Having been a physician now for 16 years, I have had a first hand view at the variety of healthcare reforms and regulation put into place over that time. Most recently, the Affordable Care Act has been at the center of our attention, but it is by no means the only thing the government has done over that time.
Today, President Trump and the Republicans are working to repeal the Affordable Care Act, and possibly replace it with something else (Something Great if you listen to Trump.) I have mixed feelings about this. I think that the ACA did some good things, but also got some things wrong. At its fundamental core, by forcing all people to buy healthcare through a private insurer (albeit through a government funded network), it was trying to create universal coverage. Unfortunately, the ACA struggled to get healthy people who would pay more than they consumed to enter the system, thus creating a system where there were often more claims than premiums.
Merry Christmas and Happy Holidays from Nicholas Fogelson and Academic OB/GYN! Dr. Fogelson is available for clinical consultation at the Pearl Women’s Center in Portland, OR at 503-771-1883. He is a better gynecologic surgeon than he is a rapper. And he’s not completely terrible at rap so there’s that.
A middle aged man named called Joe decided in mid life that he would become a doctor. A former boxing instructor, Joe felt compelled to learn medicine to help his fellow man. Already in his 30s, he worked hard to develop the prerequisite education to enter medical school, which he did in the late 1990s.
I met Joe in my first year of medical school. He was a very bright guy and had a great sense of humor. He was a bit different than most of us, and not just in age. I remember him asking me once “why would we use anti-hypertensives to treat hypertension. I mean, if a person’s blood pressure is that high, maybe that’s what their body needs it to be at!”. I remember thinking it was a strange way to think, given that allopathic medicine pretty much presumes that letting the body do whatever it will may not actually be the best course for long term health.
Joe did reasonably well through the first two years of medical school. In his third year he had moderate success, and sometimes struggled with having a different outlook on what medicine should be that the attending physicians that were instructing him. Over time, this became a bigger problem, and Joe eventually made the decision that being an allopathic physician wasn’t what he wanted to do for the rest of his life.
A few months ago we hit the seven year anniversary of Academic OB/GYN. And today, I found out that we have been nominated in the AAGL Oscars for “Most Innovated Social Media Platform”. This nomination was a pleasant surprise – I completely agree that we should compete for that title, but in truth it always a bit of a shock to find out that people in my field actually have seen what I have been doing here and appreciate it. Most people are afraid of social media, and seven years ago when I started this most people in medicine thought far more of the risks than any kind of benefits. Since that time, things have changed, and many doctors have created robust social media presence. Since I started, the big players have come on the bandwagon. Now we have podcasts from all the major journals, and several website podcasts as well such as medscape and so forth. But I am proud to have been one of the first ,and almost certainly the first to have significant presence in the field of OB/GYN. With that, I thought it would be fun to recall how it started, and how the journey has been for me, and for the brand of Academic OB/GYN.
I started Academic OB/GYN the summer of 2007 at the University of Hawai’i. The impetus to do so actually came from my fandom of a podcast called Diggnation, hosted by Kevin Rose and Alex Albrecht. This was a podcast done by two nerds talking about nerd topics for an hour or so, and also doing a fair bit of drinking. It came to me – wouldn’t it be great to do Diggnation for OB/GYNs? So the next week I lined up some guests, fired up Garage Band, and published the first episode of the podcast. It absolutely took off, and in its heyday we were getting over 500 downloads in the first 48 hours of a new podcast being published, and in some cases topping 5,000 downloads in the first month. In the early years the audio quality was atrocious. Some of the episodes were almost not worth listening to it was so bad. But people liked the content, and they seemed to listen anyway. The audio got better, though never really to a professional level. But the content kept coming, and listeners kept growing. I got lots of mail of appreciation and comments. In 2010 at the University of South Carolina I added Dr Paul Browne as a co-host, and it made the podcast even better. Listenership grew even further. This year we total over 102,000 downloads, over 50% of which listened to the entire podcast. Our most popular episode was an early one with Dr Roger Newman, with over 8,000 downloads, still rising today. Amazingly, new fans still download our old content, and while we haven’t published an episode in three years we still get 20-30 new downloads a day. While total numbers are very little compared to downloads of wider appeal products, for a product that really only appeals to a very narrow slice of the world, the popularity has been staggering.
“You should carry a gun Nick”, my friend told me as I started work in his abortion clinic. “We all do, and you never know when you might need it.”
It was sort of shocking advice to get so early in my medical career, that I should be arming myself in case some cuckoo bird activist chose to try to assassinate me for my choice to help women realize their reproductive freedom. I didn’t take that advice, as I didn’t grow up with firearms. Overall, they scare me, and I don’t like handling them. Perhaps this is why I was a little freaked out every time I got in the car with my friend and he unholstered his Glock and unceremoniously dropped it into the side door pocket of his truck. I worked in abortion clinics for years and never chose to carry, though. It would have been easy to get a carry license, given that I was a potential target of legitimate violence (as if that is required). But in the end it seemed really unlikely that a gun could be useful to me, even if somebody tried to kill me. And I could think of a tremendous number of ways it could be to my disadvantage to have it. So I didn’t carry.
But my friend thought differently. He imagined some kind of situation where a bad guy might come up on him and he would be John Wayne, outdrawing the perp and somehow taking him down. It always seemed a little ridiculous that this could possibly happen. The problem would be that you would have no idea who that dangerous person might be. By the time you realized who the bad guy is, you would be dead or injured at least. I can sort of imagine a firearm being useful in some kind of mass shooting situation, but for an abortion provider it wouldn’t be a mass shooting – it would be a directed assassination attempt. And that would be an entirely different situation. But my friend still thought it made sense to carry, and he did.
And wouldn’t you know it, one day he actually had a reason to use that gun, and he did. And this is what happened.
This week in the news there have been a number of articles about a new technology that has allowed the creation of an embryo from three parents, and boy it is creating controversy.
Three parents you say?
Yes. Of a sort.
The case in point regards a woman who unfortunately had a child with a deadly mitochondrial disease. Mitochondria are organelles (“small organs”) inside each of our cells where ATP, our primary energy source, is made. Mitochondria are special in that unlike other organelles, they carry their own DNA. In the case of this woman’s tragically afflicted baby, defective DNA that could not support much life.
Geneticists have developed technology to create an healthy embryo without the defective mitochondria by placing a nuclei from the woman’s mitochondrially defective egg into a donor egg, after removing that egg’s nuclei. They then fertilized the new proto-egg with the husband’s sperm to create a new embryo. In essence, the egg had three parents – two in the nuclei, and a third one in the mitochondria.
And the world shuddered.
From all corners were cries of “we’re playing GOD!!!”. “We are altering the human race!!” “We’re no better than Mengele!!”
Most of this comes from a bright line we have put around genetics research that says we will not genetically engineer human beings. Legitimate bioethicists have felt that this is something we should not do, because of a ‘slippery slope’ towards eugenics. Religious radicals are just uncomfortable with advancement in science in any kind. They say it is because it is against God, but I think it is because a true understanding of how the universe works deprecates the validity of their religion, and thus sparks a crisis of faith.
But either way, most people think that manipulating human DNA is unethical.
I, for some reason, don’t see it this way. In fact, I couldn’t be happier that we have made this leap, and hope we keep leaping. We are coming to understand how we are put together, and in such we are coming to understand how to manipulate that process. That is exciting, not concerning.
We are not “Playing God”. For us to be “Playing God”, a “God” would have to have been the reason we came to be on this earth. And unequivocally, it is not. The evidence for evolution is so unbreakably strong that to claim that we are here because of “God” is purely ignorant. Humans are on this earth because our genes were selected for over millions of years, not because somebody put us here. If you believe in God, fine. But please don’t hold humanity back from our future by claiming that we are breaking your religious rules.
Even worse is the claim that to genetically engineer a human is akin to Nazi experiments. True, Hitler wanted to manipulate the future of humanity. But he didn’t want to do it by changing the genetic information of the future. He did it by murdering the people who were already here. To claim these are the same thing is an affront to geneticists, and is too good for Hitler.
In truth, I am absolutely head over heels excited to hear that we were able to eliminate a deadly genetic disease from a family through genetic means. What this means to me is that we are actually CURING disease, not just treating the symptoms that it produces.
Evolution is something that is terribly misunderstood. Its detractors really don’t get how it works. People who don’t understand it think it is about the selection of individuals over others, and thus don’t believe it could ever have ended up in us, but that is not really how it works. It is the selection of GENES that drives evolution, not the selection of individuals.
The problem in this case is that mitochondrial genes do not reproduce sexually, but are rather copied directly from their parent mitochondira, and as such they do not evolve. As such, problems in the mitochondria are passed on forever, never changing except by random mutation.
But now, for the first time, mitochondrial DNA is evolving. Perhaps not by natural selection, but it is evolving nonetheless. And that is exciting.
Don’t take this to believe that I am ignorant of the potential problems. But they are technical, not ethical. Obviously we can not open the doors to unlimited human experimentation, but this is a first step, and it is a good one.
Yesterday I was going through my closet and separating out a lot of clothes that I no longer wear to give to Goodwill. Among the many things I selected to never see again, I noted a tie that I wore to my original medical school interviews. An wow.. it was a problem. Did I really wear this? I then decided to actually put together the outfit that I wore to my interviews. And now I realize… its a miracle I ever got in.
I grew up in Oregon, where no one ever wears a tie, and no one ever dresses up. When it came to interview for medical school, I truly had no appropriate clothes. I consulted my father, who suggested the outfit you see here:
Note the tie that is missing the material in the back to allow the tie to line up. No problem there.. just use a paperclip. Really. While my father was trying to lead me in the right direction, little did I know this was the same father who fifteen years later would wear a tee shirt to my wedding.
So basically, I walk into medical school interviews looking like this:
Note the rather ill-fitting sport jacket, Mathlete regulation length tie, and unmatched pants that are too small. Ignore the pleats, they were actually in fashion then.
But how was I to know? I was a computer science major and a total geek. This was dressing up big time. I was fully expecting that when I went to interview I would be looking sharp.
Not so much. When I arrived to my first interview at Baylor College of Medicine I found myself terribly underdressed compared to all the Brooks Brothers suits sitting next to me. While I looked maybe all right, they looked good. And more importantly, they all looked the same, and I looked different.
And perhaps that was my mistake, in that this was what I was actually going for. I knew that a suit was the right thing to wear, but I had a rebellious streak in me that said ‘screw that! I don’t need to buy and wear a suit! What matters is my brain and what I have accomplished!” I also had a bloodstream that ran with Oregon blood, where most people respond to a person in a suit with the comment “so who died?” And so I proudly wore clothes that looked right out the closet of my University of Oregon math professor Schlomo Libeskind, who inspired my love for higher mathematics and modeled wearing beltless polyester pants up to his nipples.
Fortunately, I survived the process and indeed was accepted to medical school, though not as many as I thought I should have given my academic record. As I was looking back in this during residency interviews, I decided that this time was not going to make the same mistake twice! I was going to wear a suit!
And I chose this:
My mother had found it at a thrift store and extolled its beauty. It was in fact a suit, and it was in fact from a fine Italian brand. Furthermore, it was a suit that when new was quite expensive.
But what it was not was a suit that fit me. It was way too big then, just as it is today. Furthermore, being found at a thrift store, it was in fashion twenty years earlier, not at the time it was being worn. It was also brown, which still set me aside from all the other blue and black suits that interviewed for residency with me.
I did get some “nice suit” comments followed by furtive glances to the side or floor. As a person who now plays a lot of poker, I now realize that those comments were purely ironic. I also heard “bless your heart” in the South a number of times, which by the third year of my residency in Charleston,SC I knew was actually an expression of kind condescension.
Fortunately, despite this suit, I got into the residency I wanted. Apparently being the rare highly qualified male applicant to an OB/GYN residency was worth more than the ill-fitting suit cost me. And at the end of my residency, the chairman took me to a fine men’s store with the invitation “Son… they’re having a sale.. and you need a nice suit for your faculty interview.” “But I have a suit!” “Son… you’re going to a be a faculty physician… you need more than one suit.”
* * * * *
At the time, I didn’t think this dressing up business was important, but now as a faculty member I realize that it was. There is no doubt that on the days that I interviewed in those clothes, the faculty were laughing about me at the applicant review sessions. I have no doubt that at my medical school interview they were saying “how about that Fogelson guy with that sportcoat and no belt?” And at my residency interview I’m sure it was “how ’bout that huge brown suit guy!”. Of course, does that really hurt a person? As a person who interviews and ranks applicants, I can say that it almost certainly does. An applicant has only a few minutes to convince someone that on a very subjective level that they deserve to be in the medical school or residency. In the end, you hope that your interviewer is talking about how smart and accomplished you are, and not about how you were dressed. It seems so superficial, but that doesn’t make it not true.
So the truth is this: When you interview for a job in medicine, your clothes should be invisible. They should be well fitting, relatively conservative, and ordinary. They should be neither particularly bad nor the height of fashion, leaving your interviewers nothing to comment on other that what really matters – the person wearing the clothes.
When I interviewed for medical school, I interviewed at 8 schools and was accepted at one. I had great MCAT scores and way more medical experience than could be expected of any applicant. If I had been dressed like this I probably would have gotten into a lot more schools: