Romance killers

Are your drugs turning you into a vampire?

According to this, they may. If you're into doxycycline, that is.

What a way to take out the romance of the supernatural creatures. Just when you thought that you've Turned into a creature of the night, languishing for the sun and all you have is an adverse drug reaction?

Sheesh.

How to live with a hole in your soul (or torso)

Ganked in its entirety from Medscape. But it is sooooo fun and gruesome and the not-so-little geek in me just wanted to have a show and tell.

From Medscape General Surgery > Historical Perspectives in Surgery

The Case of the Wounded Woodsman and His Dedicated Physician

Albert B. Lowenfels, MD

Published: 09/02/2009

The Case

The patient was a 28-year-old, healthy itinerant laborer who was accidentally shot at close range by a companion. The shell entered the left anterolateral side of his body a few inches below the left nipple. The patient fell to the ground but remained conscious. A physician who examined the patient shortly after the accident noted a large wound of entry about the size of a man's hand, but no wound of exit. The left lung protruded through the opening along with a portion of the stomach, with an opening caused by the bullet. Several adjacent ribs had been fractured. Food from a recent meal was present in the wound.

In describing the patient's injury, his physician wrote: "I considered any attempt to save his life entirely useless." Nevertheless, his physician debrided the wound, replaced the protruding stomach and lung, and applied a protective dressing. On the following day, the patient developed fever, a cough, and had evidence of pneumonia. For the next week, the patient continued to be febrile; the wound became infected; and the patient was fed rectally.

To the physician's surprise, over the next several weeks the patient's condition gradually improved, although the gastric wound never completely closed. Nevertheless, he could tolerate oral feedings if the gastric opening was occluded with a compressive dressing. Over the next year, the patient's strength gradually returned to normal, but the gastric wound refused to close. The physician made an arrangement with the patient to follow him more closely and to study his gastric physiology; these studies continued intermittently over the course of many years.

Who was the patient?

Daniel Boone

Kit Carson

Alexis St. Martin

Paul Bunyon

Who was the physician?

William Osler

William Beaumont

Harvey Cushing

William Wells

Brief History of the Physician and His Patient

William Beaumont (1785-1853) was born into a farming family and grew up in Connecticut, where he remained until his early 20s when he joined his brother in Upstate New York.^[1] There, he taught school for several years, before deciding at the age of 25 to study medicine. Although it was possible in the early 19th century to practice medicine without any formal training, Beaumont became an apprentice to Dr. Benjamin Chandler, a prominent Vermont physician. This apprenticeship lasted for 1 year, covered both medicine and surgery, and led to certification by the Vermont Medical Society. His training never included any formal background in physiology, and it is unlikely that Beaumont was aware of the available rudimentary knowledge of gastrointestinal physiology.

Figure 1. Portrait of William Beaumont, frontier doctor and scientist.
From Gillett MC. Early campaigns in the North, 1812 to 1813. In: Matloff M, ed. The Army Medical Department 1775-1818. Army Historical Series. Available at: http://history.amedd.army.mil/booksdocs/rev/gillett1 Accessed August 26, 2009

In 1812, a few months after receiving his certification, Beaumont enlisted in the US Army, and then actively engaged in war with the British Empire. Eventually, after the conclusion of the War of 1812, Beaumont was posted to Fort Mackinac, an important trading post located on a small, remote island between Lake Huron and Lake Michigan.

By good fortune, Beaumont was at the Fort on June 6, 1822, when Alexis St. Martin, a French-Canadian employee of the American Fur Company, was accidentally shot in the left chest. Beaumont had received some surgical training during his apprenticeship and additional experience while caring for injured soldiers during the War of 1812. Without Beaumont's presence, it is unlikely that St. Martin would have survived such a serious injury.

St. Martin came from a background that was very different from Beaumont's. According to his birth certificate, St. Martin was born in 1794, in the small Canadian village of Berthier. His family, who originated from Bayonne, France, was poor, and St. Martin grew up to be an illiterate trapper. He earned his living as a fur trader and voyageur (a porter and large cargo canoe man) in the region between what is now Michigan and Canada. When he was wounded, St. Martin was 28 years old and unmarried.

When St. Martin was sufficiently recovered, he signed a contract with Beaumont, who offered him employment as a handyman in return for a stipend, food, and permission to carry out experiments on St. Martin's stomach. To facilitate the research, and to ease the financial burden on the physician, the US Army made St. Martin a sergeant, paying him a small salary.

About a year after St. Martin's injury, when Beaumont realized that the gastric wound was unlikely to close, he began detailed studies of the process of digestion within St. Martin's stomach. These experiments, conducted with the often reluctant St. Martin, continued intermittently over the course of about a decade. St. Martin agreed to travel to Europe to be examined and studied by leading physicians, including Claude Bernard, but he changed his mind before embarking on the voyage. He never did go to Europe, but he did exhibit his fistula at several American medical schools.

Despite Beaumont's efforts, the wound never completely healed; nevertheless, St. Martin was able to resume a nearly normal life if he plugged up the gastric opening with a piece of cloth. Eventually St. Martin married and had several children. He was always poor, however, and frequently drunk. His health, despite the fistula, was sufficiently robust so that he could support his family by hard labor, such as chopping wood.

Regardless of his persistent gastric fistula and his heavy consumption of alcohol, St. Martin lived to be 86 years old; even now this is well above the normal life span for white men in North America. As for Beaumont, after completing his army service, he settled in St. Louis, Missouri, where he practiced medicine until he died in 1853 from a head injury after falling on an icy path. St. Martin outlived his physician by several decades.

Prior to St. Martin's death, prominent physicians, including William Osler, had tried without success to persuade the family and the patient to agree to an autopsy.^[2] Osler was particularly anxious to examine St. Martin's famous stomach and to have it preserved in the US Army Museum. However, the family was vehemently opposed to any further contacts with the medical profession. To ensure that his body would not be disturbed, the family buried St. Martin in an unmarked deep grave. Only in 1962, more than 80 years after his death, did the Canadian Physiological Society place a marker at the approximate grave site.

What Beaumont Added to the Knowledge of Gastric Physiology

Before Beaumont's long-term observation of St. Martin's progress, other patients had sustained gastric wounds and lived with a gastric fistula, but none had been studied in a scientific fashion.^[3] Toward the end of the 18th century, the Italian Lazaro Spallanzini conducted a series of experiments and concluded that the stomach contained an active principle and that digestion was more than a simple mechanical process. In 1803, Jacob Helm, a Viennese physician, studied a middle-aged woman with a gastric fistula, noting the ability of the gastric juice to act upon stomach content. Just prior to Beaumont's first publication, an English chemist, William Prout, noted that the stomach secreted hydrochloric acid.^[4] It is unlikely that Beaumont knew about any of this work on the stomach: His observations are unique.

Without any formal training in physiology, gastroenterology, or any branch of science, Beaumont recognized a unique opportunity, and over the course of several years he performed numerous experiments that led to a solid foundation for gastric physiology. The astonishing aspect of Beaumont's research is that under difficult circumstances he took advantage of a rare chance to study digestion by visualizing the interior of the stomach and obtaining samples of gastric juice from a living subject under various circumstances. Moreover, he took careful, detailed notes.

Beaumont performed a series of 3 experiments on St. Martin at geographic locations separated by thousands of miles.

Figure 2. Map listing locations and dates for major events in the lives of St. Martin and Beaumont.

The experiments were carried out under less than ideal circumstances on a patient who was not always cooperative. Today, it would be difficult to obtain approval to perform a similar series of experiments. Beaumont describes his first experiment as follows^[5]:

EXPERIMENT 1. August 1. 1825 -- At 12 o'clock, A.M., I introduced through the perforation, into the stomach, the following articles of diet, suspended by a silk string, and fastened at proper distances, so as to pass in without pain -- viz.: -- a piece of high seasoned la mode beef, a piece of raw salted fat pork, a piece of raw salted lean beef, a piece of boiled salted beef, a piece of [unclear] bread, and a bunch of raw sliced cabbage; each piece weighing about two drachms, the lad continuing his usual employment about the house. At 1 o'clock, PM, withdrew and examined them -- found the cabbage and bread about half digested; the pieces of meat unchanged. Returned them into the stomach. At 2 o'clock, PM withdrew them again -- found the cabbage, bread, pork, and boiled beef, all cleanly digested,* and gone from the string...The lad complaining of considerable distress and uneasiness at the stomach, general debility and lassitude, with some pain in his head, I withdrew the string, and found the remaining portions of aliment nearly in the same condition as when last examined; the fluid more rancid and sharp...I did not return them any more.

*These experiments are inserted here, as they were originally taken down in my note-book....

Beaumont published his early results in January 1825, after his first series of experiments and about 3.5 years after St. Martin's injury.

His major contributions to our knowledge of the digestive process included:

• Studies of gastric motility;
• Studies of gastric acidity (recognition of the importance of hydrochloric acid);
• An important role for neurogenic influences on digestion, which eventually led to vagotomy as a treatment for peptic ulcer disease; and
• A suspicion that something other than acid accounted for the stomach's ability to digest food.

Of note, this last substance turned out to be pepsin, which was eventually identified by Theodore Schwan in 1836, shortly after Beaumont concluded his third series of experiments.

How Would the Patient's Wound Be Treated Today?

St. Martin sustained the full force of a shotgun blast fired accidentally at close range, resulting in a complex wound involving the left lung, the stomach, and the diaphragm. Beaumont describes a "fist-sized" hole (approximately 9 x 9 cm) in the left lateral chest wall. St. Martin apparently remained hemodynamically stable after his injury, although the sphygmomanometer wasn't invented for several more decades -- so there were no blood pressure measurements.

Figure 3. Beaumont's sketch of St. Martin's wound about 4-6 weeks after the injury.
From Beaumont W.⁵

Even today, this injury would present a significant challenge to a surgeon.^[6,7] However, long-term results following current surgical repair of severe chest wall injuries are excellent, with patient status being similar to the general population.^[8] Current management would include the following:

• Careful physical examination supplemented by imaging studies to determine the extent of injury.
• If there were a pneumothorax or respiratory compromise following this chest wound, ventilatory support would be provided via an endotracheal tube until the patient was ready for surgery. (Note: there was no mention of shortness of breath from a pneumothorax in St. Martin's case.)
• Exploration via a left thoracoabdominal incision.
• Careful exploration to ensure that no other organs, such as the pancreas or the spleen, had been injured.
• Debridement and cleansing of the original wound to remove shattered rib fragments, necrotic lung tissue, imbedded clothing, fragments of the shell, and food particles.
• Blood transfusion, rather than bloodletting, as was done for St. Martin.
• Closure of the gastric wound and the diaphragmatic tear.
• Repair of the chest wall defect. This would probably require application of a synthetic mesh covered by a muscle flap. If necessary, the repair in the chest wall could be closed with a split-thickness skin graft.

Summary

By a fortunate coincidence, William Beaumont -- a young, resourceful, relatively inexperienced US Army surgeon -- happened to be stationed in a remote fort on the western frontier of the United States when Alexis St. Martin, a French-Canadian voyager, received a near-fatal gunshot wound of the chest. St. Martin survived, but was left with a permanent gastric fistula, permitting Beaumont to perform a series of unique experiments that greatly expanded our knowledge of gastric physiology.

Traditionally, St. Martin's physician has received full recognition for the brilliant series of experiments carried out under primitive conditions. However, St. Martin also should be credited for participating in tedious, repetitive experiments that must have been disagreeable and sometimes painful.^[9] Although not always cooperative, he should be remembered as being perhaps the first of that special group of human "guinea pigs" who have done so much to advance the progress of medicine. Two centuries later, physicians and patients remain indebted to Beaumont and Alexis St. Martin -- Beaumont's often reluctant patient.

Additional Reading

• Green AH. The Market Cultures of William Beaumont: Ethics, Science and Medicine in Antebellum America, 1820-1865 [doctoral thesis]. Baltimore: The Johns Hopkins University; 2007. AAT 3262421.

Internet Sources

• Helms R. Alexis St. Martin (1794-1880): the intrepid guinea pig of the Great Lakes. Available at: http://www.guineapigzero.com/AlexisStMartin.html Accessed August 20, 2009.
• Life of Dr. William Beaumont. Available at: http://www.james.com/beaumont/dr_life.htm Accessed August 20, 2009.

Museums

• American Fur Company Store and Dr. Beaumont Museum. Available at: http://www.mackinacparks.com/ Accessed August 26, 2009.
• Prairie du Chien Museum at Fort Crawford. Available at: www.fortcrawfordmuseum.com Accessed August 26, 2009.
• William Beaumont Birthplace. Available at: http://www.james.com/beaumont/dr_birthplace.htm Accessed August 26, 2009.

References

1. Horsman KR. Frontier Doctor. William Beaumont, America's First Great Medical Scientist. Columbia, Mo: University of Missouri Press; 1996.
2. Sarr MG, Bass P, Woodward E. The famous gastrocutaneous fistula of Alexis St. Martin. Dig Dis Sci. 1991;36:1345-1347. Abstract
3. Modlin IM. From Prout to the proton pump -- a history of the science of gastric acid secretion and the surgery of peptic ulcer. Surg Gynecol Obstet. 1990;170:81-96. Abstract
4. Rosenfeld L. William Prout: early 19th century physician-chemist. Clin Chem. 2003;49:699-705. Abstract
5. Beaumont W. Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Mineola, New York: Dover Publications, Inc.; 1959. Available at: http://books.google.com/books?id=H6F4_9joRkgC&pg=PA8&dq Accessed August 20, 2009.
6. Koch H, Tomaselli F, Pierer G, et al. Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy. Eur J Cardiothoracic Surg. 2002;21:874-878.
7. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg. 2006;81:279-285. Abstract
8. Mayberry JC, Kroeker AD, Ham B, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009;75:389-394. Abstract
9. Myers NA, Durham-Smith E. A debt to Alexis: the Beaumont-St Martin story. Aust N Z J Surg. 1997;67:534-539. Abstract

Authors and Disclosures

Author(s)

Albert B. Lowenfels, MD

Professor of Surgery, Professor of Community Preventive Medicine, New York Medical Center, Valhalla, New York; Emeritus Surgeon, Department of Surgery, Westchester Medical Center, Valhalla, New York

Disclosure: Albert B. Lowenfels, MD, has disclosed that he has served on an advisor to Solvay Pharmaceuticals Inc.

Medscape General Surgery © 2009 Medscape, LLC

Lunacy in sanity?

I am a firm believer in self determination. If someone is ill, that person has the right to dictate the kind of treatment he/she wishes to receive and whether or not to continue with the regime. This is fairly straight forward when one is dealing with a functional adult of sound mind.

But what if that person is a minor?

The bioethics involved in treating a minor is still in a murky zone. Status quo indicates that the decision regarding the welfare of a minor rests in the hand of the child's guardian. Hence, the guardian has a a right to push or even reject a treatment for a minor. This is easy enough if a child has no bigger complains than the usual coughs and colds and playground injuries. However, it has come to fore of parents (and guardians) who are refusing treatment or seeking harmful or even allowing the minor to remain untreated for reasons of faith or even non-spiritual belief.

In the case of Colleen Hauser and her son, Daniel, who fled their home in Minnesota to escape court-ordered chemotherapy, who is in the right? The mother, who believes that her child should not have toxic materials injected in him because she favors the natural healing methods of an American Indian religious group known as the Nemenhah Band? Or is it the court who determines that Daniel would benefit from conventional treatment that has been proven to cure Hodgkin's lymphoma?

Many cultures imbue the right of parents to determine the decisions affecting their children. It is not uncommon in Asia for neighbours to look the other way while a child is being disciplined; of course in some cases, such discilinary measures not only verge but enter the realm of abuse and still people will accept that it is the right of the parents to act in such a manner. In the West, this feature has changed with the adoption of bills that prohibit parents from using corporal discipline on their children. It got to such that a mother cannot smack her toddler's bottom for being mischeavous in public.

But in the case of Colleen and Daniel, who have the right to determine what is best for him? It would seem to many that his mother is jeopardising his life by refusing him treatment and influencing him to reject it as well. In the case of Madeline Kara Neumann, who died from untreated diabetes complication, her mother rejected conventional medicine and instead, chose to have her healed via faith healing. Whether it is laying of hands or dependence on supplements and sweat boxes, these are parents who chose other treatment options for their children out of their own particular belief system (regardless of what faith they hold to). One of the extreme cases involved very young children who had the devil tormented out of them by a rabbi with consent from their mother. One of the child now suffers permanent brain damage.

As a person of faith, I am appalled at how belief system can be perverted in such a way as to inadvertently harm vulnerable children. But then again, people have used faith to justify harming other people with purely malicious intent. One would think that with the brain that The Almighty has gifted them, they could reason better than that.

But apparently, not.

*shakes head*

More reason to snip away at the prized goods ...

For all the men out there who thinks that circumcision is horrid, go and read this. Besides improving your hygiene, it might just save your life.

Learning Sans Ego

It was reported at a meeting of the Society for Healthcare Epidemiology of America in San Diego on Saturday that something as simple as balling up your paper gown and stuffing it in your gloves prior to disposal has a 26 - 62% rate of success at reducing hospital acquired infections. This measure has been included as one of three "Positive Deviance approaches that the CDC has found reduced infection rates at hospitals. PD is based on the premise that in any group there are natural problem-solvers".

The innovator: a humble patient escort named Jasper Palmer.

I'm glad to hear that august surgeons, clinicians as well as other hospital staff are willing to learn from Mr Palmer. Many a time people are not willing to learn from those they deem to be beneath them, no matter how egalitarian the society. It is nice to hear that people are serious about the problem of nosocomial infections that they are willing to listen to sensible solutions proposed by someone without a PhD.

Lovely.

Robbing Peter to Pay Paul ... The Good Version

The economic crunch is hurting pretty much everyone. You can't help but feel your blood boil when you read about how the AIG execs are still getting their bonuses (after screwing up other people's life savings, thank you very much) and the President of the Royal Bank of Scotland keeping his USD 1 million pension (also after screwing up other people's life savings).

And then you read how the doctors at the Beth Israel Deaconess Medical Centre in Boston is giving up part of their pay to help support their departments and stave off lay-offs. It appears that each of the heads of department are willing to contribute $27,000 of their annual salary to the cause. I have no idea whether this would suffice to bolster the financial woes of the hospital, but I think a contribution of $350,000 would make a dent to reduce potential redundancy.

Your faith in human nature is restored.

Paging Dr No ...

Huh. Apparently in Sweden even convicted murderers can be accepted into medical school. I guess the 6 and a half years in prison gave him plenty of time to study and get awesome enough grades to get in.

But seriously, wouldn't you worry if your physician is a convicted felon? So he's smart, brilliant etc etc, but if he has race issues and you are definitely too coloured for his taste? A bit iffy, no? Vetting for entrance into medical school has always been a hotly debated issue, ranging from scholastic performance to extra curricular activities and even mental and psychological aptitude for the work. I guess now the Swedes will have to include query of legal issues in the application forms. In Malaysia, if you were ever in trouble with the law (say, you used to boost cars in your misspent youth or was busted during a nightclub raid), you can kiss your university entrance goodbye, much less the august medical schools.

So what makes good doctors? How do we make sure that the ones with the right stuff to become good doctors are given the chance to get into medical school? Should we allow a brilliant Nazi sympathiser (and every other colour of this sort) to get in because of his/her scholastic excellence?

*rubs chin thoughtfully*

Alcohol is Not a Universal Sanitiser

I'm sure you've heard of people who said that alcohol will kill all the germs in your food. You won't get gastritis if you ate contaminated food and chase it down with hooch?

HAH.

Not happening. Note here that the Clostridium botulinum had happily gone forth to multiply and produce the toxin that made those inmates sick. Not quite the usual application of botox, no?

A Nail that Sticks Out, Gets Hammered

I remembered that quote from Tokyo Drift, the 3rd of the Fast & Furious franchise that launched Vin Diesel into the stratosphere of stardom. The father of the protagonist quoted the Japanese saying in hopes of getting his son to keep his head down, nose clean and no getting into trouble.

But what if keeping to ourselves means smothering our conscience to the expense of our health; physical, mental and emotional? I posted earlier on how nurses have one of the most stressful and dangerous job; it seems here that it does appear as though there is no way for a nurse to win.

A job should be one that not only helps pay your bills, but also fulfills something inside so that it becomes an ibadah (i.e. a way to serve God). But when you have to decide between your professional health and voicing out your concerns, it is really tough indeed. How often do you find yourself swallowing your view points that is for the benefit of your clients/patients/students/etc because you are afraid that the upper echelons will fall on you like the proverbial tonne of bricks?

Perhaps it is better to balik kampung dan tanam jagung*.

*return to the hometown/village and plant maize

Your Body is a Wonderland

I love that song. About the only John Myer song that I could listen to with any kind of regularity; sweet without being cloying, cajoling and worshipful with a dash of wonderment thrown in.

Your body is a temple; worship it. We all know that. Eat properly, get enough sleep, drink plenty of water, exercise etc. How many of us actually do all that? Well, certainly I don't join that rank of the population. Those who can afford it take short cuts via plastic surgery. A little nip here, a tuck there and voila! You're a new person.

It's easy to snicker about people who chose this route. But take a look at the clip from Nip/Tuck below. I guess the grey areas are larger than I thought.



What think you now?

Marcus Welby vs House MD

When my dad had colon cancer, he said that he wanted to have a doctor like Dr Gregory House; someone who will solve the puzzle of the disease no matter what it takes. My dad was pretty all right with House's brand of caustic acerbicism, and felt that his manic competency will outweigh any and every personality drawbacks that he have. What he got was a surgeon who was brutally honest about the treatment options and is kick ass to boot. So that was cool.

For all that Dr House saves the day (for the most part), when we are sick we don't want someone who mocks us about the poor choices we made that hurts our health or someone who runs rough-shod over our feelings. We want someone who listens and give us the advice we need with no judgment whatsoever. I am sure that all of us have had experiences with medical professionals who treat us with disrespect, annoyingly condescending and out-and-out uncaring about our pain. However, this article gave me hope that there are still doctors out there who still give their all to their calling and made their patients' life a little better all around. However, questions have been raised on whether this personal touch is impairing their judgment and affects their professional conduct adversely. Even the American Medical Association's Principle of Medical Ethics demur on treating family and friends.

Well, it should be up to the physician to decide on the lines to be drawn and crossed when it comes to arranging his/her personal and professional life, isn't it? And let's hope the ones whom we have to deal with does this in a way that makes our doctor's visit nothing like having a toe nail removed.

Malaria Destructo: Anti Retroviral Drug Goes Mediaeval on Plasmodium's @ss

Snagged from Medscape. Hoo wee! Good news in the face of rising resistance to artermisinin-based chemotherapy.

NEW YORK (Reuters Health) Jan 22 - Protease inhibitors, already valued in treating HIV infection and under investigation as anti-protozoals and anti-cancer agents, now demonstrate new potential as anti-malaria drugs.

A laboratory study by U.S. researchers has shown for the first time that HIV protease inhibitors inhibited the development of preerythrocytic-stage plasmodium parasites. Lopinavir and saquinavir separately had this effect in vitro, and the combination of lopinavir and ritonavir had this effect in mice. The study was published in the January 1 issue of The Journal of Infectious Diseases.

These data are important, "as there is currently no clinically available drug that has an effect on the liver stages in the way that we have demonstrated HIV protease inhibitors have an effect," Dr. Charlotte V. Hobbs of New York University School of Medicine told Reuters Health. "HIV proteases inhibitors are unique in their demonstrated ability to inhibit parasite development in the liver stages, at which point the parasite is initially present in much lower numbers."

Since 2004, published research has shown that HIV protease inhibitors can be effective against plasmodium in the erythrocytic stages of the protozoan's life cycle.

The current researchers found that saquinavir and lopinavir inhibited the development of Plasmodium berghei exo-erythrocytic forms in vitro, but that atazanavir, amprenavir and nelfinavir did not.

In the in vivo part of the study, which used P. yoelii, lopinavir/ritonavir exerted a dose-dependent effect in reducing the burden of liver-stage parasites in mice, while saquinavir alone had no effect, even at high doses.

Dr. Hobbs told Reuters Health that although theories have been proposed, no one knows the exact mechanism by which HIV protease inhibitors affect malaria parasites. "If one could elucidate this mechanism," she said, "one could perhaps develop a further class of antimalarial drugs based on the chemical structure of an HIV protease inhibitor.

J Infect Dis 2009;199:134-141.

I vote for Hospital X ...

Getting the best of healthcare treatment should be the rights of all individuals. Unfortunately, the healthcare market is skewed to favour those with the more moolah. But is money alone the sole determinant of getting the best treatment when you are dealing with cancer, hypertension, cardiovascular issues etc? How do you know to shop for the best place to get your gall bladder out?

This article in NYTimes indicated that it is important to shop around for the best treatment and that physicians should be ethically obligated to disclose whether or not the institution that they are affiliated with is the best place for the patient to receive the treatment indicated. But when you consider how little interaction the physician wants to have with you, as a patient, it renders this a moot point. Many physicians are still of the old school, paternalistic style: I know what's best for you and you should trust and not question my judgment/recommendation.

I was just glad that when my dad was diagnosed with colon cancer, he agreed to go to a teaching hospital that my mother frequents. Not only is the cost reasonable (hehehe, we cheated on this one as my sister is a government servant and could get massive discounts for the treatment), the surgeon (a scary and uber competent woman) does the operation on a weekly basis and thus, is well-trained for the occasion.

The thing is, many patients are still unable to communicate their needs well with their physician. It is easy to point the finger at the physician for not being better listeners/willing to spend time with the patient etc., but do we, as patients, pay attention to what and how we tell our problems to our doctors?

Point to ponder.