Evolution and medicine

What I thought would've been an interesting discussion on evolution and medicine ended being a rather unconvincing argument about how certain disease gene(s) are more prevalent than expected. What I'd like to discuss more is how medicine is hindering evolution - people who normally would not have survived to reproduce now are thanks to the "miracles of medicine". I used to think that people who were "unlucky" and were involved in say, a traumatic accident, and "saved" by medicine wasn't really "cheating" evolution. But on subsequent thought, it's exactly those "unlucky" individuals that selective pressure works against. While there are always the flukes, it's very hard to distinguish between an accidental fluke and one made more likely by being "unfit" for the environment the organism found itself in. What about all the advances made in medicine, e.g. advanced neonatal technologies that is pushing back the shortest viable gestation? The nature of medicine is itself the anti-thesis of evolution through selective pressure - which brings me to the main point of this entry: Is medicine's obligation to the individual or society? As we continue to treat people, some with serious illness, and extend their longevity sufficiently long to impact fertility, we are in a sense preventing selective pressure from exerting its effects. I believe countries with socialized medicine have already faced this issue and have made conscious decisions, e.g. limiting the efforts of the healthcare industry based upon certain eligibility criteria. If the doctor's attention is patient oriented, then who's responsible for overseeing the physicians/healthcare industry to ensure that the social group as a whole benefits?

The difficult patient

We had an interesting discussion today about difficult patients. I didn't offer my experiences, but as I sat back and thought about it - I've had very few "difficult" patients. The only patient that came to mind was an obese 64 year old African American diabetic who's already had bilateral below-the-knee amputations - one due to trauma, and the other as a complication of his vascular disease likely from long-standing diabetes. His blood glucose control was extremely poor, often in the 200mg/dL range, and required intensive insulin therapy. In the meantime, he continued to sneak in food against the recommended diet, and often refused blood draws, finger sticks, and was otherwise a rather uncooperative patient. During his protracted hospital stay, he had an episode of altered mental status, likely a transient ischemic attack (TIA), and aspirated on some food. He then developed aspiration pneumonia, spiked fevers but never had a positive blood culture. Meanwhile, the surgeons were debating who's going to get first crack: neurosurgery who wanted to perform an endarectomy since his carotids were both >90% occluded (no surprise he's had strokes in the past), or the cardiothoracic surgeons who wanted to perform coronary artery bypass grafting. The reality of the situation was that neither team really wanted to touch him at all given his high risk factors. To make the situation worse, he refused to cooperate when the surgery PAs came over to see him and evaluate him for surgery.

After nearly 1 month in the hospital, he was finally discharged home - without any surgeries because that's what he decided. Listening to my friends' tales of "difficult" patients, I'd say I had a relatively easy case.

DNRs

Today we discussed DNRs and delivering bad news. Last Friday, we had an OSCE where we presented "bad news" to a patient regarding terminal metastatic cancer. Personally, I found the exercise useful as an exercise, but I didn't really learn anything. Nor did I learn anything new in the entire hour plus lecture. There are some things that are just not plain teachable, and giving bad news isn't something that can be scripted. It's a moment-to-moment thing, and I feel that I can handle it, and if not, I'll learn by experience. My future career in Heme/Onc is likely to be filled with giving bad news. Why is it that medical school, or schools in general, and even the public at large, require - mandate - that certain things be taught merely for the sake of appearing complete, when in fact glossing over matters, pretending that they have been "mastered" is a disservice to us as students, and to those who depend upon us - be they patients, other students, or the public at large.

Grandparents

A discussion today on geriatric medicine reminded me of my grandparents. They live in Queens, and my grandfather, who suffered a stroke several years ago, is currently in a long-term nursing home. I feel terrible about not visiting them often enough, especially my grandfather who feels trapped in the institution. They don't let him out - he has trouble walking so he's wheelchair bound now. Last time I saw him, he so desperately wanted to go outside - he begged me to wheel him to a window so he could look outside and requested over and over again to take him outside. This is a person who used to walk daily to purchase newspapers, one who valued his independence. I feel his current debilitated state could have been avoided, and it was partially my fault he ended up where he is now.

I've seen dramatic recoveries from strokes, cardiac arrests/myocardial infarcts. All of them had one thing in common - a very strong family support structure. Those they recovered often had strong-willed family members not just over seeing their treatment, but also encouraging the patients to ambulate early, and more importantly, take them home and have them heal there.

My grandfather, on the other hand, lacked such a strong support structure. I was too selfish to help him, focusing instead on my studies. His daughter was living in the area, but thought it was better/easier to have him recover at a long-term rehab facility. I've seen the conditions of these facilities, though. It's not that the building itself is in poor condition, it's that the workers are often over-worked, under-paid, and most importantly, many lack empathy/concern. Immediately after the stroke, I'm sure my grandfather just languished in his wheelchair. I asked if anyone came over and helped him with physical therapy, but nobody did. They all look and see an old gentleman in a wheelchair, and just assume that it's "normal". There was no concerted effort to get him up on his feet so that he could recover his strength and walk again. I believe that nobody wanted to spend their time and energy helping him, and didn't really perceive a need.

Unfortunately, that was his one and only opportunity to leave the rehab facility. After sitting in a chair all day, moving from wheelchair to bed and back, it's no surprise at all after one year that he now lacks the strength to walk or stand up by himself.

I blame myself mostly for letting these events unfold. I failed to speak up, and more importantly, I failed to take time out of my schedule to help him. As I wrote earlier - I've seen dramatic recoveries before, and I'm quite certain that had I helped him with physical training he would've been walking and home by now. As it is, it's now much too late, and he's pretty much stuck in the rehab facility.

I really should visit him more often.

Stress management

Psych in Medicine. Stress Management. For some reason I was just able to get into things. The relaxation music, the matras and chants...relaxation is a state of mind and cannot be willed. They talked of how stress influences physiology, cardiac pathophysiology, etc. Heck - life is an eternal struggle, and while stress can be both an adaptive and maladaptive response, I do not believe that it can truly be controlled or learned. People tend to think I have a natural, positive, disposition - I personally don't see it myself. I'm just as tense and anxious as any other person, but somehow it doesn't show. All this hocus-pocus on stress relief - while it might work for some, I feel is really nothing more than lying to oneself. Denying the honest truth that life is an eternal struggle. Now tell me I'm always positive.

Adolescent Interview

We had an Objective, Structured Clinical Encounter (OSCE) exercise on Monday where we ran through 5 different patient scenarios. Yesterday, I reviewed my performance with a simulated "well visit" by an adolescent - I believe she was supposed to be 16 years old. Today, we talked a bit about child psychology and interviewing adolescents. I'm glad I still remembered some of the key points in adolescent health - "HEADS" is the acronym they teach us: Home, Education/Environment, Activities, Drugs/Alcohol, Sex/Suicide/Safety. I hit most of the key points, but the entire exercise was rather carefree in stark contrast to previous OSCEs I've taken. Much of the relaxed atmosphere came from knowing that this exercise was neither graded nor critical for passing the course - we merely had to be present. Ironically enough, it was this low-key atmosphere that made the entire interview rather pleasant and felt "real". I found myself easily discussing things like illicit drug abuse (she tried coke once), quitting smoking, sex, etc. and in the end I felt I learned something. I learned that people do not like to be lectured - they want to be informed, but not judged. I found that it was very easy to talk about the dangers of marijuana or cocaine abuse, and not be judgemental. I consistently reiterated that I'm not their parents, and I'm not there to tell them right from wrong. I'm a resource, I told her - a fund of knowledge from which she may ask any questions she wants without fear of disclosure (of course, I did insert the typical disclaimers regarding hurting someone). From there it was an easy step to talk about the consequences of certain actions and to put it in a very objective, unpersonal manner. I feel that this let the adoscelent teen put her guard down as I encouraged more participation from her in the interview versus me lecturing her on the do's and don'ts.

Contribution to society

I've often been caught between having to decide between doing what I enjoy the most, or what I believe I can do the best. Ideally, both of these should be the one and the same, but often they are not. Perhaps it was the environment of pediatric surgery, or more likely, the people in pediatric surgery especially the attendings, that made my experience there so enjoyable. I don't see myself as a surgeon, not quite the personality build-up for that. Yet, I did really enjoy myself this past week and will likely enjoy this coming final week. But if I'm not good at surgery, should I pursue it anyway because it makes me happy, or should I instead do what I believe I'm better at doing - intellectual medicine, versus procedural medicine?

I've faced this debate before - long before medical school. I've known that I'm a good programmer, but I didn't think I'd enjoy programming as a career. I loved science, or rather, the investigation of how things worked, but I wasn't particularly great at it. So which to choose? The selfish side of me says to pick the option that makes me happy, even if I suck at it - because so long as my attempts to gain proficiency remain enjoyable, it's a good life. The socialist in me (not sure if that's the correct characterization) tells me to do what's best for society as a whole, i.e. do what I do best even if I hate it.

Sometimes, I feel cursed by the availability of choices.

Do babies feel pain?

Sometimes a baby is born with portions of their intestines exposed (e.g. gastroschisis) and we had one such baby in the NICU who required daily tightening of the silo (a clear wrap around the intestines to protect it from infection and maintain moisture) in order to stretch the abdomen so that it can accept the intestinal contents when it finally gets the corrective surgery.

While you would think it is a painful process (certainly appears that way - squishing the intestines into the belly of the infant), it's probably not all that painful. The intestines lack the typical pain nerve fibers we find in our skin, for example, and really only respond to stretch or burn. I guess in theory you can slice up the intestines without the patient feeling any pain, but I'm not sure if it's been _proven_ to be true (other than the histology demonstrating the lack of certain pain fibers).

Regardless, the nurses in the NICU tend to be very protective of their charges (and perhaps rightly so), and they do insist on some sort of pain management before tightening the silo. As these are rather sick babies in general, you had to get the timing just right to ensure that they are pre-medicated prior to the arrival of the resident/attending so that the tightening can take place without much discomfort on the baby's part.

But this can come at a cost, too - these scheduling requirements can delay the process signficiantly, and until the operation is complete the baby remains in danger of popping out the silo and exposing the intestines again (and I've seen this happen once).

What am I getting at, exactly? Well - in short, there is a (potential) cost to pain management, and I'm not sure if the desire to avoid pain in the neonate is blinding us to the risks we are taking.

Pain should be avoided - true, but if I learned anything from anesthesia, it's more to relax the patient than to avoid pain per se. Given medications that induce amnesia, most patients will not recall the painful experiences (although I guess it could still be argued as a form of torture).

Do babies remember pain? Is it "torture" to inflict pain on a baby? Do babies even truly "feel" pain as we do (and by this I mean perceive it, not simply react as in crying)? We don't really know many of these answers, yet we project ourselves into the baby and try to spare it from all the pain we can - sometimes without really recognizing the new dangers we have now placed the baby into by our desire to avoid pain.

Extremely pre-mature babies and medico-economics

The typical image of the extremely pre-mature baby (say 24-28wks gestation) usually does incite quite a few emotions from people. But my experiences in the NICU, seeing an extremely premature baby supported by many medical devices does make the cynic in me come out and ask, "Is it all worth it?"

Many of these babies require months of intensive medical treatment, and many do not survive much beyond their first few months. While it's true that there certainly are babies out there that have gone through the gamut and are alive and well (in fact, we saw another baby recently who was getting his G-tube removed that had endured just such an experience, and has the multiple scars to prove it...), the exorbitant cost these babies must exact on the healthcare industry should be weighed against the potential benefits.

It's a cold, harsh, cruel world, but in an era where people are sorely lacking high quality medical care in general (supposedly due to limited resources, although I personally feel lack of access and education plays a larger role) - is it fair to a) subject this tiny baby to the trials and tortures of modern medicine for the promise of a "normal" life but odds of achieving that promise measured in fractions of a percent, and b) expend significant amounts of medical resources in a (sometimes vain yet valiant) attempt to achieve that goal of a normal life?