18 September 2014

Doubt, but verify

(My entry to an essay contest.)

I struggled with knowing when I should believe my patients on the locked psychiatric ward. Some of my patients were reliably forthcoming and honest. Other patients’ stories were clearly unrealistic (one told me that he was being chased by black, chainsaw-wielding government robots that travel through walls). And others made prosaic claims (such as their name and age) that sounded credible, but proved untrue. After being misled several times by my patients, my attending physician advised me to become more of a skeptic. I began taking what my psychiatric patients said not just with a grain of salt, but with a heaping helping.

One day, I met a new patient, Jensen, who had been committed to the psychiatric ward that morning. He was a lanky, disheveled-looking methamphetamine addict who subsisted on begging and theft. He lived in a distant town. Fresh out of prison, he had decided to come to our hospital because he had recently contemplated suicide. A staff member who interviewed Jensen on intake suspected that he was malingering in an attempt to score a warm bed and a square meal.

When I interviewed Jensen, I asked why he had contemplated suicide. He replied that he had become depressed ever since his daughter had been raped and murdered by his best friend. I assumed a look of sympathetic concern and expressed my condolences. My empathy was forced, though. I doubted Jensen’s story. And I especially did not want to be fooled by yet another patient.

Over the course of the interview, I delicately obtained more details about the supposed crime: where it had occurred, who had been arrested, where the case had gone to trial. Afterwards, I hopped onto a computer and queried an internet database of news articles. Several articles came up that confirmed Jensen’s grisly story. I felt horrified 
and sickened. I also wondered whether anyone could experience what Jensen had gone through without being plunged into despair.

Discovering the veracity of Jensen’s story forced me treat his pain as real, and to engage with it. When I met with Jensen that afternoon, I felt more sympathy towards him. I told him that my heart went out to him for what he had suffered. Despite our different backgrounds, I felt as though I was beginning to understand him. We seemed to connect particuarly well.

The tragedy that had befallen Jensen gnawed at me that day. It marred my sleep that night. As I mulled over his story, Jensen struck me as someone who had endured a near-mythical degree of torment. Jensen’s life story seemed to be an allegory, one that embodied society’s ills and condemned the cruelty of man.

When I visited Jensen the next morning, he begged me to be released from the hospital. He told me that a friend had offered to drive him home, but only if he were discharged that morning. At rounds, my team decided that Jensen no longer appeared to pose an acute threat to himself. We acceded to his request and discharged him.

I was able to provide Jensen with more humanistic care because I verified his story online. Was looking online the right thing to do here? I am not completely sure, but I think it was. 
When I am curious about how a former patient is doing, or when I want to better understand a patient’s story, I sometimes feel tempted to search online. I nearly always resist the urge, though. “Googling” a current patient is an act fraught with ethical and practical concerns. Some information found online is inaccurate or misleading, and it could inappropriately bias a clinician. Some patients may feel it is improper for their doctors to be searching for them online.

I also worry about the potential to violate patient privacy. Companies routinely store and analyze data that include the search phrases a user types in and the exact location of their computer. If a clinician seated at a hospital computer performed a series of searches on a patient, private companies (and our government) could probably piece together confidential medical information such as where that patient received their medical care and what diagnoses they carried. (I tried to protect Jensen’s privacy by using vague search terms that could not be tracked back to him.)

In the acute psychiatric setting especially, though, online searches could have tremendous utility as a fact-finding tool. Already, psychiatrists routinely solicit “collateral information,” which might include hospital records, police reports, and conversations with family members. The collateral information can reveal whether a patient’s statements comport with reality, clarifying between diagnoses such as psychosis, antisocial personality, and malingering. Another benefit of an online search is that it can vindicate a patient such as Jensen who makes genuine statements that are not believed.

On the whole, I am leery of clinicians’ “Googling” their patients. But I think there are infrequent circumstances in which searching online is warranted, my encounter with Jensen among them. I am grateful for how confirming Jensen’s story helped me connect with him more deeply, and helped me lend a sympathetic ear.

Shortly after Jensen was discharged, I hopped into my car to run an errand. Pulling up to a red light near the hospital, I recognized the panhandler standing in the center median. It was Jensen. He saw me, and smiled and waved. I rolled down my window. I explained that I could not give him money, but told him where he might be able to get a free bus pass home. He thanked me. I wished him the best.

Jensen was standing in the median because he had invented the story about his friend with a car who would pick him up. He had correctly predicted that the ruse would speed up his discharge. And so, despite my efforts, yet another patient ended up fooling me. The difference was that now, I did not mind.

The light turned green. I drove off, never to see Jensen again.

10 September 2014


The excellent PBS program Frontline has put out an insightful and tragic documentary about life in a Sierra Leone field hospital that has been overwhelmed by Ebola.

And the WHO has recently put out a situation assessment of the state of the virus in Liberia.

Also, I recommend the well-written blog of a Médecins Sans Frontières ("Doctors Without Borders" in the U.S.) obstetrician who until recently was on the front lines.

Together, these items paint a sobering picture of the state of the current Ebola outbreak.

Ebola outbreaks can be halted (and have been halted on the past) through known methods, in particular by isolating sick patients and following up with their close contacts who may have been exposed, as well as by partnering with communities to stop risky behaviors such as funeral practices that involve touching the dead body. Although vaccines and experimental therapies are promising, we need not wait on them. Perhaps with significant investment from the international community, the tide will turn in the battle against Ebola.

02 September 2014

The unacceptable

Walking one day, I spotted one of the Google self-driving cars. It looked similar to the other cars in the road, except that mounted atop the car was a spinning apparatus that constantly scanned its surroundings.

I was quite glad to see it.

Another day, while walking from the hospital, I heard a medical helicopter overhead and looked skyward. The helicopter was swooping towards the landing pad with haste. I figured that this was not a routine transport, but a medical emergency. I spun around and headed to the trauma bay to see what was up.

An alert on the emergency department's computer screen filled me in on some of the story: the helicopter was carrying a child who had been struck by a car and was now in cardiac arrest.

The trauma bay was buzzing with activity. A pharmacist was busy drawing up medications. The trauma surgeons were contemplating their plan of action. The X-ray tech was wheeling in his machine. I perched myself in an out-of-the-way corner.

The patient arrived, bloodied and pale. Worried personnel were doing chest compressions. A nurse hooked the patient up to the heart monitor, and the head doctor asked the medical team to stop compressions (so that the heart monitor could detect the patient's heart rhythm). The patient was still. We looked at the heart monitor: it showed simply a flat line. An ultrasound confirmed that the heart had no activity. There was nothing to be done. "Time of death..." intoned one of the physicians.

This patient had been killed by a car while walking to school, becoming one of the approximately 33,783 motor vehicle fatalities that occur each year in the U.S.

A leading social scientist once wrote, "the history of public health can be written as a constant redefinition of the unacceptable."

I submit that this patient's death by car should be considered not just a tragedy, but an unacceptable tragedy. As I've written previously, a major solution to these automobile deaths lies on our doorstep: the autonomous car. With a concerted push for further research and development, many of the cars on the road could drive themselves, identifying hazards and preventing crashes.

But to get there, we need to decide that automobile fatalities are unacceptable. New York City has taken a commendable step in this direction, inaugurating the "Vision Zero" program. Below is an excerpt of the City's justification for the program:
The primary mission of government is to protect the public. New York’s families deserve and expect safe streets. But today in New York, approximately 4,000 New Yorkers are seriously injured and more than 250 are killed each year in traffic crashes. Being struck by a vehicle is the leading cause of injury-related death for children under 14, and the second leading cause for seniors. On average, vehicles seriously injure or kill a New Yorker every two hours.

This status quo is unacceptable. The City of New York must no longer regard traffic crashes as mere “accidents,” but rather as preventable incidents that can be systematically addressed. No level of fatality on city streets is inevitable or acceptable. This Vision Zero Action Plan is the City's foundation for ending traffic deaths and injuries on our streets.

New York gets it. I hope the rest of the country will follow. And perhaps within my lifetime the automobile fatality can go the way of smallpox, eradicated for good.

09 May 2014

Let's shake on it

A construction worker came into our primary care clinic complaining of left elbow pain that was worse with activity. Based on his description, the location of his pain, and my exam, I thought it was lateral epicondylitis ("tennis elbow"). I couldn't remember the best physical exam maneuvers for lateral epicondylitis, so I excused myself from the room and opened up my physical examination textbook. The book described a simple maneuver called the "Handshake Test."

I went back in and shook the patient's right hand. Then I asked to shake his left hand. The next moment, he was doubled over in pain.

Diagnosis made. Sometimes it can be that simple.

07 May 2014

Death by paperwork

A patient was admitted to our hospital service with a large mass that had been growing for months, as well as significant weight loss. When I examined him, it was obvious that he had an aggressive form of cancer. But had it metastasized?

With this particular type of cancer, the prognosis is fairly good if the primary mass is removed and there is no evidence of metastasis. But the prognosis is bleak if the cancer has spread. This patient was lucky, because there was no evidence of spread.

This patient was uninsured, which is why he had put off seeing the doctor for so long. But he was eligible for Medicaid and had never bothered to apply. After getting a tissue sample, we discharged him home, and advised him to get insurance as quickly as possible, so that the surgeons could remove the mass immediately. I figured it would take a few days for the state to process his insurance forms.

I turned out to be dead wrong. Processing the patient's insurance application apparently took months. By the time the patient came back, the mass had grown nearly 20 times bigger, and it had metastasized. His prognosis had gone from optimistic to terrible.

People get sick, and some inevitably die. Yet some die needlessly, and for the stupidest of reasons.

02 May 2014

The siesta method

On the trauma surgery rotation, rounds start early. At 6:00 AM, to be exact (and medical students had best be exact, lest they show up late and incur the attending physician's scorn).

But when I was on the rotation, the workday also ended mercifully early. Often, we finished before noon. Some of the medical students would go home straight away. Others would hang around, studying for the upcoming surgery exam and waiting for trauma cases to roll in. But by the time evening fell, all of the students would have already filtered out of the hospital.

That is, except for me. Almost by accident, I was on a different schedule from my classmates. I have named it "the siesta method," and it is a true winner.

To make sure I had time to see my patients before rounds and prepare my presentations to the wards team, some days I would set my alarm for 3:50 AM. By the end of the workday, I was knackered. Too spent to study or hang around, I would grab lunch and then head straight to the medical student call room to nap. Several hours later, I would wake up to find that nightfall had descended. I would groggily grab dinner and shuffle to a classroom where I could study for my upcoming surgery exam.

Sometimes, though, the wail of an ambulance or the distant chop of a helicopter would shatter the nighttime silence. A trauma case! Trauma cases excited me much more than studying. I would sprint to the emergency room to see what new case had been brought in. Indeed, most trauma cases come in at night, in large part because night is when people most commonly consume alcohol.

During the day, as many as six medical students would arrive at a trauma case. But at night, I was the only medical student there. I got to stand near the patient and even participate in the resuscitation efforts. The residents took notice. They were impressed that a medical student had decided to stay so late, when they could be at home. I got a reputation as "that med student who's always here." The attendings noticed as well. They encouraged me to "scrub in" to (i.e. participate in) their surgeries. "We've never seen a medical student here this late," one explained. "We really appreciate it, because it gives us more opportunities to teach."

Some nights were quiet. On these nights, I would go home and catch up on sleep until my 3:50 AM alarm. Other nights, when the trauma bay was buzzing, I would stay up all night, enjoying a ring-side view of the fascinating cases that came in.

By sleeping twice a day, I ensured I was getting sufficient sleep. If I pulled an all-nighter, I would simply sleep for longer the following afternoon.

Eventually I finished the trauma rotation, and went back to sleeping only once a day, at night. But I miss the excitement of the trauma cases, and look back fondly on my siesta system. It ended up being a fantastic way to learn surgery.

25 April 2014

Fast asleep

An attending physician who I had just met was going to evaluate me in a "observed patient encounter." For about an hour, he would watch me perform a history and physical examination on a hospital patient that I had never met. Then, I would have to present my findings to him, arrive at a diagnosis and treatment plan, and write a detailed note. I explained that my performance on the activity would constitute a substantial portion of my clerkship grade.

The attending had never done this activity before. He was willing to participate, but felt that he was not the right man for the job. "I've just met you," he explained. "This would be better done by a doctor who has worked with you for a week or two, and knows your abilities and your personality." Then, the attending waxed philosophical. "This stage of your medical training can't be very enjoyable," he said, "what with complete strangers evaluating you all the time."

"That part isn't very fun," I replied. "You probably don't miss being a third-year medical student."

He stiffened. "Not to diminish what you're going through," he said, "but when I was a third-year medical student, it was much, much worse."

I am sure that he is right.

I think the best example is overnight call. Historically, a rite of passage in medical school has been pulling long shifts, many of them overnight. Some of my residents talk about having taken overnight call every third night as medical students, meaning they worked all day, through the night, and into the following day.

My experience has been different. Some nights, I voluntarily stayed late or through the night. During all of third year, though, I was only scheduled for one overnight shift. And even that time, I didn't have to stay overnight. When I showed up at 7 PM, my very nice resident told me that I could go home. (I stayed anyway, for kicks.) Part of the reason is my medical school, which has (humane) policies that discourage overnight call. It is quite possible that I will pull zero overnight shifts as a fourth-year medical student. All bets are off for residency, though.

Am I losing out on some educational opportunities by only being on the wards during the day? Probably. But not much teaching happens at night. And I am glad that I was able to spend nearly all of my nights as a third-year medical student comfortably in bed, asleep.

16 April 2014

Pressure group

Take a guess: what is the leading killer of US women?

The answer is heart disease.

Take another guess: which cancer kills the most US women?

The answer is lung cancer.

Many people, when asked either question, would give "breast cancer" as the answer. And a large reason why is the high visibility of breast cancer. There are prominent fundraisers and charitable foundations. NFL players wear pink uniforms each year to raise breast cancer awareness. Lung cancer, which almost exclusively kills smokers, has much less awareness.

Part of the reason, too, is that there are many more breast cancer survivors than there are lung cancer survivors, because breast cancer is much more survivable. It is the survivors and their family members who raise visibility for their respective disease and raise money for it.

These advocacy groups, in raising awareness, have ended up distorting the public's view of what actually kills people. In an attempt to inform, they misinform.

A group of ovarian cancer survivors came to our school, as part of an event sponsored by an advocacy organization. Students were required to attend. Although I was expecting it to be simply an opportunity for cancer survivors to share their stories, the event instead was intended to show medical students how little we know about ovarian cancer, and to teach us how to diagnose it and treat it. This deviated from how we are usually taught in medical school: usually faculty members lecture us on an organ system or on a set of diseases. In this case, the cancer survivors, who were not doctors, were going to devote the full hour to their one particular disease.

The survivors were highly critical of the medical care they had received from their doctors. They argued that their doctors should have screened them more aggressively, treated them more aggressively, and operated more aggressively. They instructed us what we should do instead, with advice that I found to be ill-informed. They also instructed us to order more CT scans on our patients, and to rely heavily on a blood test (CA125) that is largely useless. They urged us to suspect ovarian cancer in any patient complaining of (vague and common) symptoms like bloating or weight gain, and to suspect patients of any age of having ovarian cancer. One survivor said that antibiotics had helped with her cancer symptoms, and another claimed that the reason she got cancer was because her husband had died a few months before. Another thought she might have caught cancer from her friend.

I was upset that our school arranged for this session. Although the speakers were definitely well-intentioned, they were only able to view clinical practice through the lens of their cancer. The result was that they gave bad clinical advice that probably distorted the clinical judgment of myself and my classmates, who are still early in our careers. Misinformation is a difficult thing to unlearn.

I feel like I have to be wary of advocacy groups, because they only lobby on behalf of a particular constituency. An advocacy group's aim might not align with mine, which is to provide the best care to not just a subset of my patients, but to all of my patients.

01 April 2014


I was asked to assist with a bilateral standard mastectomy (surgical removal of both breasts) for a patient with cancer in one breast. There were two surgeons: the senior attending surgeon, who was to remove the cancerous breast, and the senior resident, who was to remove the healthy breast.

What made the procedure particularly interesting was that the mastectomies were done simultaneously. I had the opportunity to compare the surgeons' techniques as they performed the identical procedure, side-by-side, at the same time.

Unsurprisingly, the more-experienced surgeon did a better job. He made better use of the tissue planes that separate the different layers of the body, making for a cleaner and safer surgery. He worked faster, his dissections were more elegant, and he nicked fewer arteries and vessels, meaning he let less blood. The end result looked nicer.

The experience raised a question that author Atul Gawande discussed at length in his excellent books Complications and Better: how much of a role should trainees should have in performing surgeries? Attendings tend to do a better job than residents at operating. But if residents weren't allowed to operate, how would they ever hone their skills and become attendings?