Prescriptions | SPRING 2018
Cover Page Photograph by Mark Czeisler ’19 1
Prescriptions | SPRING 2018
Harvard’s Magazine on the Premedical Experience Editor in Chief | Patrick Magahis ‘21 Design Director | Benjamin Ho ‘21
Editors Victor Agbafe ‘19 Kushi Mallikarjun ‘19 Rachel Oshiro ‘19 Ellen Zhang ‘19
Contributors Victor Agbafe ‘19 Mark Czeisler ‘19 Jang Lee ‘19 Kushi Mallikarjun ‘19 Jude Okonkwo ‘21 Ellen Zhang ‘19
☤ With Special Thanks to: The Harvard Premedical Society
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Prescriptions | SPRING 2018
Note from the Editor This issue of Prescriptions strikes to the core of premedical student reflections. Victor Agbafe’s The Privilege of Good Health reverberates with undercurrents of personal experiences as he expounds upon the need for one to look beyond oneself and extend one’s influence to the greater community. In before chemotherapy, Ellen Zhang takes on a state of mind felt by many of those we love and interact with, demonstrating how only through poetry’s artistic delicacy and riveting insight could such a somber topic be properly highlighted . Such enlightened poetic verse continues in Jude Okonkwo’s Miracle at the County Hospital, connecting faith and medicine in such a way that reveals the respective powers and joys of each as well as the possibility for their collaboration. Finally, Kushi Mallikarjun brings us back to the reality of medical student training with a meticulously-argued piece on resident hours - providing readers with the opportunity to ponder their own futures. Thank you to the writers, editors, designers, and the Harvard Premedical Society. We here at Prescriptions invite you to read, enjoy, and reflect upon each of these pieces your peers have presented, showcasing their evolving understanding and appreciation of their respective roles and journeys in the medical field. Sincerely, Patrick Magahis ‘21 Editor-in-Chief
Prescriptions is a semesterly publication that serves as an intersection between the arts and medicine. The publication showcases student reflection on health, medicine, and insight into life as an aspiring doctor. Here, students design, write, and create distinctive pieces while sharing their own thoughts, ideas, and experiences – some relatable, each unique, and all reflective. Ultimately, Prescriptions not only aims to inspire and excite, but also strives to facilitate dialogue to create and nurture a wonderful community. Contact pmagahis@college.harvard.edu for information on how to get involved! Copyright © 2017 by Prescriptions. All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher.
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Prescriptions | SPRING 2018
TABLE OF CONTENTS | Volume 2, Issue 2 5. The Privilege of Good Health Victor Agbafe ‘19
7. “Miracle at the County Hospital” Jude Okonkwo ‘21
8. Are Resident Duty-Hour Restrictions Actually Beneficial for Patient Care? Kushi Mallikarjun ‘19
11. “Before Chemotherapy” Ellen Zhang ‘19 Illustration by Jang Lee ‘19
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Prescriptions | SPRING 2018
The Privilege of Good Health process was simplistic: “If one has healthcare
By Victor Agbafe ‘19
insurance, then one can easily see a physician
As I continue down my path towards
and quickly get the care they need.” However,
medical school, one thing has become significantly
more
evident
to
me:
I now realize that simply having healthcare
the
insurance will not resolve all the unbalanced
difference between healthcare and health.
social determinants of health that really have
Healthcare deals with health in a more formal manner. It involves access to
doctors,
necessary
medications, and a system that
will
keep
interactions
these
ongoing,
the greatest impact on one’s
“Healthcare deals with health
health
status.
My
main
in a more formal manner. It
reasons are twofold: first, we
involves access to doctors,
need to draw the distinction
necessary medications, and a
between health
healthcare
and
campus
and
(whether
in
on
particularly for those with
system that will keep these
chronic health conditions.
interactions ongoing … Health
advocacy,
on the other hand involves the
government), and second, I
ability to access good food,
am very grateful for the
consistent exercise, and to
exercise resources, and to live
resources at home and here at
live in close interactions
in close interactions with
with many people. Health
many people.”
Health on the other hand involves the ability to access
good
food,
is commonly correlated
beyond
industry,
or
Harvard that enabled me to push for better and better health. On the advocacy front, I
with whether one will be more afflicted with
believe that we need to recognize a population
chronic disease and how effective certain
needs
treatments will be in ameliorating ailments - as
significantly
more
than
health
insurance. They need food and housing
such health can often be directly related to
security of course, but, more importantly, they
socioeconomic status.
need to feel a sense of community and
My personal interest and focus has
purpose. This last aspect of heath is one that
often been on healthcare. I have been
can’t necessarily be driven by policy but is one
especially focused on learning how health
that we can take action on in our daily lives
insurance policies can expand coverage to the
and free time. We should remain consistently
most people possible. My initial thought
cognizant about staying in contact with our
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Prescriptions | SPRING 2018
friends and loved ones who have in some
many people without the same access,
ways drifted out of our sphere of immediate
financial constraints can often impede their
interest. This goes beyond the occasional
access
Facebook messenger or text but involves
carbohydrates are often the cheapest foods
pushing
face-to-face
available and if one is trying to raise a family
engagement such as eating together, playing
alone on limited resources it is financially
ball, or telling jokes. In addition, we need to
frugal that they opt for the unhealthy option.
emphasize face-to-face interactions in our
In fact, considerations of picking expensive
community service. Loneliness is often the
“gourmet” or “artisan” healthy meals would
for
greatest
legitimate
harbinger
of
illness, especially for the elderly without present family
members
and
to
nutritious
“We should remain consistently cognizant about staying in contact with our friends and
other neglected groups.
loved ones who have in some
Personally, I am grateful
ways drifted out of our sphere of
that
I
resources
possess to
the
pursue
good health. At school
immediate interest. This goes
meals.
Processed
seem unrealistic, along with making time for the gym or other
pleasures
leisurely
reading
socializing while
like
they
with
and others
could
be
working.
beyond the occasional Facebook
I write this because yes,
messenger or text but involves
the premed grind is real and
foundations in place for
pushing for legitimate face-to-
stressful at times, but I think
me to maintain habits of
face time... Loneliness is often the
that we should recognize
good health, which are
greatest harbinger of illness…”
and at home, I have
constant stress relieving
the ability to take on this work as a blessing in it of
itself. In addition, we need to complexify our
aspects of my life. In the dining hall, I have
view on how to pursue good health at the
access to a well-balanced diet: I can make my
individual and communal level to understand
plate as creative as I want without worry.
how it is a privilege that can’t be fixed by any
While my main challenges come in resisting
policy change alone.
those carbohydrates and sugary foods, for
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Prescriptions | SPRING 2018
Miracle at the County Hospital By Jude Okonkwo ‘21
Tell us again between the dusty coughs and shards of mortality of how one blinks in and out of existence what Lazarus swallowed for but a moment a shadow of flowers and I.V. lines leaking in from the other side of the curtain and love and light and lethargy
Tell us of God and Galaxies
Tell us with of a spirit twirling
your heaving breath
between two worlds having tasted from the chalice, reluctant to wander for a second time and let us for a moment dream we understood what your rigid silence whispers
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Prescriptions | SPRING 2018
Are Resident Duty-Hour Restrictions Actually Beneficial for Patient Care? By Kushi Mallikarjun ‘19
The logic behind such regulations are obvious: many have heard the horror stories of
On March 4th, 1984, 18-year-old Libby
sleep-deprived and overworked residents
Zion, after going to the hospital with the flu,
making questionable medical decisions which
suffered cardiac arrest and did not survive.
no amount of coffee can improve. Hospitals
The cause was not the flu, but rather a simple
have a financial incentive to overworking
medical error involving medication given to
residents—as the cheapest medical labor
her at the hospital. The publicity surrounding
available, they are the easiest to pay for
her death blamed the error on the fact that the
overtime. Some doctors, especially those who
two residents who treated
trained before the duty-hour restrictions,
Zion,
were
overworked and too tired to
make
safe
medical
decisions. This event, which
previously mentioned, were put
“Many have heard the
into place, strongly believe that
horror stories of sleep-
long and grueling training hours actually build a better physician.
led to enormous public
deprived and
outcry, led to the state of
overworked residents
medical
New York crafting the first-
making questionable
incentivizes
ever restrictions to lessen of
medical decisions which
medical residents in 1989.
no amount of coffee can
the
working
Following
hours
other
local
improve.”
regulations, the governing body
for
medical
This creates a culture in the
the
recommend
that
residents
to
overwork in order to please mentor physicians, who wield considerable
power
over
residents’ future. For example, mentor
residencies,
hierarchy
physicians
regularly
residents
for
particular
programs.
The
duty-hour
Accreditation Council for Graduate Medical
fellowship
Education (ACGME) in 2003 decided to create
restrictions were enacted in order to allow
national
medical
residents adequate time for sleep and recovery
residencies. Among them were an 80-hour-a-
that would hopefully reduce medical error
week limit, a 30-hour limit on shifts, and a 10-
due to impaired cognition as a result.
regulations
for
all
hour mandatory rest period between shifts.
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Prescriptions | SPRING 2018
Now that these duty-hour restrictions
because of the immense pressure that exists
have been required for nearly 15 years, many
for residents to under-report how many hours
wonder whether they have actually improved
they work. One large cause of this pressure is
patient care. Several studies since 2003 have
that whistleblower protections, rules that
endeavored to figure this out, comparing
would allow residents to report that they are
patient outcomes before and after the reforms.
being overworked without any negative
The results of the majority of these studies are
impact on them, do not exist; thus, while an
highly counter-intuitive: they generally show
individual working for a government agency
little effect, if any, of the duty-hour restrictions
is protected against employer retaliation due
on the quality of patient care. Only a few
to
studies showed even a small improvement in
Whistleblower
mortality and other patient care outcomes as a
protections
result of the restrictions. Of course, in all these
residents. What’s more, if a resident does
studies,
report
it
confounders
is
difficult
Protection
exist
violations,
against their
by
the
Act,
federal
no
retaliation own
such for
residency
implementation of the Electronic Medical
they themselves are out of a job and are forced
Record (EMR), and constant changes in
to find a new program that will accept them.
resident education and medical protocol itself.
Thus, residents may still be as overworked as
However, the result that these duty-hour
they were before the duty-hour restrictions
restrictions don’t improve quality of patient
were put in place, which could result in the
care drives the question: exactly why are the
null impact of the duty-hour restrictions.
restrictions
the
for
violation
program can be disaccredited, which means
hour
as
control
policy
widespread
duty
such
to
a
not
working
as
In addition to not actually decreasing
intended?
resident workload, another problem with
There are issues with the current duty-
duty-hour restrictions is that they increase
hour restrictions model, namely that resident
patient handoffs from resident to resident due
workloads have remained largely the same
to the limitation on how many hours straight
even with the laws and increased patient
a resident can work. This leads to disruptions
handoffs are unsafe. Perhaps the largest is that
in the care patients in hospitals receive, which
even though the restrictions apply to reported
could be dangerous for patient safety. This
duty hours, the actual hours worked are felt to
might be the cause of the net zero gain in
remain the same before and after the
patient safety the studies have found; even if
implementation of these policies. This is
the residents are less tired and are less likely
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Prescriptions | SPRING 2018
to make medical errors as a cause of being
decreased
overworked, more frequent handoffs might
decreased medical error. It is clear that no
depress patient outcomes correspondingly.
patient wants a physician impaired by
Alternative methods of alleviating this problem
stem
helping
and
thus
sleeplessness and fatigue operating on or
residents
treating them. And no medical student would
themselves to better cope with their tiredness
like to be such a physician either. However,
and their workload. Some may find it
the current resident work hour restrictions do
surprising
not eliminate this problem.
that
from
miscommunication
Strategic
Napping
was
officially recommended by the ACGME as a
On a personal note, as a prospective
technique to reduce fatigue
physician, I initially adored the
among residents. Increased
“ I believe there can be
idea of duty-hour restrictions for
emphasis on self-care and
governmental, or even
residents. Who would say no to
Mindfulness-Based-Stress-
simply market pressure on
more free time, better sleep and
Reduction (MBSR) sessions
hospitals to provide the
less work for the same gain?
are
also
increasingly
popular ways for residency programs
to
encourage
best quality outcomes, which can then allow
However, after delving into this issue more, I have come to the conclusion that this issue is best
wellness among residents,
residency programs to
served by individual residency
and results from studies on
innovate and create rules
programs, rather than at a
these methods do show
which they think create the
governmental level. I believe
best quality of care...�
there can be governmental, or
promise. However, the duty-
even simply market pressure on
hour restrictions by the ACGME still stay in
hospitals to provide the best quality outcomes,
place, with few changes. There are systemic
which can then allow residency programs to
problems with these regulations that need to
innovate and create rules which they think
be addressed if they are to achieve their
create the best quality of care. This will also
intended purposes. Of first priority should be
create competition for the best residents, as the
the creation of a whistleblower protection
best residents can gravitate towards programs
policy to ensure that residents who report
which better fit their lifestyle choices, and
violations of the restrictions will still have
residency
their job and career. Another big priority
optimize quality of care and resident choice.
should be making handoffs safer to allow for
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programs
are
incentivized
to
Prescriptions | SPRING 2018
Illustration by Jang Lee’19
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Prescriptions | SPRING 2018
Before Chemotherapy By Ellen Zhang ‘19 she lifted her arms to solo melodies afternoon sun spreading soft across her body blossoms descending upon her lacking fanfare too early sort of stage to envision anything like cells budding through her torso spreading across those lungs like jazz uncontrollable furious ferocity spring swallows air she spins & spins this image carried for weeks in hospitals: flower budding fragmenting the air fleeting
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