Conclusion

--Overlooking some of the Island from the Sand Ridge--

--Dr Bingham and Dr Lovell arguing and posing--

Well I'm back home safely now. I was up something like 30 hours on 4 hours of sleep before I finally passed out. I'm set to enjoy the last few weeks before 2nd year and the ensuing grade competition that arrives mid-August. This summer has given me great insight into how another system of health care operates. The benefits and disadvantages may be different relative to those facing the US but the underlying trends and stressors are the same. I've also enjoyed the chance to understand the focus of public health and how it can work productively w/ the medical community to accomplish common goals. I spent much of my time addressing various sources/consequences of inequalities most notably deprivation and CVD risk, and prisoner and cancer risk. I've worked with every possible level of health care from hospital housekeeping to executive directors and seen the unique problems but common dependency they all share with each other. Finally, I learned a lot about the history, culture, and people of one Island and of England, in general. The people I've met this summer--especially in the public health office--are some of the warmest, most grounded and enjoyable individuals I've ever met. I felt like an emotionless robotic blob on the way home b/c I was so tired but the first feeling that came back to me this morning was regret for not thanking them all in full and that I already miss them.

I've been told my blog posts are too long and this won't be an exception. I'll try to just summarize some of my main concluding thoughts that compare the US and UK systems. My work on cancer and CVD prevention I think would best be left to the papers and not this forum.

1. More so than anything, the professionals, system, and patients in the UK and US are more similar than different. Health professionals have the same ideals, personalities, life goals, and aspirations while patients have the same diseases, fears, trust, and growing autonomy in care. Mental health access is an issue in both countries as physicians are not "formally" trained to treat such patients or do not have the time to do so properly. Physicians spend roughly the same short 7 minutes with patients, their practices struggle financially despite being overloaded, and all professionals work long hours.

2. Deprivation and inequality are important issues that contribute to significantly different health outcomes in both the UK and US. Though race is a bigger factor (partly b/c we have a bigger minority population) it also plays a role in the UK. Just like in the US doctors often are resistant to addressing this "public health" issue b/c they're overworked and are used to just treating whoever walks in the door.

3. Despite my previous assumptions, access to care is a huge issue in the UK like it is here in the States. Though it doesn't come in the form of inability to pay, it does in that patients must often wait some length of time to see a physician. "Elective" procedures of course also have a waiting time.

Part of it I think is patient education. Though I can't say this with any certainty, patients in the US seem more proactive and informed of their options when they enter the office. The UK is also shaking off the paternalistic medicine tradition but b/c our market is more about consumerism we may be a bit ahead of them in this regard. Contrary to what we're told in the States I would say that the physician profession has more autonomy and more political power than in our system. We're simply owned by HMO's and GP's in the UK are still very much independent businessmen/women.

4. The NHS (UK) is a tax based system focused on improving the health of the population overall and not necessarily on an individual level (no politician would ever tell you this). Therefore a lot of concentration is given to improving early life mortality (under 75) and not extending life beyond all possible means until we're little vegetables running around entirely supported by machines. Therefore, strict guidelines exist for which patients qualify for which procedures. This happens in the States, courtesy of HMO's, but we seem to be more lenient on drawing the line. I think anyone would agree that the NHS's way of doing things is better in that it saves money and ensures that everyone has roughly an equal shot at living a healthy, average lengthened, life---until they get sick. At that point you want to push for every possible chance of surviving even if it costs 1 million dollars and has only a 3% chance of working.

5. The interface of public health and the medical field is maintained better in the UK. Public health doctors have all (until recently) been trained as physicians first. Therefore they have the background and experience which validates (in the eyes of medical doctors) their viewpoints. I think the UK does a better job of at least talking about prevention and trying to incorporate it into the central focus of every NHS administration. I'm not sure if they actually deliver on prevention (they're 5 to 10 years behind us in screening--cervical, colorectal cancer, etc.) but the unity between public health and physicians is important.

It seems we're actually moving to the unification of the two fields. Curiously, the UK may be moving in the opposite direction. Medical training has been taken out as a requirement for public health and meetings between physicians and public health teams are beginning to be phased out with administrators now acting as the mediator.

6. The problems affecting both systems now and those that will arise in the future are identical. The aging population is causing worries in both the UK and US. For the NHS and our Medicare/Medicaid, the balance between young payers and old recipients is shifting in the scary direction.

The rising costs of new technology, cancer treatments, and life sustaining techniques is also stressing both systems. There is a push in both countries by the public for better, faster diagnostic tools that may increase outcomes but at what cost?

The advancing field of genetics and its potential to read your "health fortune" at an early age to predict your susceptibility and drug reactions is both amazing and scary. I've seen 4 stories just this week on the growing ability to quantify risk based on genetics. Both societies will have to struggle with the ethical issues that come up. Financially, though it will reduce the need for screening the entire population, I think overall it will lead to higher costs as people preemptively undergo unnecessary procedures to prevent fulfilling their genetic fortune.

The "grass is always greener" phrase really applies to health care systems. The UK public is crying out for more competition, choice, and consumer ideals while we desire all of our citizens to be insured and for medical costs to stop rising. The future of both systems is certainly not guaranteed. Though the NHS has far exceeded my expectations and reassured many of my doubts, I don't think a nationalized system is necessarily the answer to all of our problems. It would obviously insure everyone but the problems it carries may be as unacceptable to the capitalism-minded US public as the ones we face now.

It seems the answer, as it does in everything else, is in compromise. A mixture of the benefits of a private market as well as the support of public programs I think could solve our problems. Obviously, we have something like that in place now but the extreme costs of health care prohibit people from joining the private market and the public programs cannot afford to be inclusive enough. So, the market aspect isn't working and people are left in the middle. As for how to fix this...I have no idea. Maybe I'll learn that next summer but I think I should probably do something more clinical since all of my classmates have been out saving the world this summer.

Thanks for reading my attempt at a blog this summer. Take care!

Wrapping Up

Last Fun British Word of the Day: Cheerio-goodbye, fitting for one of my last posts

The last few days have been a whirlwind. I leave Friday morning and have only one day left here on the Island. There were a few loose ends and experiences that I had to jam in this week so things have been pretty hectic. I could write pages and pages but I'll try to keep it short. Stay tuned for some sort of conclusive wrap-up that I hope to put up tomorrow, but more likely after my return.

On Monday I went with the Outreach Bus and nurses to screen people in deprived wards and offer health counseling. The bus is the spearhead of the health inequalities project that I incorporated into my comparison of US and UK cardiovascular disease prevention that I also completed on Monday (still can't figure out how to post documents). The nurses let me do the screens and counseling since the testing was very basic and I thoroughly enjoyed talking to people about their lives. I'm not sure if I persuaded anyone to change their lifestyle but at least I got them thinking about the consequences of not doing so.

On Tuesday I presented my paper on cancer deaths to the Prison Operations and Modernis(should be a z)ation board. They were really receptive and my presentation went surprisingly well. I found a lot of interesting trends in the treatment of the 20 gentlemen I reviewed and I think the board was very interested in my suggestions. I'm returning tomorrow in the morning to tour the facilities, meet a few prisoners, and speak one-on-one with the director of prison health care to talk more on my work.

After work on Tuesday the entire public health office and some of the commissioners came out to send me off. We went to a rooftop bar in Newport and had a few drinks. Again, another great time with the Brits who definitely know how to party. After talking about the problem of obesity on the Island for nearly 30 minutes we ran down to Hong Kong Express and gorged ourselves on greasy Chinese food. I met the son of one of the executive directors who brews his own beer and offered to take me to a few pubs to sample the Island's locally made beer. Thus how my intended 8pm return to my room ended up getting pushed back a few hours. The beer, however, was absolutely amazing and well worth the missed sleep.

The guy--who I wish I would have met earlier in my stay here--looked up at me after his 4th pint and said..."Kris, do you want to drive a tank tomorrow?" Apparently his friend owns the military history museum and some 50 odd WWI and II tanks that they like to drive around and fire off blanks. I must admit I didn't believe him until he showed up today and took me, in my shirt and tie, to the "battlefield" north of the hospital. I'm not sure I can put justice in words to what seeing someone drive a tank is like. Very cramped, hot, dusty, and excessive...but absolutely thrilling. They pulled some hairpin turns, climbed 20 ft dirt piles, and other likely unsafe movements and had a great time this afternoon. Tonight he (Ed) and his mother Theresa are taking me to "find" some hops to take back to the States and, if I can get them through customs, I'll try and brew some proper British beer for all of us. I'm not sure what "find" means and, like Dr Bingham's flint hunting, he refuses to explain it to me in advance. Finding amusement at my ignorance seems to be a common theme here.

Also, and I'll stop after this, I shadowed Dr Thomson, a general practitioner this morning. The NHS is more bottom heavy in terms of the distribution and responsibilities given to primary physicians so I'm glad I had the chance to see the vital role they play in gate-keeping for the system. My hands are hurting so I'll try and sum up the differences between what I saw today and our community weeks in my final post. I met a man who had a CABG (bypass-DAD) 30 years ago which makes him certainly one of the longer survivors and amazing. Shannon let me know that Michale Debakey passed away a few days ago (http://www.charlotte.com/local/story/710829.html ). He was the father of modern heart surgery and actually trained Shannon's grandfather who was also a surgeon. The article says that he performed surgery until he was 90 years old which is crazy. Anyways, a good read.

Hope everyone is doing well. Wish me luck on my return flight.

Last Weekend

---Debbie (left) and Mary who accompanied me to the workshop in London---

--Randip (one of the STI specialists) and I out with the public health office for my birthday celebration--

--Down House, where Darwin lived and wrote "On the Origin of Species"--

--Dr Bingham and I outside another random palace/castle--

View of London from Greenwich Observatory--

I started Friday off with another trip to the mainland on the car ferry and a long, but exciting meeting at the regional headquarters for a priorities meeting committee. The purpose of the committee is to decide which treatment options are permitted for which patients and to advise physicians accordingly. They essentially undertake the same sorts of conversations as our HMO's. Usually they deal with new cancer treatments but Friday's agenda was In Vitro Fertilization and Bone Marrow Stem Cell Transplants which are both extremely complicated, and, especially w/ IVF, ethically charged. I won't bore you with the details but seeing the physicians and administrators (commissioners) interact and reach compromises on very difficult issues was amazing. Determining the ages at which the NHS will pay for IVF was exceptionally complicated and heated (only 36-39 if you were wondering).

After the meeting Dr Bingham and I drove to his parent's house in London where I would stay the weekend. They are both in their late 70's but very much in tune with the world and energetic. We stayed up late one evening talking about what it was like to grow up in London during the nightly bombings by Germany which was really interesting and a discussion I'm afraid won't be possible in another 10 or 15 years. Dr Bingham's mother was a great cook and I got to sample typical English dishes like shepherd's pie, cabbage, a full english breakfast, etc.

We went to Greenwich, Downe (Darwin's house), a roman castle, and walked around the hills overlooking London where Elizabeth I grew up in an amazing palace. Overall, a great weekend and fantastic ending to my time here (I have 4 work days left). I've learned a lot about the NHS but also about England in general b/c Paul and others in the NHS have been so willing to teach me the history, culture, politics, and general views of the places and people I've visited. I've been very fortunate to experience another country and health care system in such a thorough manner and though I'm incredibly excited to return, I'm sure I'll miss England as soon as I'm back.

By the way...we really should work on our isolationist attitude. Hearing the BBC Radio News on the way back to the Island today, 14 of 19 news items mentioned the US in some way. What or who in the world is Fannie Mae?...I need to catch up...

I just realized I forgot to put up pictures of people at work so definitely check them out...hopefully more to come tomorrow.

Health Inequalities Workshop

--Parliament and Big Ben early in the morning--

I woke up on Monday at the wonderful hour of 5am to grab a ferry and train to London for a Health Inequalities Workshop specifically focused on cardiovascular disease. I went with Debbie and Mary, the trust's representatives for the morning, and it was quite an experience. Public transportation is so convenient here that people are able to commute by train from as far away as Southampton (2 hours!) every day to London. The train was packed with business types messing on their laptops and chatting away on their blackberry's-a reminder of why I postponed the real world to enter medical school.

The workshop was in the Holiday Inn somewhere near the London Eye b/c I could see it out the windows of the conference hall. Speaking of which, who designs a conference hall with windows and expects people to pay attention? The workshop itself was interesting and gave me a few directions to pursue for my paper. It was great to see all the PCTs come together to swap inequalities projects and the diversity in which the programs were designed. Because I woke up before the sun did (which is 4:30 here) I let my guard down and accepted every offer for coffee that I received which ended up being 5 or so. I apparently forgot one of the first lessons I learned when coming here which is how to say no to drink offers. I actually had to leave for half an hour to settle down b/c I was starting to feel like I'd been drugged...and I guess I actually had been. Good times....

Since Monday I've been at the Medical Commissioners office seeing how the CEOs, directors, and corporate big rollers interact. I must say I'm glad I ended up on this side of medicine b/c the meetings are dreadfully long and technical and the administrators all seem a big detached from the humanistic side of their jobs. I suppose you have to be but that doesn't mean I have to envy their positions.

The girls from the office (Philippa, Randip, Joanne, Gayle) took me out for dinner and drinks last night to celebrate my birthday. It was actually in June but it took us a while to find a time that was compatible w/ everyone's schedule: not that it made a difference to me, my nights are universally open. The people from work were awesome and we had a great time.

Time is running out as I fly out next Friday. My remaining time will be spent with a GP in rural Freshwater, with the cardiovascular prevention outreach bus, and with the public health team. I'm also heading to London this weekend with Paul's family to see the spots I missed when Shannon and I visited in May and maybe check out Kent.

Nobody wants to celebrate Independence Day over here

--Stonehenge--

--Somewhere in Bath--

--Hot Spring that Supplied the Roman Baths--

Fun British Phrase of the Day: Bibs and Bobs-synonymous with "odds and ends", used when going out to buy random things or when saying that you have a little bit of this or a little bit of that to complete at work.

This weekend I made the epic journey up to Bath which is really only a few hours away but not exactly the easiest place to access from the island. The train ride, however, was well worth the inconvenience as the countryside turned more and more Welsh as I traveled north. The rolling, light green hills of southern England gave way to the rugged, darker mountains, with streams snaking through them. Every few miles or so there was a random, massive medieval castle perched up on a mountain with a town almost hidden in the valley below it. The city of Bath was beautiful as you'd expect and I especially enjoyed the roman bath museum with the bubbling hot spring and 2000 year old temple built to support it.

I saw a Boston Tea Party-titled cafe and went in to have some tea and make jokes about taxation. Unfortunately, they didn't get them and when I explained they weren't very amused. Everyone else who remembered the holiday wanted to celebrate it with me and were really open to playful jabs about our breaking from their empire. From what I've seen, the Brits seem really relaxed about their past atrocities to mankind and make jokes all the time about how they screwed up their colonies or gave us a "freedom complex." Not to say that it is necessarily a good way to handle it, but much better than our style of avoiding it or denying those topics altogether.

Bath was an infant compared to Stonehenge, which I saw along with Salisbury on the way back. I think I'd become desensitized after a lifetime of seeing photographs of the rocks but it was amazing up close. I didn't realize how large (45 tons) the stones actually were and the history and myths behind the 5000 year old monument were really interesting. Whatever the meaning of the arrangement, the location itself felt special. You could see burial mounds and additional monuments for miles around.

After checking out the cathedral in Salisbury w/ the Magna Carta and oldest clock in Britain, I headed back to the Island. All together, I used 11 forms of public transportation today without a hitch. I'm becoming more and more European by the day. Still, I can't wait to get back home and resume driving down the driveway to get the mail.

On the way up to Bath I was catching up on the British Medical Journals I've been given and was startled at the number of references to the US system. The 60th anniversary of the NHS has stirred discussion as to whether or not the founding principles still apply today. Some it seems, value the economic ideals of efficiency and competition that (arguably) frame our system. They also argue that a tax-driven system is no longer compatible with consumerism b/c patients will demand more and more expensive or experimental treatments. Correctly, I believe, they also demonstrated that as the population balance shifts towards the elderly you'll have less working, tax payers to support the retired persons who are using more of the system. At some point people will stop wanting to raise taxes to support others which is an argument that comes into play with our own Medicaid and Social Security systems.

However, one author noted that when genetics advances to the point where we're able to predetermine risk of cancer or other diseases, that an insurance-based system where patients pay according to their risk will inevitably collapse. Only a taxed, universal system that can share the risks and avoid slamming people who happen to end up w/ certain genes would survive. This is something we've talked about in school but I hadn't seen it applied to this level yet.

Hopefully, at the end of this summer, no one will ask me my definitive answer for which system works better b/c at this point I still have no idea.

2 Weeks Left!!!!

Not that I'm happy or anything.

There really isn't much to report since my last post. I've finished Darwin's ties to the island which should be published in the natural history society's journal as well as the prison paper which I'll present to the board before I leave. It doesn't look like I can attach documents so luckily you don't have to read them. The Cardiovascular Comparison btw Virginia (b/c they have better data than NC and an Isle of Wight County) and the Island here is underway and I hope to complete it sometime next week.

The plan for the rest of my 2 weeks here is to attend a conference in London, shadow the city council and medical administrators for several days, follow a GP, present my suggestions to the prison, and finish my heart disease stuff. I might also get to hang out w/ the smoking cessation ladies at some point.

My little, adopted brother has started a new treatment called Intrathecal Baclofen Therapy for Cerebral Palsy or, in his case, upper motor damage from shaken baby syndrome (courtesy of his natural parents). The "trial run" was yesterday and they gave him a lumbar puncture to administer the drug that will loosen the rigidity of his muscles and allow him to strengthen and hopefully regain motor function over time. Anyways, the tap didn't go so well and he has a tear in his dura mater and is in the hospital under observation until Monday. So if you can, think of him sometime this weekend.

Off to Bath, Stonehenge, and Salisbury this weekend which should be awesome. Watch out for pictures on Sunday.

More sightseeing and Cardiology

--Osborne House where Queen Vic and Prince Albert Stayed on the Island--

--Sailboats in Cowes Gathered to Watch Yacht Race--

Fun British Word of the Day: Welly-when you are giving something the welly you are trying really hard at it-I am giving it a welly to rush home for dinner

Quick recap from this weekend:

I went to Osborne House where Queen Victoria lived to get away from everyone, Carrisbrooke Castle where King Charles was imprisoned during the Civil War, and saw a yacht race around the island. The weather, being 70 degrees and moderately sunny, was the best I'd seen so far here so I definitely took full advantage.

This morning I shadowed Dr Dallas Price, a cardiologist consultant for the hospital. I've shadowed a few cardiothoracic surgeons and a cardiologist here or there but today was exceptionally awesome! Not only was Dr Price an amazing teacher but I also understood everything he explained! I guess first year actually did some good. I was nervous as I'd seen him grilling junior doctors (residents) in the hallway but I think I withstood his medical inquisition fairly well.

Another reason that I was so entranced today was that we saw some amazing cases. The first lady in the morning had an atrial septal defect and I was able to hear the two clinical signs indicative of the condition. We then saw an entire family who had Marfan's Syndrome which is an autosomal dominant problem w/ your connective tissue. One of the manifestations can be a dissection of your aorta where it connects to your right ventricle so we took each individual in the echo lab and measured the width of the vessel right past the aortic valve. Dr. Price demonstrated what the most common murmurs sound like, how to describe them, and where to look.

I'm also finished the prison paper and the Darwin paper and I'll post both of them once I've fished out the grammatical errors. These last few weeks I'll start work on comparing Virginia (which has an Isle of Wight County) and Hampshire (which is the region that contains the Isle of Wight Island) in how they detect, treat, etc. heart disease and maybe a bit about how the social contributors differ for the US and UK. I'm also set to go to London to work there for my final week.

Cheers!

Playing Catch Up Again...

--Tent in front of the old hospital and duck pond where the NHS 60th parties will take place--

Work has really picked up the last few days. I've been working 4 or 5 hours every night on my prison paper after getting home from the office. I've finished most of it but it's nearly 22 pages which is at least twice the length of the longest paper I've written to date. I'll have to provide a link to it, as well as a better explanation of what I've experienced this week when I have some time on Sunday.

Until then, I'll give a running list and hope that works for now. On Monday I sat in on a meeting on the dreaded Nora virus which is important here since there were 4 outbreaks on the island last winter. Apparently 2 of them were at 700+ kid summer camps and there is a cloud of litigation still settling. The meeting was interesting because it involved the tourist industry heads, hotel managers, lawyers, and public health officials so there was a lot of translation in both directions.

On Tuesday I experienced my first Joint Partnership Prison Meeting which included reps from the prisons, hospital, public health, and medical commissioning office (administrators of NHS). I told them of my intended paper topic and they all seemed receptive though I'm sure they're not necessarily thrilled to hear someone else tell them areas in which they need to improve. Apparently there is a contagious protest going around in the prisons at the moment in which prisoners smear their own feces over themselves and their cells in an act of defiance. Definitely effective but unclear as to what exactly they're protesting at this point.

Next stop was the HPV immunization (spelled immunisation here) meeting with the school heads (principals). That was interesting as most of the public health officials here, and some in the States as well, don't think this vaccine is a great cost effective measure to reduce cervical cancer. However, they had to represent the government so everyone went in ready to do battle with the faith-based schools. It was immediately apparent to me again how much I dislike principals. I'm sure they're all very nice people but I think I'll always be biased against them. What brought this prejudice to my attention again was how difficult the principals made the discussion. In the end, the only person who could refuse the vaccine was the student...even if the parents gave consent...yet the principals were not happy with the moral implications of vaccinating pre-sexually active girls against and STI and definitely made everyone suffer for it.

Today I sat in on what would be the most revealing look into the NHS I had seen so far on my trip. I believe the title of the meeting was called Low Priority Case Management which basically equated into 4 of the top local NHS officials, including Dr Bingham, sitting down to discuss whether or not to approve controversial treatment for patients who had requested it. I mean controversial in the sense that these patients were seeking treatment that did not fall in line with common practice or were asking for new, clinically unproven options. If you've ever seen "Thank for you not Smoking" and remember the trio of death (a rep each from the alcohol, firearm, and tobacco business who ate lunch every week to compete on how many people their products killed) you'll understand what this meeting was like. I don't mean of course that we were joking about killing people...but the detached, often morbid humor, was pretty overwhelming.

To be honest, some of these patients were asking for ridiculously expensive and/or unnecessary treatment, like the woman who wanted her breast size reduced from a 33EE to a 33DD to lower her buoyancy while working in the water on the side of her sailboat. However, the majority were requesting chemotherapy or internal defibrillators and they either did not fit the profile for recommended recipients (courtesy of the National Institute for Health and Clinical Excellence) or the treatment had just opened up on the market. Many of these requests would be accompanied by a plea from the GP threatening to get more expensive, yet approved treatment if the council denied the request or other threats bordering on blackmail. Others had letters from pharmaceutical companies (no doubt the ones who made the drug) validating the efficacy of the new drug.

What this meeting should have been called is rationing the NHS's funds. I know rationing occurs in all health care models (for most things, we ration by cost) but I'd never had the reality of it so close to home and I never thought we'd spend 50-60% of the afternoon joking. I suppose it's inevitable and understandable...hey the buoyancy jokes were really funny...but behind the papers were requests from people in pain and suffering looking for a miracle cure. Unfortunately the advising body, the National Institute for Health and Clinical Excellence again, was not necessarily up to date with its protocols and so some patients were requesting drugs that had shown progress recently but hadn't made it through the line to approval.

Well I guess this turned out to be more than a run through...my B

Oh yea, the picture above is taken of the tent where the NHS 60th anniversaries will be held. I think the actual date is July 4th and everyone here will be partying hard that night. I'll be celebrating something else though. There were 70 something flags up outside the tent and each represents a country that has a member working on the island's PCT. Diversity indeed.

Beginning of Another Week

--Riverside Pubs Outside of the Office--

Fun British Word of the Day: Smart--referring to someone who is dressed sharply

Quick Post for the day...just to say that I started my comparative paper on prisons and am writing on how our countries manage cancer prevention, detection, treatment, and end-of-life support. The literature is hard to come by for both countries but I think it's important given that 12 of the 20 prisoners that have died recently on the island had it. Many of them were left undiagnosed until a few weeks, sometimes days even, before they passed away.

I had to go to the ER today on account of not having a General Practitioner, not paying taxes for the NHS, and generally weighing down the system. I have otitits externa which is surprisingly painful and resistant to the antibiotics I'm taking for my tooth infection. My complement system (or would it be IgA?) is not faring well against the onslaught of British bacteria I'm afraid. If I keep it up I won't just be observing all aspects of care, I'll be experiencing them directly. Oh well...

The ER experience was quick and painless. It only took 45 minutes to be seen and I had an antibiotic and was out the door soon after at no cost. I also met my first native-born UK doctor and my nurse had visited Chapel Hill! She said it was one of the most beautiful places she'd been to. Unfortunately, she also liked Duke's Gothic architecture b/c it reminded her of home. They may have nicer stonework but we get the points for being more American.

Enjoy the Picture!

Weekend Travels

--Tudor Style House in Winchester--

--Cowes, from the ferry--

--The crypt at Winchester Cathedral complete with flooding and creepy statue--

--Random government building/surviving part of Winchester Castle--

I had the good fortune of meeting Dr. Bingham's son, John, and traveling onto the mainland this weekend. John is 18 and about to head off to medical school and it was great to be able to have someone close to my age to talk about topics not appropriate for the 40 and 50 year olds I work with. We discussed the differences between our two countries on a number of subjects including health care, politics, gun control, abortion, racism, music, clothing, transportation, alcoholism, food, history, medical school admissions, and the organization of government. Though our cultures are very different on a number of issues the same general system of ethics and values runs underneath our differences. For instance, while we differ on the last point during a pregnancy in which a woman can have an abortion, our moral constraints are the identical and we use the same terms to arrive at our own respective conclusions.

It was especially hard to explain to John what people in the States without insurance do when they get sick. He had a tough time wrapping his head around it and was also amazed at how expensive our system is. At one point he commented that they never think about how much medicine costs because they can get in an accident, rack up thousands of pounds of care, and not pay a penny for it. What was really interesting was when we took turns addressing the weaknesses we thought existed in each other's system and then letting the other either agree or argue for why that perception was incorrect. On my end I found that medical professionals here don't make that much less than we do in the States and that, assuming you have the money for it, you can utilize the private sector if you want to avoid the wait list. As for John, I had to convince him that we don't just leave poor people in need of an emergency on the street to die. He also had never heard of our public Medicare or Medicaid as I knew very little of his private sector.

John and I took a ferry on Saturday from Cowes on the island to Southampton where the Titanic set sail. We then took a train up to Winchester, the old capital of England, and saw King Arthur's round table (not the real thing I think) and Winchester Cathedral. The cathedral was built on a flood plain on unsuitably soft rock and actually sits on a body of water 9 feet under so it's had quite a hard time remaining stable the last 1000 years. Sometime in the early 1900's a diver had to actually spend an entire year switching out the old concrete for new to stabilize the church. The crypts (see picture) were actually underwater which was eerie and smelly as you can imagine.

Using the NHS

Fun British Phrase of the Day- "Drop a Clanger"-meaning to make an embarrassing mistake. A colleague at work told another that she saw his wife on the bus and did not realize that she was pregnant. He replied that she wasn't....awkward....

I had my first encounter as a patient with the NHS today and I have to admit that I was very satisfied. I called in the morning for an emergency dental appointment as I had pain and swelling up and down one of my upper incisors. I also woke with incredible pain in my ear canal. Convince and paranoid that they were related I decided I couldn't put the toothache off anymore. Surprisingly, I was given an appointment 3 hours after I called! Fearing the worst (a root canal) I walked up the stairs to a nice, clean, and warm reception area. I was even treated well by the receptionists despite having to explain how I wasn't paying taxes to support this service and that my credit card did not have the funky English security chip so they'd have to manually put it in. Since I was working at the hospital and the receptionist had a fascination with North Carolina, they said I could pay the nominal 16 pounds which covered everything the dentist could throw at me.

The dentist, a Hungarian, was also incredibly nice which is a quality I find lacking in the States. He took a quick X-ray and concluded that, while I did have an infection, it was in the bone between the roots and so I did not need a root canal! I told him he had given me the greatest birthday present I'd ever had and he said that I must live a very troubled and neglected life. I ran over to the pharmacy and paid 7 pounds for a bottle of Amoxicillin and that was it.

In the end, I was short only 23 bones ($46) for an emergency consultation, X-ray, and antibiotic and was back at work in under an hour. In the waiting room they had a price guide explaining that all crown procedures, regardless of the number needed, cost only 200 pounds. I paid 10 times that much in December for mine at our dental school.

Go cheap health care! I'm now an NHS fan for the day...until I go into work on Monday and hit the paperwork again.

Have a great weekend!

The last few days

Since Monday I've been running around collecting medical, prison, and autopsy records from various sources for various prisoners. So far I've written up 5 men who've passed recently. None were quite as "complicated" as my first but we've still found the need for recommendations. One poor guy didn't receive an X-ray telling him he had metastatic lung cancer secondary to the brain for a full week and the prison finally received the results the day he passed.

Looking at the literature from our own prisons I can't say we're doing any better. I plan to compile the 30 something prison deaths in the last few years and compare how the island is doing in relation to the United States. It should be interesting because both countries (US in 1976, UK in 2003) have said that prisoners must be treated to the same standard as any other citizen and since we've had a few decades head start one would hope we have advice for our friends here.

Another exciting project has come my way courtesy of history/nature lover, Dr Bingham. He's a huge fan of Charles Darwin and apparently the evolutionist has ties to the island. Some of his relatives lived here and he began the Origin of Species here as well. The famous picture above was taken by a photographer on the island. Recent letters and manuscripts from Darwin's life and connections to the island were just found, and the history society and Paul want me to publish this in anticipation of the 150-year anniversary of the publication of the Origin of Species. Not really medically related but baller nonetheless.

There was a suspected case of a meningococcal meningitis and public health had to check it out of course. We visited the poor girl, spoke with her doctor, and wrote down her recent contacts in case we needed prophylactic antibiotics. Luckily, it wasn't meningitis at all but cool to see that aspect of epidemiology.

Finally, we sat in on a meeting today to brief the local schools on the new HPV vaccination. They'll be administering it to all 12-16 year old girls in 3 doses at school which is different from how we do it. They also won't be using Gardasil and they're only country doing this. I didn't catch which one they are using but I know it won't have the added benefit of preventing genital warts. They're target given by the government is 90% vaccination of young girls and since it is in the schools we explored all the difficulties of reaching children in private schools, those not in schools at all, and those not attending school on the island.

My birthday is tomorrow so I'm off to find some good beer. Cheers mates!

Put to Work, My First Prisoner-6/16/08

Fun British Word of the Day-Rubbish-usually pertaining to garbage though it can be expanded to include anything not worth it's keep or unsuitable for some purpose-I was told that George Bush's final trip to Europe was rubbish.

Today I was able to write my first report detailing the events leading up to the “suicide” (not yet officially called that) of a prisoner here on the island. I made a few recommendations and Paul and I plan to submit and argue for our conclusions tomorrow at a meeting with the prison officials. Just like in our country warning signs are often ignored or misunderstood until it’s too late and when you look back it’s very obvious what was about to happen. My prisoner was transferred from one prison on the mainland to the island with a 30 year history of hypomania (bipolar II) and a strong risk of self-harm indicated. Yet, this message was not received, nor were the many official submissions to management made by prisoners and staff that the inmate’s behavior had radically changed. So our main recommendations will be to solve the breakdown in communication and find a more suitable location for prisoners with special mental needs.

Public health, at least here, is heavily involved with just about anything you can think of. We also have a meeting tomorrow to address an unexploded Canadian bomb from World War II that needs to be disposed of. What it is doing here I’m not sure. In fact, I don’t think I realized Canadians even made bombs until today though if I had, I would have bet that their's would be the one not to have exploded.

Exploring the Island-6/15/08

Fun British Word of the Day-Crusty Dragon-A booger, but not just any as it must be completely dried out...I can't even type this without laughing....no example needed I'll presume

I didn't take one of these pictures. I bet you can't guess which one...

I joined up with Mr. Bingham and his wife Jo, also a physician and public health official, this afternoon to go “flint hunting" on the western coast of the island. I was kept in the dark as we drove along the chalk ridge that runs straight in the center of the island and I feared the worst given the British vocabulary and like for extreme sarcasm. However it turned out to be exactly what you would think, that is hunting for Mesolithic flint from the stone age that had been used to make tools such as arrowheads, weapons, dish ware, etc. We searched along a cliff backing the beach which had been exposed as it slumped downward toward the sea with a fantastic view again of the white cliffs-I never get enough of them. Six feet down along the cliff was a well-preserved roman road made out of the white stone and yet another 12 feet under revealed endless pieces of carved flint stones. I now have several bags in my apartment and I’m sure it will be interesting to explain to immigration on my way back to the States what exactly I intend to do with them.

After foraging for prehistoric artifacts we drove by the needles which are the jutting white spikes I told you about earlier (see picture). They're awesome though I hear they gave ships some trouble in the past. Getting hungry now we ate dinner at King George III Blue Crab Restaurant so of course I had to endure conversation for 2 hours about how “naughty” our colonies were to abandon the great British empire.

British humor could best be compared to the carnivorous hunting strategy adopted by the Venus Fly Trap. They put a short statement out there, usually dressed up innocently as something else, wait for ages (several awkward moments), and then finally close down on you making you look like a food in front of everyone else. On the way home I was witness yet again to this relentless sarcasm. As we were nearing a dead end with either a left or right turn Paul’s wife asked him which way to turn and he simply said, as we’re bearing down at 60mph, just don’t go straight. Offering no other assistance we had to slam on the brakes until we acknowledged the disguised humor. Only then did he tell us which way to go.

NHS Structure Overview

I should have added this earlier but hopefully it will answer your questions.

From my limited research and conversations so far I gather the NHS is more centralized than many of the other systems in Western Europe. This means there are more responsibilities to the government and accreditation is a big issue. Prior to World War II health care was controlled by illogically fragmented and overabundant medical authorities. There were actually 17 different authorities or zones on the island. The push toward the NHS rode the momentum of the spirit of unity and survival following the war and led to the downfall of conservative Churchill and adoption of a Labour government favoring social state reforms. Sweden is nearly identical but with greater local control while Germany and Spain sell compulsory insurance which provides services. Instead, the NHS is a tax based approach free upon delivery. Though there are charges for dental, ophthalmic, and prescriptions (these have come and gone over the years), every other service is absolutely free.

There are significant waiting times compared to the rest of Europe but Tony Blair’s reforms have diminished them from 18 weeks to 13 weeks. This is the time it takes for you to notice a problem, contact a doctor, schedule an appointment, be seen, and receive treatment so it isn’t as ridiculously long as we are made to believe. Of course if you’re very sick you are put on the fast track to treatment. As an example, the period of time from cancer detection to treatment must occur in under a month. If you are in a car accident or shot you can luckily just walk (or be carried) into the hospital instead of sitting around a few months. If you’d prefer to pay, elective or mildly urgent surgeries can be undergone in the private sector. Their creation has helped to reduce waiting but there are arguments that it takes away the easy and routine training opportunities for residents (junior doctors here). Recently, just this year, you are now able to see any GP or hospital that is accredited and maintained under the NHS umbrella. France is actually reversing this, providing incentives to stay with one GP.

The minister of health runs the department or ministry of health whose role changes with each government but essentially oversees the entire system. Under the department are 9 Strategic Health Authorities (SHA's) that manage further divisions including the Primary Care Trusts (PCT's), NHS Hospital Trusts, Ambulatory Care, Dental, Ophthalmic, and other trusts. Primary Care Trusts manage local health needs and contain the General Pratitioners. They are the gateway into the system and each GP has a set location and subset of patients. Hospital Trusts are the hospitals, and the other services fall into other trusts. The Isle of Wight Primary Care Trust belongs, with other PCT’s to the South Central Strategic Health Authority and ultimately to the minister of health. The island is unique in that the PCT takes on responsibility for the hospital, dental, ambulatory, ophthalmic, public health, and every other conceivable aspect of healthcare. It is thus all inclusive unlike other PCT’s that manage only GP’s. For this reason I chose to intern on the island so that I could witness the interworking of all facets of care on a small scale.

"The Sex Pistols are still alive?"-6/13/08

Fun British Word of the Day-Arseholed-referring to someone who is in an advanced state of drunkenness. When told about the island's festivals this weekend I was told to watch out for crowds of arseholed people as they seem to be more unpredictable than us sober dwellers.

Today began the exciting Isle of Wight festival. Famous for it's introduction in 1968 as the largest festival ever conceived at the time, it took a 30 year break before being revived the last few years. Jimi Hendrix performed for one of the last times here and the Rolling Stones put on a great show last year. This year it will last from Thursday until Sunday and The Sex Pistols, my mom’s favorite band, and The Police are the highlights. Nearly doubling the population of the island places significant stress on an already burdened hospital so the UK has developed a new specialty of medicine called festival medicine. Here a portion of the revenue from a concert, event, or attraction must be used to pay physicians, nurses, and ambulance services to set up a triage tent on the grounds. The swarms of alcohol and drug-related accidents would simply overwhelm any hospital here so instead the events pay for the consequences of their entertainment.

I’ve begun to notice, especially while watching the European League Soccer Tournament in the physician’s mess hall every night, that there are hardly, if any native Isle of Wight physicians. In fact, I haven’t met a single doctor who wasn’t trained in places like Nigeria, South Africa, the Philippines, or Morocco. When I asked Ode, a doctor from India, he said that it is a growing trend in England, but especially on the island because it is becoming harder to attract young people to the profession. It is worse here on the island because “this is not a place to go to make a name for yourself.” Like in the States, physicians educated abroad, even in one of the colonies, must take a residency-like training before they can practice. A few told me that they arrived only to find their degre was not recognized here in the UK and they had to take the same courses again. Many of them also have to travel around their region away from their families taking 3 month shifts at different hospitals. Ode’s family lives in London and he has to take the 3 hour journey home each weekend. Soon, he’ll move again to Southampton.

Like in the numerous places Shannon and I visited before I came here, there seems to be a real interest in American Politics-and by politics I mean Barack Obama. When I explain that I haven’t decided who to vote for they look at me in complete surprise. Many don't even recognize McCain's name so it's either too generic or their media is even more biased than our own.

In fact and not just related to politics, I’d say generally the English know much more about us than we do about them. I’ve never felt more ethnocentric as I struggled even to remember their prime minister, Gordan Brown’s, name. Similarly, the only knowledge I had of the NHS before my own research seems to have been packaged behind some propaganda at one point or another. On the other hand, they know surprisingly specific details about our system. All of the countless Kings and Queens I learned about in middle school have since been placed into the junk section of my brain but they can engage in an insightful conversation about Colin Powell or lecture me on the waste of money our current colorectal cancer screening policies are.

Pandemics, Heat Waves, and Terrorism Oh My!-6/12/08

Fun British Word of the Day-Mac-as in a raincoat, not a computer as discovered when asked if I had one I replied no, I have an IBM and 5 minutes of conversation ensued to figure out the confusion.

I apologize for the length of yesterday’s entry and I promise they’ll get shorter as the culture shock wears away.

My second day was dedicated to a full 8 hour meeting on emergency preparation. We began with the H5N1 pandemic flu plan which the Brits have accepted as a looming certainty rather than a strong possibility as our professors I believe taught us. It was great because we toured the hospital to see which doors would be locked, which wards would be closed off and how patients would be isolated while allowing critical departments such as maternity or critical care to remain operating.

Brian, whose last name escapes me, came from the Strategic Health Authority to guide us in these matters because the island is very small and sometimes isolated politically from the rest of the mainland. Taking inspiration from our med soci assignment, I asked Brian what the ethical considerations were for selecting patients for a limited number of ventilators. This especially applies to the island which has a population of 130,000 and could only dedicate 40 beds to the pandemic. Though he said ethical standards were emerging, the general consensus among critical care doctors was that they would handle the decisions themselves and did not need outside, governmental intervention. After all, they deal with bed shortages on a daily basis and know best how to handle them. Bed shortages, especially in critical care units, was a significant and unpopular problem before Tony Blair’s government and though they have doubled since, more room is still needed. When pressed Brian said the ethical standards would follow a first come, first serve ideology and then additional decisions would be made only on overall health without attention to social or economic factors. So sadly, our friend the physician (person D?) would have been left without a ventilator. The one exception would be VIP’s who would be given preference. I assume this would be the same in the states though we might not admit it on a public level.

We spent the remainder of the afternoon discussing the heat wave, ship wreck, and fuel crisis plans and then presented them to the Isle of Wight Council politicians. There is a fuel strike to begin this next weekend by truck drivers so the fuel crisis has very real applicability. One physician complained that they were striking when they made 35,000 pounds (~70,000 usd) which is much more than physicians here on the island.

One thing that strikes me about the British is the amount of drinks that are offered to me at any given hour of the day. During my 2^nd day I had 3 cups of coffee, 1 of tea, and a hot chocolate and I accepted less than ½ of the offers. Someone unable to say no would die of a caffeine overdose here. And it seems to be a standard act of courtesy, not stratified by importance or bound to anyone's role in that setting. For instance, one of the Isle of Wight Council members was to begin the meeting but was late. However, upon entering out of breath, she took the time to ask me if I wanted coffee. I said no of course but she insisted and took another 10 minutes to brew and pour me a cup…and then the meeting started.

My First Day as a Public Health Intern!-6/11/08

Fun British Word of the Day: Keen-willing, able, smart, eager or just about any other verb or adjective you don't feel like saying.

After a 20 minute walk into town this morning I arrived at the Isle of Wight Public Health Office, at first a disappointingly small brick building on the main street near the harbor. Resembling a DMV office more than anything, the building’s large windows that faced that street were plastered with yellowed signs advertising a range of campaigns including smoking cessation, nutrition, and the new colorectal cancer screening. However, after ringing the bell, being let in, climbing 3 staircases and navigating through several tight turns I realized the public health office was deceptively large and held offices for some 20 officials.

I first met Dr Paul Bingham who will be my temporary supervisor until Dr. Jenifer Smith, the chief medical adviser for the island, returns from vacation. Dr Bingham (though it is proper only to address him as Mr. Bingham-explained later) and I went for coffee in town near the 12^th century Catholic church. As consultant to the public health office and 2^nd in command behind Dr. Smith, Mr. Bingham is a shy, somewhat quiet man but is incredibly intelligent and radiates passion for his work. He trained as a surgeon, later completed an obstetrics internship in Nazareth, and has finally settled into public health on the island, where he was born.

Though I’ll likely take part in some way with the Cardiovascular Prevention Research Project that I was expecting we agreed that in order to be of the most help to the office and come back to the States with a paper of my own it would be best to help elsewhere, specifically with the prisons. Several years ago, the NHS was assigned to take over prison health care as it was either absent or severely insufficient at the time. The goal then, very much like our Supreme Court Decision in 1976, was to raise standards so that all prisoners would receive care equal to that an ordinary citizen could expect. Due to its isolated geography, the island has 3 prisons and so it has been quite a challenge to find the resources for this recent expansion.

My role will be to act as a detective and review prisoner deaths as they come in to see if they were treated to the standards of the NHS and to offer recommendations for improvement. This year there has been a large increase in prisoner deaths or suicides so we will also look into the factors that may have led to this. However, I was cautioned that there is still a strong fraternal allegiance and protection among health care professionals left over from the days before the NHS, so to tread lightly as public and open blaming is strongly discouraged within medicine.

After returning from coffee Paul introduced me to the rest of the public health team. On the bottom floor are 4 or 5 women that handle the highly successful smoking cessation program. I promised to show them a hilarious poster featuring a superhero beating up a cigarette that I encountered on Barceona’s beaches. The next floor up hosts the STI crew who are hilarious and eager to share their dark humored sex jokes. They mistook the white geese on my tie as sperm and then insisted that I try on the “Chlamydia pants” or the Mr. Condom suit that they wear out for public events. I declined the pants primarily because I couldn't determine what plain looking pants had to do with Chlamydia. Up again, on Paul’s floor, are the county cooks, nutritional experts, Heather-the office manager of sorts, and a room of women dedicated to the various screenings that the island implements.

After lunch I had the awesome opportunity to sit in a meeting that took place in a pub (surprised?) between public health officials and the trust’s commissioners (essentially top name doctors who preside over different fields like surgery or accident and emergency, A&E). This meeting essentially fulfilled one of my key goals this summer which was to see how public health officials and physicians interact, argue, and form connections. There is some departmental loyalty but overall the groups seemed to mix well.

One limitation of government-run care was immediately evident as our 4 hour meeting concentrated on a great deal of overlapping evaluation systems the NHS requested from each Primary Care Trust. For example, there were 50 health outcomes (life expectancy, cancer survival rates, etc.) of which the island (and every other PCT) had to choose 8 and then pledge to improve them by 5% in 3 years. This of course could potentially allow the island to pick the easiest to improve and would not, at least in my inexperienced eyes, necessarily equate to better health. The public health officials wanted indicators like cervical cancer screening which has fallen lately while the physicians preferred lung cancer admissions rates which of course related to tangible issues at their hospital. The next evaluation system was a list of 192 data points the NHS requested each trust collect to evaluate its efficiency and ability to provide care. Finally, there was a third scheme that overlapped considerably with the other two but with different achievement targets and goals. And all of these schemes are dressed up with fancy public relations titles such as Joint Strategic Needs Assessment or World Class Commissioning. At the end of the very long meeting Dr. Bingham asked me in front of 25 top level officials for any suggestions and, after an uncomfortable delay, suggested that I go home and convince others not to let government take a hold of our health care.

My last lesson of the day concluded with an explanation as to why some doctors (like Dr . Bingham), who have an MD, are not referred to in person as doctors. Apparently anyone trained as a surgeon, or an OBGYN, after passing their review test are no longer referred to as Dr. so and so in conversation. Though in writing or on paper they are Dr.'s, in conversation a cardiothoracic surgeon would be offended if you preceded her name with that title. In addition, women are referred to as Ms. even if married and always by their maiden name. The reason lies with the origins of medicine in England with surgeons, university educated primary care doctors, and primary care doctors not trained at a university composing the three guilds. Due to competition and British eccentricism surgeons find Mr. a more prestigious qualification--though only in conversation of course.

Into Newport and a bit about St Mary's hospital-6/10/08

Up early this morning to explore Newport--the town where I’ll be working--which was very busy in the morning with markets of all sorts taking up the two city squares. The skyline (if that even applies to towns) is dominated by the steeple of St. Thomas's church. The rest of the town lies along the river which is dominated by very large and very aggressive swans. Ducks and their droppings run rampant throughout the streets but luckily there are no pigeons who I’ve grown to fear after traveling in London, Paris, Nice, and Barcelona.

It was only lunch time but people were outside at the pubs visibly tipsy singing about a random soccer match that was going on. I have noticed in town through attendance taking that there are plenty of the elderly, teenagers, young wives and their children, and middle-aged couples, but absolutely no 20-30 year old men and women. England is either fighting another war I didn’t know about or young people leave the island for bigger and better things. Either way it seems it will be difficult to meet people here. On a plus note, there is a McDonald’s in case I haven’t gotten sick of it already, a KFC, and Pizza Hut. There is also a public library, several grocery stores, and a cinema!

I came back and explored the hospital near my apartment. The site accommodates 400 beds and can handle everything except severe burns, open heart surgery, and violent trauma. One of the physicians told me he cannot remember the last time they saw a gunshot wound.

As far as appearances (see picture), the hospital looks nothing like ours in that it resembles a factory or warehouse, there are few windows, and the interior is very narrow and plain. Also next to my apartment are 3 prisons and a secure mental health facility which still uses electroshock therapy for schizophrenics. The island has a large number of the mentally ill and drug abusers as is indicative of most isolated communities I suppose.

My Epic (ly Long) Arrival 6/9/08

After a flight from Barcelona, train to London and then to Portsmouth, a ferry to the Isle of Wight, and a taxi to the staff accommodations at the hospital in Newport, I finally arrived! I think the journey ended up taking 12 hours and I traveled a distance equivalent to that from Charlotte to Boston.

The island is beautiful. It resembles Southern England in some ways but its higher temperatures and geography give it that scrappy, wind blown, sandy-type feel of our own beaches. St. Mary’s hospital--where I’m staying--is set on a hill overlooking the town of Newport and I can see rolling hills and white cliffs (like those in Dover) for miles. There are hordes of rabbits running around--at least 7 under my window right now--and they don’t seem afraid of me at all. I imagine that won’t last long. Occasionally I’ll see several hundred sea gulls stir up together from the hills in the distance and fly away somewhere. The human presence here seems more at harmony with nature than back home--or maybe nature is just more stubborn.

The island is actually really big so don’t ever trust Google Earth. It contains 147 square miles of farmland, developed areas, and coastline. Though it has no cities there are 7 sizable towns with Newport being the 2^nd largest behind Ryde. 130,000 people live here in the winter though that tends to double or triple in the summer. A hill, where the Romans used to build their villas, runs down the width of the island for 24 miles dividing it almost equally in half. The northern half has clay like soil similar to North Carolinas and is unsuitable for farming but the southern half has incredibly rich land and all kinds of fun veggies are grown. There are 12 public, well kept beaches, many with white cliffs adjacent and at the western end there are a series of white spikes that jut into the ocean in series called the “needles.” Apparently this is where the island was connected to mainland Britain long ago.

The main employers on the island are the NHS, a factory that makes propellers and hovercraft, and sailboat construction. There are significant inequalities, a disproportionate elderly population, and a below average GDP so the public health aspect should be busy.

My objectives here will be to observe the workings of a nationalized health care system on a small scale, get a feel for public health, and contribute to the Cardiovascular Research Prevention Program which identifies risk factors and is targeted to undeserved areas.

I plan to explore Newport tomorrow and find food, entertainment, and glory!