Money and medicine: the Nexium swindle

If you live in the United States, you have almost certainly encountered advertisements for Nexium (esomeprazole), a prescription medication for heartburn relief. Its ad slogan is "the purple pill." (If you live in any other developed country, your government will have forbidden advertising a prescription medication over the television.)

Nexium is a drug that shouldn't exist. It contains the exact same active ingredient*, in the exact same amount, as an older drug, Prilosec. Prilosec (omeprazole) is currently available over-the-counter as a relatively inexpensive generic drug. But Nexium is currently the third-highest-selling prescription medication in the U.S., with sales of over $6 billion a year.

How could this have happened?

The abbreviated version of the story is that years ago, AstraZeneca, which originally manufactured Prilosec, recognized that it would lose billions of dollars in sales once Prilosec lost its patent protection. And so, it developed Nexium and set in motion an enormous advertising campaign. It gave incentives to doctors and patients who switched their prescriptions from Prilosec to Nexium. The plan worked beautifully. This "Nexium swindle" is just one of many unethical but legal practices in the pharmaceutical industry that each year net tens of billions (possibly hundreds of billions) of extra revenue.

Many issues in health care (doctor shortages, expensive health insurance, steep medical school tuition, difficulty in getting a primary care physician, burnout amongst medical providers) really could be solved with more money. And yet Congress, under pressure from the pharmaceutical lobby, has mandated that Medicare pay full price for prescription medications. Congress also forbade Medicare from keeping a formulary of preferred drugs. It amounts to a massive ongoing handout to the pharmaceutical industry.

We ought to stop paying for useless drugs like Nexium, which have excellent and dramatically less expensive alternatives. If every patient on Nexium were switched to Prilosec (which is virtually the same drug), there would be enough money to pay for every current medical student's tuition, with billions of dollars to spare. And that's just one drug of many.

America is being scammed, and very few people realize it.
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 *The key difference between the two drugs is that omeprazole contains an inactive ingredient that is absent in esomeprazole. For those who know a bit of organic chemistry, omeprazole contains a racemic mixture while esomeprazole has only the active enantiomer. Unsurprisingly, the manufacturer has had a difficult time showing any difference in effectiveness between drugs.

"The Woman Who Decided to Die", by Ronald Munson

Perhaps I feel partial to this book because Prof. Munson's introduction to medical practice came the same way mine did: through the lens of clinical ethics. Munson is not a physician, but a bioethicist. His book, "The Woman Who Decided to Die," features 10 vignettes of striking, yet representative ethical predicaments that he has encountered over his career. Munson is a gifted writer, and this book benefits from his succinct, rich, and approachable form of narrative.

The format of the chapters is straightforward: in each, he tells the story of a patient he has worked with. Then, he devotes a couple of pages to the ethical issues inherent to the case, and how doctors approach these issues clinically. For example, a convicted murderer is admitted to the ICU with a failing heart. Prof. Munson is called in for an emergency consultation to determine whether the patient should be put on the transplant list. Should a murderer get a heart before someone innocent?

Perhaps surprisingly for a book about ethics, the book vividly portrays the patient's stories, through the help of lengthy interviews with the patients. Munson also conveys very well the art of medicine. Through his writing we witness the thought process going through the minds of doctors, and the delicate and careful ways that they elicit information from their patients and provide guidance. The book discusses complex issues in medicine in a way that non-scientists can understand, which is rare.

Prof. Munson has written an excellent book. I heartily recommend it as an introduction to clinical medicine and bioethics.

Now, go pee in this cup

Some moments in medical school are surreal.

Our morning lecture concerned urinalysis (a standard set of important laboratory tests done on urine samples). We were all issued specimen cups and instructed to obtain urine samples (i.e. go pee in our cups). Throughout lecture, students slipped out of the auditorium and returned toting transparent containers that now were partly filled. When lecture ended, we tromped upstairs, specimen cups still in hand, and then as a group performed medical assays on our urine. Since most people's urine was normal, we hunted for classmates whose urine had abnormal findings, like crystals, blood, nitrites, or white blood cells.

It's entirely sensible that this activity was conducted the way it was. We need to learn how to perform urinalysis, and for technical reasons the urine ought to be fresh. We're at a stage in our training in which we're expected to be professional and comfortable handling bodily fluids.

But the image of me and my classmates, walking the halls of our school each carrying a plastic cup filled with his own urine, is pretty weird. Just another day in the life of a medical student.

Needless suffering

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I attended a talk by Dr. Howard Koh, the current Assistant Secretary for Health. While practicing as a physician, he encountered too much of what he called "needless suffering." He gave as an example a young father whose potentially-treatable cancer had been diagnosed too late, because he lacked health insurance. Dr. Koh decide that he ought to enter public health and policy, so that he could improve the way health care is delivered and help many lives.

Many of our country's children suffer needlessly, whether from violence, from poverty, from abuse, from preventable diseases, from motor vehicle accidents, from broken schools, from obesity, from broken homes, from lack of opportunity, and on and on. I say "needlessly" because many of these problems could be at least partly fixed, if only we made doing so more of a priority.

And yet we are reversing past gains. The life expectancy for certain segments of our population has been dropping over the past years. For example, the life expectancy of white women without a high school diploma was 5 years less in 2008 than it was in 1990. We are needlessly losing ground.

Our country has united in mourning the 20 children and 6 adults in Newtown, CT whose lives were cut short. Our profound feeling of loss ought to remind us that life is precious, and that one of our highest callings is to love our fellow man and protect our youngest. I hope that their memory will compel us to alleviate that suffering which needlessly afflicts those among us. Our work is cut out for us.

Book recommendations

I like reading books about medicine, and I have found some of them particularly gripping and enlightening. You might enjoy them too. All of these books were written for a general audience.

Practice of medicine
-"Complications," by Atul Gawande
-"Incidental Findings," by Danielle Ofri
-"Better," by Atul Gawande

Cancer
"The Emperor of All Maladies," by Siddartha Mukherjee

Neurology
"The Man Who Mistook His Wife for a Hat," by Oliver Sacks

Medical ethics
-"The Woman Who Decided to Die," by Ronald Munson

Medicine in literature
-"The Plague," by Albert Camus

Big Pharma
-"White Coat, Black Hat," by Carl Elliott
-"The Truth about the Drug Companies," by Marcia Angell

Medical errors
-"Internal Bleeding," by Robert Wachter and Kaveh Shojania

Infectious disease
-"The Great Influenza," by John Barry
-"The Coming Plague," by Laurie Garrett
-"The Hot Zone," by Richard Preston
-"House on Fire: The Fight to Eradicate Smallpox," by William Foege

Endocrinology
-"Why Zebras Don't Get Ulcers," by Robert Sapolsky

Medicine during wartime
-"Long Walk Through War," by Klaus Huebner

Emergency medicine
-"The Blood of Strangers," by Frank Huyler

Today's events

I was touched by our president's heartfelt remarks on today's shooting at a Connecticut elementary school:



In reflecting upon this tragedy, I see the deceased not only as victims of gun violence but as victims of mental illness. Those of sound mind do not massacre children.

As we reflect on how we can prevent future violence, I submit that in addition to tightening up our gun-control laws (why can people still lawfully obtain high-capacity magazines?), we might combat criminal insanity by strengthening our country's debilitated and woefully underfunded social support programs. Making mental health treatment more accessible will prevent some would-be shooters from ever having the intention to kill.

My thoughts are with the victims and their families.

(from "Willa's World")

Money and medicine: medical schools and primary care

I attended a talk by the dean of admissions of one of the most competitive medical schools nationwide. The topic was primary care and community health. He talked at length about how not enough medical students were entering primary care. He put up some graphs showing that the most lucrative specialties tend to be the most competitive ones, with primary care among the lowest-paying and least-competitive. He said that medical schools need to be making primary care more appealing. And he talked about how, in his long tenure as dean of admissions, he has been steadfastly committed to selecting those applicants who are committed to becoming the next generation of leaders in primary care.

I went up to the dean afterwards and alluded to the fact that nearly all graduates from his medical school go into medical specialties instead of primary care. Has his school considered creating a loan forgiveness program for students who pursue careers in primary care, giving them an added incentive to enter the field?

His response: "There's no need for such a program, because I'm confident that our medical students don't choose their specialties based on financial considerations."

Me: "But during your talk you put up a graph showing that medical students nationwide do exactly that."

Dean of admissions: "Our graduates have some of the lowest debt levels in the country, so financial constraints aren't a concern."

Me: "If financial constraints aren't a concern, and if you're admitting students based on their likelihood of going into primary care, then why are so many of those admitted students going into specialties? Is it because it's difficult to predict what specialty an applicant will eventually pursue?"

Dean of admissions: "Not at all. We're quite good at picking the right students..."

____________

And so, this fruitless conversation dragged on for longer than it should have.

The dean of admissions may well care passionately about primary care—after all, he cared enough to give a talk on that topic. But his school certainly doesn't see its mission as training primary care doctors, a notion borne out by the careers its graduates enter. And why would the school care about primary care? Primary care doctors tend not to make the big-deal research discoveries that net Nobel Prizes. They tend not to accrue the sort of wealth that would someday allow them to endow professorships. They tend not to invent new procedures and new drugs. Their work goes largely unnoticed, except by the patients they care for.

If schools truly cared about training primary care doctors, then they would reduce the financial barriers to entering primary care. They could do so by defraying the tuition of those who commit to enter primary care, or by forgiving some of the loans of those students who enter primary care. In fact, some top law schools do exactly this for those students who commit to entering careers in public service or as public defenders. Some business schools do it for MBAs who work for non-profits.

But I don't think most medical schools care, and this ambivalence rubs off on its students. It's one of the contributors to the dearth of American medical students entering primary care.

More on money and medicine in subsequent posts.

Money and medicine, introduction

From a well-written Business Week article on concierge medicine [emphasis mine]:

The [Affordable Care Act] will enable 30 million previously uninsured people to get coverage through an expansion of Medicaid. They’ll need primary care, but it’s not yet clear who will give it to them. By 2020, the Association of American Medical Colleges estimates, there will be 45,000 fewer primary-care doctors than the U.S. needs. “For the last 13 years, very few students have been going into it,” says Patrick Dowling, chairman of the department of family medicine at the University of California-Los Angeles’s David Geffen School of Medicine. “What motivates medical school students is income, just like everyone else.”  

What's supposed to set physicians apart from other professions is a deeply-held code of ethics, which demands that one place the patient's interests ahead of one's own. If Prof. Dowling is correct that income truly is what motivates medical students, "just like everyone else," then this code of ethics no longer applies. Medicine is simply a business, its physicians no different from financiers and salesmen. It appears that Prof. Dowling has ceased to believe in his profession.

In my next posts, I will explore money and medicine. What motivates medical students, if not income? Why, when our country spends the most (per person, in absolute expenditure, and as share of GDP) on health care in the world, is America's health so lackluster? Where does the money go? How can the system be improved? What will the Affordable Care Act do to medicine? I also invite you to write a comment about what topics might interest you.

A sad day

The purpose of the present Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.

—from the United Nations Convention on the Rights of Persons With Disabilities, an international treaty that came up for ratification in the Senate yesterday. 126 countries have already ratified.

____________

This is one of the saddest days I’ve seen in almost 28 years in the Senate, and it needs to be a wake-up call about a broken institution that’s letting down the American people.

—Sen. John Kerry (D-MA), after Republican senators yesterday voted down the ratification of the treaty.

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According to the Kaiser Family Foundation, other international treaties pertinent to global health that the Senate has also declined to ratify:

• the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW);
• the Convention on the Rights of the Child (CRC);
• the Convention on Biological Diversity;
• the Kyoto Protocol to the United Nations Framework Convention on Climate Change;
• the Stockholm Convention on Persistent Organic Pollutants (POPs);
• the WHO Framework Convention on Tobacco Control (WHO FCTC);
• the Cartagena Protocol on Biosafety to the United Nations Convention on Biological Diversity;
• the Convention on the Protection and Use of Transboundary Watercourses and International Lakes (Water Convention);
• the London Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes; and
• the Ottawa Treaty (Mine Ban Treaty).

____________

The United States can hardly consider itself a world leader in health when it abandons so many worthy global health efforts. And now, in rejecting the United Nations Convention on the Rights of Persons With Disabilities, we have deserted the cause of those least able to help themselves. A sad day indeed.

This is your brain on football

From a previous post in January:

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?

Moments ago, a big-deal paper out of Boston University (BU) was released by the journal Brain. The BU team discovered 15 previously-unknown cases of CTE in former NFL players. That means that of the 34 brains of deceased NFL players examined so far by the BU team, 33 have been found on autopsy to have CTE. The team also diagnosed CTE in some football players who didn't play football beyond college or high school, as well as in some NHL hockey players. The paper also looked at controls (patients who played sports besides hockey or pro football) and found few with CTE. The team also catalogued the devastating neurological symptoms suffered by the players with CTE, like depression, explosivity, and dementia. It strikes me as a thorough and well-done paper with major findings.

In my mind, the release of this paper is a watershed moment. The science on CTE is in. Football clearly destroys some of its players' brains. The questions at this point are how many of its players are affected, and how badly.

I don't feel conflicted anymore. Until the sport changes, I'm done with following football.

Insurance

A New York Times article a few years back tried to find out why health insurance companies didn't cover the cost of test strips for diabetics who needed to check their blood sugar levels. Test strips are fairly cheap, and without them, it's impossible to control one's blood sugar. Uncontrolled diabetes can eventually lead to lots of bad medical problems, like kidney failure, limb amputation, and cardiovascular disease, all of which are quite expensive. Wouldn't it be profitable for insurance companies to cover test strips now and avoid complications later?

The answer the Times found was a cynical but rational one. People spend an average of something like seven years with their health insurance company before switching to another (perhaps by changing jobs, or by their employer changing health insurers). If one insurance company provided test strips free of charge, the savings in eventual health costs would be passed on to that company's competitors. When insurance companies emphasize prevention, they lose money.

For years I've had an idea that I've never seen anyone suggest. What if your health insurance company also provided your life insurance? That way, there would be some added profit incentive for your insurance company to keep you alive for longer.

Foresight

HERDSMAN
If you are in fact what this man says,
God have pity on you! You were born to misery.

OEDIPUS
Oh! Oh! All come to pass, all true!

I find Oedipus Rex tough to read, because everyone but Oedipus sees where things are headed. Oedipus doggedly investigates the death of the king. He is blindsided (and blinded) by the sudden revelation (see above) that he had unknowingly killed the king (his father) and wed his mother. Throughout the play, Oedipus is a step behind everyone else. He's the last to know the truth.

---

A patient came in with rapidly progressive weakness of recent onset. In his usual state of health just months ago, he could hardly walk without falling and could barely summon the strength and dexterity required to button his shirt. He wanted to know why.

At the start of the visit, the physician and I assembled differential diagnoses in our minds. The physician obtained an excellent patient history, eliciting answers that ruled out some of the diagnoses on our lists. Pretty soon, all of the potentially reversible illnesses on my differential were ruled out. Nothing much seemed to fit the patient's symptoms, except for amyotrophic lateral sclerosis (ALS, also called Lou Gehrig's Disease). It is an awful disease, progressively paralyzing the body's muscles while leaving one's mental faculties intact.

We moved on to the physical examination. The doctor performed tests specific to ALS, and our findings increasingly supported that diagnosis. I was filled with a horrible sense of foreboding. I could tell that within minutes the diagnosis would be confirmed. Given the rapid progression of his disease, he didn't have many more months to live. I steeled myself for the wrenching moment when the patient would be informed.

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Our medical training confers upon us some prophetic powers. In making diagnoses, we interpret signs on the body that are inscrutable to most. With our medical knowledge, we can sometimes accurately predict the course of a disease. Like Cassandra and Tiresias of ancient Greece, we issue dire warnings ("if you don't quit drinking, it will kill you!") that often go unheeded.

But as neat as it is to see the future, I now understand that this faculty can be a burden. Like those prophets of old, we were condemned to foretell this patient's tragic fate yet powerless to alter it.

You can't stay pluripotent forever

The human body contains all kinds of cells: cells that secrete mucus, cells that sense light, cells that make up your skin, cells that make up your brain. But we begin as embryos, which are devoid of these "differentiated" types of cells. No matter how much you dig, you will not find in an early embryo the specialized cell that manufactures your stomach acid. Rather, embryos contain "pluripotent" cells. These remarkable cells, which multiply in number during development, can differentiate into progressively more specialized types of cells. Taken together, the pluripotent cells possess the unique ability to become any type of cell in the body.

Once a pluripotent cell differentiates, it cannot become pluripotent again. A taste bud can't become a sweat gland. Its job is ordained.

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As an undergraduate, I had a romantic image of myself as doctor. I had arrayed in my mind brief snapshots, as though from a movie, of myself (with grayed temples and long white coat) performing manifold deeds:

-counseling a newly pregnant woman on prenatal care
-uncovering a tricky diagnosis in an emergency room patient
-delivering a newborn child
-helping a teenager overcome an eating disorder
-tailoring a cancer treatment to a patient's genetic signature
-leading a community in the face of a frightening pandemic
-performing a circumcision
-treating patients in a refugee camp

Although a doctor's license technically allows him to practice any kind of medicine, what I had barely grasped was that a doctor's specialty largely dictates which diseases he does (or does not) treat. Internal medicine doctors don't deliver children. A spine surgeon will not medically manage a thyroid disorder. A pathologist doesn't see patients in outpatient clinic.

I used to think that to become "super-doctor," I needed to enter the medical specialty that offered the broadest scope of practice. The obvious choice was family medicine, which includes basic surgeries, childbirth, and treating patients of all ages. Family medicine physicians excel when working in sparsely-populated areas, where their broad set of skills proves especially valuable.

But recently I've begun valuing depth over breadth. When I shadow specialists, I find that within their specialty, they tend to outperform non-specialists. Pediatric hospitalists are particularly good at taking care of hospitalized pediatric patients. A knee surgeon is particularly good at operating on knees. An oncologist is particularly good at treating cancer. I feel I'd serve my patients best if I too focused on some segment of medicine that captures my particular interests and plays to my strengths.

It's hard to stomach that someday I will probably see either adult patients or pediatric patients, but not both. I entered medicine because I wanted to help all people, not just those with gastric cancer, or with cataracts, or who are under the age of 18.

Being a medical student is an exciting time. We study all disciplines of medicine. We perform mandatory clerkships in all of the core medical specialties. During fourth year, we can take electives in whatever field we want. But we cannot forever remain medical students. Eventually we have to choose a path, and leave behind options once open to us. I take solace in some sagely advice I once had received: "You can't stay pluripotent forever." For now, I intend to enjoy this time of limitless potential.

Home birth

Sometimes I find myself in arguments on medical subjects with non-medical people (for example, with seatmates on airplanes). One argument concerned "natural" home birth. My stance is that if I were a pregnant woman, I would be quite uncomfortable with having my birth at home.*

Pregnancy and birth is a wonderful, yet involved, process. Pregnancy stresses the female body, altering the homeostasis (the equilibrium) of many of the body's systems. For example, pregnant women are more likely to experience blood clots, in part because of a change in their hormones. They have to urinate more often. Some parts of the pregnant woman's brain grow new neurons (which is actually a huge deal, because adults weren't previously thought to be able to grow new brain tissue). Towards the end of the pregnancy, the gigantic uterus competes with the lungs for space in the body, making breathing more difficult. The spine has to adjust to carrying more weight. The heart is more likely to arrest. The list goes on.

Childbirth especially places the body under stress. Sometimes, deliveries have complications. Arterioles can rupture, causing hemorrhage. The fetus can be positioned the wrong way in the birth canal. The fetus's umbilical cord can wrap around its neck, strangling it. The variety of potential complications is substantial. Fortunately, obstetricians can do quite a lot to resolve these complications when they arise, sparing the life of the mother and the child. What is frightening is that grave complications can come on suddenly and without warning, and they need to be dealt with emergently.

As I alluded to in my recent post on diagnosis, when approaching a complex matter, it often helps to break it down into its simpler, constituent parts. Those working on maternal mortality worldwide have done just that. There is a "three-delay" model of contributors to maternal mortality in complicated deliveries:

1. delay in recognizing problems in labor and deciding to seek medical help;
2. delay in reaching a skilled medical facility; and
3. delay in obtaining the appropriate intervention on arrival.

The trouble with home birth (relative to at a hospital or a birth center) is that it definitely delays number 2 and usually delays numbers 1 and 3. Delays in medicine are costly. Regarding strokes, neurologists say that "time is brain." Regarding heart attacks, cardiologists say that "time is muscle." I am coining the aphorism that in obstetrics, "time is life"—that of the mother and that of the fetus.

To be sure: most low-risk pregnancies result in uncomplicated deliveries, whether in one's home or in a hospital. It's when a delivery doesn't go smoothly that one will want to quickly find herself in the hands of a skilled physician.

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* Summary statement of the American College of Obstetrics and Gynecology's Feb. 2011 position paper on planned home birth:

Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

The evacuation of NYU Langone hospital

An NYU medical student recounts the emergency evacuation of his academic teaching hospital after Hurricane Sandy. I can hardly imagine how frightening that experience would be.

I respectfully disagree with one assertion in his account:

Last Monday night, these buildings flooded, and PSE&G shut off electricity to all buildings below 40th Street. And then, as you've probably heard, the unthinkable occurred: the hospital's backup power generator failed. 

The loss of backup power generators was quite "thinkable". It happened in New Orleans hospitals during Hurricane Katrina, and Manhattan is known to be at risk for flooding from storms (especially NYU, which is close to shore). Although the evacuation of NYU Langone and Bellevue hospitals is a story of how the medical community came together during trying times to save their patients, it also is a lesson in how foresight and preparedness go quite a long way.

A tradition of mentorship

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

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

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

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

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

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

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

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

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

Sweat the small stuff

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

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

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

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

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

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

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

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

Nobel Prize for Economics

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

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

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

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

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

Diagnosis II

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

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

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

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

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

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

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

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

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

'Incidental Findings', by Danielle Ofri

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

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

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

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

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

Diagnosis

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

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

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

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

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

Where Are Today's Philosopher-Physicians?

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

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

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

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

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

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

---

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

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

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

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

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

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

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

Card-ology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Trying patients

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

Headache specialist: I am a headache specialist.

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

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

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

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

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

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

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

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

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

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

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

Harrison's Ch. 27: "Sleep Disorders"

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

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

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

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

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

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

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

---

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

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

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

Uh-oh.

Rare

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

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

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

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

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

Happy anniversary!

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

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

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

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

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

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

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

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

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

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

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

---

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

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

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

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

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

Going zebra-hunting

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

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

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

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

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

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

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

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

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

 

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

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

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

Among the less fortunate

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

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

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

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

Attraction

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

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

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

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

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

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

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

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

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

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

Landmarks

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

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

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

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