriculture Department. The program ran from 1939-1943 and was stopped when the economy improved with the onset of World War II. The food stamp program was revived as a pilot project in 1961 by President Kennedy, but was made permanent by President Johnson as a component of the Great Society. Food stamp caseloads have contracted and expanded over several decades, with a notable decrease in caseloads in the 1990s due to welfare reform. The 2002 farm bill increased the cost of the program, re-established eligibility among non-citizens, and increased benefits for large families. SNAP serves over 31 million citizens at a cost of $30 billion dollars annually. People who live at 130% or greater than the poverty level automatically qualify for SNAP, and citizens with greater resources may qualify if they utilize a portion of their income to care for elderly and disabled persons at home. There is no time limit for food stamp access; recipients can stay on the program as long as they are able to demonstrate a lack of sufficient income. The work requirement to access SNAP is a formality at best; adult household members are required to be registered for, or looking for work, while on SNAP. This work requirement is being temporarily suspended while allotments are increased in the economic stimulus plan of 2009. The stimulus bill increases the food stamp allotment per eligible family by 13.6%. Food inflation in April 2009 was 3.3%.

Overall, food subsidy programs like SNAP cost taxpayers $55 billion in 2007. 61% of the USDA budget is dedicated to food assistance programs. The largest programs include SNAP, school breakfast and lunch programs, summer food service, after school snack and meals, child and adult care food programs, and Women Infants and Children (WIC), a program that provides a basket of specific food appropriate for improving the health of women and young children. In total, there are 26 food and nutrition programs operated by six different agencies. There is no cross talk between the programs to determine how many people receive overlapping benefits. As a result, social service agencies will enroll people in every program they are eligible, resulting in duplication of services.

Food stamps and increased obesity

Fortunately, a lack of food is no longer the central concern of health advocates. Instead, the problem of insufficient calories has been replaced by growing obesity problems. Nearly 70% of US adults and over 30% of child are overweight or obese, and the problem disproportionately affects low or no-income people. SNAP was established as a healthy food supplement for many of these families, but the program facilitates unrestricted access to calorically dense, nutritionally empty consumables that feed the obesity epidemic. Research has demonstrated that food stamps do not ensure consumption of nutritionally adequate diets. The inability of SNAP to perform its function may be due to several forces, including inefficient household budget management and inadequate nutrition education. It has been suggested that limited economic resources shift dietary choices towards an energy dense diet that provides maximum calories per the least volume and the least cost. Such a statement overlooks the role SNAP plays to bring low-income families to a purchasing power equal to or greater than similarly sized working families. In these cases, food choices are not about obtaining enough calories or staving off hunger. High calorie foods are generally not filling, because they are low in the fiber and water content. As a result, the food takes up little space in the stomach, and the stretch receptors in the stomach that signal fullness are not activated. As a result, more dense, high calorie food is needed to signal ‘full’ versus foods high in fiber and water content that expand to create a feeling of fullness. Rather, high calorie foods are chosen because they dominate the food environment and satiate a palate accustomed to high-fat, high-calories foods.

The link between food environments, food choices, and obesity is well established. The presence and intake of high fat, high-sugar food establishes a reward system in the brain that operates similarly to the addictive model of opiates. Naloxone, an opiate antagonist typically used to reverse overdoses of opiods like heroin or fentanyl, has also been demonstrated to reduce sucrose cravings in an animal model. Continued, unrestricted exposure to the offending substance needs to be addressed to break the cycle of unhealthy consumption in SNAP-sponsored food environments. The food stamp-obesity relationship has been studied and a model developed describing a three-week period of overeating when SNAP funds are available, followed by a one-week period of involuntary food restriction when resource have been depleted, followed by overeating when the allotment is restored. The twin insults of unhealthy food choices and uneven utilization drive the obesity epidemic in poor communities.

According to the USDA, most low-income people spent their limited SNAP funds on energy dense foods largely composed of added sugars and fat. Fruit and vegetable consumption did not increase in families on SNAP assistance. There are several examples of food stamp recipients who have successfully met the twin objective of spending within the food stamp limit and buying healthy foods. These successful cases did so by spending a larger share of the food dollar on grains, fruits, vegetables, and milk, and less on meat, soft drinks, sweets, and fats. Tight federal control over SNAP allotments presents an opportunity for the government to restrict the food choices of SNAP recipients to direct food purchasing towards healthier foods. When considering the benefits and burdens to the state, the merits of restricting food choices are plainly evident.

An argument for restricting the food choice of SNAP recipients

The primary reason to restrict food choices of SNAP recipients relates to health. SNAP can currently be used to purchase gum, candy, soda, chips, and every other junk food waiting in the aisles. Do these foods honestly serve the mission of SNAP to supplement homes with healthy food? The food stamp industry lauds the consumer choice in the SNAP program. Is consumer preference an appropriate consideration in a government sponsored ‘anti-hunger’ program? Are Cheetos and Coke required to stave off the hunger and poor nutrition SNAP portends to address? The USDA claims that SNAP benefits levels are set to allow households to purchase a set of low-cost foods that meet current Federal nutrition regulations. What regulations are they referring to? SNAP purchased food does not have to pass a nutrition regulation; this statement refers to the regulations that simply qualify something as a ‘food’. No serious policy contributor could suggest that allowing purchases of junk food with federal dollars serves the purpose of the SNAP program or the long-term health care goals of the country.

In an effort to influence choice, the USDA had expanded its investment in nutrition education. These programs are voluntary, and states must apply for additional funds to support these programs. $247 million was spent in 2006 on education programs that have not demonstrated an effect on purchasing patterns. Education programs are notoriously unsuccessful, especially in the realm of consumer behavior like food purchasing. The government is spending to subsidize purchase, and to influence purchase. Why not simply restrict purchases?

Proposed restrictions

There are several options available to alter the purchase patterns of SNAP recipients. The first and most logical option is to create a purchase package for SNAP recipients similar to that developed for the WIC program. WIC is a preventive nutrition program that provides nutritious food, nutrition education, and access to healthcare for low-income pregnant women, new mothers, and infants and children at nutritional risk. WIC enhances the nutritional quality of the diet of participants through a prescription food package, a specified set of important foods that includes low-fat milk, cheese, juice, eggs, iron-fortified cereals, infant formulas, beans, and fruits and vegetables. WIC vouchers are used to pick up WIC packages at appointed stores. WIC studies on dietary intake in pregnant women demonstrate that the program increases intake of food energy and a number of nutrients, including protein, vitamin C, iron, and calcium.

Analogously, SNAP recipients could receive a specified set of foods that constitute a healthy diet. Such a process would ensure SNAP fulfills its mission. Will all the offerings be to consumer preference? Such a question distracts from the core function of SNAP: to provide families with healthy food. Consumer preference is secondary to balanced nutritional needs. There is no consumer preference when the costs are not born by the consumer.

A second, less restrictive model may allow people to pick from a set of foods available in store. Fresh, canned, or frozen fruits and vegetables would be permitted. Whole wheat bread, pasta, and specific breakfast cereals would be permitted. From dairy, low-fat/skim milk, yogurt, and cheese could be purchased. Olive oil and canola oil would be allowed for cooking. What else needs to be included if the goal is bellies full of healthy food? Explicit restrictions would be placed on soda, chips, juice, cake, cookies, and ice cream.

A central issue for poor people in urban and rural environments is the lack of access to large markets that offer high quality, healthy foods at reasonable cost. A key part of the policy recommendation on restricting food choices must recognize that the food access problem has to be dealt with through creative business models that can serve the low-income market. In the short-term, restriction on the purchasing options under SNAP will compel the small, expensive stores in poor communities to alter the fare they offer if that store relies on food stamp income.

A proposal to decrease food stamp allotments

A proposal to restrict choice compels an analysis of the amount of money apportioned to households on SNAP. According to the Food Marketing Institute, the weekly grocery bill for a household of one has been estimated at $61, two people at $91, 3-4 people $111, and 5+ people at $135 dollars. If these are industry averages, and the maximum monthly SNAP allotment for a family of 4 in 2009 is $668 dollars per month, why is the SNAP allotment $224 more per month than the average family of four would spend? For five people, the allotment is $252 more per month than the average family spends.

SNAP and junk food advocates will defend these allotments by suggesting that eating healthy food is expensive. This is a common retort of supporters who seek to expand food stamps or who suggest that restrictions will drive people into hunger. Studies on the costs of eating healthily vary widely. The argument that healthier eating is more expensive shrivels in light of the food stamp allotments. Subsidies are 33% higher than an average wage earning family that eats statistically healthier food would spend. This is in addition to the provisions offered by overlapping food programs that have dual eligibility.

Addressing Food Access Barriers

Proposed SNAP restrictions and decreased allotments shed light on the challenges of healthy food access in urban centers. In the modern American city, it is easier to find a BigMac and soda than to buy a banana and skim milk. These zones are food deserts, defined as regions in which people experience geographical or financial barriers to acquiring healthy food. The price of healthy staples, if available, is 20% higher in urban corner stores than a full-service supermarket, and healthy meals cost 30% more to make. Low-income urban residents pay this “poverty penalty” because market fundamentals do not bear on their economy; there is no competition to drive prices down, improve quality, convenience, and access to needed goods. Traditional approaches to food deserts involve enticing companies to build stores in urban neighborhoods. Companies resist because of revenue, safety, and purchasing power concerns. Negotiations are individual, complex, and costly to the city. Given the economic climate and the considerations, industry continues to resist exhortations to locate in urban zones. Other efforts attempt to place healthier foods in existing corner stores. These enjoy limited success, while requiring negotiations with individual stores to manage unfamiliar perishable inventory. Such efforts fail to create a market in which retailers compete on price, and in which consumers select from an array of quality products.

Several other innovations have sprung up to address this barrier. For example, farmer’s markets in cities nationwide have been wired to accept food stamps; users may receive a credit to their account when healthy foods are purchased. Sites from Kansas to Phoenix, to San Francisco and Cleveland are wired for these transactions. Unfortunately, farmers markets tend to be seasonal and inconsistently dispersed throughout urban centers.

Second, a virtual supermarket could be established to transform urban food deserts into neighborhoods that enjoy convenient, rapid access to affordable, healthy food. In this model, urban community groups enable pooled purchasing and same-day delivery to local neighborhood points via Internet ordering of healthy foods from large supermarkets. This option is unique because it solves the food desert problem through Internet-based food distribution channels. It marries the expertise of public health at targeting community needs to the expertise of supermarket retailers at distribution and managing inventory. This model can move quickly because it does not have to convince stakeholders to act in contrast to their missions. Neighborhoods and public health want healthier food; industry wants to sell it to them. Removal of the access barrier via the power of the global, online marketplace will be a transformative step towards ensuring that all consumers in the United States, regardless of location, race, or income levels, can access a range of healthy foods at fair prices. With access to such a model, SNAP recipients will enjoy more convenient access to healthy foods. This model is being piloted in Baltimore City.

A third option for cities to pursue is aggressive support of urban gardens. There is an increasing interest in transforming unused urban landscapes into productive farmland. The produce is subsequently harvested for personal consumption or for sale at markets. The development of these food sources within urban communities represents a win-win for several stakeholders: unused urban land is put to use, unemployed residents of the area are employed to grow food, and individuals become responsible for providing a portion of their family’s food needs and/or income. Most major cities has such ventures up and running; cities and business start-up groups should consider the development of urban gardens as a component of the solution to ensuring that inexpensive, healthy foods is available in urban neighborhoods. Philadelphia is one of the best examples of successful urban gardening efforts. 465 vegetable gardens are tended by 618 families, resulting in the production of $1.5 million worth of food.

Perhaps a portion of the billions spent on food subsidies could be converted to low-interest business loans designed to assist entrepreneurs in leasing vacant urban land for food production?

Who will resist changes to the SNAP program?

The central issue for policymakers to overcome is an unwillingness to restrict the choices and consumer preference of SNAP recipients. Philosophically, an individual’s ability to choose preferences from the market is restricted when someone else, in this case the taxpayers, is paying the bill. A similar approach is taken in health insurance; restrictions are placed on the utilization of services to encourage certain behaviors and to restrict program utilization. Gifts of goodwill from taxpayers to citizens in need can be restricted to serve many ends. Welfare, for example, was curtailed in the 1990s, and a time limit and work requirement were added to the program. Why, then, has the SNAP program been given a free pass – no time limits, no purchase restrictions, and benefits in some instances above the average costs shouldered by working, self-supporting families?

SNAP has continued unexamined because it is the chief subsidy program for agribusiness. 61% of the USDA budget is dedicated to the SNAP program and other food programs to serve the same constituency. Food manufacturers lobby vigorously against restrictions on specific foods, suggesting that any restrictions would be too cumbersome, require constant review, and would hinder the ability of food manufacturers to ‘innovate’. Any threat to the foodstuffs market is construed as a threat to choice, costs, and profitability.

To encourage alterations in policy, the most influential stakeholders- agribusiness, taxpayers, and policymakers - must be convinced that change is in their interests. Taxpayers ought to know that recipients can buy a cartful of Twinkies and Coke and the USDA is happy to pay since these meet the mission of providing ‘healthy food’ to the community. It must be made known that there are no time limits on food stamp assistance. How does this motivate movement away from dependence, towards independence? Taxpayers should know that politicians actively recruit people onto the food stamp program, because it brings federal dollars into the state. Politicians need to be convinced that the health benefit of restricting choice far outweigh the potential backlash from food stamp users and the food stamp industry that utilize and administer the program. Recipients of food stamps and their advocates will be at a loss to justify unrestricted purchase. Who can defend Twinkies and Pop Tarts in the public interest? Agribusiness will continue to fight for unrestricted access to its goods, but their rationale is ringing increasingly hollow in light of the obesity pandemic.

The most hysterical advocate from the food program industry will fret that restrictions to food choices or allotments will cause people to drop out of the program. I am tempted to ask the obvious question: so what and to what? Dropouts will seek food elsewhere and be able to meet needs outside government assistance; this is exactly what food assistance programs should promote. SNAP should be a last stop solution for achieving food security; a drop-out on account of purchases restrictions is likely not in a food security crisis.

In an ideal circumstance, SNAP would cease to exist and food security would be achieved through a combination of work, urban farming, private charity, business innovation and community support for its poor. In the short-term, while working towards a gradual dissolution of SNAP, there are several policy changes that can return food assistance to its core function: to be targeted, temporary, and driven by nutritional needs.

The restriction on purchases and purchase points sends a strong signal from the Obama administration that it understands the relationship between food environments, obesity, and disease, and that the federal government will not stand to see its resources spent on unhealthy foods that drive disease. Restriction on allotments would further emphasize that SNAP is meant to be temporary, and that options among those receiving public assistance to guard against hunger need not include unhealthy goods. Transparency in purchasing will reveal to stakeholders how restrictions alter food choices. These gestures can begin to transform SNAP from a saturated agribusiness highway to a small temporary program that offers survival sustenance to households transitioning to independence.

Hmmm...

I'm a little confused. Let me see if I have this straight.....

* If you grow up in Hawaii, raised by a single Mom and your grandparents, you're "exotic, different " and not a real American.

* Grow up in Alaska eating mooseburgers , a quintessential American story.

* If your name is Barack you're a radical, unpatriotic Muslim.

* Name your kids Willow, Trig and Track, you're a maverick.

* Graduate near the top of you class from Harvard Law School and you are an elitist who's not a real American and certainly not qualified to be President of the U.S.

* Attend 5 different small colleges before graduating or finish close to last in your class at the Naval Academy , you're well grounded and the most qualified to hold the two highest offices in the U.S.

* If you spend 3 years as a community organizer, become the first black President of the Harvard Law Review, create a voter registration drive that registers 150,000 new voters, spend 12 years as a Constitutional Law professor, spend 8 years as a State Senator representing a district with over 750,000 people, become chairman of the state Senate's Health and Human Services committee, spend 4 years in the United States Senate representing a state of 13 million people while sponsoring 131 bills and serving on the Foreign Affairs, Environment and Public Works and Veteran's Affairs committees, you don't have any real leadership experience.

* If your total resume is: local weather girl, 4 years on the city council and 6 years as the mayor of a town with less than 7,000 people, 20 months as the governor of a state with only 650,000 people, then you're qualified to become the country's second highest ranking executive.

* If you have been married to the same woman for 19 years while raising 2 beautiful daughters, all within Protestant churches, you're not a real Christian.

* If you cheated on your first wife with a rich heiress, and left your disfigured wife and married the heiress the next month, you're a maverick and a someone to be looked up to as promoting Christian values.

* If you teach teach children about sexual predators, you are irresponsible and eroding the fiber of society but if while Mayor of your small town, you charge rape victims for rape kits you are to be applauded for your leadership.

* If, while governor, you staunchly advocate abstinence only, with no other option in sex education in your state's school system while your unwed teen daughter ends up pregnant, you're very responsible.

* If your wife is a Harvard graduate lawyer who gave up a position in a prestigious law firm to work for the betterment of her inner city community, then gave that up to raise a family, your family's values don't represent America's ; however if you can't remember how many houses you own, your wife is one of the richest people in America who inherited her money and wears dresses every day that cost several hundred thousand dollars, the two of you have more in common with and can relate better to "real" Americans than the snooty Harvard Law graduates who paid their own way through college and law school. *

If you're husband is nicknamed "First Dude", with at least one DWI conviction and no college education, who didn't register to vote until age 25 and once was a member of a group that hates America and advocated the secession of Alaska from the USA, your family is extremely admirable.

* If you repeatedly lie about your own record and that of your opponent while your opponent refuses to make up lies about you, you're a maverick who is to be admired while your opponent is weird, out of touch elitist.

'She is like me'

Women who say to themselves, 'I like Palin, she is like me', need to ask themselves: do you think you should be the vice president, or the president of the free world, and why?'

Mike Huckabee with Longer Hair

Sarah Palin is Mike Huckabee with longer hair. If you like the stances of Mike Huckabee, vote for Sarah Palin. Since the Repubs wont lets her off the hook long enough to say anything substantial, lets get a REMINDER of where this Huckabee doppelganger stands for. Keep in mind, women, this person could be the PRESIDENT OF THE UNITED STATES. If you do not believe in evolution, vote for Sarah Palin et al., because she does not believe in evolution either. She also does not believe in global warming. She believes the Iraq war is ordained by God. She does not believe in reproductive rights. She does not believe in equal pay for women. She said nothing about the number one concern of Americans: the economy. If McCain dies, and he realistically could, this is the future President. Mike Huckabee with longer hair.

You will not hear any of these in a replay of her adolescent acceptance speech, which basically talked about energy for 2 minutes and spent the other 30 minutes making fun of Obama and Biden. She apparently never got out of high school. She is still running for beauty queen of Wasalia by making fun of the competition’s hair, or job, or wife. The Republicans have no issues to stand on, so they are going for character assassination and gossipy one liners. Do not be fooled again. This is culture war 101. Women know better than this. Seriously. Stop dividing people based on culture choices. It is not less obvious because you are using a high heel instead of a wedge.

Furthermore, I am disappointed by her reliance on mockery. This is the sign of a weak person with no real ideas to offer. My mama, Audrey Hope Monti, also has 5 children, and gave me one of the wisest pieces of advice I have ever heard. We were driving along in the back seat of our little Subaru, coming home from KinderCare day care center, after my mom had been at work all day as a high school teacher. We were bickering at each other. She pulled the car over, stopped dead on the side of the road and said, ‘There are enough people in the world to make fun of you. I do not know why you have to make fun of each other.” That is a working woman’s wisdom. Not to insult people and then do high fives over the margarita blender in the kitchen. This country needs more grace than that, more recognition that we are in this together. She is a blatant dive back to Bush politics.

In the meantime, here are five questions to ask Palin, if she is ever allowed off the leash:

1) Do you believe in equal pay for equal work for women?
2) Do you believe God has ordained the Iraq war?
3) Do you believe in evolution?
4) What do you think causes poverty?
5) Who do you think are America’s top allies, and why?

O - HI - O

Ah, election season in Ohio. I watched the 2004 primaries from overseas and tried to answer my Spanish friends' questions about America's political leanings: "But how could people possibly re-elect Bush?" I told them they had never been to Ohio.

The Economist has started its series on swing states with Ohio. It only took three paragraphs for the infamous I-71 billboards to make their appearance:

In the Cup-o-Jo Cafe in Columbus, the state capital, 20-somethings sit around eating vegetarian food and talking about how much Mr Obama inspires them to hope for a better world. Out in the rural areas the signs on the road tell a different story—“Hell is real,” reads one, and then, a few miles later, “Repent!”.

It's unclear what the presence of fire and brimstone on highway billboards means for the 2008 elections - we can revisit Issue 1 some other time. Here, The Economist does a good job of capturing in a short article both the usual issues (what do the Ohio voters care about? is Obama too "coastal elite" for the state?) and the more interesting ones at the present moment (changes in both parties' strategies since 2004, challenges for both).

I think The Economist has actually used the word "elite" in the promotional material it sends to my house from time to time, so I find it the whole discussion of Obama's elitism a bit ironic. Any magazine which runs the following sentence should probably not be debating whether a public figure is perceived as too "airy-fairy" for office:

In 2004 the Democrats argued, with some evidence, that Ken Blackwell, the staunchly conservative secretary of state, was not overzealous in ensuring that all Democrats could exercise their right to vote.

Then again, The Economist isn't trying to get elected in Ohio this fall.

* * * * * * * * * * * * * *

Full disclosure: I should admit that I love The Economist not just because of its use of hard data and balanced reporting but also because of its writing.

Is he WHAT?

As they say in the vernacular, I got called out the other day – by my roommate Jenn, of course, who is particularly good at detecting inconsistencies in people's behavior. We were talking about homophobia, and I was relating a recent incident which had disgusted me, in which someone had said something I found offensive and medieval.

I related the story. I was on call at the hospital and admitting a man with acute kidney failure. He was sick: emaciated, with awful radiation burns from a bout with cancer a few years ago and lingering weakness from a mass in his brain. We weren’t sure what the mass was, but it was undoubtedly related to his AIDS. His nurse and I worked together to get his vital signs, listen to his lungs, make him comfortable in bed. I was impressed by how gentle she was as she turned and lifted him – I followed her lead. As I was writing his admission orders – IV fluids, cream to his burns thrice daily – his nurse joined me again.

“Is he gay?” she asked, her voice rising in pitch as she drew out the last word. I was shocked: was she serious? Did she really care?

“So what did you say?” Jenn asked me.

I had tried to remain neutral. “I really don’t know,” I’d said in what I hoped was an irritated voice. I was more than irritated: I was shocked – this was, in my experience, something out of bad TV. This was morbid curiosity, plain and simple, her brush with the exotic, with the other half, with those people.

“You missed an opportunity,” Jenn observed pragmatically. What I should have said was, “Why do you care?” or “Why does it matter?”

I should have told her that his sexual orientation was immaterial. I could have gone a step further and said that the way he acquired HIV – was this why she was asking about his sexuality? – was irrelevant to his kidney shutdown, that he was very sick right now and what mattered was that we treat him, not that we probe into his personal life.

Instead I said nothing. My approach was completely passive-aggressive: I hoped my irritated tone would convey some of my disapproval. But really, was a nurse going to be surprised by some doctor-in-training being snippy? Probably not. People give nurses crap for far less important things all day.

About a year ago I missed a similar opportunity. A relative of mine said, upon hearing that I wanted to move to Seattle, “Seattle is full of Asians and queers.” Verbatim, this is what he said. Again, what did I say? Nothing much. I stammered something about that not really being true, and asked if he’d ever even been to Seattle. (He had not.) What I should have said was, at a minimum, “Hey, not cool.”

Why do I remain silent in these situations? In the hospital, it was mostly shock – I was thrown off-guard by the disconnect between the tender care the nurse displayed and the callow fascination underneath. But the only reason I said nothing when it came to my family was the desire not to rock the boat, the abstract goal to All Just Get Along. I gave him a temporary free pass for being a 19-year-old boy. I repeated the story to friends, always with the parenthesis of, “Can you believe he said that?”

It’s one thing to be a card-carrying member of the HRC, but a little confrontation goes a long way sometimes. If I never speak up, then I can’t be surprised that people do say these things.

Give me a pint ... or not

This spring, I spent a month on the Hematology consult service. In theory this meant I ran around the hospital and tried to answer other people’s questions about the blood, but in practice it meant I came up with a number of questions of my own. All of them boiled down to something I’ve planned on addressing for some time: how can medicine use blood more wisely?

Not infrequently I wrote that patients’ caregivers should “transfuse as needed.” In some cases this was a passive-aggressive way of saying, “why did you call a hematology consult in the first place?” I wrote this in the charts of patients with myelodysplastic syndrome and anemia (where the bone marrow produces either too few blood cells or dysfunctional ones). I wrote it in the chart of patients with low platelets. Usually I didn’t clarify that statement – I left it up to the primary team to decide what would necessitate transfusion.

Transfuse as needed: part of the problem with the blood shortage is the liberal interpretation of that recommendation. What are the criteria for “as needed,” anyway, when it comes to transfusing blood?

There exist, of course, standards for transfusion of blood products. According to the Red Cross,

red blood cells are indicated for patients with a symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to a decrease in circulating red cell mass. They are also indicated for exchange transfusion and red cell exchange.

If that sounds less than straightforward, the Red Cross thought so, too, and so they have attached a few numbers to help with the “decrease in red cell mass” part: a hemoglobin of greater than 10 grams per deciliter does not require transfusion, and a hemoglobin of less than 6 g/dL should be treated with transfusion (we'll say normal is 13 to 16 - a little higher than this for a man, a little lower for a woman). For platelets, the recommendations are similar: basically, use platelets if the person is bleeding and has either low numbers of platelets or adequate numbers of dysfunctional ones. The Red Cross also recommends prophylactic platelet transfusions: over 10,000 if the person is stable and not bleeding, for instance, and over 50,000 if the person is going to be undergoing an invasive procedure.

It’s the range from 6-10 where the Red Cross says to use your discretion, and it’s the range where I see transfusions whose benefit I sometimes doubt. “The lowest I’ve ever seen is a hemoglobin of one – and that person recovered,” said my attending one day as we discussed how to boost a patient’s hemoglobin before surgery. We gave her some intravenous iron, some folic acid (both required for blood-cell production) and finally a shot of erythropoietin, the hormone which stimulates the bone marrow to make more red cells. None of these things was going to have an effect before surgery, but still we wrote for them.

I got pretty used to seeing anemic patients over the course of a month, and I started to become desensitized to hemoglobins of 12, 11, 10. I wondered whether the body, too, became desensitized. Why not? We avoid dropping blood pressure too rapidly in people who routinely have higher pressures – not because it’s good to be hypertensive but because the body gets accustomed to the higher pressure. Does the body also get used to a lower hemoglobin level? An article in April’s issue of Transfusion starts to answer that question. The authors looked at both the absolute lowest concentration of hemoglobin during / after surgeries requiring cardiac bypass as well as the relative decrease in hemoglobin during or after surgery and related it to adverse outcomes. They found that the relative decrease in hemoglobin, not the absolute lowest value, was more important for outcome.

This work needs to be replicated and expanded, but, along with studies that show no difference in outcome in ICU patients transfused liberally (to a hemoglobin of 10) or restrictively (to lower values, like 7 or 8). These data are still controversial, but I believe them. Less controversial is the need to revise our blood transfusion policies such that they are consistent with both evidence from well-designed clinical trials and with the shortage of blood available for transfusion.

Later: how can we improve the system of blood donation?

Give me a pint... part one

When I was growing up, the Red Cross used to call our house on a weekly basis. They were looking for my father, who was a regular blood donor, and they always called during dinner. These calls always infuriated my father – theoretically, they were calling to remind him to donate as soon as he was eligible, but often we’d get calls nightly for the week or two after he’d already donated again. He was not hesitant in sharing his frustration with the Red Cross representative on the other end of the line: why must they call during dinner? Why were there so many delays last time he donated? Why didn’t they know he had donated last week? Eventually we were instructed to tell the Red Cross he wasn’t home and to hang up; yelling was optional.

Despite the dinner interruptions, my dad kept donating, and his example is probably why I started donating when I turned 18. I considered it an adult obligation, right up there with voting – actually, I’d donated twice by the time I voted once.

Today I donated blood for the fourth time, which is actually pretty pathetic given the number of times I could have donated by now. Yes, I’ve been turned away in the past because I was anemic, but I really don’t have a good excuse for most of the opportunities I’ve missed. The sad thing about my paltry four donations is that they make me a pretty good donor: only five percent of eligible US donors actually give blood, and thirty percent of first-time donors never give again.

These dismal statistics are why the Red Cross harassed my father.

There are three main avenues from which the blood donation crisis needs to be addressed: first, the donation system needs a massive logistical overhaul; second, the medical community needs to be both more innovative – develop blood product alternatives that work; and, third, more people need to donate[1].

I’ll start with the last reason: donating blood is altruism at its most fundamental level. You’re giving part of yourself to someone who needs it, without asking for anything in return. At the Red Cross’s donor website, the I-gave-blood-today sticker each donor gets is described as a “badge of honor” that will make the wearer special in the eyes of his or her peers. That argument is really designed to appeal more to young donors, who are looking for reasons to be cool and admired, and I doubt that it actually wins over many potential donors.

That said, I’m wearing my sticker today, for a reason that surprises me – it’s Ash Wednesday. I haven’t been a practicing Catholic (or any sort of Catholic) in years, but Ash Wednesday still makes me contemplative. Wearing ashes on my forehead would be hypocritical at this point, since to do so would be to identify with a belief system and with dogma that I don’t truly support.

In lieu of ashes, I am wearing my blood donation sticker. It’s a statement of my belief system, and I don’t think it’s any less profound than the ashes I used to wear: altruism, one pint at a time. You could call this sort of ideal atheistic altruism, or altruistic atheism, though to me that sounds like the same misguided school of cheesy alliteration that gave us “compassionate conservatism,” which is a movement I do not associate with.

The blood donation system in this country needs a massive overhaul – that is undeniable. Some things have gotten streamlined since the first time I donated six years ago –the long list of questions about sexual and travel exposures are now on a computer instead of on paper, in tiny font. Still, it takes longer than it should, and it’s entirely understandable that people are loath to take time out of a busy day to donate, especially if they are unsure how long, exactly, it will take.

The ethics of blood donation ought to transcend political ideology and religion. The Red Cross should not have to bribe donors. If you can donate your blood, you should. Bottom line.

Basics to get you started:

• You can donate once every 8 weeks
• You have to be 17 or older and over 110 pounds to donate
• Yes, there are exclusion criteria – certain medications and travel locales will rule you out (see the Red Cross site above)
  

This is the easy argument to make. Coming soon: parts two and three of Empty Barrels’ take on blood donation – what the medical community needs to do, and what can be changed about the system.

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[1] Here again we can place some of the blame on the system – how are donors recruited and sustained?

Reason #45 to go veggie

This article, from last Sunday's New York Times, nicely articulates one of the main reasons I am a vegetarian. I stopped eating meat almost seven years ago, for the relatively adolescent reason that I just didn't like it anymore. It probably helped that two of my best friends were vegetarians - and their parents, also non-meat-eaters, were gourmet cooks.

Since then, the argument of distaste has been superseded by more refined ones: it's healthier to be vegetarian, and it's better for the environment. Plus, I don't miss meat at all - being a vegetarian is not a question of self-deprivation.

You can yell at me about not getting enough protein, how my muscles will disappear, blah, blah, blah - that's not what this post is about. For the record, I get plenty of protein, and when I don't, it's because I am eating like a typical med student (read: junk), not because I can't find meat-free protein sources.

Think about it: meat is basically processed food. Take raw fuel (soybeans, oats, wheat) and feed it to a machine which will require use of energy, water, and land before giving you a product - which itself will have to be processed again to be useful. This doesn't even take into account the waste produced by said machine. To be fair, I should probably stop eating processed meat substitutes like commercial veggie burgers and energy bars – but I find it hard to believe that these have anywhere near the environmental impact of commercial meat farming[1].

The following excerpt sums up the Times article's main argument:

Though some 800 million people on the planet now suffer from hunger or malnutrition, the majority of corn and soy grown in the world feeds cattle, pigs and chickens. This despite the inherent inefficiencies: about two to five times more grain is required to produce the same amount of calories through livestock as through direct grain consumption, according to Rosamond Naylor, an associate professor of economics at Stanford University. It is as much as 10 times more in the case of grain-fed beef in the United States.

The environmental impact of growing so much grain for animal feed is profound. Agriculture in the United States — much of which now serves the demand for meat — contributes to nearly three-quarters of all water-quality problems in the nation’s rivers and streams, according to the Environmental Protection Agency.

You can call me a yuppie bleeding-heart-liberal for this post, but I don't care: at least I'm consistent. I am always claiming to care about the environment, but in my everyday life I'm pretty wasteful (still use that car, dry my clothes in the dryer, etc).

Not eating meat is probably the single best thing I do for the environment. If you are trying to find ways to be more environmentally conscious, you might think about doing likewise. At the very least, you could stop buying your chicken breasts in styrofoam packages.

(Note: one day I could post the boring-but-valid Top Ten Reasons to go Vegetarian, or - this would be funnier - Most Ridiculous Things People Have Ever Said to Me about Eating / Not Eating Meat.)

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[1] At some point I'll look for data on these, or on which favorite habit of the leftist youth is actually better for the environment (recycling versus vegetarianism).

Overdosed at 2.5 years

If you listen to Sharon Brownlee[1], I am what’s wrong with the American system of health care. Not me personally – I hope – but medical students in general. There are too many of us, she says. Too many future specialists, too many future generators of bills and referrals, too many people who will wind up ordering too many expensive tests.

Although Brownlee’s opening put me on the defensive, I had to admit that the crux of her argument was basically what bothers me the most about the academic medical centers where I will do most of my training: too many cooks spoil the broth.

All the time, the doctors I work with say things like, “well, I think you have X, but I’m going to refer you to Dr. So-and-so Specialist so s/he can take care of it.” Often it is unclear to me why the referral is generated: because the doc genuinely has no idea how to proceed? Because the internist thinks s/he knows what’s going on but wants to call in the specialist for CYA[2] purposes? Because the primary doctor is already running an hour late and everyone – patients, nurses, schedulers, the doc him or herself – is too flustered to take additional time to think, research, come up with a game plan? The other day a physician admitted to me that he was referring his patients to other specialists simply because they existed at our hospital. He could have taken the time to work through the other complaints, he said, but he referred instead.

We are told by our deans and mentors that we should become specialists – mostly because of money[3]. “If you want to become an internist,” I was told in the spring of my first year by a doctor whose specialty I will not disclose, “you’d better marry rich.” At the time I was actually thinking about his specialty, but after hearing similar comments from several of his colleagues, I sort of soured.

I’ve since moved on to the blood. Part of me is drawn to hematology, or hematology-oncology (read: blood, or blood and cancer), because I am an unabashed nerd. I find the blood fascinating, and I want to work in a specialty where I might be able to help people both live well and die well. But a career in heme-onc means I’ll be working at an academic medical center forever – because the field changes so fast that I think I’d get behind in private practice.

Another part of me likes the idea of running my own show as an internist. You’ve got heart problems? Diabetes? Lung problems? I’ll deal with it. I understand that I wouldn’t be able to handle everything, but I couldn’t stand being in a specialty where I would be consulted simply out of convenience.

At one of her bioethics classes, my roommate Jenn met a Belgian doctor. I don’t recall his area of practice, but he volunteered some disparaging opinions on the US system of practice. Dermatology in particular took a beating: it did not really exist as a medical specialty in Europe the way it did in the US, he said. General internists knew dermatology – and if somebody had skin cancer he or she went to the oncologist. I suspect there was some degree of exaggeration in his answer, but at its most basic level he’s entirely right. Becoming a competent doctor is all about seeing enough of the same things over and over and over. It’s an apprenticeship during which you learn the right way to treat somebody by first seeing and then treating dozens, hundreds of similar patients. If you refer all your patients with rashes to a dermatologist, you are never ever going to do a good job diagnosing and treating skin conditions. If I were practicing without the ability to refer someone to dermatology, you can bet my loans I’d get damn good at figuring out rashes.

The worst example of the too-many-cooks principle I’ve encountered was a phone conversation I overheard while sleeping in the residents’ lounge one night. I was next to the phone, and at some early hour I heard someone trudge across the room to return a page. “This is neurology,” he announced in typical medical hyperbole. There was buzz from the other end, to which he replied, “no, you want epilepsy, beeper #WXYZ.” More buzz. “I understand,” he continued in the patient-but-annoyed tone I use with small children, “but this is neurology – you want epilepsy.” I assumed that this exchange could only concern a patient having a seizure, and, half-asleep, I was indignant on the part of the buzzing person on the other end of the line. What is wrong with the system when your patient has a seizure and the neurologist is the wrong specialist to call?

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[1] Sorry, couldn’t get the whole article since I no longer subscribe to the Atlantic, but you get the point with the first half…

[2] CYA = cover your ass. Yes, this really comes up in hospitals and doctors' offices, such that the occasional answer of a resident to an attending’s question of “why did you do that?” is, “for CYA.”

[3] Again, it is unclear to me when the money question stops being about having enough to pay back your med school loans before you retire and when it starts being about buying sports cars.

Tree Update

I need to add to Anna's initial tree descriptions. Our tree does not come to a point. Its like a church without a steeple. It is Howard Roark's tree (any readers out there? Who can name it?) I think our tree might be missing some chromosomes. Or have too many. The more the merrier we say at this time in the season. I have not fed the tree since that first night we turned it into a diabetic. I bathe the leave in metformin twice a day, glipizide on days when it acts very thirsty. Who feeds a tree soda? It can make its own food. Let just bottle up some sunshine and put that in the till.

O Tannenbaum

My roommates and I got our first Christmas tree the other day, and the arguing began before we even got the tree in the car. I guess this sort of thing is bound to happen – all four of us have set notions of how Christmas ought to be celebrated, and the tree quickly became the vessel embodying all that expectation.

You could say I started it. Bundled up and squinting through the foggy windows of Jenn’s car, I was concerned, as usual, about something that was still a few steps away: what did we have to trim the tree? I had one string of lights, but no real ornaments. I was envisioning some long ribbons, classy chains of silver or gold balls, but when I suggested “tinsel” as a broader category of trimming supply, all hell broke loose. Turns out Dari hates tinsel; Alli suggested popcorn strings and was probably sorry she did.

We had wanted to cut our own tree down, but as the freezing rain continued all afternoon we opted for pre-cut, on the grounds that at least we weren’t getting a fake tree. We had scoped out the tree sales in our neighborhood, and we cruised around the eastern suburbs of Cleveland, yelling about tinsel all the way to our first stop. The first church was closed; the second looked more promising. We filed out of Jenn’s car into the parking lot, hidden under hoods and hunching our shoulders against the freezing rain.

Our options were scotch pine (the cheapest), then Douglas Fir, then another tree which we immediately disregarded because it seemed to be going for around $95. “We’re girls on a budget,” I told the Christmas tree guy, who looked dubious about our prospects of buying anything from him.

Alli wanted to know if a group of trees had been painted. (Painted?) “Yeah, those are the painted ones,” the tree guy told us grudgingly, and as soon as he admitted this, I realized it was pretty obvious – the needles were a shiny blue-green that, after having been to many Christmas tree farms as a child, I did not recognize.

“How did you know they were painted?” the tree guy’s supervisor asked, in a tone which implied that the rest of the sentence was, “and don’t tell anyone else about it, either.” (Alli’s inside information came from having gone Christmas tree shopping with her mother the weekend before.) Dari and I refused to have a painted tree in the house, but we also refused to pay $95, so we headed back to the car. Shivering, we waited with Jenn while Alli negotiated with the tree guys. Jenn was hopeful: “this is the part where she comes back with a tree for $20.” But alas - an unpainted tree for $44 was the best we were going to get, so we gave up and headed to the one place guaranteed to have a tree which would fit both our living room and our pocketbooks: Home Depot.

Home Depot had Douglas Fir, Blue Spruce, and a variety of pine which we did not further investigate because Jenn refused to have a pine in the house, for reasons she did not delineate. Personally, I have always like Douglas Fir[1], but it’s hard to go wrong with blue spruce, which is what the rest of the house wanted. I felt like Charlie Brown as we stood in the rain in the Home Depot courtyard and picked out a tree which did not quite look the six-to-eight-feet advertised by its label. It and all its neighbors were wrapped in blue plastic netting, which made Alli nervous about any defects hidden underneath. “What if we get home and it’s all scraggly?” someone wondered aloud.

We could only find a plastic stand, which led to a lot of griping about what had become of Christmas these days. (“What happened to metal stands?” I asked.) Once we had the tree in the car, though, we inhaled deeply the smell of Christmas and forgot all about the plastic stand.

On the way home a second dispute was born over the issue of nutrition: did the tree require any sort of supplement? I said no, just water, and called my father for confirmation. Dari claimed that trees needed soda (“Black or clear?” Jenn wanted to know), which we deemed preposterous.

I insisted on setting the tree up to dry in the basement. Jenn and I freed it from the plastic hair net and opened up the branches, which turned out to be a relatively painful endeavor. (Dari later told me this was the first she’d heard of drying the tree.) A few hours later we pulled it up the stairs. Five-foot blue spruces weigh more than you’d think, and we listed up the stairs, squeezing ourselves through the door and back again on our way to the living room. We released a shower of needles with every movement. Jenn held the top – and most of the tree’s weight – as I guided the trunk into the stand. I seemed to remember that there was a lot more yelling when my father and brother set up our family tree.

We tackled the lights next. The decision to use white lights was unanimous, but I also insisted on using the lights with green wire – which, along with using straight-up water to feed the tree and drying it before placing it in the stand, is in accordance with Linden Brady Christmas tree dogma[2]. Instead, my green-wired lights ran out after one loop around the base of the tree, and we had to finish with icicle lights. Taking great pains to hide as much of the white cord as possible, we sang along to WHAM! and Mariah Carey (thank you, satellite radio).

The sum total of tree trimmings was the following: half-a-dozen miniature ornaments, the largest about a cubic centimeter in volume; a stuffed animal mouse; two colored globes, sans hooks, which we balanced on the branches; a lego angel which I got in my shoe on St. Nicholas Day about 14 years ago; and two long, red shoelaces[3] which I draped like ribbon between the boughs. Halfway through the trimming Dari announced that her mother had confirmed the value of soda in tree nutrition, so we spiked the tree’s water with Sprite. “We’re making the tree diabetic,” yelled Jenn, but despite the high-sugar diet, I felt it would be hard to destroy the tree in the two weeks remaining before Christmas.

We wondered what to put on the top of the tree. A star – maybe. I vetoed an angel. Jenn suggested a blood donation bag, at which point I informed her that she could never call me a nerd again. I wasn’t sure what should go on the tree, but I felt it should embody a value of our house. (Hence no angel.) Should we put up the blue-and-yellow HRC equals sign? A toy stethoscope? A peace sign? So far the tree remains relatively unadorned, but that hasn’t detracted from the effect it’s had on the collective mood of our house. Just the sight of the lights through the window as I arrive home is enough to lift my spirits with memories of Christmases past.

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[1] My attachment probably stems from a childhood of Decembers spent listening to our cassette of Raffi Christmas songs, which included “Trimming the Wicks on Douglas Mountain.” It’s not exactly Johnny Mathis or Robert Goulet, but it’s a fine album – “Petit Papa Noel” is probably my favorite track.

[2] I say “Linden Brady” dogma because my cousins, the Summit Bradys, always used colored lights on their tree, and I can’t truthfully speak to the particulars of all the other Brady trees.

[3] If you were to investigate the tree closely, you might notice that the shoelaces say “The LaSalle Bank Chicago Marathon” in black lettering. They’re an appropriate decoration for our house; we joked about adding old sneakers – maybe they could go on top, especially since the tree sort of plateaus, rather than peaks.

A Kit Kat has 218 calories (thoughts on Halloween)

I’m a little nostalgic for the Halloweens of old. Gone are the days when my siblings and I trooped around in the Buffalo snowT before coming home to dump our candy on the family room floor, the better to search for the razor blades and syringes that might be hidden among our loot.

I am the one passing out the treats these days, not without a significant amount of guilt – I’ve seen too many diabetic and obese patients struggle with changing their eating habits to feel good entirely good about passing out candy to little kids. Still, one evening (or a few) of candy binging isn’t going to ruin anyone, and I’ve always liked the eerie, semi-pagan atmosphere of All Hallows Eve. It’s the Celtic in me.

My roommates and I got pretty into things this year: we carved three pumpkins[ – at the neighborhood coffee shop’s pumpkin party, no less – and roasted pumpkin seeds, then arranged our schedules so someone would be home for the neighborhood kids.

At the hospital during the day I’d bragged about how tough I was going to be: “No candy without a costume or without saying ‘Trick-or-treat,” I’d claimed. We – my fellow medical students and I, the nurses, the social workers – had complained about the many ways in which people violated Halloween these days. Teenagers who show up without costumes, whoever it is smashing pumpkins overnight, parents who insist on collecting candy for the baby who is “at home.” If your baby is at home, this chocolate is calorie-free. (And if baby really is at home, too young to be out trick-or-treating, what are you doing bringing home a pillowcase full of candy for him or her?)

In reality, I was less firm when the time came to light our jack-o-lanterns and pass out Kit Kats, Hershey bars, and Almond Joy (chosen because they were on sale and because we’d appreciate the leftovers).

I harassed a few people: every kid without so much as a bandanna or ski mask was asked, “And what’s your costume?” Inventive answers included “just a boy,” and “a kid skipping school – don’t tell my mother.”

“You have to say the magic words,” I told a group of five or six teenage boys who silently held their plastic bags out in anticipation. They obliged in a mumble. “I haven’t had to say that since I was like twelve,” one boy said. I rather thought this proved my point, I told my roommate Dari. If you’re too cool to say “trick or treat,” then you are too cool to be on my doorstep asking for candy.

I won’t pretend that kids who showed more effort got more candy (we had a light turnout, and my roommates and I have a collective sweet tooth that made keeping too many Kit Kat bars around a dangerous idea). It’s occurred to me that some of these kids might not be able to afford a great costume, or their parents might not have the time to spend on an elaborate homemade one. But there’s really no excuse for not saying “trick or treat.”

“Is she old enough for candy?” I asked one woman who was filling a bag for her child, sleeping behind her in a stroller. “She’s one,” the mother replied. One-year-olds really need those Almond Joys.

My yuppie self sat there, eating edamame and squash while snarking about childhood obesity, during the two hours which had been designated for trick-or-treating by Cleveland Heights. This irony was not lost on me, and I started thinking about ways to make Halloween more healthy for the neighborhood kids next year. Little raisin boxesX? Mini popcorn bags? We’d be that house, the one where you don't get anything good. Probably we’ll give out candy again. Halloween just isn’t the same without it.

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T Actually, I only remember it snowing once, but nostalgia is all about exaggerating. I should note that we also walked uphill both ways while trick-or-treating.

[ It was suggested that we make our three pumpkins into a non-traditional family (two mommies + baby) until I pointed out that pumpkins were gender-neutral, which made them sort of radical decorations to begin with.

X Apparently when my parents took me trick-or-treating for the first time, I got a box of raisins at the first house and wanted nothing more than to go home and eat them. My confused parents forced their three-year-old daughter to go to a few more houses and collect candy before giving in. I then hated raisins for about twelve years.

Dr. God-complex

At work the other day, I heard such profanity as I've never heard in real life before. It was like the YouTube clips of The Departed or Good Will Hunting which feature four straight minutes of profanity. I swear, no pun intended.

Really, I have never heard the F-word used so much in real life. "Pass me the f&#!ing [this / that]." "Could you f%!@ing hurry up?" "Jesus, what the F^&! is taking so long?" Literally hours of swearing like this.

I have to believe that in any other field the person spouting these epithets would be fired - who would stand for this sheer disrespect? What other working professional, what other adult, could get away with this sort of behavior?

Only surgeons. What is it about medicine that makes people feel they have carte blanche to do whatever they want? They can speed, run red lights, swear at everyone in the operating room, talk incessantly about themselves, and society is supposed to put up with it. After two-plus years of medical school, I understand the joke in the West Wing where President Bartlett, upon meeting someone who mentions his son is a doctor, says, "Oh, I'm so sorry. I'm married to one. Wait, you meant that as a good thing."

Something about the medical field makes doctors and doctors-in-training think we are above everyone else. Don't get me wrong - medicine is an amazing profession, surgery's incredible (more so when it works, which isn't every time). Yes, we save lives. But so do a lot of other people - in different ways, some more obvious and some more subtle. Soldiers, aid workers, lawyers who defend otherwise vulnerable people against the death penalty, against dictators, against all sorts of crimes; teachers who work in the inner city and make sure all kids have a shot at a career and a life; engineers who design the devices we doctors use.

No, there is such hubris in medicine, and what gets me is that many doctors - even medical students - acknowledge this without the slightest hint of remorse. The same surgeon who swore for hours at every person in the operating room (besides the patient, who was under the age of one) bragged to me later about how I'd be telling my friends about the asshole attending I met. I've had other people admit to me that they feel they are entitled to passage through traffic because - as a second-year medical student - they're worth more than, you know, the lawyers and city officials and firemen and nurses and teachers and parents making their way home after a day at work. I'm not joking.

Do I sometimes hear what people do and think, whoa, where's the greater good in that? - and feel a little superior. Yes, I do. But the self-righteous proclamations of those in medicine are worse, I think. We're on our way to making a lot of money - potentially, though there are plenty of docs who don't make the outrageous salaries of, say, neurosurgeons.

My desire to do work that matters and which helps others is one of the things which drew me to medicine, but I will readily acknowledge that medicine does not have a monopoly on work that matters. Far from it. I frequently think that if I really wanted to have a big impact, I'd drop out and go into journalism, or teaching, or law.

I realize that assholes can be found in every profession and every avenue. It just seems that there are a lot in the medical field, and I will have to work with these people for years. I just hope I don't become one.

The Pride of North Buffalo... still

This story in today's Buffalo News is about my old parish school and the pastor who's served there since before I was born. I think this sort of community spirit is why my parents continued to drag us to Mass years after we realized they didn't really believe much, if any, of the Roman Catholic doctrine we heard there.

Dangerous precedent

I don't have much more to say about this story from the New York Times besides the fact that this situation is absurd: two doctors who have voiced reservations about a new drug developed for prostate cancer have received threats for their trouble. The drug, Provenge, is waiting to be approved by the FDA for use. (The FDA voted that it seemed "generally safe" but has asked for more information before it gives the go-ahead for use.) Two physicians who are not convinced that the benefits of the drug outweigh its risks have received threats - one a death threat - after they voted against approval.

Now, I admit that I have not read the Provenge trials, and that I do not treat people with prostate cancer. That said, does the name Vioxx ring a bell? Remember, the fantastic painkiller which later turned out to increase the risk for heart attacks?

The bottom line is that drugs get approved all the time and are later found to be dangerous - there aren't enough people in the studies to catch all the possible adverse effects. The job of the FDA and the scientists who help it decide whether to approve drugs is to be cautious without unduly restricting. Threatening doctors who voice concerns about the efficacy and safety of a drug helps no one.

It's not as if someone woke up one morning and thought, "Gee, I'd really like to make life harder for people with advanced prostate cancer, so I'll vote against this drug."

Regardless of what ultimately happens with Provenge, it is NOT acceptable to threaten people who advocate for patient safety. Doing so sets a dangerous precedent - literally.

Do you feel a draft?

I wish someone would just have the guts to call for a draft. Everyone and his mama, include the Dub and Barb, know we do not have enough troops to do what they think needs to be done. Someone out there, anyone, with an ounce of political will, with serious intention, bring it up again. It has been said in so many ways, now lets just use plain English: It is not working. Or the Queen's English: Ye olde surge hath rendered ye little. No funciona, people. You can't run a business without workers! Call for the draft. Lets get everyone lined up and see how the tone changes. I am in. Sign me up. Birthdate 8.22.80.