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凶残医生杀手
作者:USMedEdu
发表时间:2010-12-24
更新时间:2010-12-24
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发信人: againstwind (逆风而行), 信区: residentwhisper
标 题: 医学八卦:美国史上最凶残的医生杀手
发信站: BBS 未名空间站 (Thu Dec 23 23:45:04 2010, 美东)

1954年,有一个叫做Michael Swango的男孩子出生在伊利诺伊。这个孩子天性聪颖,在
大学就获得美国化学组织的大奖,并且参加海军陆战队的服役并得到honorable
discharge.退役后他进入了南伊利诺伊大学医学院。

在大学的时候,麦克就表现出对濒死病人的一种特殊兴趣,他自告奋勇做救护车随员,
后来调查的时候,人们发现他那时候接触过的病人都经常会突然code,至少有五例死亡。

1983年,麦克医学毕业后来到俄亥俄州立大学做外科intern,并且准备进入神外住院医
生。在他intern轮转病房期间,护士们逐渐发现,原来情况都很稳定的病人,继而连三
地神秘地死亡,而每次都发生在这个intern on call的时候。有一次一个护士发现麦克
在给病人注射不知名的药物,后来这个病人也不幸遭遇同样的命运。护士们开始向医学
院汇报,但是因为那个时候,医生和护士的地位是无比悬殊的,一个护士要指责一个白
人男医生,那几乎是不可能的事情。护士们被上级骂paranoid。但是随着例子的逐渐积
累,终于医院展开了调查,1984年因为没有确凿的证据,他被认为是没有犯错,但是因
为一些怀疑,俄亥俄州立大学决定不继续他的神外住院医生了。

于是麦克被迫回到了他出生的小城,在急诊室里做medical technician. 不久,在那里
工作的staff都在吃了麦克带来的食物后上吐下泻,有几个还病的很严重。麦克最终被
逮捕,警察发现他家里有砷和其他多种毒物。他被判刑五年。审理过程中,律师们对俄
亥俄州立大学的做法开始提出疑问,质疑他们当年没有报警而就自己私了,导致含冤未
能昭雪,并导致多人继续受到伤害,他们想重新调查他的案子,却因为无法采集证据而
不了了之。

1989年,麦柯出狱。他在一家能源公司打工,而且还结了婚。1991年,麦柯把名字改成
Daniel J. Adams,然后又开始了自己的医学梦,他伪造了大量的文件,把自己塑造成
一个德高望重的医生形象,他把自己投毒的经历改成自己是因为意气用事大家而入狱。
着一个举动是非常天才的,因为投毒是felony,他就不能获得执照了。他最终在
Sanford USD Medical Center in Sioux Falls找到了工作,而且混得如鱼得水,有点
翘尾巴的时候,却犯了一个错误,就是去申请AMA的会员,AMA毕竟是见过大世面的,立
即就找出了他过去的犯罪背景。麦克于是又被赶走了。

神秘地消失一段时间以后,麦柯神奇地出现在State University of New York at
Stony Brook School of Medicine的精神科住院医生program,可怜的病人们又开始莫名
其妙地死亡。

这时候麦克的妻子神秘自杀,他前妻的母亲得知那个疯狂女婿竟然又在行医,当时就抓
狂了,她立即通知了那个精神科。岳母的这个举动,直接导致舆论强烈谴责stony
brook的医院,医院和精神科的dean都被迫辞职。辞职之前,这位医院的dean还是很有
良心和勇气的,他向全国125家医学院,一千多家教学医院发出声明,从而成功地阻止
了麦克的重新进入其他residency的企图。

从那以后,麦克销声匿迹了。1994年FBI发现他一家公司里做化学师。也是个能人阿,
真是啥都能做啊。他被起诉伪造医学简历。但是那一年的11月,他突然消失了,原来他
潜逃出国,去了津巴布韦,并用假造的档案在那里做起了医生。可怜的非洲病人们又开
始陆续神秘死亡,非洲警察也不是盖的,不到一年就抓住了麦克投毒的证据,并且正式
起诉他。在审判前,他却又一次逃走了。此后的一年,他用假名在沙特阿拉伯行医。

在国内的FBI们从来没有真正放过这个如同毒蛇般狡猾残忍的医生,他们聘用了几位著
名的法医心理学家,因为缺乏证据逮捕他,他们反复分析他的行为,最后发现可以用他
用假造的建立去VA医院并且处方止痛药,这一点可以正式逮捕他。最终在芝加哥机场,
当麦克短期回国准备再次去沙特阿拉伯的路上,被抓住了。

铁证如山,加上FBI威胁说要联系津巴布韦的警察,麦克承认伪造简历罪,1998年他被
判处三年半徒刑。大家都很害怕他在监狱里故伎重演,所以规定他不能参与准备和递送
食品及药品,赫赫。

在他坐牢期间,调查还在继续进行,他们进行重新解剖死者尸体以及对幸存者进行检查
,发现了投毒的证据。他最多用的氯化钾,砷,或者用病人已经用的药物但是大大加大
剂量。在他刑满前的一星期,麦克被指控三项谋杀,一项故意伤害,等等,津巴布韦的
警方也联合指控他七项谋杀。如果他不在美国认罪的话,就会被津巴布韦带回去审判,
和咱们中国一样,那就是极刑伺候了。麦克于是在美国认罪,被判三个终身监禁。后来
的调查指出,麦克可能至少杀害了35个病人,但是FBI说至少有60个,如果那样的话,
他就是美国历史上人命最多的系列杀手了。

写这个故事的原因是,OSU最初因为这件事情,遭到极大的谴责,包庇自己的学生,即
使知道有杀人嫌疑除了开除没有任何举动,直接导致后来麦克的连续得逞,我认识的那
个退休老伯伯那时候是dean,据说经历了非常严重的公关危机。

从那时后到现在,美国的医疗系统已经完善很多,很难再会发生这样的不同州作案而不
互通情况的事情了,但是每个州还是要重新申请执照,也真的是很痛苦的一件事情。

最后好奇的是,到底是什么样的心理,让他作为医生要这样无法遏止地杀害病人?
--
逆风的方向,更适合飞翔。我不怕万人阻挡,只怕自己投降

※ 来源:·WWW 未名空间站 海外: mitbbs.com 中国: mitbbs.cn·[FROM: 65.24.]

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1   [USMcdEdu 于 2011-02-07 20:55:58 提到] [FROM: 199.]
发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

 
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