30 January 2012

A burrito that's worth its salt?

Our car was barely inching along, caught in horrendous rush-hour traffic. Three classmates and I were on our way to a concert, and we needed to grab dinner before curtain. We pulled off the freeway and found a Chipotle restaurant (part of a national burrito chain). In line, I was amused to find that Chipotle now offers brown rice as a way of catering to health-conscious customers. Just what is in a Chipotle burrito?

Using Chipotle's online nutrition facts, I tabulated the sodium content for a typical burrito consisting of a flour tortilla, shredded beef, brown rice, pinto beans, mild salsa, cheese, and guacamole. This burrito contains 2,460 mg of sodium. With chips, it's 2,880 mg.

To put these numbers in context, the FDA advises that "Americans 51 or older, African-Americans of any age, and people with high blood pressure, diabetes, or chronic kidney disease should restrict their [daily sodium] intake to 1,500 mg." For the other approximately half of Americans, the FDA recommends a daily sodium intake of under 2,300 mg. The meal above substantially exceeded the recommended limit. I even held the sour cream, and I didn't order salsa for the chips!

Not that the salt is necessary. When I make burritos at home, the sodium content is about a quarter of a Chipotle burrito's (and I get to add delicious sauteed vegetables like zucchini). I don't wish to accuse Chipotle of being a particularly bad offender--indeed, it's admirable that they display their nutrition facts so prominently. Rather, these crazy values are typical of the food we eat out of a can, from a bag, or in a restaurant. It also begins to explain why it is so out of the ordinary for me to encounter patients in the free clinic who do not have hypertension.

On Thursday, I explore Congress's and the FDA's inaction on regulating the salt content of our food.

26 January 2012

Getting to know you

Our school offers an optional program for first-year students where we are divided into small groups and assigned a doctor in the community. We sit in a circle and confidentially discuss our feelings, our deeply personal stories, and our conflicting emotions about how we have had to change ourselves to accommodate medical school. Many tears have already been shed, and it's only been the first session.

The people in my circle are classmates that I encounter every day, but who I never really got to know until now. I already feel more of a sense of community. All it took was a patch of floor, some conversation, and some tissues.

I'm surprised by how much is stressing, gnawing at, and tormenting our class just below the surface. Med school seems to have whittled away some of our resiliency and ability to deal with stresses. I can better understand why mental health issues are so pervasive among physicians, and I suspect that in some of us, the bottled-up inward tension will occasionally erupt.

I'm glad to to have found blogging as an outlet. It helps me take a step back. It lets me make sense of what I am doing and why I am here. And I do appreciate how readers like you let me share it with you.

23 January 2012

Playoff weekend

Football seems to subject its players to enough physical and neurological risk that I expect I'll discourage my future patients from joining a competitive football team. Friends of mine who played Division I college football loved it and have gone on to play professionally. They continue to live and breathe football. But I noticed a toll--frequent concussions, dramatic injuries and surgeries, shocking addiction to painkillers, and a difficulty in balancing the competing demands of being a student and of being a quasi-professional athlete.

Scientists are finding that the constant hits (even "microtraumas" that don't rise to the level of concussions) that football players endure can cause chronic traumatic encephalopathy (CTE). CTE is a progressive, untreatable, dramatic, and ultimately fatal decay of the brain that can only be diagnosed post-mortem. Researchers are increasingly conducting autopsies on NFL players and college football players, and they are finding shockingly widespread evidence of CTE. Even deceased players in their 20s and 30s are turning up with CTE, which is otherwise seen only in the elderly. The science in this field is preliminary, yet it is increasingly clear that professional, college, and high school football is a tremendously risky endeavor.

I really do enjoy gridiron football, and on the brisk evening of a big college game I was one of the shirtless guys in the stands wearing body paint. Yet recently I've stopped attending games and I even feel conflicted about cheering my home team while I watch on TV. Wouldn't it make me a hypocrite to say one thing to my patients and do another? Am I taking all of this too seriously?

More generally, does a model physician also need to be a model patient? To what extent is being a physician a job, and to what extent is it a way of life?

That last question might be rhetorical. It feels like medical school has subsumed so much of my life that it's hard for me to know where one ends and the other begins.

19 January 2012

Glad I asked

When I am assigned a patient, I am handed a medical chart with write-ups of their past visits. The chart contains invaluable information. I can quickly ascertain whether the patient's weight has dropped, which could be a sign of serious illness. If a patient's blood pressure is high, I can instantly determine whether it developed recently.

Sometimes the chart contains scattered clues that, only when taken together, suggest a serious and unaddressed illness. I like reading through a chart the same way I read a mystery novel: scouring it for hidden leads and seeking to unmask an unseen culprit.

One patient presented in our free clinic for a minor complaint. An old entry in her chart matter-of-factly noted that she was still on a medication that she began after having a significant organ removed as a young adult (I have to be vague because of patient privacy). The chart did not offer an answer for the question that raced through my mind: why had the patient needed this major surgery?

So when I met with the patient, I asked. She said it was because of cancer, but she refused to elaborate and said she doesn't talk about it. We moved on, but I sensed that this revelation was potentially major and that I ought to find out more. Over the course of the visit, I determined that she was at high risk for developing cancer.

I revisited the point later, using a less direct line of questioning. Eventually she opened up to me that she had recently noticed a large pelvic mass that is constantly growing, but that she was not emotionally ready to have anyone examine it. Her description of the mass alarmed me and instantly made me think of a tumor. Despite my best efforts, she simply would not submit to examination or imaging, and I had to let it go. My efforts were hopefully not in vain. The mass is now mentioned in her chart, and when she returns to clinic a different med student will encourage her to have it examined. And at that next visit, she may feel more ready.

We learn in class that a careful history can reveal many medical diagnoses. There is a real art to the interview. One has to ask probing and uncomfortable questions while still maintaining the patient's trust. One has to cast a wide net so as not to miss a major medical problem, but also intensely follow up on particular leads. And patients can sometimes have poor memories, or be reluctant to bring something up.

I think the delicacy and intricacy of taking a medical history is one reason why computers will not be replacing primary-care physicians anytime soon. The interview is a distinctly human and social part of medical practice, which is one reason why I really enjoy performing it and reflecting upon it.

17 January 2012

Obesity wake-up call

The CDC has just updated its obesity statistics. In 2009-2010:

33.1% of American adults were overweight (25 ≤ BMI < 30); and a further
35.7% of American adults were obese (BMI ≥ 30).

In sum, about 69% of American adults are either overweight or obese. This is a national disaster.

16 January 2012

Views about news: Federal government mandates pharmaceutical companies to disclose drug payments

The New York Times reports:
To head off medical conflicts of interest, the Obama administration is poised to require drug companies to disclose the payments they make to doctors for research, consulting, speaking, travel and entertainment.
 I was quite excited until I read this sentence:
Companies will be subject to a penalty up to $10,000 for each payment they fail to report. A company that knowingly fails to report payments will be subject to a penalty up to $100,000 for each violation, up to a total of $1 million a year.
To a pharmaceutical company, $1 million is nothing. A $1 million penalty per year translates to $250,000 a quarter. Pfizer reported 2011 third-quarter earnings of $3.74 billion.

If you wish to read up on the pharmaceutical industry's influence on medical practice, I recommend White Coat, Black Hat or The Truth about the Drug Companies.

Left in autism's wake

A family member sent me a PBS NewsHour documentary on autism that I enjoyed watching. Congress mandated that students with certain disabilities, including autism, be provided until age 21 with an education targeted to their particular needs. One segment (below) poignantly asks the question, who will care for autistic patients once they become adults? Many autistic people require supervision and constant education, yet the availability of public services depends on the local government and is often limited. The sharply increasing prevalence of autism makes this question particularly urgent.

There's a strong case to be made for Congress to fund lifetime accommodations for those with serious illness (perhaps as part of Social Security). The only way this will happen is through public awareness.

The entire documentary is available via PBS. It runs approximately an hour and ten minutes long.

11 January 2012


Although we've been taught how to perform a physical exam, I have a hard time knowing what is concerning and what is normal. If an obese patient can only weakly push up against my hand, does it signal underlying neurological damage or is it just a sign that they don't exercise? Is that yellowish coating on the patient's tongue a stain from tobacco or a precancerous lesion? What is a normal range of motion for the shoulder of a 70-year-old? Given my lack of experience performing physical examinations and interpreting them, I place little stock in my physical exam findings.

Something sounded funny when I listened to one patient's heart. Since she was morbidly obese, it was difficult to hear clearly through the layers of fat. I couldn't even figure out at which stage of the heartbeat I thought the irregularity was taking place, or what the irregularity might signify. I just knew that my "spidey sense" was going off. Another med student was also in the exam room, and I asked him to confirm. After listening for a long time, he gave up. "I can't hear anything strange."

When I stepped out of the exam room, I thumbed through her chart. The patient had been seen in clinic several times, and there was no mention of a heart murmur. This left three possibilities:

1. Her heart sounds were actually normal and I heard it wrong;
2. Her heart sounds were abnormal and every med student in the past had missed it;
3. Her heart sounds had changed recently from normal to abnormal.

I presumed that the answer was number 1, but I made sure that the attending physician had a listen anyway. The doctor listened for a long time and then announced that there was a faint (and harmless) systolic murmur. The patient confirmed that as a child she was told she had a slight heart murmur.

It felt good. I think I'm getting the hang of this.

09 January 2012

Boom and bust?

With each passing year, becoming a medical student appears less financially feasible. My school has hiked its tuition annually by over 7% over the past two years, which is typical. The median indebtedness at graduation for medical students nationwide rests above $150,000. These loans typically accrue at APRs of 7% and 7.9%. The interest accrues throughout medical school and residency: Congress recently eliminated the type of federal loan that subsidizes interest during medical school. All the while, physician salaries are decreasing and primary care physicians are increasingly being replaced by lower-cost nurse practitioners and PAs. I reckon that a typical student who begins medical school in fall 2012 would take on an additional $12,000 in loan principal relative to someone who begins in fall 2011.

This financial picture worries me. Given the rising cost of training and the decreasing compensation after training, something will have to give. What will it be?

Just because a profession was dependable does not mean it will continue to be so. Law is an excellent example. The legal market has stagnated, while the number of accredited law schools continues to grow and tuition continues to spike. The consequence has been massive unemployment and financial desperation among newly minted lawyers. With each year's crop of newly minted lawyers, the problem worsens. Compounding the issue is that computers and inexpensive lawyers in India are performing tasks that were formerly the domain of entry-level attorneys. A law professor whose blog I follow laid out his exasperation with the collapsing legal sector in a worthwhile post.

There's reason to be optimistic about medicine by comparison. The number of government-funded residency positions is capped, preventing a glut of physicians. And as a colleague pointed out to me, at the end of the day, someone still has to be there to deliver a baby.

One problem with this financial squeeze is that it limits students' options to help the underserved, or to branch out in their educational program. The cost of interrupting medical school for a year to, say, receive an MPH is prohibitive now that loans accrue during graduate school. And I expect that graduating medical students will continue to prefer high-paying specialties over primary care.

It is odd that, in a way, medicine is becoming a victim of its own success. Schools can afford to raise tuition to any amount because they know that there will still be students seeking to enter the profession.

05 January 2012

The drive towards safety

There is a revolutionary cure in the works for an affliction that kills over 42,000 Americans annually and injures many more. It is the 9th-leading cause of death in our country.

The affliction is the "motor-vehicle traffic accident." And the solution nearing market is the self-driving car. Google, in conjunction with a Stanford research team, has already built an autonomous car. They have driven it for over 175,000 miles on California and Nevada roads, accident-free (see a video of a reporter going for a ride on a busy Bay Area freeway in the Google car). Nevada has legalized texting while driving so long as the car is a self-driving car. It surprises me that people are paying so little attention to the advent of the autonomous car, and especially the medical community.

I took a class in college on transportation system optimization, and the field is absolutely fascinating. Traffic systems require careful planning and thought to make everything work harmoniously. I firmly believe three items: that the self-driving car is inevitable and will be commercially available within a decade; that government policies could make the adoption of the self-driving car a rather good thing or a rather terrible thing; and that the self-driving car will absolutely revolutionize our lives and our identities of place.

Humans are not great at driving cars. We fall asleep, we drink, we text, and we can only look in one direction at a time. There is a delay between when we observe a car stopped ahead of us and when we slam on the brakes. Computers lack these flaws and already operate some of our modes of transportation: many subway systems are under computer control, and planes already fly on autopilot. Computers need not be perfect drivers, just to surpass humans.

The technology for the self-driving car already exists, as does most of the software. The question now is how cheaply the most expensive parts (such as the sensors) can be produced and how quickly the infrastructure can be constructed. Google is moving quickly to bring its car to market. Even if the first self-driving cars are expensive, I can't foresee it taking more than a few years for the first to be sold to the public. I foresee that at first the cars would only be allowed to run on freeways, eventually spreading to all roads.

There are a number of market incentives for self-driving cars. Some demographics that cannot drive (the young, the elderly, the infirm, the vision-impaired) would suddenly be able to. Reducing the number of car crashes would save in medical costs and insurance reimbursements. Self-driving cars could also reduce traffic congestion (it would be safer for cars to drive closer together), free up parking spaces (the cars could park themselves), and run off alternative fuels (the cars could drive to charging stations).

Like any new technology, many conflicts will arise now that the first policies governing self-driving cars are being enacted into law. Will law enforcement try to more closely monitor our movements by car? Will government restrict the movements of certain groups (felons, sex offenders)? Will the rich be able to travel at faster speeds than the poor in exchange for paying more (akin to toll roads)? This is largely uncharted territory, but then again, the automobile and the airplane are not so old.

The effect on our lives
The automobile profoundly altered our way of life. It allowed the development of suburbs and exurbs and altered our social structure. What will the self-driving car do? Will cars look more like RVs, mobile homes where people travel from place to place while asleep?

Car crashes very much impact our lives. World history would be quite different if some crashes had been avoided. Some well-known people killed in car crashes include: author, philosopher, and Nobel Laureate Albert Camus; heir to the Syrian presidency Bassel al-Assad; Princess Diana; jazz trumpeter Clifford Brown; and artist Jackson Pollock. Also, car crashes are more likely to affect the young than some leading causes of death, such as cancer and heart disease.

What should we conclude?
Car crashes are a leading cause of death and injury in our country. The self-driving car already exists and it is a question of how long it will take before you and I can buy one for ourselves. The introduction of the self-driving car would be a massive public-health win, akin to the development of a successful vaccine to a deadly disease. Yet we must tread carefully. The self-driving car will disrupt our current way of life, and whether this change is for better or for worse will hinge upon the wisdom of our policies.

The health potential of the self-driving car underscores why the medical community ought to have an open mind about what it pays attention to. We are responsible for improving people's lives and preventing disease, and the self-driving car strikes me as one of the most promising medical therapies in years.

02 January 2012

Getting with the PA program

How comfortable would you feel if your clinician had never examined the inside of a human body?

I chatted for several hours with a physician assistant student who is six months away from receiving his license. "Bob" struck me as a genuinely good guy, and he intends to help people where they need it most--in war zones for the military and in underserved rural areas. It usually takes two years to become a physician assistant (PA), and in most states they are licensed to prescribe certain drugs. They technically have to practice under physician supervision, but "supervision" here is defined loosely. Some supervising physicians simultaneously supervise several PAs spread over several cities. In many rural towns, the PA is the sole provider of clinical care.

Bob mentioned that he wished he had a deeper understanding of the human body. His program does not teach gross anatomy but instead requires it as a prerequisite. Yet very few universities and colleges are able to teach undergraduates anatomy using human cadavers. Bob's anatomy class had only used prosections of cats (a prosection is an anatomical specimen that an expert has previously dissected, for the sake of instruction). Some students become PAs without ever seeing a human cadaver.

Bob's understanding of physiology was quite basic. For example, his program gave only a cursory overview of what causes diabetes, and he did not understand why diabetes causes symptoms such as polyuria (excessive urinary output). Bob confessed that he has such a hard time with math that he stopped at introductory algebra. His classroom education prior to PA school was a two-year stint in community college, where he earned an associates' degree.

I had a great impression of Bob, and we really hit it off. But the medical background his program provides strikes me as flimsy. He would need to know statistics to interpret published medical studies. He likely lacks some of the vocabulary one would encounter in a medical chart. And his limited background in physiology would give him a hard time understanding the mechanisms of the drugs he prescribes, let alone predicting whether they might interact with other medications.

PAs like Bob are increasingly becoming America's first-line primary-care providers, taking the place of physicians. The Bureau of Labor Statistics (BLS) forecasts a boom in new physician assistant jobs over the next decade. The pay is good, too: BLS estimates the median salary nationwide is at $81,230. By my back-of-the-envelope calculations, some older students would have a higher lifetime earning potential if they entered PA school instead of medical school. They would earn money more quickly and dodge the hundreds of thousands of dollars in high-interest student loans.

Medicine is a big tent, and PAs are occupying an increasing section of it. It was eye-opening for me to talk to Bob and understand more about his training.