Photo Friday: Harriet Tubman’s Underground Railroad Byway & Visitor Center, Maryland, USA

2016.12.10 Harriet Tubman's Underground Railroad  09391
2016.12.10 Harriet Tubman’s Underground Railroad 09391 (View on

“I was conductor of the Underground Railroad for eight years, and I can say what most conductors can’t say— I never ran my train off the track and I never lost a passenger.”

Cope, Stephen (2012-09-25). The Great Work of Your Life: A Guide for the Journey to Your True Calling (p. 231). Random House Publishing Group. Kindle Edition.

A woman. Of color. Who was someone else’s property. Who was illiterate. With debilitating migraines and seizures throughout life due to a head wound received as a child. I went to go see her world close up.

In late 1850, after a number of months of freedom in Philadelphia, Harriet got word from Maryland that her niece, Kizzy, was about to be “sold downriver” into the Deep South— precisely the way Tubman’s sister had been many years before. This was a fork in the road for Harriet. She decided that she must put her own freedom on the line to help rescue her niece. She must go back into Maryland— a slave state where she herself was wanted as a fugitive— to help with the rescue.

Cope, Stephen (2012-09-25). The Great Work of Your Life: A Guide for the Journey to Your True Calling (p. 220). Random House Publishing Group. Kindle Edition.

2016.12.10 Harriet Tubman's Underground Railroad  09348
The view of a slave being auctioned off. Dorchester County Courthouse | 2016.12.10 Harriet Tubman’s Underground Railroad 09348 (View on

The Underground Railroad Visitor Center is opening in March, 2017. It will be worth a visit.

She always remembered her refrain on the Underground Railroad: “If you are tired, keep going; if you are scared, keep going; if you are hungry, keep going; if you want to taste freedom, keep going.”

Cope, Stephen (2012-09-25). The Great Work of Your Life: A Guide for the Journey to Your True Calling (p. 231). Random House Publishing Group. Kindle Edition.

Photos below. Click here to see them on The bottom photo is a 360-virtual reality shot. Click here to see it in 360.

Photo Friday: Sunset at The Universities at Shady Grove, Maryland, USA

University of Maryland Shady Grove 09033
University of Maryland Shady Grove 09033 (View on
As we finished teaching the class together (see: Walking and talking about transgender women’s health: HLTH471 University of Maryland Shady Grove ), Sabrina (@SabrinaMatoffSt) noted the sunset and pronounced it this week’s photo friday. And she made a fine choice, didn’t she.

The building photographed is LEED Gold certified, by the way: SG III | The Universities at Shady Grove

Photos from “Which Health Care Metrics Matter?”

Which Health Care Metrics Matter? Explored gaps between quality data and its use by the public to improve health and health care. (View on

With great thanks to the team from Mid-Atlantic Permanente Medical Group, Kaiser Permanente Mid-Atlantic States (@KPMidAtlantic), NCQA (@NCQA), National Quality Forum (@NatQualityForum), and the medical directors/health officers of the health authorities of Maryland, Washington, DC, and Virginia: Joshua Sharfstein, MD (@DrJoshS), Joxel Garcia, MD (@HealthDiplomacy), William Hazel, MD (@VaSecofHealth)


And, congratulations Kaiser Permanente Mid-Atlantic States for its 2014 ranking of #13 out of 500+ health plans in the United States.

Love continues to be unbeatable, thanks to the courage of our neighbors

I have pledged to write a post for every State in the Union to embrace equality (see the series: Love Always Wins), which happened multiple times yesterday. I’m losing track, it’s happening so quickly now.

Before I found the right photograph for this morning’s post, it found me:

It was accompanied by this e-mail, from Josh Seidman, PhD (@jjseidman):

Subject: For your “Love Always Wins” Files…

I thought you’d like this picture of my wife and four kids campaigning for Marriage Equality in Maryland.
Can’t wait ‘til baby Julia is old enough to know about her first campaign of political activism was about the first civil rights issue of the 21st century.
It was 8-year-old RJ who came up with the idea of putting “scales of justice” on their homemade posters.
What a great day!
Hope all is well.

The woman in the picture, Jocelyn Guyer, who Josh is married to (and vice versa), is Co-Executive Director of Georgetown’s Center for Children & Families – who has helped shape policies over the last 20 years that have led to many low-income kids & families getting access to health coverage.

I do like this picture. A lot.

It is a show of support for equality (which equals health, as the data shows) and it is a show of a support for me. The day after the 2008 election was difficult – I was in California, and there, we were not celebrating the presidential election, we were mourning the passage of Proposition 8. That happened to be the day I met ePatientDave (@ePatientDave) (see: Meeting ePatientDave for the very first time | Ted Eytan, MD), who was so sympathetic to the disappointment I and so many people across the country felt.

It’s now four years later, and people, neighbors, friends, and their families aren’t sending notes of sympathy, they are sending notes of support and stories of their courage, that causes love to be unbeatable. That’s why this is the best Love Always Wins photo today. Thanks, Josh, Jocelyn, and family.

  • Civil Rights Protesters, Washington DC
  • Let Freedom and Love Ring
  • Please!
  • Chris and Hampton
  • Prop 8 ruling outside Federal court in San Francisco 4
  • Washington DC Demonstration for Equality November 15 2008 15664
  • reason to celebrate
  • The Death of DADT - 352/365
  • Standing on the Side of Love with LGBT People Everywhere!
  • Marriage Equality Celebration by The Stonewall
  • CA Day of Decision
  • Civil Marriage Protection Act 2012 Signing Ceremony
  • SCOTUS - DOMA  20991
  • Boy Scout Memorial 19242
  • 2013 Rally for Transgender Equality 21169
  • SCOTUS  26251
  • March on Washington 2013 29383

Why Place Matters – at Net Impact Conference 2012

When I was a medical student, I didn’t have access  to the Net Impact organization. It was being conceived by a small group of graduate students, who had their first meeting of 52 people. Instead, I had access to a jarring and sad American Medical Association convention, where I watched my profession fail for the people it was supposed to serve. For dramatic photographs, see: ACT UP Demonstrations – a set on Flickr. I think seeing this was actually very motivating, as Regina Holliday (@ReginaHolliday) and I will be discussing in our upcoming TEDxTalk at Henry Ford Innovation Institute (@HenryFordIdeas) on embracing failure, on November 8.

Back to Net Impact –

Net Impact is:

a community of more than 30,000 changemakers who are using our jobs to tackle the world’s toughest problems. We put our business skills to work for good throughout every sector, showing the world that it’s possible to make a net impact that benefits not just the bottom line, but people and planet too.

They’ve grown from 52 to over 3,000 as you can see from the photograph above.

Governor Martin O'Malley Keynote at NetImpact 16754

The Conference was keynoted by Governor Martin O’Malley (@GovernorOmalley) who did an incredible thing – he preceded his remarks with an appeal for marriage equality in Maryland, to thunderous applause. In 2012 compared to 1992, he’s now channeling the majority view of Americans asked about this (see: Photo Friday: Picturing Equality | Ted Eytan, MD). At the same time, to see a sitting governor place this importance on equality is…impressive. He also spoke of Maryland’s 21 Benefit Corporations, a new concept designed to create corporations that create a “material positive impact on society.” Finally, he quoted from Robert F. Kennedy’s March 18, 1968 speech about what our GDP counts – “air pollution and cigarette advertising, and ambulances to clear our highways of carnage…it measures everything in short, except that which makes life worthwhile. And it can tell us everything about America except why we are proud that we are Americans.” A great way to start a meeting like this.

Why place matters, A Holistic Look at Health in America

I joined David Harrington from CommonHealth ACTION (@commmonHealthACT), Jessica Kohnen Karaska (@jkohnenkaraska) from Playworks Baltimore, and Kimberly Perry from Washington, DC, Regional Convergence Partnership, to dialogue with 60-70 of the participants on this topic. And it was a dialogue – I am so glad my fellow panelists and attendees ditched the row of microphones and rearranged the room in a circle of chairs.

I was present, representing Kaiser Permanente, because of our commitment to our communities. It’s worth noting that Kaiser Permanente invested $1.8 billion nationally in Community Benefit programs in 2011. In 2010 and 2011 combined, Kaiser Permanente invested more than $130 million through Community Benefit in the Mid-Atlantic region, including $7.5 million in community initiatives to address access to healthy foods, walkable/bikeable neighborhoods, safe streets, healthy schools/after-schools, smart land-use for parks, trails and healthy retail, and more.

That’s a lot, and what it really means is that a health system can and does do more than consider the hospital/medical office environment in improving health, and its physicians, nurses, staff, and members/patients are part of this system. Our participants were pretty savvy about this, in my opinion, and they have the energy to do something about it (also, in my opinion). Maybe they haven’t had an AMA convention to shape their conviction to do something different in their careers, but they study, walk, and interact in the communities that in 2012 show unbelievable rates of obesity and easy access to unhealthy environments.

In yesterday’s discussion, they did have access to innovative ideas like Playworks, which will bring physical activity to every child in America (and to every worker as well), food equity, which means bringing the benefits of a healthy food system to all, and The Port Towns Community Health Intiative.

Recognize the change in yourself

While striving for more, sometimes we forget about the changes we’ve already made.

This hit me when a participant, a nurse (feel free to identify yourself in the comments), brought up the issue of educating the physicians they work with about healthy eating among the families they care for.

My response was to bring the voice of the families into the conversation (and model my Walking Gallery jacket…) and allow them to start the dialogue about what they need. I know, easier said than done. And then I looked in the back of the room where Kait Roe (@kaitbr) was sitting. She was there because I reflexively asked Net Impact several days before if she could be invited to be in the conversation, because, I told them, we wanted patients in every dialogue. They of course said yes. I didn’t solicit the question or plan on talking about Kait’s role because I don’t even think about doing this anymore, I just do it. What a wonderful thing, to come to teach, and end up being taught something about myself :).

Thank you, Net Impact. I hope to see you again in many conversations about health. Oh, and Prevention is the new Health Information Technology.

Thou Shalt Not Stand Idly By – Yet our health care system does – Kait and Ted’s story

“Thou Shalt Not Stand Idly By.” Click to enlarge, courtesy Iris Eytan, Esq.

My sister, who I wrote about recently, took the photograph in this post when I asked her, “What inspired you?” because she inspired me. I remembered visiting her a year ago, while she was working on the case, and how resolved she was to make sure that Tyler would not be imprisoned unjustly because of his disability. Last week, she was successful.

This picture hangs on her office wall – you can see the Denver skyline in the background. On the bottom of the photo you can see 3 years of work to save one person, Tyler Sanchez. On the top of the photograph is the inspiration (read more about the origin of the expression here).

The picture shows what it takes to save a life. Sometimes it doesn’t take much work. All of the time, it takes the ability to care.

The people who serve in the health care system, who are uniformly exceptional in my experience (you have to be to do a job this hard), have an incredible ability to care. 

Why does our health care system not let them?

What happened last week – Kait and Ted’s story

On Tuesday, Kait sent me an e-mail with just the subject : “Advice?” In it, she described acute withdrawal symptoms she was having from her anti-depressant because her mail-order refills had not arrived in time, and did I have any ideas that did not involve an emergency room. There were a few complications – she was not in DC at the time, she was in Baltimore visiting her girlfriend.  Her primary care physician, based in Maine, was not available because of a state holiday there.

I immediately called her and proceeded to do my best to help her get care urgently.

I contacted the Baltimore Medical System and reached a medical center manager, who said Kait could not be seen that day. She escalated the issue to the Medical Director of the entire system – could she be evaluated quickly and given a refill of her prescription to arrest the acute withdrawal until her regular supply arrived? 

She called me back and said the answer was no.

I was told that all of the care providers were full that day and a new patient would not be seen that day. Now, I have been to Baltimore Medical System (see my blog post from the experience: “A resilient population” – Baltimore Medical System”)  and I believed what they told me. I was told that she would need to go an Emergency Room or attempt to book for the next day, with no guarantees.

I gave these options to Kait. Johns Hopkins ER it was going to be. Again, I tried to assist by calling the Johns Hopkins ER to facilitate the care for them and for Kait. It usually makes things easier/faster for everyone, if the receiving physician can know what’s going on – the “warm handoff.”

I called the Johns Hopkins Physicians Access Line, for an emergency physician referral, which is what I could find on their web site. I was transferred and then hung up on. 

I asked Kait to keep the communication up by texting me her experience as it happened. Here’s the interaction between us:

Kait:: I fear the fix is a very long way away. Until we get parity through govt, no insurance will bother to cover it properly. 3:13 PM
Kait:: In a room. Eye exams happen here. But I’m guessing they just want me to be seen. Hahaha 3:24 PM
Kait:: No idea what will happen here. No one has asked me for proof of meds, taken a hx or asked any pertinent questions. 3:25 PM
Kait:: They did ask if I had any pain. But they didn’t mean emotional- I don’t think. 3:26 PM
Kait:: They did a survey. Do I want more info on depression, high blood pressure, and several other things I’M ALREADY BEING treated for. 3:27 PM
Kait:: I answered no. They also asked if I wanted an HIV test. And they tried to tell me it would be anonymous, even though it would be in my record. 3:32 PM
Kait:: They also asked if I would be willing to use a kiosk to check my med record and make sure the info/med lists were correct. I said YES! 3:38 PM
Kait:: Ok, now have seen an NP. She is really good. I may have to be really nice about this experience. 3:39 PM
Kait:: Script in hand 3:51 PM
Kait:: Seeing about a voucher for $ for meds 3:54 PM
Me: Cool! I’m saving these texts. 3:54 PM
Kait:: Amazingly kind. 3:56 PM
Kait:: ER security totally dropped the ball and sent me on a snipe hunt for the wrong social worker. Heading back to ED to get the RIGHT social worker. 4:00 PM
Kait:: Apparently the correct SW is in a trauma room right now. Left hand, right hand – get familiar. 4:03 PM
Me: Omg this is getting hilarious. 4:36 PM
Me: It may be more therapeutic than the medication 🙂 4:36 PM
Kait:: Yes. And I saw the SW finally, but -get this. The vouchers can’t be used for Psych Meds. 4:41 PM
Kait:: So I have two discount cards. My girlfriend will front the $ if I need more than I have to fill the 15 pills. 4:42 PM
Kait:: Laughter IS the best MED. 4:42 PM
Me: Totally! I am on board but my gvoice will store the SMS for storytelling purposes. Keep laughing. 4:43 PM
Kait:: When I’m not sobbing… 4:44 PM
Kait:: 🙂 4:45 PM
Me: Laughter always wins. Send the serotonin soaring. So does love. 4:45 PM
Kait:: Yes, that too. 4:46 PM

See something interesting? As she gets closer to a human being in the system, the “care” part of health care becomes more apparent.

If you think this only happens to people without access to care, you’re wrong. 

I am breaking the silence on an almost identical incident with someone very close to me, my mother, who, as a medicare beneficiary has access to too much care.

She was referred to a sub specialist for a superficial nerve block for severe pain – the kind of nerve block that a family physician can easily do (I have done many myself). When the injection did not work and she called the office of the sub-specialist in severe pain, she was told by the office staff, “Go to the emergency room, we are full this afternoon.” They were adamant, she told me.

I know what would have happened if she went to the emergency room -> narcotics, maybe an admission to the hospital, maybe an infection, a medication error, a fall. All because of a failed superficial nerve block.

I called the sub specialist’s office from 2,500 miles away, got the physician on the phone and asked him if it was possible that the injection was misplaced and could he try again (it is possible to miss the nerve). He agreed this was possible and pleasantly and helpfully said he would be happy to and could my mother come right in. She did, he performed a re-injection and the pain was completely relieved. 

Commonalities – amazing people, less than amazing system

With all of the talk that the emergency room is overused and medical homes are the answer, where’s the walk?

In Kait’s case it was made clear to us that this medical emergency, easily treated in the outpatient setting, would not be managed anywhere but an emergency room, against her wishes, and really against appropriateness. What if she was hemorrhaging blood instead of serotonin, would the outpatient system turn her away before stabilizing her? Acute anti-depressant withdrawal due to lack of medicine is a complete waste of Kait’s time. It could have wasted her life. 

My family’s entire experience could have started and ended in a family physician’s office, without any intervention from me.

Making every day count

I’m going to reveal something in this post that Kait doesn’t know yet. I was able to receive her e-mail and act on her behalf because of a mistake I made right before she contacted me. I read the time wrong on a flight and arrived too late to the airport. I missed the flight, I would lose a day of travel, and it was all my fault. As I walked away, I said to myself that I would make sure that this day counted for something. Now, I am so happy that it did.

People who know me know that I do not use my physician credentials to facilitate care for myself – I don’t even like being called “Dr.” When it comes to other people, though, I will leverage the credentials to the max (just the “MD” part, which I own, not my employer’s name, which I don’t own). That’s why society provides those credentials to us, to be used to lessen suffering. 

Not standing idly by.

I really want more than to lessen suffering for just Kait or my family, though. I want our health care system to change. For real, not pretend.

And…. the only solution I have found, the only one, after 20 years in medicine, that will solve this problem, is to have the patient in the room.

Kait Roe has given explicit permission to share details of her care experience on this blog:

Ted, I LITERALLY have no secrets. If someone doesn’t hire me because I have a mental illness (which this episode clearly shows is controlled phenomenally by medications) I don’t want to work for them. And wouldn’t that be a fun post! As for the choices. Print it all, again. I mean that – and I’ve been back on my meds for two days and feel quite myself again. No crying for two days! 

Photo Friday: Love Always Wins in Maryland, Too

Compared to the last Photo Friday featuring Maryland Governor Martin O’Malley, this photograph features him winning the passage of the Civil Marriage Protection Act of 2012.

Equal access to civil institutions is a social determinant of health, because of the validated better health, better community happiness, reduced health care utilization, and reduced health care costs, that come with ending marriage discrimination.

Here’s the video of Governor O’Malley signing the bill into law, and his remarks underneath it. Maryland is State #8 to end discrimination in the United States.

“For a free and diverse people,… for a people of many faiths,… for a people committed to the principle of religious freedom,… the way forward is always to be found through greater respect for the equal rights of all; for the human dignity of all.
“Religious freedom was the very reason for our State’s founding. At the heart of religious freedom is the freedom of individual conscience.
“If there is a thread that unites the story of our people, it is the thread of human dignity; the dignity of work; the dignity of family; the dignity of every child’s home; the dignity of every individual.
“We are One Maryland, and all of us, at the end of the day, want the same thing for our children: to live in a loving, stable, committed home protected equally under the law.” – Statement from Governor O’Malley

  • Civil Rights Protesters, Washington DC
  • Let Freedom and Love Ring
  • Please!
  • Chris and Hampton
  • Prop 8 ruling outside Federal court in San Francisco 4
  • Washington DC Demonstration for Equality November 15 2008 15664
  • reason to celebrate
  • The Death of DADT - 352/365
  • Standing on the Side of Love with LGBT People Everywhere!
  • Marriage Equality Celebration by The Stonewall
  • CA Day of Decision
  • Civil Marriage Protection Act 2012 Signing Ceremony
  • SCOTUS - DOMA  20991
  • Boy Scout Memorial 19242
  • 2013 Rally for Transgender Equality 21169
  • SCOTUS  26251
  • March on Washington 2013 29383

Photo Friday: Love tends to keep winning

Governor Testifies on Marriage Equality
Maryland Governor Martin O'Malley Testifies in favor of Marriage Equality - Maryland senate hearing

Photo credit MDGovpics

Since I try to keep Photo Friday linked to Washington, DC, this week’s photograph is of Maryland Governor Martin O’Malley, after testifying in favor of marriage equality, to end discrimination against LGBT residents in Maryland State. I chose this pose because it shows that this does not come easy, even to a governor. You can listen to his testimony here, and the Washington Post’s endorsement of his efforts.

He was the third governor this week to have, within reach, the better health, better community happiness, reduced health care utilization, and reduced health care costs, that come with ending marriage discrimination. This is why equality = health.

May the remaining 41 states also experience what the current 6 plus the District of Columbia do today.  I plan on writing a post each time because I think it’s important to remember the lesson  in the title of these posts …. and if love wins this much and this quickly, maybe there will be less than 41 since they’ll be grouped together :).

Today’s ruling is a victory for fairness, a victory for equality, and a victory for justice. Proposition 8 denied to gay and lesbian couples the equal protection to which all Americans are entitled. By striking this unconstitutional law from our books, the court has restored dignity, equality, and respect to all Californians. – Kamala D. Harris, Attorney General, State of California

  • Civil Rights Protesters, Washington DC
  • Let Freedom and Love Ring
  • Please!
  • Chris and Hampton
  • Prop 8 ruling outside Federal court in San Francisco 4
  • Washington DC Demonstration for Equality November 15 2008 15664
  • reason to celebrate
  • The Death of DADT - 352/365
  • Standing on the Side of Love with LGBT People Everywhere!
  • Marriage Equality Celebration by The Stonewall
  • CA Day of Decision
  • Civil Marriage Protection Act 2012 Signing Ceremony
  • SCOTUS - DOMA  20991
  • Boy Scout Memorial 19242
  • 2013 Rally for Transgender Equality 21169
  • SCOTUS  26251
  • March on Washington 2013 29383

Now Reading: Place, not race: disparities dissipate when blacks and whites live under similar conditions

When I was reading about social determinants recently, I came across an error in one of Sir Michael Marmot’s writings, in this JAMA article (“Action on Health Disparities in the United States“). In it, he says:

The gap in life expectancy between men in Washington, DC, and in suburban Maryland is 17 years.

The error he made is that the 17-year gap is for African American men in Washington, DC, compared to men in Montgomery County, MD (I assume that’s the suburban he’s talking about), not the average of all men in Washington, DC. That gap is 9.1 years (as of 2007).

This paper is useful because it calls the racial distinction into question. It might be more accurate to say “a man living in Ward 8, Washington, DC” above, taking race out of the picture altogether, and therefore focus more on the Ward 8 neighborhood.

What the authors did was choose a community with a mix of African American and white residents with similar income, education, and location (they’re in the same community), interviewed 42 percent of them (1,489 people), and took their blood pressure. They then compared what they found to national statistics for the measures they assessed.

  • And….whites and African Americans with the same social determinants looked a lot more similar than different. There were a few notable differences.
  • African Americans still had higher blood pressure, albeit not as higher in this matched community
  • African Americans were no more obese, no more likely to have diabetes than their white counterparts
  • African Americans smoked less than their white counterparts
  • African Americans were  more likely to have a health care visit within the past year

With this conclusion:

When whites are exposed to the health risks of a challenging urban environment,15 their health status is compromised similarly to that of blacks, who more commonly live in such communities.

I wonder even further if whites are less able to tolerate an unhealthy neighborhood environment, given that they smoke more and use health care less. This is just speculation on my part, though.

The study points out and reinforced what’s being discussed about social determinants already, which is that local conditions have a huge bearing on health and looking to customize interventions based on an individual’s genetics or behavior may not be as useful as taking a walk down the street where they live.

Tying this all back to Washington, DC, there’s a vibrant neighborhood blog scene here, so you can electronically walk the neighborhoods in an authentic, personal way. I’ve put together a link cloud of the major ones. Anacostia is Ward 8. See if you see the differences in place. If the differences aren’t obvious there, you can check out this post on local blog TheFightBack for a more intense view of life in Ward 8.

Photos from @mhealthsummit Tweet and Meetup, Oxon Hill, Maryland

Me? Take photos? I can’t imagine…

Thanks to Emily Hackel (@emilyhackel) and last evening’s sponsors (Blueprint Health, HBS Healthcare Club, Fresh Tilled Soil, Massive Health, & Medivo) for believing that the #epicenter could make it to Oxon Hill, Maryland, to catch up. It was nice to see many of the faces of innovation in mobile health today (you know who you are, feel free to tag yourselves in the photos on Flickr).

I am not attending the conference, and I am excited to learn see how social determinants thinking and an app for that come together to produce breakthrough ideas. Photos below, click to enlarge. Creative Commons license, download, use, re-use…