Connections

One cool thing about learning the mechanisms behind disease in such detail is that now, some seemingly unconnected details in a patient history would steer me to a particular diagnosis. Some examples:

-A couple comes to your infertility clinic after trying for a year to conceive, without success. The husband has a poor sense of smell.

Kallmann syndrome involves improper migration during development of those parts of the brain that are responsible for smell and that secrete hormones involved in fertility.

-A elderly man comes into the emergency department of your hospital because of transient blue-green colorblindness after sex.

The enzyme that Viagra (sildenafil) inhibits to maintain erections is closely related to the enzyme in the eye that discriminates between blue and green. In some people, Viagra acts upon both.

-An elderly woman comes into clinic complaining of months of fatigue and unintentional weight loss. The eyes look different from each other, and one of them is yellowed.

The woman has jaundice, a sign of liver dysfunction that presents as both eyes being yellow. However, only one eye is yellow. This means that the other eye must be a glass eye. The single unifying diagnosis is malignant melanoma of the eye. Years ago, the woman had her eye removed because of melanoma. Melanoma of the eye often metastasizes to the liver, sometimes taking years to reveal itself. This metastasis to the liver is causing jaundice as well as her other symptoms.

Poets, teachers, detectives, and comedians perform their crafts by illuminating connections between things that aren't initially obvious to most of us. It's fun that medicine allows for the same thing.

Birth

I am studying childbirth. While female apes more or less pop out their offspring, humanity made life difficult by electing to walk erect and altering its skeleton as a result. Pushing a baby through a female human pelvis makes for a tight squeeze, and the baby, propelled by the mother, has to perform complicated acrobatics to make it out. The baby must be oriented properly, with its head lower than its feet and its back pressed against the inside of the mother's belly. Once inside the birth canal, its head is whipped side to side and its head to and fro in a very particular sequence. Once its head emerges, the anterior shoulder comes free, followed by the other shoulder. If all goes well (and it usually does) a baby arrives in the world.

To become more familiar with the steps, I reenacted birth from the standpoint of the fetus, curling up in the fetal position on the floor and contorting my body as I navigated the descent. The sequence is complex and difficult to memorize. It's pretty spectacular.

One of our professors urged us to hold on to our sense of wonderment. He showed us a picture of a fertilized egg.

"Don't be afraid to be amazed by what you study," he told us. "Inside this tiny egg are all of the instructions needed to make a human being--the heart that beats billions of times, the eyes, and feet, everything. It is absolutely miraculous."

Clinical ethics II

I expand upon the case I relate in my previous post. It brings up several rich ethical topics.

My outline of the relevant theory:

Medical care should be beneficent and nonmalfeasant: it should strive to serve the patient's best interest and to avoid harm. Harrison's points out that medicine and business possess distinctly different philosophies: "do no harm" on the one hand, and "buyer beware" on the other.

Physicians should have respect for patient autonomy, a respect for the patient's wishes regarding what is done to his body. This does not mean that the doctor needs to do everything a patient demands. If a patient requests an inappropriate surgical procedure or an improper drug, the physician need not comply. However, if the patient is of sound mind and has reasonable justification, the patient is entitled to decline medical interventions. The physician is obliged to ensure that the patient is well-informed (and educate him if he is not) and to verify that the patient is capable of making a reasoned decision.

In addition, the physician has an obligation to people beyond just the patient. If a physician learns that a patient intends to murder to another person, he is obliged to act, perhaps by notifying police. If a physician diagnoses a patient as HIV-positive, he is obliged to report it to the local public health department and to ensure that the patient's sexual contacts are notified that they have potentially been exposed to the disease.

With the help of the concepts above, we can reason through this case:

The patient is of sound mind and has a coherent justification (religious beliefs) for refusing blood products. What complicates matters, though, is that there are children involved--one in utero and five of them born. The doctors must ensure that these children will not suffer the harm of being left without a caretaker.

According to Massachusetts law, the mother would be allowed to decline blood products so long as someone had agreed to become the children's legal guardian in the event of her death. In this case, the patient was married; by default, the husband would have to take responsibility of the children. Therefore, the patient was entitled to decline products, independent of her husband's wishes.

The case is interesting not only from an ethical standpoint, but from a medical one. In a coup of extensive planning, advanced technology, and skilled execution, the surgical team delivered the child, performed a hysterectomy (removal of uterus), and sealed off the arteries before the mother lost a dangerous amount of blood. Mother and baby both lived. Since the mother elected for a hysterectomy, which sterilized her, she will never again have to make the same wrenching decision about her pregnancy.

Again, the original case, as related in the New England Journal of Medicine, can be found here.

In a future post: what are the consequences of the dearth of training in clinical ethics for budding physicians?

Clinical ethics I

Derived from an actual case:

You are an obstetrician in Massachusetts. A pregnant woman comes to your clinic for a routine prenatal (before birth) exam. She is 21 weeks pregnant with her sixth child. The ultrasound reveals a worrisome picture: the woman's placenta has migrated to the wrong location--it covers the cervix (placenta previa) and is adhering to the uterine wall (placenta accreta). These conditions occur more often in patients like this one who have undergone a prior Caesarean section. The pregnancy will pose a substantial risk both to fetus and mother.

The mother declines to consider an abortion. In 3 months, the baby will be at full term and can be delivered only via Caesarean section. Even if the procedure goes well, the mother will lose a worrisome amount of blood.

Now for the kicker: the mother belongs to the Jehovah's Witnesses and refuses any blood transfusions. Even more problematic is that she has anemia (a inadequate amount of functional red blood cells). She understands that her refusal to receive transfusions substantially increases her risk of death. Her husband disagrees with her decision.

The major question is: if the mother hemorrhages (bleeds uncontrollably) in the delivery room, can the medical team ethically overrule her wishes and infuse her with blood anyway, thus sparing her life? Do the doctors have an obligation to the woman's five children to keep her alive against her will? How does one even begin to untangle an emotionally-charged dilemma such as this?

The field of clinical ethics provides a framework for thinking through these types of thorny and emotionally-charged situations. It marries medicine with philosophy. Few doctors formally study clinical ethics, though. At my school, we received a total of two hours of formal lecture on the subject during our first year. This is typical of schools nationwide. This dearth of instruction in clinical ethics seems to be at odds with the profession's (and the public's) firm expectation that we act ethically, honorably, and in compliance with the law.

In subsequent posts, I discuss why I am grateful to have studied bioethics as undergraduate, as well as how the case I've described was ultimately resolved (mother and baby both lived).

An ambitious attempt

No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding.... Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. [The patient] is human, fearful, and hopeful, seeking relief, help, and reassurance.

So begins Harrison's Principles of Internal Medicine, a dense, 3,600-page two-volume tome that is the nearest thing to a bible in clinical medicine. In its 397 chapters, leading physicians comprehensively explain the diseases of the adult human body and their treatments. My internal medicine professors consult Harrison's regularly. I shall come to know this text well.

I recently saw a documentary (which I recommend) called Jiro Dreams of Sushi. It profiles Jiro Ono, an 86-year-old chef in charge of what is widely considered to be the best sushi restaurant in Japan. Ono explains that he and his assistants make a point of eating the finest food, because how can a chef make excellent food unless he is surrounded by it?

Similarly, if I'm going to practice excellent medicine, I think I will need to surround myself with the finest learning materials. As I've discussed previously, I intend to do more than our curriculum demands. A classmate mentioned that a professor he admires had read Harrison's in its entirety during his training. I thought, why not me? And so, I've resolved to read the whole thing. I've dusted off five chapters in the last 24 hours, which means that only 392 remain. A spreadsheet logs my progress. I predict that I'll finish my undertaking in 12 months. I'm optimistic that it will be worth it. Knowing diseases in depth should help me make some difficult diagnoses and provide good care.

Bird's-eye view

I last read The Great Gatsby 7 years ago. For some reason the character I remember best is a minor one: the owl-eyed man. The man is myopic both in his vision (he wears thick glasses) and in his way of thinking. In one of his appearances, the owl-eyed man crashes his car into a ditch and stumbles onto the road. There, he informs passersby that he has crashed his car. He never thinks to mention that the woman who was with him remains trapped in the smoldering wreckage. In my interpretation, the owl-eyed man vividly sees superficial and trifling details but fails to grasp the bigger picture. Wealthy people like Owl Eyes who have vision yet don't see (and The Great Gatsby has many of these characters) are F. Scott Fitzgerald's indictment of high society.

In a similar vein, clinicians make detailed observations and then must integrate them into the larger story. I was reminded of this maxim during our class about how to interview patients.

This week, it was my turn to interview the standardized patient (an actor who convincingly portrays a patient) while two professors and eight of my classmates watched. I showed her to her seat and asked, "What brings you into clinic today?"

"I just want some birth control."

I questioned her extensively about her sexual history.
-When did you last have sex? "Last night."
-Were you using protection? "No."
-Do you have sex with men, women or both? "Both."
-Have you ever been pregnant? "Yes, twice."
-What was the result of those pregnancies? "I got an abortion."

And so on. Although her responses were evasive, the picture that emerged was dramatic. She reported having unprotected sex with more men and women than she could count. It seemed she had been treated for chlamydia. She used several types of illicit drugs frequently.

Her responses set off a mental checklist in my mind:
-she probably needs emergency contraception ("Plan B").
-she needs to be tested for STDs, including HIV.
-she will need a contraceptive that requires little effort (such as Depo-Provera, a one-time injection that offers 3 months of protection).

Midway through my interview, I asked the class for feedback. One of my professors encouraged me to ask broader questions and to take a different tack. And so, I asked the patient "how she keeps herself busy most days" (so as not to presume that she has a job). After a bit of coaxing, she admitted to being a sex worker. Aha. Now the puzzle pieces fell together nicely. Only after more prodding from the professor did I ask another crucial question--whether she ever been tested for HIV. She had tested positive several times, but never saw the point in starting treatment. This was a bombshell.

Although the first part of my interview uncovered important details, I was slow to establish the larger picture, that the actress portrayed a sex worker who was spreading HIV to her clients. Even so, I outdid the owl-eyed man. F. Scott Fitzgerald would be proud.

Presenting

When medical students do their clinical rotations, an important ritual is the presentation of a new patient case to the medical team. The student tries to orient the team to all relevant aspects of the case, including (among other things) the patient's age, gender, and background; the patient's "chief complaint"; the history of the illness; the relevant lab findings and imaging studies; the differential diagnosis; and the presenter's recommended plan of action.

Presenting is a real art. The presenter needs to condense all they have learned about the patient (how many grandchildren they have, what they ate for lunch) into only a digest of the most relevant details. But who can know just what details are most relevant? A patient's broken arm might have an underlying cause, like a genetic defect in bone formation, a tumor that has invaded the bone, or a history of trauma from an abusive spouse. Different diagnoses center around different aspects of a case history: a history of prior broken bones for a genetic defect; a history of unexpected weight loss for cancer; a history of marital strife for domestic abuse.

The problem is that the diagnosis is usually uncertain. If the presenter has a good idea of what the diagnosis will be, he focuses his presentation around that hypothesis. But at the same time, he needs to include enough details so that even if his hunch was wrong, the listener could arrive at the correct diagnosis nonetheless. Medical students must tread especially carefully, because they are not as experienced as attending physicians at assembling the constellation of symptoms, history, and physical findings into a unifying diagnosis.

Emphasis matters. While shadowing, I heard a presentation that emphasized minor details but buried a worrisome lab finding that suggested urgent life-threatening disease.

The presentation objectively informs and subjectively argues; the presenter draws upon what he knows yet is mindful of what he does not. From the outside, the practice of medicine might seem formulaic and almost robotic. But the presentation is not. It hinges upon one's unique ability to observe, investigate, reason, and communicate.

Levity

I shadowed a specialist who could have made it as a comedian. In the back room where the physicians and residents write out their patient charts, he cracked jokes about everything from matzah to Taco Bell chalupas to male-pattern baldness. It made the day much brighter.

What makes having comedy during the workday so pleasant is the heavy nature of the job. A different day, while shadowing a different physician, I was at a patient's bedside when the doctor intimated that she would need to be on a ventilator for life. The patient was anguished. It was rather sad. Yet once we exited the room the doctor and I went back to our previous conversation, about basketball. After all, what's the alternative? Being sad all day? Not many of that physician's patients recover from their illnesses. He constantly gives patients bad news.

Good doctors (and good people) must have empathy. But having too much empathy or having it too often is disabling. So part of medical training is learning how to harness and structure one's empathy, in the same way that a wrestler learns to limit his violent tendencies to his time in the ring, or a soldier learns to limit his anger to the battlefield. It's an odd demand, in that we are expected to be superhuman at times, and almost inhuman at others.

Disgust, discussed

Why do some sights and smells disgust us? There appears to be a sound evolutionary basis. For example, when one bites into a fruit and then sees that it is infested with insects, one's visceral reaction is to spit out the food and possibly even vomit. Both of these actions quickly eject the offending agent from the oral cavity and the gastrointestinal system, reducing the risk of harm. Disgust often protects us. Similarly, we find repulsive the smell of feces as well as that associated with decomposing matter. Given that objects that issue these putrid odors often harbor disease, it is sensible and live-preserving that our senses urge us to steer clear.

Medical practice sometimes demands that we suppress this important and innate instinct. While I was shadowing an outpatient pediatrician, the six-month old girl we were examining took the liberty of defecating into her diaper. The pediatrician didn't mind, because it afforded her the chance to glance at the stool and confirm that it looked healthy.

I, on the other hand, found the situation nearly insufferable. The oppressive smell assaulted me. Would it ever stop? My eyes searched the room in desperation, seeking some sort of relief. I inwardly cursed whoever had designed the room to have windows that don't open. Yet I soldiered on, maintaining my blank expression and steadfastly refusing to make known the extent of my despair.

When we finished seeing the patient, I asked the doctor to pinpoint when in her training the smell of feces ceased to faze her. She thought for a long time, and replied matter-of-factly, "It was sometime around the first year of residency."

Many aspects of medical school would seem impossible if not for the knowledge that other people have done it and survived. I don't understand how I will manage the long hours of residency, but I know that I will. I don't understand how I will know about so many diseases, but I know that I will. And so, someday I too will be a physician who is impervious to poop. I don't understand how I shall arrive at this point, but I know that I will. My nose and I will anxiously await that day in the meantime.

A surprising statistic

I was skeptical when a doctor casually mentioned that 2% of all pregnancies are ectopic pregnancies (in which the fertilized egg is implanted somewhere other than the uterus, usually the fallopian tube). Without treatment, a common outcome is fallopian tube rupture, which jeopardizes the life of the mother. It is a serious medical concern. I shot a confused look at a fellow first-year medical student. Two percent? It seemed way too high.

I checked the literature, and the doctor was indeed correct. 2% of pregnancies are ectopic pregnancies, and ectopic pregnancies constitute 6% of pregnancy-related deaths. Why was I never aware of this? Many women I have encountered in my life have undoubtedly had ectopic pregnancies, but no one speaks of it. Illness lurks in people's lives much more than they make apparent, and my medical training is making me acutely aware of that discrepancy.

In the past few weeks, I've become increasingly aware that my medical training and white coat constitute a sort of "all-access pass." Recently I was passing through our hospital's ER on a personal errand. Upon seeing my white coat and badge, the rather aloof security guards smiled and simply waved me through the entrance to the medical bay.

In the ER, I spotted a med student I knew who happened to be rotating there. She and a resident were about to examine a patient, and on a whim I joined them. Saying little, I listened to the patient describe deeply private aspects of his life: his methamphetamine use and drinking habits, his family problems, his history of mental illness, and his hopes for the future. I watched as the medical team debated the patient's diagnosis and treatment. And after about half an hour, I went on my way. A year ago, I would have been stopped at the entrance to the ER; now, no one questioned why I was there. I am part of the club. It feels so strange.

Practicing medicine involves a tension between isolation and connection. On the one hand, I am quite estranged from people. I have so little free time that when I interact with someone, they are usually either my patient, my family, or someone in the health-care field. And yet I learn about and am witness to the most intimate aspects of random people's lives. Learning medicine is a lonely pursuit, but by accompanying people as they grapple with illness, will I become more connected to my fellow man?

So far, the answer is no. Medical school has transformed how I view people and interact with them. When I am at a party and see someone with an abnormal gait or a cold sore, I automatically start reasoning through a differential diagnosis. When I chat with my seatmate on a plane, I find the need to whitewash what I encounter in the hospital, because people understandably prefer not to hear about illness and death more than they have to. Doctor and patient do not behave as equals, and even though I am not yet a doctor, and even though the people I encounter are not my patients, I can't entirely ignore this feeling of detachment, of otherness.

Repetition

Today I observed an orthopedic surgeon. He specializes in performing one particular kind of procedure on one particular joint. He does this same surgical procedure hundreds of times a year. And he's good at it. He keeps a detailed database about all of his surgical patients and tracks their outcomes. When an outcome is bad, he works backwards to find what he could have done to avoid it. His modus operandi is repetition and constant refinement. At the operating table, he is comfortable, fluid, and fast.

What I witnessed today epitomizes super-specialization in medicine. Atul Gawande, a surgeon and my favorite medical writer, describes in his extraordinary books Better and Complications how, on the whole, surgeons with the best outcomes are reliably those who have done that procedure the most times. Yet what draws me to medicine is its breadth. Being a good primary-care doc requires a ready knowledge of lots of things, and I think what draws me to medicine as opposed to surgery is the constant variety and the intellectual challenge.

The good news is that medicine is a big tent. Different medical specialties require different goals and temperaments, which makes it more likely that a med student like myself will find something that fits.

Pathology

When a doctor takes a blood sample or a surgeon collects a tissue biopsy, it's sent to "the lab" for analysis by a pathologist. The pathologist's job is to assist in diagnosis and treatment by analyzing tissues, fluids, and cells. They are responsible for performing blood tests as well as autopsies (dissections that identify deceased patients' cause of death). A pathologist was kind enough to spend a morning showing me around "the lab."

When a surgeon removes, say, cancerous breast tissue, the tissue is sent to the pathology department. There, the tissue is immersed in a series of chemicals that render the tissue stable and that halt the reactions (including decay) that cells undergo. The tissue is mounted onto microscope slides and then stained in special dyes that colorfully render the features of cells. Sometimes, the pathologist will order special tests that test for the presence of a certain protein on the cell's surface. For example, a breast cancer drug called trastuzumab works by acting on a protein called "HER2." HER2 is expressed on the surface of tumor cells in only some types of breast cancer. By testing for the presence of HER2 on the cell surface, the pathologist establishes whether the drug can be used. In nearly all aspects of medicine, pathology findings are a valuable tool in deciding on treatment.

One of the most interesting parts of the tour was the frozen section room. A neurosurgeon operating on a patient removed some brain tissue and submitted it to the frozen section room, which is strategically placed near the operating rooms. A team prepared the sample and a pathologist put it under the microscope. Tragically, he determined that the tissue was a highly malignant form of brain cancer. Using this information, the neurosurgeon could modify his procedure to make sure that he removed all of the cancerous tissue.

Pathology is a very intellectual field that requires knowledge of rare diseases and very obscure parts of medicine. Most pathologists do not interact with patients, but they are in constant touch with doctors across all specialties. I enjoyed my inside look at this behind-the-scenes aspect of clinical medicine.

Mentor

Every student has a faculty member assigned to them as an advisor. If students were to choose their advisors rather than have them assigned, I doubt I would have known to select my current professor. My interests lie in adolescent medicine and public health, and I'm rather boisterous. He works as an internal medicine hospitalist (he exclusively sees hospital patients) and is introspective and unassuming.

In our first advisor meeting, he said that I'm welcome to join him as he sees patients in the hospital. I gingerly took him up on his offer. And so, we occasionally meet at the hospital entrance and crisscross the halls of the hospital to check on his patients.

When I join my advisor, I am not an observer but a student. Before we see each patient he reviews their lab results, imaging studies, and clinical history with me. If he finds something unusual on his physical examination, he has me take a look or a listen. And after a few hours, we go for a walk and he asks me what questions I have about what I saw that day. When I go home, he has sent me medical journal articles relating to the day's cases. I feel guilty that his day becomes several hours longer because of how much time he spends teaching me.

Yet I learn quite a lot. Not only do I get to review what I learn in class, but I also see how my advisor talks with his patients. I learn the layout of the hospital and better understand how the house staff interacts. I become more familiar with the abbreviations the residents use and the format of how they present their clinical cases to their colleagues. These are things that can't be learned in a lecture hall. And seeing patients with unfamiliar diseases and medications motivates me to read up on them and master them.

Students entering medical school use all kinds of metrics to decide where to attend: location, U.S. News rankings, whether the school is pass/fail, whether the students are attractive...but some things can't be known until you get there. I couldn't have known how lucky I would be to get an advisor who genuinely cares about being a good teacher and a good mentor. And it has made quite a difference.

Music and medicine

At our school's comedy show in a few days, I'll be playing piano and singing some songs I composed. Oddly enough, I feel like my singing and musical abilities have improved while I've been in med school, even though what I study has nothing to do with the humanities. And I've had a blast collaborating musically with classmates, because we get to work as a team in a context besides learning medicine.

Hopefully I'll be able to hold on to my musical hobbies throughout training. It's something that keeps me tethered to the outside world.

'Polio: An American Story,' by David Oshinsky

Poliomyelitis was a uniquely frightening disease in America during the 1940s and 1950s. Good sanitation generally diminishes the threat of infectious agents, and the widespread adoption of soap and indoor plumbing during the early 20th century had reduced the prevalence of scourges such as black plague, tuberculosis, and typhoid. Yet polio became more menacing as sanitation improved. Because Americans were not exposed to polio as infants, they did not gain immunity early in life. American children became increasingly susceptible to fierce outbreaks of polio that left some paralyzed. The seeming randomness of where polio struck and the life-long toll on its sufferers' bodies mobilized the public to find a vaccine.

'Polio: An American Story' chronicles American medical research's coming of age as well as its loss of innocence. Oshinsky also recounts the fierce and sometimes ugly rivalry between the researchers who tried to win the race to develop a vaccine. In creating the first successful polio virus, Jonas Salk became the first researcher-celebrity. Salk deviated from scientific tradition by leaking his results to the press before they were published in scientific journals. In the book, Salk appears tragically flawed, a keen and enterprising scientist whose selfish and heterodox actions earn the derision of his colleagues.

Oshinsky profiles the March of Dimes, a charity that pioneered the use of heavy advertising and celebrity power to combat disease. March of Dimes created a national army of volunteers (primarily mothers) who fund-raised to support polio victims and develop a vaccine. The degree of public support was extraordinary: over two-thirds of Americans donated to the March of Dimes.

Lastly, the reader also witnesses the triumph and hubris of the vaccination effort. With the public clamoring to receive Salk's polio vaccine, government oversight was relaxed, the manufacturing was rushed, and a handful of lots proved to be contaminated with live virus. The resulting paralysis of dozens of children greatly damaged the public's trust in medicine and forced federal government to regulate more strictly the practice of medicine.

The book was fascinating for showing the origins of the politicization of science in modern America. I was also struck by how short our collective memories are: just 60 years ago the public was desperate for a polio vaccine, and many parents unhesitatingly signed their children up to be the first to receive the experimental vaccine. When it was announced that the polio vaccine was a success, it triggered a national celebration. Yet today, some see vaccines and scientists as the enemy. The public's ignorance of the lessons of the past threaten to undermine our progress in combating disease. It's so that I am not doomed to repeat history that I enjoy reading books like Oshinsky's about the history of infectious disease.

'County', by David Ansell

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

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

Poker face

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

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

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

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

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

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

A beginning

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

A few thoughts:

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

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

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

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

Our elegant selves

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

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

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

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

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

A sense of purpose

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

Medicine is a social science, and politics is nothing more than medicine on a grand scale. -Rudolf Virchow, famed German pathologist.

I'm finding my courses increasingly demanding, and my treasured free time has continued to diminish. My social circle barely extends beyond my community of medical students, nor can it. What keeps me going is the hope that, by pressing on, I'll be uniquely able to help my fellow man. It is strange giving up much of young adulthood because of an idea.

Negotiating patient care

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

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

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

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

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

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

'Internal Bleeding', by Wachter and Shojania

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

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

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

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

Our diet, under assault

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

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

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

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

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

A burrito that's worth its salt?

Our car was barely inching along, caught in horrendous rush-hour traffic. Three classmates and I were on our way to a concert, and we needed to grab dinner before curtain. We pulled off the freeway and found a Chipotle restaurant (part of a national burrito chain). In line, I was amused to find that Chipotle now offers brown rice as a way of catering to health-conscious customers. Just what is in a Chipotle burrito?

Using Chipotle's online nutrition facts, I tabulated the sodium content for a typical burrito consisting of a flour tortilla, shredded beef, brown rice, pinto beans, mild salsa, cheese, and guacamole. This burrito contains 2,460 mg of sodium. With chips, it's 2,880 mg.

To put these numbers in context, the FDA advises that "Americans 51 or older, African-Americans of any age, and people with high blood pressure, diabetes, or chronic kidney disease should restrict their [daily sodium] intake to 1,500 mg." For the other approximately half of Americans, the FDA recommends a daily sodium intake of under 2,300 mg. The meal above substantially exceeded the recommended limit. I even held the sour cream, and I didn't order salsa for the chips!

Not that the salt is necessary. When I make burritos at home, the sodium content is about a quarter of a Chipotle burrito's (and I get to add delicious sauteed vegetables like zucchini). I don't wish to accuse Chipotle of being a particularly bad offender--indeed, it's admirable that they display their nutrition facts so prominently. Rather, these crazy values are typical of the food we eat out of a can, from a bag, or in a restaurant. It also begins to explain why it is so out of the ordinary for me to encounter patients in the free clinic who do not have hypertension.

On Thursday, I explore Congress's and the FDA's inaction on regulating the salt content of our food.

Getting to know you

Our school offers an optional program for first-year students where we are divided into small groups and assigned a doctor in the community. We sit in a circle and confidentially discuss our feelings, our deeply personal stories, and our conflicting emotions about how we have had to change ourselves to accommodate medical school. Many tears have already been shed, and it's only been the first session.

The people in my circle are classmates that I encounter every day, but who I never really got to know until now. I already feel more of a sense of community. All it took was a patch of floor, some conversation, and some tissues.

I'm surprised by how much is stressing, gnawing at, and tormenting our class just below the surface. Med school seems to have whittled away some of our resiliency and ability to deal with stresses. I can better understand why mental health issues are so pervasive among physicians, and I suspect that in some of us, the bottled-up inward tension will occasionally erupt.

I'm glad to to have found blogging as an outlet. It helps me take a step back. It lets me make sense of what I am doing and why I am here. And I do appreciate how readers like you let me share it with you.

Playoff weekend

Football seems to subject its players to enough physical and neurological risk that I expect I'll discourage my future patients from joining a competitive football team. Friends of mine who played Division I college football loved it and have gone on to play professionally. They continue to live and breathe football. But I noticed a toll--frequent concussions, dramatic injuries and surgeries, shocking addiction to painkillers, and a difficulty in balancing the competing demands of being a student and of being a quasi-professional athlete.

Scientists are finding that the constant hits (even "microtraumas" that don't rise to the level of concussions) that football players endure can cause chronic traumatic encephalopathy (CTE). CTE is a progressive, untreatable, dramatic, and ultimately fatal decay of the brain that can only be diagnosed post-mortem. Researchers are increasingly conducting autopsies on NFL players and college football players, and they are finding shockingly widespread evidence of CTE. Even deceased players in their 20s and 30s are turning up with CTE, which is otherwise seen only in the elderly. The science in this field is preliminary, yet it is increasingly clear that professional, college, and high school football is a tremendously risky endeavor.

I really do enjoy gridiron football, and on the brisk evening of a big college game I was one of the shirtless guys in the stands wearing body paint. Yet recently I've stopped attending games and I even feel conflicted about cheering my home team while I watch on TV. Wouldn't it make me a hypocrite to say one thing to my patients and do another? Am I taking all of this too seriously?

More generally, does a model physician also need to be a model patient? To what extent is being a physician a job, and to what extent is it a way of life?

That last question might be rhetorical. It feels like medical school has subsumed so much of my life that it's hard for me to know where one ends and the other begins.

Glad I asked

When I am assigned a patient, I am handed a medical chart with write-ups of their past visits. The chart contains invaluable information. I can quickly ascertain whether the patient's weight has dropped, which could be a sign of serious illness. If a patient's blood pressure is high, I can instantly determine whether it developed recently.

Sometimes the chart contains scattered clues that, only when taken together, suggest a serious and unaddressed illness. I like reading through a chart the same way I read a mystery novel: scouring it for hidden leads and seeking to unmask an unseen culprit.

One patient presented in our free clinic for a minor complaint. An old entry in her chart matter-of-factly noted that she was still on a medication that she began after having a significant organ removed as a young adult (I have to be vague because of patient privacy). The chart did not offer an answer for the question that raced through my mind: why had the patient needed this major surgery?

So when I met with the patient, I asked. She said it was because of cancer, but she refused to elaborate and said she doesn't talk about it. We moved on, but I sensed that this revelation was potentially major and that I ought to find out more. Over the course of the visit, I determined that she was at high risk for developing cancer.

I revisited the point later, using a less direct line of questioning. Eventually she opened up to me that she had recently noticed a large pelvic mass that is constantly growing, but that she was not emotionally ready to have anyone examine it. Her description of the mass alarmed me and instantly made me think of a tumor. Despite my best efforts, she simply would not submit to examination or imaging, and I had to let it go. My efforts were hopefully not in vain. The mass is now mentioned in her chart, and when she returns to clinic a different med student will encourage her to have it examined. And at that next visit, she may feel more ready.

We learn in class that a careful history can reveal many medical diagnoses. There is a real art to the interview. One has to ask probing and uncomfortable questions while still maintaining the patient's trust. One has to cast a wide net so as not to miss a major medical problem, but also intensely follow up on particular leads. And patients can sometimes have poor memories, or be reluctant to bring something up.

I think the delicacy and intricacy of taking a medical history is one reason why computers will not be replacing primary-care physicians anytime soon. The interview is a distinctly human and social part of medical practice, which is one reason why I really enjoy performing it and reflecting upon it.

Obesity wake-up call

The CDC has just updated its obesity statistics. In 2009-2010:

33.1% of American adults were overweight (25 ≤ BMI < 30); and a further
35.7% of American adults were obese (BMI ≥ 30).

In sum, about 69% of American adults are either overweight or obese. This is a national disaster.

Views about news: Federal government mandates pharmaceutical companies to disclose drug payments

The New York Times reports:

To head off medical conflicts of interest, the Obama administration is poised to require drug companies to disclose the payments they make to doctors for research, consulting, speaking, travel and entertainment.

 I was quite excited until I read this sentence:

Companies will be subject to a penalty up to $10,000 for each payment they fail to report. A company that knowingly fails to report payments will be subject to a penalty up to $100,000 for each violation, up to a total of $1 million a year.

To a pharmaceutical company, $1 million is nothing. A $1 million penalty per year translates to $250,000 a quarter. Pfizer reported 2011 third-quarter earnings of $3.74 billion.

If you wish to read up on the pharmaceutical industry's influence on medical practice, I recommend White Coat, Black Hat or The Truth about the Drug Companies.

Left in autism's wake

A family member sent me a PBS NewsHour documentary on autism that I enjoyed watching. Congress mandated that students with certain disabilities, including autism, be provided until age 21 with an education targeted to their particular needs. One segment (below) poignantly asks the question, who will care for autistic patients once they become adults? Many autistic people require supervision and constant education, yet the availability of public services depends on the local government and is often limited. The sharply increasing prevalence of autism makes this question particularly urgent.

Watch Autism Now: For Adults With Autism, Few Support Options Past Age 21 on PBS. See more from PBS NewsHour.

There's a strong case to be made for Congress to fund lifetime accommodations for those with serious illness (perhaps as part of Social Security). The only way this will happen is through public awareness.

The entire documentary is available via PBS. It runs approximately an hour and ten minutes long.

Improvement

Although we've been taught how to perform a physical exam, I have a hard time knowing what is concerning and what is normal. If an obese patient can only weakly push up against my hand, does it signal underlying neurological damage or is it just a sign that they don't exercise? Is that yellowish coating on the patient's tongue a stain from tobacco or a precancerous lesion? What is a normal range of motion for the shoulder of a 70-year-old? Given my lack of experience performing physical examinations and interpreting them, I place little stock in my physical exam findings.

Something sounded funny when I listened to one patient's heart. Since she was morbidly obese, it was difficult to hear clearly through the layers of fat. I couldn't even figure out at which stage of the heartbeat I thought the irregularity was taking place, or what the irregularity might signify. I just knew that my "spidey sense" was going off. Another med student was also in the exam room, and I asked him to confirm. After listening for a long time, he gave up. "I can't hear anything strange."

When I stepped out of the exam room, I thumbed through her chart. The patient had been seen in clinic several times, and there was no mention of a heart murmur. This left three possibilities:

1. Her heart sounds were actually normal and I heard it wrong;
2. Her heart sounds were abnormal and every med student in the past had missed it;
3. Her heart sounds had changed recently from normal to abnormal.

I presumed that the answer was number 1, but I made sure that the attending physician had a listen anyway. The doctor listened for a long time and then announced that there was a faint (and harmless) systolic murmur. The patient confirmed that as a child she was told she had a slight heart murmur.

It felt good. I think I'm getting the hang of this.

Boom and bust?

With each passing year, becoming a medical student appears less financially feasible. My school has hiked its tuition annually by over 7% over the past two years, which is typical. The median indebtedness at graduation for medical students nationwide rests above $150,000. These loans typically accrue at APRs of 7% and 7.9%. The interest accrues throughout medical school and residency: Congress recently eliminated the type of federal loan that subsidizes interest during medical school. All the while, physician salaries are decreasing and primary care physicians are increasingly being replaced by lower-cost nurse practitioners and PAs. I reckon that a typical student who begins medical school in fall 2012 would take on an additional $12,000 in loan principal relative to someone who begins in fall 2011.

This financial picture worries me. Given the rising cost of training and the decreasing compensation after training, something will have to give. What will it be?

Just because a profession was dependable does not mean it will continue to be so. Law is an excellent example. The legal market has stagnated, while the number of accredited law schools continues to grow and tuition continues to spike. The consequence has been massive unemployment and financial desperation among newly minted lawyers. With each year's crop of newly minted lawyers, the problem worsens. Compounding the issue is that computers and inexpensive lawyers in India are performing tasks that were formerly the domain of entry-level attorneys. A law professor whose blog I follow laid out his exasperation with the collapsing legal sector in a worthwhile post.

There's reason to be optimistic about medicine by comparison. The number of government-funded residency positions is capped, preventing a glut of physicians. And as a colleague pointed out to me, at the end of the day, someone still has to be there to deliver a baby.

One problem with this financial squeeze is that it limits students' options to help the underserved, or to branch out in their educational program. The cost of interrupting medical school for a year to, say, receive an MPH is prohibitive now that loans accrue during graduate school. And I expect that graduating medical students will continue to prefer high-paying specialties over primary care.

It is odd that, in a way, medicine is becoming a victim of its own success. Schools can afford to raise tuition to any amount because they know that there will still be students seeking to enter the profession.

The drive towards safety

There is a revolutionary cure in the works for an affliction that kills over 42,000 Americans annually and injures many more. It is the 9th-leading cause of death in our country.

The affliction is the "motor-vehicle traffic accident." And the solution nearing market is the self-driving car. Google, in conjunction with a Stanford research team, has already built an autonomous car. They have driven it for over 175,000 miles on California and Nevada roads, accident-free (see a video of a reporter going for a ride on a busy Bay Area freeway in the Google car). Nevada has legalized texting while driving so long as the car is a self-driving car. It surprises me that people are paying so little attention to the advent of the autonomous car, and especially the medical community.

I took a class in college on transportation system optimization, and the field is absolutely fascinating. Traffic systems require careful planning and thought to make everything work harmoniously. I firmly believe three items: that the self-driving car is inevitable and will be commercially available within a decade; that government policies could make the adoption of the self-driving car a rather good thing or a rather terrible thing; and that the self-driving car will absolutely revolutionize our lives and our identities of place.

Inevitability
Humans are not great at driving cars. We fall asleep, we drink, we text, and we can only look in one direction at a time. There is a delay between when we observe a car stopped ahead of us and when we slam on the brakes. Computers lack these flaws and already operate some of our modes of transportation: many subway systems are under computer control, and planes already fly on autopilot. Computers need not be perfect drivers, just to surpass humans.

The technology for the self-driving car already exists, as does most of the software. The question now is how cheaply the most expensive parts (such as the sensors) can be produced and how quickly the infrastructure can be constructed. Google is moving quickly to bring its car to market. Even if the first self-driving cars are expensive, I can't foresee it taking more than a few years for the first to be sold to the public. I foresee that at first the cars would only be allowed to run on freeways, eventually spreading to all roads.

There are a number of market incentives for self-driving cars. Some demographics that cannot drive (the young, the elderly, the infirm, the vision-impaired) would suddenly be able to. Reducing the number of car crashes would save in medical costs and insurance reimbursements. Self-driving cars could also reduce traffic congestion (it would be safer for cars to drive closer together), free up parking spaces (the cars could park themselves), and run off alternative fuels (the cars could drive to charging stations).

Policy
Like any new technology, many conflicts will arise now that the first policies governing self-driving cars are being enacted into law. Will law enforcement try to more closely monitor our movements by car? Will government restrict the movements of certain groups (felons, sex offenders)? Will the rich be able to travel at faster speeds than the poor in exchange for paying more (akin to toll roads)? This is largely uncharted territory, but then again, the automobile and the airplane are not so old.

The effect on our lives
The automobile profoundly altered our way of life. It allowed the development of suburbs and exurbs and altered our social structure. What will the self-driving car do? Will cars look more like RVs, mobile homes where people travel from place to place while asleep?

Car crashes very much impact our lives. World history would be quite different if some crashes had been avoided. Some well-known people killed in car crashes include: author, philosopher, and Nobel Laureate Albert Camus; heir to the Syrian presidency Bassel al-Assad; Princess Diana; jazz trumpeter Clifford Brown; and artist Jackson Pollock. Also, car crashes are more likely to affect the young than some leading causes of death, such as cancer and heart disease.

What should we conclude?
Car crashes are a leading cause of death and injury in our country. The self-driving car already exists and it is a question of how long it will take before you and I can buy one for ourselves. The introduction of the self-driving car would be a massive public-health win, akin to the development of a successful vaccine to a deadly disease. Yet we must tread carefully. The self-driving car will disrupt our current way of life, and whether this change is for better or for worse will hinge upon the wisdom of our policies.

The health potential of the self-driving car underscores why the medical community ought to have an open mind about what it pays attention to. We are responsible for improving people's lives and preventing disease, and the self-driving car strikes me as one of the most promising medical therapies in years.

Getting with the PA program

How comfortable would you feel if your clinician had never examined the inside of a human body?

I chatted for several hours with a physician assistant student who is six months away from receiving his license. "Bob" struck me as a genuinely good guy, and he intends to help people where they need it most--in war zones for the military and in underserved rural areas. It usually takes two years to become a physician assistant (PA), and in most states they are licensed to prescribe certain drugs. They technically have to practice under physician supervision, but "supervision" here is defined loosely. Some supervising physicians simultaneously supervise several PAs spread over several cities. In many rural towns, the PA is the sole provider of clinical care.

Bob mentioned that he wished he had a deeper understanding of the human body. His program does not teach gross anatomy but instead requires it as a prerequisite. Yet very few universities and colleges are able to teach undergraduates anatomy using human cadavers. Bob's anatomy class had only used prosections of cats (a prosection is an anatomical specimen that an expert has previously dissected, for the sake of instruction). Some students become PAs without ever seeing a human cadaver.

Bob's understanding of physiology was quite basic. For example, his program gave only a cursory overview of what causes diabetes, and he did not understand why diabetes causes symptoms such as polyuria (excessive urinary output). Bob confessed that he has such a hard time with math that he stopped at introductory algebra. His classroom education prior to PA school was a two-year stint in community college, where he earned an associates' degree.

I had a great impression of Bob, and we really hit it off. But the medical background his program provides strikes me as flimsy. He would need to know statistics to interpret published medical studies. He likely lacks some of the vocabulary one would encounter in a medical chart. And his limited background in physiology would give him a hard time understanding the mechanisms of the drugs he prescribes, let alone predicting whether they might interact with other medications.

PAs like Bob are increasingly becoming America's first-line primary-care providers, taking the place of physicians. The Bureau of Labor Statistics (BLS) forecasts a boom in new physician assistant jobs over the next decade. The pay is good, too: BLS estimates the median salary nationwide is at $81,230. By my back-of-the-envelope calculations, some older students would have a higher lifetime earning potential if they entered PA school instead of medical school. They would earn money more quickly and dodge the hundreds of thousands of dollars in high-interest student loans.

Medicine is a big tent, and PAs are occupying an increasing section of it. It was eye-opening for me to talk to Bob and understand more about his training.

Is it a boy? The foreseeable bad consequences of medical advances

There is a healthy debate over whether a lab that created an extremely infectious version of influenza ought to publish the genetic sequence. The debate speaks to a larger problem: sometimes, medical advances do the world a disservice. The medical field could use some soul-searching, just as physicists did in the wake of the Manhattan Project.

A few years ago, I read a neat research finding: in a pregnant woman, some of the fetus's DNA crosses the placenta and circulates in the mother's bloodstream. Drawing on this finding, some researchers developed a clever blood test that is allowing pregnant women to non-invasively screen their fetuses for Down Syndrome (whereas in the past, amniocentesis or chorionic villus sampling were the definitive screens). Good on them.

Yet other researchers have done gone a step further, offering both maternal blood tests and a maternal urine test that reveals a fetus's gender. One of these researchers, Prof. Diana Bianchi of Tufts University, justifies her development of a blood test because it will help mothers receive early warning about whether their children are at risk for genetic, sex-linked conditions such as hemophilia and congential adrenal hyperplasia.

This benefit strikes me as far too small relative to the tests' tremendous downside: it will greatly worsen the calamitous global phenomenon of the Missing Women.

The expected sex ratio at birth is 105 boys born for every 100 girls, or 1.05. Yet in some countries, the sex ratio at birth is quite skewed: for example, China's is 1.13 and Vietnam's is 1.12. What results is a demographic disaster, with over 100 million women missing worldwide (and a number of unhappy single men left in their wake). This glut of unmarried men may even contribute to global unrest, as unmarried men are more likely than married men to engage in armed conflict or become terrorists.

A renowned economist, Amartya Sen, established that cultural bias against women underlies the deficit. In countries where it is economically advantageous to have a boy, some families murder or neglect their infant girls or abort their female fetuses. Currently, ultrasonography is the only non-invasive way to determine the gender of a fetus. Some of the affected countries have forbidden ultrasound clinics from revealing a fetus's gender, and some intermittently crack down on those profitable yet illicit ultrasound clinics that flout the rules.

But a maternal blood test or urine test will prove impossible to regulate. Making it easier for mothers to determine gender will almost certainly lead to more female fetuses being aborted worldwide, with all of its concomitant problems. I would at the very least like to see a fraction of the proceeds for this blood test go to empowering women in affected countries (by boosting primary education and decreasing maternal and infant mortality), which would begin to help the problem. I doubt we will see it.

Some medical disasters are not easily foreseeable. For example, most leading orthopedists did not expect metal-on-metal hip replacements to become a massive fiasco. Yet developing a maternal blood test for fetal gender has so little justification and its ramifications are so potentially terrible that I believe its developers acted unethically. It's a shame that some scientific advances leave the world worse off than before, because I believe that scientific inquiry possesses a unique ability to make the world rather wonderful.

Mercury news

Echoing Paul Krugman, I want to point out how huge a deal it is that President Obama and the EPA have issued new national standards limiting heavy-metal emissions from power plants. From the EPA's press release yesterday:

The U.S. Environmental Protection Agency (EPA) has issued the Mercury and Air Toxics Standards, the first national standards to protect American families from power plant emissions of mercury and toxic air pollution like arsenic, acid gas, nickel, selenium, and cyanide. The standards will slash emissions of these dangerous pollutants by relying on widely available, proven pollution controls that are already in use at more than half of the nation’s coal-fired power plants. 

EPA estimates that the new safeguards will prevent as many as 11,000 premature deaths and 4,700 heart attacks a year. The standards will also help America’s children grow up healthier – preventing 130,000 cases of childhood asthma symptoms and about 6,300 fewer cases of acute bronchitis among children each year. [emphasis mine]

11,000 premature deaths per year is a big number. By comparison, the CDC attributes 42,000 deaths annually to "motor-vehicle traffic" accidents. The September 11 terrorist attacks caused just under 3,000 premature deaths, once. And mercury is scary stuff. It tends to accumulate in large fish and in mammals that sit atop the food chain. Pregnant women are discouraged from eating certain types of fish (including albacore tuna) because ingesting the amount of mercury they contain can cause birth defects.

As hard as my classmates and I will try to take care of our patients as physicians, what we can accomplish as individuals cannot come close to the impact of prudent regulations such as this. Bear in mind too that some of the energy sector lobbied hard to prevent these standards from being issued. Good on the Obama administration for protecting the environment and bettering human lives.

How we learn

I worry somewhat that learning for learning's sake can be a liability in medical school. Perhaps out of necessity, my class devotes the bulk of its energy to excelling on exams. Sometimes this drive to perform runs counter to learning: one of the most effective study tools is to obtain old copies of quizzes and exams. One can do quite well by memorizing the answers to questions that historically appear on exams, even without understanding quite what they mean. Another winning strategy is to come up with mnemonics particular to the examination ("The four arteries we were supposed to remember begin with the letters MIDS").

It makes sense why some classmates would opt to limit their studying to what will be assessed on exams and boards. Many have girlfriends, boyfriends, spouses, and children that (deservedly) compete for their energy and time. Getting top marks in courses yields academic distinction and hefty scholarships. Even our class's lingo revolves around the test: topics likely to appear on an exam are termed "high-yield." Wasting classmates' time with "low-yield" topics is a cardinal sin. Few students read the assigned textbooks, because the exam material derives from the bolded bullet points in our lectures' PowerPoint slides. We were told ahead of time exactly which physical examination methods we needed to know on the final exam; others were summarily ignored.

Even the boards that we take second year (the standardized examination that all allopathic medical students take, and that plays heavily into residency placements) promote shortcuts. If a question begins: "A 19-year old female sex worker comes into your clinic," I instantly know that the answer they will want me to put is a type of STI. Real life is not so simple. Clinical decisions do not involve choosing the best answer of the five choices proferred.

The fundamental question is: should we consider medical school an educational experience in its own right? Or should we treat it as a stepping-stone to our desired residency and career? I fear that learning to the test prevents us from becoming that breed of excellent physician that inspired me to enter the profession.

'Smallpox: The Death of a Disease', by D.A. Henderson

D.A. Henderson led the WHO office that coordinated the global smallpox eradication effort. His 2009 book focuses on the bureaucratic and diplomatic challenges that he and his shoestring staff had to overcome to combat the disease. He gives of an overview of how eradication unfolded in each of the endemic countries, including Bangladesh, which was torn by civil war, and Ethiopia, which had poor infrastructure and a substantial population of nomads. Despite seemingly insurmountable challenges, even the poorest countries accomplished this extraordinary public health feat. Young health care professionals bounding with creativity and ingenuity ultimately prevailed. Henderson also discusses the evolving debate over whether to destroy the remaining stockpiles of smallpox, as well as the threat of a bioterrorism attack involving smallpox. Henderson's work propelled him to a distinguished career as dean of the Johns Hopkins School of Public Health and as a senior White House administrator.

"Smallpox: The Death of a Disease" is a more academic and bird's-eye view of smallpox eradication than is William Foege's "House on Fire: The Fight to Eradicate Smallpox" (which I reviewed earlier). I would recommend first reading "House on Fire." If you find that book particularly stimulating, you will likely enjoy Henderson's book, as I did.

'House on Fire: The Fight to Eradicate Smallpox', by William Foege

William Foege, a physician who went on to become Director of the Centers for Disease Control, recently wrote memoirs of his experiences leading the smallpox eradication efforts in Nigeria and India. Foege pioneered the successful "surveillance and containment" eradication strategy, which let health teams avoid vaccinating the entire population. Instead, dedicated search teams located infections, and containment teams vaccinated those cities that were sites of outbreaks. Using this method, smallpox was eradicated worldwide in the 1970's. Interestingly, eradication saved the U.S. a substantial amount of money--what it spent on smallpox eradication was only a fraction of what it spent each year on domestic vaccination and on verifying that travelers to the U.S. were immune. It's important to note the debt owed to many countries, including the U.S.S.R., which first championed global eradication and donated a tremendous amount of vaccine.

Given how deadly, disfiguring, and persistent smallpox was worldwide, its eradication is perhaps the proudest accomplishment of global public health. Foege's account illustrates how this monumental effort succeeded only because of scrupulous planning, careful research, a shared vision among health workers, and several strokes of good luck. He writes of his experiences in Nigeria, where civil war broke out, and in India, the leaders of which were largely skeptical of eradication.

I found the book fascinating, insightful, and brief. I strongly recommend it to those interested in public health, health systems management, and infectious disease.

Why policy matters

You may have read that the U.S. is mired in a shortage of many common generic drugs. Many important chemotherapy drugs are in such short supply that patients cannot complete their cancer treatments, or are being switched to less appropriate or more expensive treatments. Some drug trials have been suspended because the control group is not able to receive the standard of care.

The severity of the shortage is startling. It also deserves some introspection. Our government spends a tremendous amount on researching new drugs (the NIH estimates that it alone spends $31.2 billion annually on medical research). Why aren't we devoting more of our efforts to manufacturing and delivering those inexpensive drugs that we already know to be effective?

Better policies could have prevented such a shortage. Part of the problem seems to be that Medicare is required to pay such low prices for generic drugs that there is little profit margin for manufacturers, and thus, little incentive to invest in maintaining factories and in keeping up production. If Congress were to nudge the reimbursement rate for generic drugs slightly upwards, Medicare would probably save money overall by avoiding expensive shortages. There also may be something more insidious going on, in which manufacturers and middlemen find it profitable to limit supply and thus drive up prices (much like Enron did with California's electrical supply in 2000 and 2001). The government could also develop stronger penalties if drug manufacturers fail to fulfill their contracts to supply drugs to federal health entities (such as the VA and the Indian Health Service).

Medicine does not occur in a vacuum, and this shortage should be another wake-up call that it behooves doctors and patients to understand more broadly what impacts our nation's health and medical care. After all, any of us may become the patients so desperately needing these drugs.

A milestone

I have successfully completed my first semester of medical school. This means that I am approximately a tenth of the way towards receiving a license to practice medicine (four years of medical school and a subsequent year of internship). I have learned much, yet I feel like I know only the tiniest fraction of what a good physician ought to.

Next semester we will begin studying the ways the body becomes diseased and the treatments for those illnesses. I wonder, after completing my next final exams in six months, how much closer I'll feel to being a doctor.

Resemblance

Sir Ernest Shackleton, the famed Antarctic explorer, climbed in 1915 across then-unexplored South Georgia Island with two members of his shipwrecked expedition. Famished, freezing, thirsty, exhausted, and underequipped, their desperate journey was their last hope of reaching civilization (in the form of a whaling station on the other side of the ice-encrusted, mountainous island). There, they hoped to inform the outside world of their comrades who were stranded on Antarctica and needing a rescue.

In his excellent memoir, South, Shackleton recalled his perception of someone accompanying the men during their harrowing tramp:

I know that during that long and racking march of thirty-six hours over the unnamed mountains and glaciers of South Georgia it seemed to me often that we were four, not three. I said nothing to my companions on the point, but afterwards Worsley said to me, "Boss, I had a curious feeling on the march that there was another person with us." Crean confessed to the same idea. One feels "the dearth of human words, the roughness of mortal speech" in trying to describe things intangible.

Tonight, I was drawing a schematic of a left-to-right ventricular shunt (a type of heart defect) while working out a tough physiology problem. Staring back at me was a smiling Picasso-esque human face, accompanying me as I studied into the wee hours of the night:

I always dreamed of emulating a bold adventurer like Shackleton. Unfortunately, passing my medical school courses lacks the heroics of Shackleton's escape from the Antarctic ice and the eventual rescue of his entire expedition. At least I can dream up some parallels and pretend.

Exams

The blog will wind down for the next couple of weeks because of our upcoming comprehensive final exams. The amount of material we're responsible for feels staggering. I have never studied this hard in my life. But in going over all that we've learned, I've been delighted to see just how far we have come. I know tremendously more about the human body than I did four months ago. I'm eager to discover what the next few years will hold.

Charon

The anesthesiology resident who writes at the Asclepion blog has likened his work to that of Charon, the ancient Greek ferryman of the underworld:

I have wondered if anesthesiologists are similar (but distinctly different) mariners [to Charon].  We dare to cross that threshold with the faith that our trips are not one-way. We take those, coin in eye, who have some need of transient depth, who trust us as navigators and cartographers. Are patients the modern day Heracles and Orpheus? Do we carry them across some mythical river and return them safely from their katabasis?

An experience in clinic had made me compare my work to Charon's, but in an entirely different way. Given the wonderful ambiguity of some Greek myths, it's only fitting that we'd establish different connections to this same character.
 
My patient was an impoverished illegal immigrant with a shockingly low potassium level, so low as to be fatal for most people. His blood pressure was also quite elevated. The attending and I whittled down his differential diagnosis until it pointed strongly to primary hyperaldosteronism, an oversecretion of a particular hormone that is often caused by a tumor. We scheduled him for a more extensive work-up.

And yet, beyond treating symptoms, there would probably be little our free clinic could do. We lacked the capacity to perform CT's, MRI's, X-rays, or ultrasounds, any of which we would need to find a tumor. If the presence of a tumor were confirmed, our patient would not be able to afford the life-saving surgery. As an illegal immigrant, he lacked insurance and was ineligible for county services. He could only be admitted to our university hospital if he became so ill that it would be illegal for the ER to discharge him. Entirely because he could not access care, his prognosis looked grim.

Here, I felt like Charon, who ferries people to the underworld. Our laws and medical system prevented us from healing this human being. All I could do was briefly and helplessly accompany him as he traveled to the other side.

Last year, Congress shot down a proposal that would have allowed tax-paying illegal immigrants to purchase health insurance. It's fortunate for our legislators that they don't have to witness the consequences firsthand.

On a happier note, children under 18 are insured by the state and federal government, regardless of immigration status. I haven't seen any in clinic, and that's the way it should be.

Secret hospitals

My favorite television program, FRONTLINE, recently ran an extraordinary piece on the ongoing Syrian uprising. The reporter went undercover with the underground resistance and experienced firsthand the brutal repression of the Assad regime and the public's noble attempts to gain democracy.

Heartrending for me was the segment on Syria's underground hospitals. Wounded protestors face arrest, torture, and death at the hands of state police if they seek treatment at a public hospital. Doctors who treat protestors risk a similar fate. Sympathetic doctors have improvised, treating seriously-wounded protestors in secret homes, using spartan donated equipment and in constant fear of discovery. This is not what medical care should have to look like. It is a forceful argument for why everyone in our country, including our prisoners, ought to have health care as a basic right. It also argues for non-judgmental regard in medical practice, a complex ethical concept that I haven't entirely come to grips with.

The particular segment on hospitals is below.

Watch Syria Undercover on PBS. See more from FRONTLINE.

I encourage you to watch the entire "Syria Undercover" piece at FRONTLINE's website.