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Monthly Archives: October 2007

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.

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