Foggy Bottom Lantern

Off for Christmas

2007-12-24T18:12:00.000Z

Last year I wrote about Christmas in the hospital. This year I’m home in Alaska for the first time in three years, taking advantage of my luck in having the holiday off. We get so used to working weekends and holidays in medicine, helping others to stay healthy, that having Christmas week to ourselves seems extravagant, like a special bonus. It feels good to put up the white coat for a week, to escape the wards. Too much time in the hospital, in the face of unrelenting illness, can make you forget what life is supposed to be like, what you’re fighting for in the first place.

As physicians, we stand at the intersection between the constructed world of our daily lives, which is ordered, meaningful, even protected, and the cold, impartial reality of the natural world. In Alaska the divide is particularly evident – though our lives are filled with the normal stuff of human existence – friends, family, food, films, music, plans, jobs, dreams, they are lived in the shadow of the simple reality that with one misstep – a car breakdown in mid-winter, a frozen set of water pipes, everything could come crashing down. It happens rarely; mostly we are allowed to live our lives peacefully, but on occasion the natural world forcefully collides with the quotidian one, obliterating it. A woman is diagnosed with breast cancer. A tsunami hits Thailand. What we’re fighting for is to keep our safe, purposeful, constructed worlds, of competitive sports and holiday parties, intact, shielded from nature’s unwelcome intrusions.

We’re somewhat successful. Most people live a rather insular existence, sheltered from natural disaster. The well are frustrating to care for because they think that they are impervious to illness, that they will never get sick; as a result, they tend poorly to their bodies. They feel that the world is fundamentally fair. As doctors we are fallen from this illusion. We live in the midst of the natural world’s devastation. We know that anyone can get sick, can up and die. A young man at the height of his powers, contributing greatly to society, raising a family, can collapse suddenly without warning.

The medical fight is an important one, but seeing sickness and disease every day wears on you. Being greeted a daily good morning by failing kidneys, bid good evening by an ailing heart, paid unexpected nightly visits by struggling lungs: it takes a toll. The curse of the chronically ill is to experience pain that nags just enough to constantly remind the sufferers that they are ill. The curse of the doctor is to be cognizant of his patients' sufferering. On interval, a break is needed, an escape from the hospital, a vacation.

This week I’m going to forget that disease even exists. I’m going to experience Christmas the way I hope my patients do: oblivious to hardship and suffering. People say to live each day like it’s your last, but that’s rubbish, or at least, it’s lousy advice for a vacation. How about relaxation instead? True luxury is to live as if you were going to live forever, to dally with each and every trivial pursuit. To watch movies and feel no guilt about how you could be better spending your time, to sleep in late, to indulge yourself completely: that is vacation at its best. That is how I intend to spend this Christmas.

One's own authority

2007-12-14T05:40:00.000Z

One of the sobering things about the third year of residency is coming over that sophomoric high of second year, when you were finally able to start taking care of patients somewhat autonomously. Where in second year you think “yes, I nailed the management of that hypertensive urgency,” in third year you start to wonder, does hypertensive urgency even exist? Was it necessary to admit that patient to the ICU, place an arterial line, and use an iv infusion to bring down the blood pressure of a completely asymptomatic patient? You come to appreciate that you know very little, and most of what you do know is suspect.

As I transition into becoming an attending, I’ve been paying more attention to what I know and what I don’t. One of the things I’ve realized is that knowing something isn’t enough; you have to know where you learned it. A piece of information without a source is like a carton of milk without an expiration date: you don’t really know if it’s safe for consumption, and by the time you’ve found out it’s too late. Whether a pearl came from Attending A or Attending E, from a pharmaceutical rep or a published paper, it carries a vastly different weight. When you confuse where you learned something, you open yourself up to all kinds of trouble.

Ideally, knowledge in medicine is evidence based, originating from scientific studies and grounded in some type of objective, reproducible data. In reality, though, medical training is an apprenticeship; our education occurs in the work environment, at the hands of our mentors. For this to succeed, it requires our mentors to have a certain authority. We must be able to trust that when they say something, they know what they are talking about, that their input is based upon experience and knowledge of the literature. That way we don’t have to challenge every little assertion, which would be impossible to do anyway.

Even so, taking things on the authority of others only gets you so far. At some point you have to stand up and take ownership of your own body of knowledge. As an aspiring attending, that means becoming your own authority, which can entail going back and relearning everything that you know. It’s a slow and frustrating process, one that I wonder if I ever will complete; indeed, some of my current attendings still cite their own former attendings when teaching me things. Years into practice, they still do things based upon the authority of those former mentors.

Perhaps ‘relearning’ medicine is a mischaracterization, it’s really that you have to make it your own, the way a dancer first learns and then possesses choreography. You have to integrate it into the fabric of your being so that you can wield it rather than simply regurgitate it. I guess that’s what third year is for. That’s what the seventy first case of pneumonia is for – for the gelling process to occur. By working through it now and building the foundation just a little bit firmer, maybe my form will actually stick when the molding is removed next year.

Notice of employment

2007-12-07T05:25:00.000Z

The ‘sorry I haven’t posted in a long time, I promise to be better’ post is such a common one in the blogosphere that there should be a pre-written template or form-post just for the purpose. Simply write in your excuse, and all of the other pleasantries will be taken care of for you. Mine currently is that I’ve been traveling – job interviewing, to be exact. I was looking at hospitalist jobs in the Pacific Northwest and actually found a good one; I’ll be relocating to the greener, rainier Washington this summer. Also, I was rushing to finish a research project on time and trying to meet the deadline for The Great Sufjan Song Xmas Xchange. Have you ever tried to write a Christmas song? It’s harder than it sounds – Santa, Rudolph, Frosty, and baby Jesus have all been done. I ended up writing some silly thing about imagining that Christmas was in a season other than winter.

Anyway, with employment secured and some of my other projects taken care of, maybe there will be more time for blogging. I hope so. A few thoughts have been bouncing around in my head, and they are dying to get out.

Charades

2007-11-13T01:30:00.001Z

Think about this one: guy falls down, breaks his ankle, gets taken to the hospital. Wait a minute, falls down and breaks his ankle? How is that humanly possible? Breaks his hip, maybe, or femur, or cracks his skull open, but c’mon, his ankle? Suddenly rounds turns from seven doctors and two medical students slouching against the walls, preoccupied with their own thoughts, to a melee of chaotic activity, as each one simultaneously perks up and starts acting out his or her own rendition of just how the tragedy might have occurred.

Idle call

2007-11-04T22:55:00.001Z

Rarely but occasionally during our tenure as residents, we have slow call days in which there are no or few admissions, and which can be spent at our own leisure. These usually occur on the weekend, when patients are too preoccupied with their own interests to bother coming to the hospital. Greatly appreciated, they help to make residency bearable: without a lucky break or two somewhere along the way, few residents would likely survive. Often a light call seems to come just when you need it most, when another rough one would surely have done you in.

There's something wonderful about getting paid to sleep, or to read, or to write on your blog. Online shopping at the hospital is scandalously fun. One of the nice things about being stuck there for thirty hours is that, if there is truly nothing going on, you have few distractions. E-mails long delayed get written. Schedules long left unchecked get reviewed and revised. Resumes get updated, bills get paid, books get finished. Being in the hospital is not unlike boarding an airplane and knowing that for the next several hours you will be stuck there, alone with your thoughts, free from outside demands on your time. I tried to keep a journal in college, but the only time I ever wrote in it was when I was flying home for vacation or back to school. Many people only read books when they fly. Surely great medical ideas must have been conceived by physicians whiling away time in the hospital.

The slow call night that lets you sleep is triply rewarded: not only are you able to relax instead of working in the first place, but there will be fewer patients to follow up in the morning, and your post-call day will be spent awake rather than sleeping. It is a gift that carries a generous momentum. A downside does exist, I suppose, in that your idleness can beget laziness. When you do receive that rare page on an otherwise still day, you resent it all the more for disturbing your peace. When busy, you accept such pages matter-of-factly; when resting, you do not want to be called to work. You spend your entire day just hoping and wishing that your pager will remain silent. A call day with just two admissions is doubly as painful as one with four.

Even on the most quiet of calls, though, meals are eaten quickly, and the resting heart rate is rapid. The pager pressing into your hip reminds you of a fact that you would never forget anyway: disaster could strike at any moment. Better, therefore, not to admit that you're having a good call day. Better to deny it. Someone might overhear you and decide you need work. Of that, even on your slowest day, you certainly already have enough.

Hot potato

2007-10-29T02:52:00.000Z

There’s a certain kind of patient in the ICU who crashes early and hard, who comes in from the medical floor, nursing home, or community clinging to life by the frailest of threads, and who only through aggressive resuscitation is kept alive. These patients are so sick that there is no hope of meaningful recovery. They are doomed from the outset; critical care interventions have been initiated too late to have a chance of reversing the process already set in motion.

When you have one (or more) of these patients, and you are one of four residents rotating and trading call and code responsibilities, the patients represent a constant source of anxiety. If the family is understanding, and the patient is made Do Not Resuscitate for the inevitable cardiac arrest, the situation is defused. If not, passing the patient becomes a frenetic game of hot potato. As laboratory markers and vital signs tell you that the game is nearing an end, each pass of the code pager grows more desperate, as each resident frantically tries to temporize the patient just long enough so that the whistle doesn’t blow on his watch, so that his hands will not be the ones to futilely pump and crack that stiff chest.

Law number three

2007-10-22T04:49:00.001Z

At first I thought it was one of those guerilla veins that vanishes into thin air as soon as you think that you have him. Alternatively, Dr. Heisenberg, looking down from above, was trying to teach me a lesson about the uncertainties of a vein’s location at any given time. No matter how many times I stuck, I could not find the rascal. I put two fingers over the artery and felt the pulse bounding strongly. A finger-breadth medial, the vein had to be there. Yet it wasn’t. Switching positions, I couldn’t feel the pulse with my left hand. Checking again, yes, it was there with the right. Wait a minute, this was bizarre. Was I losing feeling in my left hand? Could it have been peripheral neuropathy from undiagnosed diabetes? Had I damaged the ulnar nerve putting it to sleep too many times from lying on it in awkward positions? But it was 3 am; strange things happen at that hour. Better to worry about it in the morning. I felt again with my right hand: there was the pulse. Stick and stick. No luck. Actually, wherever I placed my two fingers, there I seemed to find that pulse. Maybe all of the extravasated blood from my poking had made a soup that was diffusing the conduction of the pulse waves. Then I noticed, the pulse on the monitor was faster than the pulse I was feeling. I checked my own pulse. There it was, mocking and traitorous. I had disobeyed the Fat Man’s law. Using my left hand from then on, I found the vein and placed the line.

Blog or blot

2007-10-12T15:24:00.000Z

Well, the end is in sight -- it's time to begin searching for hospitalist positions for next year. Apparently, it's a doctor's market; the day after I registered an online profile with Locum Tenens, I was bombarded with phone calls from physician recruiters, and a week later I'm still receiving multiple phone calls daily. I'm currently brushing the dust off my resume, preparing it for the market, but I've realized that I have a bit of a dilemma on my hands. Namely, Foggy Bottom Lantern. Should I include it in my resume?

My blog is, after all, one of the most interesting and original things that I do, and outside of work, it is the project into which I invest the most time and energy. A few months ago, perhaps in a moment of daring after a particularly satisfying post, I tagged it on to my resume. Creator and author, I called myself, and listed it under Community and Extracurricular Service, figuring that several of my posts have been informational and possibly of service to the world online community. Now, though, that I'm actually distributing my resume to potential employers, I'm not sure that was such a good idea. At least in the medical community, I'm afraid, blogger is a title more associated with trouble than anything else.

Oddly, when I first started my blog, my hope was that if it became successful, it might be a boon to my program and to my university. That it might become some tidbit of trivia on program tours, that potential residency candidates might hear something like, "Our residents have a variety of interests and hobbies. . . one of them runs the blog Foggy Bottom Lantern, which maybe you've heard of. . ." I wanted to make my program director proud. I saw all of this potential upside and thought that if done carefully, the downside could be reasonably well controlled. Now, though, like everyone else in the medical blogging community, I'm just afraid.

I've kept Foggy Bottom Lantern professional, and I do believe that if a potential employer actually read my blog, his or her impression would be favorable. There's been some talk on the blogosphere of blogs eventually replacing resumes. Simply listed, though, a blog raises concerns without having any power to overcome them. On a first and blind paper date, that's not what I want to do. Thus, Foggy Bottom Lantern is off of the resume for now. In a more open and sensible future world, perhaps it will reclaim its rightful place.

The ICD gap

2007-10-08T04:36:00.000Z

We should be proud of ourselves as Americans. This past week, the Journal of the American Medical Association published two papers showing that white males receive significantly higher numbers of ICD’s (implantable cardioverter-defibrillators) than black males or women. These are little machines that shock your heart if it goes into a deadly rhythm, often restoring a normal rhythm and in the process saving your life. Having one is like having a whole resuscitation team, electric paddles and all, tucked neatly inside your chest. That white men are receiving them disproportionately should bolster our faith that our free market health care system is working: it proves that if you have money, you can buy better healthcare. Granted, patient preferences may explain part of the ICD gap, and bona fide racial and sexual discrimination may also be occurring. When the devices cost $30,000 each, though, and the disease against which they protect (heart failure) affects many pre-Medicare age people, we can rest assured that financial restraints are playing a central role. That’s where we’ve done well; that’s precisely what makes this country so great. Here, the wealthy don’t have to stand in line with everybody else. If they did, you might as well be living in France or Sweden; we might as well just have adapted the socialist model. No, in the U.S., money still makes a difference, and the American Dream is still alive. We didn’t want to share our health care resources with the poor, and the JAMA studies show that under our current system, we don’t.

Medication reconciliation

2007-10-01T01:28:00.000Z

Aspirin. . . zocor. . . clonidine? I don’t like that drug. It’s dangerous, shoots the blood pressure all over the place. A single missed dose and the BP can bounce up to 200 systolic. Besides, this guy doesn’t look like the kind of patient who is going to take every dose. Maybe I should stop it. Eh, this probably isn’t a good time. It’s not like he prescribed the medication for himself; a doctor wrote it for him because the doctor wanted him on it. Somebody who knows him a lot better than I do decided this is a good drug for him. This drug is hardly good for anybody, though. But why should I override his primary care doctor, who is the one who will be following him after this hospitalization anyway?

Ah, Mr Lamb is back, recently in the hospital. Let’s look at the discharge meds. . . aspirin. . . zocor. . . clonidine? Was thinking about pulling that one. Bad drug. The guy was on it when he first came in, never could figure out why, didn’t want to overhaul his meds on his first visit, though. Maybe I should stop it. But he was just in the hospital and they deliberately left him on it. Maybe they thought he needed it. Maybe they tried to wean him off of it and had trouble. They had him in-house, under observation, that would have been the perfect time. Better leave him on it for now. . .

Bullets from heaven

2007-09-19T04:54:00.000Z

When it comes to a loved one, death never makes sense, but there are certain ways of dying that just seem to be more difficult to accept than others. Sudden, unexpected deaths, for example, seem to leave deeper, coarser scars than gradual, anticipated deaths. Painful and violent deaths can jar loved ones as if they themselves were stricken. Most frustrating, perhaps, are preventable deaths, which tease us with the possibility that they might never have happened at all. Medical errors are a common reason for such deaths, but at least these are generally good-faith errors; more infuriating are those preventable deaths that result from carelessness, recklessness, or just sheer stupidity. In the movie Babel, when the little boy shoots his father’s new rifle at the travel bus, it is excruciating to watch. We expect to suffer loss from evil, but idiocy makes a surprising and thereby bewildering foe; a terrorist purposefully shooting at the bus would have seemed less senseless and been easier to stomach.

Death by indirect gunfire, thus, may be even more of an outrage to decency than a shooting in cold blood. I for one would rather go by the latter – at least someone will be held to account. We needn’t look far, though, before we see a systemic problem of unchecked indirect gun violence. One can hardly turn on a television of the Middle East without seeing young men firing rifles joyously into the air in celebration of some event or piece of news. I’m sure that for them it’s elating, but there can't be many ways of dying that are more ironic or pointless than being struck down by a stray celebratory bullet. Following the Iraqi soccer team’s victory in the Asian Cup this summer, four people were killed in such a manner. What an odd but horrible piece of knowledge for Iraqi star player Younis Mahmoud that his championship goal resulted in these deaths. Why does the practice continue, you may ask? Ignorance seems to play a large role; a common misconception appears to be that bullets fired skywards will simply continue outward into space. (Ordog) This, unfortunately, turns out not to be the case:

The escape velocity of a bullet has been calculated at more than 7 miles per second. Thus a bullet would have to be fired at a muzzle velocity of greater than 36,766 fps to escape the gravitational pull of the earth and end up in space. Obviously conventional small-arms weapons that we see in civilian practice cannot achieve this type of velocity, so the possibility of escape from the earth is nonexistent. Thus all spent bullets will return to earth. (Ordog)

Examining the physics a little bit more closely:

When a bullet is fired vertically into the air at >2500 feet per second (fps), the air resistance slows the bullet down about 60 times as fast as does gravity. When the velocity decreases, air resistance decreases and has less effect. Gravity reduces the upward velocity at the rate of 32 fps until the bullet has stopped its upward flight; then gravity starts it toward earth at 32 fps, and then there is a 32 fps increase for every second that the bullet drops, less the amount that air resistance holds it back. When the bullet reaches the top of its flight, it is still spinning, and if it is stable it falls back base first. Occasionally, it falls back either point first or tumbles, thus either decreasing or increasing its flight time. With a very sharply pointed bullet, the resistance on the bullet is less, and on the square base much greater, so that bullets coming down nose first fall faster than those that fall base first, but even so, a 150-grain, .30-caliber bullet tends to balance its weight against the air resistance at a velocity of about 300 fps. (Ordog)

This, the CDC summarizes, is a force “sufficient. . .to penetrate the human skull and cause serious injury or death.” In Puerto Rico, where celebratory gunfire is quite common, the news media has estimated that on New Year’s Eve, approximately two people die each year and 25 more are injured.

In a war zone like Iraq or Afghanistan, the threat of raining bullets is only one of your concerns when firing weapons into the air. More dangerous is the worry that you might give someone the wrong impression. In 2002, 48 Afghanis were killed and 117 wounded when U.S. airmen mistook their celebratory gunfire at a wedding party for hostile fire. The same sad story has played out in Iraq several times since then. What, also, about that other presence in the sky? You would think that the deeply religious, before firing their weapons skywards, might pause in fear that God would misinterpret their intentions. What if He thought you were actually firing at Him? Would you not expect Him to return fire?

After the 2005 earthquake in Kashmir, a close friend of mine with connections there told me that the faithful reacted in three different ways. One group found its faith to be a source of strength to get through the crisis. Another lost its faith entirely. A third, moved to extreme anger, fought back by shooting weapons into the sky. How people could have that kind of courage, to take on their god face-to-face, is beyond me. As much respect as I have for their bravery, though, I was also just relieved to finally discover a group of people who were firing shells into the air and knowing exactly what they were doing.

Celebratory gunfire obviously needs to end, and the sooner the better. Following the Iraqi soccer victory, I was glad to see mosque leaders strongly condemn it, but unfortunately, their efforts didn’t seem to have much immediate effect. The practice may already have taken too strong of a cultural hold for it to be vanquished overnight. Where young men have guns, they will likely fire them. While that remains the case, perhaps both the Kashmiris and the wild type gunmen would do well to replace their steel bullets with rubber ones; neither deicide nor manslaughter is a crime that weighs lightly on the conscience.

Medical instinct

2007-09-07T22:35:00.001Z

I’m not normally a superstitious guy. I don’t read horoscopes, I don’t believe in ghosts, and I’m suspicious of all things spiritual. It’s true that I never admit to having a good day when I’m on call, but that’s more because I’m afraid of how my team might react than any potential consequences. (Good days are highly jinxable, or so I’m told.) This past year, though, when a patient informed me on a particular night that he was going to die before morning, I’ll admit that I was unnerved.

This was the kind of guy who was frail enough to go at any time, but there was no real reason that I could see why he should pass on that particular night. His blood pressure was fine, his labs were reasonable, and in eyeballing him, he just didn’t appear toxic. Why he thought he was going to die was a mystery to me, but he had a look in his eye like he knew something. To make the situation worse, he waited until just before I was heading home to let me know.

I’ve had many patients die, but this was the first time a patient had ever told me before it was going to happen. Usually it’s the other way around; I’m the bringer of bad news. Perhaps if he’d have given me a warning shot, as we’re taught to do (“Doc, I’m afraid I’ve got some bad news for you. . . “), I’d have handled it better. But he didn’t, and the news stunned me. The problem was, since I couldn’t identify anything immediately life threatening to him, I didn’t know what to do about it. I ended up signing out for the cross cover to check in on him that night, and went home for a restless night of sleep myself.

The first thing the next morning I went to see my patient, who was doing fine, precisely as I had left him. Silly me. Apparently, my medical instincts had proven more reliable than his spiritual ones. It was a victory for medicine and science, and I was cleared from incompetence. Either that or the Grim Reaper simply hit the wrong room. I can’t claim to know exactly what transpired that night, but at least the next time somebody announces his or her impending doom, my reassurances to the contrary will carry the weight of a little bit more experience.

The cost of learning

2007-09-02T08:17:00.000Z

They say you haven’t put in enough central subclavian lines until you’ve given someone a pneumothorax (an air leak into the chest). That’s when you find out how deep is too deep to plunge your needle. Likewise, you haven’t performed enough lumbar punctures until you’ve given someone a headache, intubations until you’ve chipped someone’s teeth, paracenteses (abdominal needle taps) until you’ve left someone with an ascites leak, or hysterectomies until you’ve punctured someone’s bladder. You haven’t learned how to administer fluids until you’ve put someone into pulmonary edema, or how to diurese someone until you’ve shut down his kidneys. The point being this: to become a competent doctor, you must hurt people along the way. Just as the evolution of a species occurs through the death of its less fit members, the evolution of a physician from inexperienced intern to practiced attending requires spilt blood. Residency, of course, is the prime time for this bloodletting, and the old piece of inside medical advice holds as true as ever: if you value your health, don’t get sick in July.

It’s a little bit depressing to start residency and think that before you finish, there will be scores of victims left in your wake, people who will entrust their care to you and for that trust have to pay a price. Sometimes the price will be small, such as a missed meal after a procedure when a late-tray was never ordered, and sometimes it will be significant, such as when inappropriate antibiotics were ordered for an infection. Rather than sulk, though, I think as residents we have to be vigilant and fight against the threat that our inexperience poses to our patients. In some areas, we are already probably less likely to make mistakes than our seniors; our awareness of our considerable limitations makes us more likely to pay extra attention to detail and to check our facts. The truly dangerous practitioner, it is often said, isn’t the one who knows that he doesn’t know something, but the one who thinks he knows something that he doesn’t. Residents, especially interns, are less susceptible to this particular pitfall, and so one of the best ways to avoid mistakes in residency is also one of the most natural: to ask for help when it is needed. It’s a terrible thing to harm a patient because you are too proud to seek help.

A second way of avoiding mistakes is by learning from those of others. That means being open and honest about mistakes and willing to share them to help others learn. If residency programs collected and distributed a monthly list of mistakes made by their residents, it could be an amazing teaching tool. Personally knowing the people involved would make the lessons all the more memorable.

My purpose here isn’t to methodically go through the ways of reducing medical errors, but simply to point out that, for residents who care, the mistakes of residency and their impact can be greatly lessened. Also, before I start scaring patients away from teaching hospitals, let me point out that there are many reasons why it’s good to have students, interns, residents, and fellows participating in your care. For one thing, our mere presence keeps the attendings on their toes; teaching concepts requires a higher clarity of thought than simply acting upon them. We like to ask questions, and having an additional bright, eager young mind going through the details of your medical case can’t be a bad thing. Less bound by time constraints, we will listen to your full story, and the substantial knowledge that we do possess, while hopelessly incomplete, at least is current. Some procedures we even perform better than attendings, because we do them more often. Truly, to request that no residents or students be involved in your care is to miss an opportunity for excellent care.

Like everyone else, I’ve had my fair share of blunders during residency. I’ve dropped people’s blood pressures, dried out their kidneys, and stuck them with needles to the point of absurdity. There were days when calling me a walking disaster would have been entirely appropriate. I’ve also saved lives, though, and for most of my patients, I know that their care was better because I was involved. Maybe I’m giving myself too much credit, but I think my patients would also attest that despite its fearful reputation, the cost of learning turns out to be surprisingly manageable.

Out of the fog

2007-08-26T04:11:00.000Z

Like any activity that requires effort in its maintenance, with blogging it's just really easy to fall into a period of inactivity and neglect. What starts as a day off quickly turns into several, and then several more, until that nagging feeling that you are overdue to write something finally just fades into the background. That's when things get dangerous and blogs go for months without posts. Thanks to Grace, we have a label for the blogger who behaves in this way: neglectablogaroon. It's a funny name for a curious problem. After all, as amateur bloggers we supposedly create our blogs voluntarily because we enjoy writing, not because we're looking for more responsibility and stress in our lives. Yet, the blog takes on a life of its own, and when we don't write we feel guilty, like bad parents or binging bulemics (Grace is wrong about no remorse). To be completely honest, I'm surprised that I was able to keep my blog going for as long as I did without any major interruptions; the last time I started a new workout routine, by comparison, I lasted only one session.

These relapses serve a purpose, though. They help to purge us of our primal needs (passing out on the couch, in this case) and of our excuses that we've been working really hard. (Rationalizing that you need a break is more difficult when you haven't lifted a finger in weeks.) They allow for rest, for rejuvenation, and for the marination of thoughts and ideas so that when they eventually come out, the flavors are more zesty and vibrant. They let the hunger return, the ambition grow. With just a little perseverance, the energy used to return from relapse can build into a raging force.

People (internets), I'm back. I'm sorry I left you hanging for the last couple of months, but stay with me and you will see action over the coming days and weeks.

Watermelon man

2007-06-07T04:33:00.000Z

Have you ever, on a hot summer day, gorged yourself on watermelon, letting the sticky, sugary juice dribble down your chin as you chomp down upon mouthful after mouthful of sweet, succulent fruit? Last summer, in a bid to overcome the powerful mid-July heat, I devoured an entire half-watermelon in one sitting. It felt similar to how pregnancy must feel, my belly reaching absurd levels of distension that I wouldn’t previously have thought possible. If I hadn’t been overcome by such a strong desire to lie down and take a nap, in fact, I would have sought out the nearest sumo ring to find out whether my new body habitus was associated with any talent. As it was, though, I had a hard enough time just stumbling over to my bed. My hope was that after a few hours of sleep some of the fluid would redistribute out of my belly to somewhere with more room, and that I would be feeling quite a bit better. Redistribute it did. Every thirty minutes the threat of bladder rupture had me up to the bathroom, urgently opening up my spigot to let the water run out. The ultimate diuretic, it turned out, was not lasix or a thiazide, but a red and green melon named after its affect on urine. (Interns take note, if a patient’s urine output hangs frighteningly low, a little bit of the red stuff aptly slipped onto the right dinner tray may turn the I’s and O’s in your favor.)

Imagine, though, if I had not been a healthy young male, but an end-stage renal disease patient on dialysis who didn’t, who couldn’t urinate. All of the water that my kidneys so happily had drained off would now have had no place to go. It would have overflowed – into my belly, my lungs, my legs, anywhere that the path of least resistance might have taken it. A watermelon man, that’s what I would have been. Or is that what a dialysis patient always is? With no drain, water never stops to accumulate in the body; its level steadily rises. Present not just in the fluids we drink but also in the food that we eat, water is unavoidable. A man will drown who doesn’t get to dialysis on time.

Strange that a watermelon, of all things, could be a deadly food. Stranger yet to think that the miserable way I felt after ingesting half a watermelon is the same way that a dialysis patient must feel all the time, every two days before the water again is mercifully removed.

Medicine upside down

2007-05-24T05:57:00.000Z

Sometimes in medicine, the hierarchy breaks down. Our etiquette, which rivals the military’s in its degree of structural rigidity, fails to inform our behavior in particular situations. It happened to me the other night in fact: I had a physician as a patient. That may sound trivial, but here’s how I ended up introducing myself to him: “Hi Dr. Lambert, I’m Wyatt, and I’ll be the medical resident handling your admission this evening.” Of course, he loved it, instinctively raising his chin and straightening out his posture in the gurney. By my addressing him as doctor and myself by first name, I had just indicated that I was planning on giving him the full respect that I would afford one of my own attendings. Not only would he receive the utmost politeness and consideration, but his opinion would be given a very heavy weight. From my few words of greeting, he knew that the full VIP treatment was his.

Myself, I felt more ambivalent about the tone I had set for our interactions. By addressing him as a superior, I had just conceded my power as the doctor over to him. This would be one warped doctor-patient relationship: he would be calling the shots and I would simply be carrying them out. In fact, in all actuality he would be his own doctor. The implications of this were still unclear to me, but I figured that basically I would run all of my orders by him while avoiding any uncomfortable questions or elements of the examination that I might otherwise have performed.

Directing your own medical care may sound nice, but I can testify that in reality, it’s not. For one, it’s impossible to see yourself objectively. To verify this, simply take a stroll around the hospital ward counting the number of bare buttocks that you see. Those nice hospital gowns that cover everything up so neatly in the front, it so happens, leave gaping holes in the back if even a single renegade string goes untied. Moreover, doctors are notorious hypochondriacs. When you know the constellation of symptoms for hundreds of rare diseases and see people sick with them on a daily basis, you forget that rare diseases are actually rare. If left to yourself, you’d likely cause your own drawn out death from bleeding due to excessive lab testing. Alaskans, already familiar with the concept of death by mosquito bite, know what I'm talking about.

Fortunately, this doctor was much cooler than expected, and he pretty much let me run the show. Having an attending physician asking and caring about my opinion felt really great and restored the standing that I had abdicated earlier. It turned out that he actually wanted to have a doctor, rather than be one, so we both ended up satisfied. In fact, the experience was so positive that next time not only will I keep the same introduction, I won’t even skip out on the rectal exam.

Saturday Night Syndrome

2007-05-13T04:17:00.000Z

One of my least favorite things about residency is the one-day weekends. If it wasn’t bad enough already, the one day off is marred by the certainty of work the next day. Most people are familiar with this feeling on Sunday evenings – knowing that a long and hard work week is about to begin and being unable to fully enjoy the evening because of it. To have Sunday Night Syndrome on a Saturday, though, is particularly painful. Everyone else is out living up the prime night of the week, staying out after hours with the comfortable knowledge of a late sleep-in and casual brunch coming the following day. You on the other hand are at home, stressed out about the next day and going to bed depressingly early. It’s hard to get used to.

The holiday season, they say, is the most active for suicide because seeing others happy and together intensifies loneliness. I know, I am supposed to be grateful to belong to this profession and to have an opportunity to serve. It’s just that sometimes that gift of service feels like a double-edged sword when it demands that you serve even when you’re not yet rested and ready.

Question and answer

2007-05-09T03:44:00.000Z

Attending: How does heparin work?

It prevents clot formation by enhancing the action of anti-thrombin III. . . wait, heparin’s not a thrombolytic, it’s not supposed to break up clot, it just prevents more clot from forming. . . anti-thrombin III breaks up clot that’s already there so that can’t be right. . . wait, where the hell does anti-thrombin III actually act? . . it must inhibit thrombin. . . maybe it doesn’t break up clot after ---

Someone else: It activates anti-thrombin III.

Damn.

Attending: Right. And how does plavix work?

It inhibits platelet aggregation. . . but how? . . . can’t be a IIb-IIIa inhibitor because integrillin and reopro are the IIb-IIIa inhibitors. . . but IIb-IIIa is the way that platelets crosslink so it must act somewhere on those receptors. . . hmm, could it act on fibrin or fibrinogen?. . . that doesn’t sound ---

Someone else: It impedes platelet aggregation.

Arggh.

Attending: Very good.

Petits morceaux de France

2007-05-03T03:31:00.000Z

I spent this last week in France, dividing time between Paris and Monaco, which explains why I haven't posted anything on my blog in awhile, and which led to these morsels of thought.

***

The yogurt in France is so creamy and delicious that it's no wonder they feel the need to ease their guilt by studding it with cholesterol medication. I'm just wondering what happens to a foolish American tourist who downs four cartons of the stuff all at once.

***

It's a good thing they don't have Coca-Cola Light in this country. I’m having a hard enough time controlling my Diet Coke addiction as it is without them throwing that dangerously tasty brew into the mix.

***

Beautiful old buildings that give Paris its characteristic charm and evoke the early 20th century: great for city ambience, scary as hospitals.

***

Getting rid of all public toilets in fact does not eliminate the human need to urinate.

***

I don’t understand the foie gras controversy. You could force-feed me baguettes all day long without a whimper of complaint.

***

The contrast between French waiters, whose tips are for the most part already included in the bill and who often seem annoyed to serve, and American waiters, who work for tips and really try to satisfy their customers, really speaks to the power of positive incentive. It makes me think that more positive encouragement and feedback in the over-critical world of medicine could go a long ways.

***

Smoke-free DC was a great idea. Air never felt so breathable.

***

Please tell me that fruit tarts count as one of my recommended daily servings of fruit.

***

It's possible to forget an awful lot of medicine in one week.

An American duality

2007-04-21T17:48:00.000Z

Let’s say you want to invent a killing machine. You have anything and everything at your disposal: toxins, germs, drugs, explosives, radiation, lasers, sharps, gears, and gadgets. If brought forth and marketed in the U.S., you can expect your invention to be highly scrutinized, its use heavily controlled and limited to a military or police setting. Unless, of course, it involves firing a projectile through a cylinder (one projectile per pull of the finger), in which case instead it will receive near immunity from regulation and instant approval for distribution to American homes.

Now let’s say you want to invent a new medicine, one that will cure a human disease. On average, you can expect laboratory and animal studies to take 3.5 years, your phase 1 clinical trial to establish basic safety one year, your phase 2 clinical trial to establish dosing and efficacy 2 years, your phase 3 clinical trial for further assessment of safety and efficacy 3 years, and your FDA review another 2.5 years. You will be lucky if your medicine can be sold on the market in less than 12 years.

It's the difference, I suppose, between protecting life and destroying it.

Silent Night

2007-04-14T16:28:00.000Z

Finally, a moment to lie down.
The tasks of the night are complete
and the ward is still and quiet.
If their illnesses will allow,
the patients too now may sleep
and take a short respite from the
symptoms that ail them.

A rare luxury it is
to remove the white coat
and sleep with one’s patients,
letting the lines of distinction blur
between carer of and cared for.
A sweet slumber it will be,
restorative to body and mind.

Sweet, yet cautious.
The shepherd too knows sleep like this,
one eye shut in rest
and the other partially open,
scanning the field for shadows
that may flick and flitter across it
and threaten his flock.

Interruptions are begrudged,
but most feared is the completely silent night,
which suggests that the sleep was too deep
and that luxury may have turned into negligence.
The sleep of call is usually devoid of dreams,
but a recurrent nightmare does exist:
that upon awakening the flock will be one fewer,
a cloud of oblivion having obscured
the helpless calls of a patient who lay dying.

Rebirth

2007-04-10T01:28:00.000Z

This blog has and always will be foremost about the writing, but even I had to admit, it was time for a makeover. Although “dots dark” served me well as a template throughout my blogging infancy, wearing it was starting to feel like going to the prom in a display dress from Neiman Marcus: not only do you see plenty of others wearing your dress, but everybody knows where you got yours. The intrigue in that I'm afraid was limited. Every time I would come across one of my evil doppelgangers of the internet, that same feeling of anxiety would strike me as upon encountering a namesake in real life. Was this other blogger representing the template well? Were readers associating their feelings about the other “dots dark” blogs out there with mine?

These were troubling questions, and most troubling of all was that I didn’t feel as if I had my own unique identity. So, I went to the knife – purely cosmetic surgery, mind you, but transforming and utterly satisfying nevertheless. After two days of tinkering and experimentation, Foggy Bottom Lantern has been reborn. What do you think? Don’t grow too attached to the new format, though, because the tinkering is likely to continue for the next few days and weeks – we all know how addictive plastic surgery can be.

Of sirs and noodles

2007-04-03T18:31:00.000Z

[Two residents meet in a busy afternoon clinic.]
Resident 1: Hey Noodle, how are you?
Resident 2: Sir, very good, Sir. How, are you, Sir?
Resident 1: Great, Noodle, just great, it's good to see you Noodle.
Resident 2: Hey, I had something I wanted to show you. [Pulls ekg out of pocket.] What do you think of this, Sir?
Resident 1: Interesting, Noodle, interesting. Look at the morphology of that QRS. [Points to squiggle on ekg.] That's pretty! What do you think, Noodle, are those fusion complexes?
Resident 2: Sir, that's what I thought at first, but when I calculated the derivative of the curve I was able to map the impulse to a specific location on the anterior right ventricle. Those are PVC's from an ectopic ventricular focus firing at a rate of 13 beats per minute.
Resident 1: Well done, Noodle, you're a genius!
Resident 2: Not at all, Sir, not at all.
Resident 1: So how's your wife, Noodle?
Resident 2: Very good, Sir, in fact, she's better than ever. And your wife, Sir?
Resident 1: Oh, she's doing just great. You know, Noodle, we should all get together again some time soon.
Resident 2: Sir, it would be my pleasure.
Resident 1: Noodle, the pleasure would be all mine. I'll give you a call.
Resident 2: Very well, Sir. See you later.
Resident 1: See you later, Noodle.
[Residents depart.]

To my regular readers: I apologize for this piece of esoterica. I simply could not resist.

A fevered Earth

2007-03-26T23:39:00.000Z

I don’t know who first thought of describing global warming in terms of a fever, but when Al Gore used the language while testifying before Congress last week, it really caught my attention. By suggesting a medical nature to the problem, he moved it from the purview of physicists, engineers, and environmental scientists to that of the medical community. Are we not the ones trained for and equipped to handle fevers? At Gore’s invitation, I’d like to think about this problem from a medical perspective and see if doing so can contribute something to its understanding and management.

The most important thing we know about fevers is that they cannot be ignored; they are a surefire sign that something is wrong, and that’s why we regard the temperature as the first vital sign. It is a powerful tool for stratifying the severity of medical problems. Without a fever, a cough is merely a bronchial irritation, but with one it is a pneumonia. A swollen joint from trauma is not an emergency, unless it is accompanied by fever, in which case the joint is presumed to be septic and must urgently be drained. The body has a highly refined control mechanism for temperature, and when it runs off course it is not by accident: we are obliged to assume that some pathologic tampering has occurred. For hospitalized patients, the minimum work-up required for a fever includes a chest x-ray, urine analysis, urine culture, and blood culture. A persistent fever of unknown origin may lead to CT scans, lumbar punctures, ultrasound evaluations, white blood cell scans, and often will trigger the initiation of empiric antibiotics. These are not pleasant things; they are painful and costly. The consequences of an undiagnosed and untreated fever are simply too great, however, for a fever ever to be brushed off.

Some fevers are iatrogenic, or man-made. They are caused by reactions to medications or as a result of i.v. lines and foreign bodies, and they are the best fevers to have because they are easily reversible by stopping the medication or removing the foreign body (granted, if it’s your prosthetic heart valve that’s causing the fever it’s not a good thing). If somebody says wait, you can’t prove that the fever is iatrogenic, and if they are right, you worry more, because natural causes of fevers tend to be more severe and difficult to treat. Flesh-eating bacteria, for example, will not stop their feasting if you simply ask them nicely. A fever of unknown origin is particularly worrisome because it suggests a deep-seated occult infection or inflammatory disease. It lurks and taunts and wears down the patient and her physician, defying diagnosis and thereby defying all sense of security. Two diagnoses are unnecessary– a single diagnosis is sufficient with fever and allows your searching to stop, but without that diagnosis you can never reassure a patient that her fever is benign.

This brings us back to the Earth. The Earth’s fever is caused either by carbon dioxide, as Mr. Gore and many suggest, or not, as many others suggest. Let us hope that Mr. Gore is right. The consequences of an undiagnosed and untreated earthly fever are catastrophic, and if we are not able to identify the problem quickly and address it appropriately, we may very well have a disaster coming. The Earth’s fever must be assumed to be pathologic; with a fever the burden always lies upon the medical team to prove that the fever is benign, rather than with the patient to demonstrate that the fever is malignant. Can Joe Barton and James Inhofe really reassure us that global warming is harmless? If they are to do so, they must first be able to provide us with a diagnosis. I don’t mind that they cast doubt on carbon dioxide as the cause of global warming, but what disturbs me is that they seem to find those doubts reassuring. Those doubts should be terrifying. If carbon dioxide indeed is not the culprit, we must raise the alert and vigilantly renew our scientific efforts until the true diagnosis is found. Until then, carbon dioxide toxicity remains the best working diagnosis and we should treat it aggressively.

Barton, Inhofe, and others who deny that global warming is a serious problem find themselves in an awkward position that we encounter frequently in medicine: that of holding a stance that by the nature of its incredible convenience is inherently suspect. They find themselves in the position of the medical resident who, after evaluating a patient with headache and fever, decides that a lumbar puncture to rule out meningitis is not necessary. This resident, even though he may have made a perfectly valid clinical decision, will face close scrutiny in the morning simply by virtue of the fact that he chose a clinical pathway that let him avoid a difficult and time-consuming procedure. His judgment and integrity are called into question, and in knowing this, the resident in advance must make sure that he stands on very solid ground. I ask Barton and Inhofe to imagine themselves as this medical resident, and to evaluate their positions in the same way that he might.

With headache and fever, though, lumbar puncture and antibiotics are almost always necessary. It’s considered preferable to make the diagnosis by LP than by autopsy. With global warming also, the consequences of a missed diagnosis are so great that we must err on the side of over-treatment. With an issue so complex, we are unlikely ever to arrive at absolute certainty regarding its causes and very best plan of treatment. However, we cannot afford to let our doubts stall us; after Katrina, such inaction would be utterly inexcusable. Granted, time will reveal the true nature of the Earth's fever – whether it is a passing fancy or a trend, malignant or benign, curable or not. Learned from the other side, though, that knowledge would be oh so unsatisfying.

Redirection is what’s required

2007-03-19T04:35:00.000Z

Sometimes we shoot ourselves in the feet in internal medicine by overly glorifying the blocking of ER admissions. Granted, it takes a strong resident to convince an ER attending that the patient actually doesn’t need admission to the medicine service but in fact would be better served either on another service or back in his or her own bed. The feat therefore confers some distinction on the resident who accomplishes it. The euphoria of pulling it off, in fact, can be quite intoxicating; besides marking your growing strength as a resident, it means you’ll have one less patient to admit and comforts you that occasionally justice and reason can prevail even in the ER. It’s easy to proudly notch the block on your belt and think about how you’ll tell the story to your medicine buddies in the morning. The problem, though, is that going into each admission evaluation wanting to block anything possible does a poor job of addressing patient needs and creates a hostile atmosphere in the emergency room.

The ER attending, after all, can sniff a block attempt from miles away. We complain that they can’t be talked to—that they won’t listen—but it’s hard to blame them entirely when we are the ones that have conditioned them to be that way. Sometimes you can almost see them bristle as you approach them, and that’s because they know your intentions exactly. Just as a Washingtonian knows when approached on a walk by a street person that the request will be for money, so too does an ER attending know when approached by a medicine resident that a block is desired. Maybe the admission was legit, or maybe it was soft—a “review of systems” admission (based upon an incidental finding on the history and physical questionnaire) rather than a “chief complaint” admission. In any case, the attending’s better judgment is being questioned, and a notch on your belt is one against him or her. In all fairness, a bit of resistance should be expected.

I’m not sure all the tension is necessary, though. There don’t have to be notches at all, and there doesn’t have to be a medicine versus ER mentality. Just thinking of ourselves all as members of the same patient care team opens the door for communication and the sharing of our respective expertise. That’s why I don’t celebrate blocks or high five my intern in front of the ER attending when a patient planned for admission gets dispo’ed home. In fact, the block is a maneuver I’d like to wipe out of both my playbook and vocabulary. I’m the last one to wish for unnecessary hospitalizations, but sometimes redirection, rather than obstruction, is what’s required.

A hypothetical question

2007-03-11T04:40:00.000Z

Let's say you were suddenly granted the magical power to wipe one human disease off the face of the earth, as if it had never existed. Which disease would you choose and why?

Before I give my answer, let me explain why the question interests me. I’ve noticed that there seems to be a lack of thought and communication in medicine regarding the implications of disease. As physicians we hand out diagnoses left and right without really explaining what those diagnoses are going to mean to our patients. What does it mean, for example, to live with diabetes, or coronary artery disease, or rheumatoid arthritis? How devastated should you feel if you are given one of those diagnoses, and how will the diagnosis change your life? To the extent that we do answer these questions, we tend to downplay the impact to our patients. “It could be worse,” we might say, or we may neglect to tell them some of the more depressing details of their new condition. How likely, for example, would we be to tell a 50 year-old woman newly diagnosed with rheumatoid arthritis that she is now much more likely to have a heart attack and that her life expectancy has just dropped by 4 years? In the semi-dispassionate setting of this blog, I’d like to open a more frank discussion about which of mankind's diseases are its worst enemies.

The question also comes to mind in part because of the controversy surrounding the HPV vaccine. Many conservatives, apparently, are against universal vaccination because they feel that it would encourage sexual promiscuity. Presumably, if they had the power to eliminate the virus simply by pushing a button, they would pass on the opportunity. Never mind the thousands of women who die from cervical cancer every year around the world; their fate apparently is a necessary reminder that sex should be reserved for marriage. I wonder, would these people also decline the chance to remove the world of HIV? It’s a mystery to me how with such attitudes the religious right can still be considered to hold the moral high ground in this country.

But let’s talk diseases. Here are some considerations:

Scope – how many people does the disease affect, and how many does it kill?
Demographic – does it affect young or old people?
Preventability/treatability – can it be prevented and/or treated?
Potential for cure – does a cure seem to be just around the corner anyway?
Sin factor – does it strike indiscriminately or is it related to drinking, smoking, drug use, over-eating, and/or philandering?
Personal – has the disease affected my family or people that I care about?
Chill effect – does the disease have any particularly terrifying aspects?

My answer:
stroke.

Stroke kills an extraordinary amount of people (second worldwide) from early middle age to old age. It has taken down some of the world’s foremost leaders including Woodrow Wilson, Franklin Roosevelt, Winston Churchill, and Ariel Sharon. We know how to reduce its incidence by treating blood pressure, cholesterol, and aneurysms before they rupture, but it’s a disease that we are unlikely to be able to control to any great extent in the near future. It strikes indiscriminately but with a predilection for certain families; if you belong to such a family, your life is lived in fear, and if you don’t, well, you shouldn’t make the mistake of thinking that you’re safe.

What’s really frightening about stroke, though, is its debilitating morbidity, which comes swiftly and without warning. A listless limb isn’t such a huge loss, but when you lose cognitive function – the ability to think and speak, your memories, your personality even, then you’ve lost something sacred. The feeble thoughts that enter your brain can no longer be trusted, and the you that people used to know and love is no longer you. What could be more damaging to a person’s dignity than having his or her very identity destroyed by disease? In an instant, one can go from an intelligent, articulate, fully self-sufficient individual to a lifelong invalid, unable to care even for one’s own most basic needs. With all of the uncertainty and potential for suffering in life, if just the mind could be protected, I think that would be of the most added benefit and comfort.

Any other takers?

Futile hoping

2007-03-04T05:25:00.000Z

As residents are we really so different from our patients, who hope against hope that their diseases might be miraculously cured?

On Mondays, we say, "It's too early in the week for people to get sick."
On Tuesdays, we say, "Stranger things have happened than a quiet Tuesday."
On Wednesdays, we say, "In the heart of the week, people are too busy to seek medical attention.”
On Thursdays, we say, "Last Thursday wasn't bad, maybe this one won’t be either."
On Fridays, we say, "The excitement of the coming weekend should make any illness more tolerable.”
On Saturdays, we say, "Thank goodness the clinics are closed and won’t be sending us any patients; it should be a light day."
On Sundays, we say, "Very few problems can’t wait until Monday."
On wet, rainy days we say, "No patient is going to brave this miserable weather to come to the hospital."
On beautiful, sunny days, we say, "Who would ruin such a gorgeous day by coming in?”
In the spring we say, "People in bright spirits rarely become ill."
In the summer we say, "Good thing it’s the slow season for hospital admissions!"
In the fall we say, "The fresh air should keep people healthy.”
In the winter we say, "Maybe the cold will keep the patients at bay."

Actually, we don't say any of these things, we only think them, because uttering them would be to invite disaster; we’re a superstitious lot.

Oh, the power of positive thought!

Gowned

2007-02-28T06:06:00.000Z

It’s been known for centuries that the clothes make a man. Dress him up in a military uniform, he’ll look majestic and formidable; put him in a clown suit, he’ll look like a fool. A man wearing glasses appears more intellectual than a man without them, while a man wearing a tank top and baseball cap appears less intelligent than a man without them. If looking put together didn’t make such a big difference, people wouldn’t be willing to spend so much money for just the right look. In the hospital we don’t worry about such vanities, but like anywhere else, in addition to relying on impressions we are susceptible to them. We also feed them: by placing all of our patients in hospital gowns and accessorizing them with iv poles, we make them look, well, sick.

The power of a hospital gown is really quite remarkable. A grown man, independent and strong in his home environment becomes feeble and helpless when gowned and hospitalized; his power turns out not to be stored in the locks of his hair but in the cotton cloaking his body. I’m always amazed at the degree of patients’ transformations at the time of their discharges. The same patients who minutes before look pale, fragile, and older than their years, when returned to their street clothes suddenly appear young and fresh, entirely rejuvenated both in body and spirit. Occasionally, if I’m feeling a little bit uneasy about a discharge, I’ll be reassured by a repeat visit to the patient’s room just as he or she is leaving; dressed for the road and sitting calmly on the side of the bed chatting with family, the patient will look like a different person from the one on morning rounds. Somebody looking so good couldn’t possibly be sick enough to need hospitalization, I tell myself.

A patient sent home a day earlier is something to value these days when economic pressures demand shorter hospital stays. Indeed, many services that previously required hospitalization now are routinely being performed at home: chemotherapy, subcutaneous blood thinners, iv antibiotics. If we really want to get patients home faster, though, the answer may not lie in medicine at all, but in fashion. Just last week the Oscars showed us that people can look fantastic when done up with the right makeup, hairdo, and gown. A careful look at this country’s hospital gowns is in order – surely with the right designer and enough sparkles and feathers, a gown could be created to make the sickest of the sick look positively bright. With hospital stays running a minimum of $1000 a night, there should be budget room to spare. We’ll empty out our hospitals faster than John Edwards can say malpractice. A cosmetic fix rather than a curative one, you say? Well yes, absolutely, as Americans we should play to our strength, and besides, as a beautiful country we should look the part. Our female patients will love us, and the men will discover sides of themselves they never knew. Best of all, our hospitals will be able to guarantee, with absolute certainty, that each and every patient will look better going out than they did coming in. That, my friends, would be something in which the American healthcare system could truly take pride.

Dying on schedule

2007-02-23T04:57:00.001Z

This weekend I watched The Barbarian Invasions, a Quebecois film about the last days of a man dying from cancer. The man’s son, an investment banker in England, flies home to help take care of his father, going to extraordinary lengths to ensure that he dies as happily and comfortably as possible. Thanks to the son’s efforts, the father’s final days of life are a veritable love fest filled with lavish foods, intravenous heroin for optimal pain control, extended visits from family and friends, video messages from his daughter who is out at sea, and time spent at a peaceful and breathtakingly beautiful lakeside cabin. Then, on a final starlit evening, after all have said their farewells and as if it were the most natural conclusion to a life well lived, the father’s aid helps him end his life with a lethal dose of heroin. The son holds his father’s hand and everybody else looks on approvingly. This, the film boldly seems to state, is dying at its best, on one’s own terms and on one’s own schedule.

Is it such a ridiculous proposition? All of life’s other important events—weddings, graduations, birthdays, celebrations of any kind, really, occur on a schedule. They are better that way: the food stays warm, the band gets booked, the necessary preparations are made, and most importantly, the guests show up. Even in medicine, which deals with problems unconfinable to working hours, we are able to arrange most things on a schedule. If you want to see your doctor, you make an appointment, hoping you’ll still be sick when you finally get to see him. If you need surgery, the surgeon will give you a date and time. An MRI of the head? Book it in advance. Even for our hospitalized patients, it’s rare that a service is provided without the patient first being put on a schedule of some sort. Emergency procedures and surgeries are risky and stressful for everybody, so scheduling them is almost always better, even if the scheduling is for later in the same day. Waiting until a problem becomes emergent is simply bad medical practice.

Emergencies do still happen, of course. In medical school, on explicit instructions from the attending surgeon and in a futile attempt to speed up a surgery, I once hijacked a patient from the ER, commandeering his stretcher and carting him up to the OR myself. Although I got high fives from the surgical residents for this, the nurses and OR staff were less than pleased. I was thoroughly chastised, in fact, and told how much it actually slows things down when patients are carted around without the proper paperwork, before the nurses have had a chance to give each other report. I apologized, but the rush from flying that patient around the hospital at full speed lingered.

Yes, unpredictability and spontaneity make life fun and exciting, but is death really the time when we want them? For healthy people clairvoyance is more likely to be a curse than a blessing; knowing the date and time of one’s death well in advance would certainly precipitate bizarre and unwanted psychological side effects, such as wanton recklessness, or mad last minute attempts to cheat death. For people who are actively dying, though, it seems that the more transparent the process, the easier. Families of dying patients are certainly always hungry for more information about what is happening with their loved ones. Physicians, though, are often less than forthcoming, uncomfortable with predictions and quick to explain that they don’t hold crystal balls. Would we want them to? Surely if dying meant catching an airplane to the other side, we would want to know what time it left so that we could show up to the gate on time with our bags packed. The Vikings buried themselves in their ships because they seem to have considered boating to be one of the best ways to travel to the afterlife; maybe it’s just the Viking in me that thinks knowing a departure time might be nice. Granted, some hopes might be shattered by definitive knowledge of impending death, but after all, those hopes would have been false anyway. For most people, I suspect that knowledge would provide peace and comfort.

At least some warning certainly would be nice. It is the sudden, unexpected deaths that are hardest for families to absorb. People who rapidly go from healthy to deathly ill leave a path of destruction in their wake, giving friends and family no time to adjust to the change in condition or to let them go. The Grim Reaper is perhaps one of the most feared characters in the human imagination, but at least if you see him lurking in the background, you have time to say some final good-byes. A close friend of mine whose mother recently passed away told of how her father called her home from work early on the day of her mother’s death. Her mother was just holding on when she arrived home and seemed to have waited for her to arrive before letting go. Having a chance to say that final good-bye meant a lot to my friend. They were fortunate, but death can be quite difficult to predict, and her mother might have passed suddenly, without notice. There might easily have been no warning.

Often there is none; death comes swiftly and abruptly. A young man, a father, can be perfectly healthy playing basketball one moment, and lay dead on the floor the next. Alternatively, a dying person, having made his final peace, might lie around for days or even weeks in waiting. The farewells are finished, the permission from family members to pass has been granted, and the personal demons have been worked out, but upon closing the eyes, nothing happens. The person experiences terminal insomnia, the most insufferable kind. Who is to begrudge that person a little heroin as a sleep aid, just to help keep his flight to the other side, or to shorten the layover? Who has the right to tell him that he must toss and turn on his death bed?

Most people, I suspect, would answer that God does. But, even conceding God for a moment, is it really He who determines when people live and die? As physicians most of us consider our patients to be in our hands while they are still alive, not God’s; that is, their diseases are ours to cure, or to fail to cure. When we extend lives we certainly don’t feel guilty about keeping God waiting. Why then, can we not hasten death, or put it on a schedule? Great care would have to be taken that it was truly the dying person’s schedule and nobody else’s, but why must we obsess so about securing those final days or hours of life? In the film, at an earlier point when the father admits fear of dying, his caregiver questions him about it and concludes, “It’s not the present you cling to. It’s your past life. That life is already dead.” She makes a valid point—unless you have urgent unfinished business, the process of dying is not about living. Hours spent dying are like hours spent on an airplane: they are to be passed, not necessarily enjoyed.

Phrased in the more familiar language, I suppose I am asking, do we have a right to die? Conversely, do dying people have an obligation to endure the entire natural course of their death, as a final rite of passage? For many people, their religious convictions state that they do. For those with more flexible belief systems, though, hastening death may be a reasonable option. I don’t think I would ever schedule my own death, but for those who prefer an earlier flight to the other side, well, I wish them a peaceful journey. And, in case their plane falters, I’ll be right behind in my Viking longship.

Pressurization

2007-02-15T23:06:00.000Z

I’m disgusted with myself. I’m in the middle of a week of vacation and I’ve failed to accomplish anything. I’ve written nothing for my blog, I’ve read one chapter in Rand’s We The Living and a few haiku, I’ve seen one movie (Garden State, which was great until the cheesy ending ruined it), and I’ve watched some uninspired television. I did successfully cook this chicken curry casserole dish of my mom’s yesterday that was fantastic, but other than that I’ve basically spent the whole vacation sleeping. I feel lame even admitting it. Vacation is rare and precious—it’s supposed to be a time to escape residency and remember what it feels like to be a real person, but so far I’ve squandered it behind shut eyelids.

I think the problem is one of pressurization. You know those teddy bears in a can, that pop out when you pull off the lid? That’s the kind of pressurization that I’m talking about. One of the most interesting phenomena in medicine is actually pressured speech, which is seen in some of the psychiatric disorders. You get these people who have just this intense desire to speak, so that they can’t even get the words out of their mouths fast enough. They’re horrible to interview, because as the physician you can’t get in a word edgewise, much less get them to stop talking. You simply have to examine them through the noise, hoping to catch a heart sound or two when they pause to gulp for air. I don’t have pressured speech, but I do suspect that my current hypersomnia is due to pressured sleep. For the last three months, I’ve been averaging about 5-6 hours of sleep a night, which I thought was sufficient, but apparently not. My body, it seems, was just waiting to enter hibernation. (Hmm, maybe humans are more closely related to bears than previously thought. Anybody else been having cravings for raw fish?)

The question, though, is how I was able to pressurize my sleep. Why didn’t I just fall asleep every night for the last three months, instead of all at once now? The answer, I think, is pressurized time. When you’re working eighty hours a week, you don’t really want to spend your free time sleeping. In fact, you really don’t want to spend your free time sleeping. So, the time pressurization trumps the sleep pressurization and you slowly sink yourself deeper and deeper into sleep deprivation. Now that I’m on vacation, though, with time to burn, my sleep can has popped open and I’ve gone comatose.

Pressurized sleep, it turns out, is actually some of the sweetest sleep around. Maybe we should pressurize other things to make them better. Any ideas? (Stay clean on me people, stay clean.)

Stitching

2007-02-12T16:08:00.000Z

The Barley Field

Up the barley rows,
stitching, stitching them together,
a butterfly goes.

--Sora (1648-1710) (trans. Harold G. Henderson)

Pretty, no? I'm sure he was practicing for the OR.

Harold G. Henderson, An Introduction to Haiku. New York: Doubleday and Co., 1958.

Playing the favorite

2007-02-05T03:14:00.000Z

It is the cardinal sin of parenting to divide affection unequally between one’s children. The favored child certainly may flourish, but the disfavored one, starved for attention and encouragement, is assured of failure to thrive. Just as for twins in the womb, when even the slightest imbalance in blood flow can lead to devastation for the malnourished infant, so too for children in a home can parental favoritism disrupt and destroy the growth and development of the neglected child. Hiding it is of no use, for children will not be deceived; they are exquisitely sensitive to any tempering of the affection that is their birthright. Even an abusive parent, if that abuse is consistently applied, is more tolerable to a child than a parent who dotes partially, as the latter’s bias ruins the sibling bond that otherwise makes almost any hardship bearable.

So too with medicine, we should not play favorites among our patients. Regardless of race, religion, class, sex, mental capacity, or disposition, all patients should be granted the same high professional level of care – that is one of the bases for our fiduciary contract with society. We must work to overcome any personal prejudices. Additionally, we must strive to provide the malodorous patient, the tedious patient, the verbose patient, the histrionic patient, the belligerent and verbally abusive patient, and even the patient who refuses treatment with an equal quality of care to that of our most likable patients, regardless of whether doing so requires extraordinary persistence and patience. Because many of these patients, like children, are unable to care for or think for themselves, it becomes our duty as physicians to protect them from their own poor decision-making. For them we must employ a paternalistic model of medicine. Anything less, besides being immoral, would both compromise the integrity of our profession and erode the fabric of our society.

Yet, it happens from time to time that we encounter a patient who strikes some deep chord within ourselves, a patient whose disease ignites within us a powerful rage of indignation. Perhaps the patient is the mother of a medical student, or a physician herself; perhaps a high school teacher, a professional musician, a writer, or a social worker. Someone whose entire being radiates kindness, warmth, and understanding. For this person, we want to do more, to give more, to fight harder. But is it wrong to do so? Must we deny our desire to go above and beyond the call of duty in her care in order to make sure that we do not favor any particular patient? The answer, I think is no. To do so would be to deny one’s humanity, like passing on life-sustaining food when starving or holding back tears when they ache to be shed. No, I say, let us embrace our desire to nurture, to fight for the patient; let us play the favorite! Let us proofread her orders an extra time, search the literature for any new treatments of her condition, spend the time with her that we want and let her know that we care. Because by doing so, in addition to acknowledging our own humanity, we will learn what it means to be great physicians. And that knowledge is something that we will be able to use to elevate the care that we provide to all of our patients, no matter how beloved to us they are.

A job for the Department of Weights and Measures

2007-01-31T11:15:00.000Z

You know the Department of Weights and Measures, that agency that goes around checking the accuracy of various scales, meters, weights, etc., all for the public good? That benevolent branch of the government that makes sure that gas stations don't rip you off by dispensing less gasoline than they claim? Well, I have a job for them, and it’s a consultation of some importance, if I do say so myself.

I’m not talking about Iraq, that disaster where our government in its rush to produce oil neglected to install meters on the oil pipes, making it impossible to know how much oil was actually flowing out. No, the Department of Weights and Measures actually requires meters in place before it can perform a consultation. Neither am I talking about medical school, which cost me something like $35,000 annually to sit in a lecture hall for the first two years and then run around hospitals helping out doctors in any way that I could for the next two. That one didn’t add up quite right either, I have to say, but unfortunately I don’t think the Department of Weights and Measures can do anything about it.

No, the consultation that I had in mind deals with the hospital pain scale, that simple yet practical measuring tool used to quantify the intensity of a patient’s pain. The pain scale comes in a variety of formats and colors, from the very straightforward one-to-ten numbered scale to the brightly colored face chart showing cartoon faces in different degrees of distress. (Instead of making the faces themselves, the patients point to the illustration that best demonstrates their degree of agony. Communicating human suffering has never been so easy!) Unfortunately, lately the pain scale has been causing me all kinds of grief, so let me explain the problem, starting with an example.

The other night when I was evaluating a patient with abdominal pain, I asked him to rate the severity of his pain on a scale of one to ten, with ten being the absolute worst pain he could imagine. The man furrowed his brow for a moment and then smiled, rubbed his belly, and looking as content as Drew Carey might look after finishing a bowl of ice cream, calmly reported an eight. Now, if I hadn’t already been acutely aware that my pain scale was having calibration problems, this would have greatly surprised me. "An eight?" I would have asked, bewildered. "You mean that as I’m standing here asking you these questions you are going through terrible, deep-to-the-bone, hand-on-a-hot-stove, weak-in-the-knees, soul-searching, gut-wrenching agony?” Maybe I simply have a particularly fertile imagination, but 80% of the worst possible pain I can imagine is still a heck of a lot of pain.

Instead I casually commented, "all right," and rather than running to find the nearest nurse to deliver a dose of that blessed panacea morphine, I nonchalantly continued onward through the next five pages of my history and physical questionnaire. It was just an eight after all. His experience, rather than that of having all of the hairs on his body savagely ripped out at once, was merely that of having 80% of his body hair ripped out. There’s definitely a difference. Not that I haven’t seen tens who looked more comfortable than this particular patient. Some of my tens, yawning, look more interested in taking their next nap than in pain relief. When that happens, I sometimes feel a need to add some urgency to the situation myself, to make up for their apathy and just to keep the situation from becoming farcical. “Wow!” I’ll exclaim. “Child birth kind of pain! I’m surprised you’re able to handle it so calmly, let me run right now and get something to try and take the edge off!”

The problem I seem to be having with my pain scale is that it is lopsided, falsely weighted towards the higher side, as if Shaquille O'Neal were sitting on the ten trying to seesaw with Peewee Herman sitting on the one. As supporting evidence, I submit the following fact: since I started clinical medicine four years ago, I've never once had a one. I must have used my pain scale thousands of times with thousands of different people, but never ever has somebody reported to me that their pain is simply a one out of ten. Oh, I've had hundreds of tens, scores of twelves, handfuls of hundreds, and even a few thousands. I did have a two once. I was ecstatic, besides myself, standing on the other side of the room. I shook the man's hand. “Sir,” I said "you are a fine specimen of a man. This may sound funny to you, but you are my first two, and although that may not seem remarkable, trust me, it is. You are a rare breed, a throwback to a different age, and a true gentleman if there ever so much as was one.” He apologized for having bothered me with a two, and I loved him even more for it.

Now, some skeptics out there might contend that although I’ve never had a one, I’ve never had an eleven either. Could it not be that my pain scale is working perfectly fine, and that it just so has happened that I’ve cared for a lot of patients who have had a lot of pain? To these naysayers I freely admit that it’s true, I’ve never encountered an eleven. However, eleven is not a number between one and ten and therefore cannot technically be considered a valid response on my scale. Therefore, I still must submit that the score distribution on my pain scale is very suspicious, and that I may indeed have a problem on my hands worthy of the attention of the Department of Weights and Measures.

I’ve come to realize that evaluating pain is a war of rhetoric between physicians and patients, and that it’s a conflict that is only escalating in degree. I'm not sure who started it, but I am keenly aware of being deeply entrenched in the battle. After becoming convinced that my patients were artificially inflating their pain scores in order to impress me with their pain, I decided to take action. I started deflating the numbers for them. I invented the “reality factor”, a carefully worked-out constant that corrects for the increased sensitivity to pain of the modern age. Let’s face it, men aren’t what they used to be, and neither are women. Therefore, in order to correct these systematically inflated pain scores, I began adjusting all scores by a factor of 0.8. A ten became an eight, a six a five. It was a stroke of genius.

Unfortunately, some of my patients are catching on. Sensing that I am deflating their pain scores (although I do believe that the details of the reality factor still remain secure), these patients are readjusting their scores preemptively to account for my “correction”. Where they might previously have reported twelves, these savvy guerillas are now reporting scores of sixteen, eighteen, even twenty. Frankly, I feel at a loss -- outdone and outmaneuvered. Don’t count me out entirely yet, though, because I’m planning a strategic move bolder than anything I’ve tried before, what I’m convinced will become a landmark victory for truth and accuracy in reporting. Just as Nabisco, in response to healthier snack foods encroaching upon its historical territory, launched its blockbuster product the Double Stuffed Oreo, so too am I going to raise my game to the next level. My brainchild? The "double dose of reality factor". The world will never be the same. This factor works its magic by taking the reality factor-corrected pain score and multiplying it by an additional constant of 0.6. When somebody reports a ten, the "reality factor" corrects the score to an eight, but the "double dose of reality factor" then corrects it further to a five (8*0.6= 5). It’s brilliant! Pain will never be treated out of proportion to its actual existence again!

Wait a minute, I'm confused. Little numbers are running around in circles in my head. I’m seeing ant wars, dancing turtles, flying headless chickens. Ok, a patient states his pain is an eighteen out of ten -- quick, how much morphine do I order? Fourteen milligrams IV? Twenty three milligrams PO? Nineteen milligrams SC? Uh . . . uh. . . uh. . . Help! HELP!

Dear Department of Weights and Measures, if you truly exist and are out there, hear my plea! I need a consultation, stat! Please bring your bag of tools, your measure-correcters, your scale-straighteners, in fact, all of the gizmos and gadgets at your disposal, because the problem that I have for you is one of monstrous proportions. I beg you, please come by my hospital once and for all and fix that broken and dysfunctional device that is the hospital pain scale.

These DC streets

2007-01-23T22:08:00.000Z

As DC residents, one of the issues that we all have to come to terms with is how to handle the daily requests for money from street beggars. They are as much a part of DC’s urban landscape as the hotdog stands, the museums, the wide sidewalks, the square buildings, and the ubiquitous identification badges, with one key difference: they don’t stay in the background. DC’s street people are experienced enough to realize that being successful in their business doesn’t involve letting you pass them by unsolicited.

We all probably have different strategies and philosophies when it comes to dealing with them, and my approach has been evolving. When I first moved here a year and a half ago, I made regular contributions to their coffers. I figured that anybody who needed a dollar badly enough to ask me for it probably needed it more than I did, and I never seemed to miss the money after giving it away. The thought that the person might spend it on alcohol or drugs never bothered me that much; after all, they also needed money for food, clothes, and other important things. Gradually, though, I came to feel overwhelmed by all of the requests for money. Walking to and from work, I would pass at least a dozen or so beggars, and at one point I realized that walking had become more expensive than riding the metro. Mind you, I wasn’t giving money to every person along my path, but giving even to a fraction of them was adding up. Taking walks around the city in the evening, one of my favorite things to do, had become not only expensive, but mentally and emotionally exhausting. I was tired of evaluating all of these cases to determine their merit and constantly having to brace myself for withholding aid from people. I wasn’t willing to give up my walks; instead, I stopped the giving. I figured I’d let my DC tax dollars do the work for a while – I knew from working with indigent patients in the hospital that multiple shelters, soup kitchens, and other services are available throughout the city for those in need.

I let myself become hardened. One of the things that I overcame was the fundamental need to be polite. I realized that the best beggars were preying on my politeness, manipulating it by dragging me through their stories, shaking my hand, or buddying up to me in ways that made it extremely difficult for me later to refuse them money. I came to see, though, that as strangers doing these things to me, they were the ones who were behaving badly, who were breaching etiquette. I didn’t need to be polite, or to extend them the courtesy of hearing them out just so that they could take advantage of it. I still acknowledged people, but I no longer listened to their requests; “sorry,” became my one-word response.

The unfortunate consequence of the hardened me was that, like most Washingtonians, I became difficult to approach in the street. Unless I could see that you were clearly either lost or a tourist, I was not going to stop for you. A few weeks ago when I was out for a walk with my brother, we passed a group of three young teenage girls on a corner block who appeared to be just hanging out. As we walked by, though, one of them called out to me, “Sir, would you be willing to contribute to our school band fundraiser?”
“Sorry,” was my automatic response. I only took one more step before I turned back around.
“Did you say school band?” I asked, delighted.
The girls nodded.
“Hey, I was the captain of my high school band. What instruments do you guys play?”
“The clarinet,” one offered.
“Me too.”
“The flute,” said the third, shyly.
“Do you guys march?”
“Yeah,” said the first, with the other two nodding in agreement.
“Well, I played the trombone. I’m from Alaska and it was too cold for us to have a marching band, but we played at the basketball games.”
They smiled and I signed my name on their list of donors.

The nice thing about refusing all routine street requests for money is that it frees you to give when you really want to. Of course, these girls were band members, not street beggars, but to me the point was that I was giving freely, not out of awkwardness, guilt, or undue pressure. The upside of the new me, it turned out, was that I could be a virtual ATM when I felt like it.

Sometime thereafter, I was walking around downtown on a day off, and a pleasant-mannered, pleasant-appearing, middle-aged man approached me, asking for a second of my time. He hated to bother me, he said, but he had just rolled into town from North Carolina, and he was going to have surgery here in a few days, but the hospital (which happened to be one of the hospitals at which I rotate) hadn’t helped him to arrange accommodations. It was two days before he would be able to check into the hospital, and he had no money and no place to stay. He wondered if I wouldn’t be able to help him out.

I didn’t share with him that I was a doctor at the hospital where he would be having his surgery in a few days and that for all I knew I would be his doctor, or that he had somehow connected with a boyhood fantasy of mine that there is something romantic to the notion of hopping on a bus to Washington without a penny to your name or any definite plans. The money, however, never flowed so easily.
“Sure, I’d be happy to help you out. You’d have thought the hospital would have done more about the arrangements.”

I’m not sure that I’ve arrived at any ultimate destination in terms of handling street solicitations, but I have come now to a comfortable place. Being able to give on my own terms signals not only that I've become more secure with myself, but that I’ve settled upon a harmonious way of living with the other people who populate these DC streets. Necessarily so, it’s a way that respects both their humanity and my own integrity.

The art of apology

2007-01-17T05:22:00.000Z

Recently I admitted a patient whom I told I was going to give a blood transfusion, but didn’t. You see, when his repeat blood count came back, it showed that the transfusion probably wasn’t necessary. I canceled the order pleased that I was sparing him an unnecessary transfusion, but unfortunately, I never told him that. He lay in bed all night wondering where the heck his blood was, just waiting for the transfusion to start. When I popped into his room for morning rounds, he understandably was irritated. I brightly announced that he wouldn’t need a transfusion after all, to which he responded sourly, “it would have been nice if somebody would have told me that last night.”
“Oh, sorry, didn’t the nurse tell you?” I asked uneasily.
“No, nobody told me.”

I left the room not only feeling guilty about having been remiss in updating him the night before, but professionally embarrassed because I was now going to have to pass off a grumpy patient to the day team. I also felt ashamed at having tried to blame his nurse, and enough so that before leaving the hospital I went back into his room.

“Hey, I just wanted to say I’m sorry for leaving you in the dark last night. I should have been the one to tell you that the transfusion was off, not the nurse. I'm the one at fault.”
His mood shifted completely.
“That’s all right,” he said smiling warmly. “Say, it’s shaping up to be a mighty fine day, do you think I’ll be able to go home by this afternoon?”
I grinned. “We’ll see what we can do.”
I was forgiven, and I felt so much better.

Sometimes I feel like I’m the only one who has noticed that it can feel really good to apologize. Not that the apologizing itself is so great – you do after all have to admit that you were wrong – but the potential for forgiveness can make it very appealing. Think about it – you injured somebody, but through apologizing you have a chance to restore relations and make amends, even to wipe the slate clean. That’s powerful. Yet, we live in a society that is loathe to apologize. Our celebrities and leaders rarely apologize, and when they do it is done so cautiously that it hardly seems like an apology at all. Any admission of wrongdoing is removed, and the blame is often placed on the offended party for misinterpreting the well-intentioned words of the apologizer.

Consider the Pope. Back in October, in a move that probably wasn’t his wisest, the Pope quoted 14th century Christian Byzantine emperor Manuel II on Islam in a speech at the University of Regensburg in Germany:

Show me just what Mohammed brought that was new, and there you will find things only evil and inhuman, such as his command to spread by the sword the faith he preached.

Afterwards, he issued the following ”apology”:

At this time, I wish also to add that I am deeply sorry for the reactions in some countries to a few passages of my address at the University of Regensburg, which were considered offensive to the sensibility of Muslims. These in fact were a quotation from a medieval text, which do not in any way express my personal thought.

I’m sorry for your over-reaction? If that’s not heartfelt I don’t know what is. For some reason people seem to think that if they can include the word “sorry” somewhere in a statement, it then becomes an apology. Pope Benedict’s apology only deepened the initial insult by affirming that he stood by his original statement, and by insinuating that those who were offended were actually the ones in the wrong.

To me, explaining what exactly you are sorry for is one of the key elements to a good apology. An ex-girlfriend of mine used to refuse to do that. She said that if I didn’t know what she was apologizing for, I probably didn’t deserve the apology in the first place. To her, an apology was a three-word phrase, spit out as if it was some despicable thing: “Fine, I’m sorry!” Unfortunately, besides obscuring the apology’s meaning and making me question its sincerity, this also left me in the position of doubting whether she knew what she was apologizing for herself. (e.g. that she wrongly accused me of forgetting to take the car in for repairs, that she refused to talk to me for two hours afterwards, or that she called me an incompetent idiot during the ensuing fight)

Apologizing can be difficult, though, and sometimes we’re not sure exactly how we hurt somebody. If, as someone who was wronged you are able to explain your feelings and don’t insist completely on the other person figuring them out on his or her own, you are going to receive much better apologies. Asking for (not demanding) an apology can be a great way to resolve a conflict. A good discussion can often also lead to a double apology – after you apologize the other person both accepts and apologizes back, usually for over-reacting or handling the misunderstanding ungraciously. With a double apology, you really know you are forgiven. I think that might have been what Pope Benedict was going for when he got the parts mixed up: he was supposed to apologize for what he said, and the Muslim leaders were supposed to apologize for the over-reaction, not the other way around.

As physicians we’re really bad at apologizing, for multiple reasons. We’d like to blame it mostly on the lawyers, but the truth is that most of us (66% in a large study published by the Archives of Internal Medicine) believe that apologizing to patients actually reduces our medical liability. Even if the legal climate doesn’t prevent us from apologizing, though, I think it does negatively impact the language that we use. When pronouncing people dead, for example, we commonly tell family members, “I’m sorry for your loss.” To me this just sounds cold and detached, and I think the reason we say it that way is because we want to be clear that we aren’t accepting any liability for the death. Expressing sorrow for death, though, is a benevolent apology that doesn’t naturally imply accountability. I prefer the more simple, “I’m so sorry,” which I think shows family members that I’m on their side.

I suspect that what we’re really afraid of in apologizing and admitting medical mistakes to patients is losing their confidence. Without the trust of our patients, we are worthless as doctors, and that is a frightening proposition.

The art of apology is tricky and filled with potential pitfalls and misunderstandings, but I wish that our leaders would be more ready to put themselves on the line with higher quality apologies. A person willing to apologize is a person whom I’m willing to trust, but someone who withholds apologies is either weak or mean-spirited. The difficulty and fear involved are not reasons to back away from apologies, but are what make them refreshing and meaningful in the first place. Without them, forgiveness can simply not be granted. And I would suggest that when you’ve hurt somebody and feel bad about it, there’s nothing better than to be forgiven.

Top ten ways to get back at your intern

2007-01-08T16:27:00.000Z

I’m not condoning an all out war with the medical intern; certainly, the most fruitful doctor-patient relationships are those built upon mutual trust and respect. Nevertheless, there are times at which it may be appropriate to behave in ways towards him or her that otherwise would be considered counterproductive, if not totally suspect. For example, let’s say you don’t like your intern. Maybe the guy’s an arrogant prick with about as much common sense as a rock toad. Maybe he went to Ohio State and you are from Michigan. Maybe he forgot (or so he said) to order your sleeping pill. Whatever the reason, an intern like that needs to be dealt with swiftly and severely, and I here offer a list of tried and true insider methods that are guaranteed to get his goat.

Before proceeding to the list, I’m going to warn you that some of the things I’m proposing may seem somewhat harsh and unnecessary. That’s nonsense. Part of the reason you came to a teaching hospital in the first place (besides the allure of the pretty, young female medical students and residents) was to allow your illness to help train the next generation of physicians. (And yes, it is reasonable to hold against your intern that he’s not a beautiful young girl.) What kind of training would it be without any challenges to overcome? Do you really want to be responsible for your physician-in-training failing later in his career because he was never tested during residency?

There’s another consideration as well, and that is the extreme boredom of staying in a hospital room for many days, simply staring at the ceiling or the TV. Nobody is going to fault you for infusing a little bit of melodrama into your relationship with the medical team, just for the heck of it. Besides, keeping yourself occupied will prevent the boredom from driving you to more dangerous kinds of mischief.

10. Think of your intern not as your doctor, but as your biographer: she is there to learn and record your life story. Do not leave out any of the details and do not let her cut you off. You wouldn’t want to compromise her work, would you? With practice, you can make a pre-round visit last up to an hour.

9. When your intern arrives with his attending on morning rounds, ask him to explain how your chemotherapy medications work. Seek out and exploit any weaknesses in the explanation.

8. When your intern first comes to introduce herself, suggest that the patient she is looking for was just moved upstairs. Start your timer to see how long it takes her to come back. Besides letting her know from the start who’s in charge, this will let you measure her competence. If she returns in less than a minute, you’ve got a star on your hands. If it’s within ten minutes that isn’t bad, but if it takes more than fifteen minutes, brace yourself because you’re dealing with a trainwreck who’s going to require a lot of extra training.

7. Writhe in pain on attending rounds, denying that you said you felt great to the intern thirty minutes ago. Alternatively, writhe in pain for the intern and look great for the attending. This will undermine the intern’s credibility in case she later tries to call you out on any of your pranks.

6. During attending rounds, claim that some rascal stole your jewelry. Compliment the intern on her bracelet and mention that it looks an awful lot like your old one.

5. When your intern comes into your room on pre-rounds, just before his exam declare an urgent need to use the restroom. Bring a good book for the toilet seat. Something like War and Peace.

4. On attending rounds, ask the intern if you were sleeping when she came to pre-round, because you don’t remember her visiting you earlier that day. If she recovers from that one, ask her if she really is sure that you’re dying.

3. Declare a game of hide-and-seek with your intern (don’t tell him, he’ll figure it out), with him being “it”. There are all kinds of interesting places to hide in a hospital.

2. After polishing off your breakfast and telling your intern that your appetite has been great, call down to the cafeteria and order a second tray, to be left untouched by your bedside waiting for attending rounds.

1.At the time of discharge, forget where you put your house keys. Have no idea how you are going to get back into your home. Consider it a final test of your intern: if he is able to see the discharge through and can arrange a way for you to be brought inside your home, then you know his training has been successful and that he’s ready to be let loose on the world.

Conclusion:
Employing the techniques described above will undoubtedly enhance the entertainment value of your hospital stay. As a final comment, I'd like to point out that the discharge is one the most dangerous time during a hospitalization. Medications can be missed, follow-up plans neglected, and instructions glossed over, leading to re-hospitalization often under scary conditions. You don't want that, and neither does your intern. If you use my tactics of getting back (or simply getting at) your intern, you can be assured that your discharge will never be handled with so much careful attention to detail--the poor kid will do everything in his power to make sure that he never has to see your face again.

Glossary:

Intern: first year medical resident
Attending: supervising physician
Pre-rounds: when your intern checks in on you early in the morning before presenting your case to the attending
Attending rounds: when the intern returns to your room with the attending, so that he or she may also see and assess you

Cycles and time

2007-01-01T04:24:00.000Z

A few months ago my brother and I were sitting around one evening watching the US Open tennis final, and he wondered, what if scoring in tennis were simplified to being the first man to 100 points, period. No games, no sets, no tie-breakers, none of that confusion, just points, and when one player has reached 100, the match is over. It would make more sense and be easier to follow, he pointed out. There would never be any doubt as to who was ahead at any given moment. After thinking it over, though, we concluded that nothing would kill the sport of tennis more readily. The deuces, the mini-games, the key points, the breaks of service, indeed, all of the elements that make tennis fun to watch depend upon the traditional game-set structure. Without them, and without the moments of tension and release that they produce, tennis would be a very dull sport.

We are a cyclical people living in a world of cycles. Although we did not invent the concept of years, seasons, and days – cycles that are mandated by the stars – we have grown dependent upon them. We need them to help us process the passing of time, and to help us order our lives. Imagine if we didn’t have years, if we instead measured time in terms of days, for example. Some days that would be important to remember: 4745, the day at which you can finally get in to a PG-13 movie; 6574, the day at which a girl becomes legal; 7665, the day at which drinking alcohol is no longer illegal; 12775, the day when a woman’s biological clock runs out; 17520, the average age for a mid-life crisis; 23725, the day at which you can begin collecting social security (at the cost of finally having to admit you’re an old man). Counting time in days might have its charm, but what a headache it would be to remember all of those numbers! Give me a cycle, not a line.

Thus, when people tell me there’s nothing special about New Year’s, that it’s just another day, that a New Year’s resolution is no more timely than any other resolution and that if truly worthwhile it should be carried out at its moment of conception, I say wait a minute, that’s simply not true. New Year’s marks the end of one year and the beginning of the next – it represents the ticking of the most significant division of time that we have. If we believe at all in the possibility of change, of new beginnings, of new chapters and new leases, of building new accomplishments upon past ones, then a new year is the most natural time to renew those efforts.

I don’t wish to suggest that the year is the only meaningful unit with which to measure time; the seasons are lovely as well, and they have frequently been an inspiration for music composers, such as for Vivaldi and Piazzolla in their seasons cycles. Medically, the seasons are the most interesting. When checking the mental status of patients, orientation to time is one of the basic measures of cognitive function that we assess. In the hospital, because there are few clocks, no calendars, no clear days or nights, and vital sign and medications schedules pay no attention to daytime-nighttime cycles, disorientation to time is a frequent problem. While we ask about years and months and dates, I find orientation to season to be most telling. If the patient knows the season, I can be reassured that he'll probably be all right. His perception of reality might be somewhat altered, but his fundamental hold on when he's living remains intact.

This is New Year’s Eve, though, and the discussion at hand is one of years, not of seasons. Tomorrow will be the first day of a new voyage of the earth around the sun, and I’m delighted to be here for it. I’d love to let it infuse my own life with fresh energy. To a tennis player, a new set means new life, another chance to fight for a come-from-behind victory. I don’t see why a new year for me should be any different. I have a feeling it's going to be a good one.

Hospitalized on Christmas

2006-12-25T23:22:00.000Z

This morning as I rounded on my patients in the hospital, I wished each of them a Merry Christmas. It felt good to say but at the same time slightly odd, not because I worried that somebody wasn’t Christian, but because spending your Christmas sick in the hospital probably isn’t anybody’s idea of a merry Christmas. It’s kind of like when you go to the doctor and he asks you, “how are you?” and you say “fine, thanks,” to be polite, but you both know that if you really were fine you wouldn’t be there in the first place. The exchange somehow only serves to highlight that something is wrong. And so wishing Merry Christmas to my patients, as cheerfully as I tried to do so, in part only seemed to emphasize their misfortune. For no matter how caring your nurses, how thoughtful your physicians, how friendly your roommate, how beautifully decorated the hospital, how frequent your visitors, the ugly truth remains that the hospital ward is a horrible place to spend Christmas.

It’s only the last couple of years when residency has prevented me from returning home to Alaska over Christmas that I’ve realized the importance of spending Christmas at home. My parents have been coming here to celebrate with my brothers and me, but as nice as it’s been to see them, Christmas in Washington just isn’t the same. What’s missing? The boxful after boxful of Christmas decorations that my mom starts putting up after Thanksgiving; the making and decorating of gingerbread cookies with Dad; the mustard-encrusted Swedish Christmas ham that provides daily lunchtime ham and cheese sandwiches; the luxury of being on vacation; the Christmas tree with its entourage of multi-shaped and multi-colored Christmas presents; the straw Swedish Christmas goat with its red necktie; the cozy darkness that sets in shortly after noon and the Christmas lights that softly brighten it; the dozen or so different kinds of Christmas cookies that Mom bakes; the nightly living room concerts with us brothers alternately singing and playing the piano; the glowing white snow coating the entire outdoor landscape; Swedish Christmas dinner on Christmas Eve with broccoli soup, spare ribs, meatballs, potatoes, glogg, whipped rice pudding dessert; American Christmas dinner on Christmas Day with the entire extended family. In short, what’s missing in Christmas in Washington for me is everything that makes Christmas special.

Patients realize this as well. They do their darnedest to stay out of the hospital over the holidays, minimizing symptoms, ignoring pains, waiting out dizzy spells, in vain attempting anything possible to convince their fragile bodies that staying home will be ok. One of the questions we normally ask when admitting patients is what changed in their condition that day that made them seek out medical attention. (Admittedly, sometimes we are curious why, if the pain has been going on for six months, the patient decided to come in just on our particular shift.) During the holidays, though, we instead find ourselves asking, “Why on earth did you wait so long to come in?” The invariable answer: I was hoping I could make it through the holidays. It’s hard to be mad at a patient like that. I mean, you’d think people would realize when they can’t move one side of their body that the problem bears some urgency, but just wanting to spend Christmas at home is a wish that's much too understandable. Those patients, despite their best efforts, will hear Merry Christmas from someone like me. Others, though no more determined, are more lucky. The medicine service at my primary hospital averages roughly sixteen or so admits over every twenty-four hour period during the winter. Over the past three days, we had seventeen admissions total. Pity the resident who gets assigned call on the day after Christmas.

As the hospitalized patients and I have discovered, though, there are worse things still than spending Christmas in the hospital. On the bright side, and despite its reputation for being a cold and foreboding place, the hospital actually turns out to be quite conducive for meaningful human encounters, conversations, and interactions. Telling someone that you love them is easier in the hospital. People are always around, so nobody has to be completely alone. Additionally, there is a deeper sense of camaraderie in the hospital during the holidays, as healthcare workers from the top of the command chain to the bottom feel increased solidarity and commitment to our profession.

For these reasons, my mood was bright this morning as I showed up for work, and I was genuine in wishing each of my patients a Merry Christmas, and in hoping that I wasn’t just rubbing in that they were more or less missing Christmas this year. They smiled and wished me a Merry Christmas in return, the more clever ones maybe feeling reciprocal misgivings in figuring that rounding on sick patients in the hospital wasn’t exactly my preferred way of spending Christmas either. But despite our perhaps mutual concerns, and despite our less than ideal circumstances, on both sides I think we took satisfaction in the greeting. Because when it comes down to it, no matter what your religion, and no matter what your disposition, it’s hard to take a well-wishing negatively, especially when that wish is for a Merry Christmas on Christmas Day.

Staying the course

2006-12-20T08:01:00.000Z

One of the best attendings that I’ve ever had was an ICU attending whom I worked with as a fourth year medical student. Born, raised, and educated in India, he had completed his residency and fellowship in the U.S. and stayed on to become a bright and shining young medicine professor. Although his bedside manner was somewhat hampered by an inability to mince words, his patients were always keenly aware that they were receiving outstanding medical care. Each morning on rounds as he listened to patient presentations, he would focus carefully on every word, furrowing his brow at any irregularities or surprises. He would jot down notes, pouring over the data on his flip cards, and when the presentation had finished and the plan had been fully presented, he would reach into his magical hat of medical tricks and pull out an additional suggestion or two. No matter how long the patient had been in the ICU, with the same illness and the same basic treatment plan, he always had something new to offer, be it an antibiotic change, a new bowel regimen for constipation, a new physical therapy activity, or any other small change that might improve patient care or comfort. Staying the course was not part of his vocabulary. Although he didn’t explicitly state it, my attending seemed to feel that if there was not some new thing he could do for each patient each day, he would be better off just staying home.

Of course, now the specific language has been ruined for us by the war in Iraq, but the concept of staying the course was never a very good one to begin with. Whether in medicine, warfare, or just everyday life, staying the course implies a lack of imagination. It means that you can’t think of anything else to do that might improve your situation; that you are plain out of ideas, run completely dry. There are certainly times when a therapeutic plan or maneuver takes more than one day to implement and/or see through, but staying the course suggests satisfaction with the current progress and hesitancy to attempt anything else. As I learned in my ICU rotation, however, there’s almost always something more you can do.

Self-help isn’t really my thing, but I wonder what would happen if we applied our hospital techniques of patient evaluation to ourselves. What if we woke up each morning and asked ourselves if we had any concerns since the day before; if we examined ourselves, reviewed our own charts, considered in detail each of our own active and chronic issues and the best daily plan for each. It would certainly be overkill, and should we find ourselves behaving in such a way, ordering psychiatric evaluation of ourselves would definitely be warranted. Yet, if we were able to look past the eccentricity of holding self conversations and thinking about ourselves in the third person, imagine the power of addressing our problems in such a systematic and thoughtful way. Nearly anything could be conquered, any goal achieved. And if we believed that a new day was worthy of a new approach, idea, or endeavor, that in general it would be ok to maintain the overall plan but that the details would demand something fresh to be discovered or pursued, then the power to achieve and to build success would only be greater. A higher quality of life could perhaps be achieved. And the previous day would have to be truly amazing before one would ever say on the following one that the plan was simply to stay the course.

Publication bias

2006-12-13T03:57:00.000Z

One of the field of medicine’s most attractive qualities is that it is inhabited by people of skeptical minds, and to convince anyone of anything requires quite a substantial feat of proof. I suppose the underlying reason for this is that do no harm remains one of our central tenets, and when patients’ lives are at stake, we want to be absolutely sure we know what we’re doing.

In contrast, I’m continuously amazed at how low the threshold for acceptable evidence seems to be in the public sphere. The guilt by association smear is a particularly common and egregious example of this, as it insinuates without offering any evidence at all. (e.g. Nancy Pelosi sounds a lot like Michael Moore these days, talking about limiting the sale of handguns.) More dangerous is when evidence is used to draw conclusions that it doesn’t actually support. I remember watching a debate about gay and lesbian adoption rights on the Oprah Winfrey show a few years ago and getting irritated as one of the speakers kept citing evidence that children raised without fathers do less well than other children, in support of his claim that lesbian couples make inferior parents. Nobody on the show pointed out the ridiculousness of this logic, but in a medical conference he’d have been a laughing stock. Let me get this right – instead of studying the children of lesbian couples, you want to make assumptions about them using the children from broken homes as a proxy? I have a better idea, how about I prescribe you a medication for attention deficit disorder that has been proven safe in tortoises! Never mind that by his logic gay male parents would have made the best child-rearers, as they'd have provided the steady influence of not one but two fathers. I’d have found this man much less objectionable had he simply stated that he was opposed to lesbian parents because he was opposed to lesbianism.

One of the ways that we can stay honest, in medicine and in life, is by identifying bias in the information that we receive. The point isn’t necessarily to eliminate the bias, but simply to recognize it so that we can factor it in when we form opinions. Conservatives, for example, would like us to correct for what they see as a liberal media bias. Claiming that the news is biased, however, is a dangerous game to play; if the news seems biased, that is, if reality seems biased, it implies that the bias actually lies in the person perceiving it.

A kind of bias that I find particularly fascinating and that is commonly described in medicine is publication bias. Publication bias results from considering only information that has been published and neglecting other information. If you think about it, publication bias in one form or another influences everything that we learn and know, since we are unable to access information that hasn’t been published or broadcast in some way. By filtering out information that is not worth being heard, publication bias serves as a useful form of quality control, but it does mean that we must rely on others to supply us with information that’s relevant, important, and entertaining. On the micro level, in conversation between people, publication bias becomes speech bias. When talking with someone, you only hear the thoughts that they decide are worth or safe speaking. Since the dullest, dumbest, and riskiest thoughts are filtered out, speech bias makes people seem smarter than they actually are, and probably leads us to doubt our own capability and worth. Maybe those really arrogant people out there in the world would seem less intimidating if we could somehow eliminate this bias. There are definitely certain minds where I would love to implant a thought recorder and register the thinking as is. Of course, unfiltered speech can also be hazardous – I’ve been exposed to enough of it in the psych ward to know its capacity for harm. A wish to be able to read minds is exactly the kind of wish that the devil loves to grant. Yet, speech bias does act as an impediment towards peace and understanding between people in conflict. If we could all just plug our brains into a global neural network where ideas and information were exchanged freely, wouldn’t the world be a better, more peaceful place?

Wait a minute, that sounds an awful lot like the blogosphere.

The power to reassure

2006-12-06T00:21:00.000Z

While covering the ICU (intensive care unit) earlier this year, I received my first call on the pacemaker hotline. This hotline service is offered by one of the hospitals at which I rotate to patients who have pacemakers, so that when they have emergency issues they can call in and transmit electrical tracings for interpretation. I’m not sure who staffs the line during the daytime, but at night and on weekends, it falls to the ICU resident to field the calls and give advice.

Let me just pause for a moment and note that the whole concept of a pacemaker hotline, as great as it sounds, is probably somewhat flawed. Pacemakers, it so happens, are rather complex machines; they are the gadgets of electrophysiologists, physicians so specialized that they have completed not one but two fellowships after their internal medicine residency. In contrast, I have not even completed half of my residency, which to me suggests that I have about as much business interpreting a pacemaker tracing as I do trying to repair a malfunctioning jet engine before takeoff.

Despite these reservations, I nonetheless was the on-call ICU resident, and the nurses were telling me that a little old lady was on the other end of the pacemaker hotline, expectantly awaiting my advice.

“Hi, this is Dr. C,” I said.
“Hello, doctor.”
“How can I help?”
“Well, doctor, I have been having stomach pains most of the afternoon. I think it might be related to something I ate for lunch, but I thought I would see if it could be my pacemaker.”
“Hmm, are you having any chest pain?”
“No.”
“Palpitations or shortness of breath?”
“No, doctor.”
“On a scale of 1 to 10, how bad is the pain?”
“About 4 to 6.”
“ And it started after lunch?”
“Yes, it started about an hour after lunch, and has been going on for a couple of hours.”

I looked at the tracing that had been placed in my hands. It looked ok to me, but then again, what did I know? The tracing only showed one lead, as opposed to the twelve-lead EKGs or two-lead telemetry strips with which I was familiar, and it didn’t specify which lead it was. The heart rate was normal, though, and the pacemaker seemed to be pacing appropriately. I stared at the thing for a minute or two, and I must have appeared to be somewhat confounded, because one of the more experienced ICU nurses came over to me, and winking knowingly, said, “Just send her to the ER.”
“Is that what the residents usually do?” I asked.
She nodded. “Yeah.”
“But I think she just has a stomachache.”
She shrugged helplessly.

“Miss, your pacemaker tracing looks fine. I’m not sure why you’re having abdominal pain, but I don’t think it’s related to your pacemaker,” I said. “If the stomach pain is bothering you, I suggest that you go to the ER to be evaluated.”
“Ok, doctor, but I think I’ll just wait it out then. I’m sure it will get better in a little bit. Thank you very much.”
“All right, you’re welcome, have a good night.”

I hung up the phone feeling pleased with myself; I had just saved this lady a trip to the ER, which would have been a great inconvenience to her and definitely ruined the rest of her night. I started jotting down a note in the logbook. Suddenly a pang of doubt hit me – was I really sure that she was ok? The cardinal rule of medical hotlines is to always send the patient to the ER, no matter what the complaint. Not only had I broken that rule, I had taken a stand on my own and would be personally responsible for anything that might happen. I thumbed through the other entries in the logbook – one after the other, the entries read, “patient agreed to call 911 for an ambulance,” “patient to leave immediately for ER,” “patient waiting for EMS.” Uh-oh. I looked again at the tracing – wait a minute, this tracing wasn’t completely normal, one of the waves had an abnormal shape. It was probably just her baseline waveform, and not really a reason to be having abdominal pain, but was I really willing to put my neck on the line?

The same ICU nurse, who could sense my doubt, repeated, “Just send her to the ER.”
“What do you think, do I need to call an ambulance for her or should I let her drive herself?” I had no experience in this.
“Maybe somebody can take her. Or she can call an ambulance herself.”

I called her back. “Hi, this is Dr. C again. I was just looking at your tracing further, and I decided that based upon the tracing, I can’t really be certain that nothing is going on with your heart. I have to strongly recommend that you go to the ER to be evaluated. Do you think there is someone who can take you?”
“No, doctor, I’m sure that I’m fine. The nearest emergency room is an hour’s drive away, and there’s nobody to take me.”
“Well, can’t you call an ambulance?”
“No, doctor, really, I’m going to be ok.”
“The problem is, without being able to see you and evaluate you, I can’t be sure that you aren’t having a heart attack.”
“But doctor, I’m not having any chest pain.”
“Yes, well, sometimes a heart attack presents unusually, as abdominal pain, or as a variety of other symptoms. I just can’t really tell from here. I have to strongly recommend that you go the ER for evaluation.”
I held back from playing my ultimate trump card, that is, threatening her that she could die, since I was pretty sure she just had a stomachache.
“I understand doctor, but I’m just going to wait a little bit and see if it doesn’t get better.”
“Ok.”

This time I hung up the phone feeling deeply unsatisfied. I had set my imagination in motion, and it was leading me in directions I didn’t want to go. The abnormal electrical wave on the lady’s pacer tracing started glaring at me, mocking me. Did I need to absolutely insist that she go to the ER? There was only one thing to do: I paged the cardiology fellow.

“Hey, this is Wyatt, the ICU resident, I’m sorry to bug you, but I was wondering if you could look at a tracing from the pacemaker hotline. It’s a little old lady having abdominal pain, and I think the tracing looks ok, but I’m not entirely sure how to interpret it.”
I faxed him the tracing. He agreed, the tracing was fine, but he thought she should go to the ER to have her abdominal pain evaluated.

At least now I could let the matter rest. I didn’t need to call her back to insist upon anything – I would just let my “strong recommendation” to go to the ER stand. I felt cuckolded, though; this was not why I had become a doctor. A patient had called for reassurance, one of the greatest things that a physician can offer, but I had only heightened her anxiety. I had said and done things that I didn’t believe simply because of fear of liability. In fact, in the end I had made it my chief objective to ensure that she received absolutely no comfort from talking with me. Defensive medicine, we call it. A result of our hyper-litigious society, it is one of the most destructive forces in medicine today, paralyzing our ability to care for our patients if we let it. In this case, my lady would have been better off not speaking to me at all.

18:40, that was the low point of my call night. Three hours later, after I had resuscitated a coding patient, set him up on a mechanical ventilator, thrown in a subclavian central venous line, and tucked him in for the night, I felt a whole lot better. I was a doctor again.

Twenty dollars

2006-11-30T23:28:00.000Z

These “hide the money” jokes came up during MICU rounds last week. As they were new to me and quite entertaining, I decided to run with the idea. Variations of the first five can be found all over the web, and I credit J. Tishon for a variation of the sixth. The rest are my own invention.

How do you hide twenty dollars from. . .

An orthopaedic surgeon?

Put it in a medical textbook.

A general surgeon?

Hide it in the chart.

A dermatologist?

You can’t hide money from a dermatologist.

A neurosurgeon?

Stick it to his child’s forehead.

A radiologist?

Give it to her patient.

A cardiologist?

Give it to his wife.

A plastic surgeon?

Hide it in any location with a winter climate colder than Florida.

A pathologist?

Place it anywhere above ground level.

An ob/gyn?

Just send it to her malpractice lawyer.

A malpractice lawyer?

You’re an idiot for even considering it.

An internist?

Hide it anywhere – an internist doesn’t have the foggiest about where to find money.

A resident?

Put it under her pillow.

An ER doc?

Put it in the medical history.

A medical student?

You evil, evil person – would you also steal money from a blind beggar on the street?

Feel free to add to the list!

Simple tasks (at 04:30)

2006-11-26T13:42:00.000Z

It sounds simple enough. Every night before the other residents arrive in the morning, it is the duty of one of the on-call residents to update the team census (a spreadsheet containing an enumeration of the team’s patients) with the new patients from call and to assign patients to residents for the coming day. Rules must be followed: the post-call residents (referred to as on-call above) are to take only their new admissions from the night before; the short-call residents should not be assigned patients as they will be called away from rounds to admit new ones; the pre-call residents when possible are given a reduced patient load to help them have an early day before their impending call; and the new on-call residents, who have no chance of escaping the hospital anyway, are to carry the brunt of the patient load. Usually the task of updating the census and assigning patients is performed in the wee hours of the morning, around 04:30, after all of the night’s admission (fingers crossed) have been tucked in. Compared to the other tasks that we perform as residents, this task is remarkably simple; it requires no analytical or deductive thought and demands little in the way of computation. Yet, as often as not the census contains mistakes – a resident gets assigned too many or too few patients, the wrong patient goes to the wrong resident, a patient somehow goes uncovered – any number of mishaps can occur.

You see, 04:30 is an hour inhabited naturally only by insomniacs, whose charged, restless minds mercilessly repel the sleep that their bodies so need and crave, and by new lovers, whose irrepressible affection for each other transcends the need for sleep, allowing them time to blissfully and tenderly dissect each other’s bodies in consummation of their nascent love. It is an hour proscribed from others, and to venture there uninvited is to struggle against the laws of God and nature. Like petting an animal against the grain of its hair, hyper-extending a joint, or building a sand monument on a windy shore, persisting in wakefulness to 04:30 is only to court disaster. The simplest task becomes painful and unbearable as the mind, weighed down by a thick coat of dullness, struggles to function. It enters a dream world, a state of half-wake and half-slumber where every suggestion contains hidden pitfalls and sustaining a thought becomes like trying to harbor a ship in port without anchor: unseen currents inevitably carry it toward a precipitous and calamitous end.

As residents we invade this no-man’s land every fourth night, intrepidly but vainly attempting to swath a path through the fog in order to care for a patient, or to finish our work. We are not, however, blessed with Herculean strength, and although we may rage against the taunting sirens that beckon us with sleep, our endurance is limited. Eventually, and insidiously, our minds becomes clouded enough that we can’t perform even the simplest of tasks without error. Yes, I want you to ask it, I demand that you ask it: what about the complex ones?

The luxury of being half asleep, Ian McEwan writes, is that it allows you to explore the fringes of psychosis in safety. Perhaps from the cozy confines of your Saturday morning bed, but how untrue, how devastatingly untrue at 04:30 in the uncomfortably bright lighting of the hospital ward.

Medicine for our mothers

2006-11-23T15:13:00.000Z

In tribute to Thanksgiving, I repost my first substantive posting, Medicine for our mothers, which I had taken down a few months ago because I thought it might interfere with a research project on the subject. I've decided there is no problem.

*****

We hear it about once a week on wards, at times when particularly troubling or trying decisions arise regarding patient care. Usually, it’s the attending who poses the question, but it’s always spoken from a more senior to less senior team member, as it carries a subtle implication that the currently proposed plan may not be quite good enough: “If it were your mother, what would you do?” The effect that this question has upon the team is both striking and predictable. (It does rely on the assumption that the team members love their mothers, but would they really have become doctors if they didn’t?) Several moments of chin rubbing, head scratching and soul searching ensue, after which it is generally agreed to raise the level of care or renew efforts with yet another attempt at diagnosis or therapy. Occasionally the question instead spurs a move towards patient comfort or palliation. All involved are reassured that the patient is getting the best possible care because it is what they would have done for their own mothers.

The mother hypothetical is a ritual of medicine that I have participated in countless times, although I’ve never raised the question myself. Somewhere between my 4th year of medical school and internship its great irony struck me. As physicians we are forbidden from practicing medicine on our mothers for the very reason that when it comes to them, we are completely incapable of reason, rationality, or measured decision making. Yet with our most difficult decisions, at the times when we most should be relying upon reason to guide us, we instead emotively plea for guidance to the specters of our beloved mothers. Oddly enough, it usually helps. Still, I have to wonder, are we asking the right question? Does mother know best? Perhaps our decision making would be better if we instead pondered about Uncle Albert. Or, an even more novel concept, what if we just asked what was best for that patient?

News you already know

2006-11-18T21:26:00.000Z

Is it really such an annoying thing, to receive news that you already know? Granted, your thoughts may have been interrupted, your pager going off might have given you a mini-heart attack, and a few seconds of your time may just have been wasted without any appreciable gain, but somebody did just make an effort to tell you something they thought you might like to know. Even if the person was a complete moron, in all probability the disturbance was actually an attempt to make your life easier. Anyway, sometimes the point isn’t necessarily to inform you, but more to make sure that you are already informed. I’m not saying there’s no such thing as a stupid page or call, but I hate it when good faith is met with irritation. Why not just be courteous?

I find the way in which a person receives news that he already knows to be telling about his character. Is the person someone who always has to point it out when he already knows something? Does the person thank the informer but then later make a snide remark? Along the spectrum from graciousness to malignancy, where does the person fall?

Here are various responses that I have heard at one point or another as a medical student or resident.

1. (gracious) “Oh yes, I heard, it’s worsened, hasn’t it? I agree, he’s going to need a transfusion. . .thanks for calling.”

2. (pleasant) “Right, I just saw that. We’re thinking he’ll need a transfusion. . .”

3. (neutral) “Oh yeah, I actually commented about that in my note. We’re going to transfuse him.”

4. (annoyed) “I know that. I discussed in my note this morning. . .”

5. (uncalled for) “Yes, if you had read my note you would know that I already commented on that. . .”

6. (malignant) “Look, don’t waste my time. Go read my note from this morning and you’ll be able to see what I thought about that.”

Aren’t nice people just so much more pleasant to work with?

On the television

2006-11-15T01:32:00.000Z

Most of the time the television in a patient’s room is more of an annoyance than an item of interest. On continuously, it is usually cranked up to some absurd volume where communication with the patient becomes difficult and auscultation for cardiac murmurs and other subtle sounds becomes nearly impossible. (Say what? Your nurse just gave you a spanking? Oh, pardon me, you said your nurse is bringing you a blanket!) I usually try to turn the thing off when I can get away with it, but for some reason many nurses and family members seem to view the television as comforting to their non-awake patients or kin, leaving it on 24/7. Awake patients do need the television to ward off boredom, that I understand, but it so ends up that nine out of ten occupied rooms in your average hospital will at any time have their T.V.’s brightly lit up, hour after hour drowning ear drums and burning retinas.

Where the television can really become a problem, though, is when there is an item of intense interest to the medical team on the T.V. Instead of paying attention to the patient, team members will steal glances up at the screen, straining their peripheral vision in an effort to discreetly absorb as much information as possible. I can recall several times over the past few years seeing patients while being more interested in their televisions than in the patients themselves. I can’t say I felt great about it, but let’s be honest – it has to be a pretty good story of chest pain to match the excitement of catching a glimpse of the World Cup final. I was only a first year medical student on 9/11, but I imagine that hospital rounds on that day must have been excruciatingly painful. The medical staff, starved for images and information, would have wanted nothing more than to sit down together with their patients and to fix their eyes upon the flashing television screens.

The lesson for patients, I suppose, is that if they want to command as much of their physicians’ attentions as possible, they should turn the T.V. off and keep distractions in their room to a minimum. We do care, we’re just a distractible bunch. Besides, it goes both ways – it’s not an uncommon patient who’s more interested in what’s on the television than in what his docs have to say. (“Sir, I’ve been asked to see you because your kidneys aren’t working.” “That’s nice, but I don’t care.”) A few minutes sans T.V. for some sound medical advice – that’s not such a bad bargain. What’s more, we’ll actually be able to hear your heart sounds.

Electoral musings

2006-11-08T06:33:00.000Z

Although this is not a political blog, I figure that election night in DC deserves some sort of commentary. In the past, medicine and the country’s electoral process have had an uneasy relationship. In 2004, we heard about election workers visiting nursing homes and helping demented patients to absentee vote. As illustrated by that case, much of the tension between medicine and our electoral process seems to concern the voting rights of people whose diseases hinder their ability to vote intelligently. As doctors we declare patients incompetent to make medical decisions, but what about making political decisions? Should you have to be able to communicate, for example, the country in which you live, in order to receive the right to vote? It would be an interesting study to find out at what level of orientation people forget their political party affiliations. Is it before or after you forget how old you are? Before or after you forget your spouse’s name? These are uncomfortable questions, but we’re one of the oldest democratic countries in the world, and we teach other countries how to hold free and fair elections. Shouldn’t we have some answers?

My personal concern is that some election night I’m going to be stuck in the hospital on a 30 hour call shift, not having had the chance to vote. I wonder how many hospitals provide absentee ballots for their residents and patients. I sense a possible political scheme here – politically savvy chief residents arranging call schedules to disenfranchise residents of the opposite political persuasion. The West Wing meets Grey’s Anatomy?

Apologizing is easier (than asking for permission)

2006-11-05T21:47:00.000Z

The GI fellow I’ve been working with this month recently was telling me about her daily interactions with a particularly grumpy middle-aged patient on our service. When I say grumpy, I mean the kind of guy who responds to a cheerful “Good morning, sir,” crossly with “what do you want?” – and that’s if you’re lucky enough to find him, because most of the time he’s out in the hospital courtyard puffing on cigarette after cigarette. In any case, my fellow confessed that every morning as she would examine and press upon his hip, the maneuver would incite shouts, invectives, and in all honesty a substantial amount of real pain. She would then quickly apologize.
“Why do you do that, when you know it’s going to hurt him?” I asked bemusedly.
“Well, I keep forgetting that he’s tender there.”
“And he keeps letting you examine him day after day, despite this profound agony?”
“Yeah, well, he keeps forgetting too. His memory is pretty bad you know—he still doesn’t even know who I am.”

No wonder the guy’s always pissed off.

You see, as physicians, we’re horrible at asking for permission. Sure, we obtain the required written informed consent before administering blood, performing spinal taps, dialysis, and other major procedures, but when it comes to medications, lab draws, iv lines, and just plain old physical examination, we have a tendency to shoot first and answer questions later. After all, when you only have a couple of hours to run through your census of 20 patients, stopping to ask, “may I now press upon your hip?” is going to be at the bottom of your list of priorities—it’s not that big of a deal (hopefully), and you really don’t have time for negotiations. Granted, it would be nice to have the patient’s permission, and maybe to give him some warning that a little bit of hurt is coming his way, but in the grand scheme of things, it’s just more practical to commit the offense and then to apologize. It’s an imperfect system, and we are bound by the multiple conflicting demands of our work. Hopefully our patients understand that; in fact, we rely on their forgiveness for a lot of the little things we do. In return, I suppose we can cut a guy a little bit of slack when he doesn’t greet us in the morning with a cheerful, “Good morning Doc, it’s good to see you!”

A curious encounter

2006-11-01T04:15:00.000Z

After finishing a long workday at the hospital last week, I was trekking through its long corridors on my way out to the parking lot when a rather peculiar experience befell me. Just as I had turned a corner and was heading down a particularly dimly lit green hallway, I felt an icy draft on my neck. Startled, I spun around to look behind me, only to see an empty hallway. Slowly I turned back around, but in doing so I bumped right into a quickly moving dark-clad figure.
“Whoa!” I said, falling back a step, and gaining a chance to size up this new obstacle in my path. Before me stood a tall, slender, pale-white man in his forties, impeccably groomed with slicked back hair and a black and red cape covering an all-black outfit. He was fumbling with a red handkerchief.
“A bit early for Halloween, isn’t it?” I asked.
“Atchoo!!!” was the only reply, and he raised the handkerchief to wipe his nose.
“Bless you,” I said, moving to walk around him and continue on my way. Before I could take two steps, though, I felt a cold hand on my shoulder, deceptively strong and firmly preventing my progress.
“Excu-use me, doctor-r?” he intoned in a thick foreign accent that I couldn’t quite place.
I nodded.
“For-r-give my intr-r-usion, but I am si-ick and need help. I seem to have caught something dr-r-eadful out in ze cold.”
I looked at him blankly.
“I’m sor-r-r-y, please allow me to intr-r-oduce myself. I am Count Dr-r-acula.”

My first urge was to point out the sign to the psych ward, but as I was in a relatively good mood, I instead decided to play along with him.
“Dracula? Don’t you live in Eastern Europe or something?”
“Y-es, that is tr-r-ue. But my friend ze Fr-r-ankenstein monster-r –- he invite me for-r a par-r-ty in ze White House. You know it? It’s called ze Monster Mash. It is always a gr-r-aveyard smash.”
“Nice! Frankenstein throwing a monster mash in the White House?! Why does that not surprise me?”
“Y-ess, well, next week, on Halloween. As you point out, I am ear-r-ly. I come for sight seeing. This Washington, what a s-splendid city.”
“Oh yeah, the sights are great. I take it you’ve been to the different monuments and museums?”
“N-no, no. No time for-r such nonsense. I visit ze Arlington cemetery, and ze unknown soldier – actually, we invite him to ze par-r-ty, but I think he don’t come. He says he must s-stand watch. And ze staircase vere my friend from ze Exorcist had so much fun. You know zis s-staircase? Ver-r-y inter-r-esting. Las-st night, I visit a place, Madam’s Or-r-gan. Mz. Or-r-gan, she under-r-stand ze car-r-nal pleasur-r-es in life. I enjoyed zis ver-r-y much. Except I have a ver-r-y nas-sty cough. So I come to you. How can you help me?”
I go through a quick history and perform a cursory exam – it turns out that our friend, in addition to his cough, has swollen tender cervical lymph nodes and white spots on his tonsils. Oddly, he feels unnaturally cool to the touch.
“Well, Mr. Dracula, I’m afraid you have a case of strep throat, in addition to a touch of bronchitis. You need a course of antibiotics.”
“Penic-cillin? I know zis medic-cine, it iz ver-r-y popular in my countr-r-y. In fact, I know wher-r-e I can find some. My fr-r-iend R-r-ush, he has a ver-r-y lar-r-ge medicine supply. He will give me.”
“That’s nice, but why don’t we get you your medicine here? Come with me, I’ll show you where.”
I start leading him down the hall towards the psych unit. As the unit clerk comes into sight I wave.
“We’ve got one of yours down here!” I call out.
She waves back.
“These nice people will take care of you,” I say. “Just head down to the lady at the desk.”
“Doctor-r your-r assis-stance is-s gr-r-eatly appr-r-eciated.” He bows formally.
“No problem. I suppose if treating the undead bothered me, I wouldn’t be doing my residency in DC.”
I start heading back out to the parking lot, but before I turn the next corner, I can’t help but take a peek back over my shoulder. The psych unit clerk is still at the end of the hall, but Mr. Dracula is nowhere to be seen.
“Where’d he go?” I call out.
She shrugs.
"Crazy patient," I mutter. Shaking my head, I continue towards the exit.

BCG vaccination for TB – an investigative journey

2006-10-28T20:16:00.000Z

Intro

Not to be difficult, but recently a few questions about the BCG vaccine for tuberculosis (TB) have been bothering me. I keep hearing it stated that when it comes to interpreting the tuberculosis skin test (TST), BCG vaccination status doesn’t matter – a positive test should be treated as latent disease. Fine, that’s the policy. Does it really make sense, though? Since we know that BCG vaccination causes a positive TST, it seems a little strange. Additionally, why the dismissive language? I mean, clearly BCG vaccination status does matter – it means that if your skin test is positive, even if we are going to treat you for TB, you probably don’t have the disease. I hope we aren’t just being vindictive in trying to show other countries that not only do we disagree with BCG vaccination, but we feel strongly enough about it to make BCG vaccinated immigrants undergo a full course of unneeded TB treatment.

Background

To investigate this matter, let’s first look at the big picture. According to the World Health Organization (WHO), tuberculosis:
-- exists as a latent infection in one third of the world’s population (2.23 billion people)
-- causes 14.6 million active infections
-- causes 8.9 million new active cases yearly
-- causes 1.7 million deaths yearly

World TB incidence. Cases per 100,000; Red = >300, orange = 200-300; yellow = 100-200; green 50-100 and grey <50. (Wikipedia)

The vaccine

The vaccine in question is an attenuated live vaccine (Bacillus of Calmette and Guerin) prepared originally from Mycobacterium bovis (a sister bug of Mycobacterium tuberculosis) in 1921 but that now exists as a variety of strains. It is of variable effectiveness, and the particular strain used may be important, but it seems to be about 50% effective in preventing active pulmonary tuberculosis and 85% effective in preventing disseminated or meningeal TB, the worst kind1. This is comparable to the protection given by treating latent TB, which was shown to be between 25 and 93% in studies done in the 1950s and 60s1. The vaccine’s ability to prevent childhood tubercular meningitis, in fact, is one of the primary justifications for its administration.

Over 100 countries currently have universal childhood vaccination policies, including Japan, Finland, Portugal, Ireland, and Poland. In the U.S., we have never had a universal childhood vaccination, mostly because tuberculosis is somewhat rare in the U.S., vaccination is only of limited effectiveness, and because the vaccine interferes with the TST. Current CDC guidelines in fact recommend considering BCG vaccination only in two very rare situations: when children with negative skin tests are living with actively infected adults who are untreated, ineffectively treated, or have multi-drug resistant strains of TB, and when health care workers are working in high incidence settings where TB control precautions have failed and there is ongoing transmission of TB to health care workers.

The problem

The problem with BCG vaccination and the TST is that 90% of people will have a positive skin test within 8 weeks of receiving the vaccine, but only 20% will still have a positive skin test after 10 years1. Therefore, if someone is five years out and has a positive skin test, it’s unclear whether the positive result is because of BCG or because of actual latent disease. In the U.S. we treat these people for latent TB even though there is no evidence that treating in this case is actually beneficial.

The solution

So why don’t we have a better TB test that can tell the difference between latent TB infection and BCG vaccination? Well, now we do. It’s called serum interferon gamma testing, it was approved by the FDA in 2005, and it detects tuberculosis as well as the skin test without being affected by BCG vaccination status. There’s no longer a reason to treat people for TB unless they actually have it.

The UK Experience

The UK was universally vaccinating school children until 2005, but at that time it decided the prevalence of TB was no longer high enough to justify routine vaccination. Instead, it adapted a policy of offering the BCG vaccine to high risk children, which it defined as children who:

–live in areas where the incidence of TB is >40/100,000
–live with parents from a country where the prevalence is >40/100,000
–themselves are new unvaccinated immigrants from countries with a high TB rate

This type of program is typical of European countries. The International Union Against Tuberculosis and Lung Disease actually offers guidelines to nations regarding universal vaccination policies, and when they may safely be discontinued2. Currently, they state that when the TB incidence rate falls below 15/100,000, it is safe for countries to discontinue universal vaccination.

TB in the U.S.

The U.S. currently has a rate well below that threshold; in 2004, U.S. incidence of active TB reached an all-time low of 4.9/100,000, down from 52.6/100,000 in 1952. In DC, however, the rate is much higher, most recently 12-15/100,000 in 1999-2000. (I was unable to find more current data.) If you exclude the Northwest quadrant of the city, that rate would clearly be much higher yet. Considering that we do have pockets of high TB incidence like DC in the U.S., switching to a European-style policy of offering vaccination to high risk children may make good sense.

(Source: CDC)

An Aussie Idea

A recent paper in the Medical Journal of Australia suggested offering BCG vaccination to Australian medical students. They noted that although the Australian incidence of TB is low, Australian medical students like to perform foreign electives in areas of high TB prevalence, where having been vaccinated would benefit them.

A Few Conclusions

BCG isn’t a great vaccine, but it does provide an intermediate level of protection against TB, and it appears to be about equally effective as the treatment of latent disease once somebody has been infected. In this new era of serum interferon gamma, although cost may be an issue, TST interference is no longer a reason to withhold vaccination. BCG vaccination status matters, and we no longer need to treat our BCG vaccinated patients with positive TSTs if their interferon gamma is negative. As for the rest of the U.S. policy, it may be time for some revision.
Adapting a European-style vaccination model of offering vaccination to those children at highest risk for TB could selectively protect the children who need it without compromising our current methods of diagnosis, treatment, control, and prevention.

References (direct links provided to the others):

1Glassroth, Jeffrey and Christopher Crnich. Tuberculosis in Baum’s Textbook of Pulmonary Diseases. 7th ed. Lippincott Williams and Wilkins:2004.

2Criteria for discontinuation of vaccination programmes using Bacille Calmette-Guérin (BCG) in countries with a low prevalence of tuberculosis. A statement of the International Union Against Tuberculosis and Lung Disease. Tuber Lung Dis 1994;75(3):179-80

There's a study for everything

2006-10-22T19:00:00.000Z

Like its religious counterparts the Bible and the Koran, both notorious for providing great interpretive flexibility in their guidance of moral human behavior, the medical literature also, while providing a framework for best medical practice, leaves plenty of space for, well, the art of medicine. The Bible and the Koran are well known for passages that have been used to rationalize slavery, violence, and hatred, even while their over-riding themes teach against these practices. In the medical literature, similarly, if you are willing to dig a little bit (and extrapolate to a reasonable extent), there is in fact a study for everything. If you want to prove that eating red clover slows down aging, there’s a study to back you up. Conversely, if your point is to show that red clover is actually toxic, well, you’ll find that too. What’s important is not the details of the particular study, but your ability to spout it off quickly and confidently. Because evidence (the noblest form of which is the randomized controlled trial) occupies such an exalted place in medicine, beyond the reproach of common practice, logic, physiology, sensibility, or any other possible objections of the mere human mind, one good study in your pocket is all you need to justify pretty much anything you wish to do. In fact, the more obscure your study, the better, as nobody will be able to challenge a study that they haven’t read.

Pharmaceutical companies and representatives are well acquainted with the power and the flexibility of studies. It’s a simple numbers game actually: if aspirin and plavix, for example, work equally well in stroke prevention, and you run the study comparing them twenty times, requiring 95% confidence for a positive conclusion, on average one out of those twenty studies will show that plavix works better. Eureka! You can discard the other nineteen studies, since, as already mentioned, all you really need is one.

Medicine does have a defense against the capriciousness of individual studies, though; it’s called the meta-analysis. In a meta-analysis, you collect all of the studies you can find on a subject, pool them together, and determine the overall result. Unfortunately, even meta-analyses don’t always agree with each other. Case in point, my review of pseudomonas double coverage last month: a meta-analysis of 17 studies by Safdar et al. in 2004 showed that antibiotic double coverage of pseudomonas bacteremias decreases mortality by half, while a meta-analysis of 64 studies by Paul et al. in 2006 showed no benefit to double coverage. What we need is a meta-meta-analysis. A supercalifragilistic-expialidocious-alysis.

Of course, there aren’t any studies when it comes to doing things that actually make sense. The study, for example, to determine if parachutes reduce mortality in sky diving, has never been done. Crazy ideas, like making residents go home after 30-hour shifts instead of finishing out their work days post-call—those are the only ones that need studies. For that reason, the next time that somebody quotes a study to you, be advised that whatever it is they’re proposing, it’s probably nuts. After all, if you need a study to justify something, it means it already failed the test of common sense.

A harp in the hospital

2006-10-16T03:47:00.000Z

As much as I love classical music, I’ve never really appreciated the harp. Give me the violin with its impassioned cry, the piano with its majestic voice, the cello with its silky song, the oboe with its saccharine sweetness, but the harp? I know it’s the instrument of angels, but it reminds me more of the harpsichord, that plucky and clumsy instrument people used to play before they invented the piano.

A harp in the hospital, though, is an entirely different matter. Imagine yourself standing there on rounds, concentrating on the patient presentation but also thinking about getting to morning report on time, about rushing off to clinic, about the dozens of discharge summaries that are building up, and then from out of nowhere you hear these soft, beautiful, arpeggiated chords, each pluck of string producing a perfectly round bead of music that courses through your body and just dissipates any and all stress. A run of six notes, then eight, then twelve, and the tension that you didn’t even realize you were carrying magically resolves; it effortlessly dissolves. You look around for the source of this miracle, and there she is, a pepper-haired, gentle-faced, middle-aged woman, ever so slowly making her way down the corridor, spreading her music by letting it float out in concentric circles from her golden harp. Your heart cries out, “Linger! Stay near us just a minute more! For although we are not patients here, we also need your healing!” And she does, for a second, but then she continues on, as there are more who need the gift of her song. Back to rounds—actually, the patient presentation never stopped, but now it is somehow more bearable, a bit more important even? I wonder, does she think because we are doctors that we don’t believe in the healing power of her music?

The doctor card continued. . .techniques of disclosure

2006-10-07T12:39:00.000Z

Before continuing, please make sure you have read the intro and Part I.

Part II. Techniques of disclosure

These techniques are really only practical in one situation: when you need a little extra help with your dating game and don’t mind humiliating yourself to get it.

1. Direct and shameless:
”Hi, I’m not sure we’ve met. I’m Sara.”
“Hi, I’m Doctor Adam Miller.”

It’s all in the intro. For those a little less brazen, this could be softened by “Whoa, I can’t believe that just slipped out. . . I’ve been spending WAY too much time in the hospital!”

2. That reminds me:
”Oh, so you’ve recently been traveling in Germany? That reminds me of this German patient I have in clinic who has just the largest nose. . .”

Rather flexible and simple—very useful!

3. The concerned patient:
Step 1: Set your cell phone to go off after 3 minutes.
Step 2: Initiate conversation with the person of choice.
Step 3: When the phone rings, excuse yourself but audibly begin the following script:
“Mr. Johnson?. . .No, it’s quite all right for you to call me on my private line. . .your epigastric pain is still bothering you? I want you to go ahead and double the dose of the protonix you are on. . .that’s right, I think you will be feeling better soon. I’ll see you in clinic next week. . .you’re welcome, good-bye. . .[returning your attention to your conversation partner] . . .Sorry about that. So you were telling me about the local beaches?”

Beware, this technique can be associated with feelings of guilt, and if it fails, you may find yourself sunken to a new low.

4. The business card:
Your most beloved and trusted friend.

5. The location slip:
”I was just leaving the hospital where I work today, and I saw the strangest thing. . .there was a rainbow in the sky, but it was in black and white. . .”

Amazing things can happen on one’s way to and from the hospital.

6. DOC or MD plates:
You’ve seen them. Don’t knock it until you’ve tried it.

7. Heimlich this:
Step 1: Pay your buddy five bucks.
Step 2: Enter into conversation with a desired party.
Step 3: Signal your buddy, who then begins to loudly and dramatically choke on an olive.
Step 4: Rush over behind him and quickly deliver three epigastric thrusts, the last of which should dislodge the offending olive.
Step 5: Nonchalantly return to conversation with the desired party.

Don’t inform your buddy, but make sure you choose a bar that’s within five minutes of a hospital, just in case the olive decides to play tough guy.

8. Scrubbing it:
Don’t be afraid to show your working blues. Some tips on how to maximize their impact:
1. For added credibility, the more scrub-clad group members, the better
2. More effective at happy hour than on Saturday night
3. Good hygiene is important, but if you are freshly showered and clean shaven, it does raise the question of why you didn’t get a chance to throw on some real clothes.
4. Try khaki bottoms for a hip and more seasoned look

9. The teetotaler:
“Yeah, I’m sticking to the non-alcoholic stuff tonight—I’m on call for the hospital and could have to go cover at a moment’s notice.”

Mysterious and exciting, yet responsible. . .that’s hot!

Final thought:
Armed with these methods, you should be able to reveal or conceal your M.D. status as you choose. Some of them are rather simple to employ, but others require considerable practice, nuance, and planning. Don’t be afraid to put in the necessary work. Getting into medical school wasn’t easy, and neither is becoming a skilled socialite. Whether the goal is to avoid the curious inquiries of over-eager onlookers or to win the heart of that very special person, the payoff may be greater than you think.

The doctor card

2006-10-02T23:43:00.000Z

My brothers believe it’s the ultimate trump card, that all I have to do in casual conversation with a woman to win her over is to somehow slip in the information that I’m a medical doctor. Every woman, they believe, is yearning, aching even, to be with a doctor, and the moment I reveal my profession, nothing more need be said. I can simply sit back and let the title do its work.

Stated in general terms, medicine is perceived to be a noble, prestigious, and well paying profession, and its practitioners are thought to be intelligent, dedicated, and compassionate. Yeah, as residents we know it, being a doctor is sexy.

Most of the time, though, we’d rather not play the doctor card; we’d prefer to just fit in. Although we’re privately proud of the hard work that turned us into doctors, we don’t want to flaunt it or flash it in anyone’s face. In DC, where one’s profession comes up early and often in polite conversation, being able to handle the topic tastefully is a particularly useful skill. But how do we reveal our profession graciously without attracting unwanted attention? Is there a way to subtly change the topic and avoid revelation at all? Additionally, for those times when we do want to tap into the prestige of being a doctor, how do we so tactfully?

Coming up with a good strategy for when and how to play the doctor card, and when and how to withhold it, is key to resident survival. In the following guide I humbly introduce and comment on the effective use of several conversational techniques that I have found to be especially useful.

Part I. Techniques of obscuration

These techniques are practical in a variety of situations, but are intended for social settings where downplaying your status as medical doctor/resident may be appropriate. This includes, but is not limited to, situations where:

--your conversation partner has just announced that he/she is newly unemployed
--ten minutes ago a bystander collapsed and you innocently looked on, feigning non-interest
--you’re having difficulty getting out more than a few words at a time because of the four cigars you have stuffed in your mouth
--the rest of the group is laughing about the idiot doctor they just nailed in malpractice court
--you just stiffed your waiter to save a buck
--a smallpox outbreak was just discovered at your hospital
--you were unable to come up with the answer when somebody casually asked, “What’s in Nyquil, anyway?”
--for once you are actually feeling confident enough to get the girl/guy on your own merit

1. Perpetual vagueness:
“So what brought you to DC?”
“Work.”
“Where do you work?”
“At Georgetown.”
“Do you teach there?”
“No.”
“So what do you do?”
“I work at the hospital.”
“And what do you do at the hospital?”
“I take care of patients.”
“Ok, so you’re a nurse?”
“Uh, something like that.”

Most people will take the hint after the 2nd or 3rd question, and you’ll rarely be pressed to the bitter end. The danger of this technique is that it is known to cause extreme irritation in the opposing party.

2. The spy con:
“What do you do?”
“I work for the government.”
“What type of work?”
“You know, one of those jobs where it’s best not to get into the specifics.”

Since Medicare pays for us, not technically a lie. This technique works best in Washington; in other locations (particularly Red states) people will just think you’re unemployed.

3. Technical jargon:
“What do you do?”
“I’m a house officer performing an elective rotation in electrophysiology. How about you?”
“Say what?”

The more specific, the better.

4. No English:
“What do you do?”
“No English, no English.”

Harder to pull off if you're white.

5. The intern deception:
“What do you do?”
“I’m an intern.”
“Oh really, where?”
“One of the companies in Foggy Bottom.”
“How’s that going?”
“Not bad, not bad.”
“Oh, that reminds me, I have a problem maybe you could help me with. My wife keeps giving me crap about the coffee I make . . .any suggestions on how to keep it tasting fresh?”
“Good one.”

6. The sleight of ear:
“What do you do?”
“What do I think of the zoo? Oh, aren’t the pandas just wonderful?”

Works well in chain sequence. (i.e. “No, I asked what do you do?”. . .“What? There’s something on my shoe? Good heavens!”. . .)

7. The counter attack:
“What do you do?”
“Nice try, asshole. You’re probably some hotshot doctor or lawyer asking me what I do just so I’ll return the question and you’ll be able to show off your impressive job. When’s the last time a janitor asked ‘what do you do?’”

Not recommended for use against women.

8. The beast within:
“What do you do?”
“Excuse me, nature calls.”

Coming soon:
Part II Techniques of disclosure

HIV and the ostrich

2006-09-27T04:26:00.001Z

In a recent speech I had the opportunity to attend, Dr. Julie Gerberding, director of the CDC, illustrated a point about meeting the challenges of the future by bringing up the ostrich’s supposed behavior of sticking its head in the ground at the first sight of danger. She cited the relevant Wikipedia article, which reads:

. . .there have been no recorded observations of this behavior. A common counter-argument is that a species that displayed this behavior would not likely survive very long. . .burying their heads in sand will in fact suffocate the ostrich. When threatened, ostriches run away, but they can also seriously injure with kicks from their powerful legs.

I like the way that this logic applies to HIV testing and the new U.S. federal policy of recommending annual testing for at-risk teenagers and adults. Living with HIV, but refusing to be let aware of it and thereby foregoing the possibility of life sustaining treatment, like the ostrich burying its head in the sand, is a behavior incompatible with life. It also poses a substantial threat to public health. The current policy climate in most states of validating such behavior by requiring documented consent before testing simply no longer makes sense.

Consenting somebody for HIV testing is more nuanced than it sounds; you don’t just ask the patient whether or not you may test him or her. Obtaining informed consent means explaining the pros and cons of the proposed action, and for HIV, I have tended to say something like the following:

Sir, before testing you for HIV, as we are suggesting, I have to obtain your written permission. The reason for this is to make sure that nobody is tested without their consent or knowledge. The benefit of testing is that then we will actually know whether you have HIV, and if you do, you will be able to receive life saving treatment. The downside of testing is that if you do have HIV, it can be difficult news to take, and in the past there have been certain social stigma associated with the disease. Of course, I strongly recommend testing.

A speech like this immediately raises suspicions--if testing is such a good idea, why does it require documented consent? Clearly, HIV is not an easy diagnosis to receive, but neither are a host of other chronic diseases from herpes to leukemia. Can you imagine your physician asking you for documented informed consent before testing you for say, schizophrenia? I’m not suggesting that HIV testing should be mandatory; within reason physicians should obtain permission before testing for any disease, but let’s stop this charade of pretending that declining or delaying testing is a reasonable choice. In DC, where one out of twenty of our metro riders carry the virus, annual HIV testing for at-risk teenagers and adults makes particular sense.

Genius

2006-09-23T04:27:00.000Z

This word gets thrown around way too much.

Work that you cannot begin to imagine achieving yourself, that displays a ruthless, nearly inhuman element of self-enclosed perfection—this is his idea of genius.

--Ian McEwan, in his novel Saturday,
which chronicles a day in the life of neurosurgeon Henry Perowne.

Two diagnoses is the gracious approach

2006-09-21T05:13:00.000Z

One diagnosis is the ideal of medicine, the most elegant and parsimonious way of explaining patient symptoms and findings. The patient with shortness of breath, pallor, weight loss, and chest pain, for example is not an anorexic asthmatic who snorted cocaine, but a victim of colon cancer, whose disease by chronic occult bleeding caused severe anemia and demand cardiac ischemia. This concept, one of medicine’s most revered principles, is taught to us early in medical education and hounded into our minds thereafter.

Two diagnoses, however, as an attending recently noted on rounds, is the more gracious approach. When a senior team member (i.e. attending) suggests an unusual diagnosis to the team when a more common diagnosis is already known to be active, the tactful resident or fellow will offer that both diagnoses may be contributing. (“Well, we thought the anemia was probably due to her severe iron deficiency, but certainly she could be hemolyzing as well.”)

Put two distinguished attendings on rounds together and you’ll never see so many dual diagnoses, our attending commented.

Of course, if you open your mouth as a medical student, you’ll be shot down before you even know what happened. A favorite teaching tactic of attendings, in fact, is to make you tell them why the diagnosis you just suggested is unlikely (or very unlikely). To prevent such humiliation, most students and residents will preface any proposed diagnosis with one or two reasons why it doesn’t quite fit. Such are the growing pains of medical education, and appropriately so; after all, one diagnosis is the ideal model for medicine. Nonetheless, we can take comfort in the knowledge that some day, when we have reached the necessary level of seniority and respect, we too may be indulged with that second diagnosis.

Top ten most dreaded night float pages

2006-09-18T22:03:00.000Z

Here's a list that I compiled last year while covering intern night float, which at our institution means cross-covering on 100+ patients for all the major and minor problems that occur after hours, or as one of our attendings puts it, the "things that go bump in the night."

Most of these contain inside humor, usually the implication of an especially onerous task. I left out "Doctor, I wanted to let you know that your patient's blood pressure is 135/70. . .oh really? You're not concerned?. . . you just had fallen asleep?. . . sorry, doctor" as it fits more in the annoying category than dreaded one.

10. Doctor, Ms. Adams is crying again, could you please go talk to her?
9. Doctor, the patient was just found down on the floor. . .no, we’re not sure how long he’s been there. . . no, he doesn’t know how he ended up there. . .
8. Doctor, the lab just called about Ms. Baker, you know, the one you were just examining. . .she has scabies. . . you mean you weren’t wearing gloves?
7. Doctor, I just finished vital signs rounds. . . you may want to sit down for this. . .
6. Doctor, the patient is refusing to take her psych medications. . . she says the voices tell her she shouldn’t. . .
5. Doctor, the patient’s iv just infiltrated. . .but doctor, he has no veins!. . .well doctor, his iv antibiotics were supposed to start 4 hours ago and his temperature is 102.4. . .
4. Doctor, the patient still hasn’t had a bowel movement and is complaining of worsened bloating and abdominal pain. . .no, that’s right, neither the fleets, soapsuds nor oxbile enemas had any effect. . .
3. Doctor, the patient’s pain seems to be improved, but she is no longer waking up. .
2. Doctor, the patient just pulled his NG tube out again. . . yes, he’s still wearing the four point hard leather restraints and straitjacket. . .
1. Doctor, the patient’s pulse just shot up to 230, his blood pressure is 240/120, and he’s complaining of chest pain. . . no, only two of the three bags of cocaine that he swallowed have passed so far with the golytely

HIV on the metro

2006-09-16T04:04:00.000Z

A rather chilling poster decorated the insides of our metro trains this spring, carrying the following message:

For every 20 people aboard this train, one is infected with HIV.

That's the language I remember, anyway; I can’t currently seem to find a copy of it. The poster's purpose being to shock and scare, that’s exactly what it did. I remember one evening riding home from work, seeing the poster, and thinking that there must have been several hundred people on the train, perhaps a few dozen of whom carried the virus.

Of course, it obviously wasn’t true. The author would have used DC HIV infection rates, ignoring that most metro riders live outside of the city. But just how close to the truth was it? From the never-ending stream of HIV infected patients at the different hospitals where I work, I knew there must have been some basis for the claim, but do we really have an HIV epidemic in DC of African proportions?

According to the DC Department of Health,

As of December 31, 2004, the reported prevalence of HIV (not AIDS) in the District of Columbia was 17,205 cases. Of that total, 81.7% was African American, 14.6% was White,3.2% was Hispanic, and less than 1% was Asian/Pacific Islander and American Indian, whereas 70.1% was male, and 29.9% was female.

Considering there were 572,059 people living in DC, that makes a prevalence of 3.01%. The Department of Health estimates that up to 25,000 people (4.4%) may actually carry the disease. Round that up to 5% and there’s your poster.

How does DC compare to other states? Not very well. For persons living with AIDS, DC leads all other states with 1.906 per 100 people, over 4 times higher than New York, the next closest state. To be fair though, let's look at how Washington compares to other cities. These are the 5 metropolitan areas with the highest yearly AIDS incidence (newly diagnosed disease) per 100,000 people (2004 numbers):

1. New York 56.7
2. Washington DC 40.3
3. San Francisco 33.5
4. Orlando 31.2
5. Tampa 25.7

DC’s got HIV, and it's got it bad. Even if posters like the one on the metro exaggerate the threat, I’m glad to see someone’s doing something about it.

The lovenox story, part II

2006-09-12T12:32:00.000Z

The lovenox story part I

Removed for the time being because I was unhappy with how the story came out. If you have an interest in this particular story, let me know and I can e-mail you a copy.

The lovenox story, part I

2006-09-11T03:48:00.000Z

Removed for the time being because I was unhappy with how the story came out. If you have an interest in this particular story, let me know and I can e-mail you a copy.

The lovenox story part II

Our patient?

2006-09-07T04:12:00.000Z

For as long as I can remember, I’ve been introducing patients in my presentations on rounds as “our patient.” For example, “Mr. X is our 54 year old male with HIV and pneumonia.” Most of the other residents and students I’ve noticed do the same. Well, earlier this week our attending, who trained in the Age of Giants, suddenly and impulsively asked in the middle of a student presentation, “When did it become ‘our’ patient?”

We had all kinds of answers for him: “it IS our patient”. . .”it’s natural”. . . “it’s taking ownership of the patient”. . .”it’s just nicer.”

He harrumphed and didn’t really reply. During the next presentation, however, when a resident presented “our patient,” he was quickly corrected to “the patient.” After 3-4 more corrections during the rest of rounds, our attending effectively purged the words “our patient” from our vocabularies. I resented this at first; why on earth, I thought, was he doing this? After listening to several presentations with the new phrasing, though, I began to agree with the attending. “Our patient,” although certainly neither incorrect nor inappropriate, did carry a sort of pseudo-intimacy that colored the clinical picture. It just wasn’t really necessary and perhaps sounded a little too cutesy for academic medicine. Unencumbered by this false emotional attachment, “the patient” was just the cleanest and most simple way of presenting a patient.

Amazing, the feeling when you’ve been unwittingly looking through a rose-tinged lens for as long as you can remember and then somebody suddenly removes it.

Dining companions

2006-09-04T20:07:00.000Z

This past weekend I stooped to a new low while on call. It had been a relatively slow Saturday, but I’d had three admissions interspersed over the afternoon and evening, and by the time I finished admitting the last patient, a high school-aged boy named Tim, an empty gnawing sensation had somehow crept its way into my stomach. When I went back into Tim’s room to follow up on a question I had forgotten to ask him earlier, I was surprised and jealous to see and smell that he had ordered Chinese food from a neighborhood restaurant. Now in my defense, the cafeteria was closed by then, and the only food available was the snacks in the vending machines. As I went over the details that I had returned for, I couldn’t help but take a few looks at the impressive amount of food that was sitting around his room, much of what appeared to be leftovers. “How was the food?” I asked him, “That looks really good.” We chatted a bit more, and I snuck a few more looks at the apparently left over chunks of deep-fried sweet and sour chicken. Finally the offer came, “I’m not going to eat all this food, would you like some? I promise I didn’t spit in it or do anything weird.”
“Well, it does look pretty good,” I said, offering no protest. “Sure, I’ll have some!”
I sampled one of the chicken pieces. “Not bad.”
“Take the whole carton,” he said.
“You’re sure you aren’t going to eat any more of it?”
“Yup.”
“Thanks!”

I had just scored a free dinner from my teenage patient. I have to admit, I felt a little dirty about the whole thing, and to boot, I didn’t have a clue what germs might have landed on that chicken. My stomach had no qualms, though; it was feeling a whole lot better already. Somehow, I sensed that Tim felt good about the interaction too. Here was a kid who had been sick all of his life with a devastating congenital disorder predisposing him to all kinds of different infections. He had always been different, and he looked the part; his disease had stunted his growth and badly damaged his hair and skin. Yet, there I was, a young male medical resident, casually accepting his offer of food, demonstrating not only that I didn’t consider him unsanitary or covered in cooties, but that I also trusted him and thought that he was cool enough to eat with. Giving is an obvious way of demonstrating friendship, but sometimes being willing to put yourself into somebody else’s debt says just as much. In admittedly odd fashion, we reached out to each other, and in doing so we set a positive and trusting tone to the rest of our interactions for his hospital stay.

Double coverage and pseudomonas, part II

2006-09-02T20:29:00.000Z

Having spent some time looking into this matter and benefited from some ID tutelage, I can affirm that there are two general justifications for double covering pseudomonas and/or other gram negatives. The first is to ensure appropriate coverage; with the high incidence of multi-drug resistance bacteria in our hospitals currently, we want to make sure that our monotherapy doesn’t consist of a drug to which the bacteria is resistant. The second justification, as the pharmacist suggested, is indeed to prevent the emergence of further antibiotic resistance. Let’s evaluate each of these rationales.

But first, let’s familiarize ourselves with the profile of the enemy. Using pseudomonas as our poster child, antibiotic resistance patterns measured in the DC VA in 2004 were as follows:

Anitbiotic Percent susceptible
Piperacillin 78
Ceftazidime 79
Gentamicin 83
Tobramycin 88
Aztreonam 64
Ciprofloxacin 63
Levofloxacin 68
Meropenem 89

Improving outcomes
So, does double covering severe gram negative infections reduce mortality or lead to better patient outcomes? You would think so, considering that for the single antibiotics we would use there’s a 10-20 percent chance that the bug is going to be resistant. The evidence, though, is less than impressive.

The main support for double covering pseudomonas seems to come from a meta-analysis by Safdar et al. published in the Lancet in 2004. Their meta-analysis included 17 studies looking at monotherapy versus combination therapy for patients with gram negative bacteremia. Most of the studies used beta-lactams and aminoglycosides in single and combination therapy. While overall there were no differences in mortality, analysis of the Pseudomonas bacteremias showed a quite substantial mortality benefit (OR 0.50, 95% CI 0.30-0.79) with combination therapy. The authors concluded that combination antimicrobial therapy was indicated when there was a strong suspicion for Pseudomonas, but not otherwise.

Contradicting Safdar’s findings, Paul et al. conducted a large meta-analysis of 64 trials including 7586 patients comparing beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for sepsis. They found that double coverage conferred no advantage over single coverage in sepsis, even when gram negative and Pseudomonas infections were analyzed separately. They did find more nephrotoxicity in the double coverage group, and they concluded that aminoglycosides should not be added to beta-lactam therapy in sepsis.

They also did not find that double coverage affected the development of resistance.

Other studies:
De Pauw et al.: Ceftazidine was safer and as effective as the combination of piperacillin and tobramycin for empirically treating febrile neutropenic patients.

Eggimann and Revelly: ventilator associated pneumonia should not be treated with antibiotic combination therapy, which may promote the emergence of drug resistant bacteria. Cunha and Damas et al. draw similar conclusions.

From this, I would say that double covering for pseudomonas makes sense for patients with unspeciated bacteremia where pseudomonas is thought likely, but not in other circumstances.

Preventing Resistance
As far as preventing antibiotic resistance, there seems to be little evidence. The Infectious Diseases Society of America guidelines lists the following factors that can contribute to antibiotic resistance:

Greater severity of illness of hospitalized patients
More severely immunocompromised patients
Newer devices and procedures in use
Increased introduction of resistant organisms from the community
Ineffective infection control and isolation practices and compliance
Increased use of antimicrobial prophylaxis
Increased empiric polymicrobial antimicrobial therapyHigh antimicrobial usage per geographic area per unit time

They make the following comment:

The last strategy suggested in table 6, use of combination antimicrobial therapy to reduce emergence of resistance, is theoretically attractive and is the basis for current treatment of tuberculosis with multiple antimicrobials. It has not been adequately tested clinically to determine if overall institutional resistance can be reduced by the use of combination therapy for individual patients [47]. In one study of Enterobacter, no benefit in reducing emerging resistance was observed when combined third-generation cephalosporin and aminoglycoside therapy was used [48]. The risks include increased antimicrobial costs and the potential for increasing resistance by raising the number of antimicrobials and antimicrobial courses administered. The use of combination therapy is, however, already widespread for the treatment of seriously ill patients, so controlled trials to determine the effect on resistance prevention are reasonable.

It seems to me that the additional risk of toxicity from these powerful antibiotics probably outweighs the potential benefit of delaying the development of drug resistance, when there’s also a chance that the additional antibiotic exposure could actually speed up the development of drug resistance. I have a hard time justifying this one. Anybody with a different take?

Double coverage and pseudomonas, part I

2006-09-01T23:21:00.000Z

Enough of this fluff, it’s time for a little meat. Here’s a clinical problem I experienced as an intern last year: the pharmacist called because my patient with a leg ulcer was growing out pseudomonas, and she was concerned that the patient was only on single coverage with zosyn.
“The pseudomonas is sensitive to zosyn, though, right?” I asked.
“Yes,” she confirmed.
“So why would we want to double cover?”
“Well, usually it’s recommended to double cover against pseudomonas so it won’t develop resistance.”
“Hmm, I’m not sure that makes sense to me – I thought we only double covered empirically until we found out the sensitivities – let me talk with my team and get back to you.”

So who was right? Discussion to follow. . .

The tin psychiatrist

2006-08-31T21:04:00.000Z

He was a charming man, but an operator too smooth, greased from head to toe in the lubricant that runs the machine. On Tuesdays he played golf with local top executives at the most exclusive country clubs. Two other days a week, he dined with pharmaceutical representatives (only the most attractive female ones) at fancy restaurants. Psychiatrist by training and practice, he was also my mentor for some extra-curricular shadowing that I had arranged during my second year of medical school. Strictly speaking, he was more of a pharmacotherapist – he avoided psychotherapy as much as possible – his clinic patients had five minute appointments and he would squeeze in thirty patients per morning as this maximized efficiency and profits. He had the business of medicine all figured out.

Besides his clinic duties, our psychiatrist spent a fair amount of time in a downtown rehab center, and it was when I followed him there one afternoon that his behavior made a lasting impression upon me. He took me into his musty, oak furniture office, sat me down, and began to tell me briefly about two patients we were to interview that afternoon. He pulled out their files, shuffled some papers around, and then to my surprise picked up the tape recorder on his desk, flipped it on, and began dictating the first patient encounter. He sped through it, in sixty seconds documenting the patient’s appearance, mood, concerns, his assessment and plan, and everything else that belongs in a note for a thirty minute psychiatric patient visit.

This confused me--I was pretty sure we hadn’t seen the patients yet, unless he had already seen them during lunch before I arrived, yet he had talked to me about the patients as if we were going to see them together. Before I had a chance to ask, however, he was off dictating the second patient encounter. This one took all of seventy seconds, and by the end of it I had mustered up about all the courage that I could find.
“You dictate your notes before you see your patients?” I intoned as innocently as possible.
Looking at me for a brief second, he shrugged, “Yeah, I already know what they are going to tell me, it’s the same every time, and doing it this way helps me stay more organized.”
In afterthought, he added, “If anything turns out differently, I go back and change it.”
We proceeded to see the two patients, and as he had predicted, there were no major surprises.

Fast forward four years, and the other day I found myself writing a progress note for a patient using a computer template. She was a patient that I had taken care of all month who was no longer acutely ill and whom I knew very well, and I printed off the progress note in advance of seeing her, leaving blanks for the subjective findings. After seeing her, as I filled in my note, my eyes settled upon the physical exam section, which I had typed in earlier that morning, but which I could only now verify as being accurate. Remembering our dear psychiatrist, I shuddered and hastily scribbled in some additional physical findings.

Thank you, sir, for you were my teacher too.

Medicine for our mothers

2006-08-30T17:57:00.000Z

We hear it about once a week on wards, at times when particularly troubling or trying decisions arise regarding patient care. Usually, it’s the attending who poses the question, but it’s always spoken from a more senior to less senior team member, as it carries a subtle implication that the currently proposed plan may not be quite good enough: “If it were your mother, what would you do?” The effect that this question has upon the team is both striking and predictable. (It does rely on the assumption that the team members love their mothers, but would they really have become doctors if they didn’t?) Several moments of chin rubbing, head scratching and soul searching ensue, after which it is generally agreed to raise the level of care or renew efforts with yet another attempt at diagnosis or therapy. Occasionally the question instead spurs a move towards patient comfort or palliation. All involved are reassured that the patient is getting the best possible care because it is what they would have done for their own mothers.

The mother hypothetical is a ritual of medicine that I have participated in countless times, although I’ve never raised the question myself. Somewhere between my 4th year of medical school and internship its great irony struck me. As physicians we are forbidden from practicing medicine on our mothers for the very reason that when it comes to them, we are completely incapable of reason, rationality, or measured decision making. Yet with our most difficult decisions, at the times when we most should be relying upon reason to guide us, we instead emotively plea for guidance to the specters of our beloved mothers. Oddly enough, it usually helps. Still, I have to wonder, are we asking the right question? Does mother know best? Perhaps our decision making would be better if we instead pondered about Uncle Albert. Or, an even more novel concept, what if we just asked what was best for that patient?

Lighting the lantern

2006-08-29T21:00:00.000Z

A lack of conversation, that’s the problem I’m trying to address with this blog. As medical residents, our lives are filled with incredibly rich daily experiences—we witness miracles and tragedies, encounter the extremes of human behavior, face and sometimes overcome daunting challenges. Yet, we don’t talk about it. We don’t talk about our experiences and we don’t talk about how those experiences affect our lives and shape us as ordinary people. You’d think we would, but we don’t. In house, well, we’re too busy—there are patients waiting to be seen and duty hour rules to follow. Socially, well, nobody wants to be the party spoiler bringing up medical shoptalk. At home, well, I think for various reasons we’re just reluctant to bring that conversation into our homes.

Having now finished intern year and moved on to the distinguished rank of PGY2, I’ve consumed so much residency experience that it’s backed up my throat and flowing out my ears. Indigestion is my ailment; Foggy Bottom Lantern my proposed therapy. The conversation I want to hold here is one about the experiences of residency – the trivial, the substantive, and the profound. Gather ‘round the lantern, friends, lets trade stories and help our alimentary tracts digest what we’ve seen and discovered.