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Monthly Archives: February 2008

Although like many medical students I began my professional training only months after the end of college, I believe in the value of medical schools welcoming (or even actively recruiting) older students who have established themselves in areas outside of medicine. In particular, I greatly admire the men and women who come to medicine having already found lifelong partners, started families, or achieved success in other careers. The process of training physicians requires great maturity at the outset, but it also necessarily involves personal change and challenge to our egos and senses of self along the long and winding road. Where, as we muddle our way through the books and anxiety and sleepless nights, do we find our centers? I count myself lucky to have befriended and found good role models in fellow students whose ages are matched well by an increased maturity, self-awareness, and steadfastness against the tendency to lose self-control and courtesy so often experienced by immature physicians (of any age or level of training).

It may be true that recruiting older students (as a criteria) is not a sufficient means of acquiring students with greater maturity before the onset of medical training, just as recruiting minority students does not necessarily encourage the recognition of value in diversity and cultural differences. Rather, if I were ever in the position of recruiting students, I would look much favorably on those who have achieved or are achieving the “developmental milestones” of adulthood:

1) Greater self-confidence resulting from success in prior employment or an ambitious project unrelated to medicine.

2) Happiness in companionship, marriage, and family.

Perhaps the most important aspect would be that such successes are not connected to medicine. Why this requirement? Because the medical profession can all too often dominate the physician’s sense of self-identity. As medical students, we see ourselves as being devotees to a worthy cause, and we should be given respect and recognition for our self-sacrifice. As physicians, we measure our self-worth (and those of our colleagues) by our demonstrations of clinical skill and success. As we move through our professional training, making personal sacrifices along the way, we as medical students might hope that our excess cost in time, personal pursuit, and interpersonal interaction with friends and loved ones will end with our graduate medical training (e.g. residency and fellowship). There must be a light at the end of the tunnel. However, the increases in salaries are not accompanied by a sudden relief in stressors and professional commitments: if anything, the commitments increase (whether in private practice or academic medicine), and the stressors are just better compensated monetarily.

Is this reason for despair? I don’t think so. However, it does give one pause to reflect:

1) Am I putting off my life during my medical training?

2) What exactly will get better after my medical training is done?

3) What am I missing out on?

Medical training is intense and demanding. However, I do think that there is a choice in viewing one’s contribution as either self-sacrifice or dedication. A few months into my first year of medical school, I identified happiness as a necessary prerequisite to being a successful physician-in-training. More than a year later, I couldn’t agree more: in order to deal with the stresses and challenges of our training and future profession, we need to have happiness in our lives unrelated to medicine. These sources of happiness keep us human, centered, and well-rounded.

The great physicians of the distant past were often more than doctors: they were ministers, mayors, shopkeepers, husbands, fathers, and community leaders. In more recent decades (the time of training of many elder physicians today), a blind self-sacrificial approach to medical training was the norm. Would it be surprising if many of these physicians are reluctant to retire, and thus, lose their primary means of self-validation?

People find great, self-enriching happiness in many different things. For me (and many of my classmates), one source of great happiness is that found in love shared with another person. As my recent engagement marks entry into a new stage of life, I find myself paradoxically more energized, focused, and committed to my professional commitments. True happiness is not a distraction: it makes us greater, better, and more than we were before. The medical profession requires us to be just that – greater, better, and more – for the benefit of our patients and for our own sustenance. Another way of looking at it is this: medicine is a profession centered around giving and sharing – compassion, knowledge, and care. An empty shell has nothing to share, while one filled does. In gaining more in our lives outside medicine, we have more to give.

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I’m written previously about the controversy surrounding the diabetes mellitus drug Avandia (rosiglitazone), and I found interest in the recent news story that reviewer for the New England Journal of Medicine had leaked an early copy of a meta-analysis on rosiglitazone to the pharmaceutical company that makes the drug, GlaxoSmithKline. The physician-scientist, Steven Haffner at the University of Texas Health Center in San Antonio, was a peer reviewer for the Nisset and Wolski (2007) study that suggested that rosiglitazone had a small increase in risk for acute myocardial infarctions (heart attacks) over placebos (later, it was shown that it had an increased risk over older treatments for diabetes mellitus such as metformin and sulfonylurea). According to a Nature article, he explained his behavior in this fashion:

“Why I sent it is a mystery. I don’t really understand it. I wasn’t feeling well. It was a bad judgment.”

Although this story broke several days ago, I didn’t want to write about it until I had time to reflect and have a better understanding about why it bothered me so much. I personally have great admiration and respect for the NEJM editors with whom I worked for some time, but this is not what perturbed me as much as the greater implications of Haffner’s actions.

First, Haffner’s actions are on the border between legality and criminality. Disclosing information to stockholders (executives at GSK) that may affect the company’s stock price (e.g. a study reporting that a company’s blockbuster drug is not safe) may be seen as inappropriate insider trading; however, a representative for the GSK executives denied selling their stock, though this matter has not been investigated for lack of readily available evidence.

Secondly, Haffner used a very common excuse in a questionable way: “I was sick.” This has multiple implications. It may support a misguided impression that people who are sick (to any degree) are also typically impaired in judgment (I previously wrote about the role of pain and suffering in impairing judgment, but this is not always a predominant factor in every patient). If Haffner was sick, how sick was he? He claims he “wasn’t feeling well,” but there are plenty of people in our society who don’t feel well on a particular day but have perfectly intact judgment. If he was so sick that his judgment was impaired to the point of commiting a crime, he needs to see a doctor! Alternatively, Haffner may have recently been suffering emotionally from a close personal tragedy or difficulty that would not be appropriate to disclose to the public, but again, impaired judgment of this magnitude is not a key feature of normal bereavement (mourning) and is still highly questionable with regards to situations of emotional distress.

It’s possible that Haffner didn’t have a clear understanding of his role as a peer reviewer and the importance of confidentiality in medical science’s peer review process. Much of science and medicine functions on a system of honorable action and gentlemanly conduct, a system that can be much abused by those who care only for success and gain for themselves and their allies. Haffner had worked on previous clinical trials for rosiglitazone, had served on a steering committee for the drug, and had received “considerable” amounts of speaking fees from GSK for prmoting rosiglitazone. Upon publication of the Nissen and Wolski meta-analysis, Haffner was famously quoted in a newsletter as saying, “The three major medical journals are becoming more like British tabloid newspapers. All they lack is a bare-chested woman on Page 3.” It seems mind-boggling that a physician-scientist of his standing would make such a callous comment while making a serious and obvious breach of medical professional ethics.

Does Haffner truly lack an understanding of his actions? I do not think this is the case. Rather, I suspect that the physician-scientist is deficient in the mechanisms that would keep improper actions in check. It seems highly unlikely that he would not know prior to the public reporting of his actions that his faxing of the manuscript to a GSK employee was a breach of professional conduct: confidentiality is one of the most basic, simplest, and obvious rules made clear to reviewers when they are invited. Confidentiality is a key principle in both ancient and modern medicine. The Hippocratic Oath itself clearly binds physicians to confidentiality (within reason): “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” I think that it is more likely that Haffner understood his actions but was willing to break the rules for the benefit of himself and his friends. Rule-breaking, to some degree, is often celebrated in our society: we celebrate the James Deans (”Rebel Without A Cause”), the O.J. Simpsons, and Jack Sparrows. However, while many or most people in their lives engage in some degree of rule-breaking, most do not break rules so egregiously or in ways that may have profound negative effects on other people. The rules normal people break (outside the context of clear injustice, such as during the Civil Rights movement) tend to be rules that are perceived as arbitrary, and so there is almost a sense of justice (or at least ambivalence) in breaking them. This physician-scientist, on the other hand, demonstrated the breaking of a rule not for perceived arbitrariness or injustice, but rather, for personal gain. This is akin to the premed student that cheats on a test, plagiarizes a paper, or modifies an article on Wikipedia so that other students who might call up that page for answers will be misinformed. Normal people, even under duress, still have scruples and principles guiding their actions. There is something wrong in the minds of people who choose to do otherwise, something that would impair this physician-scientist’s ability to function within the broader context of his profession.

Despite my early interests in specializing, I strongly believe that there are several fields I want to develop as my core competencies that will contribute to my skill as a specialist. If I choose to be a Pulmonary and Critical Care physician, cardiology, nephrology, and infectious diseases are obvious complements. An additional field I want to develop a strong foundation in is psychiatry, the current subject of my coursework (known to medical students as “Behavioral Science”). As a medicine physician (as opposed to a surgeon) working with adult patients, I will become very familiar with depression (common in the elderly), delirium (from electrolyte imbalances secondary to many common medical conditions), and dementia (e.g. from Alzheimers, hypertension, etc.). As a student of medicine in New Orleans (and hopefully in my future residency program and work settings), I am also going to become very familiar with another population: the homeless.

I, like many others, have not always been particularly sympathetic to the homeless, but this is largely a product of inexcusable ignorance. This is partly a result of my background as an immigrant: many immigrants hold to productivity and hard work as core principles of their existence and pathways to better lives. The struggle is the cost we pay for success and happiness; failure to thrive is the greatest disgrace and loss of honor. When we see others not working, we sometimes assume that they do so willingly and to their own deserved detriment. This view is, at best, misguided. According to one of my psychologist instructors, approximately one half of all homeless people are suffering from a mental illness and became homeless as a result of their mental illness. Of this 50%, most of them have schizophrenia, a disorder that is poorly understood by the general public. Schizophrenia is not multiple personality disorder. Instead, it is characterized by periods of time when they suffer from hallucinations (false sensory perceptions, especially auditory or voices), delusions (false beliefs not held by others), and other symptoms such as social withdrawal and disordered behavior (odd speech patterns and content, poor grooming, etc.). One problem that frequently occurs with schizophrenics is the downward drift: their difficulty in functioning in social and work situations causes them to slide into problematic living situations (e.g. losing jobs, relationships, housing, support structures, etc.). Unfortunately, illicit drug use is common, particularly since sometimes drugs like cocaine and alcohol are the only effective methods of quieting terrifying hallucinations or are needed to complement medications (which may not reduce 100% of schizophrenic symptoms). For some, homelessness is actually a preferable option to living in a house: the isolation of homelessness is sometimes more amenable to the ways they perceive interactions and the world around them, and our normative ideas of living are very difficult for them to adapt to. However, this life is a difficult one: “knowing which fast food restaurants one can sleep in and knowing how long they’ll allow it, staying awake at night because that’s when bad things happen.”

Does knowing that half of homeless people suffer from a disabling mental illness make one more sympathetic or interested in helping them? For me, yes. Our society likes to cast blame on others, and I believe that it is never right to blame someone for the adverse effects of the disease they suffer. The disabling aspects of schizophrenia impair the ability of these individuals to lead normal lives in the absence of consistent, conscientious, and proactive care. In the absence of family support or societal acceptance and aid, who else can lend these people a hand and show some understanding?

Recently, a homeless schizophrenic killed a young female police officer in New Orleans, resulting in a media frenzy and a flurry of pointed fingers. As all sides try to cover any potential liability on their parts, the news has portrayed the man as one who has “taken advantage” of the hospital system. Several psychiatrists I have spoken to instead contend that this tragedy is a failure of the mental health system, which has been struggling to revive itself after Hurricane Katrina. Notably, there are only about 40 psychiatric beds in New Orleans, as the DePaul psychiatric hospital in uptown New Orleans has not been reopened, partly as a result of the discouragement of locals in the neighborhood.

Today, we had a man with bipolar disorder and a woman with schizoaffective disorder speak with us about their diseases, their experiences with physicians, and their struggles to stabilize their lives and help others in distress. One of the patients (who works to help others with mental illnesses) said, “This is nothing to be ashamed of. This is something that can happen to anybody. We need people to listen to us and realize that we’re just like anyone else who needs help.”

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