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VOA: 走访灾区:地震孤儿可能数以千计
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发表时间:2008-05-25
更新时间:2008-05-25
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走访灾区:地震孤儿可能数以千计

            记者:特林德尔

中国四川汶川大地震造成五百万人无家可归,许多家庭被拆散,许多父母和儿童还在苦苦寻找对方。在这场混乱里,特别值得关注的是,可能有数以千计的孩子已经成了孤儿。

成千上万的灾民现在就住在这个体育馆里,因为他们的家已经在地震中被毁。扩音器里播出失踪者的名单。

许多无家可归者是和父母失散的儿童。他们最关心的是,未来几天谁来照顾他们。特别是,如果他们的父母也在在地震中遇难的话,将来谁来照顾他们。

中国政府已经开始着手为这些孤儿寻找收养家庭。

王女士坐在体育馆外的一张桌子边。她的工作是让人了解有关的收养法规。王女士说:“如果有孤儿,我们将遵照中国有关收养的法律,他们将通过程序被收养。”

*欲收养者踊跃报名*

王女士说,在愿意收养孤儿的名单上签名的接近两千人之后,她已经不再让人登记了。中国媒体报导说,全国各地还有好几千人表达了收养孤儿的意愿。

在体育馆里,甚至本身还是地震灾民的人,比如朱耀冰(音译)女士,也排队希望能够登记收养孤儿。

朱耀冰说,相比之下,自己家的情况比很多人都好,希望能尽一切力量,来帮助那些孤儿。她说,他们家的房子没了,东西都没有了。但是至少还都健在,可以再去找工作,可以继续支撑一个家庭。

虽然朱耀冰本人安全,但是象这里的许许多多的人一样,她还在继续想尽一切办法寻找失踪了的亲人。她觉得她的侄子在5月12号地震发生的时候,有可能正在北川,而那里是这次灾情最严重的地区之一。她说,谁要知道刘贵军的消息,务必请转告他,跟他在鞍山的妹夫联系。

一时找不到侄子,朱耀冰就趁著这个机会,帮助其他的人。她已经问了负责领养孤儿的官员,是否能帮忙照顾一位还在寻找自己父母的孩子,至少在这个时候给孩子一些温暖。

*是失散还是永别?*

到目前为止,负责领养的政府官员把那些没有跟大人在一起的孩子都集中在体育馆里,保证他们在寻找父母过程中有一个安全的地方落脚。两个月以后,那些找不到亲生父母或者是其他亲戚的孩子,将被登记为孤儿。

眼下,很多孩子还都抱有一线希望。一个16岁的女孩儿说,地震发生的时候,她没有跟父母在一起,但是也许过去这些天里,他们曾经在路上擦肩而过。

她说,父母都出去到外地打工了,但是他们很可能在地震发生以后,回家来寻找亲人,但是不知道亲人们已经离开当地了。

这会儿,她希望能跟父母在绵阳相会。

□ 美国之音

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1   [USMcdEdu 于 2011-02-07 20:55:22 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):

 
2   [USMcdEdu 于 2011-02-07 20:55:01 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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