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Monthly Archives: March 2008

If forgiveness of others for wrongs done to oneself lifts an undue burden of physical and psychological stress, then forgiveness of oneself should remove twice the burden: the grudge as well as the guilt. However, it would not surprise me if this latter task is very difficult for physicians and physicians-in-training: part of our training involves our hypersensitization to the consequences of our treatments, decisions, and interpersonal interactions with our patients. I believe the hardest challenge for me will be to find forgiveness for my own actions that harm another person, especially a patient under my charge.

For the past year and a half, I have maintained an online journal to facilitate self-reflection, a practice that is essential for physicians through the provision of periodic assessment of skills and performance and identification of areas requiring improvement. Although such self-reflection need not be exercised through writing, I have found that expressing my thoughts and self-criticisms, especially with public disclosure, has given me the opportunity to carefully evaluate my development in a transparent and feedback-amenable manner. The title of the weblog, Apollo, M.D., arises from my interpretation of Western medicine’s origins with Aesculapius, the son of Apollo and the god of medicine and healing: I find this characterization arrogant or at least naively idealistic, as it expresses the deified ability of physicians to do good for their patients without acknowledging the equally potent ability of physicians to do harm. Apollo, unlike his offspring, was a bringer of both healing and plagues: I believe this is a more accurate model for the modern physician, as we venture into the realm of illness and health without full knowledge of the consequences of our actions, even if we bear good intentions.

One of the greatest burdens I carry is guilt for a single action: a few callous words I spoke to my mother not long before she died. My mother is the source of most of my inspiration to pursue medicine as a life and career path: her wealth of love and compassion, her long and painful battle with a rare leiomyosarcoma, and her indomitable capacity to forgive all slights and harm done to her by others and the slings and arrows cast upon her by life’s unfair circumstances. It seems unfathomable to me that she could forgive a mother who didn’t notice that her 7-year-old daughter came home with a broken arm and who denied her the opportunity to pursue a career as a physician, instead sending her to the slums of New York City to work in sweat shops to raise money for her brother’s medical education. It confuses me that she could forgive me, then a selfish, self-concerned, and ungrateful boy, when I showed no respect or acknowledgement of the life of sacrifice she led to better and remove the hardship she had suffered from the lives of my father, brother, and myself. I immediately knew what I said was wrong, and what followed was the most painful and remorseful letter I have ever written, expressing the apology I then was too ashamed to say aloud. As I later sat by her side as she slept in the hospital bed during the last two weeks of her life, it didn’t seem unusual or unnatural to me that I knew my future path would follow the “pay it forward” principle. After many more years of soul-searching to determine whether or not my reasons for pursuing this path were meaningful and enough to carry me through the hardship, I am back where I started: I have collected many new motivations and reasons along the road, but a significant portion of my motivation still draws from my burden. I could not undo the wrongs I had done before she passed away, and knowing her, she would not have wanted me to make any special effort to appease her. Instead, this burden is now part of my responsibility and my duty to serve the world she saw fit to love, despite the hardships in her life.

Since that time, I have often found forgiveness of others to be an uncomplicated if not easy goal. Self-forgiveness, however, has become a much more challenging task. I suspect that it is easy for most people, including physicians, to rationalize their actions to protect themselves from the emotional trauma of guilt or the affront (of being wrong) to their egos. I hope that as I continue on my journey through medicine that I do not become desensitized to the need to be aware of my actions and their consequences for others: being a physician at this time seems to carry with it a degree of magnetism for excess criticism. Many people might choose to ignore this excess criticism completely, and then as time goes on, all criticism. Where is the time to be concerned with false criticism, or even guilt? In writing and in self-reflection, I hope never to stop listening to the my own internal critic, whether it agrees with other critics or voices the pain of another who chooses not to speak.

The past two years, and the two that will follow, are all about giving you knowledge…. But
the day will soon come when the dissemination of knowledge will cease. And on that day, will be first day of the rest of your life. The quality of your craft… and the magnitude of what you can do for your patients… will hinge entirely upon how empowered you are to teach yourself. The medical literature exists for this reason… not only to advance the profession’s collective knowledge, but also to enable physicians to extend their knowledge such that the world does not pass them by.

Your ability to teach yourself after medical school is entirely dependent upon your ability to navigate the road of the medical literature… Those who master it will eventually be great. Those who do not, will be antiquated even before the game starts.

These are the words passed on to my class by our Chief of Medicine. Medical knowledge changes and evolves very quickly, and it is imperative for physicians and physicians-in-training to constantly cultivate our minds, our most valuable tool in the art of healing. The medical training process places a strong emphasis on the prerequisite of demonstrated intelligence and the sharpening of our analytical skills. I see this as a two-pronged approach: the honing of our minds to make it a more effective tool of analysis, and the maintenance of knowledge hygiene to help us differentiate between truth and falsehood.

However, it is a difficult task, and one that many people are not eager to do. It’s too easy for students to focus on what is “enough” or “sufficient”: the amount of knowledge we need to know seems to keep growing beyond the capacity of our slowly expanding minds. On the one hand, I wonder if it is too early for my class to be exposed to medical literature in detail (such that they might not understand its importance); on the other hand, I think that this is a late introduction, perhaps too late for some to develop a level of comfort that makes the reading and critical thought feel natural. Today, while leading the discussion of a paper in the first of three journal club sessions of a small group of classmates, it became very obvious to me that several of my classmates are quite proficient in mentally handling medical research (i.e. being able to discuss a study on an unfamiliar topic) and several more of my classmates are possibly reading papers for the first time. I remember how painful and tedious those first experiences were. Nonetheless, it’s necessary to resist the urge toward mere “adequacy”: it is this tendency that has entrapped our predecessors in the habit of allowing themselves to be swayed by the marketing of pharmaceutical representatives, too often not to the benefit of patients.

On this backdrop, it’s hard for me not to find reason to be disgusted in a seemingly distant event: the attempts of the pharmaceutical company Pfizer to force the breaking of confidentiality of reviewer reports for clinical trials on Pfizer’s drugs published in the New England Journal of Medicine. Many might wonder what might be the relevance of this legal action. There is nothing “sacred” about the peer review process: it’s quite simply an essential condition for the proper evaluation of scientific research. In order to properly evaluate studies, editors of journals ask a few intelligent leaders within a field to read and critically evaluate studies before they are accepted for publication. In this process, experts in a field are able to weigh in on the findings, see if the findings make sense and match the assertions of the authors, and suggest the new for additional experiments or additional evidence to support the claims. This is a confidential process, and the importance of the confidentiality lies with the reviewer: some wish to have confidentiality, others might not and would be happy to speak directly to the study’s authors. However, when dealing with giants, one must be careful: good scientists who have spoken out against giant pharmaceutical companies are often targets and can end their careers in the fight for truth. The confidentiality of peer review protects physician-scientists and non-physician researchers from the heavy-handed tactics of industry and other groups who have strong financial interests in the publication of positive or negative studies related to medical treatments.

Without this measure, we live in a tyrannical environment predicated on fear and marked by the further silencing of those who would seek to uphold the truth and protect us. We, physicians and future physicians, rely on the distribution of new, truthful knowledge by medical journals, because we have no guarantee of truth offered through the brochures, presentations, dinner talks, and advertisements given to us by pharmaceutical and biotechnology companies. We rely on our peers, our fellow physicians, and not those who wish to use us.

This is by no means an attempt to cast a halo upon journal editors: they may have bias, they may have fault in their reasoning, and they may have agendas not in accordance with the well-being of the public. However, it is the universal task of journal editors to critically evaluate research and determine its truth and relevance. The more they strive for truth and succeed in this task, the more they are respected and the more their selection and opinions are valued. To this end, it’s not for naught that NEJM is the most respected, valued, and competitive of medical research journals, and similarly, it’s not surprising that it is frequently the target of attacks by the pharmaceutical industry and other interest groups who would like to see this measure of protection eliminated for their financial gain. Which brings me back to my class and our begrudging task of learning how to navigate the medical literature: Please learn this skill, for we are surrounded by a confederacy of dunces that seeks to take advantage of us to the detriment of ourselves and our patients.

“When a true genius appears in the world, you may know him by this sign, that the dunces are all in confederacy against him.” – Jonathan Swift

Many physicians are technology-averse, for both good and bad reasons. On the one hand, doctors, regardless of their political or social beliefs, tend to be conservative in their practice of medicine as is often required: although we have to function with a considerable degree of uncertainty, we cannot be too quick to jump to conclusions based on incomplete or insufficient evidence. This conservative stance sometimes extends to the adoption of new techniques, technologies, and ideas. On the other hand, technology can be overused with little potential or demonstrated benefit. Medical technology is generally very expensive, and its overuse is at least partly responsible for the unreasonable expense of modern medical care. Many doctors are quick to adopt new technologies to get a competitive edge over other practices; however, these trendy advances may not be true advances with respect to benefit for the patient.

One medical technology that is now commonplace is the medical PDA (personal digital assistant), a miniature computer held in the palm that carries medical applications and access to medical resources on the web (such as Up to Date, Access Medicine, and Epocrates). These devices, if designed and used well, can be incredibly useful: instead of thumbing through a textbook or running off to find a computer, a physician can find answers to a variety of questions that may come up minute-by-minute in the practice of medicine: What is the current standard for empiric antibiotics for aspiration pneumonia? What are the current guidelines of treatment for moderate-to-severe asthma? Are there potential drug interactions between the patient’s current medications and the medications I plan to give? I know I learned this in my Pathology course in medical school, but what in the world is systemic lupus erythematosus? If the hospital is particularly tech-savvy, these devices might also be able to view patient charts, lab studies, and imaging studies such as X-rays, CT scans, and MRIs.

However, the adoption of this technology is far from universal, and the devices (much like diagnostic sets) are often neglected for a variety of reasons. For example, some of these devices have poor interfaces, poor battery life, or are poorly designed to accommodate the pathways of thought underlying a physician’s diagnostic process (e.g. these programs are often designed by programmers, not health care professionals). At other times, the physicians simply forget to carry the devices with them for lack of developing this habitual behavior: I once followed a physician with a few other students, and we spent a few minutes desperately probing our minds for a simple, basic science detail that could have been quickly and easily answered with the physician’s PDA (which sat on his office desk). Still furthermore, I wonder if there is an underlying machismo that remains in medicine about the nature of medical knowledge and the use of tools: that all the knowledge we need should come from our brains or our superiors (e.g. attendings, residents, etc.), and that “devices” are simply crutches for a poor student. I could not disagree more. With no intentions of being arrogant (the bastard mimic of true confidence), I think I can hold a candle to most other medical students at my stage of development and that I am striving in the right direction toward an ideal balance of qualities required for excellence in medicine (intelligence, perseverance, decisiveness, humility, confidence, compassion, personability, empathic ability, cooperativity, leadership, resilience, etc.). Again, I think if I can do a little more to help my patients (i.e. by not relying solely on my memory or supposition or that of others to ascertain true medical fact), I will try my best to do that. The goal is not to be an Inspector Gadget, but rather, to take the opportunity to make my abilities and actions better informed, more sensitive, and more discriminative. There is a line between reason and excess, and this is well within the realm of reason if used well.

After some thought, I decided to go out on a limb and invest in a relatively new device that is not yet commonly used as a medical PDA: the iPod Touch. While I have long been a fan of Apple, I have been less than pleased about Apple’s recently corporate policies regarding the iPhone and its phone-less cousin. I was partly inspired by the story of a physician in private practice who is attempting to use his iPhone to run his one-man portable practice. Nonetheless, after doing some research that yielded mostly inconclusive results and posed new questions, I decided to give it a shot. Here are some of the results of my initial attempts to transform this device into a customized medical PDA:

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Meet the iPod Touch! Note the WebApps (Safari bookmarks on the home screen) leading to Gmail, Google Reader, and Access Medicine.

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My primary objective: to develop a system of storing and reading PDFs on the iPod Touch. While hopefully Apple will allow the development of such a system with its recently previewed Software Development Kit (to be available publicly in June), I am currently able to read PDFs in the Mail program through my Gmail account. With the ability to keep 200 e-mails in the program’s memory and read PDF attachments (at least up to 2 megabytes) offline, I suspect I will be able to keep up to 200 attachments in the program’s cache without having to load the files with a Wi-Fi connection. Access Medicine allows one to “print chapters” of its various texts, and I currently have the 2007 edition of Harrison’s Internal Medicine – all 364 chapters. Ogod – I’m going to have to e-mail myself 364 times. That’s ok, I already e-mailed myself 100 times this weekend, and I can load all 100 PDFs offline. Apparently I’m just that compulsive.

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The iPod Touch does wonderfully reading PDFs in landscape mode, but you can also read in portrait mode as well. Landscape mode can barely fit the full width of the 8.5″ x 11″ pages with the text being very small but still readable with the incredibly clear and bright screen.

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Is that ARDS in your pocket, or are you just happy to see me? Actually, this is a schematic of the pathogenesis of ARDS (acute respiratory distress syndrome), courtesy of Access Medicine. The site’s image bank selects images, tables, and charts from the various texts published by the company. I can load this images as photos into the iPod Touch’s photo system, giving me quick access to this information.

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NEJM rocks, but hey, I’m biased. The most respected of medical journals has an excellent series of videos on its website that are designed to provide an initial video-based, guided training for various medical procedures. Need to learn how to put in an arterial line? Want to learn the fundamentals of repairing lacerations, performing a paracentesis, or inserting a chest tube? Look no further. These videos are custom formatted for the iPhone, iPod Touch, and iPod video.

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The beauty of the Apple Store? Free engraving. Here’s look at you, kid.

Other thoughts on the iPod Touch as a medical device: The clincher is that Apple demoed a version of Epocrates, one of the most popular and widely used medical software packages, on the iPhone at its March 6 SDK conference. The company that makes Epocrates is committed to bringing it to the iPhone and the iPod Touch (which runs all of the same software). The device is well on its way to supplementing my knowledge base in the 10-15 minute downtime periods during my clinical clerkships (my third and fourth years of medical school), and it has other uses too! I can easily check and send e-mails through my Gmail account (synchronized to my Tulane e-mail account), read RSS Feeds (syndicated/customized news) through Google Reader, and access and edit my calendar to keep track of my schedule (synchronized to the Tulane course calendar). Of course, it’s an iPod, so I can also play music, watch TV shows and movies, check the weather, maintain a database of contact information, set an alarm (or use the stopwatch or timer features), use the calculator, write To Do and grocery lists, and surf the web. I’m eager to try out Up to Date when I’m on the medical campus, although that resource will be much more useful for me later in my training and when I actually have the fundamental experience and knowledge to guide the treatment of patients. Lastly, the iPod Touch is ideal for me (who does not need a new cell phone or cell phone plan) as I do not need to pay for the phone capabilities or the data plan, and New Orleans has a plethora of options for free wireless internet access in many areas of the city.

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