In memoriam

I recently learned the sorry news that my childhood pediatrician has died. Not only was he my pediatrician, but he was also my father's pediatrician. Our family became rather close to him over the years.

He came from a different generation of doctors, one that made house calls, that served in wars abroad, and that learned how to diagnose patients in the days before MRIs and CT scans. Even though I was little while I was his patient, I clearly remember how much he relied upon the physical examination and upon instruments like the reflex hammer and the tuning fork that few doctors carry today.

Most striking was his unwavering dedication to his patients. Although today's aspiring physicians (myself included) seek "work/life balance," his work pretty much was his life. Even on weekends and nights, he was working tirelessly for his patients, visiting his charges at home and in the hospital. To him, medicine was not a job, but truly a calling. Although old age forced him to give up his practice, it did not seem like he ever retired. I saw him frequently at the medical school's weekly pediatrics grand rounds, always sitting in the front row.

He was one of my main inspirations for wanting to become a physician. I grew up feeling indebted to him for having looked after me with such care, and it saddens me considerably for him to be gone. I hope to live up to his example, although I doubt I will come close to emulating his commitment to this profession. As my father remarked, "they don't make doctors like him anymore."

Although this past year of medical school, my first, has better acquainted me with illness and death, it hasn't taken any of the sting out of the loss of a loved one. Entering medicine has eased, though, the inevitable soul-searching that accompanies such sad news. In mourning, I ask myself, what is my purpose here on earth? How will I leave my mark? How can I best honor the memory of the deceased? It was my pediatrician who had first offered me some of the answers. Medicine can be a noble line of work, and by taking it seriously I hope to repay my debt to him and my obligation to humanity.

May he rest in peace.

Ain't that the truth?

It is unfortunate that one must be slightly skeptical of what patients say. Although the doctor-patient relationship is premised on mutual trust and truth-telling, some patients lie.

Mr. Williams came into clinic because he had lacerated his arm on a dirty, rusty metal fence. Dr. X and I were concerned about the risk of tetanus infection, which although potentially deadly is completely preventable through vaccination.

Dr. X: Did you get a tetanus shot in the past five years?

Mr. Williams: Yeah, I'm covered. I got the tetanus shot last year.

I didn't believe him and happened to have his chart in front of me.

Me: Dr. X, you might want to have someone check if there's a problem with your electronic medical record system! It doesn't show any record of Mr. Williams's having received any tetanus shots for at least the past 18 years--

Mr. Williams: All right, I lied. I didn't get tetanus. I just hate getting shots.

Although the lie was harmless, I found its brazenness upsetting. Everyone deserves medical care, but it is frustrating working to help those who do not take you seriously and who you cannot fully trust.

Ultimately, the doctor didn't pressure the patient into getting the tetanus shot. Telling the truth at the outset would have been the best policy.

The difficult conversation

A patient I examined had an unexpected, rapidly-progressive, and unquestionably-fatal disease that gave her perhaps weeks to live. A number of opportunistic diseases were ravaging her body because her immune system was compromised by her treatment. The patient was weak and in great distress. Her medical problems were extensive and complex.

For whatever reason, the patient and her family had tried to avoid the gravity of the situation. The patient had not crafted an advanced directive. Although home help, assisted-mobility devices, hospice care, and psychotherapy would all have been helpful and appropriate, either they hadn't been offered or the patient had not taken advantage of them. The emotional strain and the difficulty of caring for someone so ill had taken a toll on the family. What were the goals of care for these last few weeks of this patient's life? I didn't know, and neither did the patient or the patient's family. The result was a rudderless ship whose addled crew was adrift at sea.

A difficult conversation needed to have taken place. A doctor needed to sit down with the patient and ask: do you want to be fed artificially, even if this will substantially prolong your pain and suffering? Will you sign on to hospice care, so that you can relieve some of the burden on your family? What do you hope to accomplish during these last precious days on earth, and how can we best assist you with those goals?

I decided that it was inappropriate for me to be the one to have that conversation. I was only an observer, and I knew little about the patient's history, disease, and prognosis. And yet, I joined the ranks of all the other medical providers that this patient had seen, each of them hoping that someone else would someday perform that delicate, sorrowful, yet necessary task of plotting the future with one whose days are numbered.

Power of deduction

 From one of my blog posts in October 2011:

Sapira's, my favorite book on physical diagnosis, reminds the reader that a clinician's examination of a patient begins the moment he opens the door to the exam room.

An English physician, Arthur Conan Doyle, was taken by the outstanding powers of observation of one of his professors, Dr. Joseph Bell. Doyle later became an author, and Bell became the basis for Doyle's celebrated detective, Sherlock Holmes.

While wrapping up an examination of a patient, I glanced into the exam room's wastebasket. Inside were several paper towels that were dotted with blood. I asked if the blood was the patient's (it was), and what part of the body the blood was issuing from (the patient's nose). That the patient had frequent, severe nosebleeds ended up being an important finding when we crafted our treatment plan.

Perhaps "one man's trash is another man's treasure," after all.

Teaching

I had the opportunity to teach a large audience of pre-meds about the patient interview and about how to generate and hone a differential diagnosis. It is a blast looking back and seeing how much I've learned in the past year. I now feel familiar enough with some of the concepts of medical practice that I feel comfortable teaching others what I know.

The joy of getting in front of an audience, cracking jokes, and presenting my thoughts in a fun, interactive way reminds me that I would love to teach in some capacity once I finally become a physician. Teaching medicine seems just as exciting as practicing it.

Waste

A phone bank I toured was staffed by several nurses. The nurses' job was to fulfill a legal obligation that an insurance provider placed on their corporation: to call certain patients annually, to ask them a lengthy set of questions, and then to generate a detailed health plan. The nurses estimated that they spent an average of half an hour on each patient. A medical assistant spent her days organizing databases that catalog these annual health plans. Much of her workload (such as removing the leading zeroes from medical record numbers) could have been automated with a simple computer script that would have taken me a couple of hours to write.

Once the detailed health plans were generated, who saw them? Because of a change in policy, almost no one. Most simply were filed away. A small number were sent to the patients' primary-care physicians, who usually ignored them.

Two thoughts:
1. How would you feel if you spent each day dutifully generating products that you knew that virtually no one will ever use?

2. 18% of our country's GDP goes towards health-care spending. This is shockingly and unsustainably high, especially considering how we haven't even insured all of our citizens. Our health care system is filled with inequities and inefficiencies, and I got to see this one tiny inefficiency close-up.

Harrison's Ch. 80: "Involuntary Weight Loss"

Perhaps you watched the film "Julie and Julia" a few years ago. It is partly about a blogger, Julie Powell, who spent a year making every recipe in Julia Child's best-known cookbook.

I am doing something similar (albeit less tasty and less likely to be made into a feature film starring Meryl Streep). I am in the process of reading Harrison's Principles of Internal Medicine in its entirety. Harrison's is a dense, 3,600-page, two-volume tome that is the closest thing to a bible in clinical medicine. I am reflecting upon some of its chapters during the year or so it takes me to finish. 

From Ch. 80 ("Involuntary Weight Loss"): 

Involuntary weight loss (IWL) is frequently insidious and can have important implications, often serving as a harbinger of serious underlying disease. Clinically important weight loss is defined as the loss of 10 pounds (4.5 kg) or >5% of one's body weight over a period of 6–12 months. IWL is encountered in up to 8% of all adult outpatients and 27% of frail persons age 65 years and older. There is no identifiable cause in up to one-quarter of patients despite extensive investigation....Weight loss in older persons is associated with a variety of deleterious effects, including hip fracture, pressure ulcers, impaired immune function, decreased functional status, and death. Not surprisingly, significant weight loss is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years in the absence of clinical awareness and attention.

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The patient seemed healthy enough. In her 60s, she had stopped smoking 10 years ago and loved doing aerobics. She was getting over a cold. Although she was being treated for hypertension, her blood pressure now was substantially below 120/80 (i.e. her blood pressure was not high).

The doctor asked her how she had managed to get her blood pressure so dramatically in check. "I've lost a lot of weight," she beamed. "I used to be overweight, but now I've really slimmed down."

"How did you manage that?"

"I dunno. Recently I haven't had much of an appetite." The doctor and I looked at the chart, and the woman had lost about 20% of her body weight over the past year. She had been slightly overweight before and her weight now was the low end of normal.

Upon seeing the numbers the doctor and I shuddered almost imperceptibly. While the patient thought her weight loss was good news, we felt the opposite. We now had to order a variety of lab tests and a chest X-ray, checking in particular for cancer. The doctor cautioned that if this initial battery of tests came back clean, he would have to order yet another panel of tests and imaging studies.

Lots of things can cause weight loss in the elderly, some of them deadly and some of them not. How hard should we be looking for the underlying cause? If we ordered every medical test known to man, we still might not have a clue of what was causing the weight loss.

Part of the art of medicine is deciding how far to pursue leads. How long should a doctor take the patient's history? How many tests should we order? How extensive should a surgery be? There are no clear answers, and part of the burden and challenge of being a medical provider is that it falls to them to make these impossible judgment calls.

The spitting image

The two images on the left are from one of my textbooks. They are theoretical readouts from a spirometer, a simple yet important machine that measures how quickly air flows in and out of the lungs while the patient takes the deepest breath they can. At top left is a hypothetical normal patient; at bottom left is a hypothetical patient with obstructive lung disease (a common outcome of cigarette smoking). The diseased lungs are especially bad at exhalation.

Now for the part that fascinated me. Look at the readout on the right, from a patient in clinic today. Then look at the image at bottom left. Compare the outlines of both, as well as where the outlines reside on the x- and y-axes (you can ignore the noisy lines inside). Even without knowing a thing about pulmonology, you can see that they're virtually identical.

Even though each person is complex and unique, diseases can be consistent and predictable in the way they present. Today's case was one of these "textbook" examples.

Harrison's Ch. 251: "Approach to the Patient with Disease of the Respiratory System"

Perhaps you watched the film "Julie and Julia" a few years ago. It is partly about a blogger, Julie Powell, who spent a year making every recipe in Julia Child's best-known cookbook.

I am doing something similar (albeit less tasty and less likely to be made into a feature film starring Meryl Streep). I am in the process of reading Harrison's Principles of Internal Medicine in its entirety. Harrison's is a dense, 3,600-page, two-volume tome that is the closest thing to a bible in clinical medicine. I am reflecting upon some of its chapters during the year or so it takes me to finish. 

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Although I should have been asleep, last night I was determined to get through another chapter of Harrison's. On a whim, I read "Approach to the Patient with Disease of the Respiratory System." The chapter describes the mechanisms of certain respiratory illnesses and instructs the doctor in how to use physical examination techniques and diagnostic tests to inform his diagnosis.

In a stroke of good fortune, today I evaluated a patient with a nasty cough that began a week ago. It hurt when she breathed deeply. I suspected pneumonia and pleuritis (inflammation of the outer surface of the lung).

I took a lengthy history, and posed some questions that must the patient must have found strange. I asked for a domestic travel history, to rule out the endemic mycoses (three pneumonia-causing fungi found only in particular parts of the country). I asked for her history of international travel, to rule out tuberculosis. I asked if she had pets, to rule out psittacosis (a pneumonia-causing bacterium transmitted from birds).

Then I performed my physical examination, paying particular attention to the lungs. My leading diagnosis became even more specific: a bacterial pneumonia of the left lower lobe of the lung, with pleuritis. My calling which lobe of the lung was affected is a bit like a billiards player calling the pocket where he's going to send the 8-ball. My confidence stemmed partly from my having read the relevant section in Harrison's the night before.

We took a chest X-ray, and sure enough, my diagnosis was on the money.

It was a proud moment because it was a big milestone. I've seen many patients, and I've suggested many diagnoses, but never before have I been able to learn whether my diagnosis was ultimately correct. The number of diseases I'm familiar with grows by the day. My hunches are becoming more accurate, and I'm asking patients the right questions more often.

It's fun to compare how I feel about my skill level now to what I wrote just four months ago. Although I still am far from being a doctor, I'm definitely getting the hang of this.

Harrison's Ch. 1: "The Practice of Medicine"

Perhaps you watched the film "Julie and Julia" a few years ago. It is partly about a blogger, Julie Powell, who spent a year making every recipe in Julia Child's best-known cookbook.

I am doing something similar (albeit less tasty and less likely to be made into a feature film that stars Meryl Streep). I am in the process of reading Harrison's Principles of Internal Medicine in its entirety. Harrison's is a dense, 3,600-page, two-volume tome that is the closest thing to a bible in clinical medicine. I am reflecting upon some of its chapters during the year or so it takes me to finish. 

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From Ch. 1 ("The Practice of Medicine"): 

The Physician as Perpetual Student

It becomes all too apparent from the time doctors graduate from medical school that as physicians their lot is that of the "perpetual student" and the mosaic of their knowledge and experiences is eternally unfinished. This concept can be at the same time exhilarating and anxiety-provoking. It is exhilarating because doctors will continue to expand knowledge that can be applied to their patients; it is anxiety-provoking because doctors realize that they will never know as much as they want or need to know. At best, doctors will translate this latter feeling into energy to continue to improve themselves and realize their potential as physicians...

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I felt tremendously relieved when I recently finished my last exam of the first year of medical school. The relief was not just at being finished with exams, but at finally being able to study the parts of medicine that interest me without having to worry whether it is distracting me from my coursework. Even though I had just begun break, within a few hours of finishing my exams I was back in the library, reading textbooks. I'm not sure whether it's because I find my studies relaxing or whether I've simply forgotten how to relax.

In recent months I've solidified my foundational knowledge enough that I'm now able to learn about complex diseases. I understand the fundamentals of pharmacology, anatomy, biochemistry, histology, and physiology. I comprehend more of the medical terms I come across and can make some sense of blood tests and X-rays. Now that I have the tools, I now feel an unrelenting urge to tackle the massive compendium of knowledge I will need in order to recognize diseases and effectively treat them. In under a year I'll be on the wards seeing patients! I feel way behind, that there's no time to lose.

But of course, I can never be done. There is always more to learn. And we constantly have to refresh our knowledge: some things we learned in our classes just weeks ago have already gone out of date. Beyond that, physicians can always improve the way they interact with their colleagues and with patients.

Going into med school, I didn't expect learning about medicine to be quite this engrossing. I'm surprised at how willingly I've devoted my free time to improving my craft, to the exclusion of other pursuits. Being a "perpetual student" is an enormous obligation.

Cartoon

How do I deal with the stress of major exams? I draw silly cartoons.

Notification

One of a doctor's most difficult jobs is to notify someone of the death of a loved one. Death notification is of particular relevance to ER doctors. The death of those who are pronounced dead in the emergency department (such as those brought in by ambulance) is often sudden and unexpected. The act of notifying the family is difficult for all of those involved.

A textbook on emergency medicine, Tintinalli's, devotes a chapter to grief, death, and dying. I found one of the paragraphs uplifting:

There are data which demonstrate that properly performed death notifications may mitigate the impact of substantial negative effects on the surviving family members. For example, well-delivered death notification may reduce the incidence of PTSD in sudden death, particularly those involving the loss of a spouse or the death of a child. As emergency physicians, we must begin to think of death notification not as a difficult conclusion to an already difficult case but as an opportunity for prevention: reducing the incidence of secondary trauma to the family by the way in which they learn of a death.

In helping families confront death, the physician has an opportunity heal the living.

Knowledge

One of my high school physics teachers likened final exams to baseball. Fans don't care what your record was during the season; they only care how well you do during the playoffs.

He told us he didn't care when during the semester we learned the material, only that we had learned the material by the end. Physics is cumulative, so being able to do advanced physics demonstrates that one has mastered the basics. And so, days before our final, he announced his grading policy. If one did better on the final exam than on any earlier exams, then those exam scores would be corrected upwards to one's score on the final. If I scored 90 on the final, any prior exam score below that would become a 90.

In some regards, medical school has a different philosophy. I took anatomy during my first semester of medical school. After taking my final, I will never be tested on the material until I sit for my boards at the end of second year. Similarly, physical exam skills are tested once, early in first year. But they never appear on the boards, so they aren't even tested again.

Perhaps it's because I'm currently in the thick of finals, but it seems like a more cumulative approach would be better. Otherwise medical students segregate knowledge into what is testable and what is OK to forget. The real world and the human body are much more intertwined than that.