31 October 2011

Power of deduction

One professor told us that entering the medical profession would make people see us differently. Another told us the corollary: that entering the medical profession would make us see people differently. I can already feel it happening.

Twice today I noticed a person whose gait was abnormal. Automatically I tried to classify the abnormality and predict what underlying disease it might signify.

26 October 2011

Time remaining

The milestone of the world's population reaching 7 billion is a fitting time to reflect upon life expectancy. Life expectancy is a rough marker of humanity and medicine's progress in the age-old battle to attain old age.

Those born in the US this year are expected to live until 78.37 years of age if current mortality rates persist. This puts us at a sobering 50th in the world.

How long is someone your age expected to live? It's tempting, but erroneous, to calculate it as follows:
Current life expectancy - my current age = my expected remaining years
Why? For one, your overall life expectancy increases as you grow older; lumped into the life expectancy figure were those who died in infancy and childhood. A 30 year-old today is expected to live until 81.5 years; a 65 year-old until age 85. The key resource here is an actuarial life table, such as this one published by the Social Security Administration.  More detailed actuarial estimates will take into account your family history; your medical history; your smoking, eating, and drinking habits; your weight; and your education level; all of which contribute substantially.

Knowing how long a patient has to live can inform treatment options. The use of CT scans in children is kept to minimum, because the high levels of radiation can induce secondary tumors decades later. On the other hand, patients with terminal cancer sometimes undergo radiation therapy to relieve pain--their current cancer will prove fatal long before a cancer induced by the radiation. A patient's estimated remaining number of years are factored into screening guidelines for breast and prostate cancer.

This increasing reliance on life expectancy brings up all kinds of fascinating ethical conundrums. If too many medical decisions become centered around life expectancy, life expectancy could become a self-fulfilling prophecy and an entrenched form of discrimination. Should a teenage male needing a kidney should get preference over an elderly woman, simply because he is expected to live longer? If so, should an African-American person get a kidney before a Native American? Should a richer person get a kidney before a poorer person? What about people with life-shortening diseases that hit certain ethnic groups more frequently (sickle-cell anemia, Huntington Disease, Gaucher disease, cystic fibrosis)?

Seeing how life expectancy changes over time gives us a sense of how far we have come, largely thanks to advances in nutrition, sanitation, and combating infectious disease. In 1850, US life expectancy at birth was 38 years, just under half what it is now. 38 years is also the current life expectancy of someone born in AIDS-ravaged Angola.

Why is the US life expectancy so low relative to other industrialized countries', especially when our politicians claim we have the greatest medical system in the world? Monaco's is 90! Main contributors are our obesity rate and smoking rate, or put another way, our government's lack of emphasis on public health. Low-hanging fruit would include increasing cigarette taxes (which significantly decrease smoking rates) and tackling our burgeoning obesity problem.

78.37 years is a simple number with immense ramifications.

25 October 2011

One glance

Four classmates and I were swapping stories at our table in a restaurant, unwinding after a major exam. One of us was still in his scrubs, and our waiter, overhearing our conversation, asked if we were medical students. When we responded in the affirmative, he told us that his mother recently had been diagnosed with a brain tumor and had to get it surgically removed. "It was so stressful waiting for the neurosurgeon to come into the waiting room and tell me and my dad how the procedure turned out," he told us.

"Finally, he came out, and his face was a total blank. Absolutely no expression. Couldn't read anything. I guess that's what he has to do, but those fifteen seconds when the surgeon walked over felt like an hour. With each step he took I kept feeling like something must have gone wrong, my mom must be dead.

"Then he pulled my father aside, and said that everything went great. I was so mad at him that I wanted to punch him, but I was so happy about what he said that I wanted to dance. I can't believe what that guy put me through."

Our once-boisterous table was silent.

Some weeks back, a professor had told us that practicing medicine is a privilege and a burden--you can restore life or take it away, and with one glance or a few words you can alter someone's life, for better or for worse. He told us that people will treat us differently and expect more of us, just because we are medical students and someday, physicians.

Our waiter just wanted to tell us his story. And without knowing it, he had reminded us that our professor was right.

24 October 2011


The ongoing Conrad Murray trial has introduced the public to one of medicine's underworlds--those doctors who break laws and abuse the status and privileges conferred by their profession.

I occasionally read state medical licensing boards' write-ups of disciplinary actions, and some read like crime thrillers. One case report abhorred me. A New York general surgeon had an affair with a married patient just after performing her hysterectomy (removal of the uterus). What made the case particularly sinister was the abuse of the doctor-patient relationship. The surgeon repeatedly phoned the patient requesting that she return to clinic for post-operative follow-up (generally, office staff place these types of phone calls). He had her come in after-hours, when office staff weren't around. When the patient revealed her worry that her husband might no longer find her attractive, the surgeon replied that he personally found her beautiful and kissed her on the lips. An affair developed, the surgeon's insistent overtures leading to a nighttime liaison at a motel. Patients with hysterectomies are supposed to wait a certain number of weeks before engaging in conjugal relations, and the surgeon damaged the patient's stitching.

The medical board investigation found that the surgeon also had badly botched at least two patients' surgeries and had made inappropriate sexual advances on at least two other female patients. Its condemnation was harsh:
Respondent has shown himself to be morally bankrupt...[He] used his status as a physician as a tool to obtain personal gratification from women who were his patients. In perverting his standing as a physician, Respondent did not only have a negative effect on the individual patients, he disrupted entire families.
Furthermore, as the facts in this matter become known, first to colleagues and ultimately to the community as a whole, Respondent has hurt his entire profession. Each time a physician betrays the trust bestowed upon him by virtue of his status as a license holder, the public has a right to take notice and wonder at the trustworthiness of all practitioners.
The board revoked the surgeon's license, its most severe punishment. I doubt the surgeon's wife was pleased. I couldn't find a record of criminal charges being brought against him, and it's not clear to me what he could have been charged with.

Yet there was also a hero of sorts: the patient's primary-care doctor. During a routine office visit with the patient he intuited that something was wrong. He asked around and gathered from another patient that the surgeon was behaving inappropriately. He brought the matter to the attention of the state board.

Plenty of violations result in reprimands, probationary licenses, restricted licenses, suspension, and for the most egregious misdeeds, revocation. Doctors get rapped on the knuckles for failing to promptly inform the board of a DUI conviction, or for repeatedly botching surgeries in ways that should have been avoided, or for keeping poor notes. Although policies vary state to state, looking up a physician's record used to be expensive and slow. Now, most states provide these records on-line, free of charge. I think the trend is on the whole a good one. Patients ought to know who they are entrusting their care to.

There is plenty more to discuss here. The medical board system resembles the criminal system: it is punitive, reactionary, and slow. There isn't a good infrastructure to help physicians whose performance is slipping (for example, a surgeon who is losing dexterity). And there aren't many jobs doctors can do besides medicine, meaning doctors who ought to hang up their stethoscope, and want to, might not be able to.

We need to discipline doctors who violate the rules. Yet we also need to set up a system that makes it easier to identify at-risk physicians and get them help, before the state medical board has to take their license away.

23 October 2011

Who is a doctor, anyway?

As an undergrad I bristled at lecturers' (non-faculty instructors) being referred to as "Professor". I don't believe a title should be used until it's earned. Yet as a student who sometimes examines patients, I'm occasionally referred to as "Doctor" (sometimes by patients, sometimes by physicians). I shy away from the title, although I feel uncomfortable correcting an attending physician in front of a patient. That said, students sometimes try out the title as though trying on a spiffy business suit, incorporating "Dr." into their e-mail addresses and blogs or addressing classmates in jest as "Doctor."

Lots of people are clamoring to be called "Doctor", and a recent New York Times article focuses on some nurse practitioners' push to be called "Doctor" in a clinical setting. Nurse practitioners now have to earn a DNP, a clinically-oriented doctoral-level degree (although it often entails three years of training beyond a bachelors', which would make many Ph.D. students green with envy). The subject of the article is a nurse who introduces herself thusly to patients: "Hi. I’m Dr. Patti McCarver, and I’m your nurse."

I believe Nurse McCarver errs in using the title of "Doctor" in a clinical setting.

First, an analogy. A classmate entered medical school with a doctorate in Romance languages. During our third-year rotations, could he rightfully introduce himself as "Doctor" to a patient? Absolutely not. It's confusing at best and disingenuous at worst. Yet, if the Ph. D. shouldn't be called "Doctor" in front of patients, why should a DNP?

Also, if most health-care providers were to refer to themselves the same way, wouldn't the title lose some of its ability to convey useful information in a health-care setting?

Physicians, optometrists, dentists, podiatrists, and some psychologists can unquestionably call themselves "doctor" when interacting with human patients. I fail to see the need to include some types of nurses as well.

State legislatures have entered the fray, with a handful of states explicitly awarding nurse practitioners the title and a handful expressly forbidding it. So long as this turf war wears on, there will be no shortage of confused patients.

21 October 2011

A walk through the valley of the shadow of death

"Medical student syndrome" is a mainstay of medical training: many students become convinced that they or those around them are experiencing the symptoms of some of the diseases they study. I don't feel like I am suffering from the syndrome, but learning the sheer variety of diseases has made me more frightened of succumbing to one. I had been blissfully ignorant of most of the myriad ways our extraordinarily complex body fails. I now find myself worrying more about aging and about those I love falling ill.

Becoming acquainted with death and its pernicious relations is part of the burden and privilege of medical training. Soon we will be assuming shared responsibility for our patients' well-being, and we must know their enemies to best protect against them.

Fretting that things might be more serious than they appear can be a mark of a good physician. If a teenage patient breaks his femur while playing football, it's one thing to repair the leg and cast it. It's rather another to step back and wonder if the bone had broken because it was weakened (perhaps by cancer or an endocrine disorder). Seemingly innocuous complaints (muscle twitches in the leg) can have unlikely but serious conditions in their differential diagnosis (amyotrophic lateral sclerosis, aka Lou Gehrig's disease). This decision of whether to pursue a case further is informed by years of experience, something I currently lack.

I was taught that one needs to feel concern in moderation; too much worry is disabling and too little is reckless. I hope to strike the right balance, for my sake and for my patients'.

15 October 2011

Responding to mass-casualty plane crashes

It heartens me to see the medical community's tremendous response to extraordinarily demanding disasters. The Reno airshow crash this September sent 35 patients, many of them grievously wounded from complex trauma, to a particular hospital's emergency department. Reno's main newspaper described the situation inside the ED in a riveting article.

The ED began preparing for patients as soon as they received word of the crash, and an automated telephone system requested that off-duty emergency medicine physicians come in immediately. Physicians from all types of specialties flocked to the hospital unasked so that they could be on-hand. What resulted was remarkably efficient and collaborative care.

I'm reminded also of the 1989 crash of United Flight 232 in Sioux City, IA. 296 people were aboard the DC-10, which due to improper maintenance lost its tail engine and all of its hydraulics. This meant no flight controls (throttle, rudder, elevators, ailerons), no landing gear, and no brakes. All that the pilots could control was the amount of fuel going to their two remaining engines. By opening and cutting off the fuel lines, the pilots were able to very crudely control their altitude and somewhat guide the plane, which was constantly turning right. Through a combination of sheer luck, skill, experience, and the assistance of a quick-thinking air traffic controller, the pilots guided the plane over Sioux Falls airport and crash-landed near the runway.

Approximately 200 survivors were rushed to Sioux City's hospital. Physicians, in turn, rushed in to help assist. There were so many physicians on hand that the hospital director arranged for each arriving patient to be met by a team of a doctor, a nurse, and a technician. This team would remain with the patient until they were either discharged from the hospital or admitted. Miraculously, 185 aboard the plane lived.

Sioux City had conducted a mass-casualty simulation a little over a year prior to prepare its emergency response services. The scenario: a passenger aircraft crash-landing at Sioux City airport.

Tragedies can sometimes bring out the best in people, and in these tragic crashes the medical community put its best foot forward.

12 October 2011


The wisdom of the ancient Greeks can still inform modern medical practice.

In mythology, Procrustes was a mischievous innkeeper who offered every traveler a bed. However, the bed was made of iron, and he would either stretch the travelers out or amputate their legs to make them fit perfectly. In one version, Procrustes kept two different-sized beds to ensure that no one fit. The Athenian hero Theseus killed Procrustes, ending his reign of terror.

An excellent contemporary book on physical diagnosis, Sapira's, advises how to ask the patient good questions about their history. It warns against having preconceived notions of the patient's diagnosis and forcing the patient's story to conform to it, calling such practitioners "Procrusteans."

Doctor Hotspot

The most expensive place in the hospital to receive health care is in the Emergency Department. Federal laws mandate that hospitals treat critically ill patients regardless of their ability to pay, leaving taxpayers to foot the bill.

A pioneering family practitioner, Dr. Jeffrey Brenner, found that a small handful of patients in his city of Camden, NJ were responsible for a disproportionate share of ER costs. He decided to provide those patients with primary care, keeping them out of the hospital, with substantial savings to the public. Among his innovations are including "health coaches" on his medical staff, who befriend and encourage the patients to follow their health regimens.

FRONTLINE, my favorite TV program, teamed up with Dr. Atul Gawande, my favorite medical writer, for this 15-minute documentary on Brenner's work.

Watch Doctor Hotspot on PBS. See more from FRONTLINE.

Gawande also wrote a longer piece for the New Yorker last year.

Dr. Brenner's model is exciting because it highlights the likely strengths of a robust primary-care system: cost savings and better health.