28 February 2012

'County', by David Ansell

What's an idealistic medical student to do? Upon graduating from medical school in the 1970s, David Ansell and three of his classmates from SUNY Syracuse had the wild idea of interning at Cook County hospital in Chicago. County was the hospital for Chicago's poor: shamefully underequipped, understaffed, and overstuffed. Despite its problems (or more accurately, because of them), Ansell stayed on at County for decades, growing into a mature physician as he and his colleagues worked desperately to reverse the shocking health inequities they encountered. While at County, Ansell co-authored a famous study that alerted the medical world to the phenomenon of "patient dumping" (private hospitals transferring uninsured patients to county hospitals, sometimes killing them in the process). The paper led to the passage of EMTALA, which requires all emergency rooms to treat deathly ill patients rather than sending them elsewhere.

Ansell's profile of Cook County hospital makes for compelling reading. He clearly loves the hospital, loves his patients, and hates the unfair health and political system that has failed both. I recommend the book for medical students and for those interested in minority health.

24 February 2012

Poker face

One afternoon I donned my white coat and "shadowed" (observed) a physician in the community. This physician was particularly talented at bonding with her patients. Several patients made a point of telling me that I was fortunate to be learning from a doctor who listens so well.

We encountered a patient who was fidgeting and whose eyes appeared sunken. When the doctor asked what had brought her into clinic, she replied that it was anxiety.

The doctor asked her to describe what was making her anxious.

The patient had infidelity problems in her marriage. Their son had recently been diagnosed with a major illness. She had discovered that her husband had secretly spent their life savings pursuing an addiction. Her husband was refusing counseling.

Her tragic story tore at me (how could it not?). While she was telling it, I was unsure how I ought to outwardly react. Should my facial expression and my body language reveal or at least hint at my horror and my sadness? Should my brow be furrowed or not? Should I be nodding or shaking my head? Throughout the patient visit, my preceptor needed to convey to the patient that she understood her pain, that it was natural for the patient to feel the way she does, that the patient was no less of a person because of all of this, and that there was hope. I studied my preceptor intently throughout the patient encounter, and her expression was rather neutral and calm throughout. In all, I thought the preceptor did an excellent job, and the patient appeared to be feeling more relaxed by the end of the visit.

Our curriculum includes workshops on patient interaction, although I'm not sure to what extent these skills are innate and to what extent they can be learned. A doctor needs to be many things to be effective with patients: an astute observer, a motivated learner, a good communicator, and an engaged listener. Even if a clinician is the right person for the job, it is a tough balance to strike.

21 February 2012

A beginning

Today I participated in my first newborn exam. An excited couple let our gaggle of eight medical students and an attending physician into their hospital room to examine their darling one-day-old child. We listened to her heart sounds, tested her reflexes (such as the "Moro reflex": one lifts the infant slightly up by the arms and lets go, and the infant flails his arms and cries), checked her over head to toe, and even changed her diaper. We felt for the pulse of the femoral artery (artery of the leg) to make sure the blood was circulating properly. We made sure her hips didn't dislocate easily. We checked her face for symmetry and folded her ear to confirm that it flopped back properly. Although newborns and adults are both human, the physical examination for each differs radically.

A few thoughts:
-It still amazes me that just because we are medical students, the couple let us take custody of their most precious thing in the world. Had I gone to public health school instead, I would never have had this chance. The couple explained that they were happy to participate because they were grateful for the excellent care they received from the doctors at the hospital. The patients I see in the free clinic are often in pain, distressed, or mistrustful, and it was a bit strange encountering a happy patient.

-Seeing a newborn made me rather sentimental. It bespeaks new beginnings and clean slates, yet also a connection to the timeless fellowship of man. Human civilization has changed radically over the millennia, so much so that the world today must seem completely alien to someone born even two hundred years ago. Yet there is a common thread: people begin life looking and behaving like the child I had the privilege of examining today.

-The parents had been preparing for months for this birth, and in chatting with them I found that they were a swirl of emotions: giddy, scared, and enamored.

It was my first time handling an infant, and I am amazed at how delicate and adorable these little chaps can be. Our attending physician maintains that she has the happiest job in the hospital. After today, I can see why.

16 February 2012

Our elegant selves

A professor performed a card trick for us. He had a student pull a random card from the deck and replace it without showing him the card. After some theatrics, the professor successfully guessed the card and even extracted it after shuffling the deck.

Some classmates and I spent a while afterwards working out how the trick was done. We admired the professor for the substantial amount of hard work required (among other feats, he needed to memorize the order of the entire deck). Yet in our solving the mystery, the magic became diminished.

Not so with the human body. Learning how it works makes it all the more fantastic. Right now I'm reading about the heart. Although it sometimes fails, for most people it beats billions of times with no problem. The heart is brilliant. It generates its own heartbeat, but responds to the body's signals by speeding up or slowing down. It pumps harder when our body demands it and eases off when it can relax. Even the tiny proteins and receptors that drive the heart work together as a kind of virtuoso symphony.

Also striking is how often the molecular machinery in the human body resembles our modern machines (or is it vice versa?). The way our heart muscle contracts closely resembles the way a bicycle pedal transfers its energy to a bicycle chain. The protein that synthesizes ATP, a molecule that stores the body's energy, is a sophisticated motor that rivals those crafted by man. The way our immune system fights off viruses and bacteria is not unlike the way our military fights its wars.

In their perpetual fight to thrive despite insult, aging, and disease, our sophisticated bodies exhibit some of the same dramas that we see in the world around us. It is a delight to have a window into this hidden world within.

14 February 2012

A sense of purpose

One doesn't ask of one who suffers: what is your country and what is your religion? One merely says, You suffer, this is enough for me, you belong to me and I shall help you. -Louis Pasteur, famed French chemist and microbiologist.

Medicine is a social science, and politics is nothing more than medicine on a grand scale. -Rudolf Virchow, famed German pathologist.
I'm finding my courses increasingly demanding, and my treasured free time has continued to diminish. My social circle barely extends beyond my community of medical students, nor can it. What keeps me going is the hope that, by pressing on, I'll be uniquely able to help my fellow man. It is strange giving up much of young adulthood because of an idea.

09 February 2012

Negotiating patient care

Some years ago, a diplomat recommended to me a book on negotiations called "Getting to Yes." Last month I purchased a copy (from my local independent bookseller!), and I've quickly learned that skill in negotiating is a huge help in clinic.

Our medical school has us interact with "standardized patients"--paid actors who convincingly pretend to be patients with certain diseases. In front of a panel of classmates and professors, I had to convince a hypertensive "patient" who does not like following doctors' orders that she either needed to improve her diet, exercise more, and track her blood pressure at home, or go on medications.

I thought back to my negotiations book. I began the conversation by emphasizing that we were partners on the same team working to defeat hypertension. We tailored the treatment plan to her personal goals. Although she did not want to go on medication, we agreed to she would need to go on them if she failed to meet certain objective criteria (having her systolic blood pressure drop to a certain number within a set number of months). In the end, the patient seemed committed to her customized treatment plan, and I was satisfied with the likelihood that her blood pressure would eventually drop to a reasonable level. There was room for improvement, but the result struck me as a successful negotiation.

Successful negotiation tries to find ways to satisfy both sides' interests. It need not a be a zero-sum game. The book tells a proverb of two sisters who are arguing over an orange. They compromise by dividing the orange in half. Later, one sister eats the fruit of her half an orange and throws out the peel. The other sister throws out the fruit and bakes the peel into a cake. If the sisters had negotiated on the basis of their interests ("I want to bake a cake," rather than "I want the orange,") both sides could have emerged happier.

The doctor-patient relationship could use some strengthening. Patients usually do not adhere to their treatment plan (for example, by skipping medications) or modify their lifestyles. And I talk to many patients who do not feel like their physician understands them or listens to them. There needs to be more of a sense of shared ownership, which is something that successful negotiation encourages.

The good news is that in medicine, doctor and patient usually have the same shared interest: making the patient happier and healthier. It's a good basis for a successful partnership.

06 February 2012

'Internal Bleeding', by Wachter and Shojania

Medicine is complex, and slip-ups inevitably occur. "Internal Bleeding," a book by two prominent internists, details some of the harrowing mix-ups that have occurred at their hospitals and ask, why do medical errors occur so often and how can we do better? Medical errors are one of the leading causes of death (the Institute of Medicine approximates the figure at 100,000 per year in the U.S.), but it is so commonplace and hidden that it escapes the public's imagination.

The stories in the book are frightening and instructive. A child is given what would have been a life-saving transplant, except that the blood type of the donor had not been checked against the patient. A patient undergoes the heart procedure another patient with a similar-sounding name was supposed to receive. At a major academic center, an elevator is shut down for maintenance, preventing the transfer of a critically-ill patient from the wards to the ICU. For each of these, the authors study the root causes--what was the accident chain that allowed this to occur, and where could it have been broken and the error prevented?

The authors' perspective is refreshing. Even the best-trained, most competent physicians commit errors. And even when a doctor commits an error, they don't necessary deserve blame and censure. More useful is to try to see how modifying the health-care delivery system could have avoided the error. The authors suggest we follow the model of aviation accident investigators of plane crashes, who look to see how modifying protocols or changing the plane can prevent a future crash.

I recommend the book to medical students, those interested in the issue of medical errors, and those interested in health-care delivery systems.

02 February 2012

Our diet, under assault

Last month, I bought a bottle of vanilla extract so I could add an extra kick to my plain yogurt. Even though the store didn't ID me, my vanilla extract contained 35% alcohol by weight, in the form of bourbon. Why? Alcohol is used in the vanilla bean extraction process, and so to ensure quality, the Food and Drug Administration (FDA) mandates that any product labeled as vanilla extract contain at least 35% ethanol. The FDA regulates quite a number of food additives, stipulating how much or how little can appear in our foods. It even regulates how many fly eggs (thirty) can be present in 100 grams of tomato paste.

Because of persistent lobbying by the food industry, the amount of sodium in foods is not regulated by the FDA. I attended a talk by a kidney specialist, who pointed out that the FDA requires all bars of antiperspirants to carry a warning: before using, anyone with kidney disease must consult with their physician. This is because the deodorant contains aluminum, which could theoretically harm those on dialysis if it somehow entered their bloodstream. He also held up a small bag of Cheez-Its, and pointed out they contain so much salt that eating them is an absolute disaster for someone on dialysis. But Cheez-Its carry no warning, because the FDA does not regulate salt content.

The Institute of Medicine released a strongly-worded 2010 report warning of dire consequences should the FDA fail to act soon. It points out that the average American adult consumes over 3,400 mg of sodium per day, far above the recommended daily value. Most of this sodium comes from processed foods--the IoM reports that about 5 percent of sodium consumption derives from salt added at the table. Unsurprisingly, about 29% of American adults have hypertension.

Perhaps sodium doesn't receive the attention the public pays to carbs, fat, and saturated fat because its effects are relatively hidden. Eating a persistently high-fat diet will give you an obvious belly. Eating a persistently high-sodium diet will predispose you to hypertension, which, until it becomes severe, is fairly asymptomatic.

But there is hope. The Obama administration and the USDA unveiled new standards for school lunches. Although industry lobbying weakened the regulations (since pizza contains tomato paste, it is counted as a vegetable), schoolchildren's lunches will soon contain more fruits and vegetables, more whole grains, and yes, less sodium. It's a step in the right direction.