Sunday, April 11, 2010

MOAS-After reading Chapter 2 & 3

Respond to these two questions by Friday April 16th:

1.) Do you think Dr. Nolen should have asked the Attending Physician for more help during his first appendectomy operation? Why? Why not?

2.) Dr. Nolen describes treating wealthy patients differently than poor, indigent, alcoholic ones. This is a problem with our health care system. What do you think could remedy this situation so that all patients are treating fairly and equally?


  1. 1.) While admittedly, Dr. Nolen did have some trouble with what was not only his first appendectomy, but really his first surgery ever, I believe that he did the correct thing in simply doing everything he could on his own. While it could be argued that, unlike other smaller tasks where he has received what amounted to permission from his teachers to carry out on his own, this major surgery doesn't seem to have been approved by any higher-up who thought he was ready, the entire purpose of the internship program is for students fresh out of medical school to be transformed, bit by bit into doctors. A lot of that transformation, as Nolen notes in his day-to-day experience, is simply, well, experience. Hands-on learning is necessary before anyone goes out doctoring on their own, and Nolen would eventually need to perform an appendectomy on his own. It makes sense that he should do the best he can with the knowledge and nerves he currently possesses, and learn from whatever mistakes he makes. And of course, Dr. Walters was there to make sure that the mistakes he made would not be too horrible.

    2.) It is a sad reality in a capitalist system such as ours that people with money get preferential treatment over people without. That's simply how our country has evolved over the years.

    There are numerous possible solutions, among them a medical fee structured in the same way as income tax, or complete anonymity for patients, but it is a certainty that each suggested solution will come with its own complications and its own problems. It is my opinion that there is no workable solution, that any solution that purports to solve the entire problem of socioeconomic class in health care would either cause some other rather glaring problems or be so hopelessly byzantine in its attempted prevention of any problems that the only people who would understand it would be lawyers and not the dedicated doctors who had to labor under it, which would of course be a problem in and of itself.

    The best solution so far, one that many doctors try to use now, is most simply a need-based system, a prioritizing method that is the most intuitive. The people who need the most medical help, should get the most medical help. This is in accordance with the Hippocratic oath. Of course, things like lawyers combined with angry people with too much time, too much money, and too large a view of their own self-worth complicate even this relatively simplistic idea with things like malpractice cases brought against these hardworking physicians by both aforementioned lawyers and aforementioned persons with too much time on their hands and a bull-headed objection to being ignored for people who more desperately need medical attention.

    This specific problem, of course, could be solved with an addition to the Hippocratic Oath wherein all physicians swear to administer an extremely painful poison to any lawyers they happen upon, but that solution has its own problems.

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  3. The question on hand this week is one of the human capacity to learn from error, and to understand the answer one must trace the evolution of the human race. When the homosapien species evolved into the modern homosapiensapien species so many years ago, the species not only changed physically but also mentally. It gained the two aspects that have always set humans apart from the other animals on God's earth: a newly developed self-conscience and a blossoming imagination. In order to hone and perfect these acquired evolutionary benefits, the early humans used trial and error processes, and often these processes led to the untimely death of the experimenter or the object of experimentation.
    At this crude stage humans did not worry about the consequences of their actions as long as their experiment yielded a fruitful result.

    But as the mini epochs that have defined our temporal existence passed, humans realized that losing a life during the study and practice of medicine was not a decency but a corruption of the imagination that had helped their race survive and evolve. By the time of the renaissance many physicians had begun preaching the new medical code: keep patients alive.

    Surely with the might of modern medicine against him, Dr. Nolen made a poor decision to handle the appendectomy without the assistance of the Attending Physician, a well trained professional who could have corrected Nolen's mistakes without tampering with the learning process. But the ignorance cultivated in Nolen prevented him from seeing that he was not only defying the wisdom of the modern medicinal age but also suffering from the plight of the male gender: arrogance and self pride.

    He should have asked for help, but he was unable to.

  4. The second question's dilema lies directly in the question itself. The prompt states, "Dr. Nolen describes treating wealthy patients differently than poor, indigent, alcoholic ones. This is a problem with our health care system." The second statement is simply untrue. One must only look at the world's history to understand this flaw.

    Centuries of political turmoil and strife have proved that the economic system of capitalism is the most durable, efficient, and beneficial system employed in the world. Capitalism has always been quickest way to a country's success; even Soviet Russia reverted to capitalism after World War II in order to stabilize its economy enough to make the social and economic shift to communism.

    The power of capitalism resides in its main ideal: the free market. The market can create a stable economy in any place and has helped men from the most humble backgrounds rise to fame and fortune. In no other system could a poor Huguenot such as John D. Rockefeller rise to the elite society of America.

    But as with any economic system, capitalism has its flaws. For any wealthy man, there must be many poor men to keep that man wealthy and powerful. But such is the sacrifice a country must make to maintain stability and civility. Although there is different treatment for those with more money, the beauty of capitalism is that there is any treatment for the poor. Capitalism provides for everyone the quality they can pay for and nothing more. It is what makes our system the most advanced on the planet, and even though socialist countries such as Denmark and Cuba have nationalized healthcare, their private practices will never even begin to match the medical powerhouses available to all in America who are willing to work their hardest.

  5. I agree with Mitchell's idea that a doctor cannot progress in his career without hands-on learning and doing surgery on his own. As Dr. Nolen notes in his book, real learning takes place when a doctor is able to finally do surgery solo without the help of another senior doctor. This situation is similar to a kid learning how to swim in a pool; they cannot obviously have an instructor holding them all the time, so at one time the kid must swim on their own to finally come full circle. How can a doctor become a real doctor if he must always have his senior doctor on his hip? There's a severe learning curve, especially in medicine, if the learning process is to be successful, and Dr. Nolen made the right decision by attempting to undergo the appendectomy himself and learning from this mistakes he made in this surgery.

    There has been a lot of talk over the American health care system and the lead weight it has become to the American economy. Unfortunately, as Jacob noted, in this capitalist economy, the wealthy are allowed to be treated first because they have money, and the poor are left behind, further tarnishing the reputation of the once-proud American health care system. However, there seems to be no solution to the problem that Americans face today in health care. Any future solutions seem to be quite futile in our eyes today, especially universal health care. The problem with universal health care is that we spend out hard-earned money on bums on the street who do not contribute to society, and just reap the benefits of the generous social systems riddling the American health care system. Instead, as Mitchell notes, the best system we can use today to ensure equality for all is the first come, first serve basis. It has worked for over centuries and it is an effective strategy to employ in our current health care system.

  6. A Post about other people's comments

    I thought both of the guys who posted made good points but I was wondering what you you think about the healthcare bill passed recently? As we all know it's been received criticism from the right and praise from the left. What does everyone think? Will the bill help the anyone in the Bellevue hospital? And if so, who?

  7. Dr. Nolen should not have asked for help on the surgery. I completely agree with Mitchell’s statement about how he needs to learn how to perform the surgery and that Dr. Walters was there to make sure Nolen did not kill the patient. While the patient may have had to stay in the hospital for a few more days, now Nolen has learned enough to not make the same mistakes he made before and because of this, eventually he will be able to watch over an intern’s first surgery and the cycle will continue. As Jacob mentioned, his arrogance and self-pride may have not made his want to ask for help when he was clearly struggling, but looking back, I felt that Nolen was glad he wasn’t helped and even said that he was glad Walters had been so patient with him because otherwise he wouldn’t have been able to learn as much.

    I don’t really think there is a true way to remedy the difference in how the rich and poor are treated. I agree with Mitchell in that working on a need-based system is one that is great in theory, but does not always work. There will always be issues and people who are unhappy with the situation and I don’t think that there really is a way we can fix this issue.

  8. There are two sides to the question of whether Dr. Nolen should have requested more assistance or asked more questions during the operation: 1. Doctors need to learn from hands on experience. If a doctor never seems what an organ looks like in a living breathing human being, they will never be able to sufficiently help people who are in medical need. This also means that, like the rest of us, they need to learn from their mistakes. If they had asked for help, then perhaps they would get the correct answer, but it would stick more and perhaps be better in the long run to screw up now and learn the lessons to be learned. 2. However, the downside is, you are messing with a living breathing human being, and besides the legal issues, there are plenty of moral questions about using a human being as a learning curve.

    Wow, this is a question that very much applies to our lives. The American medical system is obviously not as fare as it should be. People with more money get better care because they can pay for it. A brutal capitalist or social darwinist would argue that this makes sense because the wealthiest are the fittest, and thus deserve the best care. However, that is not a realistic view of the world. Most people aren't wealthy, and people are much more compassionate than we often think they are. While a singular sweeping solution to this question is almost impossible to come up with, I believe that a government provided health care option is the most fare solution to the lopsided nature of healthcare. It is the government's job to guarantee our basic human rights, and one of those is to a healthy and happy existence.

  9. Well, I kind of addressed these two questions in my earlier response (see the responses for the first question about chapter 1), but I find what Patrick is saying (about question 1) to be both relevant and interesting (and true). I feel that it is extremely important for a surgeon in training (or any doctor for that matter) to have hands-on experience, and to actually really know what is going on within the body. As we learned from Dr. Nolen's experiences, textbooks and practice (practice that is not actually done on a human body) can only go so far. One needs to truly experience the human body for his or herself, and become truly intimately acquainted with it in order to become a successful surgeon or doctor. However, as Patrick astutely pointed out, "practicing" on a human body poses a huge moral issue. I know that if I were having surgery, I would not want to be told that someone was "practicing" on me. I would surely want a seasoned veteran doing the operation. So, I basically think that was has been said is correct; the amount of help that Dr. Nolen received was perfect in order for him to both grow as a surgeon and not kill a patient.

    And, in response to what has been said about the second question, I really completely agree with pretty much everything mentioned. As Taro mentioned, the problem with universal healthcare is that some of us work really hard to earn the money we do, and yet we will end up paying for "bums on the street" (as Taro put it) who might have never worked a day in their lives, or even tried to improve their own conditions. However, even this is too harsh. As we all know, there are plenty of wonderful people out there (aka not bums on the street) who have done nothing wrong and simply cannot afford to pay for healthcare. Widows with multiple children, people who lost their jobs and simply cannot find work, etc. All these people want and need healthcare for themselves and their families, but cannot afford it. Therein lies the problem we have all been talking about. Plus, as Jacob mentioned, yes, there is universal healthcare in other countries, but the level of care in those places cannot remotely compare to the level of care in the US. Now, I know I am quite conservative and therefore quite biased, but my aunt, who works at MD Anderson (one of the top medical institutes in the country), has treated dozens of patients who left countries with universal healthcare to come to the US specifically for treatment. In fact, one woman (about whom my aunt talk on television about six months ago) was told that she was certainly going to die within weeks. She came to MD Anderson from Canada (which has universal healthcare) and my aunt cured her within months. She is still alive today, and this occurred six years ago. Situations like these really complicate the situation. However, I believe that if a truly perfect solution to this problem exists, it would have been presented by now. And, I think until then, our system is the best possible option.

  10. Daniel said...

    1. In my blunt opinion (and i guess you could say experience), the best way for people to learn is by doing. And often times, being thrust into situations that are somewhat out of one's comfort zone and making mistakes is a big part of that doing. It's written in our human genetic code. We have evolved and developed the ability to
    observe the certain outcomes of situations and come to rational conclusions based on those outcomes. We have evolved the ability to
    learn from our experiences more quickly than any other species, which is why learning by doing is such a valuable approach for our species.
    Furthermore, in a place like Bellevue, there aren't too many ways to gain experience without allowing one's self to be thrust into situations that are all too real in which one has no safety net. Otherwise, a young surgeon will never learn to do things on his or her own. Consequently, (in my humble opinion) Nolen is by no means
    to blame for taking advantage of this opportunity to gain experience as a surgeon by using his innate ability to "learn by doing" (and I
    cite this quote because it is a fitting phrase that was the mantra of one of my favorite TV surgeons in a similar situation (Turk from Scrubs, pilot episode- check it out yo)).

    2. Being an ultra-left-wing-pinko-commie-elitist-liberal-freedom-hating-Russia-loving advocate of communism, i would suggest a completely socialized heath care program like France or Switzerland (i think i got those countries right). These systems run off of high taxes and widespread government regulations, but allow anyone to get any type of medical service for free. There are a number of benefits to this type of system. First of all, with such a well financed and organized medical system there would be no competition for resources like supplies, time, or even doctors and there would be no need to favor those who can pay or even make donations over those who can't. Similarly, when you have everyone paying the same amount for the same
    services, any distinctions between patients become completely negated for the doctors, forcing them to see all patients in exactly the same way. Such a change to the system would eliminate all the unfairness created by the current system.

  11. The book raises many interesting questions about morality and the purpose of learning. The pursuit of knowledge has always been a core tenet of academia, but Dr. Nolan should not risk his patient's life in order to learn how to do an operation. The Hippocratic oath says "Do no harm", yet Dr. Nolan put his patients life in danger by not asking the attending physician. He placed the patient directly in harm's way. Surgery is not a time to "learn on the job". If I were going into surgery I would expect my surgeon to be qualified and not to make 'educated guesses' but ask a more knowledgeable person if they had any questions. Dr. Nolan sacrificed his patient's rights on the alter of academia.

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  13. I really liked the question that Jacob posed (april 14th, 8:30 pm) and would like those of you have not yet posted to address it as well.

  14. 1. I believe Dr. Nolen in the long run benefited more from not asking for help with the appendectomy. He probably SHOULD have asked for help, but because he did not, he gained both a sense of humility and a message branded into his memory never to go in blind to a surgery ever again.

    It's not as if Dr. Nolen was performing his first spinal tap or lobotomy on a patient. As far as dangerous surgeries go, appendectomies lie on the lower end of the spectrum, and the patient had to have assumed the risk of an unorthodox surgery when coming to a hospital as under-equipped as Bellevue. That said, the man suffered from Nolen's mistakes. Eli's point about the Hippocratic Oath is completely right, and I think that Dr. Nolen must have realized that after the surgery. Trying the surgery unaided was a partial violation of the oath. However, it is just like being let off with a warning from a speeding ticket on the freeway; you're not too scared or paranoid to keep driving, yet you immediately start watching the speedometer and keeping your car comfortably at or below the speed limit. So, although Nolen was wrong in the short-term to operate unaided on the man, it benefited him in the long term.

    2. As I see it, there are two main problems with how hospitals treat the poor vs. how they treat the rich. Firstly, richer patients expect as quick a treatment as possible, while poorer patients may end up wanting to stay at a hospital for the food and shelter, such as the man who undid his stitches the day before he was supposed to leave. And, because the rich people are treated first much of the time (like the businessman in the book), the poor are left in the waiting room to spend an even longer time at the hospital, preventing more people truly in need of treatment from getting an appointment with the doctor. Like it or not, I believe the solution is to have rich people wait their turns. Short of emergencies and critical cases, the rich have no need to be treated faster than anyone else, especially since they want to leave as soon as possible. Therefore, everyone should be treated on a first come, first serve basis, or at least close to it.

    The other problem applies more to the type of alcoholic or drug addict type of poor that come to Bellevue Hospital in the book. Because they receive a far less nutritional diet, those types of patients don't heal properly and require longer recovery time and more treatment in the hospital. So, this problem is one I think our new healthcare system can address. I think vitamin supplements and nutritional consultation should be mandatory with any physical checkup, especially if checked into a hospital. Any steps that can be taken to create a healthier America should be taken at the most opportune time. On another note, fast food chains like McDonalds and Burger King should be legally mandated to have minimum vitamin and mineral supplements in their food, as well as an overhaul of health policy.

  15. Sasha said...

    1)I think that doctors need to learn by doing, but I wish there was some sort of release form that would allow you the choice between an experienced doctor and on that is new. This would be difficult at a poorer hospital, and clearly some medical help is better than none at all, but I think people who pay for their hospital care should have a right to an experienced doctor. Although then it would be much harder for residents to practice. This is a complex issue and I don't have a definitive opinion on it.
    2)I am opposed to preferential treatment, but I also take issue with some of the assertions about health care other people have made. While I do love my conservative friend Brett, I have to completely disagree with him about our health care system. In the last WHO international health care survey, France, a country with socialized health care was rated first in the world, while the United States, sandwiched between Costa Rica and Slovenia was ranked 37th. I think our assumption that we have some sort of superior system stems from our nation's large amount of money and our perception of America as the world power. We are definitely the world's richest country in terms of GDP, if not per capita. So it isn't a surprise that we have better doctors than, say, Cuba or Denmark, not because we have some superior work ethic originating in our use of capitalism, but because we actually have more money. Smaller, poorer countries have fewer resources to devote to hifalutin medical schools, hospitals and supplies, not to mention pharmaceutical research and cutting-edge surgical techniques. By claiming that our country has better doctors just because we work harder, we become just like that wealthy man in the waiting room looking down on others and thinking that we got where we are today on our own.
    3) On a last note, I would just like to say that Matt Rosenthal's plan to demand that “Any steps that can be taken to create a healthier America should be taken at the most opportune time” worries me a little. I mean maybe I've seen too many sci-fi movies, but isn't it always the “fluoride in the water” that the government benignly tries to save us with that turns us all into radioactive wolves? Just saying.

  16. Karli said...

    1) While I agree with Mitchell about how "mistakes allow one to learn", I can't help but think that these are not harmless mistakes that Nolan makes. Sure, they are necessary, but they aren't the kind of mistakes one makes on one's homework or on one's test. These very mistakes endanger the patient's life, something that should not be taken lightly whatsoever. Sure, to Nolan, these mistakes definitely allow him to grow, but at the possibly great expense of someone else.
    Nolan's cockiness could (and practically did) have had drastic results- yet, as Jacob says, this cockiness didn't allow him to ask for help, as should have been necessary.

    2) As Mitchell said, the way our health care system has developed allows those with money to threaten the workers, thus allowing themselves the best treatment. Many doctors, however, are not not pleased with this system- yet their jobs lie on the line. There is nothing we can do to fix the system, unless we go into a "free health care for everyone!" system, as Canada currently has. Then everyone would get the treatments as needed. This is extremely expensive however, and all the Republicans currently in our government would absolutely refuse to allow such blasphemy, especially with the debt as it is now.

  17. In response to the first question, I understand why Dr. Nolen did not ask for more help, he was completely confident going into the surgery and was therefore hoping that his confidence would return. This is a perfect example of how much difference there is between field work and work in a classroom. Prior to the procedure he'd only read about performing this surgery and watched other people do it. Of course had Dr. Nolen not attempted the surgery as he did he would have the made the same mistake further into his career. I believe that he would have asked more questions were he not paying so much attention to showing that he knew he was doing when he didn't. In a situation like this I think it would have been better if he'd put aside his seeking approval and paid more attention to ensuring a successful surgery by asking a few more questions here and there.

    In response to the second question, Healthcare is an issue that is under constant debate. The ability or inability to afford extensive healthcare is a defining factor in whether or not the person gets treated successfully. All people, rich or poor come in to times where they need medical attention, the fact that the rich get treated more efficiently most of the time is unfair to those who cannot afford it and therefore do not receive treatment. It is not right that a person should die due to their lack of ability to afford efficient healthcare. There are many solutions to this problem, all of which will have repercussions. One possible solution is the institution of universal healthcare. Healthcare that is free to everyone. This sounds wonderful in theory but could be met with upset feelings from both sides. The rich would realize that their tax dollars were going towards the treatment of someone who may not pay taxes. This realization would cause an immense amount of hard feelings and protest. The poor however may not use the healthcare that is available to them because they are not used to it, and do not want to admit themselves into the hospital. Honestly there are so many things that could go wrong with any attempted solution but this cannot be dwelled upon if progress is ever to be accomplished.

  18. 1) Of course he should have asked for help. One could technically argue that people need to figure things out for themselves but simply assisting someone with an operation does not mean that the person being helped learns nothing from the experience. By seeking help from the Attending Physician, Dr. Nolen would still learn a valuable lesson from the surgery. Just because it was not ingrained into his brain because of a traumatic event or because he would been scared by the consequences of a failure does not mean that he still will not understand the concept. Yes, experiencing the surgery first-hand is essential to one's knowledge and capability to perform that surgery in the future. However, why can't this first experience be guided and overseen by a more skilled surgeon who knows what he/she is doing?
    We also have to consider the fact that the patient that Dr. Nolen was operating on was alive and breathing. Should he make a dire mistake, there goes the life of an innocent patient. And for what? So Dr. Nolen would not screw up in the future? It seems more logical to me to guide the surgeon through the process a few times before letting them attempt a solo surgery, instead of sacrificing a patient's life or causing them serious health problems once in order to ensure that most future surgeries go better.

    2) It is an interesting problem. Sure, we could set up a system in which patients are ideally treated not on the basis of how wealthy they are but how critical their medical situation is. But that will not stop the doctors from intervening. If the problem is going to be solved, the solution will lie in changing not the system but the doctors themselves. Sadly, I can not honestly think of a way to solve this terrible dilemma. The difficulty is that we need to change human nature and that simply is not possible. In our capitalist society, people are taught from the very beginning that money is good and that the more you have, the more other people will like you and the happier you will be. We would have to somehow make people think that money is not beneficial and frankly I don't see that happening any time soon.