23 July 2013


To a mother, it means something is wrong.

To a passenger boarding an airplane, it means that the next few hours will be that much more unpleasant.

But to my team of anesthesiologists and surgeons packed into the operating room, hearing the crying of an infant was music to our ears. It meant that the little guy we had operated on had woken up from anesthesia and was doing all right.

Context is everything.

21 July 2013

Drug or Pokémon?

Prescription drugs have ludicrous names.

Pokémon is a Japanese TV show/video game/card game featuring cartoon characters with ludicrous names.

Distinguishing between the names of drugs and the names of Pokémon characters? Devilishly hard, even as a third-year medical student.

16 July 2013

Patients are people

During first year, I was assigned to spend a few half-days with a preceptor who was a family medicine doctor. He was fantastic at connecting with his patients, and his patients clearly adored him in return.

The first time I met with the preceptor, I asked him how often he sees acute presentations of disease, as opposed to seeing chronic conditions. He looked dismayed.

"I don't see conditions and diseases," he said. "I see people."

He pointed at his list of patients for that day. "Look at Mr. Oikos here. He worked as a pharmacist in his native country but retired to the United States to live closer to his family. They don't visit him very often anymore." He pointed out another name on his schedule. "Mrs. Lennison runs the restaurant at the local golf course and enjoys spending time in her garden. She feels that her relationship with her older daughter is becoming strained. Mr. Waters here is an electrician who just retired and is trying to figure out what to do with his free time. These people are my friends. I care about them.

"I hate that the electronic medical record shows the patients' 'complaints' when I see the list of the day's patients. Yes, some of them are sick, but some of them are just coming to see me. Maybe they're lonely, they're scared, or they just want to talk to someone who understands them. Take Mr. Oikos. He has had terrible pain all over his body for years. He comes here every two months, and each time, I examine him and then offer him medication for his pain, because I have no other way to treat it. But each time he refuses. And he's a pharmacist, so he knows all about the medications I'm offering him.

"Why does he keep coming back, even though I have nothing new to offer him? Because he feels comforted by talking to me, by having someone examine him, by knowing that someone cares about him.

"My patients are not diseases, they are people. You must remember that."

Whenever possible, I look to research a patient's chart before I see them. In clinic this year, I saw a patient without having looked at their chart beforehand. He had crashed his car at high-speed, hitting his head. As a result, he had no memory of the crash.

It was my job to sort out what had gone on, and whether it constituted a medical problem that needed treatment. Was this a seizure? A cardiac problem? Perhaps the patient fell asleep at the wheel, or perhaps was distracted and not paying attention?

After taking a brief history and a physical exam, I wasn't very confident in a diagnosis. I immediately found my preceptor and presented my differential: the either patient fell asleep at the wheel, had been distracted, or had lost consciousness. I was leaning towards being distracted.

The preceptor asked me if anything else could have been going on. I couldn't think of much (maybe the patient intentionally crashed their car so they could collect on insurance?). My answers evidently disappointed him.

We went in to see the patient together, and he pulled up the patient's chart. It showed that the patient was taking high doses of a number of narcotics. While he was driving, he was probably so zonked out on narcotics that he wasn't able to pay sufficient attention to the car ahead of him. I had missed two chances to pick up on this fact: first, when looking through the chart, and second, when taking my history from the patient. It was sloppy of me, and it made me miss the diagnosis.

Afterwards, the doctor sat me down in his office. "You're quite good at the technical parts of medicine," he told me. "You're quick and efficient, and you're good at working up whatever problem they've come in for. But you need to be addressing their broader needs. Spend more time getting to know the patient. You need to look through their chart and ask them open-ended questions. Find out who they are and how they're doing.

"These patients aren't just medical problems, they're people. And if you get to know them as people, you'll be better at treating their medical problems."

Years apart, given by different doctors in different contexts, came the same pointed reminder: Patients are people.

In the pre-clinical years of medical school, there is so much book work and studying that it's easy to ignore this fact. This is the beauty of our clinical rotations. It fleshes out the rest of our education, and reminds us what we are here for as doctors.

14 July 2013

Surgical exploration

Note: This post describes a surgery. It has content that some would find graphic. Please use discretion.

12 July 2013

A new era

A young woman came into clinic because of a rash. Thumbing through her chart, I noticed that another doctor had referred her to a cancer center for genetic testing. As it turned out, the patient's father had recently been diagnosed with breast cancer, which is rare in men. Some men with breast cancer have the BRCA2 mutation, a rare genetic mutation that can be passed on to children. Those who inherit the BRCA2 gene are at significantly higher risk of developing certain cancers, particularly breast cancer.

I asked the patient if her father had been tested for the BRCA2 mutation. She replied that her father had indeed been tested, and it showed that he didn't have the mutation.

I gently pointed out to the patient that since the BRCA2 mutation is inherited, and since her father didn't have the BRCA2 mutation, she couldn't have inherited the BRCA2 mutation from her father. But the patient was steadfast. She and her siblings were all planning to get the genetic test regardless (their health insurance was paying). I moved on.

The doctor who serves as my preceptor later pointed out to me that the BRCA2 test costs over $3000 per person. Thousands of dollars were about to go down the drain. And no one besides my preceptor and me cared.

A couple of hours after examining the young woman, I climbed into my preceptor's car and we drove through the countryside to a patient's home. The patient was not old. He was dying of metastatic cancer and was on hospice. We said hello to the patient, and the doctor performed a brief exam. Then the family invited us into their living room. As soon as I plunked down on the sofa, the family dog hopped up next to me, begging to be petted. No one had been paying much attention to her these past few weeks.

I scratched the dog's belly while the doctor offered the family his support, adjusted the patient's pain medication, and helped the family plan for what lay ahead. The patient's wife cried while she told us how difficult these past few weeks had been, how shockingly quickly the disease was overtaking her husband. She could not bear to leave the house for more than an hour for fear of being away from her husband's side when he finally succumbed. We reassured her that she was taking good care of him and urged her to make some time for herself. When it came time to leave, the family was incredibly grateful. "I didn't realize doctors made house calls anymore," they said.

Although the doctor would like to do more house calls, he can only volunteer so much of his time. Our home visit wasn't compensated at all. Even the cost of gasoline came straight out of my preceptor's pocket.

What if we canceled our patient's worthless BRCA2 test, and instead spent the $3000 on paying for house calls? My preceptor could probably visit 30 more dying patients at their homes.

Within the span of a few hours, I witnessed both medicine's past and medicine's future. The era of the house call has given way to the era of genomic sequencing. Which of them offers people more healing? And which of them have we decided to pay for?

08 July 2013


Paramedics brought a patient into the ER who was involved in a motor vehicle collision. She claims she saw an object in the roadway and swerved to avoid it. After rolling an unknown number of times, her car came to rest upside-down. Because she was wearing a seat-belt, she was in pretty good shape when she came in.

Part of the initial panel of labwork for trauma patients is a blood alcohol level. This patient's came back as 0.14: way over the legal limit. I was surprised, because she didn't seem very intoxicated. This suggested something even more worrisome: that she consumed large amounts of alcohol regularly. Given her apparent willingness to drive under the influence, she was a lethal threat to herself and others. Drunk drivers kill.

I asked the patient if she had had anything to drink that day. She said that she had consumed only one drink that day, in the morning. I gently prodded her to see if she would fess up, but she stuck to her guns.

I don't think this patient should be allowed to drive until she gets help. But I was powerless to do anything. Patient confidentiality prevented me from reporting her blood alcohol level to the police. The best I could have done would have been to convince one of the doctors to formally diagnose the patient with alcohol dependency. Then the doctor could notify our state's department of motor vehicles that the patient had a diagnosed disease that threatened her ability to drive. But it's doubtful that the DMV would have done anything. And I don't think I could have convinced any doctors to do it.

Part of patient confidentiality is that we hold people's secrets. But some of these secrets are awful burdens. I wish they could see daylight.

02 July 2013

Surgery, the video game

The anesthetized patient on the operating room table had several giant kidney stones that needed urgent removal. The solution was "laser lithotripsy." We threaded an endoscope (thin camera) through his ureter until we could see the stone on a TV screen. Then we threaded a fiber-optic laser into the camera apparatus until it was touching the stone. The surgeon pressed a button that activated the laser for a fraction of a second. Its energy shattered the stone. Then we used a wire basket to retrieve the shards of stone and place them in the bladder, where the patient would have no problem passing them. We repeated this process for about half an hour, until the stones had been fully removed.

Watching the surgery felt like watching a video game, with a first-person shooter element (aiming the laser at the stone and zapping it) plus a tricky kind of arcade game in trapping the stone in the wire basket. With a few modifications, the main portion of this surgery probably could be done remotely from a computer on the other side of the world.

While the lithotripsy portion of the surgery required immense skill, it didn't require that the surgeon know much of anything about medicine. I think that with sufficient practice, a middle-school student could have performed the surgery quite capably.

I also observed ESWL (extracorporeal shock wave lithotripsy) procedures. In these procedures, a device produced loud shock waves that fractured kidney stones. No cutting was needed. Although a urologist was present for brief portions of the procedure, most of it was performed by an expert technician. The urologist was barely needed at all.

I think what I witnessed is a harbinger of the future. I imagine that quite soon, some surgeons will routinely operate on patients who are thousands of miles away. And I imagine that the trend of non-surgeons performing portions of some surgeries will accelerate. What this means for patients, I know not.