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.

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* 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.

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.

A tradition of mentorship

A friend was working an overnight shift in the ER for one of her mandatory rotations, so I popped in to observe. The ER was surprisingly quiet. A classmate was also observing that night, and like me, he was standing around, bored. We spotted an electrocardiogram (EKG) readout lying on a desk where a resident was working, and we asked him if we could take a stab at interpreting it (an electrocardiogram tracks the electrical activity of the heart, and a skilled interpreter can use it to reliably diagnose heart problems). He handed us not only that piece of paper, but the EKGs from some other patients who were in the ER. "I'm going to see a patient," he said, "and when I come back, tell me your results and whether any of these people is having an emergency."

A 12-lead EKG (like the one we interpreted) in a normal patient.

At that point, we had learned only the basics of reading EKGs. We wrestled with the readout, trying to flesh out the story told by the squiggly gyrations of the EKG lines. We opened a textbook on cardiac disease and reviewed the way certain diseases of the heart express themselves on an EKG.

The resident returned and quizzed us on our findings. Then, he shared strategies for reading EKGs that he'd picked up over the years. The three of us read through the EKGs together. In a final flourish, he picked up a new patient's complicated EKG readout and accurately diagnosed a subtle type of abnormality in the heart's electrical conduction.

Medical residents are extremely busy people. Even though this resident had never met us and probably would never see us again, he happily took some time out of his night to teach us. This tradition of mentorship seems omnipresent in medicine. Most doctors enjoy having medical students shadow them so they can share so-called "clinical pearls" of wisdom. They do so because they remember a time when they were medical students, when doctors went out of their way to teach them. Although an academic medical center like my school tends to attract those most inclined to teach, even when I am out in the community I find that doctors are eager to share what they know.

Another element of teaching on the wards is called "pimping." During rounds (when the full medical team convenes), the more senior person quizzes the more junior person on medical factoids until the more junior person misses a question. Pimping does a few things: it gives both people a chance to show what they know. It (supposedly) teaches. It motivates people to go home and study so that they don't get humiliated.

Pimping also puts the more junior person in their place. The teaching that goes on in the wards is only a one-way exchange of knowledge, from teacher to student. If the teacher makes a mistake, it isn't considered appropriate for the student to correct him. And so, a paradox is at play here. Teaching elevates the student, improving his level of knowledge. Yet how doctors teach fortifies the pervasive perception within medicine that those who are most senior are universally more knowledgeable, and that level of seniority automatically dictates the amount of respect one commands. Teaching students on the wards is both selfless and self-serving, humble and haughty.

That doctors have good job security contributes to their willingness to teach. Doctors don't have to worry that the person they are helping will someday be their replacement.

My sense is that medicine outshines other professions in its long-held tradition of mentorship. My superiors' consistent eagerness to teach me makes medicine refreshing. As for my time in the ER, I couldn't think of a better way to learn how to read EKGs.

Sweat the small stuff

Our professor began our small group session, on how to properly examine a patient with lung disease, by leaping onto a table. He held up his hands and explained that we would get started soon, after he returned a phone call from a patient. In one bound, he leapt down from the table and exited the room.

My classmates and I were mystified. We had never met this physician before. Although he was at least 65 years old, he had hopped off of the impressively high table with a gymnast's ease. He wore a white coat, tie, and dress shoes, and rather incongruously, a bright orange baseball cap.

After a few minutes he returned and hopped yet again onto the table. He held up his hands. "What's different about me?"

We all noticed that his baseball cap was gone. I mentioned that something looked different about his tie. That was it.

The doctor explained that he had altered his appearance dramatically. He had switched from a blue necktie to a red one. His wedding ring had switched from his left hand to his right, and his wristwatch vice versa. He had even changed out of his dress shoes, into loafers.

"One of the most important parts of the patient examination is 'inspection,'" he said. "You're now at a stage in your medical training where you need to start looking for subtle visual details. Otherwise, you'll miss something important in a patient."

And so, as a group we inspected a set of lung-disease patients with an eye for detail. We spotted tiny surgical scars that suggested that the patients' lungs had been biopsied. We noticed the "buffalo hump" (an accumulation of fat on the back of the neck) that is the signature of high doses of corticosteroids. We watched one patient who was breathing quite fast, and another who coughed constantly and whose neck muscles were pathologically straining to help her inspire. We listened with our stethoscopes to the 'crackles' at the base of one patient's lungs. The crackles sounded like the faint popping of bubble-wrap.

Slowly, without the patients saying a word, we began to piece together what diseases they might have and what their life story might be. Our spry professor had mischievously taught us a good lesson.

Nobel Prize for Economics

This year's "Nobel Prize for Economics" (see footnote) went to Alvin Roth and Lloyd Shapley. They studied ways to design markets that efficiently match up agents according to their preferences. Medical students like myself are indebted to these two economists for their hand in setting up and refining "the Match," the process whereby medical students are assigned to residency programs.

Medical students apply to residency programs and then rank, in order, their list of preferences. Residency programs also submit a ranked list of their preferences among applicants. Sometime in the spring, a computer processes the preferences and assigns students to programs.

The algorithm used is quite elegant and favors student preferences to the greatest extent possible. It is always to a student's advantage to rank his choices according to his actual preferences. Roth even helped refine the Match to allow couples to match jointly.

It's cool how the application of economic theory has made the lives of medical students like myself less stressful. Now, if only the process of getting into medical school had been that straightforward.

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Historical footnote: Alfred Nobel endowed in his will an annual set of prizes to be awarded "for outstanding achievements in physics, chemistry, medicine, literature, and for work in peace." The prize for economics was set up many decades later by a Swedish bank, but it is still considered a "Nobel Prize."

Diagnosis II

A patient at the free clinic complained that over the past few years he had lost most of his ability to taste and smell. "I put lots of spices on my food, but it barely tastes like anything."

The patient clearly had "hyposmia," a decreased sense of smell. It's potentially worrisome, because it can be an early sign of degenerative brain diseases like Parkinson's and Alzheimer's. It could also be a symptom of a brain tumor. I wanted to get to the bottom of whatever was going on. How could I approach this diagnosis?

I did so by breaking the action of smelling into its constituent parts.

• First, air carrying a scent is transported to the bridge of the nose, where olfactory receptors reside.
• Next, the olfactory receptors fire. They send a signal along nerves that traverse the skull and enter the brain.

And so, there are two main categories of causes of diminished sense of smell:

• Conductive: a problem getting air to the olfactory receptor. Usually treatable.
• Sensorineural: A problem affecting the olfactory receptors, the nerves, the skull, or the brain. Usually permanent.

Now my job was to figure out what category of hyposmia the patient had. So, I asked a simple question: "Have you ever managed to temporarily regain your sense of smell?" The patient had. He had bought a nasal spray from the dollar store, and when he used it, for a few hours he regained some of his sense of smell.

Although the patient couldn't remember the name of the spray, it didn't matter. I now knew that the patient had conductive hyposmia. We ended up prescribing him a nasal steroid, which would help improve breathing through his nose. And he didn't need to get a head CT, which is expensive and would needlessly expose him to a hefty dose of radiation. I made this diagnosis methodically, drawing on my knowledge of the mechanisms of disease.

I've learned how to formulate diagnoses by reading textbooks and medical journal articles entirely about how to do them properly. Diagnosis as a stand-alone academic subject has been given only a superficial treatment in our classes. I like studying it on my own because I see the art of diagnosis as fundamental to the practice of medicine.

'Incidental Findings', by Danielle Ofri

In this collection of essays, Dr. Danielle Ofri muses on transitions: of maturing into an attending physician, of becoming a caretaker to her patients, of becoming a mother, and of becoming a patient.  

Ofri's interactions with her patients evoke powerful memories from her past. While working a brief stint as an internal medicine physician at a Catholic medical center, one of her patients has an unwanted pregnancy and wants an abortion. Ofri is forbidden from referring her to an abortion center, but feels conflicted. Ofri reveals to the reader her experience of undergoing an abortion as a frightened seventeen-year-old. Ofri decides that helping her patient is more important than following clinic policy. She refers her patient to an abortion clinic and helps the patient through an emotional trying time.

In another story, Ofri describes a bright 20-year-old patient who has no medical problems but lacks the ambition to go to college. Ofri encourages him to pursue higher education. They set up follow-up appointments, in which Ofri tutors him on his SAT.

The stories cut at the heart of the issues clinicians face. With the tremendous demands on clinicans' time, how can we still take care of the emotional needs of our patients? How can a doctor overcome his hospital's impersonal rules? How much should we reveal about ourselves to patients? How much can we trust what our patients say? Ofri parses these issues in an insightful and personal way. The "incidental findings" of the book's title are the unexpected life lessons Ofri gets from practicing medicine.

In these essays, Ofri is finding her voice as a writer. She experiments with different writing styles, and a few of the chapters are clunky as a result. Still, the richness of Ofri's perspective made reading this book worthwhile. I enthusiastically recommend this little book.
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Note: I also reviewed Dr. Ofri's "Medicine in Translation" last month. I enjoyed them both, yet "Incidental Findings" seems the stronger of the two.

Diagnosis

Our patient had become increasingly socially withdrawn, emotionless, and impulsive. He had started falling with increasing frequency, not even bothering anymore to put out his hands to break his fall. And he had been taken to specialist after specialist, undergoing test after test. But each doctor was stumped as to what disease (or diseases) might be responsible. The patient had been referred to the clinic where I was observing, desperately seeking answers.

I largely watched as a more senior medical student conducted a lengthy and thorough interview and exam. By the end, both of us were leaning towards the same diagnosis: progressive supranuclear palsy. It is a progressive degenerative brain disease, and an insidious one at that. It causes dementia and impairs motor function, slowly paralyzing the muscles involved in gaze, talking, and swallowing, and causing frequent, spectacular falls. There is neither a cure nor an effective treatment (although some therapies are currently in development). Most patients die of complications from it within years. Very few doctors know about the disease or know how to pick up on the disease's subtle signs, often misdiagnosing it as Parkinson's. To be fair, the patient's condition was less advanced when she saw her previous physicians, which would have made the disease harder to recognize then.

The medical student presented to the attending physician, who became even more certain than we were that the patient had progressive supranuclear palsy. It was time to broach the news to the patient and his family. I thought that this would be a devastating moment: learning that you (or your loved one) are afflicted with an incurable, progressive, and tragic disease. In large part, the patient and his family responded as though a burden had been lifted. They had finally gotten a satisfying conclusion to their quest for a diagnosis, and now they could predict what might happen to the patient in the coming years. Above all, they were relieved that something finally explained what was going on: that a known disease was responsible for the befuddling combination of behavioral and motor problems that were increasingly affecting the patient. Within this tiny snapshot of time, the family responded bravely to the news of the diagnosis.

Getting the diagnosis here was a help for the family. Had the correct diagnosis been given earlier, the family could have avoided a lot of hassle, expense, and anxiety.

I'm considering neurology more seriously as a specialty, fully aware that many of the conditions I would be dealing with are largely incurable and untreatable. Where I think I could make a difference is in making the right diagnosis where others might stumble.

Where Are Today's Philosopher-Physicians?

I recently finished "The Man Who Mistook His Wife for a Hat", by neurologist and popular author Oliver Sacks. It is about the philosophical ramifications of his patients' diseases. 

• A patient with Korsakoff's Syndrome (severe damage to the memory-forming regions of the brain, due to a vitamin deficiency) lacks the ability to create new explicit memories. Decades after World War II has ended, he does not realize that time has passed beyond the year 1945. He knows himself only as a young man, and has entirely lost his own adult identity. Can someone really "live" if they don't know who they are, and if they have no ability to gain new knowledge or modify their personal narrative and sense of self?

• One patient with Tourette Syndrome finds that his nervous tics enhance his talent as a session drummer, forming the basis of wild improvisations that bring him musical acclaim. Since it is benefiting the patient, should Tourette Syndrome here be considered a disease? Should the Tourette Syndrome be treated? To what extent does Tourette Syndrome define the patient's personality?

• Another patient is mentally retarded but displays a remarkable spiritual and poetic wholeness that gives her life substance. Is it fair to consider her mental faculties as diminished? Are our psychological and neurological tests able to capture her strengths? 

• An elderly patient's new-onset seizure disorder makes her to see vivid flashbacks of her forgotten early childhood, unearthing pleasant memories that had long been buried. During her seizures she can accurately picture her parents, who died when she was age 4, as never before. The memories of her halcyon days of youth put her at ease in her waning days. Her case, among others, suggests that humans have a virtually unlimited faculty for storing memory. We seem to be limited only in our ability to recall those memories, an ability that can be paradoxically enhanced by debilitating diseases.

Sacks discusses these cases as a neurologist, as a historian, and as a student of philosophy. He uses his fascinating patients to try to make sense of the human condition.

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Sacks attended medical school in England and graduated in the late 1950s. I wonder, is my medical education engendering scholarly thought in a way that might produce writer-thinkers like Prof. Sacks? The answer is no. There are notable physician-writers of the present day (Atul Gawande, Danielle Ofri, Abraham Verghese, and Siddartha Mukherjee come to mind), but they strike me as an exception to the rule.

Part of the problem is medical education. We learn the mechanisms of disease and of treatment in thorough detail. But there is little discussion of the wider consequences of what we're learning. The humanities are virtually divorced from my medical education. My school spends about 2 hours of lecture on clinical ethics, with no opportunity to receive further instruction. We are not taught about the history of medicine, or of the philosophy of the mind-body problem, or of the mathematical underpinnings of diagnostic medicine. We learn little about the laws, corporations, and political systems that govern the practice of medicine, about other countries' medical systems, about ways to implement population-scale interventions that prevent disease in the first place. There is so much medicine to learn that we are reduced to learning it in a vacuum, isolated from the fascinating scholarly fields that border, affect, and inform medicine. In many respects, medical school feels like trade school, like learning how to repair cars. We are expected to be learners, but not scholars.

Aren't we missing something substantial? Authors, poets, and philosophers have spent millennia grappling with death and illness, understanding how to make sense of the human experience and how to understand our interactions with others and with ourselves. It offers something that science cannot (and I say this as an undergraduate science major): it offers resiliency, insight, and perspective. When our medical education teaches science at the expense of the humanities, doesn't it also untether itself from humanity? Is it wise for our healers to be ignorant in literature and philosophy? Indeed, can those ignorant of literature and philosophy even be healers?

Part of the problem too is the medical admissions process. Getting into medical school demands that one excel at conventionality. Prerequisites are science and math classes, and applicants are strongly encouraged to net publications and shadow physicians. It demands that an applicant check boxes well, and that they be a scientific kind of thinker. Yet the pre-med process boxes out creative and compassionate thinkers that could innovate the field. The medical profession is beginning to recognize this problem, and is retooling the MCAT to emphasize ethics and social sciences. At the end of the day, though, the MCAT is just a multiple-choice test. Multiple-choice tests demand uniformity of thought, which is the exact opposite of creative thought. Fittingly, virtually every exam I've taken as a medical student has been multiple-choice.

The question really comes down to our identity: what do doctors believe a physician should strive to be? I think most doctors would say, a physician works in a medical setting in the care and treatment of patients. Medical school is structured around this particular mission, and it tends to accept those applicants that abide by it.

My view of medicine's aims is more expansive. I believe that physicians should improve the plight of man, using a knowledge of science as well as whatever other tools are available to them. This could be through patient care, through politics, through education, through research—anything. If medical schools were to adopt this far-reaching mission, and to teach students through that lens, medical education would necessarily look dramatically different. I think our country would look dramatically different, too, and for the better.

I'm hardly the first to believe that medicine should broaden its "scope of practice". The field of pathology, a branch of medicine that involves little patient interaction, was partly founded by Rudolf Virchow. Virchow also founded "social medicine," a nearly nonexistent branch of medicine that studies and addresses the societal determinants of disease (like famine, war, and public policy). In his words, "The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction." Though written over 150 years ago, I believe they hold quite true today.

Card-ology

Although I've only played poker once in the past three years, I entered a (free) campus Texas Hold'em poker tournament and won handily. It was shocking. My competitors were devoted poker fans who spoke in poker lingo and followed the competitive poker scene. I, on other hand, was so rusty that I had to ask players to remind me of the order of poker hands. As of writing, I still don't recall if a straight is worth more than a flush. And yet, everything worked. I accurately predicted when to fold, succeeded every time I bluffed, and subtly pressured my opponents into making unwise decisions that I ultimately collected on.

My performance differed from how I fared the few times I had ever played poker, and I wonder if my victory can be attiributed to my transformation into a medical student. Medicine and poker involve managing uncertainty, and most elements of my poker strategy involve skills that I have been honing in medical school.
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Anchoring: One of the most common pitfalls in making a diagnosis is that we tend to anchor ourselves too strongly to our initial hunches, even in the face of data to the contrary. It's not just physicians who anchor.

For example, you might ask someone: "How many calories are in an apple?"

You might ask a second person: "How many calories are in an apple? 250? 300?"

The second person will tend to give a higher number than the first. An apple actually has about 100 calories. But by suggesting caloric values of 250 and 300, you have subconsciously anchored them to values near those numbers.

Fast-food chains and stores like Walmart use this trick all of the time. The Subway chain prominently advertises how certain subs on its menu are low in fat. But many of their other subs are actually quite high in fat. By advertising that some of their subs are low-fat, they anchor people to the unwarranted belief that Subway subs generally are low in fat. The effect of Subway's advertising is explored in the wonderful book "Mindless Eating", which I previously reviewed.

Doctors must make sure not to follow their initial hunch too doggedly. While playing poker, I was cognizant of how I mustn't get too attached to my hand, even if I've already bet a substantial amount on it. Several times I resisted the urge to keep betting and folded.

Probability and Bayesian inference: In an intriguing case mentioned in a New England Journal of Medicine case report, a neurologist examined a patient who had been diagnosed with multiple sclerosis. Upon questioning, the patient mentioned that both of his brothers had been diagnosed with multiple sclerosis (MS) as well. The neurologist immediately doubted that the disease was MS, because MS is not a very heritable disease. The neurologist knew that if one's sibling has multiple sclerosis, one's odds of having it are only 1 in 25. For all three brothers to have MS was virtually impossible. Sure enough, the neurologist found that what the brothers had was not MS, but instead a rare (autosomal dominant) genetic disease called CADASIL. Probability led to the correct diagnosis.

In poker, if I am one of eight players at the table, I know that in each round there is a 1/8 chance that I have been dealt that round's best hand. This knowledge makes me fold often.

During each round, I ask myself: probabilistically, how strong are my cards relative to the others'? If someone had been dealt a better hand than me, what is the likelihood that they have folded by now? If there were still a person in this round who has better cards than me, what is the likelihood that I could make them fold? Is the way that a particular person is acting consistent with their having a better hand than me?

These same types of conditional probability questions are what underpin Bayesian inference, a branch of statistics that impacts decision-making. The best diagnosticians use Bayesian inference, consciously or unconsciously, to arrive at the correct diagnoses.

Reading people and interacting with people: Interacting with patients in clinic is helping me with reading people generally. When I ask a patient if they smoke tobacco and they hesitate, I know that no matter what they say afterwards, they smoke tobacco. I'm learning how to make a patient feel more calm, which means that, by extension, I'm learning how I could make them feel bothered.

In poker, I frustrated one of my opponents by intentionally placing a needlessly high bet against her early in a round. I correctly predicted that she wasn't confident enough in her cards to call my bet, and she angrily folded. Her reaction suggested to me that she would want retribution, and that the next time I placed a large bet she would call. Sure enough, when I placed another large bet against her, she called and lost on a weak hand. A few hands later, she went "all-in" against me to try to get me to fold. I suspected that her hand was probably weaker than mine, and I called. She lost and had to give me all of her chips. Her frustration in the face of mounting pressure got the better of her.

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I've mentioned some of the ways that becoming a physician seems to be changing me, and not always for better. At the same time, though, medical school is maturing and strengthening some parts of my personality and my thinking. Strange that it was a poker tournament that reminded me of that.

Trying patients

While shadowing a headache specialist in clinic:
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Patient: All you neurologists keep saying the same thing about my headaches. I mean, there has to be someone who actually specializes in headaches. Maybe I need to go see them instead.

Headache specialist: I am a headache specialist.

Patient's wife: Yeah, but I'll bet you only see people with migraines. Not real headaches like his.

Less than perfect: Harrison's Ch. 104 "Disorders of Hemoglobin"

Note: While I attempt to read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing occasional reflections.

Paradoxically, some parts of our body work best when they fail under stress.
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An illustrative story from my freshman year of college:

I decided to buy a wheelie chair for my (miniscule) dorm room from a student who lived 1.5 miles away. How could I transport the chair across campus when I didn't have a car?

I didn't feel like wasting an hour walking there and then walking the chair back. Instead, I elected to waste three hours dreaming up and building an alternative. I decided I would tow the chair with my bicycle by running a rope between them. The only rope I could find, though, was an Ethernet cable that was too short. I improvised, tying the cable to my bike rack and then lengthening the contraption by adding some plastic hangers as a kind of towing hitch. A friend grabbed a chair and took it for a test ride (below).

After a few modifications, the setup worked surprisingly well. So long as I didn't decelerate or turn suddenly, the chair trailed the bike by a comfortable four feet.

I bought the wheelie chair and sped it through the streets and paths of campus, dodging parked cars and drawing whistles and shouts of approval from onlookers. Two-thirds of the way through my journey, though, things went wrong. I steered my bike to the left of a bollard, and the chair instead traveled to the bollard's right. I watched helplessly as the line went taut and then snapped, pulverizing the hangers into a shower of plastic shards.

While cleaning up the mess, I realized with a shudder that my originally-intended design (a simple rope connecting chair to bike) could have seriously injured me. The plastic hangers had dissipated the tremendous shock by shattering and by disconnecting my bike from the chair. Had nothing been there to absorb the shock, my bike would have been flipped backwards, throwing me onto the cement headfirst and onto my back. Oddly enough, my design flaw saved me.
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A similar phenomenon, of the "useful design flaw," underlies some of the disorders of hemoglobin. Hemoglobin is the critical enzyme in our red blood cells that carries oxygen to our tissues and carries carbon dioxide to our lungs. Hemoglobin disorders such as sickle-cell trait and thalassemia minor are particularly prevalent in areas endemic to malaria, and for good reason. Put simply, in these diseases hemoglobin is either mutated or unevenly manufactured, weakening the red blood cell. These weak blood cells are less hospitable to infection by the parasite (Plasmodium falciparum) that causes the most lethal form of malaria. And so, for those living in areas plagued by malaria, having weak blood cells is adaptive and life-prolonging.

Examples of other helpful design flaws abound in nature. Hepatitis C and HIV replicate their genomes with significantly lower fidelity than do humans. The numerous mutations generated by these replication errors help the viruses elude our immune systems and frustrate our attempts at making a vaccine.

My classmates and I are striving to become physicians who don't make mistakes. Nature, though, doesn't have to set so high of a bar for itself. Sometimes, less than perfect is just right.

Harrison's Ch. 27: "Sleep Disorders"

Note: While I attempt to read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing occasional reflections.  

From Harrison's Ch. 27 ("Sleep Disorders"):

Driving is particularly hazardous for patients with increased sleepiness. Reaction time is equally impaired by 24 h of sleep loss as by a blood alcohol level of 0.10 g/dL. More than half of Americans admit to having fallen asleep while driving. An estimated 250,000 motor vehicle crashes per year are due to drowsy drivers, causing about 20% of all serious crash injuries and deaths....

Failure to recognize and treat [sleep apnea] appropriately may lead to impairment of daytime alertness, increased risk of sleep-related motor vehicle accidents, hypertension and other serious cardiovascular complications, and increased mortality. Sleep apnea is particularly prevalent in overweight men and in the elderly, yet it is estimated to remain undiagnosed in 80–90% of affected individuals. This is unfortunate since effective treatments are available.

Traditionally, doctors and patients haven't given terribly much thought to the health impact of the third or so of our lives we spend in bed. But as we become more overweight (causing sleep problems) and as we better understand the health burden of sleep problems, perhaps there will be a renewed focus on sleep.

When I was seeing patients in a primary-care clinic, I asked some of them whether they felt well-rested during the day. Most said they were sleepy all the time. When I then administered the Epworth Sleepiness Scale, a standard test to assess risk for sleep apnea, some of the results were startling. One patient scored a 21 out of a possible 24, with 9 being the cutoff for urgent referral to a sleep expert. Patients were falling asleep during business meetings and while driving. I dutifully referred them for a home sleep study. I regret not having asked more patients about their sleeping habits, because I'm sure that many of them had undiagnosed sleep apnea. I vividly recall years ago hearing a sleep expert call sleep apnea a "walking time bomb."

I also saw a handful of patients who had been diagnosed with sleep apnea and who were on treatment (typically CPAP, a mask worn at night that supplies air). They said they felt like new people.

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I recently came across the excellent "Anonymous Doc" blog, written by a medical resident. He writes about a time he was very sleepy.

Harrison's discusses the phenomenon of tired medical residents in the chapter:

Resident physicians constitute another group of workers at risk for accidents and other adverse consequences of lack of sleep and misalignment of the circadian rhythm. Recurrent scheduling of resident physicians to work shifts of 24 h or more consecutive hours impairs psychomotor performance to a degree that is comparable to alcohol intoxication, doubles the risk of attentional failures among intensive care unit interns working at night, and significantly increases the risk of serious medical errors in intensive care units, including a fivefold increase in the risk of serious diagnostic mistakes. Some 20% of hospital interns report making a fatigue-related mistake that injured a patient, and 5% admit making a fatigue-related mistake that results in the death of a patient. Moreover, working for >24 h consecutively increases the risk of percutaneous injuries and more than doubles the risk of motor vehicle crashes on the commute home.

Uh-oh.

Rare

I saw a patient with Menkes Disease, a rare and serious disease in which the body cannot adequately absorb copper from the diet. Most doctors know this disease only as a paragraph in one of their textbooks, or as the subject of twenty seconds of one medical school lecture. Although it is tragic to see a patient with an incurable disease, encountering the flesh-and-blood embodiment of this rare entity felt something like a stroke of luck. I now am among the privileged few to have seen the real thing up close.

'Medicine in Translation: Journeys with My Patients', by Danielle Ofri

In "Medicine in Translation: Journeys with My Patients", Dr. Danielle Ofri retells the remarkable stories of about a dozen of her patients. Dr. Ofri is an attending physician at Bellevue Hospital in New York City, the nation's first public hospital. Dr. Ofri's stories are about moving to a new country: her patients are immigrants who are trying to maintain their identity in the American melting pot. One patient was left horribly disfigured by a politically-motivated attack in his home country. Another needs a heart transplant but cannot obtain one because of her undocumented status. They persevere in the face of tremendous obstacles.

Dr. Ofri tries to bridge the cultural and language barriers that separate her from her patients. She decides to become an immigrant of sorts: she relocates her family to Costa Rica for a year as a break from medicine and as a way of acquainting herself with the culture and language of some of her Hispanic patients.

It is a touching little book. Dr. Ofri cares for her patients and cares about them, too. Her writing captures how she learns from her patients and uses their example to better herself.

Happy anniversary!

From my first blog entry, on August 18, 2011:

Science only gets the doctor so far. We understand the biochemical mechanism of hypertension, we understand how deadly it is, we can easily diagnose it, and we know how to cheaply and effectively treat and even prevent it. Yet hypertension still afflicts a third of adults in the U.S. and kills a substantial fraction of them. We can't escape the fact that patients are people, with people's foibles, strengths, and shortcomings. This makes treating chronic illness frustrating and sometimes ineffectual. But that I am dealing not just with kidneys and arteries and hearts, but with people, is what also makes clinical medicine intensely rewarding.

115 entries and one year later, I mark the anniversary of this blog.

To my surprise, more and more people have been stopping by. Since November, readers from 70 countries have visited. Within the United States, visitors came from 47 states plus the District of Columbia. The blog comes up on the first page of search results when one types "reflex hammer" into Google. The American College of Physicians featured the blog on its website, as a "Notable Voice of Internal Medicine." It has been an electrifying feeling. When I started, I figured the only people who would read my writing would be my family and a few friends.

I'm grateful to readers like you for allowing me to share my story. Thanks very much!

Harrison's Ch. 392: "Alcohol and Alcoholism"

Note: While I attempt to read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing occasional reflections. 

In Lysistrata, by the ancient Greek playwright Euripides, the wives of the warring Athenians and Spartans revolt. The women collectively agree to withhold sexual privileges from their husbands and lovers until the men of the two cities make peace. A peace conference quickly follows. A treaty is successfully negotiated, thanks in part to the hefty amount of alcohol consumed by the ambassadors on both sides:

1ST ATHENIAN
I've never known such a pleasant banquet before,
And what delightful fellows the Spartans are.
When we are warm with wine, how wise we grow.

2ND ATHENIAN
That's only fair, since sober we're such fools:
This is the advice I'd give the Athenians—
See our ambassadors are always drunk.
For when we visit Sparta sober, then
We're on the alert for trickery all the while
So that we miss half of the things they say,
And misinterpret things that were never said,
And then report the muddle back to Athens.
But now we're charmed with each other. They might cap
With the Telamon-catch instead of the Cleitagora,  
     ["they could perform Spartan poetry instead of Athenian poetry"]
And we'd applaud and praise them just the same;
We're not too scrupulous in weighing words.

From even before the time of the Greeks, alcohol consumption has been a part of our literature and a part of our lifestyle. 

---

The time I am spending on the hospital wards is showing me another side of alcohol: the terrible toll that it exacts from some of its consumers. One such patient who was in her twenties had suffered complete liver failure because of heavy alcohol consumption. As such, she was badly jaundiced. The whites of her eyes were now a dark yellow and her fair skin was now a dark green-brown. Her chances of being alive in 3 months' time were under 15%. Another patient had lost the ability to walk or sit up unassisted because of alcohol-induced degeneration of the part of his brain (the cerebellum) that regulates balance. According to Harrison's:

Because 80% of people in Western countries have consumed alcohol, and two-thirds have been drunk in the prior year, the lifetime risk for serious, repetitive alcohol problems is almost 20% for men and 10% for women, regardless of a person's education or income. While low doses of alcohol have some healthful benefits, the intake of more than three standard drinks per day on a regular basis enhances the risk for cancer and vascular disease, and alcohol use disorders decrease the life span by about 10 years.

As much as I enjoy having a beer, I've started to see alcohol as a poison above all else. Although you might think that doctors would know better, Harrison's also points out that "the lifetime risk for alcoholism among physicians is similar to that of the general population."

Alcohol consumption is increasing in the United Kingdom and Russia and is surging in new markets like India and China. As an increasing number of people worldwide try alcohol for the first time, more will abuse alcohol, with the concomitant problems that alcohol wreaks on the body and the mind.

Although treatment for alcohol addiction is in its infancy, doctors are getting a better sense of what interventions are effective. There even are a few medications, such as naltrexone, that seem to blunt cravings. The outsized public health impact of alcohol consumption also means that medical innovations in this field will have an outsized effect on people's well-being.

Going zebra-hunting

The aphorism handed down to medical students like myself goes: "When you hear hoofbeats behind you, don't expect to see a zebra." In medical parlance, "zebras" are rare diseases. Zebras are those obscure diseases that a doctor learns about in medical school and then never encounters again.

Recently I went zebra-hunting on the hospital wards. While the professor showing me around checked on an ill patient with a failing organ, I noticed at the patient's bedside table a large tub of fancy imported licorice. Some of the licorice had already been eaten. I asked the patient if she likes licorice. She responded that she loves the stuff, and eats a substantial amount every day.

What the patient didn't know was that a compound in licorice, glycyrrhizic acid, inhibits an important enzyme found in the adrenal glands. Consuming moderate-to-severe amounts of licorice can cause certain medical problems (like hypertension and fluid retention) that would have been particularly harmful for this patient. I brought this up to the medical team, and they told her to stop eating licorice.

Another patient had episodes of disabling, unremitting headaches that would last for weeks. I suspected hemicrania continua, a rare headache disorder that seemed to fit the case quite nicely.

I had read somewhere that those most likely to diagnose rare diseases are old doctors (because they've seen everything) and those still in training (because they spend a disproportionate amount of their time learning about rare diseases). I am still early in my training. It's not clear to me whether the reason I am finding zebras is because my eye is keen or because I don't know what I'm doing. I'm becoming increasingly confident that it is the former.

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Housekeeping note: If you follow the blog, I recommend doing so via RSS feed. RSS allows you to follow your favorite blogs without having to visit the websites individually. A brief primer on RSS feeds is available here. 

Piano Sonata No. 16 in C Major, K. 545

In a secluded room on the top floor of our medical school is a piano by a window. I consider this spot my little birds' nest. Although I only remember how to play a handful of songs, every once in a while I dart upstairs and tap out a tune while overlooking the world below.

Recently, a surprise awaited me atop the piano. Someone had left a book of classical sheet music. I quickly set to work on a lovely Mozart piano sonata that I had always wanted to learn (performed by a professional musician in the video below).

 

Some academic pursuits directly involve the act of creation. Art students create sculptures, computer science students write programs, creative writing students compose stories, and doctoral students craft theses.

Medical school, by comparison, does not demand that we create. It demands that we accumulate and regurgitate knowledge, in the hope that it might help us someday assist patients. The fruits of our labors will come years down the line, in nebulous and intangible ways. I recently read an article about the ethics of harvesting the eggs from a brain-dead patient and then using them for in-vitro fertilization. Will it ever make a difference that I spent those 10 minutes reading that article instead of watching TV? It's hard to say. I doubt I'll ever know. When I go to lecture or read a textbook chapter, it's not immediately clear what I am accomplishing, if anything. Our quest for medical knowledge often lacks a human element. Our examinations are entirely multiple-choice. Selecting from one of five given answers precludes individuality, emotion, and expression.

And so, I find my respite in playing the piano. I hit a key, and instantly it sounds. Sometimes my fingers effortlessly flit across the keyboard: it's as though my hands already know how to play the tune, and my brain's job is simply to sit back and enjoy. There is the technical challenge of obeying the sheet music and getting my hands in position for the notes still to come. Then comes the artistic exercise of making the music have feeling. The payoff is gratifyingly fast. Each time I play the sonata, it sounds better. Not only am I creating, but I am creating something beautiful.

Among the less fortunate

I joined a professor as he rounded on patients in the adult hospital wards. As always, the patients we saw on the wards were quite sick, suffering from several chronic diseases with little chance of cure.

Although some patients were in a bad way of their own volition (alcoholism leading to liver failure, smoking leading to lung problems), some were there because of bad fortune. One patient's spine had been injured in a car crash when she was a teenager, paralyzing her legs, limiting movement in her arms, impairing her breathing, and leaving her incontinent of urine. Her impairments left her vulnerable to infection, and a particularly nasty one had landed her in the hospital. Just one car crash had altered her life's trajectory.

Another patient was a nurse with liver failure because of Hepatitis C infection. Although it wasn't clear how she contracted the virus, her exposure probably came from one of the patients she had cared for.

Why were myself and the physician the ones in the white coats and the patients the ones in the beds? In large part, because of chance. It boggles the mind.

Attraction

One evening years ago, I happened to be studying in the law library of one of the most prestigious law schools nationwide. I was dressed nicely. It was getting late, and the library was nearly empty.

Imagine my surprise, then, when an attractive sorority girl in heels and a rather short skirt plunked down next to me and struck up a conversation. She seemed keenly interested in anything I said. After flirting with me for a couple of minutes, she asked what I was reading.

"It's a textbook on evolutionary biology." I said. "It's fascinating stuff!"
"Huh," she replied. "Why is a law student reading about evolution?"
"Oh, I'm not a law student. I'm an undergrad."

Her disappointment was palpable. Moments later, she was gone.

Before plunging back into my textbook, I mused: what would have transpired just then had I actually been a law student?

Now, years later, I am a medical student. Although my status as a second-year medical student carries little cachet, occasionally it affects how a person interacts with me. A few months back, while traveling between clinics, I had to dart into a market while wearing my white coat. The girl working the checkout stand was my age and started chatting me up. She seemed to be taking a deliberately long time to ring up my order. Sometimes when I've rotated in clinics, members of the ancillary staff have pulled me aside. They have asked me a few times how old I am and even whether I'm single. Some mothers have tried to give me their daughters' cell phone numbers.

At some level, it is nice feeling wanted and appreciated. Yet it bothers me that what garners attention usually doesn't seem to be me or my personality, but simply my belonging to the medical profession. I feel like these interactions sometimes don't happen for the right reasons. It makes me more guarded and suspicious of people's intentions. Part of me prefers the anonymity of when I was nothing more than a wide-eyed undergrad.

Our professors warn us to be cognizant of romantic advances, especially in the clinical setting. An otolaryngologist (ear, nose, and throat doctor) recounted to me one of the first patients he saw as an attending physician. An attractive female patient had come in with an ear complaint. During his examination, she loosened her gown, exposing her breasts. He was dismayed and terrified. No chaperone was present and the patient's state of undress could have given the appearance of something unseemly. Interestingly, a psychiatrist advised us that certain personality disorders make patients particularly prone to pushing the boundary between doctor and patient.

I imagine that as I progress towards becoming an attending physician, the effect I've noticed will become more pronounced. Being a physician will make some people more inclined to befriend me, and others less inclined to befriend me. Regardless, it will become increasingly difficult to dissociate my personal identity and my interpersonal relationships from my professional calling. Is this a good thing?

Medical school is dramatically altering the way I think and the way I perceive people. Perhaps it's only fair that it will alter the way some people see me, for better or for worse.

Landmarks

Median view of the brain (nose would be on the right)

I'm currently studying neuroanatomy, the anatomy of the brain. Although the brain might appear homogenous and dull from its exterior, inside is a richly varied landscape. Lakes and rivers of cerebrospinal fluid course through the mountains and valleys of neural tissue. A few bridges of neural fibers span the division between cerebral hemispheres, allowing the higher brain's two halves to converse. Many structures were named (in Latin) for an object they resemble: an almond ("amygdala"), a belt ("cingulate cortex"), a knee ("genu of the corpus collosum"), a seahorse ("hippocampus"). Colors also were an inspiration: particular landmarks appear black ("substantia nigra"), white ("white matter"), gray ("gray matter"), red ("red nucleus"), and even cerulean ("locus coeruleus"). Even the tiniest anatomical features are named. Some names are whimsical: the "mammillothalamic fasciculus of Vicq d'Azyr", the "habenular trigone", and the "calcar avis".

The brain is valuable real estate, its compact structures multifaceted and intricate. By necessity our maps of the brain are exquisitely detailed.

Admittedly, it is a chore to be learning several hundred unique structures of the brain: their functions, their interconnections, and their relative positions. But it also is fabulous traveling this well-trod ground. It reminds me of looking up at the night sky and rediscovering the constellations traced out by those of old.

The reflex hammer

Perhaps the title of my blog will become a self-fulfilling prophecy.

Assorted neurological physical exam tools

I named my blog "The Reflex Hammer" as a nod to "The Lancet," a prominent British medical journal. Reflex hammers have always intrigued me. How is that the doctor tapping just below my knee causes my leg to swing out wildly? Although a humble instrument, the reflex hammer is so powerful that it briefly usurps a person's ability to control the movement of their own limbs. Because reflex hammers test the function of the nervous system, they are of particular importance to neurologists.

What I didn't realize when I picked the title of the blog was how exciting I would find neurology. The brain and spinal cord are composed of complicated neural pathways that each carry particular types of information. One part of the spinal cord carries sensory input about temperature. Another part of the spinal cord carries directions that go to muscles. Another part carries sensory input about proprioception, the position of the parts of the body in space. The pathways each travel a confusing and unique course, wending this way and that as they traverse the spinal cord and the regions of the brain.

When something goes wrong (for example, a patient loses the ability to look upwards), the neurologist must visualize the various neural pathways to reason through where the problem lies. Upon identifying the physical location of the lesion, he also must figure out what caused the lesion in the first place. Was it a stroke? A tumor? An infectious disease? Neurology has a reputation of being highly intellectual and of requiring studiousness, cleverness, organization, and careful thought. I think it suits my personality better than most fields.

As with most medical students, I am constantly testing the waters of different specialties to see which I like the most (and which I like the least). No longer will I reflexively rule neurology out.

But that's crazy talk!

Part of our psychiatry class involves interviewing a psychiatric patient. We know nothing about the patient when we start the interview.

I joined two classmates in interviewing one such patient. One classmate went first, and for his 15 minutes he did a good job laying a foundation. He got an overview of the patient's life story, social history, and medical history. The patient struck us as a bit odd, but his answers seemed credible and he seemed to be an ordinary guy who had fallen on hard times.

Then it was my turn, and my job was to assess his psychiatric state. I quickly managed to open the floodgates. He revealed his delusions about being the son of god, that within a few months everyone's eye color would change, that he was adopted but that his birth family is profoundly wealthy and runs the American government. His story contradicted itself, showing that his thoughts were not only unhinged from reality but disorganized as well.

It took longer than I expected for us to uncover this patient's profound psychiatric disorder, even though we knew he was a psychiatric patient. First impressions can be deceiving.

Case in point

Wednesday is fast becoming my favorite day of the week, because it's the day when the New England Journal of Medicine (a prominent medical journal) releases its newest issue. I immediately look at the latest installment of "Case Records of the Massachusetts General Hospital." It is a write-up of an interesting medical case seen in Harvard's main teaching hospital.

"Case Records" has been published continuously since 1924, and I think it is one of the most effective ways of learning medicine. A detailed write-up of the patient's history is presented. Then, a physician comes up with a differential diagnosis, predicts what disease he thinks it is, and explains his reasoning. Finally, the true diagnosis and outcome of the case are revealed, and an expert explains to the reader the mechanism of the disease at hand.

Reading through a case is rather engaging. After reading the patient history, I try to guess the diagnosis and then compare my reasoning to the physician's. The thrill of untangling the mystery of each case makes me want to learn about the disease. That there's a real human story behind each case makes the cases stick in my memory. By my tally, I've completed about 70 cases thus far.

Unfortunately, the cases take up an inordinate amount of time. Each one takes me anywhere from twenty minutes to four hours, because I try to read pertinent chapters in my textbooks as I go along. Some of my buddies poke fun at how ridiculous I look when I review a case in the med school library--I occupy a whole table, with all kinds of random medical books splayed about. Despite my best efforts, I haven't succeeded in getting my classmates to share my enthusiasm. After all, time spent studying cases is time not spent studying what will be on the test. It's not immediately obvious how I benefit.

Sometimes I present a professor with a case and ask them to explain a part that I didn't fully grasp. A handful of them have broken into a smile and revealed to me that they, too, used to study "Case Records" in their spare time when they were medical students. Now when I sit in the library poring over a case, I feel connected to an invisible community of eager medical students who, over the decades, have stolen off to the library to perform this same ritual, learning for learning's sake.

Harrison's Ch. 97: "Gynecologic Malignancies"

While I attempt to read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing occasional reflections.

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Cervical cancer is not so scary to Americans anymore because of the Pap smear. Pap smears are good at detecting pre-cancerous cervical cells, and over the past 50 years its widespread adoption has dramatically reduced cervical cancer diagnoses and deaths in the developed world. Unlike most cancers, cervical cancer is usually caused by a viral infection. Certain strains of the human papilloma virus (HPV) predispose cervical cells they infect to malignancy. Now that vaccination against some of these HPV strains is available in the U.S., we can expect the cervical cancer rate to drop even further. It is a triumph of preventive medicine.

These triumphs have barely helped the developing world, though. One of the most preventable forms of cancer still kills surprisingly many.

A handful of researchers are trying to help. Doctors in the U.S. sometimes apply vinegar (acetic acid) to the cervix so that they can visualize cervical cancer cells with the naked eye. The acid turns the cancer cells white. It seems that vinegar could be similarly used in the developing world as a low-cost replacement for the Pap smear. If the health worker sees white lesions, he can freeze them off with a simple metal rod cooled by liquid carbon dioxide.

I think it's incumbent upon us to translate our high-tech scientific advances into low-tech tools that can benefit all.

When it rains, it pours

In 17th- and 18th-century England, milkmaids had a reputation for having pretty faces. This was because they rarely seemed to get smallpox, which left pockmarks on the skin of its survivors. Milkmaids did, however, catch from their cows a milder, related disease known as cowpox. English physician Edward Jenner famously hypothesized that the milkmaids' contracting cowpox made them immune to smallpox. Using this observation, he successfully created the first vaccine. This is where we get the word "vaccine": in Latin, vacca means "cow."

And so, having a disease (cowpox) sometimes protects you from another (smallpox). For example, getting oral herpes can sometimes offer slight protection against genital herpes. Although being born with no spleen (congenital asplenia) can cause problems, it does eliminate the chance of a ruptured spleen (which can be a life-threatening complication of a motor-vehicle accident).

Unfortunately, the opposite usually holds: most diseases simply invite more disease.

• Myasthenia gravis is a disease of muscle weakness. Some patients have difficulty swallowing (dysphagia) and aspirate their food, leading to pneumonia. 
• Untreated gonorrhea inflames the lining of the vagina in a way that makes a woman more susceptible to HIV infection. 
• Hypertension, diabetes, tobacco use, and smoking all lead to a host of ills.
• Being in the hospital exposes patients to a whole host of nosocomial (hospital-acquired) infectious diseases, like C. difficile, a bacterium that causes persistent diarrhea. 
• Autistic patients are more likely to have nutritional deficiencies because they tend to be picky eaters.

For the most part, "when it rains, it pours."

This used to depress me, but I've started seeing it differently. If I can diagnose a disease promptly and treat it appropriately, the patient will stand less of a risk of contracting the additional diseases that may follow. It's like a two-for-one.

Hypocrisy

New York City's mayor, Michael Bloomberg, has championed a proposal to ban the sale of sugary drinks larger than 16 ounces in regulated food establishments. Unsurprisingly, the beverage and movie theater industries are pushing back. From the New York Times City Room blog:

Robert Sunshine, a lobbyist for the movie theater industry in New York State, said that while his clients agreed that obesity was an epidemic, “we believe it should be handled through education.”

“No one,” he added, “should be told what they can do and what they can’t do.”

Oh really? Then what gives your clients the right to tell moviegoers that they can't talk on cell phones during films? Yeesh.

A happier kind of math

A patient I saw in free clinic was overdue for her breast and colon cancer screening, because she had lost her health insurance years ago. This is so commonplace that by now I am shocked when patients at our clinic are current on their screening. It's a shame, too, because cancer screening is one of the most effective health interventions we can provide a patient population. For example, by undergoing regular Pap smears, women increase their life expectancy by 2 to 3 months. Then again, since our patients are uninsured, few of them could manage to receive treatment if a screening test came back positive.

As for my patient, our clinic doesn't perform mammograms, which are the standard screening test for breast cancer. That left the doctor and me in the familiar position of estimating whether our patient should spend her own money on a mammogram at an outside clinic. On the one hand, our patient said she was short on cash. On the other hand, she had a family history that placed her at substantially higher risk of breast cancer. Had enough time elapsed since her last test to justify the expense of a new mammogram? We decided, probably not. It's a grim calculus, the sort of mathematics that I hate having to perform.

Yet this week, the discussion was different. The question was whether our patient could hold off until 2014, when the remaining provisions of President Obama's Affordable Care Act (ACA) take effect. Under the ACA, our patient's cancer screening will be fully covered. She won't even be charged a co-pay. I don't think I've ever finished a day in clinic feeling so optimistic.

Medical school has introduced me to patients in desperate straits. One of my first patients appeared to have a hormone-secreting tumor that had set her body's electrolyte balance awry. Surgically removing the tumor probably would have cured her. But she couldn't afford it. She couldn't even afford the imaging study that would have confirmed the presence of the tumor. Instead, when I had seen her, her electrolyte levels were so skewed as to be nearly incompatible with life. By now she is probably dead. I couldn't help but ask myself: why must this be?

I used to talk about "the uninsured" as an abstraction. Now I examine them in the exam room, and I am increasingly entrusted with their care. They are people, just like you and me. Their hearts beat and their stomachs growl. I feel responsible for them. I want to see them lead happy lives.

My recent experience in clinic was the moment when it truly sunk in: many of the uninsured patients I see are entering a new era. It won't be a perfect era. But it will be an era where I'll get to perform a happier kind of math.

Update: A classmate informs me that, thanks to a grant, a nearby clinic will perform patients' mammograms for free of charge.

Getting the patient on board

I spent several weeks seeing patients in an internal medicine clinic. Often the diagnosis and treatment were obvious, and the challenge was motivating the patients to take their medications and keep a healthy lifestyle. How could this be accomplished?

Interestingly enough, the patient interview can be used to encourage the patient to change their behavior for the better. "Motivational interviewing" involves structuring questions in a way that encourages the patient to alter their behavior for the better. If a patient smokes, I ask them if they have ever tried to quit. If they say yes (and nearly all of them do), I ask them why they had felt motivated to quit at the time. My follow-up question is whether the reasons they had back then still apply today. I might also ask the patient what their first step would be if they were to try quitting again. This line of questioning makes the patient more prepared to attempt to quit once more. Motivational interviewing is more pleasant and effective than simply admonishing patients that they need to stop smoking. [As a side note, the same concept underlies the contemptible practice of "push polling."]

During my interview, I like chatting to patients about their job, their hobbies, their kids, and their travels. Not only is it fun to get to know them, but it usually tells me things that I can later use to encourage them to adhere to their treatment plan.

One patient was the star running back of his high school football squad. For reasons that his doctor wasn't able to determine, his blood pressure was quite high. The high blood pressure had persisted for years, because the patient didn't feel like taking his blood pressure medications. He is hardly alone. It's particularly difficult to convince people to take their blood pressure medication. The side effects from the pills are immediate, but the injuries caused by high blood pressure often take decades to manifest. Most patients prefer feeling better now to the vague promise of feeling better later. How could the doctor convince this teenager to take his medication? Some chatting revealed an answer. The patient was angling to get a scholarship to a top football program. The doctor pointed out that until the patient brought his blood pressure under control, he would fail the medical clearances necessary for recruitment. Problem solved.

A diabetic teenager seen in clinic stubbornly refused to control his blood sugar. His girlfriend was with him in the exam room. The doctor casually mentioned that diabetes causes vascular problems that can disrupt several body parts: the kidneys, the toes, the penis, the retina, the fingers. The patient turned white as a sheet. "What happens to people's penises?" the patient asked. After the doctor discussed erectile dysfunction, the patient became much more keen on learning how to use his insulin.

The effective primary-care doctor apparently has to be something of a salesman.

Blocked thought

Years ago, I spotted an acquaintance I hadn't seen in a while. The conversation was odd. A few times, I would ask a question and he would begin to respond, only to trail off into silence and stare blankly into space. He would remain frozen until the moment I said something else, whereupon he would act normally. He seemed completely oblivious to the fact that he had trailed off and had never answered my question. Indeed, he didn't seem to remember that I had asked him a question at all.

These episodes felt interminable--in one instance I waited a good 30 seconds before catching his attention and changing the subject. I wondered for how many minutes he would have remained "paused" if I had never said anything.

I had forgotten this conversation until I came across a passage in our psychiatry textbook describing this exact phenomenon. It is called "thought blocking," and many patients who have it are schizophrenic. Intrigued, I asked a psychiatry professor about it (one of the perks of being in medical school). He told me that blocking sometimes happens because a hallucination distracts the patient. It also can be because certain impulses in the brain fail to arrive at their proper destinations. For example, one part of the brain is responsible for keeping the brain focused on certain tasks, like tying a knot to completion or answering a question in a conversation. This part of the brain might have had a faulty neural connection with the regions of the brain responsible for formulating and vocalizing the answer to my question. It's fascinating.

Currently in anatomy class, we are dissecting the brain. It is not a particularly large organ (perhaps it's the size of a cantaloupe?), nor is it terribly heavy (about three pounds). Yet it contains everything that makes us human. This pink blob is not only what makes us see and breathe, but also what underlies envy and love, music and literature, war and civilization. Discovering new things about the brain makes it all the more inscrutable: how is it that two almond-sized regions of the brain contain our most visceral emotions and fears? It's baffling. One of my textbooks points out that the number of neuron cells in one's brain approximates the number of stars in the Milky Way.

Wonderment at the splendor of the human brain goes back as far as Plato. Yet today, not only do we understand much more about the human brain, but the rate at which we are unlocking the mysteries of the mind continues to accelerate.

I often dwell on the sacrifices that medical school entails--financial, social, personal, relational, and emotional. But, we get to study the brain. We even get to marvel at it by picking it up and holding it in our own hands. It reminds me yet again that this enterprise of becoming a physician is a rare privilege.

Victory lap

Paul Krugman reminds us who the real winners are of today's Supreme Court decision: Americans.

Supreme court decision

What would have happened if the Supreme Court had struck down the health insurance mandate as unconstitutional? It would have set universal health care, in any form, back by decades.

It's been heart-breaking seeing patients whose lack of health insurance prevents them from getting the sometimes life-saving treatment they need. Everyone deserves health care. I'm elated that the Supreme Court stayed on the correct side of history.

As goes dentistry, so goes medicine?

Frontline, my favorite television program, just aired an enlightening and dismaying hour-long documentary on America's broken dental safety net. It focuses on the poor's lack of access to quality dental care, as well as the proliferation of for-profit dentistry chains that sometimes derive revenue through shoddy work, unethical billing, and predatory lending.

It is strange seeing how the frightening changes described in the documentary are also manifesting themselves in American medical practice. Solo medical practices are becoming unprofitable, and in their stead are large health-care conglomerates that are often focused on their bottom line. Similarly to dentists, physicians feel threatened by the rise of so-called "mid-level providers," the physician assistants and nurses that are being granted increasingly wide scopes of practice. Not that these changes are unique to America: I recently read Nobel Laureate Alexander Solzhenitsyn's Cancer Ward, a semi-autobiographical novel set in a Soviet hospital. Although written 50 years ago, the doctors' complaints of the erosion of professional standards and the demise of the solo practice would just as easily apply to this country today.

The Frontline documentary portrays a badly-broken dental system, which causes grievous harm to children and adults and which has no clear solution on the horizon. As much as I'm partial to my profession, I have to wonder, is medicine today so different? And is medicine immune to the pressures bearing upon the dental profession?

On a side note, medical students find it easy to get jealous of dental students. Dental students can practice general dentistry after completing four years of dental school, whereas medical students must undergo additional training. Also, being a general dentist today is generally more lucrative than being a primary-care physician, especially because HMOs haven't completely taken over the dental field. Dentistry is an important medical field, as the documentary clearly demonstrates. Even so, I'm happy to be in a profession that permits me to focus on almost any part of the body.

Smoking gun

Watching actors smoking cigarettes on screen makes young viewers more likely to smoke. The tobacco industry has known this maxim for quite a while, and decades ago they offered free lifetime supplies of cigarettes to actors and actresses.

Although tobacco companies are no longer allowed to expressly pay for product placement in American films, smoking still appears in a number of current movies. Movie studios claim that they need to be allowed to show smoking, in part so that they can maintain the historical accuracy of films set in the past. For example, the Oscar-winner "The Artist" is full of characters puffing away.

If studios cared about historical accuracy, they ought to also incorporate other elements into films set in the 1920s:

-People were shorter than today, because nutrition was not as good. Hire shorter actors.
-Orthodontia didn't really exist. Only hire actors with crooked teeth.
-Dentifrice (toothpaste) didn't whiten as effectively as today. Only hire actors with yellowed teeth.

Movie studios are selective about what they choose to include when they portray historical periods. I'm not sure why cigarettes should be so sacred.

When politics and medicine mix

The C.I.A. hired a Pakistani physician, Dr. Shakil Afridi, to run a 2011 hepatitis B vaccination campaign in the Pakistani city of Abbottabad. The vaccination campaign was a front to investigate the Abbottabad residence where Osama bin Laden was thought to be hiding, and for Dr. Afridi to obtain DNA samples from the house's residents. Although Dr. Afridi did not manage to collect a DNA sample, his observations from visiting the house helped confirm that the house was bin Laden's. (In what appeared to be a politically-motivated verdict, the Pakistani government recently sentenced Dr. Afridi to 33 years in prison.)

Although the phony vaccination campaign helped kill bin Laden, it badly undermined the credibility of global health efforts. The New York Times reports that the Taliban is forbidding polio vaccinations in a Pakistani province that is one of the only remaining regions in the world where polio is endemic:

A Pakistani Taliban commander has banned polio vaccinations in North Waziristan, in the tribal belt, days before 161,000 children were to be inoculated. He linked the ban to American drone strikes and fears that the C.I.A. could use the polio campaign as cover for espionage, much as it did with Shakil Afridi, the Pakistani doctor who helped track Osama bin Laden.

This is awful news. Polio kills and paralyzes. The global community had gotten tantalizingly close to eradicating polio, convincing even those countries that feared ulterior motives to get on board. Vaccination drives have always attempted to separate themselves from wars and politics. During the successful smallpox eradication drive, some warring African nations even held ceasefires so that aid workers could vaccinate communities.

The C.I.A. program has ruined the credibility of vaccination drives, or at the very least has given cover to those who would use their participation in vaccination efforts as a bargaining chip. So long as North Waziristan refuses to vaccinate, it seems to me that polio cannot be eradicated.

There is a reason why the practice of medicine is supposed to be insulated from politics. In attempting to kill a terrorist, the C.I.A. violated this profession's core ethics and helped perpetuate another terror's reign.

See also a worthy New York Times news article about the ongoing impacts to international aid efforts stemming from the phony C.I.A. vaccination program.

Medicine by-the-book

I saw a patient who had injured his knee. I performed a handful of physical exam tests that I was familiar with: pulling on his leg to check the integrity of the anterior cruciate ligament (ACL), twisting his joint in a particular way to check some other ligaments known as the collateral ligaments. Still, I wasn't sure of a diagnosis. There were a handful of other tests that I wanted to perform which I had never done before. I didn't remember how they were done, and I didn't want to guess for fear of injuring the patient. So, with the patient in the room, I pulled out Sapira's, my gem of a physical exam textbook, and read for a bit of its section on the knee. Thanks to the exams it described, I was quickly able to pinpoint his injury to the posterior horn of his medial meniscus, without needing to take an X-ray or an MRI.

The patient seemed fine with my consulting a textbook mid-examination. "After all, you're just a student," he had said. But it felt uncomfortable. Bringing out the book was a tacit acknowledgment that I am falliable, that I don't know everything I need if I'm to help the patient. Most primary-care doctors I shadow excuse themselves from the room when they want to look something up. They don't mention to the patient that they're consulting other sources. For that matter, most primary-care doctors rarely consult outside sources when assessing and treating patients.

Should it be such a bad thing to consult a textbook with the patient present? Using a textbook conveys humility and demonstrates that the doctor cares. Double-checking against the textbook helps the doctor confirm that they're providing the most up-to-date and appropriate care.

I'm not sure that that's how patients feel, though. Patients want their doctors to be smarter than their textbooks. I'm willing to concede that, in some respects, the textbook knows more.

A legal action

A patient came in because he was litigating a worker's compensation complaint and hoped his physician would support his case. Everything bad that had happened in his life over the past few years he attributed to an injury to a limb that he claimed he had suffered on the job.

The examination was quite uncomfortable for me, because the patient actively tried to sell me on just how injured he was. Things became adversarial at times: he asked me if I doubted that the injury was the only explanation for his medical problems. When I touched the affected extremity, the patient cowered in pain and admonished me. The affected extremity did look abnormal. Then again, he had stopped using it since the injury. When a part of the body isn't used, it atrophies, distorting the anatomical structures and its appearance.

Was he exaggerating his pain to sell me on his legal battle? Was his pain in part psychological, brought on by the perceived injustice of having suffered an injury on the job? To what extent was the original injury responsible for the pain, and to what extent was it due to atrophy after the patient decided to stop using it? Was this a rare pain disorder? Was this all an invention by the patient, in a nefarious bid to collect disability and retire early?

This was not the fun kind of medicine, especially because I was more referee than healer. Some physicians specialize in workers' compensation cases, and serving as an expert witness in legal cases pays quite well. It's not what I came into medicine for, though, and this case made me quickly decide that this type of medical practice is not for me.

Patient follow-up

A patient came in complaining of a cough, shoulder pain, and vertigo. She was having difficulty walking and sitting up straight. I took some of the patient's history, and she complained how the last doctor refused to give her cough syrup with codeine, which is a heavily-regulated mild narcotic.

Although she was a bit dramatic and rubbed the doctor and me slightly the wrong way, her story seemed credible. The doctor prescribed her the codeine and wrote a note excusing her from work.

An hour later, I took my lunch break and walked to a restaurant a few blocks away. There, I spotted the patient (without her seeing me). She looked like a new person, ambling about in no apparent distress.

Long before I started my medical school applications, I knew that as an aspiring physician I would encounter lots of drug seekers. I did not expect the extent to which they would dim my view of humanity. No one likes feeling that they've been had. Drug seekers undermine the doctor-patient relationship, and they make doctors less likely to prescribe pain medication to those who truly need them.

Harrison's Ch. 148: "Pertussis and Other Bordetella Infections"

While I read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing reflections.

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From Chapter 148:

Pertussis is an acute infection of the respiratory tract caused by Bordetella pertussis. The name pertussis means "violent cough," which aptly describes the most consistent and prominent feature of the illness. The inspiratory sound made at the end of an episode of paroxysmal coughing gives rise to the common name for the illness, "whooping cough."...The Chinese name for pertussis is "the 100-day cough," which accurately describes the clinical course of the illness.

In two weeks, I examined two patients who I was rather certain had pertussis. They had recently begun having coughing fits lasting several minutes. Their lungs sounded clear, and neither was feverish. The fits were so severe that it kept them up at night, and sometimes the force of the coughing fits made them vomit. This last feature, known as post-tussive emesis (literally, vomiting after coughing), is a trademark of pertussis. Whooping cough wasn't a perfect fit--both patients had been vaccinated against pertussis, and neither could recall being exposed to someone with the illness. But nothing else seemed to fit very well, either

We obtained a nasal swab from both patients and sent it to the lab. Both times, the test came back negative! This was quite aggravating. Did I go wrong somewhere?

It's important to note that no test is perfect. This particular test for pertussis has a 90% sensitivity, meaning that only 90% patients with pertussis would have a positive result. Still, this means that the likelihood of two patients having pertussis both getting negative test results is only 1%.

Maybe the specimens weren't collected properly? I reviewed the CDC's guidelines. I hadn't left the swab in one patient's nose for as long as recommended. The swabs weren't refrigerated during transport, which could have potentially caused problems. But even these potential missteps don't seem like they would change the tests' outcome by much.

So was it pertussis? Was it another disease that I didn't think of? Were my textbooks wrong?

These are not just philosophical questions. When a patient has pertussis, not only are they given heavy-duty antibiotics, but so is everyone living in their household. The antibiotics have side effects and can breed resistance. Proper treatment here requires knowing the probability that a patient has the disease.

Medicine is full of ambiguities. I don't know what my patients had, and therefore, I don't know whether the treatment helped them or made things worse. In most cases, I have to learn to be OK with that.

What's in a name?

Such a variety of diseases bring patients in to see their doctor that I find it quite significant when I see two patients with the same disease. Recently, I've seen two patients with inflammation of the eyelids, or blepharitis. What makes blepharitis so fun is not just its zany name but the zany names used to further describe it.

Blepharitis can manifest as an infection of the glands of Moll or the glands of Zeis, which are the sebaceous (oil-secreting) glands located at the margin of the eyelid. Such an infection is called a stye, or hordeolum. Blepharitis can also lead to the formation of a cyst in the eyelid, known as a chalazion. The reason is chronic inflammation of the meibomian gland.

These words seem more appropriate in a Dr. Seuss book than in a medical textbook. Then again, now that Dartmouth's medical school is named after Dr. Seuss, the two might no longer be so distinct.