Fall

The outpatient pediatrics clinic where I was spending the day had fancy electrified exam tables that could be raised and lowered using a foot pedal. Although I was supposed to be seeing patients on my own, the doctor I was paired with would only let me observe her. She would be the one asking the questions and examining the patients.

The doctor finished examining a 4-year-old girl while I watched. The child was perched on the exam table, which was about 4 feet off the ground. The child and parent were to wait where they were until the medical assistant came in to administer the child's flu vaccination. I walked over to the foot pedal and began lowering the table, because I was worried the child might fall. The doctor motioned for me to stop. "You know," she said, "the child still needs to get her vaccinations." I wanted to argue. The assistant might not arrive for 20 minutes. And when the assistant did arrive, it would take her seconds to raise the table back up. But in working with this doctor, it had become clear that she did not want my input. I simply stepped away from the pedal and then followed her out the door.

_____

An hour later, I watched the doctor finish examining an infant, an active crawler who was perched on the high-up exam table. Again, the patient and her parent were to remain where they were until the medical assistant arrived to administer the infant's vaccinations. This time, I didn't bother making a move for the foot pedal.

_____

Ten minutes later, while in with another patient, the doctor and I heard a loud CLUNK that seemed to shake the walls of the clinic. There was a piercing wail and some panicked yelling. I headed to the room holding the infant, because I instantly knew what had happened. When I later examined the inconsolable infant, a bump on the scalp indicated to me that she had landed on her head. The exam table was about 40 inches off of the hard ground. The patient's parent was quietly sobbing.

_____

At a well-child visit, this infant had suffered a potentially life-threatening injury. It was an injury that I had foreseen but had been forbidden from preventing.

Snapshot

I examine a patient who I had rounded on earlier that day. Visiting patients in the afternoon is enjoyable. Unlike in the early morning, patients are awake and eager to chat. They also appreciate having someone check in on them. I ask my patient about her plans when she gets discharged from the hospital. She is going to be starting nursing school. What made her decide to become a nurse was her serious illness, which has made her spend considerable time in the hospital. After a pleasant conversation about her future, I walk to the elevator bay to head to a different floor.

Within moments of pressing the down button, an elevator arrives. Only once I've stepped into the elevator do I realize that it has other occupants. A man and a woman, both wearing black, are enmeshed in a tight embrace. The woman is sobbing. The man's head hangs downwards. They are immobile, never acknowledging me or so much as glancing in my direction. The somber mood makes me feel self-conscious about the whimsical children's tie that I'm wearing for my pediatrics rotation. I stand at the opposite corner, staring ahead at the doors and trying to give them their space. After some seconds that feel interminable, my floor arrives and I hop off. The couple remains frozen in place. The woman's sobs echo through the hallway until the elevator door closes.

I had wandered from the story of the future nurse into the story of this couple, who had just been visited by some unknown tragedy. It's as though I had just walked into the girls' bathroom by mistake. I did not belong there. Their narrative was not one that I was meant to inhabit.

Gone mommy gone

A quick physical examination of the infant had revealed what the untrained observer could not have perceived: this one-year-old had a time bomb within, ticking at 120 beats per minute. A severe heart defect present since birth had gone unrecognized. The associated heart murmur was so loud that it could even be heard along the patient's back. Her heart was having to work so hard that her chest was visibly heaving. Her heart was beginning to fail. The infant had been brought to the ER for an unrelated complaint. That problem turned out to be minor, but she was quickly admitted to the hospital for a proper cardiac workup.

Why hadn't the heart problem been diagnosed earlier? One possibility was that the baby's physician had missed it (if so, the doctor should be investigated by the state medical board). Another possibility was that the infant had never been seen by a doctor. We quickly discovered that it was the latter, and untangled a story of striking child neglect. The state assumed custody of our patient and her parents were forbidden from entering the pediatrics ward. The infant would remain on my panel of patients until the state figured out her next move.

When I rounded on the patient in the early morning, she was lying sideways in her crib, had kicked off all of her blankets, and was sprawled out on her stomach, asleep. I lowered the crib railing and roused her. With some effort, I managed to roll her onto her back so that I could perform my physical examination. Each time I placed my stethoscope on her chest or tried to palpate a peripheral pulse, she pushed my hand away with remarkable force. She eventually gave up, grabbed her bottle of juice, and put it in her mouth. After feeding for a long time, she nodded back off to sleep, still with the bottle in her mouth. Wait a minute, I thought. Infants shouldn't go to sleep with bottles in their mouths, right? It will rot their baby teeth. She could even aspirate the liquid.

I tugged on the bottle. The infant woke up and groggily pulled with all of her might. I relented and waited for her to fall asleep. Then I delicately tried prying the bottle yet again from her clutches. Still no luck. I considered trying more forcefully, but decided not to bother. This infant had had an incredibly rough day. She deserved some comfortable sleep.

I tucked the infant back into her blankets. By the time I had raised the railing of her crib, she had already kicked the blankets off. Although I knew I only had a few minutes to round on my other patients, I spent some moments peering down at the sleeping infant, my chin resting on the crib railing. She looked innocent, even with that bottle resting in her pursed lips in an act of stubborn defiance. This child no longer has parents, I mused. For the time being, my colleagues and I are the closest thing.

I'll catch you if you fall

My resident and I braced ourselves for the meeting ahead. It was not going to go well. The patient had been informed that he would be involuntarily committed to a mental hospital because we believed he was a danger to himself. The patient was quite upset and had angrily demanded a meeting. Now it was time to meet with the patient as well as his family to explain what was going on. Most of the hospital staff had already gone home.

My resident asked me to jot off a quick message to the attending physician, letting him know what was up. I sent a quick text message to the doctor's pager. We hurried to the patient's room.

After a lengthy, impassioned back-and-forth, things were not going where we wanted. The family and the patient fiercely disagreed with our plan, and they were becoming irritated. I scurried down the hallway towards the page phone so I could notify our attending.

When I got to the phone, I spotted my attending sitting comfortably at a computer in the distance. He was typing up patient notes. What a relief! I went over to him. "Just who I wanted to see!" I said. I brought the attending up to speed and directed him to the patient's room. The attending took over and did a fantastic job of calming down the situation.

What was our attending physician doing in that particular hallway of the hospital, of all places? After receiving my page, he had come up to our floor without telling us. I think it was intentional that he had positioned himself out of the way, where we couldn't see him.

He had trusted us to handle the meeting on our own, but was ready to help at the drop of a hat if we needed it. It was perfect.

Class act

At a small group session with some classmates on my rotation, we began with a "check-in" where we discuss how we're doing. I said that I was getting sick and feeling out of energy. I came home to find a bag on my porch filled with flowers, several varieties of tea, and a very nice note. Another classmate sent me a message offering to help however she could. These acts of kindness put a huge smile on my face. It's the happiest I've felt since I started my rotation. I feel good about people, about humanity as a whole.

I don't think I deserve such nice classmates. But I feel blessed to have them. Hopefully I can repay the favor.

DSM

If someone looks euphoric, can we say they are having a manic episode?

To practice psychiatry, one must become intimately familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM). This tome lays out the diagnostic criteria for various mental illnesses. It's helpful because it ensures that clinicians are speaking the same language with each other. For someone to be classified as having a manic episode, they have to exhibit a certain number of particular symptoms, such as decreased need for sleep, racing thoughts, or grandiosity. The diagnostic criteria also specify that the symptoms must last for a certain amount of time and in the absence of other potential causes such as drug intoxication.

For many years, the DSM-IV has been the bible of the field of mental health. After fierce debate and negotiations, a new edition came out earlier this year: DSM-5. On the whole, the changes strike me as improvements. For example, there now is a single entity, Autism Spectrum Disorder, that replaces the confusing and seemingly artifical amalgam of five autism-like diseases found in DSM-IV. Under the old criteria for anorexia nervosa, pubescent girls had to have problems with menstruation. This criterion did not seem useful and has been dropped in the newest DSM.

When we were taught psychiatry during our pre-clinical years, we were taught the DSM-IV. But during my clinical rotations now, my attending physicians request that we use DSM-5 criteria. I think this is good. Academic institutions rightfully pride themselves on abiding by best practices.

At the end of my psychiatry rotation, we have to take a national exam that substantially impacts our grade. This exam uses DSM-IV. Part of the reason (I presume) is that it takes years to write new test questions and test them for validity.

What results is an odd and sometimes frustrating contradiction. During the day, I get grilled on the new DSM-5 criteria. But at night when I study, I have to learn the minutae of the DSM-IV, carefully mulling over details that no longer matter.

Testing, testing

Our school makes us complete online educational modules to reduce their liability in the event that we get hurt on the job. We have to watch mind-numbing videos and then answer vapid quiz questions. Our latest module, on bloodborne pathogens, made me answer this gem:

Which of the following practices will prevent the transmission of HIV, hepatitis B virus, and hepatitis C virus?

A. unprotected sexual contact with multiple partners
B. individuals positive for hepatitis B, hepatitis C, or HIV donating blood
C. not sharing personal care items with blood on them, like razors or toothbrushes
D. sharing needles or syringes

My prior post on the mindless busywork we have to endure as medical students.

Falling on my sword

Before team rounds, I went over the patient list with my resident. One patient was still sick and was not improving. "Bummer," I said, "I guess we're going to have to keep Patient X for a few more days."

"No," the resident replied. "He's to be discharged today or tomorrow."

"You really think so? He looks pretty bad."

"Yes."

"So what's my argument to the team? He's not going to improve any further, so there's not any reason for further hospitalization?"

"Yes."

My cheeks felt flushed. This patient was not ready to go home. This was going to be a disaster. But we are often told that our job as medical student is, above all, to make our resident look good. I would get in even more trouble if I contradicted the resident's plan.

During rounds I presented the patient to the team. The clinical findings I recounted couldn't mask the fact that the patient was in bad shape. Then I arrived at the portion where I present my assessment and plan: "My opinion is that the patient is ready for discharge because we cannot expect further improvement from continued hospitalization."

The attending physician (the head of our team) disagreed and started questioning me aggressively. What did I mean the patient wouldn't improve? Had I allowed enough time for the medications take effect? How could I send a patient out who's in such a condition? I didn't want to argue. The attending was right.

I looked pleadingly at my resident. Please help? The resident sat stone-faced and didn't say a word. I was on my own.

I didn't have an answer to the attending's questions. I grimly shook my head. "My mistake," I said. "We'll keep the patient for at least a few days and see how he does."

Time of death

Note: This post describes patients' deaths. It has content that some would find graphic and upsetting. Please use discretion.
 

World leader

The CDC estimates that 8.3% of the U.S. population (all ages) have diabetes.

Surprisingly to me, the diabetes rate in the U.S. is far from the worst in the world. In fact, the International Diabetes Foundation puts the U.S. at 73rd in the world in terms of our diabetes rate.

The worst-off countries are in Oceania. The Marshall Islands, Nauru, and Polynesia are the hardest-hit. The International Diabetes Foundation estimates their diabetes rates among adults as 27.1%, 30.1%, and 37.3%, respectively. These countries' diabetes rates are nightmarish. Their obesity rates are nightmarish too: 71.1% in Nauru, compared to 35.7% in the U.S.

The reasons for this discrepancy are manifold, but a key player is the adoption of a Western diet. Whatever the cause, it's alarming that there is such a health burden around the world of diabetes. Diabetes is a huge health problem here in the U.S., where diabetic patients tend to have access to good treatments and medical care. I can't imagine what it is like for a country to have treble or quadruple our diabetes rate.

Picky canines

The patient needed a refill on his narcotics--in fact, several months' worth, because he was leaving in a few days for a long trip. I pointed out that, per our records, his last prescription had been filled recently. The patient's adult son, who cohabitates with his father, chimed in. "The pills get mailed to us," he said, "and they keep getting stolen right out of our mailbox. Big problem in our neighborhood. I have to take Norco for my elbow, and the damn thieves take my pain pills, too."

I relayed the story to the doctor, pointing out that it contained numerous red flags. The doctor mused that his patients use the same excuses to explain they need an early refill on their narcotics. Stolen from the mailbox is a favorite. Another classic is that the dog ate the bottle.

"Tell me, [Reflex Hammer]," he said, "how many times has a patient told you that they need a refill on their blood pressure medication, because the dog ate it?" He paused. "It's remarkable how dogs have such discriminating taste in pills."

Health stat of the day

According to the latest American Cancer Society estimates, lung cancer kills more Americans each year than breast cancer, prostate cancer, colon cancer, rectal cancer, and pancreatic cancer combined.

Cigarette smoking causes 90% of lung cancers. Is it trite to reiterate that smoking kills?

Unplanned and unwanted

A patient who is younger than me agrees to take a pregnancy test. It is positive. She sobs.

"Until now, I've always been fiercely anti-abortion," she says. "But, there's no way I'm going to keep this baby..."

Hoarders

"When you go to the bathroom and use some toilet paper, do you dispose of it?"

The patient hesitated. "That's a good question," she said. More seconds ticked by, still with no answer to my query.

The patient was a compulsive hoarder. By her admission, her house had become virtually unlivable. She couldn't even find her medications or her telephone, because they were completely buried in an ever-accumulating pile of junk. She came to our clinic desperate for help. She couldn't bring herself to throw anything away. She had spent what little money she had on hiring a professional crew, but when they arrived she refused to let them throw away any of her belongings. She was stuck. Repeated fines from the city for keeping her yard in disarray were adding up.

We did what we could: we gave her encouragement, we crafted strategies of how she could begin to tackle the problem, and we referred her to a psychiatrist (she had already been referred multiple times in the past). We even talked about different TV shows about hoarding and tried motivating her to watch an episode. We probably accomplished nothing. She might not even schedule her appointment with the psychiatrist, because she can't locate her telephone.

Some patients' problems are way beyond our powers. Practicing medicine is sometimes an exercise in helplessness.

Context

To a mother, it means something is wrong.

To a passenger boarding an airplane, it means that the next few hours will be that much more unpleasant.

But to my team of anesthesiologists and surgeons packed into the operating room, hearing the crying of an infant was music to our ears. It meant that the little guy we had operated on had woken up from anesthesia and was doing all right.

Context is everything.

Drug or Pokémon?

Prescription drugs have ludicrous names.

Pokémon is a Japanese TV show/video game/card game featuring cartoon characters with ludicrous names.

Distinguishing between the names of drugs and the names of Pokémon characters? Devilishly hard, even as a third-year medical student.

Patients are people

During first year, I was assigned to spend a few half-days with a preceptor who was a family medicine doctor. He was fantastic at connecting with his patients, and his patients clearly adored him in return.

The first time I met with the preceptor, I asked him how often he sees acute presentations of disease, as opposed to seeing chronic conditions. He looked dismayed.

"I don't see conditions and diseases," he said. "I see people."

He pointed at his list of patients for that day. "Look at Mr. Oikos here. He worked as a pharmacist in his native country but retired to the United States to live closer to his family. They don't visit him very often anymore." He pointed out another name on his schedule. "Mrs. Lennison runs the restaurant at the local golf course and enjoys spending time in her garden. She feels that her relationship with her older daughter is becoming strained. Mr. Waters here is an electrician who just retired and is trying to figure out what to do with his free time. These people are my friends. I care about them.

"I hate that the electronic medical record shows the patients' 'complaints' when I see the list of the day's patients. Yes, some of them are sick, but some of them are just coming to see me. Maybe they're lonely, they're scared, or they just want to talk to someone who understands them. Take Mr. Oikos. He has had terrible pain all over his body for years. He comes here every two months, and each time, I examine him and then offer him medication for his pain, because I have no other way to treat it. But each time he refuses. And he's a pharmacist, so he knows all about the medications I'm offering him.

"Why does he keep coming back, even though I have nothing new to offer him? Because he feels comforted by talking to me, by having someone examine him, by knowing that someone cares about him.

"My patients are not diseases, they are people. You must remember that."

_____ 

Whenever possible, I look to research a patient's chart before I see them. In clinic this year, I saw a patient without having looked at their chart beforehand. He had crashed his car at high-speed, hitting his head. As a result, he had no memory of the crash.

It was my job to sort out what had gone on, and whether it constituted a medical problem that needed treatment. Was this a seizure? A cardiac problem? Perhaps the patient fell asleep at the wheel, or perhaps was distracted and not paying attention?

After taking a brief history and a physical exam, I wasn't very confident in a diagnosis. I immediately found my preceptor and presented my differential: the either patient fell asleep at the wheel, had been distracted, or had lost consciousness. I was leaning towards being distracted.

The preceptor asked me if anything else could have been going on. I couldn't think of much (maybe the patient intentionally crashed their car so they could collect on insurance?). My answers evidently disappointed him.

We went in to see the patient together, and he pulled up the patient's chart. It showed that the patient was taking high doses of a number of narcotics. While he was driving, he was probably so zonked out on narcotics that he wasn't able to pay sufficient attention to the car ahead of him. I had missed two chances to pick up on this fact: first, when looking through the chart, and second, when taking my history from the patient. It was sloppy of me, and it made me miss the diagnosis.

Afterwards, the doctor sat me down in his office. "You're quite good at the technical parts of medicine," he told me. "You're quick and efficient, and you're good at working up whatever problem they've come in for. But you need to be addressing their broader needs. Spend more time getting to know the patient. You need to look through their chart and ask them open-ended questions. Find out who they are and how they're doing.

"These patients aren't just medical problems, they're people. And if you get to know them as people, you'll be better at treating their medical problems."

_____

Years apart, given by different doctors in different contexts, came the same pointed reminder: Patients are people.

In the pre-clinical years of medical school, there is so much book work and studying that it's easy to ignore this fact. This is the beauty of our clinical rotations. It fleshes out the rest of our education, and reminds us what we are here for as doctors.

Surgical exploration

Note: This post describes a surgery. It has content that some would find graphic. Please use discretion.

A new era

A young woman came into clinic because of a rash. Thumbing through her chart, I noticed that another doctor had referred her to a cancer center for genetic testing. As it turned out, the patient's father had recently been diagnosed with breast cancer, which is rare in men. Some men with breast cancer have the BRCA2 mutation, a rare genetic mutation that can be passed on to children. Those who inherit the BRCA2 gene are at significantly higher risk of developing certain cancers, particularly breast cancer.

I asked the patient if her father had been tested for the BRCA2 mutation. She replied that her father had indeed been tested, and it showed that he didn't have the mutation.

I gently pointed out to the patient that since the BRCA2 mutation is inherited, and since her father didn't have the BRCA2 mutation, she couldn't have inherited the BRCA2 mutation from her father. But the patient was steadfast. She and her siblings were all planning to get the genetic test regardless (their health insurance was paying). I moved on.

The doctor who serves as my preceptor later pointed out to me that the BRCA2 test costs over $3000 per person. Thousands of dollars were about to go down the drain. And no one besides my preceptor and me cared.

_____

A couple of hours after examining the young woman, I climbed into my preceptor's car and we drove through the countryside to a patient's home. The patient was not old. He was dying of metastatic cancer and was on hospice. We said hello to the patient, and the doctor performed a brief exam. Then the family invited us into their living room. As soon as I plunked down on the sofa, the family dog hopped up next to me, begging to be petted. No one had been paying much attention to her these past few weeks.

I scratched the dog's belly while the doctor offered the family his support, adjusted the patient's pain medication, and helped the family plan for what lay ahead. The patient's wife cried while she told us how difficult these past few weeks had been, how shockingly quickly the disease was overtaking her husband. She could not bear to leave the house for more than an hour for fear of being away from her husband's side when he finally succumbed. We reassured her that she was taking good care of him and urged her to make some time for herself. When it came time to leave, the family was incredibly grateful. "I didn't realize doctors made house calls anymore," they said.

Although the doctor would like to do more house calls, he can only volunteer so much of his time. Our home visit wasn't compensated at all. Even the cost of gasoline came straight out of my preceptor's pocket.

What if we canceled our patient's worthless BRCA2 test, and instead spent the $3000 on paying for house calls? My preceptor could probably visit 30 more dying patients at their homes.

_____

Within the span of a few hours, I witnessed both medicine's past and medicine's future. The era of the house call has given way to the era of genomic sequencing. Which of them offers people more healing? And which of them have we decided to pay for?

DUI

Paramedics brought a patient into the ER who was involved in a motor vehicle collision. She claims she saw an object in the roadway and swerved to avoid it. After rolling an unknown number of times, her car came to rest upside-down. Because she was wearing a seat-belt, she was in pretty good shape when she came in.

Part of the initial panel of labwork for trauma patients is a blood alcohol level. This patient's came back as 0.14: way over the legal limit. I was surprised, because she didn't seem very intoxicated. This suggested something even more worrisome: that she consumed large amounts of alcohol regularly. Given her apparent willingness to drive under the influence, she was a lethal threat to herself and others. Drunk drivers kill.

I asked the patient if she had had anything to drink that day. She said that she had consumed only one drink that day, in the morning. I gently prodded her to see if she would fess up, but she stuck to her guns.

I don't think this patient should be allowed to drive until she gets help. But I was powerless to do anything. Patient confidentiality prevented me from reporting her blood alcohol level to the police. The best I could have done would have been to convince one of the doctors to formally diagnose the patient with alcohol dependency. Then the doctor could notify our state's department of motor vehicles that the patient had a diagnosed disease that threatened her ability to drive. But it's doubtful that the DMV would have done anything. And I don't think I could have convinced any doctors to do it.

Part of patient confidentiality is that we hold people's secrets. But some of these secrets are awful burdens. I wish they could see daylight.

Surgery, the video game

The anesthetized patient on the operating room table had several giant kidney stones that needed urgent removal. The solution was "laser lithotripsy." We threaded an endoscope (thin camera) through his ureter until we could see the stone on a TV screen. Then we threaded a fiber-optic laser into the camera apparatus until it was touching the stone. The surgeon pressed a button that activated the laser for a fraction of a second. Its energy shattered the stone. Then we used a wire basket to retrieve the shards of stone and place them in the bladder, where the patient would have no problem passing them. We repeated this process for about half an hour, until the stones had been fully removed.

Watching the surgery felt like watching a video game, with a first-person shooter element (aiming the laser at the stone and zapping it) plus a tricky kind of arcade game in trapping the stone in the wire basket. With a few modifications, the main portion of this surgery probably could be done remotely from a computer on the other side of the world.

While the lithotripsy portion of the surgery required immense skill, it didn't require that the surgeon know much of anything about medicine. I think that with sufficient practice, a middle-school student could have performed the surgery quite capably.

I also observed ESWL (extracorporeal shock wave lithotripsy) procedures. In these procedures, a device produced loud shock waves that fractured kidney stones. No cutting was needed. Although a urologist was present for brief portions of the procedure, most of it was performed by an expert technician. The urologist was barely needed at all.

I think what I witnessed is a harbinger of the future. I imagine that quite soon, some surgeons will routinely operate on patients who are thousands of miles away. And I imagine that the trend of non-surgeons performing portions of some surgeries will accelerate. What this means for patients, I know not.

Note-unworthy

A patient was determined to be brain-dead, meaning her brain had no activity. By law, the patient was now dead. The family decided to have her organs to be harvested for transplantation. An anesthesiologist was called in to evaluate the patient ahead of the organ harvesting.

I found this line in the anesthesiologist's write-up of that evaluation:

Risks and benefits of General and Regional Anesthesia discussed with patient.  Questions answered and patient wishes to proceed.

A brain-dead patient who talks? I'm sure.

There are major problems with the switch to electronic medical records. Because of onerous and shortsighted regulations by the government and private insurers, our notes have to be chock-full of useless documentation. Time constraints necessitate us to use pre-fabricated computer templates that automatically fill out lengthy portions of our notes. The doctor is supposed to go back and change the portions of the computer-generated note that are untrue or do not apply.

In reality, the notes are rarely checked carefully enough, and crazy things routinely slip into the notes (like brain-dead organ harvesting patients who ask questions about the anesthesia, or pediatric patients who are 133 years old). The notes also become so lengthy and unwieldy that they are difficult to read. After all, they are written more by computer than by man.

In attempting to document everything, we end up documenting nothing, because our clinical notes are becoming worthless. Thanks to the increasingly bureaucratic nature of medical practice, the accurate and thoughtful medical record is becoming a thing of the past.

Death and disease

Note: This post describes a patient's death. It has content that many would find graphic and upsetting. Please use discretion.

Gunshots

A young patient came into the trauma bay with part of her face blown off. Someone had shot her point blank with a high-velocity round from an assault rifle.

It was horrifying inspecting the damage one human being was willing to inflict upon another. But seeing the evisceration of the delicate anatomical structures in this patient's face furthermore felt like a personal affront. As I've come to know the human body, I've come to appreciate it as a elegant, beautiful specimen. Examining this patient was like beholding a Monet painting that someone had torn off the wall of a museum and then smashed a hole into with their knee.

Gunshot wounds are more than just murderous. They are profane.

Non-judgmental regard

When I first met the patient, two armed corrections officers with serious expressions were standing at his bedside. I wondered why he was in jail. I'm sure the other members of my medical team were curious as well. But we all knew that it would be highly unprofessional for us to ask. After all, what he stood accused of should have had no bearing on how we treated him. This attitude exemplified "non-judgmental regard," a precept of medical practice that I've been grappling with for years.

From a post of mine in August 2011:

...[I find] the most extraordinary and difficult tenet of modern medical ethics [to be] "non-judgmental regard." Physicians are supposed to take patients exactly as they are, without judging or discriminating. In principle, then, the armed robber and the man he injured, in neighboring beds in the ER, are provided the same degree of care. The morbidly obese smoker with a heart attack should be treated with the same earnestness as the thin one. Judgments of worth or character are independent of treatment...

Because I've decided to become a medical student, I have to make medicine's ethical precepts my own. But I have a difficult time with shedding judgment. I don't treat people equally in my own life. I have friends, acquaintances, and enemies, and I care about some of them more than others. In clinic, some patients' stories touch me more than others'. One patient had developed a crippling Parkinsonian tremor, probably secondary to his addiction to meth that he had tried and failed to kick. His circumstances were wrenching and I especially wanted to help this man. My next patient, a woman with conjunctivitis who lambasted me for fumbling at first with the blood pressure cuff, was less inspiring. Some patients are especially kind to me in a way that I particularly want to reciprocate... 

I couldn't shake my curiosity about the patient, and ultimately did discover why he was in jail. He was a convicted murderer.

My professional ethics dictated that this revelation shouldn't matter to me. But I felt conflicted. After all, whenever someone is assigned to me or my team as a patient, I care about them. I smile at them when I see them. I stop by their room, sometimes several times a day, to say hello and to see how they're doing, to see how I might help. And I sincerely want to see them become healed. But, for a murderer? On a rotation so busy that I felt I was neglecting my friends and family, could I justify lavishing this kind of endearment upon a murderer?

I reflected on the ideals of our legal system, which stipulates that every person deserves legal representation. I reflected on the ideals of our penal system, which hopes to reform prisoners into moral and functioning members of society. I also reflected on the ideals of religion, which strives to improve all men's souls. Should medicine, the art of healing, be any less noble and discriminate among who it cares for?

What has kept me going throughout medical school, and what compels me to set my alarm for 4 AM some days, is an idea. It's a belief that medicine is a worthy calling, a profession that can improve others and improve myself. This medical profession behooves me to care for even the most depraved among us, no matter how vexing that might feel. We must respond to hate with love. We must strive to relieve suffering and to do no harm.

If you do read my full post from 2011, you'll see how ambivalent I was about treating all patients the same. My thoughts have since shifted. I more firmly believe now that non-judgmental regard is an aspiration worth pursuing.

Gunshots

In the wee hours of the morning, the emergency department intercom came to life, crackling that a patient with serious trauma would be arriving within minutes. A dozen of us rushed over to the trauma bay and started suiting up in gowns and face shields. Someone said that the victim had suffered multiple gunshot wounds. We ran around grabbing equipment: blood, an ultrasound machine, chest tubes. I went to the ambulance bay and spotted the patient's stretcher being wheeled in. "The patient arrived!" I shouted.

"Patient's here!" they echoed.

The patient loud yelling was muffled by his oxygen mask. That he was screaming was actually a good sign, because it meant that his airway was intact and that he was breathing. The doctors set to work, placing IVs, hooking the patient up to "the monitor" (the machine that displays vital signs), checking for gunshot exit and entry sites, palpating pulses. One doctor yelled that the patient's breath sounds were muffled on one side, a sign that the patient had hemothorax (blood accumulating in the chest). Another doctor got out a scalpel and, making a deep incision, jammed in a plastic tube to drain the blood. This made the patient scream, but he seemed to be drifting off. Another doctor injected anesthetics that paralyzed the patient and put him to sleep, while another intubated the patient and hooked him up to a ventilator. Standing at my out-of-the-way perch at the end of the bed, I checked the patient's feet. They were cold and clammy. This confirmed what we already knew: that the patient was in shock, probably due to internal bleeding. The doctor checking for gunshot wounds kept finding more and more, over ten by now in the patient's abdomen, chest, and extremities. One doctor yelled that he had a large hematoma (pool of blood) in one of his arms and no pulse in that hand. Bad news. A bullet must have severed the main artery to the arm. Two doctors using the ultrasound machine pointed excitedly at the screen. "Free blood in Morison's pouch," one yelled. "We have a positive FAST exam!" This meant that the patient was bleeding heavily into his abdomen. He'd have to go the operating room right away.

The X-ray crew cleared the room so that they could obtain an image. Taking advantage of the pause in the action, I threw out my bloodied gown and gloves, ditched my white coat, and put on my operating room attire. Then I guided the patient's hospital stretcher into the giant elevator that would whisk us up to the operating suites.

In stark contrast to the din of the past few minutes, the elevator ride was quiet. There were only three of us in the elevator, each of us stock-still, deep in his own thoughts. I gazed at the patient's vacant face and realized I didn't even know his name. "Who are you?" I wondered. "Who did this to you?" Was it a drug dealer? The police? An ex-girlfriend? I invented version after version of this man's story. With each iteration, I asked myself, couldn't this scenario have been avoided, through forward-thinking laws, more schooling, better funding for social services? Why are we so cruel to each other, why must guns even exist? This anonymous young man, blood oozing from his side and a machine breathing for him, seemed to indict our society's ills. There had to have been some opportunity we missed to prevent his being pumped with so many slugs of lead. And now, at an ungodly hour when we should all be asleep, dozens of us were working furiously on this man's behalf. Why was it only now, when he was already in the clutches of death, that we were sparing this man no expense?

The chime of the elevator interrupted my ruminations. As the doors opened onto the sterile halls of the operating suites, I steeled myself for the grim hours in the operating room that laid ahead.

I blame names

Try your hand at a question from one of our anatomy exams: What nerve supplies the obturator internus muscle (a muscle in the pelvis)? The correct answer is the "nerve to obturator internus." It's like answering who is buried in Grant's Tomb.

As a time-strapped medical student, it feels like a godsend when a medical term is named in an obvious way. Even a lay person can intuit the meaning of medical terms like "urinary tract infection," "vocal cord paralysis," and "foot drop." Unfortunately, the meanings of medical terms are rarely so obvious.

Sometimes I can decipher the meaning of a medical term by looking at its Latin or Greek roots. "Nephrectomy", the surgical removal of a kidney, is a combination of "nephro-", from the Greek root for "kidney", and "-ectomy", from the Greek root for surgical excision. By knowing roots like these, I can decipher the meaning of a new term. Thus, a ureterectomy is the surgical removal of a ureter. A nephroureterectomy is the surgical removal of a kidney and a ureter. An appendectomy is the surgical removal of the appendix. Similarly, I can tell from its name that the supraclavicular artery runs above the clavicle, and that the ovarian artery supplies the ovary. It's fantastic.

But even this approach can run me into trouble. In 1806, a dermatologist named a particular skin disease "mycosis fungoides", from the roots for "mushroom" and "fungus", because it looks like a fungal infection. We now know that it is a type of lymphoma, with nothing to do with fungus or infection. But the name has stuck. Similar examples abound.

Often a medical term has no connection its meaning. Sometimes this is because the disease is named after its discoverer. Berger's disease affects the kidney, whereas Buerger's disease affects the small arteries of smokers.

The worst offenders are when medical terms are simply numbered in the order of their discovery. Our white blood cells have a category of proteins on their surface called "cluster of differentiation". The various proteins have been numbered from CD1 up to CD350. For some CD proteins, we need to have memorized which subcategories of cell types express them: for example,

CD3: T-cell;
CD4: Helper T-cell (depleted in AIDS);
CD8: Killer T-cell;
CD15: Reed-Sternberg cell (seen in certain leukemias);
CD30: Reed-Sternberg cell;
CD56: Natural killer cell;

and so on.

Exams like our national boards are chock-full of questions that test whether you realize that "lupus anticoagulant" is erroneously named, or that IL5 stimulates allergic reactions while IL10 tamps them down. Memorizing all of this takes a lot of time.

I maintain that time spent memorizing these silly names is time not spent learning other things, like how to heal patients. Medical nomenclature is needlessly complex. We should try to make our names for things easier to decipher.

Schedule change

Most nights my eyes snap awake around 4:30 AM. I look over at my clock and realize that there's no point in going to back to sleep, because my alarm will be going off in a half-hour or so. I rush over to my computer so that I can use these precious extra minutes to read up on the day's surgical cases. I need to study the procedures and the patients' case histories so that I can give an intelligent response when the surgeons quiz (or as the profession calls it, "pimp") me in the operating room.

I'm grateful to my body for (largely uncomplainingly) accommodating the demands of the surgery rotation: the long hours standing in the operating room, the waking up early and going to bed late, the postponing meals. I haven't had to leave a surgery partway through to use the bathroom, I haven't fallen asleep during a procedure, and I haven't felt like I was going to pass out in the operating room. I've kept my cool during tense and frustrating moments. But each of these little victories has been hard-fought, requiring planning, vigilance, and conscious acts of will. I understand now how invigorating it is to be in the operating room, and I've felt very alive those times a surgeon has had me suture an incision or electrocauterize some tissue.  But the longer I spend on my surgery rotation, the less I comprehend how surgeons and surgical residents are able to keep it up for so many years.

Non-standard operating procedure

It is my surgery rotation. My team consists of a number of surgery residents and myself. Until today, I had been spending the rotation observing my team's residents in clinic, on the wards, and in the operating room.

At our academic hospital, when a surgeon (an attending physician) operates, they are expected to have an assistant (typically a surgery resident). My team made a last-minute request to have a procedure added to the day's operating room schedule. By the time the operating room coordinators granted the request, everyone on my team was tied up, except me. Who would assist? The surgeon asked me to change into scrubs and meet her at the operating room.

I was beaming as I raced to the cafeteria to cram in some food (one should not operate on an empty stomach) and then scampered up the stairs to the operating suites.

Few medical students ever have the chance to serve as "first assist." This procedure was a good one for me because it was relatively brief and low-risk. I threaded catheters and stents through the patient's body, tasks that involved a fair amount of dexterity. I also inserted tubing that drained the patient's bladder, and mixed and injected medications. The surgeon and I had to communicate well, because our tasks involved complicated steps and movements that we needed to perform simultaneously. She also had to trust me, because my hands often were out of her field of view.

The procedure ended, and the patient was moved off the operating table. I thanked the surgeon for letting me join her and she congratulated me on a job well done. She said that the next time we did the procedure, I would be the primary surgeon and she would assist. I don't think she was joking.

The comfort of the dying

Doctors are expect to comfort the dying. Sometimes, the dying comfort the doctors.

The attending physician introduced me to one of his patients. While standing at the patient's bedside, and with the patient listening, the doctor recounted "this unfortunate patient's" case history. The patient had hemophilia, meaning his blood didn't clot properly on its own. During childhood, the patient had contracted Hepatitis C from contaminated blood transfusions (with today's screening methods, the risk of this occurring is remote). Now the patient had incurable and widely metastatic liver cancer, probably because of his Hepatitis C infection. Although his body was ravaged and wasted, his mind remained perfectly intact. The patient had spent most of the preceding years in and out of the hospital.

The doctor performed a physical exam and made sure that the patient's pain was well-controlled. The doctor then informed the patient that it was his last day on duty before he took off for a week. The patient smiled, and while looking us both in the eye, he thanked us and told us that he truly appreciated the excellent care that he had received at our hospital. We shook hands and left.

Medicine could no longer help this patient avoid death, and part of me felt like my profession had failed him. But the patient was not upset with us. He even mustered up the effort to thank us for our care. His words had conviction and purity, and we received them with particular solemnity and reverence. It was one of the most heartwarming moments I've experienced as a medical student. The words of a dying man mean a lot to us.

Patient privacy

I attended a talk by author Salman Rushdie concerning the role of the novelist. He said that the novelist must remember above all that a novel is about individual people. Although people's lives are increasingly affected by abstract influences like political upheaval and globalization, only through the lens of a person's story can the novelist explore these trends and changes.

One of my favorite parts of being around patients is hearing their narratives, and there are many that I would like to recount through my blog. After all, medicine offers rich material for stories. Illness, death, and birth are replete with drama. Our reactions to these dramatic events give a window into our souls. And the story of people's illnesses are inextricably linked to societal influences: the veteran who is dying because of complications from Agent Orange exposure, the illegal immigrant who cannot obtain insurance, the young girl who receives a donated kidney. By exploring the individual stories of patients, we make sense of the human experience and also make sense of society.

The major issue I encounter is that my ethical, professional, and legal obligations disallow me from jeopardizing patient privacy. I sometimes protect patient privacy by altering or fabricating details of their cases, but I hate to do it because I perceive myself a sort of journalist, one who should strive for truthfulness and accuracy. And so, the more unique a patient's story, the more blandly I have to write about it, because I otherwise risk jeopardizing the patient's anonymity and confidentiality. Two of my favorite medical bloggers recounted powerful patient stories, and included details that were critical to the stories but which I thought might be personally identifying. On a hunch, I searched around the internet and determined the patients' names within minutes. This is no good. I want my blog to be so discreet that a patient who read my blog wouldn't think that a story was about them. I further insulate the people I discuss by keeping my identity and location anonymous.

Although I find myself wanting to write about my patients, I instead write about myself, about wider societal issues, and about news stories. I think it makes my blog less compelling, in the way that a history textbook is less compelling than a good novel. Nearly two years into my blog, I'm still experimenting with the medium.

At the threshold

Within days, I begin my third year of medical school. The start of third year marks a shift from the classroom to the hospital wards: I will be responsible for a panel of patients, arriving at their diagnoses and ordering treatments. Of course, I'll be closely supervised and constantly instructed.

I'm a bit uneasy, though, about the transition to third year:

• The grades matter. Our school grades us either fail, pass, or honors on our rotations, although virtually no one fails. Usually no more than a fifth of students doing a rotation will net honors. But you need honors to get into a competitive residency. This means that I will be competing directly against my classmates. Much of our grades is based on our evaluations by our superiors. These evaluations can sometimes be subjective and variable.


• The hours can be long. Students' clinical duties sometimes approach the school's 80-hours-a-week cap. In addition, we will need to devote extensive time to studying for our mandatory exams. There are only 168 hours in a week. If one works for 80 hours a week and sleeps for 8 hours a night, 7 days a week, that leaves only 32 hours for things like studying, driving to and from the hospital, cooking meals, doing laundry, and brushing one's teeth.


• The responsibilities can be emotionally draining. I have yet to witness a birth or a death, but certainly will during third year. Comforting the dying and appeasing the furious are taxing ordeals, especially when there's so little time to relax. Medicine routinely involves life-and-death decisions, and mistakes that harm patients inevitably occur.


• Medical students are at the bottom of the food chain. Although the practices are becoming less common, students are routinely quizzed on their medical knowledge ("pimped") in front of their team and put on mindless or unpleasant tasks ("scutwork"). Because medical students need good evaluations from their superiors, they have little recourse and little incentive to argue.

Although the older medical students I talk to confirm my picture of life as a third-year, most say that enjoyed their third year of medical school more than first year or second year. In particular, they loved that they were finally taking care of real patients.

I hope that by the end of third year I'll have adopted their view.

Halfway

Three of us were walking in the mall when we noticed a woman lying in a heap on the floor of a shop, pressed up against the window. A concerned employee stood over her. I told my companions that I ought to help, and rushed inside.

"I'm a medical student," I said, to the employee's apparent relief. She told me that the woman had been seizing and pointed out that her face was bloody. She added that paramedics were en route. I thanked the employee and asked her if she could kindly get some gloves. Then I knelt down next to the victim, who was still writhing but no longer seizing. She appeared to be breathing but unconscious. I said aloud, "I'm [Reflex Hammer], and I'm a medical student. You're all right. You're in a shopping mall. I'm going to check your pulse now."

Just when I first detected her pulse, the paramedics arrived. I quickly exited the shop so that the professionals could do their job. I rejoined my group and we continued walking.

_____

Not even 24 hours later, I was on a flight where there came an anxious request overhead for "any medical personnel: doctors, nurses, EMTs, anybody" to please hit their call button. I was the only passenger to oblige. A flight attendant rushed over and asked me to come to front of the plane. I was in the window seat, and the passenger in the aisle seat was asleep. The flight attendant woke him and hurried him out of his seat so I could get through. I grabbed a pen and paper from my bag and headed down the aisle. Although anonymous before, I realized that nearly every person on the plane was now looking at me expectantly.

At the front of the plane was a woman lying on the ground in a panic, a discarded oxygen mask lying on her stomach and a man crouched over her helping her. A different flight attendant sneered, "What are you?" 

"A third-year medical student," I replied. She sized me up head-to-toe, and then icily told me to return to my seat and that they'd find me if they needed me. As I walked back, I noticed that even more people than before were staring at me, their eyes searching me for some clue as to what had transpired. I put on my best poker face, hiding how upset I was at being immediately sent away after my help had been so urgently requested.

_____

I am almost exactly halfway towards being a physician. It is an odd, in-between state. Although I usually believe I'm able to help, people don't know whether to trust me to take care of them.

Boards

Today I sat for my Step 1 national boards exam. Every MD student in the country sits for this exam, and as such, residency programs tend to use it as a harsh initial screen to whittle down their applicant pool. Some specialties are considered to be out of reach if a student doesn't score at least a standard deviation above the national mean. Students who pass the test are not allowed to retake it, meaning that one's score is fixed for life. Those that fail typically cannot begin their third year of medical school until they have eked out a passing score.

The test is an 8-hour affair: 7 hour-long blocks of 46 multiple-choice questions, plus an hour for break. Each person's questions are culled at random from a large bank, leaving them at the mercy of the luck of the draw. Some major topics I studied in depth were never asked. And sometimes I received multiple questions about the same obscure medical topic (for example, I was asked five questions about conditions that cause women to have facial hair). I agonized over some questions because several of the answer choices seemed equally reasonable (or equally unreasonable).

A medical student friend warned me that I would emerge from the test feeling like I was hit by a truck. It's true. I still feel like I'm in a daze.

High-stakes standardized testing always struck me as a poor way to go about assessing learning, aptitude, and career potential. And I don't just say this because I'm sour grapes: I do well on standardized tests, even notching a perfect score on my college entrance exams. But these tests are an abomination, with multiple-choice answers that are starved of complexity. When a lot rides on one's standardized test score, it has a corrosive effect on learning and teaching. Learning becomes a game, at the expense of fostering curiosity and original thought. Many medical schools tailor their curricula to the boards exam, and make their course exams entirely multiple-choice to prepare students for the boards format. And so, what once was a means of assessing students' learning now dictates what we learn and how.

It frustrates me that my profession puts so much stock in this one lousy test, taken on a single day.

Arms race

From a July 2000 Reuters dispatch:

Being a successful floor trader at the Chicago Mercantile Exchange is all about standing out from a crowd of competitors in the chaos of the trading floor. All the stops are pulled out: giant-lettered ID tags, top-of-the-lungs shouting, bizarre gesticulations, neon-bright jackets you wouldn't dare wear on the street.

But the arms race now stops at footwear. The exchange said last week that, beginning tomorrow, shoes with soles thicker than two inches would be banned.

It's not women wearing spike heels or those flappy, strappy high-heeled sandals that the exchange most wants to deter: It is men in platform shoes. "I've seen them that big," one broker said, holding his thumb and index finger about 6 inches apart.

Why do traders want so much altitude? To see and be seen from the depths of the terraced trading pits [...]

But twisted ankles and foot injuries on the steps around the pits have been a growing problem that the exchange feels it must address, market participants said.

"They had a ruler out there the other day," another trader said. "I saw them measuring."

---

I saw a few minutes of 500 Days of Summer, Zooey Deschanel's breakout film. For part of the film, she looks different because she is not slathered with her usual amount of make-up. Intrigued, I found a picture of her with no make-up and compared it to her more customary head-shot:

Although she is beautiful either way, her appearance has strikingly changed. It's commendable that Ms. Deschanel was comfortable sitting for a photo shoot with no makeup on. But it does concern me that the public is constantly bombarded with images of people with unnatural features, enhanced through makeup, surgery, or Photoshop. I steered clear of Seventeen and Cosmopolitan magazine in middle school and high school (I'm a guy after all), but now if I see a copy I'll thumb through it so I can see what adolescent patients are reading. What I see scares me. Their photo spreads give an unrealistic perception of beauty and of normalcy, and their articles fixate on the superficial, preying on readers' insecurities.

I fret about physicians' role in perpetuating this societal problem. Sometimes I see newspaper advertisements from plastic surgeons advertising cosmetic enhancement procedures. Some of the ads seem designed to make the reader feel insecure about how they currently look, with phrases like "haven't you ever wanted the perfect belly?" There are aesthetic fixes for things that weren't even aesthetic problems until recently. For example, rates of elective labiaplasty (surgical alteration of the female labia) have been going up. Is this really healing people?

By offering elective cosmetic procedures to patients, we are facilitating an arms race for beauty that echoes that in the Chicago Mercantile Exchange. It's an arms race that is unwinnable. But the race's casualties, those with eating disorders, surgical complications, and skin cancer, are largely hidden from view. That is, unless your profession involves caring for them.

What I see on the hospital wards is the opposite of what's on TV: I tend to see people when they are looking their worst. Because I'm becoming more accustomed to viewing the body in its more natural state, I am increasingly able to pick up on cosmetic enhancements, like eye shadow, make-up, and breast augmentation. And I am learning about the harms that come with trying to boost one's appearance: orthopedic damage from high heels, skin cancer from tanning, carcinogens in hair-smoothing products and nail polish. While it's one thing to be well-groomed, obsessing over one's looks just doesn't seem healthy.

We are supposed to treat patients as people, no matter what their appearance. I hope that doctors make their medical practices havens for their patients, for example, by keeping magazines like Vogue out of their waiting rooms, or by supporting efforts to eliminate Photoshopping from fashion magazines. We can be a force for making people feel more confident about their appearances.

Capgras syndrome

It is striking when a very detailed and complex set of symptoms crop up in patients across history and around the world. One is Capgras syndrome, in which the patient believes that a loved one has been replaced by an identical-looking imposter.

A UC-San Diego neurologist, V.S. Ramachandran, hypothesized what might cause such a wild syndrome. One tiny part of the brain identifies faces, and another associates certain feelings with faces. In these patients, the connection between these two parts of the brain appears to have been damaged, so that the patient identifies a face as familiar but fails to associate any emotion with it. This creates a mental disconnect ("I see my wife but it generates no emotion"), and it seems that the brain's way of reconciling this mental issue is by convincing itself that the person they are seeing looks like their loved one but is an imposter. Ramachandran did some interesting laboratory experiments that strongly support his hypothesis.

The idiosyncracies of our behavior can be affected by the slightest physical changes in our brains.

A different perspective on HIV news

Several news outlets ran laudatory articles about a baby who was cured of HIV infection after being put on anti-retrovirals 31 hours after birth. The press has greeted this finding with tremendous enthusiasm. Although my knowledge of HIV admittedly pales to that of an infectious disease specialist, I'm more guarded about the significance of this case report.

First, this finding has not yet been published in a scientific journal, so the scientific community cannot satisfactorily assess its credibility. Science has a tradition of peer-review, and it is frustrating that the press is trumpeting this "cure" when the rest of the scientific community doesn't have the tools to confirm its veracity.

But even if the report is confirmed, while it would be cool, I would think that it would constitute only a slight advance in our understanding of the disease.

Our current understanding of HIV is that once it gains a foothold in the body (by infecting particular reservoirs of dormant immune cells), it is impossible to eradicate completely. Our current medications can dramatically decrease the viral rate of replication and largely contain the virus to those cells that are already infected. Not only does this decrease the burden of disease and lengthen patients' lives, but being on antiretrovirals seems to reduce the infectivity of the bodily fluids of HIV-positive patients (e.g. their semen contains fewer virus particles).

According to press reports, this baby was found to have viral genetic material in his (or her) blood and was immediately started on antiretrovirals. In subsequent tests, although viral particles were detected, no evidence of active viral infection could be found.

The report of a cure strikes me as consistent with our current understanding of HIV works. If some of the baby's cells had been infected with HIV, but the infection had not yet made it into the reservoirs of dormant immune cells, then a cure would be a foreseeable outcome. It's the same reason why health-care workers are given antiretrovirals as prophylaxis when they get a needlestick from an HIV-infected patient: it decreases the odds that the viral infection will enter the reservoirs of dormant immune cells. In short, if this baby was "cured", it would probably mean that it had never been fully infected.

My guess is that this report will change the way that HIV-infected newborns are treated. There will be a new emphasis on detecting HIV infection and on starting therapy as soon as possible.

One point that people seem to be missing is that this baby was probably infected because her mother did not obtain prenatal care. Proper prenatal care dramatically reduces the likelihood of passing HIV to one's newborn. Is prenatal care easily accessible to all pregnant women? For all of this talk in the press of cure, I wish there was some mention of the very good tools of prevention we already possess.

Boards

I'm fast entering the "dedicated study period" for the national boards exam. The boards exam, called Step 1, is an eight-hour-long multiple-choice standardized test that will largely dictate how competitive an applicant I am for residency.

Although the boards broadly concern medical knowledge, many questions are about minutiae of marginal importance: obscure diseases, medications that are no longer used, and detailed biochemical mechanisms. Medical students nationwide tend to use the same test prep materials from the same companies to prepare for those otherwise-untaught topics that perennially appear on the exam.

Although standardization can be a force of good, I do wonder if it is wise that so many students spend so much time learning from the same resources. It seems like it will reduce the diversity of knowledge that we medical students as a group will possess when we are practicing doctors.

Resistance

The CDC publishes Morbidity and Mortality Weekly Report, a weekly bulletin describing recent disease outbreaks as well as long-term public health trends.

This week's issue (perhaps to coincide with Valentine's Day?) discusses multi-drug resistant gonorrhea. Gonorrhea is a common sexually-transmitted bacterium that, if untreated, can cause pelvic inflammatory disease, infertility, and predisposition to ectopic pregnancy in women. Having gonorrhea also makes it easier to get infected with HIV, by damaging some of the body's innate defenses to the virus. In many people gonorrhea causes no symptoms, hampering its recognition.

Gonorrhea has quickly become resistant to an increasing variety of antibiotics, leaving us with a precious few that remain effective (at least, for the time being) against the bug. The report also states that "only one antimicrobial is undergoing clinical study as a potential treatment for gonorrhea." The specter of totally-antibiotic-resistant gonorrhea is frightening and increasingly possible.

A number of factors drive antibiotic resistance, among them:

• unwarranted prescriptions of antibiotics by medical providers;
• excessive use of antibiotics in livestock; and
• a lack of investment in new vaccines and new antibiotics.

Hopefully our legislators will find the latest news about gonorrhea alarming enough to craft policies that engender more-judicious antibiotic use.

Cartoon: "Pelvic Exam"

What do you want to know?

"I set it down as a fact that if all men knew what each said of the other, there would not be four friends in the world."
              —French mathematician Blaise Pascal

Pascal's quote reminds us that ignorance can sometimes be blissful.

How much should a patient be told about their medical condition? The knee-jerk reaction is to reply: "as much as possible." But as with most things, the truth is more complex.

_____

For a couple of years as a kid I played Magic: the Gathering. It's a card game where you buy up cards at the local comic book store and then assemble your favorites into decks. Your cards attack and defend in various ways. You duel against other players, using a combination of luck, strategy, and the planning you put into assembling your deck. It was a fun game to play. It also proved quite lucrative for its manufacturers. Like lots of other kids, I trooped to the comic book shop to buy sets of cards, because sometimes thrown in with the junk and the mediocre ones were some rare cards that conferred some special advantage over an opponent.

Upon outgrowing my Magic phase, I sold all of my Magic cards to a middle school buddy for a grand total of $20. That is, except for one, which I set aside because I remembered hearing that it was rare and valuable. A few weeks ago, I was cleaning out my room and came across the card. For a moment I thought I should get on the computer to look up how much the card was worth. Then I decided it was probably garbage (what are the odds that anyone even plays Magic these days?), and I tossed it in the trash.

The other day, I spoke to someone who casually mentioned that he plays Magic. I told him that I had just thrown out my last card, and I asked him if it was actually rare. We looked online and found that it would sell on eBay for $150.

I couldn't help but beat myself up for tossing out the card. Why didn't I take a few moments to check its value? I tried to rationalize away my nagging feeling, but I still felt bummed. I could have put the cash towards some extra white coats, or some excellent tickets to the symphony.

Then I felt stupider still for ever asking my friend if the card was rare, for ever going online to check the card's value. Yes, perhaps by learning its true value I might have learned a life lesson, and I can adjust the way I clean my room in the future accordingly. But I'm convinced that I would have been happier never knowing that I had chucked $150 into the garbage.

_____

A number of diseases are in some way avoidable, meaning that many patients end up second-guessing or regretting past decisions. I'm sure some of the patients I've seen dying of cirrhosis wish they had never picked up a can of beer, that some patients dying of lung cancer regret ever smoking a cigarette, that some trauma patients regret ever climbing onto a motorcycle.

But sometimes a disease's link to past behavior isn't obvious to the patient. For example, it's widely known that smoking is strongly linked to lung cancer. But did you know that bladder cancer is strongly linked as well? I doubt that most smokers are aware of that connection. If a former smoker comes in and is found to have widely metastatic and untreatable bladder cancer, should the doctor point out bladder cancer's link to smoking? Bear in mind that there's nothing the patient can do at that point to improve his prognosis. It's hard to take that sort of news, that you've probably caused your own undoing, in stride.

Sometimes, doctors perceive a link that the patient does not. Checking the blood type of multiple family members can expose that the dad did not actually father the child. In such cases, should the father be informed? In an interesting FRONTLINE interview, a doctor discusses a time that a husband-and-wife pair came in, both of them HIV-positive. Over the course of the visit, the doctor figured out that the husband must have known that he was HIV-positive for at least 10 years, but had hid it from his wife the whole time. The wife continued to have no idea. Privacy laws prevented the doctor from informing the wife that her husband had lied about his HIV status. Should the laws be changed?

 _____

As for the bladder cancer patient and the wife of the husband with AIDS, I believe that medical ethics dictates that the doctor should withhold the information.

An interesting concept in medical ethics is that the although the patient needs to be well-informed, some things should not be shared. Sometimes, full disclosure harms. This can be tough on doctors, as well, because they possess their patient's secrets, secrets that even the patient doesn't know. It is another counter-intuitive aspect of medicine, and another reason why this field truly is an art.

Cartoon

"What if practicing medicine were more like our med school exams?"

Busywork

One of physicians' main complaints is the overwhelming amount of paperwork, bureaucracy, and red tape that they encounter. The causes are manifold, and include the reluctance of insurers to pay for medical expenses, the omnipresent threat of malpractice litigation, and the growing trend of physicians' working for large, bureaucratic health-care conglomerates.

The closer I come to being a physician, the more I become mired in useless paperwork that wastes my time and saps my soul. To spend a couple of hours observing a physician, I had to fax in 37 pages'(!) worth of forms. These forms included several quizzes which asked me questions like what phone number to call in the case of a chemical spill. Beyond attesting that I was current on my vaccinations, I had to list the date of each vaccination I've received. The forms were repetitive. Several times I had to input the same information, like my emergency contact and my relationship to them, what year I will graduate medical school, and my medical school's address and phone number.

It is only getting worse. I was informed that I needed to provide proof of certification in CPR, forcing me to scramble to enroll in a 4.5-hour-long Saturday morning class. The class was taught by a college freshman. Is that who we want instructing our medical students about how to practice medicine?

On top of that, we are required to complete several online modules introducing us to electronic medical records. The modules have hours of mind-numbing videos, and we are awarded credit only when the videos play through in their entirety. I had already learned the content of some of the videos, and so, like my classmates, I simply played them in the background on mute and then answered the questions at the end.

I think part of the problem is that it costs my institution almost nothing to mandate paperwork and computer modules. Now that forms and courses are electronic and online, our school doesn't have to hire an instructor, doesn't have to reserve a classroom, doesn't even have to pay for copy paper and toner. There also is no accountability and no mechanism for feedback. I don't even know who mandated that I fill out the online modules, who to complain to about how bad they are, whether whoever assigned the videos ever watched them himself. I was informed of my assignment because an automated assignment notice was sent to my e-mail account. There's no point in fighting it. Not that I would have the time to fight even if I could.

I can't allow myself to get upset over having to jump through these ridiculous hoops. But it feels like I lose a part of myself when I submit uncomplainingly to this unnatural and impersonal labyrinth of paperwork and bureaucracy. I am starting to see why so many physicians burn out.

Our unheralded teachers

When listening with a stethoscope to a patient's heart, one sometimes hears a deviation from the typical "lub-dub" rhythm. Sometimes the "dub" is too loud, or the "lub" too soft. There might be a rubbing sound, or a harsh blowing sound. By interpreting subtle characteristics such as the location, pitch, and timing of these sounds, one can sometimes diagnose things like a diseased heart valve or congestive heart failure. It's very hard to do, and the surest ways to get good at diagnosing heart murmurs are to thoroughly understand the mechanisms of heart disease and to get lots of practice.

Our cardiology professors kindly arranged for me and my medical school classmates to examine patients with various audible heart abnormalities. We were divided into groups of eight and herded through a series of exam rooms. Three or four of us at a time would place our stethoscopes on each patient's chest, and as a group we tried to diagnose the heart abnormality. One patient had pulmonic valve stenosis, a rare murmur that most physicians will never encounter in their careers. Pulmonic valve stenosis is difficult to differentiate from its oft-encountered cousin, aortic valve stenosis, so finally hearing a patient with the rare pathology was quite useful. Some of the patients had severe disease, with classic physical findings that we've only read about in textbooks. One patient with severe aortic valve stenosis had pulsus tardus et parvus ("diminished and weak pulse"): the feeble pulse I felt in his wrist noticeably lagged behind his heartbeat. Examining these patients helped cement my clinical knowledge.

These patients, most of them elderly, were compensated for letting us examine them. I can't imagine that our examination was fun for them. The patients had to partially disrobe, and some of our stethoscopes probably were cold to the touch. I'd like to think that they came in for reasons besides the pittance they were paid.

Patients seem happy to help us learn, whether it's a couple who lets us examine their newborn or a psychiatric patient who lets us ask deeply personal questions about his life. When I tried drawing blood from one of my first patients, my first two "sticks" were unsuccessful and I informed her that I would get someone more experienced to perform the next attempt. She insisted that I keep trying until I succeeded, because she wanted to help me improve (I thanked her and found the more experienced student anyway).

Two volunteers had had their larynges (plural of "larynx") removed because of cancer caused by smoking. They could breathe only through a hole that had been surgically carved in their necks ("stoma"), and could speak only with the help of assistive devices (which made them sound like Stephen Hawking). They spent an hour with us, taking our questions and letting us try out some of their assisted-speaking equipment. They also taught us some useful clinical pearls: since their mouths are disconnected from their lungs, if they need to be resuscitated, we need to ventilate their necks.

I make sure to thank these patients, and I hope they understand how much they are able to teach us. They have my gratitude.

What's wrong?

For whatever reason, some patient visits are more memorable than others. One diagnosis that has stuck in my mind wasn't even a diagnosis.

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I asked my patient, "What brings you into clinic today?"

"My urine is dark, even though I've been drinking a lot of water."

Dark urine can be a sign of something ominous, like bladder cancer, or a kidney stone, or an inborn inability to metabolize certain types of protein ("maple syrup urine disease"), or a severe reaction to certain medications and recreational drugs. I started whittling away at my differential diagnosis by asking questions.

"Has your urine looked like it's had blood in it?" "No."

"Does it smell different?" "No."

"How long has this been going on?" "A few days."

"Is your urine brown, like the color of Coca-Cola or maple syrup?" "No."

"Is there pain when you urinate?" "No."

"Are you feeling pain anywhere?" "No."

"Have you noticed any change in your weight?" "No."

"Is there something happening in your life or the life of a loved one that's made you concerned about your health?" "No."

"Have you had vomiting, fever, headache, or any change in bowel habits?" "No."

No red flags. I asked a few more questions, each with an innocuous response. I checked to see if he was tender in his abdomen or his back (which could signal a kidney stone). He was not.

My history and physical exam had turned up nothing suspicious. After consulting with the physician, I ordered a dipstick urinalysis (a quick test for various abnormalities in the urine) and asked the patient to provide a urine sample. After a couple of minutes he returned with his specimen cup. I held it up.

"Is this about as dark as your urine has gotten?" I asked.

"Yes."

"And do you consider this dark?"

"Yeah! I mean, isn't it?"

No. His urine wasn't dark. It was quite pale. And that was the moment that I realized that nothing was wrong with this patient. He didn't need to be in the examination room. He ought to be at home, or at work, or shopping for groceries. Anywhere but here.

I was surprised that I took so long to arrive at this conclusion. But when I had assembled my mental list of potential diagnoses, "nothing" was not among the options I had considered. I had become so accustomed to patients having problems warranting diagnosis and treatment that it had hardly occurred to me that a patient might come in to clinic with nothing the matter.

I was reminded of a time I attended a play, and partway through, the actors "took down the fourth wall" and began speaking directly to the audience. It was a bewildering experience, because all of the sudden, the normal rules of theater did not apply. This patient encounter left me feeling similarly disoriented.

The patient's urinalysis results came back a few minutes later, showing no abnormalities. The doctor and I reassured him that things appeared to be all right, and we sent him on his way.

Blew it

The patient had come to the emergency room because over the course of an afternoon he had become short of breath, unable to walk more than a few feet. Now admitted to the hospital, while he was talking to me, he had to stop and take a breath after every third word.

I was meeting this patient as part of a teaching activity. The doctor who was caring for this patient was watching me as I took his history, performed a physical exam, and tried to work through the diagnosis.

When I was finished, the doctor and I went to the conference room and I was given the patient's EKG. "What's on your differential?" the doctor asked me.

I reasoned my way through several classes of disease that would cause shortness of breath: infection, left-sided heart failure, asthma, chronic obstructive lung disease, and various types of lung disease. But none of these seemed to fit this patient's presentation.

"Keep going," he said. "You're missing something."

I racked my brain and came up with some esoteric diseases that were extremely unlikely.

"I'm thinking something big," he said.

I couldn't figure it out. "I give up," I said.

"Pulmonary embolism."

Shit! Pulmonary embolism is a common disease that can be life-threatening if unrecognized. And I hadn't recognized it, or even thought to look for signs of it on physical exam. This patient's presentation was classic, too.

As it turned out, the patient's lab results were inconsistent with pulmonary embolism, effectively ruling it out. But the awful feeling in my stomach remained. The obvious diagnosis hadn't made it onto my differential. This was the sort of mistake that could kill a patient.

Of course, I'm just a second-year medical student. I'm expected to make mistakes like this all the time. I will not be solely responsible for patients for quite a while. Even so, the teaching exercise was a rude reminder that there remains quite a lot for me to master.

Money and medicine: career choices

From "The Drawn Out Days," a Stanford graduate's ongoing series of drawings that chronicle her post-college life as a Brooklyn bartender and barista:

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I went to a delightful potluck dinner where I was the only medical student (something of a rarity these days). The sun went down while we were eating, and after clearing the dishes we stretched out on the motley assortment of chairs, sofas, and pillows. In hushed tones, people started talking about their work situations. One had graduated with a degree in graphic design and could hardly find any work. Another had returned from a Fulbright fellowship and was unemployed. Several others had struck out looking for full-time employment. The job market is awful for people my age.

Their concerns felt a bit distant, because I'm still several years removed from the working world. But does being a medical student insulate oneself from the dispiriting economic realities of the day? It made me reflect upon how we choose our careers.

---

At the well-endowed university where I studied undergrad, at least a dozen professors knew me personally and were happy to meet with me and give career advice. There was also a well-staffed career advising center. For example, I stopped by the center to learn more about health professions. There I found an enormous binder of questionnaires filled out by alumni working in fields like medicine, podiatry, hospital administration, and epidemiology. Their write-ups included where they trained, why they find their work satisfying, what their average workday looks like, their salary range, what tips they have for undergraduates, etc. Many questionnaires also included contact info so that I could get in touch them and talk things over. Even with all of these resources available, I debated throughout my undergraduate years whether medical school was the right path for me.

Now I interact with undergraduates at other schools who have dramatically fewer career resources available to them. Sometimes they ask me for career advice. It unnerves me that some students I meet are basing their career choices on what I perceive as incomplete or inaccurate information.

Undergrad #1: "I was pre-med, but then Obamacare passed. It meant I would get paid so little if I became a doctor that I needed to switch careers. Now I'm planning to go into environmental law."

Me: "Lawyers coming out of law school are finding that it's a really tight job market. If money's an issue, are you sure that's the route you want to go?"

Undergrad #1: "Well, so long as I'm going to pick between sinking ships, I might as well do law."

___________

Undergrad #2: "I've been debating between med school and PA [physician assistant] school. As a PA I'd know about as much medicine as a doctor, but it's only 2 or 3 years of training."

Me: "Maybe this will be helpful for you when you're weighing your decision: I'm buddies with some PA students, and we find that PA school and medical school have pretty different aims. Becoming a physician involves learning medicine in much more depth and breadth than a PA, and that's why it takes so much longer to become a doctor."

Undergrad #2: "Yeah, but I really get medicine, so even if they don't teach us as much, I'm still going to learn it all."

And yet, can someone make a truly well-considered decision about whether becoming a physician is for them? It's hard to even figure out things like how much medical school will cost. Last year, Republicans in the House suddenly eliminated subsidized loans for medical students, meaning that new federal loans accrue interest during medical school and residency (at interest rates of 6.8% and 7.9%). This tacked on tens of thousands of dollars to the debt load that medical students will carry. Medical schools keep hiking tuition, and even the scholarships they offer students can be reduced or yanked after first year. It's increasingly common for students to graduate with over $200,000 in debt, financed at subprime interest rates. As that figure soars higher, it becomes increasingly difficult to cover interest payments and still make a dent in the loan principal.

Beyond the cost of education, the financial state of the profession is precarious. Medicare and private insurance reimbursement rates have been plummeting, and medical providers with substantially less training (nurse practitioners and physician assistants) are increasingly displacing doctors. If a student entering medical school today enters primary care, will he be able to pay off his loans within a reasonable timeframe? I can't make much of a prediction. Physicians are at the fickle mercy of legislators and private insurers. Furthermore, physicians' professional ethics and reluctance to organize leaves them particularly vulnerable to getting picked on.

And it's hard to know whether one will fit in the medical culture until one is in it. This field is extremely demanding. Some people get burned out. Some people realize it's not for them. Some people regret the specialty they train in. Some people get sick or injured and lack the physical stamina to proceed with their training. The thing is that once you've started, you can't really stop.

I don't have a good answer for the undergrads who seek my advice on whether to go into medicine. People will always need doctors, and doctors will always possess a unique means of serving their fellow man. But entering the medical profession is increasingly risky. It is a tremendous investment with uncertain reward. I hope for all of our sakes that it works out.

Diagnosis III

A longtime patient had come in complaining of progressive fatigue, weakness, and numbness in her hands and feet. Her primary-care physician and I were taking a few seconds to skim her medical chart before we stopped by her room to examine her.

I glanced at the patient's weight and noticed that she was borderline obese. A potential diagnosis came together in my mind. "Has this patient ever had gastric bypass surgery?" I asked.

Him: "No."

Me: "Darn."

Him: "Why do you ask?"

Me: "I was wondering if maybe she has a vitamin deficiency, like B12, that's causing her symptoms." Some types of gastric bypass, such as Roux-en-Y procedures, remove some of the small intestine, thus reducing absorption of certain critical vitamins. Patients are supposed to take hefty vitamin supplements for life as a result.

Him: "It was a nice thought."

We went in to see the patient. She was very unhappy because she felt like she had no energy. Her family and job were stressful. And she was disappointed with her weight. "Even after getting that gastric bypass, I still weigh too much."

The doctor's eyes lit up. "How long ago was your gastric bypass?" he asked.

"It happened maybe 4 years back," the patient responded.

"I assume after your procedure they prescribed a special mega-vitamin."

"Yeah, but I didn't like it. I stopped taking it maybe half a year ago."

I couldn't stop myself from grinning.

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Although I'm not skilled enough to be seeing patients entirely on my own, sometimes I've been able to make diagnoses that the doctors I'm with have overlooked. Part of the reason is that my training is uneven. In medical school, we spend a lot of time learning diseases that are rarely encountered in clinical practice. We also have seen so few patients that we have little sense of what is common and what is uncommon, which diseases make sense and which ones don't. When I see a patient, the list of diseases I'm considering differs from that of a seasoned physician.

But sometimes the patient doesn't have the disease a seasoned physician expects, and these are the times I get to shine. Sometimes, two minds are better than one. I wouldn't have expected it, but I think that patients get better care when they are examined by both a physician and a medical student as opposed to only a physician.