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Monthly Archives: September 2008

Much to my chagrin, I have recently taken up running as a lifestyle modification and exercise activity. Ever since I sprained both of my ankles after a two-week tryout of cross country running in the 7th grade, I have looked upon the activity with great prejudice, particularly at the “gotta love the pain (e.g. endorphins)” attitude of “serious” runners. However, especially with my fiancée’s recently commitments to regular exercise and explorations in running, I have come to recognize that running can be a form of exercise that isn’t entirely masochistic. I have long assumed that my asthma would limit my ability to do cardiopulmonary workouts and endurance training, but this has probably been mostly an excuse rather than a legitimate reason given my otherwise healthy and fit state. I plan to start slow and easy and gradually work up to reasonable, arbitrary goals of my own choosing. I do not plan to run races or marathons, but I do plan to have fun, especially in viewing running as a way of getting places rather than just as a workout.

In reflecting upon starting this habit, though, I’ve found that getting into a new form of exercise (the right way) can be quite expensive. On previous occasions when I have run, I have never had the proper shoes, leaving me with sore feet in addition to sore legs and a sore back. I also never had truly comfortably exercise clothing made for running. Lastly, I never ran with a pedometer or some other method of tracking my progress. There’s no doubt about it: running is ridiculously boring without amazing and constantly changing scenery, a conversational running partner, or an iPod with good workout music. In order to truly motivate myself to accept this new activity, it has been very important to have the right equipment, which makes me wonder how we (doctors) can hope to motivate others to adopt many forms of exercise if they do not have sufficient funds. There certainly are types of exercise that are cheap and easy to adopt, but others (like running, cycling, gym classes, etc.) do cost a fair amount of money.

My equipment so far:

• Brooks Adrenaline GTS 8 running shoes – Tried these on with the help of the nice folks at Phidippides, a specialty running shop in Metairie, LA. These may be some of the most comfortable shoes I have ever worn. Apparently I am a mild overpronator, meaning my arches are slightly flat and require some stabilization, “motion control,” and “support.” These shoes address that issue and are furthermore sized slightly wider than most shoes, allowing my claustrophobic toes to rest happily without having too much wiggle room in length (like most of my other shoes).

• Champion C9 exercise clothes – Helps keep me cool and dry on a hot, sweaty New Orleans day.

• iPod Touch with “Pedometer” and some rockin’ running mixes – Having high-energy music can really help the mind take on greater challenges!

Believe it or not, despite my sore quadriceps muscles that impeded my ability to walk up and down stairs today, I am actually looking forward to a light run tomorrow. And it is not because of the endorphins.

As I continue through my journey through the junior year of medical school and explore various fields, I have found that my interest in Vascular Neurology, particularly stroke and Interventional Neurology, has grown and is gradually solidifying into a mature interest. Despite my interest in specialization, I have typically followed the behavior pattern of a jack of all trades, dabbling in many different interests without becoming a true maestro in any one. Medicine, as a career, is offering me the chance to truly become an expert in one area of interest, but this particular subspecialty furthermore may allow me to enjoy the many aspects of medicine I am interested in and pursue goals in each:

• Clinical Work – I decided to pursue a career as a physician because I want to be a clinician, not an MD-clad bench researcher or other MD-variant. At the heart of my motivation is the desire to treat and care for patients on an personal level, to engage their troubles and diseases directly with my hands, senses, and mind, as have many generations physicians and healers before me.

• Research – A year ago I decided that I did not want basic science research to be a part of my career. At this time, I still feel a similar sentiment, but I am now exposed to research in which I do find passion that covers the range between transitional and clinical research. I have recently added Stroke (the journal) to my RSS feed, and I have started reading the abstracts with the same magnetism that would draw me to Sunday comics.

• Teaching – I love teaching, and I look forward to being able to teach medical students and residents someday. If I become an Interventional Neurologist, I would be very excited about being part of a training program for physicians in this new field.

• Broad Impact – Stroke, like heart attacks, affects such a large population around the world: no age group or race or socioeconomic group is immune. It is the second leading cause of death worldwide and a leading cause of morbidity (e.g. disability). If I become a subspecialist, I don’t want to deal with a rare disease or a set of uncommon diseases: I, as an individual physician, want to help as many people as possible.

• Public Health Education – Stroke is only now beginning to develop public health education campaigns; hopefully someday “brain attack” will be as recognizable as “heart attack,” because we want to get people to the hospital as quickly as possible after symptoms first appear. Just as “Time is Muscle” in Cardiology, “Time is Brain” in Vascular Neurology. Some education campaigns are being tested in schools: what a wonderful extension from my leadership experience with Doctors Ought to Care if I get to have the chance to teach kids about health again!

• Interventional Procedures – I love working with my hands, but I also want to use my brain’s analytical skills on a daily basis. An interventional field offers me the best of both worlds. (Not to mention that it will certainly help pay off my student loans!)

• Invention – Interventional Neurology is a very new field with the potential for the creation of many new tools and devices. Maybe someday I’ll be able to contribute in this fashion!

• Critical Care – Stroke patients are often admitted to the Intensive Care Unit (ICU) or even a Neurology ICU. My previous interest in Pulmonary and Critical Care may still live on here: I will have the opportunity to work with very sick patients with complex, multi-system management issues.

• Working with Paramedical Professionals – As I have found working with the Stroke Specialist at Tulane Hospital, a good Vascular Neurologist can benefit from building connections to multiple employees inside and outside the hospital: the paramedics that bring in the stroke patients, the ICU nurses that need to aggressively monitor and treat hyperthermia and hyperglycemia, the physical therapists and occupational therapists that are essential for the post-stroke rehabilitation process, etc. One can hopefully build a real dream team!

• Healing the Mind and Soul – It is increasingly becoming apparent that post-stroke depression is a major factor in the outcome of the disease. Although I don’t have any aspirations of being a psychiatrist, I would be excited and vigilant about helping to identify and treat depression in my patients.

• Treating the Whole Body – Stroke, in its management, is a “medical” rather than “neurological” disease: besides the diagnostic and interventional processes, one treats the patient’s high blood pressure, high blood glucose or diabetes, high cholesterol, heart disease such as atrial fibrillation, coagulation disorders, sickle cell disease, etc. The brain is the endpoint, but a stroke specialist must also consider and manage the disease of the body that supports the brain.

It won’t be long till our country, as a collective whole, has the opportunity to choose new leadership with hopes of generating the momentum and strength to bring about meaningful change in the way we conduct our lives. Rather, this is the hope for liberal voters who recognize the perilous state in which our country currently resides. The United States has lost much of the good will and influence it once had as a benevolent pro-democracy world leader. The current administration has fostered a more reactionary and radical international atmosphere with no conclusive removal of terrorists threats (partly from creating inspiration for new terrorists who despise what they see as American imperialism and interference). The domestic economy is in shambles with a shortage of employment opportunities for young Americans. Our dependence on foreign oil is pressuring and hindering domestic affairs and business and even personal travel. And, of closer interest to me, the deterioration of our health care system and its failure to fully accomplish in its evolving mandate (one that is being adapted to a new century and may outpace the mindset of some physicians) has finally garnered enough attention, anguish, and energy to push forward much needed health care reform. The other side, conservative voters, would like to believe that the hardship and troubles of the past eight years simply represent a “growing pains” period in the transition to a “Pleasantville”-style America of yore: in their eyes, things aren’t that bad (which is true, because their eyes are generally not turned towards those Americans who are in need of help or who are suffering most from these hard times), and things will only get better the smaller their worlds become.

One of my most shameful confessions is that I was once quite conservative in thought. Despite the relatively “liberal” way in which my parents raised me and my brother (free access to TV, books, movies and the Internet; considerable world travel; great emphasis on education), the conservative nature of socially-mobile immigrant thought was also imparted upon me. My hard-earned dollars are my own; why should I spare a cent for the lazy bum who would most likely spend it on drugs or alcohol? My parents came to America with a couple hundred dollars and their suitcases and were able to work their way up through socioeconomic ranks from an entry point near the bottom; why can’t people on welfare get a grip and do the same? Why would I want anyone (including government) interfering with my affairs when my parents fought so hard and long to finally achieve political freedom by becoming American citizens? It took several years of education to shape and finally break through this thought cycle, but nothing has dispelled the placating conservative myth greater than my entry into the field of medicine and an in-depth retrospective look at what brought me to this point. This is not to say that doctors are universally liberal (in fact, many are quite conservative, and it is a conservative doctor whom I respect greatly who inspired this post), but the position of being rapidly and repeatedly exposed to the lives of thousands of others, their troubles, their successes, their joys, and their suffering, questions more than a few underlying assumptions of the world and its people. Every day I play the role of the detective, storyteller, and scientist as I methodically comb through the medical, familial, and socioeconomic histories and realities of each of my patients. Repeated exposure and the perception of repeated “failure to thrive” can make medical professionals quite callous, but this tendency runs contrary to that which allows us to truly be healers rather than just mechanics of the body: the mandate and imperative to use compassion and empathy to treat the body and mind, and sometimes even the soul, to the best of our ability. I would go so far as to argue that doctors who claim that physicians should only treat the body generally lack the strength, capacity, or will to do more. Humans are complex, interactive, social beings, and physicians need to address them as such with a “multidisciplinary” approach that is generally referred to as the “art” of medicine. I personally find it hard to believe that one can fully accomplish this and still maintain a largely conservative world view.

Unless, of course, the person’s world view is small. Therein lies my best answer to the nature of the compatibility of intelligence and conservative thought: it is possible to be intelligent, well-educated, and conservative, but this sort of mind lacks true exposure to a broad range of human experience. It is complacent. True exposure requires more than CNN or Fox News, the NY Times or the Wall Street Journal or the Economist. It requires more than classes at Harvard or a few volunteer experiences. It requires more than sight, hearing, or smell. People find exposure in many ways, but for me, medicine has thus far been my path through the compendium of humanity. It is possible to travel this path with blinders or “eyes wide shut,” but I have tried to keep mine nonjudgmental and objective. Whether successful or not, it has given me the chance to share both great joy and great sadness, anguish and ambivalence, clarity and confusion. In what other profession besides medicine (whether as a doctor or nurse) do you spend so much time wading chest deep in some of the most intense, critical moments of the lives of others? Many people would disagree about my assertion of interpersonal engagement as being the measure of human experience and would argue that a “broader,” “higher,” ten thousand foot high view of the world is more ideal or accurate for assessing the state of humanity and its truths: personal interaction is subjective, emotional, and lacking universality. I think these people are lazy and lack the willingness to look another human being in the eyes and truly listen to and share in their story as if it were the person you love most speaking to you. I think these people are unwilling to engage the suffering or accept the emotional expression of others, whether it is because of their own internal fears and insecurities or because of a lack of strength to not falter and collapse under the weight of another person’s troubles. It is thought that there may be a limit to the number of human beings a single individual can develop meaningful relationships with; this, however, says nothing about the number of people an individual can meaningfully share experiences with. I believe this, I know this, because I am going to be a doctor, one of many types of people who are willing to take the heat.

With this transformation of mine in mind, I believe that our country is at the cusp of great change with respect to medicine and health care: I see this as the beginning of an era when physicians regain influence and leadership capacity by taking ownership of the change that needs to happen, and I see this as the time for reforming some of the fundamental principles of American health care that have left so many people to suffer and languish in a perverse system. I find it interesting that people talk about “perverse incentives” as a disadvantage of pay-for-performance reimbursement in medicine, and yet we forget to describe the daily function of many insurance companies, HMOs, pharmaceutical companies, and other entities in health care as “perverse” or “operating under perverse incentives.” I think that people hold physicians to a higher standard of conduct that I do not find inappropriate. However, I think in order to make that worthwhile, I think physicians need to step up to the plate and engage in the dialogue of change: reform in health care needs to happen, and if it is going to happen, why not be at the helm (or at least, one of the leading parties involved)? Health care is currently functioning in a state that seeks to exclude physicians from all management and policy decisions; how can this possibly be ideal or even acceptable, whether for doctors or patients? This may be acceptable to a complacent mind, but it is not acceptable to mine.

It’s nice, for a change, to actually feel like a doctor during my time as a third-year medical student. At the end of my twelve-hour extended duty shift yesterday (after having spent most of those twelve hours with little to do but read medical references on my iPod Touch), I finally had the opportunity to admit a patient from the Emergency Department to the general Pediatrics floor. The patient, a spunky young kid with whom I could conduct much of the interview while in the company of his parents, had burns from a cooking accident covering much of his face. The medical issue appeared quite straight-forward (a simple accident with a very low index of suspicion for intentional injury on the part of the child or his caretakers), and I was able to smoothly conduct the interview and physical exam (and build an appropriate differential diagnosis that ruled out abuse or self-injury). At one point, the parents even remarked with admiration to the intern with whom I was working when I whipped out my otoscope from my belt to examine the boy’s nose, throat and ears: “That’s so neat! How professional!”

I was actually caught off guard when the resident on duty asked me to admit the patient: during this past week on Pediatrics, my attempts at assertiveness and at assisting my team seem to have been given the cold shoulder (whether intentionally, unintentionally, or just as a result of the circumstances at the time), and I had been starting to feel underwhelmed and disconnected. While on my (adult) Neurology rotation, although I was largely inexperienced and naive in the clinical setting, I still felt as though I were an integral member of the treatment team because the attending physician, the residents, and the interns viewed me and my fellow students as such and demanded the responsibility to match. The Neurology and Psychiatry departments with which I have previously worked were also smaller and seemingly more personal than Pediatrics, despite the reputation of pediatricians as the most genuinely nice doctors with whom we (students) will work. When my (future pediatrician) fiancée had mentioned to me that she is planning to do her sub-internship in Medicine instead of Pediatrics, I was at first confused until she mentioned that some of the physicians advising her classmates had noted that there is often less independence and autonomy for medical students in Pediatrics services than in Internal Medicine services (sub-internships are done during the fourth year of medical school as an opportunity to function with the responsibility of a first year resident). I have definitely felt that way so far: the attendings seem eager to teach and the interns are quite pleasant, but I think the residents provide less direction and fewer teachable challenges than on my previous rotations. I think this is partly because my Pediatrics clerkship is structured such that we only spent 10-14 days in four different sites/services/teams, so the residents have comparatively less responsibility or emotional investment in the medical students. This rotation seems to be a “smorgasbord of exposure” to a variety of experiences that provides little depth or intensive training in any one area: indeed, we have to keep a patient log that requires that we see one patient in each of fourteen different areas of Pediatrics (e.g. cardiology, endocrine, gastroenterology, well visits, etc.) or complete a structured teaching exercise for the areas we miss on the wards.

Last night’s experience was also remarkable in that my actions were not scrutinized: I did not have to present the patient to a physician (resident or attending). The intern dictated the patient’s history to the attending physician, and so I was able to conduct my tasks with autonomy: interview and examine the patient, speak with the parents, write the admission note (history & physical), and place that note in the patient’s new chart. I will eventually present my note to a preceptor (physician) to evaluate my note-writing, but my purpose and function yesterday was independent of oversight. As a medical student, one usually presents to the resident on “work rounds” (during which one’s mistakes are corrected), and then one presents a more polished version to the attending later in the day on “attending rounds.” These two presentations are valuable teaching experiences that involve “pimping” (quick tests of knowledge base), exploration of the student’s clinical reasoning, and didactic teaching about diagnostics, treatment, and management of the patients. These experiences are very important for learning, especially with patients that are more complicated than the one I admitted last night. I value these experiences greatly, but it was nice (for a change) to be trusted to complete a simple task and actually provide assistance to the Pediatrics team (by relieving the work burden on the interns and residents). And additionally, it’s nice to be praised for good work too!

[If nothing else, I think that it would be great if medical students had more structured opportunities to have autonomy on simple cases on each core clerkship to build confidence, hone efficient interview and examination skills, and potentially develop some positive impressions of the field (e.g. seeing patients that are happier or are in better shape).]

As much as I try to second-guess my thoughts, I cannot yet shake my newfound interest passion for Neurology, especially the subcategory of cerebrovascular diseases. It’s possible that I may be overcompensating for my previous wariness of Neurology and Neuroscience; indeed, I feel a compulsion to “catch up,” which has included subscribing to Stroke on my RSS feed, reading new research on stroke treatments, and reading selections of a Neuropathology text and Pourmand’s Practicing Neurology before going to sleep. However, in the past two years of medical school and previous years as a premedical student, I haven’t found myself as excited about any other field of medicine: at least, excited enough to feel content reading beyond class requirements rather than feeling what I now recognize as ambivalence. For the time being, I am content to use stroke as a springboard for my possible career development in Neurology, Interventional Neurology, and Critical Care Neurology. Here are my thoughts on some of the new data from the field:

Today, the NEJM has an early release article comparing the efficacy of two popular antiplatelet agents, aspirin-dipyramidole (ASA-ERDP, extended-release) (also known as Aggrenox by Boehringer Ingelheim) and clopidogrel (also known as Plavix/Iscover/Clopilet by Bristol-Meyers Squibb, Sanofi-Aventis, and Sun Pharmaceuticals, respectively). Aspirin, the oldest agent, reduces the incidence of a second stroke by approximately 23% vs. placebo. Previously, ASA-ERDP had been shown to be superior to aspirin alone in reducing the recurrence of ischemic strokes (20-23% relative risk reduction) while clopidogrel had demonstrated a smaller benefit over aspirin (8% relatively risk reduction). Given these results, the expectation for this most recent study was that ASA-ERDP would prove superior to clopidogrel. However, the study showed no significant difference between the two treatments in reducing the incidence of stroke recurrence or bleeding events (recurrent stroke in 9.0% ASA-ERDP vs. 8.8% clopidogrel), and ASA-ERDP even had a greater percentage of hemorrhagic vs. ischemic strokes (though the number of fatal or severely disabling hemorrhagic strokes between the two treatment groups were comparable). This new data, combined with the potential adverse effect of intolerable headaches in ASA-ERDP and the increased incidence of potentially fatal bleeding in combined clopidogrel and aspirin therapy over aspirin or clopidogrel alone, further complicates the treatment decisions regarding the secondary prevention of stroke. Has the efficacy of clopidogrel been underestimated in previous studies? Or is ASA-ERDP not as efficacious as previously indicated? Of the three agents, there appears to be no clear winner, although aspirin, the oldest agent, is much cheaper than the two newer antiplatelet medications. (Notably, this negative study was authored by physician-researchers with financial connections to pharmaceutical companies on both sides of the competition.)

One of my attending physicians in Neurology, a Vascular Neurology specialist, asked my team a question that highlights a simple, underemphasized fact: “If a patient was on aspirin before having a stroke, did she fail aspirin treatment?” All medications that prevent a catastrophic event do so in incomplete measures: it is rarely, if ever, possible to decrease the risk of an occurrence by 100%. So, did the patient have a stroke because the medication (aspirin, clopidogrel, or ASA-ERDP) did not work, or did she have a stroke because her fate did not roll the dice in her favor despite the efficacy of her medication? If nothing else, it gives me pause when considering switching a patient from aspirin to a more expensive antiplatelet agent with questionable improvements in efficacy.

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