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Monthly Archives: August 2008

Pride goeth before destruction, and an haughty spirit before a fall.
Better it is to be of an humble spirit with the lowly, than to divide the spoil with the proud.
– Proverbs 16: 18-19

One of the redeeming experiences on my Psychiatry rotation is the time I spend with the Veteran’s Affairs Substance Abuse clinic in Alcoholics/Narcotics Anonymous groups. Unlike most of my Psychiatry experiences, the AA/NA groups have been universally encouraging and insightful. Insight is a rare trait to find on the inpatient closed psychiatric ward, and it is refreshing to be with addicts who help one another gain clarity in evaluating their condition, relapse triggers, and positive development. Today, I had the privilege of sharing some of my thoughts with one group of veterans about Step 1. In recognizing one’s powerlessness to alcohol/drugs and understanding the uncontrollable consequences of substance abuse, I noted that there is a subtle but important distinction between pride and strength. For the sickest patients I have seen during my clerkship, pride is one of the greatest and most common flaws: to me, it is the delusion that one is in control when one is not in control. It is the delusion that you can skip taking your antipsychotic and mood stabilizing medications and still regulate mood and not resort to violence. It is the delusion that the world is somehow always against you, and that you have no role in causing your problems. It is the delusion that your suffering is unique and entitles you to special treatment. On the other hand, the ones that have the best chances of recovery (like the AA/NA veterans) are the patients who have the strength to be humble, to recognize their diseases, and to make the commitment to take ownership of their problems and be guided through the treatment process by another. Inner strength gives confidence, not pride, for strength is accompanied by clarity while pride and arrogance are blinded without insight.

Notably, AA and NA have a strong spiritual theme underlying the treatment process. Many people think that spirituality and religion have few meaningful roles in the practice of medicine, but now that I have been exposed to inpatient Psychiatry, I beg to differ. I am not a religious man, but I do express spirituality through a belief in a higher power that, for convenience when sharing, I call God. When people truly believe in a higher power, that belief supports a measure of humility that encourages them to take time to step back and reevaluate their situations. Many of the patients I have encountered on the inpatient psychiatric ward, with their grandiose and persecutory delusions, lack or abandon this sort of belief. I hesitate to think of them as “God-less,” but it is apparent when some individuals lose the grounding that allows most people to interact and participate in shared communities. They do not share, because everything, whether praise or persecution, must be about them in their minds, leaving no room for a God (unless the delusion involves hyperreligiosity, which may sometimes be a delusion of grandeur) or for anyone else. Since they believe everyone else has a problem but not them, they are unable to heal. On the other hand, those patients with some spirituality or at least the capacity for self-reflection and self-evaluation are better able to understand how their diseases are affecting their lives and what steps they must take to allow for a process of healing.

Though there may not always be the time or reason, I hope my patients will be comfortable expressing their spirituality with me (regardless of religion or lack thereof). If nothing else, I hope to take from this Psychiatry clerkship this message, the opening prayer from each AA/NA meeting:

“God, grant me serenity to accept the things I cannot change,
courage to change the things I can,
and wisdom to know the difference.”

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So far, my Psychiatry clerkship has been a boon for several reasons:

(1) Psychiatry has given me the opportunity to explore the complexities of the mind and its potential dysfunctional behaviors. Accordingly, it has given me a chance to scrutinize my own thought processes, including, most recently, my rapid growing passion for Neurology. Additionally, it has given me an acute awareness of my impressions and attitudes toward my patients.

(2) Although I had equal intellectual interest in both Neurology and Psychiatry from my second year Neuropathology and Human Behavior coursework, my Psychiatry rotation has offered me clarity: I now know that it is possible for me to find a subject interesting without wanting to work in the field. By contrast, my feelings for Psychiatry have accentuated my interest in Neurology as a possible career pathway with the knowledge that I won’t fall in love with every field through which I rotate. Prior to my rotations, I had equal magnitudes of bias against both Neurology and Psychiatry, but my bias against Neurology dissolved with new knowledge, familiarity, and experience (unlike my bias against Psychiatry, which has largely been confirmed and solidified despite my increasing respect for those practicing in the field).

(3) Psychiatry has not only given me the intellectual opportunity to think about my thought processes and career planning… it has also offered me the time to do so! The days have been considerably shorter than those on Neurology, giving me time to do extra reading in Neurology and Medicine.

However, despite these benefits, this Psychiatry clerkship has been a twisted journey through the dark side of medicine. For a number of reasons, I cannot see myself pursuing a career in this field under any circumstance:

(1) By necessity, Psychiatry is far more paternalistic than any other field of medicine. In other fields, the physician and the patient can be partners with equal input into the relationship and effort. The physician can use reason and knowledge to convince a patient that a particular therapeutic regimen is the best option, and the patient can use her intellectual capabilities and logic to navigate the medical reasoning and adhere to the treatment plan. For the most part, gone are the days when doctors would simply say, “Do this, and you will get better” without further explanation; patient education is an essential part of medical treatment. However, in inpatient Psychiatry, this equal relationship does not and cannot exist. Mental illnesses are only problems when they impair an individual’s functioning in activities of daily life (work, family life, social interactions, following basic legal standards, etc.). In order for a patient to be admitted to an inpatient psychiatric ward, there is almost always a legal issue: threatening suicide or homicide, violent or aggressive behavior, disturbing the peace with psychotic behavior, etc. In treating a patient with poor judgment and insight, the likelihood of actively engaging a patient’s reasoning or logic is very low. Accordingly, the patient’s role in treatment planning is often minimal, at least initially, leaving the physician in the position of “always being right.” This creates great potential for antagonism in the patient-doctor relationship.

Would I find much personal reward in a field where one is frequently arguing with patients who express their hatred of you? No. From my observations, when confronting oppositional behavior, I suspect that many inpatient psychiatrists find purpose in keeping the world safe from the dangerous and volatile minds and behaviors of their more psychotic and delusional patients. But that would not be a powerful enough motivator for me.

(2) Countertransference refers to the emotions a physician feels for his or her patient (sometimes displaced from another person to the patient who is reminiscent of the former). By my nature and commitment, I have sought not to lay judgments upon my patients. Nonetheless, this has not restricted me from developing friendly interactions with all but three: two of the patients were comatose, and the third is a chronic paranoid schizophrenic (CPS) who is currently floridly delusional. I have had several CPS patients so far, all of whom were relatively easy to manage and talk to without argument or the development of negative countertransference. Furthermore, until my most recent patient, I have not triggered or encountered significant paranoid delusions extending to myself and the treatment team. I have generally served as the “patient advocate” to voice their concerns. Nonetheless, I now have the opportunity to work with an openly oppositional and confrontational patient who, despite my reassurances and explanations, now thinks I’m “racist” and “trying to single (him) out.” I would like to talk to him about another of my CPS patients of the same race, size, gender, and difficult legal background (homicide), and my friendly and professional interactions with him, but it is clear that logic and reasoning will not work for this patient.

The difficult part for me is that I have been willing and perhaps even eager to give this patient the benefit of the doubt (considering he was committed by a family member who provided the opposite, guilt-assigning story to his own). I was even surprised when my attending remarked this morning that this patient is very sick, as he otherwise appears reasonably high functioning. However, I now understand my attending’s astute assessment: his thoughts are truly, extensively delusional with little or no grounding in reality. In some ways, I feel very sad for him: his delusions of victimization may prove self-fulfilling, as his confrontational behavior might prolong his hospital stay or get him committed to a more high-security facility. On the other hand, my sympathy has faded with the rapid surfacing of his delusional and confrontational behavior, making the allegations of his wife-beating, treatment noncompliance, and poor outpatient functioning much more believable.

In this situation, it is requiring some effort on my part to constantly remove myself from the position of judge, and the result is that I have a painstakingly neutral attitude toward this patient. For me, this position is far from ideal: I would like to encourage and contribute to the betterment of the lives and health of my patients. In this case, it is more likely that I will be in the position of cooly watching this patient’s descent, indifferent to his fate, but rather, more concerned with the fate of those he might harm.

I feel the numbness I observed in our psychiatrists toward many of the patients. I look forward to the end of this rotation.

Lately, I have become inordinately excited about the prospect of pursuing the very new field of Endovascular Surgical Neuroradiology (aka Interventional Neurology) as a potential career pathway. A few weeks ago, my major three interests were Pulmonary-Critical Care, Interventional Cardiology, and most recently, Neurology. This new field seems to encompass several of my medical interests, all of which I might feel sad to abandon if I had to choose one over another. But now I wonder: how deep does this new interest of mine find its roots?

I believe that the various fields in medicine often attract people with similar interests and personalities (that extend beyond basic stereotypes). I have worked with doctors in a few fields so far that have impressed upon me particular styles and characteristics. For example, my fiancée loves mystery novels and puzzles (e.g. Sudoku, crossword puzzles, Bejeweled, etc.): I think this detective and puzzler archetype fits in nicely with Neurology in which the physician both methodically and insightfully unravels the mysteries of the injured or dysfunctional brain. In Cardiology, I find the doctors are much like cowboys: there’s an aggressiveness and pervasive confidence (especially given the many successes in the field), and in the Catheter Lab, it’s possible for a single doctor (with the help of a scrub nurse or other assistant) to save a person’s life (unlike in many surgeries, where the effort is much more team-based). Psychiatry has presented a variety of personality types and working styles to me, but the common theme I have found is the storyteller core: at the center of their interests, these doctors are interested in the elaborate life stories of their patients, and they often relate to others through telling their own life stories. Lastly, Infectious Disease physicians are the true biologists willing to confront the intrusion of nature into our lives: while other doctors might find fascination in disease marking the body’s failure to function properly, these ID doctors find a world of wonder in the numerous, rapidly-adapting microorganisms that wage war upon our bodies.

I have not been sure how my prior interests could connect with my future pursuits: in other words, I have not known how to draw strength and energy from the things that have interested me all throughout my life thus far. I don’t necessarily see myself at this time as the detective or the cowboy. What sort of things have I really liked and enjoyed that might reflect a core, underlying mode of operation?

Video games. I have always liked playing video games, despite my father’s constant insistence that I would fail out of school at the rate I played them. In particular, there is one long series of games that I have always enjoyed that I feel serves as an amusing, if not fairly accurate, allegory of why I am suddenly so passionate about this new field of medicine: The Legend of Zelda.


For those unfamiliar with the classic Nintendo-console series, each installment features the Hero’s Journey of a young, ordinary man with an extraordinary task and destiny (to save his homeland from evil and ruin). The series follows his journey as he fights his way through a variety of dungeons and fortresses, usually solving environmental puzzles and picking up new tools and allies along the way as he tries to reach his objective. To my surprise, the adventure parallels that interventional path to treatment of vascular diseases and highlights some of my core personal interests that can be applied to medicine!

Step 1: You have been summoned by the Great Deku Tree!

One of the biggest obstacles to the treatment of stroke is the time it takes for its victims to realize that they are suffering from one. Time is brain (much like “Time is muscle,” the slogan of cardiologists treating heart attacks), and there always exists the problem that something must be done before it’s too late! At this time, the main FDA-approved treatment is the intravenous use of tPA or tissue plasminogen activator in ischemic strokes (the vast majority of strokes), an enzyme that breaks up clots but must be used within three hours of the start of symptoms. After that point, tPA can actually increase the potential hemorrhagic conversion of an ischemic stroke, changing the nature of the disease from a vessel occlusive disease (i.e. nutrient/oxygen-started brain) to a bleeding disease (i.e. bleeding into the brain tissue and causing direct damage and mass effects). New interventional treatments (discussed below) can extend the treatment window to 6-8 hours or more. Nonetheless, time is of the essence!

It is important that family members and friends recognize common symptoms of stroke because patients are often in denial of the severity or implications of their symptoms. You can save the life of a loved one this way!

Step 2: Go, Epona, go! We have no time to lose!

It breaks my heart, but I understand why many (poor) people avoid calling the ambulance: the bills can be very expensive! ($1000+) However, if there’s one instance when it is absolutely necessary to get an ambulance ride as opposed to calling a friend or family member or driving oneself to the ED, it is with a suspected stroke (even more so than with heart attacks, in my opinion, since a heart can be augmented or replaced unlike the brain). Furthermore, calling an ambulance gives the medical team advanced notice that you or a loved one might be having a stroke, thus speeding up the arrival of treatment and avoiding the necessity for triage upon arrival in the ED. Stroke Team Activation! (At this time, if I were an Interventional Neurologist and was at home, I would get paged and would be rushing to the hospital. If I were at the hospital, I would be getting the CT scan, tPA in the ICU, and Catheter Lab ready for possible treatment.) Every minute counts.

Step 3: You have received the Map!

One of the first things that needs to be determined upon arrival is the nature of the stroke: is it an occlusive (ischemic) stroke or a bleeding (hemorrhagic) stroke? 80-85% of strokes are ischemic, and those are the ones that can be treated with tPA and interventional techniques. Hemorrhagic strokes are treated differently, but if you give these patients tPA, the damage gets even worse since you are giving a medication that breaks up clots (that would otherwise stop the bleeding)! So, noncontrast head CT, stat!

If the patient arrived within three hours of the onset of an ischemic stroke, we can treat with tPA in the Intensive Care Unit (stroke patients require specialized care in the first 24-72 hours that differs from most patients, such as keeping the bed flat, aggressive temperature control < 99°F, tight control of blood glucose, maintaining “permissive hypertension,” etc.), open up the blockage, and minimize any damage. However, what happens if the patient arrives after the three hour deadline? Then we have to assess whether an interventional procedure is possible and indicated. Where is the occlusion? Let’s take a look!

Angiography allows interventional neurologists to determine where a blood vessel is occluded by a clot, thus setting the goal for an interventional procedure. The angiogram provides a “map” to the occluded vessel, and the interventionalist can maneuver a microcatheter through the blood vessels to either deliver tPA directly into the clot (to minimize hemorrhagic conversion or damage elsewhere) or use a mechanical device to break up or pull out the clot. Is the patient aware of the procedural risks and the consequences with and without interventional treatment? Does the patient consent? Yes? Let’s go!

Step 4: Over, sideways, and under

My favorite games usually involve environmental puzzles: given the tools you have, you need to figure out a way to get from point A to point B, often requiring some maneuvering and finesse. To me, this embodies the practice of interventional techniques: you have to thread a thin wire through the blood vessels of the body, around twists and turns, beyond bifurcations (forks in the road), and into the areas of occlusion or damage. This is not always a straightforward process, and this is where skilled hands are an asset! I have been complimented various times throughout my life (including by physicians) about my hand skill and motor coordination, but I have little interest in Surgery as a potential career path and lifestyle. Nonetheless, I would like to use my hands to help heal and treat those suffering from disease, and interventional procedures may offer me this chance.

Step 5: The Final Boss

Upon arriving at the site of injury, the moment of truth presents itself: will I succeed in breaking and removing the clot without complication and collateral damage? How can I best accomplish this goal in this situation?

So far, the options of intra-arterial thrombolysis (with tPA), mechanical clot thrombolysis, and clot retrieval. All of them constitute precision strikes on the culprit clot.

Step 6: Success!

The clot has been removed, and the vessel has been revascularized! The patient can be sent back to the ICU for post-treatment care. During my time with the Stroke service, I had the chance to witness the marked difference in outcome between a patients who received tPA in time and those who were not able to be treated due to their arrival after the three hour deadline. Many people survive strokes without treatment, but it is not just a matter of life and death: it is also a matter of disability and quality of life after the stroke, as many people are permanently disabled (physically and/or mentally) by strokes, the leading cause of long-term disability worldwide. Interventional techniques offer hope of extending the treatment window and reducing the overall mortality and morbidity from the disease.

Nonetheless, the medical care does not end there. Patient education and secondary prevention of stroke is essential to prevent the ordeal from occurring again. Or ideally, we can prevent the strokes from ever happening in the first place with primary prevention and care!

Conclusion

This has been a light-hearted approach to exploring how my past interests reflect core objectives that I can achieve in my future career and engrained principles and character traits that I would like to draw upon to make each day a worthwhile adventure. Perhaps for the first time, I am thinking less about the professional experience in each field based on current standards and practices and more about what things can be in the future.

And to the future of medicine and those I hope to save, I will bring:

The resolve to protect without hesitation,
the strength to endure in the face of everlasting darkness

A month and a half into third year, I am currently having conflicted notions about my desired career path into medicine. I am very much in love with medicine so far: the issue is that the pathway I thought I would pursue within medicine is now being challenged by a new passion. There are many factors that might inspire a medical student to select one field or another. Given my background of my mother’s cancer, it might seem natural for me to select Hematology-Oncology. However, despite my interest in caring for very sick patients and dealing with end-of-life issues, Heme-Onc never seemed to rest comfortably in my concept of a career for reasons of which I still may not be fully aware. Later, finding personal experience as a motivation (e.g. childhood asthma), gaining knowledge through basic science research in the field, and finding inspiration in the doctor-patient relationships exhibited by one very talented pulmonologist and her patients, I was drawn to Pulmonary-Critical Care Medicine as a potential career path. I can relate very well to patients who do not take easy breaths for granted, and the Critical Care aspect intrigues me with respect to the procedural aspects and the constant imperative to provide some level of care to one’s patients. Additionally, there also was the added amusement and benefit of being able to introduce myself as “Dr. L(e)ung!” At the same time, my shadowing experiences with an Interventional Cardiologist attracted my desire for immediate gratification in the ability to save lives by performing direct, hands-on interventions (balloon angioplasty and stenting).

However, each of the fields, although interesting, do not quite stimulate my sense of wonder. To my surprise (and almost to my chagrin), I have recently fallen in love with many aspects of the field of Neurology. I chose to do Neurology as my first rotation so that I could “get it out of the way” and cut my teeth on a field to which I was not particularly attracted. In truth, however, I have always found many subjects in Neurology fascinating but have repressed my interests and avoided the field due to a very poor quality course in Behavioral Science during my undergraduate years and very disorganized coursework in Medical Neuroscience. Furthermore, I was turned off by the (wrong) assumption that there are few treatment modalities available in a neurologist’s arsenal for treating neurological diseases as compared to other fields (primarily, cardiology and pulmonology). However, my recent tour on my hospital’s new Stroke Service has convinced me otherwise. Indeed, neurovascular diseases fascinate me more so than any other area within Neurology. Nonetheless, trying to catch patients in the 3-hour window within which tPA can be used to dissolve blood clots seems to be an intervention with many non-medical impediments. For my attending physician, trying to streamline that road from a patient’s first symptoms to her arrival in the Stroke Unit is a logical and meaningful objective at this time. However, what would be the great battles to fight 6-10 years from now when I first enter the field as a fully-trained specialist or subspecialist?

Taking a page out of the book of my fiancée, I have found one potential answer to my search for the perfect field and fit: a synthesis of several of my interests – Interventional Neurology. The field involves the treatment of neurovascular disorders with percutaneous interventions such as carotid stenting (to revascularize occluded carotid arteries), aneurysm coiling (to seal off potentially hemorrhagic vessel wall dilations), and intra-arterial thrombolysis and direct clot removal (to treat thrombotic or embolic strokes after the 3 hour tPA administration window, thus increasing the time available to directly treat ischemic strokes). This is a very new field with many names, and most trainees come from Neurosurgery or Neuroradiology backgrounds. However, there is an emergence of the notion that Neurologists with interventional training can also contribute greatly to the multidisciplinary field by providing the knowledge to treat and manage the neurological/medical aspects of neurovascular diseases as well as the preoperative and postoperative needs of these patients (e.g. neurocritical care background not provided by Neurosurgery or Neuroradiology). Interventional Neurology, recently approved in 2006 by the Accreditation Council for Graduate Medical Education (ACGME) as Endovascular Surgical Neuroradiology, was developed to include Neurology trainees as well as Neurosurgery and Neuroradiology-trained physicians. From the Neurology entry point, the fellowship would require:

3 years of Neurology
2 years of Neurocritical Care (or 1 year of vascular/stroke fellowship)
1 preliminary year of Neuroradiology* (may be incorporated into the ESN fellowship)
3 months of Neurosurgery

The fellowship itself is usually a 1-2 year program. That does mean my training would last 7 years, but if it is for something about which I am madly passionate, I think it would be well worth it. This new field appeals to me for a variety of reasons:

1. The (neurovascular) diseases are intellectually stimulating and fascinating. Furthermore, stroke is the leading cause of long term disability in the U.S. and around the world, and in the future may replace cardiovascular disease as the number one killer worldwide.

2. The critical care background would give me the knowledge and training to work in Intensive Care Unit settings, one of the areas in hospitals in which I feel most at home. I like working with very sick patients, I am not turned off by the presence of ventilators or the process of dying, and I like the team work in ICUs (especially the ICU nurses who are pretty awesome).

3. Performing direct interventions excites me, especially since it would give me the opportunity for me to use my hands without forcing me down a surgical path. Furthermore, endovascular intervention seems to be the logical next step in the advancement of the treatment of cerebrovascular diseases like stroke. Given the success Cardiology has found with angioplasty and stenting, Neurology seems poised for great advances, hopefully in the form of Interventional Neurology.

4. The field is very, very new. This hopefully would give me numerous opportunities to teach and train other physicians in the science and procedural aspects of the field as well as opportunities to research and develop new methods and principles of treatment.

5. While I don’t like the idea of excessive pride in physicians, I would still like to be proud of the work I do. While I would find pride in other fields, there is something incredibly compelling about the brain and its growing primacy in our developing understanding of life and consciousness. As Dr. Wiese noted: in acute care situations in Medicine, the lungs and the heart provide vital functions to provide oxygen to brain. The lungs and heart are incredibly important organs without which a person cannot live. However, they are still supporting players to the brain, the captain of the team. I have not neglected to notice that Neurologists are paid less than Pulmonologists and Cardiologists, partly based on that very idea of what can be done for the patient (with procedures and imaging being reimbursed for more than pharmacological treatment or physical examination). I would be proud of any efforts I might take to demonstrate and establish the truth that Neurologists can do incredible things, including interventional treatments, for their patients, as much as any Cardiologist or Pulmonologist.

Of course, two months ago I was fairly comfortable with the notion of going into Pulmonary-Critical Care Medicine. Will Interventional Neurology be a fleeting passion, or will it even be a plausible path? If nothing else, the idea excites me. A lot.

This past week has been a crash course in addiction and substance abuse with the best trained and most experienced Addiction subspecialists in the New Orleans area. Addiction is a fascinating and complicated problem that is often not well addressed by conventional medical and health care infrastructure. There are hundreds of independent programs, often in the forms of “Houses,” that follow different paths to recovery with varying levels of commitment and self-direction. It is also a field where I suspect there is often a very wide divide between the patient and the physician: the physician, often a psychiatrist or family practitioner or internist, serves as one of the leaders of a multidisciplinary treatment team consisting of a psychiatrist, a psychologist, nurses, social workers, case managers, and more. While the multidisciplinary approach is excellent in eliciting the strengths of each team member, it also dilutes the relationship formed between the patient and any one member of the team.

Today, I had the unfortunate experience of observing a lecture by a nurse-educator to a group of inpatient substance abusers. The nurse-educator was attempting to provide scientific explanations, based in neurophysiology and neuropathology, for the development of tolerance to various drugs such as alcohol and opioid drugs, the main drugs from which the patients were detoxing. However, the nurse’s approach was very detailed and (by patient report) far too complicated for most individuals. Furthermore, for someone (like a medical student with some interest in Neurology) with a medical science background, the lecture was absolutely appalling with respect to the degree of misinformation provided. Yesterday, one of my team members (another medical student) and I did our first Health Education Group lecture to our inpatients on our psych ward which was regarded as a great success: we were able to keep things simple, provide clear messages and concrete suggestions and facts, elicit meaningful questions from the patients related to our topics of discussion, and provide adequate explanations. However, this nurse not only focused on too much detail and provided wrong information: he did a disservice to the treatment team and patients by cultivating distrust and confusion. In one case, a few of the patients were confused as to why doctors might use methadone to treat heroin and opioid dependence when methadone itself can be abused and can have terrible withdrawal symptoms. Instead of answering the question with a clear explanation of the rationale for treatment (methadone has a longer duration of action than the opioid drugs patients abuse and is gradually tapered by the doctor with close observation, thus aiming to avoid the symptoms of withdrawal that might drive a patient to seek the original drug and relapse), the speaker called methadone the “1950’s treatment” (implying that it was outdated, despite its continued usefulness at this time) and diverted the discussion to the topic of buprenorphine, a newer medication used to treat opioid dependence. The patients then expressed concern about buprenorphine as being the “2008’s methadone,” a notion the speaker failed to adequately dispel. Essentially, due to his lack of complete knowledge and his failure to say “I don’t know” when appropriate, the nurse-educator fostered distrust in current medical treatment for dependence.

Saying “I don’t know” used to be a major problem for physicians… especially in the 1920’s around the time of Dr. Richard Cabot, a well-known Boston physician who wrote extensively on the subject and the need to improve the patient-physician relationship with honesty. Dr. Cabot would say and suggest other doctors to say, “I don’t know the answer to your question, but I have a colleague in that field that will know the answer. I will consult him/her and find out the answer.” Every physician I have shadowed, worked with, or encountered has done the same when asked a question by a patient that he or she does not know the answer to. The third year of medical school trains us to do so when appropriate: we have a basic level of knowledge that cannot answer all patient questions or the “pimping” questions of our attendings and residents, so we can say, “I don’t know” and then learn from them. Is this not engrained in the professional culture of other health care workers? Today’s example exemplified irresponsibility.

The term “unholy alliance” was used today by a psychiatrist I am working with who has a number of patients who are nurses recovering from addiction and substance abuse. The question he always asks is “How can you use and not get caught?” In some cases, a health care professional might find himself or herself in a position where only one sympathetic person is overseeing the acquisition and distribution of medications by the individual. An arrangement might form where the supervisor might turn a blind eye toward the individual administering medications and fail to notice patterns of abuse. Although this problem can also affect doctors, techs, and other members of medical teams, this problem seems to be especially pronounced in nurses, the frontline health workers who are usually the ones acquiring medications from the pharmacy and delivering them to patients. In the cases I have seen, several of the nurses are highly competent and excellent caretakers, and great effort is expended to rehabilitate them and return them to work.

Nonetheless, my work on an inpatient psychiatric ward (particularly with substance abuse patients) has troubled my thoughts when combined with this knowledge of the “unholy alliance.” Health care is a very difficult and challenging environment in which to work with countless stressors and sources of frustration. I was recently reminded of the classic Akira Kurosawa film “Seven Samurai” in which a village of peasants, harried and oppressed by bandits, enlist the aid of seven samurai to protect them. In the end, the samurai are able to defeat the bandits at the cost of several of their lives. The film concludes with a celebration by the peasants that excludes the battle-bound samurai: they fight hard to save life that they cannot participate in. Increasingly, as the insertion of third parties continues to expand the rift between patients and their caretakers, health care and medicine have often become less rewarding for those taking care of the sick with the shortness of time and emotional commitment. I think there is an unspoken understanding among health care workers about their daily trials that was best summarized by a nurse who was relating to me and my resident a story about her pounding on the ceiling of her apartment to quiet down a loud neighbor: “Normally I wouldn’t bother, but somebody has to come here every morning and take care of people.” Like Kurosawa’s samurai, there is an almost divine or god-given ability and directive given to the people who work in hospitals that confers upon them solace and strength, even in the absence of gratitude or participation in the lives they save. Nonetheless, this divinity that separates patients and caretakers, which some patients might complain about in the hospital or clinic setting, is even more exacerbated and resented on the inpatient psychiatry ward: by definition, the doctors, nurses, and psychiatric aides are supposed to be even better and more capable than normal individuals (for their roles as caretakers) determining the fate of deviants. How disturbing, then, it is to have patients who are former nurses who have fallen from the position of caretaker to psychotic, depressed substance abuser. How easy is it, how slippery a slope it is to self-medicate against the unaddressed frustrations and stresses of working in the hospital?

As I lay in bed last night at 10pm with my neighbors upstairs blaring their television set, I thought about what the nurse had told me about pounding her ceiling to get her neighbors to quiet down. I thought about last summer when I had a similar problem: a neighbor was watching TV all throughout the night and was keeping me awake. And then, as I thought about my patients on the inpatient psychiatry ward, I realized what kept me awake all those nights: it was my inability to let it go. It was the anger and frustration I felt about another person’s inconsideration. It was my belief that my daytime research work in disease treatment and management was more important than someone’s need to watch TV at 3 AM. It was annoyance at myself for not being able to sleep more deeply. Those feelings and thoughts were seeds of anger, paranoia, depression, and anxiety peppering my mind with agitation. The simple beginnings to the tumultuous and convoluted psychological and emotional messes I address daily on the psychiatry ward. With a little bit of that in every aspect of life, it’s not hard to feel a need to reach for a beer or a cigarette. Something to take off the edge. To self-medicate. The need for an acceptable way to release, until the point that the acceptable method is abused. Knowing this, I thought to myself, “Well, why not just let go?” And so I did and slept well last night.

Several months ago, I wrote about my plan to use my new iPod Touch as a medical PDA in lieu of purchasing a PDA phone and using the outdated Palm OS or the volatile Windows Mobile OS. So far, I have been quite pleased with the results and can report, at the very least, marginal success in my use of the device. My fiancée and a classmate/friend have both followed the same path to the use of an iPod Touch as a medical PDA. Here are the details:

Advantages

1. Flexibility – Both the iPod Touch and the iPhone have a considerable amount of flexibility with respect to the content that can be placed on the device. With the arrival of Apple’s App Store, it is now possible to install a variety of programs onto either device that can expand their range of uses and the range of storable content. Several programs offer the ability to store, organize, and view PDFs, Microsoft Office documents (Word, Excel, Powerpoint), videos, images, and sound files. The devices themselves already have built-in capabilities provided with Apple efficiency through iTunes for viewing images (Photos – which I use for medical images from Gray’s Anatomy, Netter’s Anatomy, and Access Medicine, including Chest X-Ray reading guides), videos (Videos – which I use for NEJM Procedure Training videos, and also downloaded movies and TV shows for long plane flights), and sound (Music – which I use for music and more recently podcasts from NEJM audio interviews, Johns Hopkins Medical School discussing new studies, from Discover Magazine’s Vital Signs discussing mysterious medical cases, and from Coffeebreak Spanish to begin learning Spanish). When I discussed potential options with my fiancée for her desired new device, she spoke of how an Apple device in particular would do wonders for adding new functionality to her lifestyle: providing video/audio entertainment during gym workouts, allowing her to store cooking/baking recipes in a single location that can be readily consulted in the grocery store, etc.

2. Financial Savings – This advantage may be more tenuous, depending on how one uses the device. The iPod Touch cost me $300 to purchase, and I have since spent another $40 on iTunes App Store applications (Netter’s Neuroscience Flash Cards) to expand its uses as a medical PDA. Several programs I use as medical references are free, however: Epocrates Rx (the program I consult 20-30 times each day to look up generic names and pharmacologic classes of medications, drug prices, adverse reactions, and interactions between two or more drugs), Eponyms (a neat little program providing concise descriptions of a vast number of diseases and clinical signs with eponyms), and Unit Convertor (for changing Celsius to Fahrenheit and vice verca, since temperatures are often recorded on the same day in either modality depending on the thermometer used). Similarly, I have been able to store PDFs from Access Medicine on the device including reference materials from Harrison’s Internal Medicine, Current Diagnosis and Treatment, and Current Consult, as well as assorted files including the Walmart $4 prescription list. This has thus far allowed me to avoid having to purchase an expensive new data plan, a yearly subscription to Epocrates Essentials, new copies of pocket pharmacopeias and medical references, etc.

Disadvantages

1. New Device with Limited Medical Software Repertoire – Since the iPhone/iPod Touch is new to the market, medical software companies are still taking their time to convert their packages to these devices. Epocrates did an excellent job of making Epocrates Rx available at the opening of the App Store in July, but it has not yet provided versions of its Essentials software which would be desirable for medical professionals with less time to customize and seek out free content.

Nonetheless, Epocrates Rx, as one of the most readily updatable pharmacopeias, has given me an edge in providing my medical teams with up-to-date knowledge on medications, their prices, and interactions they might have with other drugs (the program has a handy Interaction Checker in which you can input several drugs, and it will determine any possible interactions), something the pocket pharmacopeias do not provide as well (despite being a few seconds quicker to access).

I have also found the use of Epocrates Essentials by my colleagues to be of limited use so far: the information is usually accessed on a mobile device in the context of pimping, but I don’t think it necessary looks particularly good to be asked a knowledge question and immediately pull out one’s PDA. I feel much more comfortable saying “I don’t know,” learning from the attending physician or resident, and then reading up more about the disease, clinical sign, or treatment method at home. Using medical software for guiding treatment can usually be done at the computers provided at the Nursing desks or elsewhere in the hospital, all of which should usually have access to UpToDate and similar high-quality, online medical resources. By the nature of most medical PDAs running Palm or Windows Mobile OS, the information provided by mobile medical software packages has to be more concise and abbreviated, which might not always be useful in the context of guiding subtle treatment decisions.

Unbound Medicine has opened access to its “medical software” (Harrison’s, 5-Minute Consult, etc.) to the iPhone/iPod Touch, but these packages require the Safari browser and an internet connection. For me with my WiFi-only iPod Touch in WiFi-scarce hospital areas, it makes more sense to rely on downloadable information.

2. Single Carrier – One of the reasons I chose the iPod Touch over the iPhone is to avoid having to switch cell phone carriers. While I am not pleased by the business model, expensiveness, and general lack of user friendliness of Verizon Wireless (my current carrier), the service has the best signal in the hospitals in which I work. Personally, I find that it is very frustrating (and seemingly unprofessional) when I call someone and consistently receive their voice mail because they lack cell phone signal. Frankly, I don’t want to be that person. However, AT&T is the only carrier for the iPhone right now, and their cell phone reception is very poor in virtually all of the areas in which I work. This limits the utility of the cell phone and Internet-based capabilities of the device.

Summary

Overall, my experience has been quite good, and I have found that between my iPod Touch and Pocket Medicine, I can cover most of my information needs (occasionally supplemented with a small field-specific reference, such as for Psychiatry, my current rotation). I look forward to what the future has to offer for these devices! (Already, there are several EMR/EHR and radiological imaging viewing packages.)

My iPod touch allows me to:

Medical
• Access the most up-to-date, user-friendly, and free drug database I am aware of – Epocrates Rx
• Reference anatomy and neuroanatomy resources – Netter’s Neuroanatomy, images from Gray’s and Netter’s Anatomy
• Quickly convert units – Unit Convertor
• Manage work tasks – iProcrastinate Mobile
• Locate inpatient and outpatient work sites – Apple’s Maps
• Learn medical procedures such as inserting femoral venous catheters and performing lumbar punctures – Videos – NEJM Procedure videos (downloaded)
• Stay up to date with recent studies and medical news – NEJM audio interviews, Johns Hopkins PodMed medical news discussion podcast, Discover magazine’s Vital Signs medical mysteries podcast

Life Management
• Keep a tight Calendar that syncs with iCal on my laptop – Apple’s Calendar
• Check, manage, and reply to e-mails within WiFi range – Apple’s Mail
• Surf the web and check my RSS Feeds – Apple’s Safari browser
• Check the weather and storm alerts – WeatherBug
• Write and post blog posts away from home – WordPress app
• Set recurrent alarms, use a stop watch – Apple’s Clock
• Maintain a contact database that syncs with Address Book on my laptop – Apple’s Contacts
• Write notes – Apple’s Notes
• Stay in contact with friends using Twitter and the Facebook – Twitterific, Facebook app
• Learn Spanish – Coffeebreak Spanish podcast
• Read Associated Press news offline – Mobile News app
• Use a tip calculator – Tip

For Fun
• Use language references for learning – LastMinute Spanish/French/German/Italian, Lonely Planet Mandarin
• Play weekly crossword puzzles – 2 Across (I blame my fiancée for getting me into this)
• Play random games – Sol Free (solitaire), Jawbreaker, Cube Runner
• Watch YouTube – YouTube built-in app
• Watch movies and TV shows – Videos (downloaded content)

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