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7000年前农民已会外科截肢手术 手术技艺精湛
作者:USMedEdu
发表时间:2010-02-01
更新时间:2010-02-01
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7000年前农民已会外科截肢手术 手术技艺精湛

http://digest.creaders.net/articleViewer.php?atid=285639&id=292400



一个身穿羊皮衣的人手持一块削尖的燧石,截下另一个人的胳膊……这不是一种酷刑,而是约7000年前的一台外科“手术”。

考古学家在法国一处新石器时代早期墓葬中的发现表明,当时的人类已经会做截肢手术,他们掌握的医学知识比人们过去认为的更先进。

神秘独臂人

这座墓葬位于巴黎以南约65公里处的比捷-布朗果地区。它的主人是生活在公元前4900年左右的一名男性。

墓穴长约2米,比同时期其他墓穴大。墓中陪葬品包括岩斧和动物等,这表明墓主人地位较高。

但最令研究人员感兴趣的是,这具遗骸的左前臂和左手缺失。生物学化验、射线扫描等一系列检测显示,死者生前“成功地接受截肢手术”。

这一墓葬的发现者之一、考古学家塞西尔·比凯-马尔孔认为,死者生前很可能是一名战士,在战斗、猛兽袭击或事故中受伤,不得不截肢。

虽然失去左臂,但墓葬中的物品说明他仍被视作部族一员。研究人员说,他并没有因为残疾而受到排斥。


先民智慧高

这名死者生活的时代被称为“线纹陶文化”时期,那时,欧洲先民的生活方式逐渐从狩猎和采集转变为农耕、养殖和制作陶器。

截肢手术时使用的工具无疑为石器,从创面的整齐程度看,当时的燧石加工工艺之高超出此前人们预计。

考古人员最近还在德国和捷克各发现一个新石器时代先民接受截肢手术的例子。这些新发现可能将改写外科医学史。过去考古学家曾发现石器时代的人们已掌握颅骨钻孔术,但不知道他们还会做截肢手术。

英国《泰晤士报》25日援引法国国家考古保护研究所专家的话报道:“看来欧洲最早的农民已经掌握了相当复杂的外科手术技术。”

手术技艺精

比凯-马尔孔认为,手术期间应该使用了某种止痛草药,可能是有致幻作用的曼陀罗。她说:“这一点我们不能确定,但他们应该会找到某种方法让他(患者)在手术期间一动不动。”

人们可能用其他植物,如鼠尾草,来清洁伤口。“凭肉眼看,没有发现截肢面有感染现象。这说明手术时采取了一定的消毒措施,”研究人员在刊登于《文物》杂志的文章中写道。

比凯-马尔孔同时说:“从现代意义上讲,我认为给他做手术的人不能算是'医生',但他们的确具备一些医学知识。”

进一步研究表明,这名男子患有骨关节炎。他在截肢后又生活了几个月至几年时间。

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共有1条评论
1   [USMcdEdu 于 2011-02-07 20:57:30 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):

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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