The trouble with obesity

What difference does it make if one person is obese instead of thin? More than you might suppose.

Our prenatal environment (the environment of the womb) has an outsized effect on our development. For example, drinking even modest amounts of alcohol during pregnancy can cause fetal alcohol syndrome, which includes mental retardation, stunted growth, and disfigurement of facial features (see diagram at right).

The environment of an obese woman's womb (especially one with diabetes) tends to be injurious to a fetus's metabolism. For example, a fetus will react to high placental blood sugar levels by stimulating insulin production in the pancreas or by becoming resistant to insulin. These steps apparently predispose the baby to become diabetic later in life. Among other things, being born to a obese mother makes a baby more likely to get diabetes, to have asthma, and to become obese later in life. It's not just children, either, who are affected. A convincing study in the New England Journal of Medicine suggests that when someone becomes obese during a certain interval, it makes their friends significantly more likely to become obese as well.

Preventing a patient's obesity can mean preventing their children's, grandchildren's, and friends' obesity as well. All the more incentive to act now to reverse the worldwide obesity epidemic.

[Image is in the public domain, via the NIH's A.D.A.M. medical encyclopedia]

Non-judgmental regard

On July 24, 1998, a psychotic schizophrenic gunman entered a side entrance at the U.S. Capitol. As he approached Representative John DeLay's office, he exchanged fire with two Capitol Police officers who later died of their wounds. The gunman was badly wounded as well.

Senator Bill Frist, a cardiologist, was leaving the Capitol when Congressional aides informed him that some men needed urgent medical assistance.

A New York Times article tells more of the story:

[Frist] took off his coat and ran past the police barricade. ''I'm Senator Frist,'' he told an officer, flashing his ID. ''I'm a doctor.'' 

The police, still fearing there was more than one shooter, ushered him down a long marble corridor that smelled of gunpowder. He knelt by the first victim, checking his wounds and inserting a breathing tube. He lifted him on a stretcher and assisted paramedics as they wheeled him into an ambulance. But before they could close the door, the patient went into cardiac arrest. Although Frist helped to shock back his heartbeat, he was certain the man would die from his injuries.

A medic yelled that there were more victims inside, and Frist rushed back into the building to treat another of the wounded, a slight man who was lying on the carpet and bleeding heavily. An artery in his chest was severed, and Frist concentrated on stemming the flow of blood. He then rode along with him in the ambulance, keeping him alive by forcing oxygen into his lungs. Only as they approached the hospital did he learn that the man he had rescued was the accused gunman, Russell Weston Jr. ''You're not a judge; you're not a jury,'' Frist later explained. ''You're a physician.''

The story encapsulates what I find to be the most extraordinary and difficult tenet of modern medical ethics: "non-judgmental regard." Physicians are supposed to take patients exactly as they are, without judging or discriminating. In principle, then, the armed robber and the man he injured, in neighboring beds in the ER, are provided the same degree of care. The morbidly obese smoker with a heart attack should be treated with the same earnestness as the thin one. Judgments of worth or character are independent of treatment.

Non-judgmental regard can show the best of humanity. The medical journal Lancet offered a first-hand account of the conditions in Libyan hospitals at the front lines of their civil war (PubMed citation here; institutional access needed). Although the doctor-journalist worked in a hospital run by rebels, many patients were pro-Gaddafi soldiers, who were provided the same level of comfort and care as every other patient.

Because I've decided to become a medical student, I have to make medicine's ethical precepts my own. But I have a difficult time with shedding judgment. I don't treat people equally in my own life. I have friends, acquaintances, and enemies, and I care about some of them more than others. In clinic, some patients' stories touch me more than others'. One patient had developed a crippling Parkinsonian tremor, probably secondary to his addiction to meth that he had tried and failed to kick. His circumstances were wrenching and I especially wanted to help this man. My next patient, a woman with conjunctivitis who lambasted me for fumbling at first with the blood pressure cuff, was less inspiring. Some patients are especially kind to me in a way that I particularly want to reciprocate.

Don't all doctors necessarily judge patients differently? How would one diagnose Munchausen's if one unquestioningly believed the patient's narrative? For that matter, doesn't specializing mean deciding that a certain class of ailments matter more to you than another?

I'm not sure that "non-judgmental regard" is utopian or a necessary precept of medical practice. In a world where no one was judged, there would be no such thing as justice, morals, ethics, or a need for self-improvement. Humanity is rich and varied--why not treat it as such?

There are two worthy attitudes here: respecting each person equally and accepting them as they are; and being sympathetic and rewarding kindness with kindness. Are they mutually exclusive, or can they dovetail?

Beware of fair concessionaires' fare

TV crews reporting on the political candidates and Republican straw poll at Iowa's state fair introduced the country to the boldest frontier in fattening cuisine: deep-fried butter on a stick. In case you haven't been keeping on top of your deep-fried confections, Gawker has an enlightening video from an Iowan TV station.

It's also worth noting that the Center for Science in the Public Interest released its annual Xtreme eating awards. The awards are given to restaurants with the most insanely unhealthy menu items (this year's winners include a 2,010 calorie Cold Stone milkshake and an Applebee's pasta dish with 3,700 milligrams of sodium). I actually ate some of the Red Velvet Cake Cheescake from the Cheesecake Factory, and I can verify that the frosting really is pure cream cheese.

It's hard to stay motivated to read my textbooks on keeping people healthy when I can picture my nemeses, including KFC's culinary team, dreaming up the newest ways to jam salt and saturated fat onto their customers' trays. Is the war already lost?

Issues with shoes

My patient, a homeless man in decent health, came to our volunteer clinic because he had "athlete's foot" and wanted an anti-fungal.

When I asked him to remove his shoes and socks so I could take a look, he refused. I pointed out that most doctors won't write a prescription for something unless they can examine it. He still refused and wouldn't say why. He cooperated with the other parts of the exam.

I brought in the attending physician, who asked to look at the foot. No dice. The physician and I conferred:

What's going on here? Maybe he doesn't have athlete's foot and he's getting it for a friend? Maybe it smells really bad and he's embarrassed?

We ultimately gave him a tube of prescription topical antifungal (we didn't have non-prescription). There isn't much you can do with antifungal cream (would it get you high if you snorted it?) and we didn't think there's much of a black market for Lamisil. We probably helped someone's athlete's foot, although who knows if it was the patient's.

I don't know which is more incredible: that the patient thought he could get anti-fungals without showing us his foot, or that he got just that.

A morning on the wards

An internal medicine hospitalist (a physician who cares solely for hospitalized adult patients who are not in the ICU) kindly took me along as he rounded on his patients. Together we went over his patients' lab results, imaging studies, and medical histories and then traversed the wards to check on them.

I knew that hospitalized patients ("inpatients") would be sicker than the patients I saw in outpatient clinic. But it was more sobering than I expected interacting with them and learning the extent of their illnesses. Examples of frequent medical issues during the three hours I was on the wards:

-incurable metastatic cancer
-severe and irreversible breathing problems, brought on by smoking tobacco, smoking cocaine, morbid obesity, exposure to Agent Orange, and venous blood clots that had migrated to the lungs ("pulmonary embolism")
-dementia and delirium; whether because of denial or cognitive impairments, many patients were largely unaware of their diagnoses and their treatment plans.
-urinary incontinence and constipation (a side-effect of the high doses of painkillers the patients required).
-a lack of a support network; one patient can't be discharged until the hospital can find a skilled nursing facility to house him, with no resolution in sight.

Most patients were either getting worse or staying the same. The physician had to inform several patients that the end was drawing near. One patient, who understood he was seriously ill but had a decent chance of recovery, asked hoarsely if we could "do a Kevorkian" on him. The hospitalist's response was perfect: "Not going to happen. Kevorkian was a Michigan guy, and I root for Ohio State because my kids go there for school." Instead, the hospitalist suggested that the patient change his "code status," so that medical staff would not perform CPR or place him on a ventilator should he stop breathing on his own. The patient's mood lightened, and the hospitalist secured his OK on continuing for now with aggressive treatment. Still, the patients were a depressed lot (and justifiably so, accompanied as they are by pain and the specter of death). It seemed that having family, friends, or some avenue of self-expression would have helped many of them considerably, but instead the TV was their sole means of escaping the monotony of the hospital room. If I wasn't scrambling to pay for med school, I'd be tempted to buy Etch-a-Sketches for the patients in the wards, just so they could do something creative.

I didn't shadow physicians before starting medical school (while nearly all successful med school applicants shadow as undergrads, I remain happy with my decision). I found it useful today as a medical student for several reasons:

1. It familiarizes me with the hospital and the medical records systems.
2. It gives me an understanding of what certain specialists' day-to-day routine looks like.
3. It introduces me to new medical knowledge and examination methods, and reinforces and ties together those that I already know.
4. It reminds me why this whole med school enterprise is worth it.
5. It exposes me to how a skilled clinician interacts with his patients. My hospitalist had to perform a delicate dance, of examining his patients, asking them good questions, listening to them, providing appropriate treatment (such as appropriate doses of pain meds) comforting them, and being mindful of the time constraints his schedule placed on him. He seemed to succeed, given how many patients confessed their past drug use, unprompted.


I was glad to see how grateful the patients were to my doctor. Many told him that they trust him, that he's a "good doc", or that he cares about him. Unfortunately, many of these remarks were followed by something along the lines of, "yeah, and all of those other doctors are really cold." A partial victory for the profession, but I'll take it.

One consistent theme, and a topic of a future post, is that most of the patients' diseases either were preventable (obesity, complications from smoking, blood clots due to lack of exercise) or could have been successfully treated had they been caught earlier (disseminated cancer, sleep apnea requiring tracheostomy). Better prevention, better public health measures, a more robust primary-care system, and a better support system (such as family members) would have made a world of difference to these patients, and perhaps could have avoided these unfortunate and unnecessary brushes with death. When I brought this up to the hospitalist, he said while he was painfully aware of this reality, he couldn't let it get to him. His relationship with the patient starts when they're admitted to the hospital. What he does is comfort and heal his hospitalized patients, regardless of why they're there, and then try to ensure that his patients will receive appropriate care once they've been discharged. Seems reasonable enough.

A knot-able occurence

I continue to be amazed by what random pieces of knowledge from my past are coming in handy these days. The other day, the taut-line hitch I learned in the Boy Scouts saved me from spending anatomy lab in my boxers.

While putting on my scrubs for anatomy lab in the changing room, I found to my horror that one end of the drawstring had somehow gotten pulled into the bottoms. In a panic, I yanked on the other end of the drawstring, burying the lost end even further into the no-mans'-land of my waistband. The scrubs are several sizes too big, and awkwardly clutching my bottoms (like one of the "cool" kids in my middle school with baggy pants) for the 5 minute walk to anatomy lab was all I could manage to keep them from falling down. Class was starting and dissection is difficult with only one hand free. What to do?

I wiped the "grime" off of some dissection forceps and tried vainly to grab hold of the string. Somehow this made the situation even worse and probably smeared the inside of my scrubs with formaldehyde.

The taut-line hitch

My salvation came in the form of some string that the lab provides for bundling muscles and tying together skin flaps. To tie the string into a belt, I used the taut-line hitch, which is pretty much the only knot I remember from my Scout days. Heck, I still have troubles with my shoes, which become untied so often that I've pretty much given up on them. The beauty of the taut-line is that it makes a very strong loop, the length of which can be simply adjusted even after the knot's been tied. Upon fashioning a belt that loosened and tightened, I was so proud of it that I was sad to have to tuck it out of sight under my scrub tops.

That night, the taut-line came to the rescue again when I fixed, using dental floss, the poorly-designed IKEA hanging file rack that holds my lecture notes. Now my notes smell refreshingly minty.

It's nice how med school draws together together loose ends from our pasts. I just hope some of my Scout training remains purely theoretical--like the merit badge requirement that involved jumping into a lake fully-clothed, inflating one's jeans and long-sleeve shirt, and using them as flotation devices. At least when that day comes I'll be prepared.

[Images are shown with permission via Creative Commons license: scrubs attributable to wenzday01, taut-line schematic attributable to David J. Fred]

Classes

The rumors were true: there is a lot of material to power through in medical school. One typical day consisted of five hour-long lectures:

-Signal transduction
-Disorders of hemoglobin
-Specialized epithelial glands
-Introduction to radiological techniques
-Interpreting radiological images of the spine

I'm impressed with both the depth and variety of topics discussed--we often have just a ten-minute break before we switch subjects entirely.

Following the lecture is usually a challenge--the material comes flying fast and some of us get lost partway through. Committing the information to memory is another trial. Whether or not I do a good job of assimilating the day's material (and I currently doubt that I am), the next day arrives and brings with it a whole new set of lectures.

The rigor exceeds that of my undergrad, which I felt was quite demanding. But it's awesome that med school offers an additional motivation to learn the material cold: the diseases our professors lecture us on may well present in a patient we see. Learning it properly may be the difference between bad care and good care, sickness and health.

Hypertension, and my first patients

Though med school has barely begun, I've had the opportunity to don my white coat, stethoscope, and reflex hammer and examine a total of five patients in an outpatient setting. All five presented with high blood pressure, all five had previously been diagnosed with hypertension, and all five had stopped taking their hypertensive medications simply because they didn't feel like taking them anymore. It's a fitting condition for my first patients to have, in that hypertension exemplifies both the spirit and the limitations of medical practice.

My first patient was a friendly man with an all-too-common story--he was overweight, lacked health insurance, and had severe hypertension. Although he had been on drugs for hypertension in the distant past, he stopped taking his meds years ago because he felt better. He came to clinic because when he recently had his blood pressure checked, it was extremely high (the reading I obtained was a good 40 ticks higher than I had ever seen before). I sought out the supervising physician, who examined him, wrote some prescriptions, ordered some labs to see if his kidneys were damaged, and instructed him to return in a few weeks. I played pharmacist and gave him several weeks' supply of hypertensive drugs to get started.

Another patient had hypertension despite maintaining a good diet and healthy weight, as well as hypokalemia (too little potassium in the blood). The doctor suspected hyperaldosteronism (often, a tumor of the adrenal glands that overexpresses aldosterone, a hormone affecting blood pressure). Another was a fit teenage athlete with a clean bill of health, except for a menacingly high blood pressure of unknown etiology (unclear cause).

Technology gives us remarkable tools to combat hypertension. An easy-to-use, inexpensive, and reusable device (the sphygmomanometer, or blood pressure cuff) reliably diagnoses hypertension. You need not travel further than your local supermarket to check (within seconds! free!) whether the "silent killer" lurks in your arteries. But the most effective interventions are beyond medicine's grasp. Sure, we can prescribe diuretics and ACE inhibitors, but public health is best equipped to tackle the problems that usually cause or exacerbate hypertension--the shocking and indefensible amount of sodium in processed foods; and people eating poor diets, exercising too little, and weighing too much. Funding PE in schools or having the FDA follow through on its proposal to regulate salt in processed foods would far outstrip the concerted efforts of thousands of well-meaning doctors and medical students.

Telling the patient, "improve your diet" and "exercise more" doesn't help either. Two of my patients don't speak English--how are they going to figure out what foods have lower sodium when they go shopping? Another has no job--how will they pay for more expensive, but healthier foods? Another has a bad knee--how are they going to exercise?

So we prescribe them meds, and many patients take them for a few months and then stop. It's hard to blame them--while the drugs have side effects, hypertension feels fine. Like bad sunburns, the punishment for having high blood pressure is years or decades off. If a patient isn't motivated to make lifestyle changes to combat hypertension, how motivated will they be to stick with their meds?

The point is, 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.