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.

Lack of personal responsibility

It seems to me that recently there has been a move towards avoiding personal responsibility - after all, if something goes wrong, so much the better to blame someone else rather than yourself, right? I was just listening to NPR's "Talk of the Nation" asking the question, "Who's to Blame When You Get Drunk?" and I'm disgusted to hear talk of making the bartender responsible (legally and morally) in cases where the person is obviously intoxicated. Wait a minute - was the bartender force feeding the alcohol to the patron? Who qualifications does the bartender possess to be able to make this determination of obvious intoxication? Is the bartender liable to further civil suits, e.g. if he refuses to serve someone of another race and is then accused of racial discrimination?! Further, where do we draw the line? I see hardly any difference between the scenario of a person who's clearly intoxicated purchasing more alcohol and being served and an obviously, morbidly obese person purchasing high calorie meals at a fast food restaurant. In both cases there are "clear visible" indicators (although again, I ask, what qualifications do the servers possess that will enable them to make this determination in an equitable and objective manner?), clear negative potential consequences (drunk driving, health-related issues including diabetes, etc.), and occassionally false/seductive advertising (strong proof than advertised/perceived, greater calories than advertised/percevied).
Ironically, I feel this attitude pervades even into the medical establishment. When something goes wrong, it's rarely a single person's fault, e.g. the attending. No, it's the system's fault - the nurses, pharmacists, doctors, and the whole infrastructure. Hence the whole emphasis on systems analysis. Whatever happened to ideas like commander-in-chief, captain of the ship, pilot-in-command?

In the air, there is always one person designated as "Pilot-in-command" (PIC), and no matter what else happens - even if air traffic control dictates one thing or other, the PIC is the sole person responsible for the safety of the flight. It's a serious responsibility, and one not taken lightly. I would venture to guess that a similar idea exists in the captain of a ship, and there is still some vestiage of that notion in drivers of vehicles - you don't see people complaining about system errors when they are involved in accidents/incidents - they are held accountable. Period.

Similarly, I feel the attending doctors should step up to the plate and take responsibility for everything - even the actions of the medical student. Ultimately, it's under his authority that the student is acting/learning. There should be an equivalent "Doctor-In-Command" principle and dictates no matter who says what, what rules exist or are absent, that doctor is ultimately the sole person responsible for the health and safety of the patient. Period.

So who's to blame when you get drunk? I think the keyword here is "...when you get drunk" Who decided to drink? You. Who decided to drink more than you should? You. Who decided to drive after driving? You. As others have pointed out in the comments for that NPR article, who decided to drive to a bar, intending to drink, and then walk out intending to drive home? You! Gee - who should we blame, then?

How about that argument that once you become intoxicated, you lose your ability to think clearly and make proper decisions. Gee - if a person became that intoxicated, and the bartender cut him off, where do you think he's going to go next? That's right - back into his 20,000 pound SUV and drive to another bar or go home. Do you think that a person who can no longer be trusted to make a judgement call as to whether or not he's had "too much" is perfectly fine to drive a vehicle? How does cutting him off from further drinks help this situation? Are you then going to have the bartender make sure that he's not driving? What if he walks back to his job (a surgeon, let's say) and kills someone? Who's responsible then?

Keys

When I was a kid, I used to love keys - they represented to me power and responsibility, I guess - a symbol of adulthood. I still recall being especially proud of having a nice large key ring with many keys - bicycle locks, house keys, and even keys for such small things as diskette storage bins, etc. Now that I'm older than 30, I find myself appreciating smaller key rings. I've since shed most of the ancillary keys, keeping just the bicycle lock, house, and car key. I hope it's sign that I'm maturing...

Comment on 2008 presidential election result

The elephant is in the room, and nobody is talking about it. Why is it that race is such a charged matter? For me, that defines "racism" - not the typical negative comments/feelings towards another race, but rather that any distinction is paid to race at all (other than for scientific purposes, e.g. determining phenotype/genotype frequencies and healthcare outcomes). The focus on race itself is racism, and not all racism is necessarily "bad". I'm just calling a rose a rose.

This whole thought started when I kept hearing, repeatedly on NPR, reports of how "little race" mattered in the Presidential election, how they were so proud that exit polls showed race only placed a part in the decision-making process of who the next president will be in 8% of all voters.

Well, I have a different take. Look closely at the exit poll results, and as many of the pundits are pointing out, the blacks overwhelmingly chose Obama over McCain. Nearly 100% of blacks in New York state voted for Obama according to their exit polls - how can this not be a reflection of race?

One might argue that perhaps the blacks simply liked Obama's platform better, agreed more with his views and political position. While this might be true, I find it incredibly hard to believe that he won over nearly the entire black population by his politics. Obama only gathered around half of the white population (and whatever happened to non-whites, non-blacks: Asians, Latinos, etc?) I find it very hard to believe that the decision to vote for Obama was not motivated by race.

I'll admit - even I (had I voted) would've been tempted to vote for Obama simply because it would be a historic event, just as if Hilary had been a candidate I'm sure she would've gotten a strong boost from women voters just do demonstrate that it's possible (and for this reason I worry about 2012 election if Palin decides to jump in).

Anyway, this is fertile ground for arguments and disagreements, so I'll leave it here at that. I just feel people should acknowledge the poor elephant sitting in the room to whom nobody is paying any attention. This presidential election was strongly influenced by race, and for that reason I, too, worry about what the future may bring. If Obama manages to miraculously recover this country's economy in one term (I feel the American public will be impatient and give him only one term), then all is well. On the other hand, if he fails or if the economy gets worse (very likely given the current financial situation coupled with the continued drain on resources due to the war in Iraq and Afghanistan), he not only will be be blamed for the outcome (wrongly, I feel), but it would cast a dark shadow for any future black presidential candidate.

In the pursuit of happiness

Just reading an old blog entry from a friend who pondered, "Is the pursuit of happiness all about selfishness? Can we achieve happiness without causing pain to others?"

I believe that the answer is "yes" to both questions. Happiness, by definition, is completely subjective and self-centered. True happiness comes only from being honest to one self, and therefore is "all about selfishness". One must disregard all other factors in the pursuit of happiness.

However, at the same time, there is no reason why happiness for one must cause pain for another. While one must entertain the possibility that happiness for two people can be mutually exclusive, a clear example where happiness is synergistic can be found in the traditional notion of a "romantic couple". It remains to be seen (at least for me) whether or not such a notion is entirely accurate or portrays a realistic scenario. More concrete examples can easily be found in the accomplishments of any group of people. Take, for instance, the profound joy and happiness the entire group of scientists and controllers at NASA must have felt on their Mars Rovers' success.

On the other hand, in any type of competition where there are clear winners and losers, happiness to the winner comes at the cost of pain to the losers. Life, I believe, is an eternal struggle - order against chaos at its most fundamental level. So while it might be said that happiness for one must come at a cost to others, considering that life is a constant competition (against death?) - that's a very narrow view precluding the possibility of cooperation, group formation, and team work.