Vision insurance

As part of my healthcare package, I'm covered under a "Vision Plan." Unfortunately, as I found out recently, I believe this "Vision Coverage" is really not an insurance policy, but rather a scam to provide glasses to many people. Huh - isn't that insurance? Nope - and here's why. My glasses broke two days ago, so I needed a new pair. Luckily, my insurance plan allocates to me an eye exam every 2 years and a new pair of glasses. Great - my last exam was in September of 2006, so it's been far more than 2 years. Check. Now let's see my benefits: eye exam - $10 co-pay (fair enough), frame - $80 allowance, generous, lenses: standard plastic (CR39?) covered 100% - all else, you pay 100% retail. So, let's examine two hypothetical situations and see how things come out. Let's take Person A who has mild-to-moderate myopia and needs corrective lenses at say, -4.00 diopters. At this level, he could actually get around - albeit a bit clumsy - without glasses. So while he may wear these glasses all day (mostly out of convenience), it's not necessarily a required item for his activities of daily living. So I'd say these glasses are more of a "nice-to-have" item. While it's true $80 doesn't get you much of a frame, he could easily go with the standard CR39 lenses and it'll be covered entirely.

Now let's look at Person B who has severe myopia - say, -10 diopters. At these powers, the guy wouldn't be able to perform his activities of daily living without glasses, so the glasses become more of a required item, i.e. "need-to-have". Furthermore, at these powers, the use of CR39 isn't really recommended anymore due to the tremendous size and thickness required - higher index of refraction material are suggested. Once you get into these powers, you also will need anti-reflective coating to prevent glare from headlights, computer screens, etc. And oh - those $80 frames? Since the guy'll be wearing these frames at all waking hours out of necessity, a flimsy plastic or these new, fashionable thin metal frames won't do at all - they'll break much too easily. Of course, let's not forget anything other than the CR39 and you'll pay 100% retail. By the way, it's not just the lens material - at these powers, you'll need "custom resurfacing" and all sorts of other goodies - all extra, of course!

In short - the mild-to-moderate myope can get a functional pair of glasses for free, while the severely myopic will have to pay 100% retail. Let's also consider the actual cost - the CR39, as you might guess, is relatively inexpensive being plain plastic. Higher index of refraction materials - more expensive, and as you get higher and higher the costs rise faster.

So whom does this insurance policy serve? The large populace with mild-to-moderate myopia, and at a relatively cheap rate. Who gets screwed? The severe myopic who require inordinately expensive glasses. This would be the equivalent, in healthcare, for an insurance policy to cover annual check-ups and vitamins, but operations, prescription medications, etc. would be entirely the policy holder's responsibility. Sounds like an insurance company's wet-dream, doesn't it? Insure many people and you're only financial responsibility is small.

You've probably guessed by now I'm a severe myope. I measured out to -9.00 and -9.50 diopters. I also fly, so I like to have a pair of sunglasses handy so that I'm not blinded when flyingi nto the sun. But as I wear my glasses constantly (and frequently fall asleep with them on), I don't really want to get a second pair of prescription sunglasses.

My final choice/costs? I ended up having to spring for a $200 frame that's "bendable" (so hopefully it won't break when I sleep with them on and crush them, although my last pair was also bendable and they broke at the bridge after only slightly more than 2 years of wear). Then, I had to pay another $200 for polycarbonate lenses (higher index of refraction, although certainly not the highest possible, but it's also the most impact resistant and as a volunteer firefighter I also want to keep in mind the safety factor). Add another $100 or so for additional anti-reflective coatings, custom resurfacing, etc. and I did opt for a photochromic layer (Transitions - the lenses that change color according to UV exposure so that I won't need a separate pair of sunglasses) that costs another $50 or so. The total bill after a few discounts came out to nearly $500.

So that's my experience with health care insurance so far. I know of many people around me who wear glasses, typically in in the -2 to -4 diopter range, and they would've been fully covered. Even if they had not, it wouldn't have cost them $500 for a new pair of glasses.

Well, I guess life just isn't fair sometimes. No matter - hopefully these glasses will last at least another 2 years when I can repeat this whole process again, although at these rates it doesn't matter at all whether I have insurance or not. The exam fee itslf is normally waived at most places when you purchase a pair of glasses.

So on the bright side of things - I no longer have to care about the insurance details and find in-network providers. I'm on my own.

AWB Progress Report

I had made a decision to commute to work by bicycle earlier this month, and for which endeavor my All-Weather-Bicycle (AWB) project was born. I installed a front fender and a rear rack which also functioned as a fender. These items' importance I learned while riding through puddles and patches of wet mud, promptly ending up splattered with the same. At the suggestion of a friend, I then also purchased a pannier - basically a bag that sits on either side of the bicycle, in my case, mounted on the rear via the rear rack. So far things had been going well, although I was only able to test the bicycle in light rain conditions and wet surfaces (after a rain).

Tonight was my first test in riding under "inclement weather" conditions: night-time, heavy rain with winds 23mph gusting to 38mph, ambient temperature around 8C, visibility probably at 200 feet or so with my front LED light, and road conditions were wet with patches of deep (3-4") puddles of water.

I hit my first snag right off the bat when the bicycle hit a bump and the pannier slid forwards. There is a strap holding the sides of the pannier together at the rear (difficult to describe without words), and the forward motion then carried this strap into my rear wheel. This strap, oriented horizontally to my rear wheel, was then rapidly captured by the wheel and forced forwards. The bag, however, retained the strap aft (so-to-speak) and as a result my rear wheel instantly locked up. In the conditions described above, traveling at decent speed (15-20mph), I immediately began to fishtail and had to brake heavily on the front tires without exerting too much force so that I wouldn't be thrown off the bicycle.

After re-positioning the bag, I continued on my journey back home fighting the headwinds and trying to see (my visibility deterioriated at this point to <20 feet due to the water droplets forming on my glasses).

Another bump, another fish-tail. Dis-mount, re-position, re-mount, repeat. Bump. Fish-tail. Dis-mount, re-position, repeat. Hey - I'm getting good at this, but it's getting dicey. I'm going to be riding on the road soon (currently I'm on a dedicated bike path), and fish-tailing across the road in this condition with medium traffic wasn't my idea of a safe ride. So, I unlatched the rear strap in hopes of solving (temporarily) my problems. I could also see by now the multiple contortions the bag underwent as it was dragged by my rear wheel was deforming certain stiff members of the bag, designed for forming support. As a result, it was getting more and more likely to snag on my wheel.

Oh - and each time I rode through a deep puddle, the water would stream and cascade over my legs, into my shoes...

Luckily, the ride home was rather uneventful after unhooking the strap. Yes, it did rub against my rear wheel for the remainder of the ride, but I was able to pedal against the friction force.

On arrival at home, I was better able to re-evaluate my own personal condition. By "all-weather-bicycle", I meant a bicycle that I could ride to work, regardless of the weather condition, and arrive in a presentable fashion. Being a resident/intern, this would mean a shirt/tie and pants with white coat.

I realized now that I will need much more work on this concept. While the fenders and the rear rack did their work admirably, I ended up clean but thoroughly soaked. My gloves were so wet, I had to wring them out to dry. My feet/socks/shoes were soaked completely. My pants, too, were soaked. So were my underwear. The only thing that remained dry was my shirt, safely under my rain jacket.

Lessons learned:
1) I'll need rain pants, most likely, if I'm to arrive in a presentable manner
2) I'll need to engineer a better solution of mounting the rack/pannier to the bicycle
3) Maybe additional lighting
4) Someone needs to come up with windshield wipers for glasses...it's just not working well for me these days when I can't see out my glasses...

MR

A classmate and myself stepped into a crowded elevator at the hospital and asked if "MR" was pushed. At our hospital, there is no floor 13 (silly superstitions!), but a floor titled, "Medical Records" or MR where floor 13 normally would have been. It was already selected, but then suddenly a young man in a wheelchair loudly shouted, "MR! Mentally retarded!". Horrified, the two of us looked at each other and then back at the young man who did appear, outwardly, to perhaps have at most mild MR. My classmate was the first to open her mouth: "Or, medical records." His reply, "Mentally retarded!". I had no idea what to say. He seemed proud of this fact - the ability to decipher MR as mentally retarded. Someone else on the elevator finally spoke up and said something along the lines of "Now, Charles...." in a gentle admonishment.

I hate to say it, but I think I know what was going on. I've heard "MR" used quite a bit in the medical establishment, more particularly "MRCP" for mentally retarded, cerebral palsy. This kid must've figured out, over the course of time, to decipher MRCP.

I was ashamed, and I think many of us in the elevator were ashamed that day. It's not that using MRCP is bad or that we shouldn't speak of certain medical conditions, but sometimes we forget that there is a human being on the other side of the label.

I'm sorry that I failed to see him earlier.

How much would you pay to use an elevator?

A thought just occurred to me as I was taking the elevator up from the cafeteria. The door opened and nobody stepped in on a floor, and I thought that was such a waste of energy to stop and restart the elevator. I then wondered what kind of punitive mechanism could be setup to avoid such blatant waste of resources. Then I hit upon the current idea:

1) To request an elevator to stop at your floor, you must indicate which floor you wish to stop at (helpful for efficient movement of elevators) and not simply direction of travel, e.g. up/down, and pay a fee calculated in various methods (more details below).
2) As an alternative, stairs will always be available and remain free
3) Discounts/waivers can be given for physically impaired, i.e. handicapped, people
4) A display at every level indicating whether the elevator plans to stop and where it will stop. This way, you can ride for free if someone else has already paid, i.e. it's not a per-person fee, but rather a per-stop fee. This display/device should be integrated with the payment system to reduce cost of implementation.

Many variations on this common theme, but imagine the following setup:
1) At every floor is a computer-like device with a card reader. Swipe your card and select destination floor. A deduction is then made in your account (see rate table later) and an indication will appear that an elevator will stop on this floor and will then stop on your desired floor. If someone else has already paid for the elevator to stop on this floor and your desired (target) floor, then no deduction is made (it's free).
2) Rate table: A point system can be setup such that traveling one floor up or down is much more expensive that traveling multiple floors, and can even be devised to charge more for going down (encourages more people to take stairs at least down where it's not terribly physically demanding) versus up. A sample system might be: 10 points for going down 1 floor, 15 points for 2 floors, and 2 points for each additional floor, i.e. 3 floors would cost 17 points. Going up would be discounted by 1 point per floor, so 9 points for up 1 floor, 13 points for up 2 floors, and 14 points for 3 floors up.

Now, those with offices on the higher floors may cry foul because they are penalized for their office location. To that, I say - take the stairs, they're free! But if people really object, then provisions can be made such that they get an allowance of points as a function of their office location, e.g. those with offices on 15th floor (typical cost from 1st floor going up would be 25 points and going down would be 36 points so 2 round-trips would cost 121 points - good for coming in, out and back for lunch, and leaving) could get an allowance of 121 points per day.

One can also see that the rate structure can become very creative, including caps such that say, rides going up more than 8 floors or down more than 10 would be entirely free - it's reasonable use of the elevator at that point, I think. Or, you can have a reverse rate structure such that the going down 1 floor costs 10 points, 2 floors 9 points, etc. and then more than 10 floors you'd get for free. This type of rate structure is more conducive to encouraging people to walk rather than reflecting true energy/utility costs.

Of course - the final points-to-dollars conversion would have to be specified - not sure how much people are willing to pay in terms of dollars. And for the really lazy folks, you can always mimic the subway and offer "unlimited rides" for a high cost, but this would run counter to the idea of getting people to take the stairs.

The income derived from such an operation should be sufficient to pay off the initial investment, and then provide for continued maintenance of the elevator. Furthermore, as I indicated earlier, the relocation of the control panels from within the elevator to each floor immensely aids in the planning of the efficient movement of multiple elevators. Such a system has already been implemented in certain hotels (not fee-for-use, but people indicate which floor they desire and the screen directs them to a particular elevator to use). Once on the elevator, there are no buttons to push and the elevator will stop at the requested floor(s).

An interesting social experiment comes from this, too. Since you are paying per-stop and not per-person, it would be interesting to see a) who is willing to pay for a large group, and b) at what point will people simply take the stairs as opposed to pay for a group...

I would love to see this implemented somewhere..maybe someone else already has this idea?

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?

Reflection on Anesthesiology

Well, today was my last day on the Anesthesiology rotation. Overall, I'd say I had a good time and learned quite a bit, actually. However, the rapidity with which we switch attendings makes the residents and attendings hesitant to let us really perform any procedures, I think, except for simple ones like starting IV lines versus intubation. The more invasive procedures, or at least those with greater risk of harm to the patient (in this case, their teeth), the less comfortable they are with students unless they know them well. If they could somehow improve the continuity between attendings and/or residents, then we might get more opportunities to perform more procedures. Then again, is it really all that necessary for me to learn how to perform intubations? While I'd agree it's an useful skill, potentially life-saving, without proper equipment and frequent practice, I suspect it's more of a liability than aid not unlike instrument flight where while you can certainly become certificated and legal to fly in instrument conditions, lack of experience often kills as pilots fail to recognize their own limitations.

Healthcare (again)

Today I saw my first coronary artery bypass graft surgery. I have to admit - it was very interesting, seeing the beating heart, etc. However, the circumstances surrounding his surgery highlight a lot of the tough questions that I believe lie ahead for healthcare reform. Here is an elderly gentleman, 80+ years old, with multiple medical conditions, depressed including a history of recent attempted suicide, who had a massive heart attack and found to have severe coronary artery disease. Due to an unusual reaction with a common medication used to prevent clots from forming, the patient required special drugs during and after the surgery. These medications costs upwards of $8,000 per vial, and multiple vials had to be used. The patient was also at great risk of bleeding out from the surgery, and his risk of dying right on the operating table was relatively high. The total cost of this marathon 7+ hour surgery will probably be in excess of $200,000. All this for an elderly gentleman who didn't want to live in the first place?!

I'm not advocating that we let people who attempt suicide to die (or to "finish them off"), but if we are to advocate for "healthcare for all", we must be ready to draw the line somewhere. Drawing the line is easy when we don't know the person - most would probably agree that this surgery might represent one of the "horrors" of American Medicare/Medicaid system, but to those who knew this man - who cherished his presence while he was awake and alive, would probably strongly disagree. So who draws the line, and when?

Compensation

Why is it that so many physicians I now meet talk about reimbursement rates, poor salary/pay, etc.? The talk almost always centers about the disparity between what they do and how they are compensated. It bores me to hear such talk - mostly because I care little about it. Work should be what I enjoy - and if I'm paid to do it, so much the better! But how much am I paid, I care not - so long as I'm able to survive. And by survive I don't mean a large house, fancy cars, etc. I'm earning a stipend now of $25,000 per year before taxes, and I'm still able to save $16,000 over the past 10 years. I'm not poverty stricken - I'm living well, having gone through flight school and financed the purchase of many computers and computer-related hardware (I tend to upgrade nearly annually). So my point of view is rather simple - anything more than $25,000 per year is simply icing on the cake. Put in that perspective, I can get just about any job - even working at a fast food restaurant, and I'd be paid sufficiently.

What really bothers me about all this talk, however, is clearly how hypocritical so many physicians are. On one hand, they all claim that they enjoy this job no matter how poorly they are paid. But then on the very next breath they go ahead and complain about the pay! If they really didn't care, then it wouldn't be an issue, would it?

What's my role?

There we were - 45 minutes into the procedure, multiple puncture sites in her large back, and still no success. A large, obese lady (BMI>40) just came out of surgery and was in pain. Acute pain service, my rotation for the day, was called to evaluate and possibly place an epidural catheter to deliver analgesics and narcotics into her spinal area directly. Due to her large size, we had to try multiple times and use ultrasound guidance but none of it was working. The poor lady was in pain, but worse of all was the nurse on the other side of the patient. For the procedure, it's best if the patient is leaning forward, sitting up on bed with her leg hanging off the side. As this patient was still a little dopey due to pain medications, she needed help in staying upright. The nurse practionner on the acute pain service was helping position the patient and this included holding her shoulders and propping the patient up - in essence having the patient lean against her. Remember - this is a large, 300 pound lady resting against a small, short, nurse who can't weigh more than 120 pounds. I could clearly see that she was struggling, and I was not alone. Another nurse asked if she needed help, and she said no the first time. I was observing the whole procedure on the opposite side of the patient.

Normally, I would offer to help - and believe me, the thought came across many a time while we stood there for the 45 minutes (which became closer to an hour). I was torn - on one hand I felt awful having the poor nurse prop up this beheomoth, yet on the other hand I wanted to observe the procedure and see how they handled this difficult case. It struck me then - my role was to learn, not help. We later called a clinical assistant who came over and helped. All this time while I was on the floors I tried to be helpful, do something productive. I never minded the "scut" routines. Yet in doing this I've clearly interferred with my learning opportunities. This particular example was simply an exaggeration where I had to choose between helping or learning. In the end, I chose to learn and stayed put. I was uncomfortable with my decision, but ultimately, I think I made the right choice.

Am I ready?

As the fourth year of medicine comes to a close, I cannot help but feel woefully unprepared for the practice of medicine. A lab mate tripped and fell on the escalators. At first I pretty much ignored his injuries - the mechanism of the fall didn't sound serious at all. The other first year medical student in our lab started to do all sorts of things to the wound. Finally I spoke up and suggested that they use gauze as opposed to bandages being a much more efficient manner to cover a large area without too much adhesive (perhaps the most painful component of small cuts/bruises). It was at this point that I noticed his cut appeared rather deep. It looked like a 3-4cm long laceration about 5mm deep with separated edges about 5-7mm apart when he flexed his knees along the patellar region. I thought stitches might help close up the wound and help it heal faster. I accompanied my friend down to the emergency room - tried to "fast track" him but was turned down and had to go through the entire registration process. Finally we arrived back where we started and the resident came in to examine the wound. He took a look at it, manipulated it somewhat, and then said there's nothing to stitch, all the needed was a bandage and he's done. I felt like an idiot - here I am, 4th year, about to graduate, and I cannot distinguish between a serious wound and one that merely needs a dressing?! I think I was mislead by the appearance of the wound, and that further manipulation would have (hopefully) suggested to me the same course of action - bandage and leave it alone. Nevertheless, it does make me wonder whether or not I have what it takes to become a true practicing physician.

Anesthesiologists

Spent my day at the chronic pain center where patients with debilitating, chronic pain are treated. Many of these patients are clearly suffering - they arrive at the clinic only after "failing" standard medical therapy for the most part. There are always the sob stories of patients who get bounced from doc to doc with their pain complaints ignored or untrusted, only to finally get vindication when the doctors at the pain clinic find something, diagnose them, and treat them with pain medications.

The problem is, pain is not visible, palpable, nor detectable by any person other than the one feeling pain. The feeling/perception of pain itself is not really all that well understood. Yet, the pain medications do work at blocking pain reception/perception. So it's not really all that surprising to find a story of a patient who suffers from intractable pain that nobody can really confirm, find some sort of radiological or physical exam abnormality that appears to explain the source of the pain, and then treat them with pain medications with relief. Truth be told - the findings could be completely incidental and not the true cause of pain. By now my attitude on chronic pain clinic is probably apparent - I'm not a believer.

The experience in the clinic did not change my opinion on chronic pain management but did alter my perception of anesthesiologists. I know that the statistics show that they are frequently abusing drugs, especially narcotics. It has often been blamed on their knowledge of medications, side-effects, and what I'm going to call hubris in believing that they themselves know how to administer the medication safely to avoid addiction/withdrawal. My observation of their behavior, however, suggests another far more human reason why they are more likely to become drug seekers/abusers.

As anesthesiologists in chronic pain management, they encounter people suffering from tremendous pain all day long - pain that again is invisible. It's hard to imagine someone else's pain, and more often than not we tend to over- or under-estimate the severity. The gratitude that comes with relief when a patient receives a pain-blocking medication is rather clear and obvious, however, despite again a lack of objective measurement. I believe these encounters result in the development of extremely low tolerance of pain/discomfort for these anesthesiologists. While on one hand this is extremely beneficial for the patients, and these doctors will appear compassionate and caring, it's a disaster for the physician himself. The low pain/discomfort threshold makes these doctors turn to pain-blocking procedures/medications and often perform it on themselves also with relief. It's then only a matter of time before they become psychologically, if not physically, addicted to pain-blocking medications as the most human instinct takes over - avoid pain.

I don't think this will ever change - and I believe this to be an occupational hazard, not a self-selection of drug-seeking/abusing people into the field/specialty of anesthesiology.

Medical education

I guess as students as will, inevitably, have to practice at some point. In the OR, while the patient is under anesthesia, it is remarkably easy to practice without causing undue pain to the patient. This is not to endorse senseless extraneous procedures on an anesthetized patient, but students must learn somehow. I guess I'm trying to rationalize my experience today in the OR. It all began innocently enough, with a very nice attending who went on to demonstrate and then permit me to practice insertion of a peripheral IV and then a laryngeal mask airway. These went rather well, although my initial attempts at mask ventilation was a bit difficult. Hopefully the patient didn't become hypoxic during my "practice session".

Then, we had a patient who required endotracheal intubation. An elderly, frail lady who also required large bore peripheral IVs. Mask ventilation went much easier with her, although there was some air leaking at some point. The trouble began when I attempted to insert the large bore IV. I had trouble, and then the anesthesiologist also had trouble. In the end we ended up poking quite a few times at the patient. While it's not entirely my fault, I feel that my presence is what started the whole thing. The anesthesiologist, trying to be nice and teach, also felt tremendous pressure to perform while the surgeon rushed ahead with the surgery. The delays incurred in trying to teach me as well as permit me to practice left the anesthesiologist behind the curve, so to speak. As a result of the pressure, the patient had to endure additional pokes - thankfully all under anesthesia, but I'm sure when she awakes and sees all the bruises my lesson will have cost quite a pretty penny (figuratively speaking, of course).

Consent

Heard an interesting comment today while on my first day in Anesthesia rotation. A few residents were just sitting around chatting, and got to discussing Spanish-speaking patients. In general, they tended to prefer them despite the language barrier because the residents felt that the Spanish-speaking patients were usually more relaxed and more compliant compared to American patients whom they felt were extremely anxious, in general. That got me thinking - is it that the Spanish-speaking patients are simply more trusting of physicians in general, or is it that they are simply more relaxed? I think it might be cultural - perhaps in European culture the notion that the physician knows best still remains. Here, in the United States, expectations have become so high that short of a perfect outcome, patients demand some sort of retribution/compensation, usually through a legal recourse. Perhaps the American patients are more knowledgeable, more read-up via the Internet, but then many will probably also scare themselves into imagining the worst possible diagnoses much as medical students often do. What's better - a well informed albeit potentially arrogant/litigious/anxiety-prone patient or a relaxed, compliant yet naive/ignorant patient?

Patient autonomy

If a patient has been declared to be unable to make medicine decisions for himself, and thus is not consentable - what happens if the patient has occasional periods of lucidity? We were assisting in the lumbar puncture of a rather severely demented elderly patient, yet at times I thought his words made some sense. The procedure was rather lengthy due to the presence of large, venous stasis ulcers on his legs making it difficult to turn and position him. At first he was cooperative but clearly not quite understanding what we were about to do. When we finally began with the local anesthetic, he started to complain and wanted us to stop.

Should we stop? It sounds like a reasonable request - in fact, if he had been any other patient who had been deemed competent we would have been forced to stop. But I guess since it was also rather clear he didn't really understand the rationale and the need for the procedure, it would be unethical to listen to him and stop since that's not really an informed decision, is it?

Yet, it seems rather incongruous, to say the least, when he has some semblance of rationality, to completely disregard his demands. We tried to make him more comfortable, including keeping him informed as to the progress, but it was a slow output tap and collecting those 4 tubes took much longer than I had anticipated (note to self - never say, "almost done" to the patient - it just makes them much more anxious). In the meantime, the patient had began to threaten us verbally - saying he's calling the police and will "see [us] in court!". Wow - the first time I've ever been threatened by a lawsuit!

I've dealt with patients with dementia/delirum before, and it was rather easy - you kind of just ignore they non-sensical babble or talk along with them but not really listening to the content. In Winthrop, I've had many an alcoholic hepatic encephalopathic patient who had to be strapped down to the bed, but they were, for the most part, benign. They would obviously request that the restraints be removed, but that decision was not mine to make so that made interactions with them so much the easier.

Being an active participant, however, in this invasive procedure, made matters rather different/difficult. I'm now personally, actively, restraining the patient, in a way (more for his own safety given that he's got a nice sized needle sticking out his back) despite his protests. It's uncomfortable, and goes against the doctrines of medicine: Primum, non nocere (First, do no harm).

Harm whom? Clearly, the patient. By whose standards? Ah - that's the tricky part, no? Is the decision made by the omnipotent/omniscent physcians? As a collaborative agreement between the patient and the doctor? Or, in this case, between the healthcare proxy and the physcians? Where then does the patient fit into all this?

I guess one would argue that as the patient had, previously in his right mind, appointed a healthcare proxy for situations just like this, he is represented virtually through the proxy. Yet how often is it that the health care proxy is a close loved one of the patient? Don't you see a conflict of interest there?! Just look at the past cases involving persistent vegetative state patients and the conflicting interests of familys/spouses/etc.

Perhaps it's time to re-examine the idea of a health care proxy...or perhaps it's time to educate the public that sometimes, choosing your own spouse/close family as a proxy isn't the best idea...

Level of vocabulary to use with patients

Here's an interesting dilemma I noticed today. How do you talk with patients? Do you use complex medical jargon so that the patient is completely lost? Or do you tone it down to an eighth-grade educational level (supposedly that's the average reading level in the United States?!) so that they can understand it? On one hand, we are accused to being lost in our own ivory tower speaking techno-babble that the "commoners" don't understand - perhaps in an effort to befuddle them and make them believe that we are doing "important things". On the other hand, when we try to use simpler words some patients might feel insulted and patronized. How to choose the right balance?

A good friend of mine was just recently admitted to the hospital for an acute stroke. I won't dwell on the ethics of having someone I know as a patient, but suffice it to say that luckily, as things turned out, I never did round on him nor follow him as a patient. While fortunate from an ethical point of view, this ended up being a detriment in my later interactions with him. You see, they saw some unusual spots in his MRI and wanted to do a slew of additional tests. It didn't help matters at all that, being a very popular guy, many friends and family members were coming by at all hours visiting him. As it turned out, many different family members got only a piece of what was going on, and in the end the poor guy was confused as to what the plan was or why he was even in the hospital! He became to frustrated he ended up having to call up a friend who's another physician at the hospital to try and find out what's going on.

It was at this point that I discovered he was in the hospital, and I had only a brief conversation with him. But it was clear that he was confused as to what he was being worked up for. I managed to track down the resident and told her the issue, and she re-iterated that part of the problem was that she kept explaining things to different people.

Nevertheless, we went back to his room where I stood with the resident who outlined the entire reason for his extended stay and why we were working him up. She used all sorts of technical words and I could see that the poor guy was getting lost. So I waited until the resident left and I asked him if he had any questions. He said he understood most of what the resident said, but the thing that's really concerning for him is why did he get a stroke in the first place, being relatively young for strokes, and what's the odds that he might get another one since imaging showed a history of multiple old lacunar infarcts?

It was one of those rare moments that I felt I could actually help someone as a student - not relegated to simply observing or doing the biding of a resident/intern/attending. I explained the whole diagnostic process to him in detail - starting with the initial MRI findings which were repeated, followed by additional tests including a lumbar puncture to exclude an infectious etiology, and that the fact is we may never know the reason for his stroke. I explained that we were working him up for vasculitis or other hyper-coaguability studies, but I thought that the odds of one of those tests yielding an answer was rather low. We both acknowledged that he's been a heavy smoker (in fact, I just found out right then and there that he had quit for 3 months prior to the stroke - what injustice!) and that smoking cessation probably helped the most in preventing a recurrence more than the anti-platelet therapy they were going to start him on (Plavix).

While I told him that the answer was simply, "We don't know" and we'll likely not know - he seemed to appreciate this much more than the former complete unknown. Sometimes, I guess the fear of the unknown can be great, but understanding helps to alleviate some of the fear even if the final answer still eludes you.

In retrospect, I wonder if smoking cessation was what triggered his stroke? Could his arteries be so accustomed to the nitric oxide present in his blood that the abrupt withdrawal resulted in vasoconstriction and then a stroke? Hmm...an idea for a literature search...

When to speak up

As we were rounding this morning, the patient we saw was clearing getting quite agitated. He was suffering from an exacerbation of myasthenia gravis (MG), and to compound things he has a wife at home with muscular dystrophy. Unfortunately, as physicians, we often focus on the "important" things - items/diagnoses that will kill you. Then, we work on other more symptomatic relief. Yet this patient was not at all concerned about his muscle weakness or difficulty walking - he wanted, above all, to be able to eat! See, his MG had made it difficult for him to even swallow food, and at one point he was even choking on liquids. Despite our best intentions, he felt his concerns about not being able to eat was not being attended to - rather our focus on his over-all well being was clearly getting annoying to him. We figured that the diet could always be changed to accomodate his dysphagia, but for him - food was the main reason to live. In the end, we finally did get there - a compromise was made (no dietary restrictions given - he would choose himself which foods he thought he would be able to eat given his fluctuating severity of dysphagia), but for quite awhile as we stood in his room I felt like saying something - some to smooth the waters and try to act as an interpreter to get him to understand our perspective and vice versa. Instead, I bit my tongue. I didn't want to speak out as the attending was talking with the patient, and I also didn't want to appear to imply that the attending was not making a connection with the patient's true concerns. Sometimes, I get a feeling that they do it on purpose - they do not wish to address those concerns for a specific reason, perhaps because they feel it will steer the conversation towards a route they'd rather not explore or discuss. Othertimes, I think it's just plain mis-communication, often under the umbrella of traditional medicine. It's times like these that I have to consider - just how much of a patient advocate should I become? Do I jeopardize my own educational career to further this patient's interests? What about my own? In general, a happy patient is one who will increase your educational stature/grade/performance, but not if it comes at the cost of irritating an attending. What to do?

Multiple Sclerosis Clinic

Today we saw a number of multiple sclerosis patients in clinic today. For the most part, these were young to middle-aged patients all doing well, coping well with the relapsing/remitting nature of this chronic illness. This - despite the lack of effective treatment or therapy and lots of trials/guesswork. Amazing how strong hope lives in people - is it denial or survival? The responses sure do vary, too - from patients who remain eternally optimistic despite the worst prognosis, e.g. primary progressive MS, to those who overly focus on their deficits to the point of creating new illnesses that lives only in their minds (yet I'll bet are just as real as a true disease process).

Most of these therapies, like insulin-dependent diabetes, require daily or every other day injections. Many bring with them serious side effects. And yet, for many, these therapies, like insulin, are preventative as opposed to frankly therapeutic. They are designed to prevent recurrence of MS (or in diabetes, prevent diabetic comas). For this promise (a promise which may remain unfulfilled - a realization that most of these patients are cognizant of) - they are ready to suffer injection site soreness, flu-like illness, and frequent self injections.

Yet - why should these patients trust us? We spew out data - regurgitate studies, etc., and for the most part the patients go along with the proferred promises - is it with hope on their part, or blind faith/trust? Does it matter?

For that matter - even when told about the serious potentially fatal yet rare risks - why would one choose one drug over another, safer, drug? It's true that one is more convenient - monthly dosing versus every other day, but is that worth the small yet finite risk of certain death from an adverse reaction? The choices these patients make confuse me - I can make no sense out of them, presumably because I can't fathom their motives - be it blind faith in science, medicine, or simple hope or instinct for plain survival?

Spending time with patients

I've alluded to this before, already, that I'm against the constant rush of medicine from patient to patient. Today was another example. We had a patient who's been abused as a child resulting in traumatic brain injury on top of pre-existing cerebral palsy who's actually been doing quite well, married and working a regular job and ambulates around the house but uses a wheel chair outside her home. She came in for an acute exacerbation of her back and leg pain - pain which was previously well controlled by her pain management specialist - likely caused by some minor trauma worsened by her anxiety/frustration/stress. It was rather clear that the majority of her problem lay in coping with the new pain and the accompanying mental anguish. Her moods were rather labile as we later found out - during our interview she was extremely pleasant, sometimes tearful, but always polite. When we returned to check up on her she suddenly exploded in a fit of anger that rapidly became tears of frustration complaining that her pain was not being adequately treated. I felt truly sorry for her, and when the resident left to find a nurse she demanded that I stay by her side. I did feel a bond with her as I had interviewed her first, and could see that what she needed more than any medicine was simply someone to listen to her. She continued to cry and remained anguished despite my attempts to calm her down, and finally the resident called me over and I left her hurriedly. As we walked away from her, I thanked the resident for pulling me away but now I regret my action. I had clearly abandoned her in her moment of need. I used the excuse that my resident told me to follow her as an explanation for why I abandoned her, but that was a very weak excuse. She wanted to call her husband, probably someone who would listen to her and comfort her, but unfortunately my cell phone didn't have reception in the hallway. That was one of the major issues, I felt - her lyingi n the hallway. This is someone who's struggled against so many adversities that she cannot simply lie still. She wanted a TV, a book, anything to occupy her mind. I understood - I would be in similar straights if left to lie in a bed for hours on end without anything to do. We were waiting for a room to open up on the regular floor, and there she would get much more nursing attention than lying in the ER hallway where the nurses are outnumbered by the patients in a riduculous ratio.

So what did I do? Nothing. Absolutely nothing. I fled with the tail between my legs when the resident called, and then pretended that it was a relief to leave her. It was, truly, a relief in the same manner as not having to perform some courageous act simply by the command of another. Yet at the same time there was a feeling of shame, embarassment, if not inadequacy, in running away. I wanted to return to her and tell her good bye at the very least - not dissappear suddenly without any explanation. I feared that she would feel even more abandoned and become more aggressive/frustrated which serves only to alienate her nurses more and sets her up for a long, painful, and lonely night.

Yet I was a coward - I simply followed the resident back upstairs and tried to put her out of my mind. I hope she finally was able to speak with her husband, and hopefully got the pain medication that we asked the nurse to provide. It's so bad that I'm worried about seeing her again on Monday if she's not discharged. There's really no reason for her to stay, but if she ended up in the hospital on Monday, I'm not sure I can face her honestly after abandonning her like that.

Unfortunately, much of medicine stresses the efficiency and thus my talking with her, trying to comfort her, is actually frowned upon. I feel embarassed if I were to voice my opinion that I should return and see if I can somehow calm her down some more before leaving. I knew we had lots of other things to do, many more patients to see, but is that an excuse for ignoring a patient's concerns? Where do we draw the line between efficiency and sub-optimal care? Can we truly afford an one-on-one environment? This is where I think house visits (back in those days) had the advantage. Why can't we spend that same amount of time, dedication, per patient? With all the new technology, why can't we dedicate more face time with patients? Is it all in the name of capitalism that medicine strives for efficiency?!

Clinic

Today was my first foray into ambulatory neurology or "clinic". The day went by fast, and I re-learned quite a bit about the neurological exam. In testing for hearing loss, I got confused about the bone conduction versus air conduction. For some reason I remembered that bone conduction was more sensitive than air conduction, and thus performed the test backwards. No matter - it just means I have to review much of this material.

On the floors, we encountered another interesting case. This is an elderly gentleman who's had a long history of vasculopathies (diabetes, coronary artery disease including by-pass surgery, hypertension, etc.) and had a left cerebellar infarct about 6 months ago. At that time, they found an occluded left vertebral artery and a stenosed right vertebral artery. The plan was for him to get a stent placed into a vertebral or basilar artery but when he went for re-imaging to assess his vascular status, new acute and semi-acute right cerebellar infarcts were found. Listening to his story, they may have coincided with "falls" or questionable loss of consciousness. I was then tasked with reading up on bilateral cerebellar infarcts and after clinic that day I was able to peruse Medline and gather a few articles. Regardless of the etiology, it was rather clear by a decent sized study that his prognosis was not good - those with bilateral cerebellar infarcts in general tended to do worse, had more unpredictable hospital courses, and likely (but not proven) greater recurrences. Meanwhile, in terms of etiology, I believe it's quite likely that his severe atherosclerosis (manifested by his stenotic vessels and coronary artery disease and hypertension) made him vulnerable to atheroembolic strokes. As to why the cerebellar region, several papers seem to point at the lack of sufficient collateral perfusion when stenosis is present.

You can imagine my surprise, then, when cardiology came up and after an echocardiogram showing improvement in his ejection fraction (35%->45%) but questionable new lesions in a perfusion study was considering re-vascularization procedures! I asked the fellow if they were at all concerned about additional strokes given his severe atherosclerosis, and while she acknowledged that it was a risk, she felt it was not a great risk as the strokes did not appear to be embolic in nature but rather more consistent with hypoperfusion. I disagree with that notion, given that most hypoperfusion infarcts are not territorial, tend to be small (<2cm),>2cm) while his new infarcts from two different incidents were less than 2cm there were still localized to the posterior inferior cerebellar artery (PICA). Given his stenotic/occluded vertebral arteries, I fear he is in grave danger of new cerebellar infarcts. Since he was previously ambulatory around the house and didn't give any indications of cardiac deficiencies, e.g. shortness of breath after light exertion or chest pain indicative of ischemia, I'm not sure if re-vascularization is appropriate for him. If he were my grandfather, I think I would have resisted on the grounds that the risks are too high. Until he becomes truly symptomatic from a cardiac viewpoint, I don't see the need to do such an invasive procedure. His reason for admission was really from an incidental finding on MRI indicating acute cerebellar infarct, but he remains asymptomatic except for his "falling spells". Once we've ruled out syncope as the case of the falls, then I think it makes much more sense to "fall-proof" his home, perhaps physical therapy/walker, rather than continue to meddle with his body. I would hate to see him reduced from an ambulatory, semi-independent person into a comatose or severely disabled from additional cerebellar strokes. But as a student, I can do little but stand by and watch. Should I have been more vocal in my opinion with the fellow? She got her information from the notes left by Dr. Gerber the attending who has vastly more knoweldge and experience than I. Where exactly does the medical student stand as a patient advocate?

Rounds with Dr. Gerber

I'm rather excited about Neurology and am now wondering if I've made the wrong choice to pursue Internal Medicine! We had a grand total of 4 patients on our census, and with the 3 residents, 4 students, and one attending, we outnumber the patients 2:1! But that's not what excites me about neurology. For the very first time I was able to see evidence-based medicine at the bedside. We have 2 rather unusual cases, and after discussing them the attending, Dr. Gerber, went immediately to PubMed and searched to find case reports, reviews, articles, etc. that would substantiate his hypothesis or generate alternative explanations. But I'm also missing an important point here: Dr. Gerber, the attending, performed a full physical after a thorough, focused, history on every patient while we were rounding. Amazing! Never before have I seen an attending perform a full physical, often relying on the reported abnormal findings from the residents and focusing on the problem at hand. While there's nothing wrong with either approach, I feel that I learned much more from a complete exam than a focused one. The former has the advantage of being thorough, but the latter is much more efficient.

This makes me realize how important it is at various institutions to enforce a limit on the number of patients a person sees. While I understand that part of the training is how to handle a large number of patients effectively and efficiently, I also feel that this "rushed" medicine doesn't give patients the full attention they need and reinforces the message that it's ok to do just the minimum in order to get through all the patients. This might be ideal setup for future practice where your livelihood is dependent upon the number of patients you see, but I feel it's completely contradictory to the idea that we should be the patient's advocate.

The transition

I didn't get to see any patients today - it was mostly lectures in the morning followed by case-based discussions. Once again I was reminded of how much I have forgotten, and yet also how much I still retained. Bits of pieces of random knowledge flit through my head as we go around the table asking and answering questions. All I recall from Neuroscience was falling asleep staring at the pictures of brain slices projected on the wall, and hallucinating about Mickey Mouse ears in the spinal columns. Yet, random items like the "reticular activating system", "corona radiata", jump into my head without bidding. Nevertheless, unable to make sense of much of the jumbled up bits of information, I'm dreading all the reviewing/reading I will need to catch up. I write, "Get textbook" as one of my "To do" items, along with a list of new terms I just encountered.

This transition is reminiscent of my return to medical school from graduate studies. For the past two and a half months I've been spending time in my old research lab trying to wrap up an old project and starting a new, exciting project. When I'm in the lab, I feel on top of the world - confident in my surroundings and familiar with the words, phrases, etc. of my field. When I'm in the hospital, I feel like a first year medical student all over again - timid, unsure, and uncomfortable in the basic tasks of getting a history/physical and formulating a differential. I find I much too often zoom on on a particular diagnosis and have a hard time pulling back and considering other options.

It's weird - in science I can often scrutinize the reports of other people's work as well as our own result and often bring up alternative explanations for the results. I do this to challenge the conclusions and when I'm out of objections I finally consider the results/conclusions valid. Why is it that in clinical practice I'm often unable to do this? Given a presentation, certain ideas jump into mind and I have a hard time thinking of others. Part of the problem, I believe, lies in my lack of confidence and lack of fund of knowledge, but partly also from the practice of medicine itself. I like coming up with a hypothesis and then testing that hypothesis with conclusive, diagnostic tests. However, oftentimes in medicine this is not possible. We can't always perform a biopsy to see what's going on. I feel that medicine is all about gambling - we all strive to beat the house by knowing the system, knowing the odds and betting on the odds, but rarely do we get a definitive answer. Empirical trials of drug therapy are all too common, and many of the "syndromes" and "diseases" are defined not by pathohistological/molecular/genetic standards, but rather descriptions. So many different causes can all yield similar outcomes, yet we all lump them together into a single syndrome. And then on the other hand, we have the genetic/phenotypic variability inherent in individuals that take a single causitive agent, e.g. infection with B. burgdorferis or Lyme disease, and generate multiple, different outcomes. What is medicine, then, if not simply guessing? We take a collection of symptoms and guess at the most probable cause (based on historical data) and then attempt to change the course (often with empirical trials).

Ever wondered how they got the "probability of precipitation" estimates in weather forecasting? That's right - it's a guess based on historical data compared to present day observations. Medicine is no different. We're simply glorified weather forecasters or car mechanics (more on that analogy perhaps in a later post), and that irks me.

It's odd that many physicians downplay the role of imaging - they pride themselves on being able to predict the outcome without resorting to expensive MRIs, CAT scans, etc. And yet the gold standard often remains "taking a look" - be it a surgical operation for a first hand look, a biopsy specimen for microscopic examination, or MRI/CT scans for imaging without having to open up the body. I see nothing wrong with looking at the inside of the body no matter how confident you might be in a certain diagnosis, because as I've alluded to before, it's most likely drawn on nothing more than probability, guesstimates. I believe that if we ever develop a truely non-invasive, fast, non-toxic internal imaging system, it would revolutionize medicine and change it from a "practice" to a "science". The alternative, of course, would be some sort of no-risk surgery. This idea, however, is what will ultimately doom healthcare with exorbitant costs - but more on that later.

Medicine in Contemporary Society Requirement

Part of our school's graduation requirement is some kind of ethics/morals projects titled "Medicine in Contemporary Society". I chose the diary option as it's the most flexible from all the other choices (formal lectures, supervised projects, etc.). I often find myself holding opinions rather different from the mainstream, and I felt that writing a diary entry reflecting on my clinical experiences would be a great medium to express some of those opinions without having to argue for them (not that I don't believe in them sufficient to stand up for them, but sometimes it does get tiring to keep explaining myself). So, I'm going to go ahead and write them up in here and then print it out at the end.

Today we have off for Martin Luther King's day. Tommorow, I begin Neurology.