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Monthly Archives: October 2007

It is not without some knowledge of the history of medicine in America that I assert that the next generation of physicians, my generation, has a momentous opportunity to be an integral part of a great change within medicine and our society. Our forefathers have done great things. The physicians around the turn of the 20th century were amazing innovators and great spiritual leaders, guiding our practice into a new age characterized by new partnerships and reaffirmed core principles. The great physicians in the middle of this past century were the great minds, catapulting medicine ahead with new scientific advancement and rigor, new treatments and for the first time, the promise of cures. If we can remember, we stand in awe of our history, and indeed, our leaders today would have us believe with every sinew of our impressionable hearts that for all of our future accomplishments, we stand on the shoulders of giants.

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Photograph of a White Coat Ceremony courtesy of Phil Chou, a physician-in-training

And yet, I suspect that we are too quick to self-congratulate, to be complacent while basking in the glow of our glorious past. It is not uncommon to encounter a medical school professor pontificating about the age of discovery like an art historian lovingly serenading The School of Athens, or a physician reminiscing about the good old days, when we were like knights in shining armor riding in amidst cheers and adoration, or ship captains free to roam an uncharted ocean and do as one pleases. This is not to say that we shouldn’t have our heroes and our inspirations. However, I wonder if our predecessors spend more time enthralled with nostalgia than concerned with the troubles of our own time – or the fate of medicine in our future.

Did those legendary heroes of medicine spend their days longing for past comforts? Did they hold so tightly to their territories, viewing any change as an immediate threat to the sake of the profession? I think not. They were agents of change – reformers, idealists, dreamers. They thought outside of the box to solve the problems of their times and move toward a vision of a better future. What convinced William Osler to believe that medical students should learn directly from interactions with patients rather than from the traditional library or lecture hall? Without the widespread fear in Americans of the silent, insidious spread of the debilitating disease polio, would Jonas Salk have felt compelled to pursue a vaccine? Without equality and equal opportunity as core principles in her heart, would Elizabeth Blackwell have tolerated the jeers and prejudices of her classmates and instructors on her road to becoming the first female physician in America? Each of these physicians identified a great problem, and with resolve and inner strength, they fought hard and brought about change. Once they knew which direction to go, they looked forward; they did not turn back.

As much as I have respect and admiration for my teachers, I now realize at this stage in my training something I only suspected before: the defeatist and disenchanted attitude among many young and old physicians is a result of the sins of our fathers, the mess left behind by our mentors. Many of them have fought hard to bring about positive change, but the backdrop of conservation and damage control has stifled their efforts. However, many of them seem to believe (and subsequently preach in subtext) that nothing can be done: that medicine, as a profession, is sliding into a terrible abyss. That medicine is no longer ours, that the encroachment of our would-be friends and allies will destroy the quality, and our ownership, of medicine. That the baseness of litigation has tainted the honorable and benevolent intentions of medical practice. That the more medicine becomes a business, the more readily our souls are corrupted and deprived of the grace of compassion. That today’s young physicians, despite their energy and hope, stand no chance against the winds of change.

I will not be defeated. The medical field, like many, loves to adore its own and create a culture of elder idolatry. In worshiping the past, many physicians are blind to the world around us:

They believe that medicine is a treasure to be preserved and reserved for a few. I believe that medicine belongs to everyone, because it is for others that we devote ourselves to this profession. In protecting the integrity of our profession, we must not deny our calling, even if that calling changes and grows. Many physicians look to the Hippocratic Oath as though they can only abide by its words, and anything left out is not part of our duty or purpose. I believe that as physicians it is our mission to treat disease and ease the suffering of all people to the best of our ability. We many not all choose to save ten million lives in a developing country. But, despite the excellence and equality of our medicine, we must all choose to do our best to fight discrimination and inequality in health care, whether along the lines of race, creed, or wealth.

They believe that lasting respect and admiration is won through intellectual achievement in the realm of basic science research – the fundamental knowledge of disease etiology. I believe that rewards and commendations come from one’s peers, and it is my belief that my peers and my more recent forebears seek different ideals from our mentors and teachers. Perhaps I am premature in saying so, but I suspect that the age of discovery is gradually coming to an end: there is much we know about disease and its causes, and we have developed vast amounts of therapies and treatments to stop disease in its tracks, save lives from sudden conclusions, and even reverse the course of some diseases. Research into these realms will not doubt continue, but I wonder if there will be new emphases and movements. We have our own callings, and we will commend one another based on what we hold to be valuable in our hearts and minds, not necessarily criteria that is inherited but anachronistic.

What are the callings of my generation? We want to heal the world – one world, one people, united, if nothing else, by the part of human nature that makes us care about a stranger in need. The eloquent writer-surgeon Atul Gawande has suggested a focus on delivery over discovery, the need for greater resources put toward getting health care to people who need it rather than on researching obscure diseases and minutiae. The physician-on-a-mission Paul Farmer proved to the world that it is possible to treat AIDS in a resource-poor setting like rural Haiti. The world, growing ever smaller, brings us closer together and makes us more aware of our commonality and the potential for mutual benefit through benevolence.

We want not only to treat disease: we want to stop disease before it ever begins. Preventive medicine is the catch word championed by primary care and family physicians, often among the least respected and influential in the medical profession. However, the wave is coming, and a large emphasis within the greater political movement toward universal health care is on preventing the development of disease. The only thing keeping us from wholeheartedly pursuing this mission is the taught cynicism and distrust in others handed down to us by our mentors: that people will not change, that people will not be able to make good decisions for themselves despite our attempts to educate them.

And lastly, we want more than that which was given to our forebears: we want respect, we want good lifestyles, and we want a better situation than the regrettable status quo that is so desparately protected by those that came before us. No change is one-sided, and it can be said that those that walked this path before us have ruined it for us. But that is not how those of us who have recently chosen medicine as our path see it. We want things to be different, because the way things are now is inadequate, inappropriate, and undesirable. We want change, and so does the society and world around us. Not all change is bad, and while it may be prudent to be careful and wary of change, it does no one any good to be blind to our callings.

The callings of my mentors and teachers may be quite different from my own and that of my colleagues. If that is so, then I tremor at the thought of a great change coming, a great awakening of our society to the centrality of health as a foundation of our lives and the immediate potential for the medical profession to lead that change. My generation will be part of a great movement, or if nothing else, we will not cower in fear of change. That change may not require that we all fly under the AMSA banner or preach to the choir about benevolence and mercy. But it will require that we, unlike our predecessors, reach out to our communities and regain the trust and respect that our forebears squandered. It will require that we speak openly, truthfully, and clearly to the questions and needs of our society. It will require that we learn to trust our patients as much as we ask them to trust us. It will require that we reassess our underlying assumptions and turn away from the blindness of arrogance in order to learn from our own mistakes and find strength in a calling reinforced by our honesty with ourselves. In doing so might we bring about the change we seek. All this and more, if we are not defeated by a lack of self-confidence or self-realization. I will not be defeated.

“I want to throw open the windows and get out of this narrow medical atmosphere in which the enormous healthful influences of the outside world are so largely disregarded.” – Richard Clarke Cabot, M.D.

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This week, we started our Cardiovascular block, the first of the true “Systems” blocks during our second year curriculum. During the last block, the Neoplasia/Hematology block, we began to have more clinical lecturers (physicians/M.D.s), which seems to have correlated in a dramatic increase in lecture attendance in our Pathology/Pathophysiology course. Not surprisingly, I think most of my classmates are interested in practicing medicine, eschewing graduate school and future careers dedicated to research in favor of medical training. While I doubt anyone would reasonably argue that research is not an important venture in medicine, I think that most medical schools fail to effectively indoctrinate medical students in the importance of improving clinical practice with research pursuits and the ability (and importance) of individual physicians to engage in both (including Harvard Medical School’s most recent attempt to introduce a mandatory course on the role of discovery in medicine). I suspect that the significance of research as a corollary to clinical practice is more readily accepted and learned during the fellowship stage of medical training.

Why mention research now? If nothing else, I am very fascinated by both the cardiovascular and pulmonary systems, and if it were possible, I might happily choose to be a cardiopulmonologist in lieu of pursuing a career as a Pulmonary and Critical Care physician. The mixed inpatient and outpatient work of Cardiology and Pulmonology might be broad enough to keep me as engaged as I would be with the inpatient consult and ICU work of an intensivist. Then again, perhaps I might have more interest there than just the clinical practice.

For the first time this year, I have felt inspired enough by the subject matter of my medical school coursework to read and learn more than required (by either the course, or the USMLE). Interestingly, Robbins and Cotran’s <u>Pathologic Basis of Disease</u>, the authoritative text on pathology, suggests that the atherosclerotic plaques that are at the core of Ischemic Heart Disease, the number one cause of death in the U.S. and globally (more than cancer or accidents), often rupture asymptomatically prior to a total occlusive event. That is, plaques that rupture and cause a thrombotic, coronary artery occlusion have usually ruptured previously with few or no symptoms. The authors express concern over this notion of a silent disease: there is a very large number asymptomatic individuals who are at great risk of a sudden coronary occlusive event, and we currently have few or no methods of evaluating the likelihood of plaque rupture in an individual patient.

While there have been many mysteries and insufficiencies in our knowledge of medicine and disease that have been presented during my medical training thus far, this is perhaps the first time I’ve felt compelled to actually seek out the answer. How might we effectively and inexpensively screen individuals for risk of atherosclerotic plaque rupture, and in doing so, possibly prevent the occurrence of heart attacks (myocardial infarctions)? Right now, the emphasis in cardiology is on saving lives from MIs and other cardiopathologic events, and then subsequently preventing the new MIs and maintaining heart function for as long as possible. What if it were possible to prevent MIs in the first place by screening all patients with the major predisposing risk factors? Doing so might make the risk of heart attack more real for individual patients and motivate them to pursue aggressive lifestyle changes (much like genetic screening for BRCA1 and BRCA2 genes with respect to breast and ovarian cancers).

When I think about my own heroes in medicine, I tend to think of those who changed the practice of medicine through social and clinical practice means rather than through basic science. I wonder if perhaps this is my future career path: clinical practice paired with motivated and aggressive clinical research into new methods of practicing medicine. Two of Tulane University School of Medicine’s greatest medical heroes were pioneering surgeons, Rudolph Matas and Michael E. DeBakey. Dr. Matas was the first physician to use spinal anesthesia, the first to repair aneurysms, and the inventor of the intravenous drip. Dr. DeBakey, a student of Dr. Matas, has similarly won world reknown through his innovations in cardiovascular surgeon and the invention of numerous surgical tools and devices. Maybe I too will be motivated to leave my mark on the frontlines rather than in the books.

This is what I would tell my students on the first day:

<i>Thanks for coming out this morning. Today, we are starting the _________ component of your medical training. This class will help you understand the fundamental principles you will need to practice medicine in many fields. This is, by no means, an exhaustive coverage of every single (disease, drug, etc.); some self-study will be required. Nonetheless, our teaching staff will focus on helping you build a strong, easily accessible core of knowledge in this subject that will carry you through your clinical clerkships and well into your career. You are future physicians, and so we will focus on what is most relevant to the practice of medicine.

A few logistical details about this course: there are __ exams that will cover information from each block. Each exam will have a small number of questions drawing from the most important principles of the previous block to help you prepare for the USMLE Step One. Don’t worry though: these questions will be quite straightforward, if not the first time, definitely by the time you see them again on the following exam. I (or my fellow course director) will be attending each lecture and asking questions of the speakers along with you, and we will be writing all of the exam questions based on the lecture material (to guarantee fairness and relevance). You may pick up a copy of the exam and answer key from our department’s office at a designated time after all students have completed the exam and the challenge session has finished.

Please speak with me about any problems, questions, or requests you might have. We will be providing lecture audio/video (if the school provides the equipment), but I think you will find that our lecturers are quite engaging and eager to answer questions and help you understand the material to a greater degree than if you just read the material from your textbook or someone’s notes. Our job is not only to train you to develop a broad and powerful base of knowledge, but also to inspire you to develop interests in these fields. There’s nothing worse than having a bad professor kill your interest in a subject, and that’s the last thing we’d want to do. If you ever feel like we’re going in that direction, contact me, STAT!

Again, thank you for listening. Without further ado, let’s begin.</i>

The title of this post might make one think I’m going to discuss this topic in serious terms. I am very interested in sepsis (severe sepsis and septic shock) since I have some early interests in critical care medicine, but I want to post a brief excerpt from an e-mail on our class mailing list with a response from one of my favorite Infectious Disease physicians/professors to a student’s question on what happens in sepsis:

“With bacteria that are very pathogenic to humans… there is very little local control of the inflammatory response – they get in there (usually in the blood) and multiply like mad before any localizing stuff happens, so inflammatory mediators are spilled all over (systemically), followed by anti-inflammatory ones, and ALL GOES NUTS.”

I usually try to pair photographs and other images to my post topics. This is the best I could do:

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[Caption: ALL GOES NUTS.]

Interestingly, bacteremia and sepsis are not the same, even though the terms are sometimes used interchangeably. Sepsis refers to the body’s (normal) systemic response to an infection, and it precedes bacteremia, the presence of bacteria in the circulatory system (e.g. “bacter-” = bacteria, “-emia” = in the blood). That is, the body’s immune response has to break down in order for bacteremia to occur, often following this sequence:

sepsis -> severe sepsis -> septic shock -> bacteremia

In an ICU setting, an injury or acute disease in one or more parts of the body draws the attentions of the immune system and the body’s repair mechanisms to those areas, leaving the body as a whole in a partially immunocompromised state. Certain life support technologies, such as ventilators with endotracheal tubes, occasionally allow otherwise “normal flora” (bacteria normally found in or on certain parts of the body without any symptoms) to migrate or grow into other parts of the body, such as mouth flora following endotracheal tubes down into the lungs. When this happens, some of the immune system’s signaling molecules that were previously focused on localized problems elsewhere spill out into the blood stream to try and fight off this new infection, but the response may not be sufficient as resources are spread thin. The new infection is unable to be contained locally without a strong immune response. As a result, a variety of both inflammatory (pro-immune response) and anti-inflammatory (attenuating the immune response) molecules are circulating through the body, triggering a much broader, systemic response to the various insults and injuries to the body and the growing infection (much like trying to put out multiple, widespread forest fires with a single fire-fighting plane). One of these seemingling unintended, uncontrolled, systemic responses is (septic) shock, a state in which various parts of the body cannot get the oxygen they need to function (sometimes resulting in death within hours). It is often only after (septic) shock occurs that bacteria start to invade the circulatory system and spread to other parts of the body.

There is still much to be learned and explained about the complicated processes of sepsis and septic shock, especially the observation that it is actually the anti-inflammatory molecules that are found in the greatest amounts in the blood!

One thing most medical students have in common is that they will leave medical school with a considerable, if not daunting, amount of debt. Medical school tuition is an exceptional burden, ranging from around $10,000 per year for the cheapest public schools to over $46,000 per year for the most expensive private schools. The $10,000 price tag is not common though: the average debt for a medical student graduating from a public school is around $100,000, while the number rises to around $130,000 for private school graduates (the overall average according to the AMA is $130,571 in 2006, with 72% of graduates having at least $100,000 in loans and 86.6% carrying outsanding loans upon graduating). This, of course, does not include room and board expenses, transportation, books and supplies (e.g. $700 diagnostic sets, $100 stethoscopes, etc.), which brings the overall price tag to around $250,000 for four years. For some (myself included), this will be the first time that we will have to pay for our own education. Other students may still have to repay loans that financed their undergradute education. Some take a few years off before entering medical school in order to raise money for their education. A select few have the luck of being able to have their parents pay for their education, but unless they are extremely well-endowed, the cost of education is, at the very least, an uncomfortable thought that urges one to feel grateful.

People have lambasted and lamented the high cost of medical education for a variety of reasons, but for me, there is one problem that is much easier to see from the perspective of a medical student: the problem of entitlement.

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Simply put, the more students have to pay for their education, the more to which they will feel entitled. At a time when the standing of physicians is under attack from many sides and public opinion varies considerably, a culture of entitlement is that last thing we need to foster in the next generation of physicians. Entitlement serves no useful purpose: it makes us impatient, callous, lacking in perception and perspective, and unfit to do our jobs.

What do we feel entitled to? Some desires seem reasonable and natural: for the price we’re paying, we should expect to receive a top-notch medical education from experts in the field. We expect to have good resources that come with reasonable convenience: maybe not served to us on a silver spoon, but at least accessible without a gargantuan effort.

But there are also some expectations that are not as reasonable. We should not expect that our instructors are only there to teach us and have the time to attend to all of our needs. We should not feel entitled to common study spaces and get angry when someone else actually uses them (i.e. the amount of times I’ve heard people rant at a pile of books or a backpack…). We should not feel that we are all-important, or that our clubs, causes, and purposes exceed all others in priority. We should not expect to automatically receive respect and deference from house staff as medical students. We should not believe that, as medical students with great burdens on our backs, that it is acceptable for us to forget common courtesy. Or that our burdens exclude us from the duties of being a good person: to reach out to others, to be tolerant, to be patient and understanding.

The great weight of growing responsibility that comes with medical training has a variety of effects on people. The majority of medical students are humbled, to some degree, by the experience: we feel grateful to the people who have helped make our training possible, and we feel duty and responsibility to the people who need us. We complain little, or if we do, in private and with humor or a shrug of the shoulders. However, some students react in the opposite way: they see their medical training as a route to ascension, an expensive, difficult process that will make them something greater and stronger. Given the investment and the sacrifices they are making, it seems natural that everyone else should try and make the process as easy as possible for them: give me convenience, give me respect, give me a break. I am trying to do some good, I am holier than thou, I am the one with the quarter-million-dollar debt, and still you don’t respect me and my efforts?

To my fellow medical students, I ask of you: find some strength within you and be patient. Our path will not become any easier as time goes along.

This does not preclude you from being an advocate for change: it’s all about a change in attitude and approach. Instead of feeling entitled and making demands, step back, assess the situation, and think of solutions of mutual benefit and contribution. Be willing to meet the other party halfway.

Better to light one candle than to curse the darkness.

My recent visit to a dermatologist left me a little less than satisfied. Previously, miscommunication mistake between the dermatologist, the nurse, and myself or an outright mistake on the part of the nurse left me in the position of being accused of missing an appointment that was scheduled for the wrong date. When I explained as much to the dermatologist last week, he did not seem convinced but did not press further, shrugging his shoulders and saying “These things happen,” possibly suggesting that he still thought I was most likely at fault.

Today, I had stitches removed from where two epidermal inclusion cysts had been removed, one on my chest and the other in front of my right ear. Afterwards, the dermatologist sent in two nurses to apply “glue,” an adhesive dressing to seal the remaining small wounds from the stitch removal. As the appointment with the dermatologist was concluding, the dermatologist surprised me by apologizing: he said that he was sorry for the confusion (regarding scheduling) we discussed the previous week.

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I don’t know what inspired him to say this, as I had not been showing any visible signs of hostility or holding a grudge (as far as I could tell). Perhaps he discovered further evidence that the ball had indeed been dropped on his team’s side, or perhaps he felt didn’t feel right about the previous exchange. Nonetheless, I greatly appreciated the gesture, though ironically, I replied with, “These things happen,” after having the moral high ground passed back to me.

After this experience, I feel more attuned to some of the emotional vulnerability that patients can feel as well as the uncomfortable relationship between patients, doctors, and blame. I sincerely hope that the majority of doctors who might initially have developed a tendency to cast blame unto patients take the time to reconsider and apologize. Similarly, I hope that patients in such situations are willing to speak up against unjust claims as well as work to make a patient-physician relationship better: it’s a two-person effort. It deeply bothers me when I hear of patients who verbally and psychologically abuse their physicians.

A patient I saw recently seemed eager to tie his medical condition to his own actions (the repeated use of an ointment), even though the attending physician suspected that his action was not necessarily an important contributor to his illness. It made me happy to see that the doctor was even-handed in her assessment of the situation, and similarly, that my classmates and I did not reinforce the patient’s self-blame. Again, first do no harm.

An excerpt from Dr. Jerome Groopman’s How Doctors Think:

“Availability” means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. Alter’s diagnosis of subclinical pneumonia was readily available to him because he had seen numerous cases of the infection over recent weeks.

This Monday, we started our Neoplasia/Hematology block of our Mechanisms of Disease course (Pathology and Pathophysiology). We have been learning the basic categorization schemes and behaviors of various neoplasms (cells growing uncontrollably), including both benign growths and malignant growths such as carcinomas and sarcomas. Today, I sold an amplifier (from my bygone days as a band leader, song writer and guitarist) to a friendly, local fellow. When he drove up, the first thing I noticed was the white bandage that covered his right eye. We chatted briefly about music, guitars, and the amplifier, and he also asked me a couple of questions about medical school. Then, he asked me if I had learned anything about oncology. I had been curious as to the nature of the bandage, but I haven’t quite figured out when it’s appropriate for me to ask about an unknown person’s afflictions (since as a physician, I will have the ability, and sometimes the responsibility, to cross social boundaries that most people do not, even outside the setting of the clinic or hospital). He went right ahead and told me: he had rhabdomyosarcoma in his right eye when he was a child, a very high grade, malignant cancer that at the time only had a survival rate of about 20%. Fortunately, he survived and seemed pretty healthy except for the loss of the eye (the cancer required surgical resection). How ironic that I learned about rhabdomyosarcomas yesterday, and then saw the consequences of one example of the disease today! It reminds me of how when one learns a new word, it seems as though everyone subsequently starts using that word.

Furthermore, it reminds me of one important thing I learned in my days (actually, years) as a volunteer in a cancer clinic: Cancer is not always a terminal disease, and as time goes on, we’re finding better ways to help people live fuller and better lives beyond the diagnosis and treatment of cancer. No matter what field of medicine I decide to work in, I will be working against cancer, and that is one fight I look forward to.

Lastly, my conversation with him was encouraging: without exception, I have found that individuals who have suffered from severe or potentially severe diseases are very grateful and trusting of physicians, as I wish all people were. This alone further inspires me to go towards a field of medicine involving the care of very sick patients, because I think one of the best parts of medicine is being able to help pull someone back from the edge of existence.

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