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Monthly Archives: December 2007

Shadowing a pulmonologist (and one of my medical school instructors) today was very much like watching the 1993 NBA playoffs: I stood in awe of greatness. While I have described and hear others describe “great physicians,” I don’t find it customary to refer to “greatness” in any physician which seems more like an act of hubris than a compliment. However, the greatness in which I could find grounds for hero worship is less related to the pulmonologist’s considerable skill and sharp mind than it is to the large combination of factors that come together to create great patient care. Never in any of my many hours shadowing physicians have I found such a convincing endorsement of a particular field than in shadowing this physician.

There are many things in the doctor’s approach that are admirable. She works in multiple clinical settings and is acutely aware of small but important details in the workings of each setting that can be improved upon. The patients really like her: similar to the cardiologist I shadowed during my first year of medical school, this doctor’s patients readily volunteered their admiration and appreciation for her excellent rapport and successful outcomes. She pays close attention to details and seemingly unrelated mysteries: one patient had unexplained hypotension that was being treated with three diuretics (including a new one added on by the patient’s primary care physician recently), but the pulmonologist discovered that she had recently changed the face mask for her CPAP (continuous positive airway pressure) machine for her sleep apnea.

The patient had been using an old, broken mask that may not have been functioning properly, resulting in hypertension (high blood pressure) seemingly resistant to her previous treatments. Thus, it’s possible that she was being overtreated, and her blood pressure was now alarmingly low.

The patients themselves and the diseases they experience greatly affect the doctor-patient interaction. Unlike the common heart diseases I saw in the cardiology clinic last year, the pulmonary diseases these patients experienced (primarily asthma and COPD) are very symptomatic and very noticeably reduce quality of life. Being an asthmatic myself, I understand what it is like to not be able to breathe, and so I have great amounts of sympathy and empathy for these patients. Aware of their disability and suffering, these patients are a lot more focused on treating and fixing the problems so that they can live normal lives again. Furthermore, the action plans given by asthma specialists to their asthmatic patients seems to truly empower the patients into monitoring the status of their lungs and to prevent severe exacerbations. I had the opportunity to interview one patient alone, and for the first time, I actually enjoyed and was intellectually stimulated by “office-based” practice.

I learned a lot from this physician today, giving me a glimpse of my future career. I will be shadowing and working with more pulmonologists over the next few months in my (sparse) spare time, but as time goes on, I am leaning more towards this field over others (including cardiology, the other main contestant, and infectious diseases, neurology, etc.). A few other gems:

• I do want to work in academic medicine, especially for the teaching aspect. Additionally, I am interested in research, possibly of the clinical outcomes variety (to which the pulmonologist helped me find the right words) and trials of new therapies. My research interests are less in basic science and the etiology of diseases and is more towards the action-oriented nature of discovering new therapeutics, new diagnostic methods, and improving clinical practice.

• It’s a relief to discover that I don’t need to be doing basic science research to be in academic medicine, and that at least in Pulmonary and Critical Care Medicine, the clinical service can bring in more money for the institution than basic science research might. If I chose between an M.D. and a Ph.D., I would always choose the M.D. It’s really all about bringing money to the institution in which one is employed, and for the types of research I am interested in, I will have to make sure that I go to institutions that share those interests (e.g. clinical trials, clinical outcomes, health care delivery improvement, drug trials, etc.).

• After seeing both healthy and sick patients in the clinic today, it’s remarkable how much the quality of life improves with pulmonary care. And the patients are very aware of this fact, and their approach and relationships with their physicians adjust accordingly.

I can’t help but believe that there is a considerable number of occasions in which physicians and other medical personnel give patients the wrong idea. It’s not that the information is wrong or delivered without good intentions. Nonetheless, not unlike other fields, the management of information, particularly the ascertainment of accuracy and source, is a difficult matter for those who work in medicine. First, it is difficult for physicians (and most people) to retain massive amounts of information, particularly information that isn’t used on a daily basis. Most physicians store the information they use most often in easily-accessible places in their brains while maintaining familiarity with other related subjects. Secondly, the knowledge base of medicine is constantly and rapidly growing. Our medical school clinical professors frequently tell us, “This information will likely be outdated in five years, so you will have to stay up to date with the most current literature.” Thirdly, at least partly in agreement with friend and fellow blogger Eric, I suspect that many physicians have a poor understanding of statistics and epidemiology, leading them to believe in partial falsehoods passed on to them through teachings of questionable accuracy or unaccompanied by proper disclosure of caveats. Lastly, the information we need is often not available because it is too difficult to collect.

One example of the passing of information without proper disclosure of its flaws was readily demonstrated in a problem-based learning session for my second year Pathology course. It seems that whenever a patient is presented as “gay” in this course, the implication is that the patient is HIV-positive. However, I wonder whether our PBL writers, unaware of the effects of our learning in this course on our fledgling clinical acumen, are confusing the distinctions between risk factors and prevalence. I suspect that it would be difficult to accurately estimate the number of men who have sex with men (MSM, the medical term to avoid ambiguities of the social terms “gay,” “homosexual,” or “queer”), the demographic considered most at risk for HIV transmission, given problems with self-reporting. In the absence of such numbers, it’s not possible to accurately estimate the prevalence of HIV in the MSM population (the proportion of people who are HIV-positive). Instead, epidemiologists can only discuss incidence (the estimated number of new diagnosed cases each year). With respect to incidence, the proportion of HIV transmission in the MSM population is decreasing relative to other risk factors (reference). Instead of passing on the implicit assumption that all MSM are HIV-positive, medical students should be taught about the caveats and flaws of the available information: not all men who have sex with men, probably not even most, are HIV-positive, but they are a group that we should work closely with to prevent new HIV transmission since they are at risk.

Another example closer to my interests is tobacco smoking. I hate tobacco, but I don’t believe that we should tell every smoker and would-be smoker “You’re going to die of lung cancer.” Many people believe that the statistics don’t support this statement. The more we seemingly exaggerate, intentionally or unintentionally, knowingly or unknowingly, the more our patients will think to themselves, I don’t believe you. Instead, a better message might focus on tobacco smoking as the major risk factor in various cancers and chronic obstructive pulmonary disease (COPD, affecting approximately 20% of smokers), and as one of the biggest contributors to coronary artery disease. Or, we can learn how to better interpret the information we have and find information from accurate resources.

For example, a smoking patient might wonder, “What is my risk for getting (and dying of) lung cancer?” First, one should note that lung cancers are generally diagnosed at late “stages,” meaning that when the cancer is detectable and symptomatic, it has already grown into an unmanageable state (e.g. local invasion of other organs and metastasis to distant sites in the body). Accordingly, the five-year survival rate for lung cancer (the proportion of patients treated for lung cancer still alive after five years from the diagnosis) is relatively small – only 16% (40% are alive after 1 year, 27% are alive after 2 years). That doesn’t sound good at all, but what’s the risk of developing lung cancer for a smoker? According to the American Cancer Society, the relative risk for male current smokers for developing lung cancer is 23.3 times greater than that for non-smokers. For male ex-smokers, the relative risk drops to 8.7 times the risk for non-smokers. For women current smokers, the relative risk is 12.7 times greater than for non-smokers, and for women non-smokers, the relative risk is 4.5 times greater. OK, but what if that absolute risk is quite small so that even 23 times a small number is virtually nothing? Absolute risk data is harder to find, but here is some more perspective: the ACS states that women have a 1 in 16 chance of developing lung cancer during their lifetime, an men have a 1 in 13 chance. One might think, “That’s not so bad. I’ll probably not be the unlucky 1 in 13 (7.7%) or 17 (5.9%).” Well, that is the absolute risk data for smokers, ex-smokers, and non-smokers – an average of all three categories. Only about 20% of American adults smoke, which means that the other 80% are non-smokers or ex-smokers. Accordingly, the 1 in 13 and 1 in 17 numbers are substantially underestimating the chances that a smoker would develop lung cancer. Considering that the relative risk of developing lung cancer for smokers is 22.3 times greater for men and 12.7 times greater for women than that for non-smokers, the chance of developing lung cancer doesn’t look so small anymore. Combine this with the information that for men, there are 147,000 deaths to cancer every year, and while lung cancer, the greatest cancer killer in both men and women, amounts to 89,900 deaths per year, 104,200 of all cancer deaths in men are attributed to smoking (in women, 54,300 of 104,600 cancer deaths per year are attributable to smoking).

If we want to talk about death, though, we should be knowledgeable enough to speak convincingly and rationally. I believe, though, that with respect to tobacco smoking, we should discuss more the cardiovascular problems and lifestyle difficulties that smokers suffer throughout their lifetimes, not just at the end of their days. For all patients, we should know how to find information, determine its accuracy and validity, and then know how to communicate it meaningfully to our patients.

The month of December holds great significance for many people on this planet. Notwithstanding the religious holidays and historical contexts, I would like to think that December offers an unusual opportunity to be frank and open in our expressions of affection, companionship, and friendship. ‘Tis a season of sharing love and gifts with those close to us, a time for good will to all and celebration of humanity.

In this light, it would seem to me that December would be the best month to practice medicine. As circumstances might threaten to distance us from our patients, I hope that now, and in the future, it is possible to shed our oft-misused objectivity and seemingly aloof demeanor in order to share in this more generous exchange. As medical students, we hear our instructors stress the need to form a relationship with our patients, but I wonder how my fellow colleagues might interpret that charge. For many, I suspect that their natural instinct would be to make small talk about sports, TV shows, and other light-hearted insubstantia. That’s a reasonable direction to take, but I think this season affords a welcome opportunity to talk more about family, friends, and plans for celebration – whether those subjects bring happiness, anger, or sadness. True, not all celebrate the winter holidays in the same way or to the same degree. Nonetheless, our society sets aside this time for us to celebrate something, anything meaningful to us, and few would intentionally pass up the opportunity.

This month, I count myself lucky that I will have at least two lengthy clinic sessions and possibly a third shadowing session: if nothing else, I hope to remember each time to ask the patient about their plans for the holidays, be they alone, with family and friends, or a close companion. Last time, our patient commented on his brother being murdered during the course of the history-taking, and I instinctively expressed sympathy upon hearing it. I was surprised, though, that I was the only one to express it, and I thought for a while whether it was inappropriate to do so. In the end, I think it was the right thing to do, regardless of the patient’s feelings for his brother. Are we, as physicians, doomed to always be emotionally detached and separated from an exchange of emotions with our patients? I don’t think it has to be that way. If it is fair to express sympathy and remorse within this relationship, surely it must be fair to share warmth and thoughts of happier occasions?

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