Connections

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

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

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

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

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

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

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

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

Birth

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

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

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

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

Clinical ethics II

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

My outline of the relevant theory:

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

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

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

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

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

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

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

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

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

Clinical ethics I

Derived from an actual case:

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

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

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

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

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

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

An ambitious attempt

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

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

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

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

Bird's-eye view

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

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

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

"I just want some birth control."

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

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

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

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

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

Presenting

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

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

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

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

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

Levity

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

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

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

Disgust, discussed

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

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

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

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

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