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January 30, 2008

Blind pigeon

A brilliant essay on caring for a blind pigeon.

Emergency medicine's body of knowledge

As you already know from my previous posts, I don't often blog about my job. If you want good blogging about emergency medicine, I suggest you read the EM folks on my blogroll. Panda Bear has been especially hilarious lately. Obviously, I disagree with Dr. Bear about politics (I hope it's not obvious exactly how) but I think he's spot on about what it's like working in emergency medicine. His posts almost always leave me nodding my head and thinking, "yeah, yeah, damn straight." Except when he writes about politics, when I usually think to myself "puh-leese." Oh, well, to each his own.

But don't confuse my silence about my job for apathy. Even though residency is kind of grueling and sometimes frankly sucks a$$, it's also pretty damned fun. The variety and (sometimes) acuity of the stuff you see is cool.

To give you a sense of how fun emergency medicine can be, check out some of the practice questions I've been using to study for an inservice exam coming up in February:

  • Infection with which of the following helminths is known to cause a fatal hyperinfection...
  • Which of the following statements regarding lightning strikes is correct?
  • A 26-year-old man with known hemophilia A presents after being hit in the head with a baseball...
  • A 23-year-old man is brought in by ambulance after falling off a roof...
  • A 68-year-old man with a history of Type 2 diabetes and hypertension presents with cellulitis of his arm following a scratch from his cat...
  • Which of the following is most likely to be a complication of placing an internal jugular central venous catheter...
  • A 24-year-old woman presents after an altercation at a night club...
  • Which of the following statements regarding lung abscess is correct?

In real life, of course, we see a lot of "patient presents at 3 a.m. complaining of a left ring finger itch for the past three months." Still, though, I say bring them on. Anyone, anywhere, anytime. Even if they're absolute nut jobs.

January 22, 2008

Re-reading Garrett Hardin in light of Wendell Berry

My dad recently reminded me of Garrett Hardin's essay "The tragedy of the commons", which I've read five times or more in school at various times.  Re-reading it now, it struck me how central the idea of responsibility is to that essay.

The central problem for Hardin, of course, is that people acting in their own self-interest will overuse things that are held in common.  When common goods are in limited supply and precious to us, we are all harmed by laissez-faire.  The reason free agents often pollute our water and despoil our public land is that they reap the
benefits of its use, but avoid responsibility for its destruction.  It's the exact opposite of the invisible hand of the market making everyone better off.

For Hardin, the problem of the tragedy of the commons is how we can
make ourselves take responsibility for the damage we do.  Hardin thinks there are several solutions to this problem.  Often
people I talk with misunderstand "The tragedy of the commons" to be an
argument for privatization, pure and simple.  But privatization
is only useful for Hardin to the extent that it can internalize
negative externalities, to use some commonplace economic jargon.  Reading the essay again, it's clear that he doesn't think privatization is any sort of panacea -- it can be unjust and it's often not effective.

Hardin's essay is mostly an argument for strong regulation --
what he calls "mutual coercion." This can take the form of prohibition (thou shalt not rob banks, and you will be imprisoned if you do), or of taxation (if you want to park downtown you have to feed the meter or pay large parking fines).  Since Hardin thought overpopulation was despoiling the natural commons, his essay is an argument for the regulation of reproduction: "[t]he only way we can preserve and nurture other and more precious freedoms is by relinquishing the freedom to breed. . . ."  Trying to persuade people to take responsibility was a losing proposition for Hardin.

All of this is interesting to me because a) I'm thinking a lot about the kind of agrarianism sketched out by Wendell Berry, and tend to think that it's pretty much the way to go, and because b) agrarianism of this kind is distinguished by the importance that it places on the idea of responsibility.  Why does Berry argue for localism as against globalism?  Because he thinks that when the scale of our activities becomes too large, we cannot even be aware of the effects of what we choose to do.  Therefore, we cannot possibly take responsibility for them.

The tragedy of the commons, in fact, would seem less likely when the commons in question is on a small scale.  When a common pasture is small, the rancher turning loose his extra sheep is confronted in the face with the destruction those excess animals cause.  A small park is where it's most likely that the woman who lets her doggie run free every morning is more likely to notice that her dog is leaving piles of greasy shit all over the grass, making her more likely to internalize that negative externality by cleaning up after Fido.

"The tragedy of the commons" is a scary essay.  Everything Hardin says seems to make sense, but it leads to a conclusion that's hard to accept -- few of us would welcome a forced restriction on our ability to "breed."  Thinking about Berry's arguments for limiting the scale of our activities might allow us take the best parts from Hardin's essay while rejecting the dystopian, bureaucratic, scary-as-hell vision of comrades searching our homes for illegal babies.

Anyway, these are things that I'll have time to think about more later.  I'm working a ton of shifts in the peds ER this month, and tomorrow at 7am I've got to go back to work.  Comments are, as always, appreciated.

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January 18, 2008

Best agrarian blogs

Dry Creek Chronicles, by Rick Saenz, has consistently been the best agrarian blog out there.  I don't mean to endorse all of Saenz' opinions, but I do mean to say that post for post, his blog describes the agrarian viewpoint and wrestles with its consequences better than any other blog I'm aware of.

This post, for example, exemplifies Saenz's provocative application of agrarian thinking to various kinds of dogma -- in this case laissez-faire economics.  The back-and-forth between Saenz and his commenters is enlightening.  Better yet, it's worth your time to read if you're at all interested in agrarianism.

Running a close second to Saenz is Rod Dreher, whose CrunchyCon blog has an urban and modern tone with posts that usually address events of the day rather than philosophical principles per se.  However, Dreher is usually not bound by the standard liberal/conservative dogma, and his take on current affairs is usually a very agrarianesque one.  E.g., this post about the looming recession and the wisdom of spending our way out of it.

I don't mean to endorse all of Dreher's opinions either (both Saenz and Dreher are far more religious than I am), but I read their blogs almost daily and highly recommend both of them.  Especially if you're interested in agrarianism.

P.S.  "Agrarianesque" is such a beautiful word, no?

January 15, 2008

Cloned cow and dead wolf

Two interesting items from Goat, the blog of the wonderful magazine High Country News:

Thanks to a Food and Drug Administration decision made this morning, you might soon be able to order a McClonewich at the drive-through or spread a smear of low-fat clone cheese on your morning bagel.
Sound yummy? Maybe not so much, once you realize you won't even know whether what you're eating came from cloned animals or not. The FDA has also decided not to require any labeling of "meat and milk from clones of cattle, swine, and goats, and the offspring of clones from any species traditionally consumed as food. . . ."

This decision exemplifies the "industrial" mindset that agrarians like myself loathe so much.  It blesses a novel technology that may be safe when that term is considered narrowly, but that may profoundly change the world in ways that we still do not fully understand.  It then allows this technology to enter the market without any labeling, making it practically impossible for individual citizens to take personal responsibility for the use of that technology.  After all, how can we individually exercise caution with the use of cloned animals if we don't know whether the meat we're eating is cloned or not?  Answer: we can't.  And that's just what the industrial producers of animal products are counting on.  The FDA gave them what they wanted, at our expense.

The second interesting item is this post explaining that the Department of the Interior is set to remove gray wolves in in the northern Rockies from the endangered species list.  Soon, ranchers in Idaho, Wyoming, and Montana will get to shoot the wolves without fear of punishment (not that fear of the Bush Administration's Interior Department stopped them from killing 140 of the wolves last year).

I'd be proud to be a citizen of one of those three great states:  Idaho!  Wyoming!  Montana!  Where we value "livestock" over one of the most inspiring creatures sharing our planet, the lowly gray wolf, and where our hardy livestock herders can kill these varmints at will!

Makes me want to move to Iowa, it does.

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January 14, 2008

"Small government" vs. "Big government"

Jonah Goldberg writes about the changing nature of conservatism, implicitly lamenting the rise of several conservative movements which he perceives to be "cris de coeur" against what he labels "mainstream conservatism."  It's a perceptive piece.  There does seem to be an increased reluctance on the part of many people identifying themselves as conservatives to repeat the mantra of "small government, small government" that we've heard so often since 1980.

Perhaps that's because the pernicious consequences of a government too "small" to reign in big business is now obvious to see?  That's certainly my biggest beef with both the Reaganites and the libertarians, the latter of which are at least consistent enough not to forget about limited government when it comes to military adventurism abroad.  Power vacuums will quickly be filled.  When government doesn't fill it, big business will.  That's the great Libertarian Blind Spot -- the mystifying refusal to acknowledge the threats to liberty from massive concentrations of private economic power.  Back in the Carter years we may have been suffering from a government that was "too big," but unlike Goldberg I think we've deregulated ourselves way too much, and now find ourselves with a government that's far "too small."

At any rate, the argument over the size of government is a bit absurd, because as Gary Hart used to say, no one really wants government to go away, we all just want it to give us different things.  Rod Dreher sums it up pretty well for me: "I favor a government big enough to keep big business from running over little people, but a government small enough to be defeated by little people when it tries to run over them too."  Although I'm far more liberal than Dreher, I think he's captured the absurdity of "small government" vs. "big government" rhetoric very well.  What we're all really arguing about is "good government."

January 12, 2008

What's wrong with libertarianism?

Some musings about the pros and cons of libertarianism from Michael Kinsley:

Libertarians are quick to see hidden costs of ignoring libertarian principles and slow to see such costs in adhering to them. For example, Tucker Carlson reports in the Dec. 31 New Republic that Ron Paul wants to end the federal ban on unpasteurized milk. No one should want to drink unpasteurized milk, and almost no one does. Paul himself doesn't. But it bothers him that the government tells people they cannot do something they shouldn't do.Libertarians would say that if most people want pasteurized milk, the market will supply it. Firms will emerge to certify that milk has been pasteurized. These firms will compete, keeping them honest.

So yes, a Rube Goldberg contraption of capitalism could replace a straightforward government regulation. But what if you aren't interested in turning your grocery shopping into an ideological adventure? All that is lost by letting the government take care of it is the right of a few idiots to be idiots. That right deserves respect. But not much.

Libertarians have always struck me as kind of naive -- kind of like die-hard Tolkien fans who insist on dressing like elves and wondering why, really, we don't all just fight it out with swords to solve our problems.

I'm deeply sympathetic, yes. But I still think it's a bit naive.

January 10, 2008

Law vs. Medicine, and law school vs. medical school

I've gotten several email requests over the past few weeks from people who are trying to decide whether to pursue a career in law and/or medicine, asking what the professions are like and what the training for each of them entails. Since more people with the same question may find my blog but won't want to email me directly, I thought I'd post a generic version of what I've said about the subject here.

Keep in mind, of course, that my insight is limited. Yes, I've finished both law school and medical school, and I'm now a medical resident. This gives me an interesting perspective on the training programs for both professions. But remember that I've been practicing medicine for eighteen months as a resident. I've never practiced law. My knowledge of law practice comes from my time as a summer associate with a very large firm called Sidley Austin in Chicago, and from talking with law school friends that have been practicing in various capacities and places for eighteen months.

Nevertheless, that's still some pretty unique (*smirk* to you-know-who) experience, and I'm happy to share it.

Both professions are hugely diverse, and this makes it hard to generalize about them. In my opinion this also makes both fields very interesting -- there's a million little niches in each that
suit very different kinds of people.

With the disclaimer out of the way, let's move on to the generalizations:

Medicine is literally a hands-on profession. Most docs end up pushing on stomachs and listening to various organs with a stethoscope. True whether you're an emergency doc or an internist or a surgeon. Even the pathologists and the radiologists are probing individual patients in some way (dead patients and pictures of patients respectively).

The mental work that docs do is usually diagnostic -- pattern recognition -- which sometimes doesn't feel like "thinking." They gather all the data together, recognize from past experience what kinds of data are missing and what questions haven't been asked, and then fit all those data into the patterns they've got floating around in their head. This process of diagnosis is usually instantaneous. "Ok ma'am, you've been vomiting for two days, you've had an appendectomy several years ago, you're not a diabetic, and your abdomen is diffusely tender. Badda-bing, I think you've got a bowel obstruction." Why? Because it fits the pattern.

When you're doing this, it doesn't really seem to be a mental process in the same way that writing out an argument in the social sciences or humanities does. In fact, it can seem mindless. So much so that many docs feel they need to do something else to get their intellectual kicks -- research, philosophy as a hobby, health policy, whatever.

The plus side is that you are actually helping a real person who's standing in front of you (or curled up in the fetal position in front of you). You're doing something in the real world and you see the effects of what you do.

Contrast this with law: this is a writing profession. Lawyers deal with written documents and produce written documents, almost without exception. This can mean that the effects of what you do aren't so immediate as they are in medicine. As a lawyer, you certainly have no special manual skills like most
doctors do -- you can't put a central line into some guy'sneck, you can't do any kind of surgery. The skills you have are all about documents.

Even if you're a trial lawyer that argues to a jury, you're still dealing with words, arranged in a particular way, only this time delivered orally instead of on paper. Even trial lawyers spend the majority of their time going over written depositions, writing motions to the judge, etc. And most lawyers who don't do trials work almost exclusively in writing -- corporate lawyers drafting documents for deals, appellate lawyers writing briefs, government lawyers reviewing policies.

There's a lot of room to think, in the traditional academic sense, if you're a lawyer. (Not so much as a junior associate, but as you get more experienced.) You can strategize, persuade, marshal evidence, and all the other stuff that lawyers are famous for doing. It's not as free-wheeling as arguing with your friends about Barack Obama's health plan, but hey -- it's still an intellectual and creative kind of brain work.

The downside, in my opinion, is that the effects of what you do are often much more difficult to discern in law than they are in medicine. You slave away on a motion for weeks, and then the judge denies it. Or, worse, the motion is granted, but then your client settles. You have to use your imagination sometimes to believe that what you did had some direct effect on the world. True, in medicine the patient may still end up dead, but in general you'll see the effects of what you do in medicine more than you will in law.

If you hate being in a cubicle, realize that most of the really well-paid lawyers do
just that -- sit in a cubicle. Lawyers who like to be on their feet are usually prosecuting or defending small-time crime, or (occasionally) they make a name for themselves and work on the big stuff. But this is only one small niche within the legal profession. Most lawyers are desk-driving wordsmiths.

Then there are other factors. In my own biased opinion based on limited experience:

Lawyers are much better conversationalists than doctors.
Doctors can't write worth a damn, and they're less curious.
Most people in both professions are risk averse.
Lawyers are much more money and status conscious than doctors.
But the doctors who are money-conscious are insufferable.

One other thing I should mention: the road to getting a medical license is a long one. That shouldn't stop you if you want to do it, but you've got to be prepared for the long haul, and you have to enjoy the journey.

Speaking of school: in medicine, the trick is to get into *any* American medical school. There are relatively few of them, and they all have high admission standards. Law school is different. The trick for law school is to get into a *good* law school. There are a million law schools, and for most of them, all you need to do to get in is have a pulse and be able to sign for student loans.

What this means is that in medicine, so long as you get in, it doesn't matter where you go to med school. Sure, Hopkins would be nice, but if you don't like Baltimore you can go to your state med school and do just as well. In law, if you don't go to a good law school, you'll find your employment prospects limited when you graduate. Don't let the schools tell you any different: shoot for the best law school you can get into.

For a list of good law schools, see Brian Leiter's rankings. There are other rank lists out there and these rankings are absurd, but I've said a lot about that already and won't repeat myself here. These list just give you an idea of which schools will give you the most options as a graduate.

Remember, too, that you might want to consider why you want to enter either profession. The word on the street is that both lawyers and doctors don't have as much prestige as they used to. Practitioners of both professions are, more and more, becoming highly-paid employees, and there's nothing very highbrow about that. So if prestige is what you're after, think twice. Think about starting your own business, or becoming an artist. There's many more than two ways to skin a cat.

January 08, 2008

To my friends in New Hampshire

To each and every one of my political soul mates who live in New Hampshire, please, please, please go out and vote today.

Barack Obama won a great victory in Iowa, and he's been getting a lot of good press.  But none of that may matter if you don't lace up your boots and go vote.