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Through pestilence, hurricanes, and conflagrations the people continued to sing. They sang through the long oppressive years of conquering the swampland and fortifying the town against the ever threatening Mississippi. They are singing today. An irrepressible joie de vivre maintains the unbroken thread of music through the air. Yet, on occasion, if you ask an overburdened citizen why he is singing so gaily, he will give the time-honored reason, “Why to keep from crying, of course!

Lura Robinson, It’s An Old New Orleans Custom, 1948

It is a month today since Danielle’s death. I had already planned to go to New Orleans for my 30th medical school reunion by myself prior to her death, as she was to be playing Amanda this weekend in a local production of Glass Menagerie. The play is set in St Louis. Tennessee Williams, the writer of the play, once said “America has only three cities: New York, San Francisco, and New Orleans. Everywhere else is Cleveland.” Clearly, he set it in St Louis for a reason. Danielle was a New Orleans native, and she understood those reasons.

I lived in the Faubourg Marigny (a neighborhood just outside of the French Quarter) while I was in medical school. After we married, Danielle and I moved to the Irish Channel, a neighborhood that is quite gentrified now but was much less so 34 years ago. For those of you who know New Orleans, we were one block off Magazine and spent many afternoons there walking and window shopping.

After moving to Mobile we found ourselves in New Orleans many times a year. We would go to Danielle’s mother’s house and, after a suitable time, we would make an excuse and go to Magazine Street. The children had valuable grandparent bonding time, and we had New Orleans time. This became less frequent as the children grew older. After Katrina, both of our immediate families left south Louisiana and so our visits were limited to special occasions. We still made it about three or four times a year, however, enjoying many delicious meals with our friends and extended family, and spending time window shopping on Magazine.

This weekend, I played hooky for much of my 30th reunion. Staying with friends of ours in their uptown home, we drank wine and remembered the old times. New Orleans being New Orleans, we went to the Boogaloo Festival and heard the Lost Bayou Ramblers. We spent time among the thirty-somethings, watching them  frolic in the old (not very clean looking) Bayou St. John canal. It was hot. All in all, a very New Orleans experience.

At the reunion events I did attend, word quickly spread about my wife’s death. Many came up to me and offered condolences. Most of them only knew Danielle peripherally, so I didn’t have many in-depth conversations. “So sorry for your loss,” they would say. “Thank you for your kind words,” I would mumble back. Since many of these old acquaintances are no longer married to the spouse they boasted in medical school, discussions of marriage and relationships are typically avoided at these reunions altogether. One of the more awkward moments, in fact, was when we toasted to those who helped us get where we are and the person next to me said: “Wait, am I toasting my EX-wives?”

I guess my loss really hit me when I was driving down Magazine Street on my way out of town. I saw all the familiar buildings that were built before we were born and will likely be there after our deaths, and I realized that my loss is not just the Danielle of today. My loss is the life we built together and the life we expected to continue to share. That loss includes our shared experiences and memories. Our stories. Our jokes. I realized that I had lost not only Danielle but our shared New Orleans.

“So sorry for your loss.” For those who knew us, it is a shared loss and I am sorry for your loss as well. For others, I really do appreciate the sentiment, even though I may respond less than enthusiastically at times.

 

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I was sent an e-mail regarding one of my previous posts and included was a copy of an address given by one of my former professors, Dr Charles Dunlap, at Tulane’s Ivy Day in 1975. While the scientific knowledge changes, much remains the same. For example:

Among the standards required of a physician few are more basic than integrity and simple honesty. In ordinary business dealings, each purchaser of goods or services is assumed to have sufficient knowledge of the game to safeguard his own interests. In medicine, the rules are different. Each patient puts himself, naked, alone, and helpless, into the hands of the physician. In this transaction, the sole security the patient has is simple faith in the integrity and competence of the physician.

In another part of the essay he points out that rituals are a large part of what we do. As you participate in the ritual of Thanksgiving, consider this quote Edmund Burke, also found in the essay:

Human beings participate in the accumulated experiences of their innumerable forefathers; very little is totally forgotten. Only a small part is formalized in literature and deliberate instruction; the greater part remains embedded in instinct, common custom, and ancient usage.

Happy Thanksgiving

For those of you that have not been to medical school, the clinical years can be a little stressful. Waking up at 4 am to see patients (and waking them up at 5 am with a cheerful “How are you doing this morning?” only to get a “What time is it???”), spending quality time in an operating room, and learning how to “see patients” through very different eyes all contribute to us becoming “doctors.” My 3rd year was spent predominately at Charity Hospital in New Orleans, where the patient base was mostly poor and African-American, in contrast to the Tulane medical students.

Part of this year was spent with one of the fathers of modern cardiology, Dr George Burch.  Dr Burch, who was in his 80s, would appear twice a week and help the team work through problem patients. He would then take the student part of the team up to his lab, where his lab techs (themselves in their 60s) would serve us tea and cookies as he instructed us on the nuances of medicine. We students couldn’t help but notice the three-dimensional vector EKGs inhabiting the room. These were like minimalist sculptures of hearts, and there were many hundreds lining the walls. Finally one of us got up the courage to ask about them.

“Oh, those,” Dr Burch replied. “I’ve been collecting those for years. When the patient died that I’ve done a vector EKG on  I collect the hearts as well. I have 1500 of them. Some day I am going to dissect the hearts and correlate the anatomy with the physiology.”

He died about 5 years later and I suspect never got around to completing this task. I am afraid that the frozen human hearts did not survive Katrina.

I read the Immortal Life of Henrietta Lacks this weekend. The extremely abridged version of the story is that Ms. Lacks, a poor woman who lived in Baltimore at the time, was going to Johns Hopkins for a complaint related to her “womb.” In the course of the diagnostic and therapeutic interventions, some of her tumor was collected and was the first human cell line to be able to grow independently. The HeLa cell was used to develop and test the polio vaccine,  develop techniques used for IVF and creating other cell lines, used to create the building blocks for the human genome project, and is used to test drugs that affect cell growth to this day. Although Hopkins got no money for developing this directly, their reputation was certainly enhanced greatly (5 Nobel prizes can be directly linked to HeLa). Many companies have made a lot of money using this commercially available descendent of Ms Lacks. The Lacks family, on the other hand, struggled for years with lack of access to basic education and health care as well as being treated as research subjects rather than fellow human beings.

Most medical training in New Orleans in my time was (and likely still is)  accomplished while caring for the poor of New Orleans. My choice of Tulane, in part, was because of a reputation for academic excellence and innovation by such folks as George Burch (founder of American Heart Association), Louis Ignarro (Nobel for work on nitric oxide), Michael deBakey (inventor of heart-lung machine key component), and Andrew Shalley (Nobel for discovery of pituitary hormones). I suspect ALL of these folks would have had much less success without their own Henrietta Lacks at Charity Hospital. I suspect Dr. Burch, for example, did not get solid permission for the donation of the hearts, though I could be wrong.

Modern medicine and modern society have moved beyond (I hope) the concept of poor people existing in the health care world so doctors can practice for their well-heeled private clientele. Much of the Henrietta Lacks story is one of objectification of tissue, families, and the entire African-American culture. The ethics of access to modern medical discoveries are difficult. It is when the very people upon whose backs the discoveries are made seem to be denied access systematically that we need to step in. Although not perfect, the Affordable Care Act is a start, and its promise of access beginning in 2014 is a down payment on correcting these disparities.

I was in New Orleans today for the Saints game against Da Bears. The Superdome is walking distance from the old Charity Hospital and Tulane School of Medicine. We were dropped off by old Charity and walked over to the ‘Dome. I found myself looking at the once familiar cityscape but could only think of the events post-Katrina. Charity Hospital was originally established to serve the city in 1736 and is named for the Daughters of Charity who provided care. It was Huey Long who located Big Charity (as it was known when I was in Medical School) on Tulane Avenue and placed the new public medical school (LSU) on the other side opposite Tulane in the 1930s. The two schools both used Big Charity for clinical instruction, but at the time I was in school (the 1980s) the truce was uneasy at best. Tulane, with a private school swagger, had opened a private hospital across the street named Tulane Medical Center (TMC). The poor on the Charity “service” did not get the wonders of the care delivered at TMC from the Tulane faculty. The LSU faculty, feeling outflanked and resentful, soon moved their private practice to another local hospital. As I understand it, the trauma care at Big Charity was still world class, but much of the other specialized services, as well as a lot of bread and butter medical care, had moved from Charity well before the storm.

The storm managed to do what the state of Louisiana could not: close Big Charity. As a symbol of the commitment to the citizens of the State of Louisiana to the health of  its poor, Charity was second to none. However, even before Katrina, it was known as an expensive and not very efficient symbol and as a  rich source of patronage for well-connected Louisianians. Post-Katrina Tulane reopened TMC, moved some clinical care to the suburbs, and moved some of their clinical training (as I have discussed before) into the community. LSU moved into other facilities as well but now seems to have talked the state of Louisiana into a new hospital.

This hospital will cost $1,100,000,000 and will be funded using a combination of general funds, Katrina recovery money, as well as some yet-to-be determined sources. The financial viability seems to be based on the fact that they will attract patients from the  New Orleans region  who are currently using competing health care venues but their physicians have an LSU affiliation (repatriation), they will create new demand (destination programs), and they hope to appeal to the newly “Obama-insured.” There is also a belief that some of the insured citizens are more likely to view a new hospital as less “Charity” than the previous Charity and so will choose to make this their preferred care facility.

My interest was piqued because the construction was blocking the way for us to walk from the Superdome to Canal Street, as it is a huge site. I wish LSU and the state of Louisiana luck, although it seems that they are planning more to capitalize on illness than on health.  To quote:

New Orleans Business Alliance President and CEO Rodrick Miller said, “The UMC Teaching Hospital will be a center for innovation and learning that will dramatically increase the quality of care options for patients in New Orleans, and serve as a key economic engine to spur job growth and new investment in the community. Getting this hospital on-line will solidify Louisiana’s long-term commitments to expand high quality healthcare options for New Orleanians and support a robust bio-medical industry.”

I am glad I’m not a taxpaying citizen of Louisiana. If anyone wants to know why, I refer them to The Amazing Health Care Arms Race.

Being a Tulane Medical School alumni, I get a lot of information regarding my alma mater (mostly implying I should donate money). I was heartened to be spammed with a story about the growing clinical presence in community health centers. I have written in the past about the possibilities in such partnerships and have been following Tulane’s progress for several years. They are now involved in multiple sites (website found here) and have plans to expand even further.

I sent a copy of the article to my boss and he wanted to hear what I thought we could do if we chose to emulate Tulane. After some thought, I decided we might focus on these areas:

  • Tulane made a decision to partner with Community Health Centers in part because they were able to draw down resources for caring for the poor better than they could through the old Charity Hospital system . USA Family Medicine should consider partnering with a  Community Health Center and creating a Teaching Health Center under their umbrella. This would enable us to work with Medicaid/Medicare more effectively and use the additional resources to improve the program.
  • Here in Mobile, the community safety net needs to focus on health, not illness (as happened in New Orleans after Katrina). South Alabama needs to be the leaders in this. Someone needs to initiate and carry out a discussion regarding the health of our community, and who better than a medical school. We at South Alabama have focused our energy on taking care of sick people in the hospital and that is not where care will take place in the future.
  • Our medical school should add an emphasis on training learners to care for folks with chronic illness in a non-hospital setting and what better location to do it in than a well run Community Health Center. An article published last week in NEJM demonstrated excellent diabetic care could be accomplished in Community Health Center settings. Why shouldn’t students learn about this first hand?

In short, health care delivery is changing. New Orleans, as a result of a man made tragedy, has had to face some tough choices. Regarding health care delivery, the city seems to be better for it. I hope it doesn’t take a tragedy for the rest of us to take a hard look at our care delivery efforts.

When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”

This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.

Medical training, though, is changing.

A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment.  While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities.  The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.

And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)

While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”

A far cry from the boys needing thyroids.

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