Victory lap

Paul Krugman reminds us who the real winners are of today's Supreme Court decision: Americans.

Supreme court decision

What would have happened if the Supreme Court had struck down the health insurance mandate as unconstitutional? It would have set universal health care, in any form, back by decades.

It's been heart-breaking seeing patients whose lack of health insurance prevents them from getting the sometimes life-saving treatment they need. Everyone deserves health care. I'm elated that the Supreme Court stayed on the correct side of history.

As goes dentistry, so goes medicine?

Frontline, my favorite television program, just aired an enlightening and dismaying hour-long documentary on America's broken dental safety net. It focuses on the poor's lack of access to quality dental care, as well as the proliferation of for-profit dentistry chains that sometimes derive revenue through shoddy work, unethical billing, and predatory lending.

It is strange seeing how the frightening changes described in the documentary are also manifesting themselves in American medical practice. Solo medical practices are becoming unprofitable, and in their stead are large health-care conglomerates that are often focused on their bottom line. Similarly to dentists, physicians feel threatened by the rise of so-called "mid-level providers," the physician assistants and nurses that are being granted increasingly wide scopes of practice. Not that these changes are unique to America: I recently read Nobel Laureate Alexander Solzhenitsyn's Cancer Ward, a semi-autobiographical novel set in a Soviet hospital. Although written 50 years ago, the doctors' complaints of the erosion of professional standards and the demise of the solo practice would just as easily apply to this country today.

The Frontline documentary portrays a badly-broken dental system, which causes grievous harm to children and adults and which has no clear solution on the horizon. As much as I'm partial to my profession, I have to wonder, is medicine today so different? And is medicine immune to the pressures bearing upon the dental profession?

On a side note, medical students find it easy to get jealous of dental students. Dental students can practice general dentistry after completing four years of dental school, whereas medical students must undergo additional training. Also, being a general dentist today is generally more lucrative than being a primary-care physician, especially because HMOs haven't completely taken over the dental field. Dentistry is an important medical field, as the documentary clearly demonstrates. Even so, I'm happy to be in a profession that permits me to focus on almost any part of the body.

Smoking gun

Watching actors smoking cigarettes on screen makes young viewers more likely to smoke. The tobacco industry has known this maxim for quite a while, and decades ago they offered free lifetime supplies of cigarettes to actors and actresses.

Although tobacco companies are no longer allowed to expressly pay for product placement in American films, smoking still appears in a number of current movies. Movie studios claim that they need to be allowed to show smoking, in part so that they can maintain the historical accuracy of films set in the past. For example, the Oscar-winner "The Artist" is full of characters puffing away.

If studios cared about historical accuracy, they ought to also incorporate other elements into films set in the 1920s:

-People were shorter than today, because nutrition was not as good. Hire shorter actors.
-Orthodontia didn't really exist. Only hire actors with crooked teeth.
-Dentifrice (toothpaste) didn't whiten as effectively as today. Only hire actors with yellowed teeth.

Movie studios are selective about what they choose to include when they portray historical periods. I'm not sure why cigarettes should be so sacred.

When politics and medicine mix

The C.I.A. hired a Pakistani physician, Dr. Shakil Afridi, to run a 2011 hepatitis B vaccination campaign in the Pakistani city of Abbottabad. The vaccination campaign was a front to investigate the Abbottabad residence where Osama bin Laden was thought to be hiding, and for Dr. Afridi to obtain DNA samples from the house's residents. Although Dr. Afridi did not manage to collect a DNA sample, his observations from visiting the house helped confirm that the house was bin Laden's. (In what appeared to be a politically-motivated verdict, the Pakistani government recently sentenced Dr. Afridi to 33 years in prison.)

Although the phony vaccination campaign helped kill bin Laden, it badly undermined the credibility of global health efforts. The New York Times reports that the Taliban is forbidding polio vaccinations in a Pakistani province that is one of the only remaining regions in the world where polio is endemic:

A Pakistani Taliban commander has banned polio vaccinations in North Waziristan, in the tribal belt, days before 161,000 children were to be inoculated. He linked the ban to American drone strikes and fears that the C.I.A. could use the polio campaign as cover for espionage, much as it did with Shakil Afridi, the Pakistani doctor who helped track Osama bin Laden.

This is awful news. Polio kills and paralyzes. The global community had gotten tantalizingly close to eradicating polio, convincing even those countries that feared ulterior motives to get on board. Vaccination drives have always attempted to separate themselves from wars and politics. During the successful smallpox eradication drive, some warring African nations even held ceasefires so that aid workers could vaccinate communities.

The C.I.A. program has ruined the credibility of vaccination drives, or at the very least has given cover to those who would use their participation in vaccination efforts as a bargaining chip. So long as North Waziristan refuses to vaccinate, it seems to me that polio cannot be eradicated.

There is a reason why the practice of medicine is supposed to be insulated from politics. In attempting to kill a terrorist, the C.I.A. violated this profession's core ethics and helped perpetuate another terror's reign.

See also a worthy New York Times news article about the ongoing impacts to international aid efforts stemming from the phony C.I.A. vaccination program.

Medicine by-the-book

I saw a patient who had injured his knee. I performed a handful of physical exam tests that I was familiar with: pulling on his leg to check the integrity of the anterior cruciate ligament (ACL), twisting his joint in a particular way to check some other ligaments known as the collateral ligaments. Still, I wasn't sure of a diagnosis. There were a handful of other tests that I wanted to perform which I had never done before. I didn't remember how they were done, and I didn't want to guess for fear of injuring the patient. So, with the patient in the room, I pulled out Sapira's, my gem of a physical exam textbook, and read for a bit of its section on the knee. Thanks to the exams it described, I was quickly able to pinpoint his injury to the posterior horn of his medial meniscus, without needing to take an X-ray or an MRI.

The patient seemed fine with my consulting a textbook mid-examination. "After all, you're just a student," he had said. But it felt uncomfortable. Bringing out the book was a tacit acknowledgment that I am falliable, that I don't know everything I need if I'm to help the patient. Most primary-care doctors I shadow excuse themselves from the room when they want to look something up. They don't mention to the patient that they're consulting other sources. For that matter, most primary-care doctors rarely consult outside sources when assessing and treating patients.

Should it be such a bad thing to consult a textbook with the patient present? Using a textbook conveys humility and demonstrates that the doctor cares. Double-checking against the textbook helps the doctor confirm that they're providing the most up-to-date and appropriate care.

I'm not sure that that's how patients feel, though. Patients want their doctors to be smarter than their textbooks. I'm willing to concede that, in some respects, the textbook knows more.

A legal action

A patient came in because he was litigating a worker's compensation complaint and hoped his physician would support his case. Everything bad that had happened in his life over the past few years he attributed to an injury to a limb that he claimed he had suffered on the job.

The examination was quite uncomfortable for me, because the patient actively tried to sell me on just how injured he was. Things became adversarial at times: he asked me if I doubted that the injury was the only explanation for his medical problems. When I touched the affected extremity, the patient cowered in pain and admonished me. The affected extremity did look abnormal. Then again, he had stopped using it since the injury. When a part of the body isn't used, it atrophies, distorting the anatomical structures and its appearance.

Was he exaggerating his pain to sell me on his legal battle? Was his pain in part psychological, brought on by the perceived injustice of having suffered an injury on the job? To what extent was the original injury responsible for the pain, and to what extent was it due to atrophy after the patient decided to stop using it? Was this a rare pain disorder? Was this all an invention by the patient, in a nefarious bid to collect disability and retire early?

This was not the fun kind of medicine, especially because I was more referee than healer. Some physicians specialize in workers' compensation cases, and serving as an expert witness in legal cases pays quite well. It's not what I came into medicine for, though, and this case made me quickly decide that this type of medical practice is not for me.

Patient follow-up

A patient came in complaining of a cough, shoulder pain, and vertigo. She was having difficulty walking and sitting up straight. I took some of the patient's history, and she complained how the last doctor refused to give her cough syrup with codeine, which is a heavily-regulated mild narcotic.

Although she was a bit dramatic and rubbed the doctor and me slightly the wrong way, her story seemed credible. The doctor prescribed her the codeine and wrote a note excusing her from work.

An hour later, I took my lunch break and walked to a restaurant a few blocks away. There, I spotted the patient (without her seeing me). She looked like a new person, ambling about in no apparent distress.

Long before I started my medical school applications, I knew that as an aspiring physician I would encounter lots of drug seekers. I did not expect the extent to which they would dim my view of humanity. No one likes feeling that they've been had. Drug seekers undermine the doctor-patient relationship, and they make doctors less likely to prescribe pain medication to those who truly need them.

Harrison's Ch. 148: "Pertussis and Other Bordetella Infections"

While I read the 397 chapters of Harrison's Principles of Internal Medicine, I am writing reflections.

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From Chapter 148:

Pertussis is an acute infection of the respiratory tract caused by Bordetella pertussis. The name pertussis means "violent cough," which aptly describes the most consistent and prominent feature of the illness. The inspiratory sound made at the end of an episode of paroxysmal coughing gives rise to the common name for the illness, "whooping cough."...The Chinese name for pertussis is "the 100-day cough," which accurately describes the clinical course of the illness.

In two weeks, I examined two patients who I was rather certain had pertussis. They had recently begun having coughing fits lasting several minutes. Their lungs sounded clear, and neither was feverish. The fits were so severe that it kept them up at night, and sometimes the force of the coughing fits made them vomit. This last feature, known as post-tussive emesis (literally, vomiting after coughing), is a trademark of pertussis. Whooping cough wasn't a perfect fit--both patients had been vaccinated against pertussis, and neither could recall being exposed to someone with the illness. But nothing else seemed to fit very well, either

We obtained a nasal swab from both patients and sent it to the lab. Both times, the test came back negative! This was quite aggravating. Did I go wrong somewhere?

It's important to note that no test is perfect. This particular test for pertussis has a 90% sensitivity, meaning that only 90% patients with pertussis would have a positive result. Still, this means that the likelihood of two patients having pertussis both getting negative test results is only 1%.

Maybe the specimens weren't collected properly? I reviewed the CDC's guidelines. I hadn't left the swab in one patient's nose for as long as recommended. The swabs weren't refrigerated during transport, which could have potentially caused problems. But even these potential missteps don't seem like they would change the tests' outcome by much.

So was it pertussis? Was it another disease that I didn't think of? Were my textbooks wrong?

These are not just philosophical questions. When a patient has pertussis, not only are they given heavy-duty antibiotics, but so is everyone living in their household. The antibiotics have side effects and can breed resistance. Proper treatment here requires knowing the probability that a patient has the disease.

Medicine is full of ambiguities. I don't know what my patients had, and therefore, I don't know whether the treatment helped them or made things worse. In most cases, I have to learn to be OK with that.

What's in a name?

Such a variety of diseases bring patients in to see their doctor that I find it quite significant when I see two patients with the same disease. Recently, I've seen two patients with inflammation of the eyelids, or blepharitis. What makes blepharitis so fun is not just its zany name but the zany names used to further describe it.

Blepharitis can manifest as an infection of the glands of Moll or the glands of Zeis, which are the sebaceous (oil-secreting) glands located at the margin of the eyelid. Such an infection is called a stye, or hordeolum. Blepharitis can also lead to the formation of a cyst in the eyelid, known as a chalazion. The reason is chronic inflammation of the meibomian gland.

These words seem more appropriate in a Dr. Seuss book than in a medical textbook. Then again, now that Dartmouth's medical school is named after Dr. Seuss, the two might no longer be so distinct.