Monday, September 30, 2013

Photography: Old & New II.

It was a rather somber day when I gave away all the chemicals that I have accumulated over the years of dark room work. As it happened the couple that got them were both medical doctors. Hopefully they make good use of them.

There is indeed much that modern day software can do to duplicate the work of the traditional dark room. Yet there is something magical seeing your print wet and perfect in the dark room.

I have often been asked about some of my photos:

Here are some of the technical details.

Both are taken with Nikon FM2 180/2.8 ED lens. The lens was probably the best of the hand held pre-digital lens Nikon ever produced and I still use it with my Digital Body. 

Mademoiselle
Film: Kodak Tmax100 Kodak developer.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.
 ©1995 Am Ang Zhang

New York
Sharp-eyed photographers would notice Pan Am sign thus dating the picture.

Film: Ilford 400 developed by pushed Rodinal developer to get the sharp and huge grains.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.

 ©2008 Am Ang Zhang

It is vital to get the sharp focusing of the grains.

Photoshop can in the quadtone mode assign different tones to different levels at will and the level adjustment will enhance what is often a gamble on Lith. Modern printers cannot quite produce the exhibition quality of good Fibre Base Paper of old.

Update:
© Am Ang Zhang 2012

Lith Style Photographic work.

Thursday, September 26, 2013

Anorexia Nervosa: The Peril of Diagnosis!


It is probably too late as so many doctors and psychiatrists are brought up on empirical diagnosis that sheds little light on the sufferings of the individual. The more powerful the diagnosis is, the easier it is to ignore the person as an individual and not to take into account his life history that may have a strong bearing on his treatment.

         In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.

........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.

News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.

How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........
                                                                    

Cape Floristic Region (CFR) of South Africa
 ©Am Ang Zhang 2005


                 Jane got on well with me.

          She had to, as nobody understood that to her achieving was not a hardship but something she secretly enjoyed. She was no longer allowed to pick up her books as she had not put on any weight since her admission.
         
          Cello would be banned too, if her nurse was to have her way.

          For the unit to function the nurse must have her way. After all I was not there all the time to watch her. To watch if she was eating, vomiting, exercising or whatever else they did to avoid gaining weight.
          But I was determined that it would be the first privilege she would get if she put on half a gram.  Or any excuse I could think of.
          Brutal confrontation is often what happened in many adolescent units dealing with Anorexia Nervosa. The brutality is not physical.
          But these patients are intelligent and have such strong will power that confrontation generally fails and the failure can be a miserable one.  Yet it is the kind of condition that hurts. It hurts those trying to help. It hurts because these patients deserve better for themselves. It hurts because they are not drop-outs of society. 
          Was it too hard for Jane to keep at the top academically? Someone offered that as an explanation. Perhaps she should be moved to a state school.
          The idea horrified me.
          A fourteen year old non-smoking, non-drinking, non-drug taking, intelligent Audrey Hepburn look alike virgin turning up at your local comprehensive.  It sounded like a major disaster to me.
          I had to take the matter into my own hands. She did put on some weight and at the earliest opportunity I decided she should get back to the cello which had always been by her bed at the unit.

          She missed the cello, the only thing she could use to shut out her worries.
 

          Fourteen and carrying the burden of the world.
 

          Then she started playing.
 

          “Ah. The Bach G-major!”

 
          “So you know it.”
 

           Of course I do. The hours I spent listening to Yo Yo Ma and it was such amazing music, melancholic and uplifting at the same time.

          For a moment I forgot that I was her psychiatrist and she forgot she was my patient.
 

          “My grandma gave me Casals.”
 
          I knew Casals was even more emotional than Ma, but Ma is Chinese and he was less affecting, allowing the listener to tune in to his own mood.
 
She played from memory. What talent! What went wrong?”
 

          “I wish my dad could hear me.”

          It was the first time she could talk about her father. They had a very comfortable life inSouth Africa when father was alive. It was very difficult to imagine what he would have looked like. It was never clear what he did but he was involved in a number of ventures. The plantation Jane’s grandfather ran was sold when apartheid came to an end. He was involved in some private reserve and he was a photographer of sorts but my junior told me that mum started to cry when she talked about him so she did not pursue too deeply.

Sunday, September 22, 2013

NHS: Best Health Care Days!

Best Health Care: NHS GP & NHS Specialist

Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.

Nothing.

Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neuroligical Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best Health Care: France & The NHS


Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.

NHS & Private Medicine: Best Health Care & Porsche

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.




Related:

Your Life In Their Hands: But Whose Hands?


 ©2010 Am Ang Zhang

Farewell                      Wang Wei (701-761)
Dismounting, let me share your farewell wine
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest

Enquire no more when I am gone 
Till the end of clouds, endless white clouds!

You can't sack me! I am going!


By Jeremy Laurance, Health Editor
Tuesday, 26 July 2011

Complete baloney:
The heart czar had given a speech in which he described Lansley’s claim that the NHS was over managed as “complete baloney”. He had critcised the NHS reform strategy of throwing out the old and bringing in the new “without even looking at things that have worked well,” and had warned about the dangers of dismantling relationships nurtured over years and destroying “corporate memory.”

Knuckles rapped:
Lansley was not pleased. Boyle described what happened. “Miraculously, I found myself in his office. His aides were debating whether they could sack me before they discovered I was going anyway. Lansley said he was disappointed I had gone public without telling him. Which is fair dos except he could have found out if he had bothered to see me. It was a short meeting. I had my knuckles rapped.”

Waste:
It is a pity Lansley had not made more effort to find out what Boyle was up to because he would have learnt some important lessons about the NHS and what it had achieved without the benefit of the market revolution being ushered in under the NHS reforms.

The success story: lives
During his 11 years in post - Boyle retired on Friday - the death rate from heart disease has halved. Waiting times for treatment have been slashed. There are more surgeons, more patients on drugs (for blood pressure and cholesterol), better equipped units, and around 60,000 lives saved each year - half from changes in lifestyle (such as reduced smoking) and half from improvements in treatment. Not a bad record on which to bow out.

Keeping quiet:
But Lansley was not keen to trumpet this success. And Boyle thinks he knows why - it does not play to the Health Secretary’s agenda which is to dismiss everything done before his time in order to bolster support for the revolution he has meticulously planned to open up the NHS market and subject it to more competition.

Collaboration not competition:
“All the improvements in cardiovascular care have come from collaboration and leadership. Where is the evidence that competiton between commercial providers makes a blind bit of difference to cost efficiency and quality? The competition I want to see is between clinicians vying with each other over whose service is the best. If you try and improve care by getting United Health to provide the service that would be crazy.”

“I absolutely think the NHS is the best public service in the world. It is horrific that its future is threatened.”


Jobbing Doctor: Speaking up:

He has finally blown the whistle, now he is safe from recriminations from the executive. He has had his knuckles rapped by Mr Lansley, and will not get a seat in the House of Lords (probably didn't want that, anyway).

What he says about Mr Lansley and the New NHS bill will make grim reading for the few zealots who still believe that the New Bill is a good idea.

Saturday, September 21, 2013

NHS: Mayo Clinic!

CH4

Why is America doing better?


At the Mayo Clinic Hospital in Phoenix, Arizona, they are in the best two per cent in the country. It is an impressive hospital, with piano music playing in the lobby and sunshine streaming into the rooms.

And around the hospital are signs extolling their ethos: the patient comes first. To this end they have introduced a number of safety systems, including a check and recheck system between the pathology labs and the operating theatres.
For years they have had multi-disciplinary team rounds in which everyone from the consultant to the physio, from the nutritionist to the social worker is involved in the care of that patient.
It means better communication. Everyone is treated as an important part of the team, rather than deferring, in the traditional way, to the consultant.
Professor Richard Zimmerman, a neurosurgeon at the Mayo Clinic Hospital, acknowledges that this can be labour intensive with a dozen or more people involved in each round for each patient, but he said it is cost efficient in the end.
If you go to the States, doctors can talk about problems, nurses can raise problems and listen to patient complaints.Professor Jarman
"It is less expensive than having a lot of deaths and having admissions that last longer because you don't do it right the first time," he said.
Nevertheless, critics will say that it is difficult to compare the American hospitals with the NHS and it is true that in the US more money is spent on equipment, drugs, staffing levels. And it has an expensive, much-criticised insurance-based healthcare system.
And yet, American hospitals results are better. They have more per staff per patient, for instance. But what stood out at the Mayo was the attitude to mistakes or near misses. Staff are actively encouraged to report these. Whistleblowers are welcomed. Because they do not want these mistakes repeated.
"If you go to the States doctors can talk about problems, nurses can raise problems and listen to patient complaints," Professor Jarman said.
"We have a system whereby for written hospital complaints only one in 375 is actually formally investigated. That is appalling, absolutely appalling."

 

This is not Mayo Clinic © Am Ang Zhang 2009

This is a re-working of a previous post on The Mayo Clinic: a sincere plea to the government to look closely at what could be done. The NHS had all the ingredients in place for a world class Health Care System.


The main features:

The needs of the patient come first. 

An Egalitarian Culture.

Healthcare is not a commodity.
A Fully Integrated System.
Private or Charity Patients are Equal.
No over treating at Mayo.
Competition does not serve patients’ interests.
Disincentive system that works.

What Makes the Mayo Clinic Different?

by Maggie Mahar October 21, 2008
The needs of the patient come first. 

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years,"  says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.) 

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally.

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back.  You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it. 

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates.

There is, after all, a difference between healthcare and hamburgers.  Healthcare is not a commodity.
                                                                                                       
Healthcare is not a commodity!!!!!

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors  in dispensing care.  Quite the opposite:  Extensive analysis of Medicare records done by researchers at Dartmouth Universityreveals that treatment at the Mayo Clinic in RochesterMinnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.


Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA. 


…………when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson.  This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments.  If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”


Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson.  “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.) 


“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”


Private or Charity Patients are Equal

The Mayo Clinic in Minnesota sees many local patients.  “And like New York, we have minorities—just different minorities.”


Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”


That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.


When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”


At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson. 


No over treating at Mayo.
It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.


“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 



Competition does not serve patients’ interests.

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.


More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.


In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?


Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

Read the full article: What Makes the Mayo Clinic Different?

From: Leadership Lessons from Mayo Clinic


T e a c h i n g  f o r  T  o m o r r o w ’ s  P a t i e n t


Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo  physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had  joined the Mayo    surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.



Dr. Charles H. Mayo and Dr. William J. Mayo

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”