28 November 2012


A New York Times article a few years back tried to find out why health insurance companies didn't cover the cost of test strips for diabetics who needed to check their blood sugar levels. Test strips are fairly cheap, and without them, it's impossible to control one's blood sugar. Uncontrolled diabetes can eventually lead to lots of bad medical problems, like kidney failure, limb amputation, and cardiovascular disease, all of which are quite expensive. Wouldn't it be profitable for insurance companies to cover test strips now and avoid complications later?

The answer the Times found was a cynical but rational one. People spend an average of something like seven years with their health insurance company before switching to another (perhaps by changing jobs, or by their employer changing health insurers). If one insurance company provided test strips free of charge, the savings in eventual health costs would be passed on to that company's competitors. When insurance companies emphasize prevention, they lose money.

For years I've had an idea that I've never seen anyone suggest. What if your health insurance company also provided your life insurance? That way, there would be some added profit incentive for your insurance company to keep you alive for longer.

21 November 2012


If you are in fact what this man says,
God have pity on you! You were born to misery.

Oh! Oh! All come to pass, all true!
I find Oedipus Rex tough to read, because everyone but Oedipus sees where things are headed. Oedipus doggedly investigates the death of the king. He is blindsided (and blinded) by the sudden revelation (see above) that he had unknowingly killed the king (his father) and wed his mother. Throughout the play, Oedipus is a step behind everyone else. He's the last to know the truth.

A patient came in with rapidly progressive weakness of recent onset. In his usual state of health just months ago, he could hardly walk without falling and could barely summon the strength and dexterity required to button his shirt. He wanted to know why.

At the start of the visit, the physician and I assembled differential diagnoses in our minds. The physician obtained an excellent patient history, eliciting answers that ruled out some of the diagnoses on our lists. Pretty soon, all of the potentially reversible illnesses on my differential were ruled out. Nothing much seemed to fit the patient's symptoms, except for amyotrophic lateral sclerosis (ALS, also called Lou Gehrig's Disease). It is an awful disease, progressively paralyzing the body's muscles while leaving one's mental faculties intact.

We moved on to the physical examination. The doctor performed tests specific to ALS, and our findings increasingly supported that diagnosis. I was filled with a horrible sense of foreboding. I could tell that within minutes the diagnosis would be confirmed. Given the rapid progression of his disease, he didn't have many more months to live. I steeled myself for the wrenching moment when the patient would be informed.

Our medical training confers upon us some prophetic powers. In making diagnoses, we interpret signs on the body that are inscrutable to most. With our medical knowledge, we can sometimes accurately predict the course of a disease. Like Cassandra and Tiresias of ancient Greece, we issue dire warnings ("if you don't quit drinking, it will kill you!") that often go unheeded.

But as neat as it is to see the future, I now understand that this faculty can be a burden. Like those prophets of old, we were condemned to foretell this patient's tragic fate yet powerless to alter it.

14 November 2012

You can't stay pluripotent forever

The human body contains all kinds of cells: cells that secrete mucus, cells that sense light, cells that make up your skin, cells that make up your brain. But we begin as embryos, which are devoid of these "differentiated" types of cells. No matter how much you dig, you will not find in an early embryo the specialized cell that manufactures your stomach acid. Rather, embryos contain "pluripotent" cells. These remarkable cells, which multiply in number during development, can differentiate into progressively more specialized types of cells. Taken together, the pluripotent cells possess the unique ability to become any type of cell in the body.

Once a pluripotent cell differentiates, it cannot become pluripotent again. A taste bud can't become a sweat gland. Its job is ordained.

As an undergraduate, I had a romantic image of myself as doctor. I had arrayed in my mind brief snapshots, as though from a movie, of myself (with grayed temples and long white coat) performing manifold deeds:
-counseling a newly pregnant woman on prenatal care
-uncovering a tricky diagnosis in an emergency room patient
-delivering a newborn child
-helping a teenager overcome an eating disorder
-tailoring a cancer treatment to a patient's genetic signature
-leading a community in the face of a frightening pandemic
-performing a circumcision
-treating patients in a refugee camp
Although a doctor's license technically allows him to practice any kind of medicine, what I had barely grasped was that a doctor's specialty largely dictates which diseases he does (or does not) treat. Internal medicine doctors don't deliver children. A spine surgeon will not medically manage a thyroid disorder. A pathologist doesn't see patients in outpatient clinic.

I used to think that to become "super-doctor," I needed to enter the medical specialty that offered the broadest scope of practice. The obvious choice was family medicine, which includes basic surgeries, childbirth, and treating patients of all ages. Family medicine physicians excel when working in sparsely-populated areas, where their broad set of skills proves especially valuable.

But recently I've begun valuing depth over breadth. When I shadow specialists, I find that within their specialty, they tend to outperform non-specialists. Pediatric hospitalists are particularly good at taking care of hospitalized pediatric patients. A knee surgeon is particularly good at operating on knees. An oncologist is particularly good at treating cancer. I feel I'd serve my patients best if I too focused on some segment of medicine that captures my particular interests and plays to my strengths.

It's hard to stomach that someday I will probably see either adult patients or pediatric patients, but not both. I entered medicine because I wanted to help all people, not just those with gastric cancer, or with cataracts, or who are under the age of 18.

Being a medical student is an exciting time. We study all disciplines of medicine. We perform mandatory clerkships in all of the core medical specialties. During fourth year, we can take electives in whatever field we want. But we cannot forever remain medical students. Eventually we have to choose a path, and leave behind options once open to us. I take solace in some sagely advice I once had received: "You can't stay pluripotent forever." For now, I intend to enjoy this time of limitless potential.

07 November 2012

Home birth

Sometimes I find myself in arguments on medical subjects with non-medical people (for example, with seatmates on airplanes). One argument concerned "natural" home birth. My stance is that if I were a pregnant woman, I would be quite uncomfortable with having my birth at home.*

Pregnancy and birth is a wonderful, yet involved, process. Pregnancy stresses the female body, altering the homeostasis (the equilibrium) of many of the body's systems. For example, pregnant women are more likely to experience blood clots, in part because of a change in their hormones. They have to urinate more often. Some parts of the pregnant woman's brain grow new neurons (which is actually a huge deal, because adults weren't previously thought to be able to grow new brain tissue). Towards the end of the pregnancy, the gigantic uterus competes with the lungs for space in the body, making breathing more difficult. The spine has to adjust to carrying more weight. The heart is more likely to arrest. The list goes on.

Childbirth especially places the body under stress. Sometimes, deliveries have complications. Arterioles can rupture, causing hemorrhage. The fetus can be positioned the wrong way in the birth canal. The fetus's umbilical cord can wrap around its neck, strangling it. The variety of potential complications is substantial. Fortunately, obstetricians can do quite a lot to resolve these complications when they arise, sparing the life of the mother and the child. What is frightening is that grave complications can come on suddenly and without warning, and they need to be dealt with emergently.

As I alluded to in my recent post on diagnosis, when approaching a complex matter, it often helps to break it down into its simpler, constituent parts. Those working on maternal mortality worldwide have done just that. There is a "three-delay" model of contributors to maternal mortality in complicated deliveries:

1. delay in recognizing problems in labor and deciding to seek medical help;
2. delay in reaching a skilled medical facility; and
3. delay in obtaining the appropriate intervention on arrival.

The trouble with home birth (relative to at a hospital or a birth center) is that it definitely delays number 2 and usually delays numbers 1 and 3. Delays in medicine are costly. Regarding strokes, neurologists say that "time is brain." Regarding heart attacks, cardiologists say that "time is muscle." I am coining the aphorism that in obstetrics, "time is life"that of the mother and that of the fetus.

To be sure: most low-risk pregnancies result in uncomplicated deliveries, whether in one's home or in a hospital. It's when a delivery doesn't go smoothly that one will want to quickly find herself in the hands of a skilled physician.

* Summary statement of the American College of Obstetrics and Gynecology's Feb. 2011 position paper on planned home birth:
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

06 November 2012

The evacuation of NYU Langone hospital

An NYU medical student recounts the emergency evacuation of his academic teaching hospital after Hurricane Sandy. I can hardly imagine how frightening that experience would be.

I respectfully disagree with one assertion in his account:
Last Monday night, these buildings flooded, and PSE&G shut off electricity to all buildings below 40th Street. And then, as you've probably heard, the unthinkable occurred: the hospital's backup power generator failed. 
The loss of backup power generators was quite "thinkable". It happened in New Orleans hospitals during Hurricane Katrina, and Manhattan is known to be at risk for flooding from storms (especially NYU, which is close to shore). Although the evacuation of NYU Langone and Bellevue hospitals is a story of how the medical community came together during trying times to save their patients, it also is a lesson in how foresight and preparedness go quite a long way.