A surprising statistic

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

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

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

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

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

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

Repetition

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

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

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

Pathology

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

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

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

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

Mentor

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

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

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

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

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

Music and medicine

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

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

'Polio: An American Story,' by David Oshinsky

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

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

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

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

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