How you doin'?

Hmmm...it's been a while. Usually when I don't blog for several months it either means that I have had more "in person" processing time, or that I'm really busy. Both are true in this case.

As I've accumulated more and more long-distance friendships, or friends whom I only get to see every few months, I've had more and more trouble answering the question, "how are you doing?" upon our reuniting. I generally find this a difficult question to answer because it is so broad, but it feels even more difficult when there are weeks or months worth of responses to somehow combine into a coherent thought.

So instead, here are two questions I've decided are easier for me to answer (and ask).
1. What is it like to be you right now?
2. How have you been living?

In my mind, these two alternatives are essentially asking the same thing, but leave more room to respond with something other than, "I'm fine/good/bad/ok. And how are you?" They draw out a more full response, and bring up the points that the other person is really most interested in sharing, I've found. They are questions that allow you to describe your actions (work, rest, play, things you have done recently), but also just describe a general emotional state or rhythm of life.

The first question in particular seems to allow you (or me, at least) to describe yourself in relation to your surroundings, work, relationships, emotional state...etc. The second questions allows you to describe life in a way that is more holistic (more of a focus on living, than just doing/being) than when answering the question "how are you doing?" Perhaps the distinction is too nuanced, but for me these have been more helpful questions to ask others, and be asked in return. They help me to "get into a person's shoes" and understand a little bit more what life is currently like for them.

I wonder how I might be able to tweak some of the standard doctor-patient questions to allow more room for a holistic response?

Flash Forward: medical technology and life abundant

I just finished watching a New Year's program called "Flash Forward" that highlighted some of the techology that was in its infancy 10 years ago which is now mainstream and has changed lifestyles immensely. The program went on to talk about ideas and technology that are just being invented and ironed out now which are predicted to make massive changes in the next 10 years (much of which is medical).

I'm drawn back to the same tension I've thought, blogged, and talked about before.

Techology does some amazing things. Some technology does actually trickle down. X-ray machines, vaccines, MRIs, just to name a few. Even if you don't have medical insurance, the general public does have access to these things, provided they know where to go to get them. No, they aren't distributed evenly, but overall, these are examples of technology that have vastly benefited almost all of society.

The process of researching, discovering, and inventing new technology also teaches us new things about ourselves, the world, and environment (and, I would say, sometimes even about our God).

But I don't think that new technology is always the answer. I don't think that changing our genes is necessarily better than changing our lifestyles. And our medical technology doesn't always (often doesn't) trickle down. It is an entirely different thing to ask if our technology should always trickle down to the general public. I am uncomfortable saying yes and no to that question.

It is hard for me to hear about all the crazy new technology that focuses on changing genes, super high tech procedures, and trying to double people's life spans, when there are so many people who may never have access to that technology (or at least not for a long time). What would help them now is not better technology, but health care professionals who are freed to spend a little more time with them in each visit to focus on lifestyle changes and prevension. This would require those health care professionals to be better paid (avg. primary care physician in an underserved area gets paid the same as a plumber...hard to sign up for that when you have 200,000$ + in loans). And then there is the question if all the new technology is actually what is best for us. It may be what we want, but is it what we need? Sometimes. Sometimes not.

How do we decide when to spend money on research and new technology, and when to use that money to address healthcare disparities? Is it possible to do both at the same time? When is medical technology the best solution to someone's health, and when is it something else? How do we use medicine to not just extend life by certain number of days, but to actually make that life abundant? Is that even the role of medicine?

I start the New Year stuck in the same tension between "life" as medicine defines it, and "life" as I have understood it through Scripture, felt it myself, and observed it in others. And in the tension between expensive medical advances and high profile medical care, and an increase in services and care "for the masses."

"So, what brings you in to the doctor today?"

I recently had to write a paper on the theories and models of the doctor-patient relationship. There is the paternalistic model, in which the doctor knows best and tells with patient what is wrong and dictates the care plan. There is the engineering model, in which the doctor gives the patient the facts and allows the patient to decide their own health plan. Then their is the collegial model, which emphasizes the need for relationship between the doctor and patient. It states that the doctors role is to listen, ask questions, advice the patient based on medical fact but the ultimate care plan is to be shaped by both the patient and the doctor, so that it takes into consideration the patient as a whole person, not just an isolated illness.

These all have different pros and cons, and (in my very limited experience) it really depends on the patient. In general, you (are supposed to) start with the collegial model, and adjust if you have to. The paper led me to think about the general role or job definition that physicians have. Although the obvious answer might seem to be, "heal people/improve their health," I'm learning how debated that answer is in the medical community, both in what it means and in its legitimacy as an answer to the question. A lot of the debate ends up centered around the doctor-patient relationship, and how the doctor is supposed to view the patient.

If the doctor views the patient primarily as a disease or illness, rather then a person, then the goal is simple: fix it. It might sound kind of harsh to say that these kinds of doctors don't see patients as real people, but as something to be cured, but they also get a lot more done. They see more patients a day (ie. they technically have more chances to heal), and the patient generally always receives the best care in the medical/scientific sense. Some patients seem to want this in their doctor, others don't.

If the doctor views the patient as a friend, or younger sibling, they might be really great at hearing the whole story behind the illness or injury, getting all the social/psych/family background, sympathizing or empathizing well, and maybe even sharing a personal fact about themselves. But after all of that, a lot of time has been spent and nothing has been done about the acutely medical need. Yet, a great relationship has been built, trust built, and whatever advice the doctor does give might be carried out more effectively by the patient because of that relationship. Again, pros and cons. Some patients think this is just a waste of time, others need it before they can trust the doctor.

I'm going through the gospels as my Advent reading, and its making me wonder: how would I classify Jesus' doctor-patient relationship. Sure, it gets more complicated because, well, He's the Son of God and knows people lots more intimately then I will ever know my patients. So maybe the question is more: what kind of doctor-patient relationship does Jesus teach others to have (noting the difference between following/imitating Jesus, and actually being Jesus)?

I'll let ya know what I think after I read a little more. After all, its only the second day of Advent :)

Built to Last

I am in the midst of studying for my anatomy exams, so this is just a quick thought.

When I buy something, say, a piece of furniture, or electric appliance, or article of clothing, I always hear my mom's voice in the back of my head, "you get what you pay for." And behind that little saying is the implication that things don't last forever. Applicances break, furniture gets shabby, and clothing wears thin. Sure, we can take good care of our belongings and they last longer, but very rarely do we buy something with the intention of keeping it in tact and working for the rest of our life.

As I've studied anatomy, one thing I have found so amazing about the body is that it is really built to last. Of course, we age, things go wrong, and we die, so still the physical body has its limits. (and yes, it really matters that the physical body as we know it on earth has limits, but that is a whole different topic) But in comparison to the vast majority of possessions we have, the body really is built to last a long time. What else do we use every day with so much stress that lasts for so long? It is amazing to take apart the body and see all of the tiny ligaments, tendons, joints, and muscles that hold us together. Every movement our body makes, from a long run to the slightest twitch in our sleep, relies on the fact that all these body parts are put together properly, and are doing what they are supposed to do. Individually, each of these parts are so delicate and vulnerable. I can squeeze two vertebrae in my hand with enough force to cause life-long pain in a person, but when they are inserted into the vertebral column, with all of its protections and connections, they are one of the sturdiest parts of our skeletal system. And aside from surgery, we don't really revamp our body the way we would refurbish a computer or load batteries into a flashlight. It comes with the machinery to do that itself.

Pretty cool :)

Leaf Blowers: a lot of hot air

Leaf blowers. There are probably a very select few situations in which they are appropriately used. Mostly I think they serve no real purpose and just contribute to pollution, but I suppose if you had a really really large quantity of leaves in some area, they could blow the leaves together into a pile for you to rake up more easily.

Needless to say, this is not the way leaf blowers are used typically. Every morning on the walk to school there are several men blowing leaves off of the sidewalk and into the street. Over the course of the day, the cars on the street push them back onto the sidewalk, or the staff of other businesses in the area have to deal with them (often just by blowing them back).

Perhaps you know where I’m going with this…

Why should the leaf blowers care where the leaves go, as long as they aren’t on the property that pays them to get rid of the leaves? They did they job they are paid to do. Should anything else be required? A question that at some point that all individuals and groups have to ask: Why should I/we care about anyone or anything that is not directly related to me/us? (if there is such a thing...)

The leaf blower example is over simplified, but I think it goes a long way. Not caring about what happens to the leaves, as long as it isn’t your problem, is inefficient. It gives you more work (ie. you’re not really getting rid of the problem), it diminishes the value of your work, and it creates unnecessary work for other people. I wonder how often we function like this in day to day work: simply through the routine of the work, not stopping to think about its effects. There’s more to be said about why it is important for a society to feel that the work they do has value, but for now I’ll just say that even if there is no emotional or justice-related concern for what happens to those leaves or if they actually get taken care of, it is still advantageous on a personally economic (and psychological) level to care about it.

It’s one thing to spend extra time raking up leaves, but as soon as the analogy gets extended to apply to national, international (and actually even familial) policy and practice, the situation becomes more complicated. I think this is partially due to the fact that it is harder to see and feel the personal gain that comes out of caring more deeply about the welfare of others or the quality of a particular job and how it is connected to the welfare of others.

I think that scripture affirms the notion that “your welfare is found in the welfare of others,” both in Jeremiah 29, but also more widely as a general theme. (I’m going to pull a Laura and choose not to exegete that right now). I will say though that it is a pretty dramatic command to find find one's welfare in the welfare of others while you are in exile, which was the case in Jeremiah. My own opinions on how much that philosophy of welfare, in addition to the general idea of grace, should shape and influence government and policy are in constant transition. Even if I come up with an opinion, it’s hard for me to know where to begin in terms of application. In many ways, I think addressing the topic on the level of leaf blowers is more practical, and just as biblical. At least that is how my brain is wired. Where are some practical places that small adjustments in policy and practice can be rethought to improve the value of work and move towards an economy that recognizes our interrelated welfare?

*not trying to attack the guys who blow leaves, just using them as an example.

Genomics and Immortality

Jonathan asked me the other day if I thought we could get to a point in medicine when we could make people immortal, or cure them of all disease, or at least extend life by another hundred years or so. At first I quickly dismissed those as possibilities, at least for the general population. Well, I have been in my genetics and genomics unit for the last week and now I am not so sure.

A lot of people in medicine right now are really pushing the idea of personalized care, meaning that we can sequence everyone’s DNA genome and therefore know exactly what disease they have, what kind of medication would work best, in what amount, and what kind of effect it will have. There are some great benefits to this! It means that we could know if a child has the genes for a disease that will develop later in life that could be prevented or at least lessened. It means that medication could be given effectively (a surprisingly large number of people die or are made worse due to medication complications) because doctors would know exactly how much they need, of what, and how their body will react. Treatment like this would significantly decrease a lot of health care costs, number of unneeded tests and medications, and would decrease time spent figuring out what is wrong and how to fix it.

There are also some potential drawbacks, or at least strong ethical concerns. Parents could know the exact genetics of their child while it is still in the womb, and could choose to abort if they don’t like what the genome shows. With gene therapy, parents could “fix” the genes of their in-womb child. Individuals could do that for themselves as well, though to a slightly less degree given our current technology. People could request to see the genomes of their girlfriend or boyfriend before deciding to marry and have kids. Sites like match.com could start to include a section for “genetic profile.” Ok, so that is a light-hearted example, but the point is that people who have some hidden genetic mutations, or just not “ideal genes” could be intentionally selected out of the mating pool. Here are some questions this raises for me:

-who would have access to the genomic info of another person?

-what effect would this have on insurance, if a genome showed that a person was predicted to get, or at high risk for a particular disease?

-what would the psychological impact be on society if people were able to know all of their different genetic mutations?

-what effects would this have on procreation, choosing spouses, and abortion?

-would we turn into a standardized society with a definition of “ideal” or “perfect” genes that people will preferentially select for? (ironically, diversity in the gene pool is actually considered a sign of a “healthy” population that is of low risk to severe mutation, but even that would change if you could control or fix mutations)

Right now these techniques are too expensive for the average person, but that is predicted to change over the next 10-20 years, so getting your genome sequenced could be as routine as getting your basic childhood vaccines. So this isn’t as far-fetched and distant as I initially thought.

So to return back to Jonathan’s initial questions, having your genetic sequence and using gene therapy wouldn’t definitively cure a person of all disease, but it has potential to cure a lot of the deadly illnesses.

Suddenly, an important question arrises: Is mortality an illness? If the role of scientists and doctors is to heal and cure the sick, and if we generally say that saving someone’s life is the goal of a medical procedure, then it seems to follow that trying to extend peoples’ life would be a good goal (I don’t mean just keeping old people alive forever in a state of sickness). That has certainly been the trajectory of medicine so far. One of the key methods of analyzing health of a country is to look at the average life span, and almost all countries have increased their avg. length of life over the last 100 years. But what if we have the technology to make people double their life span? No, that isn’t immortality, but it would have HUGE consequences on daily life and the core philosophy of life as we know it.

For me, this brings up the core question of what the goal of medicine and scientific research is. I think that technology has many great benefits, and I think that healing people is a good and valid life profession (or it would be hard to be in med school). I think that giving people the physical experience of going from sickness to wellness is a way of helping people experience the gospel, and a God who is all about giving health to the sick in the most holistic and eternal way possible. But I internally squirm when I think of us being immortal, or even living two or three times as long, here on Earth because of our advanced technology. I do think we are meant for eternal life. But isn't there a difference between the eternal life with God that scripture talks about and eternal life that we could give ourselves? How much does God inform and move forward our technological advances? How can we tell? The goal of life and health is similar to God and scientists/doctors, but do they move towards them in the same ways? Does God use doctors and scientists to do this? Are we even able to comprehend what God means when he talks about eternal life and health, or are our thoughts and definitions too feeble and small to really have any idea what He intends for us?

Questions that I do not have answers to, but that I think will persist thoughout med school.

"So, what brings you to the doctor today?"

I recently had to write a paper on the theories and models of the doctor-patient relationship. There is the paternalistic model, in which the doctor knows best and tells with patient what is wrong and dictates the care plan. There is the engineering model, in which the doctor gives the patient the facts and allows the patient to decide their own health plan. Then their is the collegial model, which emphasizes the need for relationship between the doctor and patient. It states that the doctors role is to listen, ask questions, advice the patient based on medical fact but all the ultimate care plan to be shaped by both the patient and the doctor, so that it takes into consideration the patient as a whole person, not just an isolated illness.

These all have different pros and cons, and (in my very limited experience) it really depends on the patient. In general, you (are supposed to) start with the collegial model, and adjust if you have to. The paper led me to think the general role or job definition that physicians have. Although the obvious answer might seem to be, "heal people/improve their health," I'm learning how debated that answer is in the medical community, both in what it means in its legitimacy as an answer to the question. A lot of the debate ends up centered around the doctor-patient relationship, and how the doctor is supposed to view the patient.

If the doctor views the patient primarily as a disease or illness, rather then a person, then the goal is simple: fix it. It might sound kind of harsh to say that these kinds of doctors don't see patients as real people, but as something to be cured, but they also get a lot more done. They see more patients a day (ie. they technically have more chances to heal), and the patient generally always receives the best care in the medical/scientific sense. Some patients seem to want this in their doctor, others don't.

If the doctor views the patient as a friend, or younger sibling, they might be really great at hearing the whole story behind the illness or injury, getting all the social/psych/family background, sympathizing or empathizing well, and maybe even sharing a personal fact about themselves. But after all of that, a lot of time has been spent and nothing has been done about the acutely medical need. Yet, a great relationship has been built, trust built, and whatever advice the doctor does give might be carried out more effectively by the patient because of that relationship. Again, pros and cons. Some patients think this is just a waste of time, others need it before they can trust the doctor.

I'm going through the gospels as my Advent reading, and its making me wonder: how would I classify Jesus' doctor-patient relationship. Sure, it gets more complicated because, well, He's the Son of God and knows people lots more intimately then I will ever know my patients. So maybe the question is more: what kind of doctor-patient relationship does Jesus teach others to have (noting the difference between following/imitating Jesus, and actually being Jesus)?

I'll let ya know what I think after I read a little more. After all, its only the second day of Advent :)

Stolen Bikes and Starbucks Seats

For the last three months, every morning on the way to school I would pass Jeffrey, who would sit outside Starbucks asking for money. After the first week, he stopped asking me for money and would just say hello, ask how I was doing, and we would chat for a few minutes. It was a small thing, but I enjoyed the regularity of seeing him every morning (although ideally he wouldn't have to beg outside starbucks). In the afternoon when I passed by, he would ask, "so what did ya learn today?" and I gave him some medical fact before going on.

As of last week, I don't see Jeffrey anymore. Starbucks put up a rail about 7 feet off the side of the building and put inside of it some more permanent tables and chairs. It looks nice. It keeps the street litter from coming in and allows people to sit and drink coffee without beeing bumped into by folks on the side walk. But it also means that Jeffrey can't sit there anymore, at least not without buying something first. Earlier today I saw him a few blocks away by CVS and said hello. He said he doesn't like sitting outside CVS as much. "The people aren't as friendly," he said. "I think coffee makes people happier, they give a little more money."

The scenario is a small picture of a much larger issue. Starbucks does something to make their store a little nicer, not in itself a bad thing at all, but it displaces Jeffrey. The same thing happens on a bigger scale when new stores and houses are built in lower class renting neighborhoods where rent prices fluxuate. What makes me frustrated is that there shouldn't be anything wrong with making a nicer store front, fixing up houses, and improving the neighborhood. These are beneficial things that don't end up benifiting the people in the neighborhood. How did the system come to be like this?!

On a related but different note, last friday a bunch of bikes were stolen from outside my apartment building. Mine had already been stolen earlier in summer. A women saw the guys doing it, yelled and said she was going to call the cops. The cops came later and asked some questions, but let's be honest...DC police have better things to do with their time then chase down bike theives. Since I live in a newly renevated building, all of the people have just recently moved into the area. As I read the responses to the bike theft (and attempted break in earlier last week) on our building listserve, I was so frustrated. These events confirm their prejudices and stereotypes and I wanted people to love the neighborhood.

It is absolutely true that stealing and breaking in are wrong. It is legitimate to feel anger and hurt in response. And if we were to look at it on the flip side, there are negative effects for our neighbors due to the fact that our building was redone, new people moved in, and it has made the block "nicer." Their feelings of powerlessness and "being moved in on" are just as legitimate (though harder to quantify).

When I think about what God's goodness looks like, I see something that doesn't discriminate. It isn't good for one person and not another. It is good, all the time and to everyone (though maybe not always felt as such). But we don't see that played out in life on earth very often. What is good for my apartment building and for starbucks was not good for the neighborhood and for Jeffrey. And what Jeffrey and the neighborhood might define as good may not feel that way to others. But God's creation was a creation of goodness. Tov! It's tov, very tov! And it's our hope that it will once again be (and is on its way to becoming) even more good. That isn't a goodness that is easy for us to see, or understand, or even to have the faith to hope for. But I think I'm learning that solid faith in God's goodness actually changes the present reality (not just my perception of it in some spiritual sense) into something that is in fact closer to the goodness of God, because it changes what I do, see, say, think, and understand. And our faith and hope in promised goodness is legitmate because "he who promised is faithful." (Heb 10:23)

Ambulence Sirens

I live a little under a mile away from Howard University Hospital. One of the things this particular hospital is known for is its excellent trauma department. I hear ambulances with blaring sirens going down the main street near my apartment all the time. At least one per hour, I would estimate, and sometimes more depending on the day and time.

I had an exam this morning, which meant that the last few days were consumed with studying. Since I have been studying mostly in my apartment, I hear these ambulances quite frequently. Hearing them while studying to become a doctor is an excellent characterization of some of my current frustration with being a student again. There I am, slaving away memorizing which enzymes cleave which parts of DNA, when, how, and what the significance is, and out there is all the action: real doctors with real patients.

Of course I am glad that those real doctors went to med school and learned their stuff, and that this is simply the stage of life I am in right now. I am generally someone who really enjoys school. I enjoy learning, and sometimes studying, and I am able to make the connection between working responsibly as a student in a subject area I love and worshipping God. God's given me a mind that can think and learn in a paticular way, and a desire to learn a particular set of material. Ignoring or not using that gift is not glorifying to Him, and I believe that God delights when we live and move and have our being in accordance with the way He made us, rather than trying to invent false selves.

But sitting there studying, even though I can feel connected to God in doing so, still leaves me longing to be out in the "real action." It isn't because the studying is boring, or because I don't understand its importance. Even Israel had to go through massive training in the "wilderness school" before being ready to live in the promised land. Yet, it is easy to disconnect time spent studying or "in training" from God's greater purpose. But the second they are disconnected, the preparation looses its purpose and despair ensues. Israel had to continually be reminded about who God is and what He promised not only because they were forgetful and it is important to not forget about God, but because their life situation wouldn't have made any sense outside of that context. They had to intepert the present through God's work in the past (creator and liberator), and through His promise for the future. Without the past there would have been no trust or sense of identity, and without the future there would have been no hope. And yet trust, identity, and hope are to be used in the present.

So in some ways, the amublance sirens are helpful in reminding me about the future (not that I want to be a trauma surgeon...). They also have the temptation of allowing me to think that for now my job is to study and that one day my job will be to heal people, when in fact we are created to preserve life, or "be salt," at all times, not just after going through the proper training.

Bright Lights

In an effort to focus on the blessings I have/am being given, and to remember how God defines himself for us as being always enough, here are some "bright lights" from daily life in DC. (this is in opposition to the moping around that I've been doing recently)

Sunrise at 6:08 am. True, it is early. But I enjoy my morning time of drinking coffee, reading some Words, and getting ready to face the day. Leaving the apartment at 7:20am. The morning air is a little cooler and people are starting to get up and move about. And, His mercies are new EVERY morning!

Georgia Ave. The street I walk down to Howard. Even though I dislike the frequent cat-calls, I do like that I am starting to recognize the different people I see every morning. I'm friends with the guys who sit outside Starbucks in the morning asking for money. Every morning Jeffrey asks, "how's it going Stefanie?" Every afternoon, "so, what did you learn today?" And I tell him a fact I learned during the day.

One of the schools I pass on the way to the grocery store. The little kids are always out in the afternoon playing soccer or football and they are sooo cute!
This is probably my favorite part of the neighborhood. It is a mural that lasts almost the length of the block and is entitled: wholistic peace. It was sponsered by the DC community economic development group. A group of youth worked on it all summer and it was awesome to see them put so much effort into it and see people stop by and ask about it and encourage them.

Some other bright spots that I don't have picture of...

Even though I've only been here 2 months, I have gotten to spend time with a lot of friends!

-Laura (my peton!) drove through and we had an excellent time at IHOP and driving.

-Margaret came for a few hours and we had some great chat time at the Potter's House.

-Lindsey came by on her way to a conference and we also had great chat time.

-Rachel Han came over for dinner while she was here with her family on vacation. Catching up was so gooood!

-Sarah Stew is now living nearby and working nearby and we had dinner and decided we should be friends :)

-And tomorrow I'm having dinner with Janice and a friend of hers.

All in all, I'm really not as alone as I have allowed myself to feel.

"Have I not commanded you? Be strong and courageous. Do not be frightened, and do not be dismayed, for the LORD your God is with you wherever you go." Joshua 1:9