PreMDpilot

Neglect

2009-11-19T15:33:00.001-08:00

Diabetes is an interesting disease. There are two types of diabetes. Type I occurs in early childhood, is unpreventable, is very severe and requires lifelong therapy in order to not develop the severe complications associated with diabetes. Type II is more prevalent, is potentially preventable, and requires escalating treatment as the disease gets worse.

In the category of Type II diabetics, there are really two styles of patient responses to the diagnosis of diabetes. The first type will almost immediately change their habits. They will lose weight, check their blood sugar religiously, modify their diet and eating habits to control their blood sugar and get regular check-ups to make sure they don't have the long-term problems. Not surprisingly, these patients invariably do well. We never see them in the hospital because they have decided to control their disease.

The second type is more common in my experience. These are the people who don't feel any different and therefore don't believe or don't understand that they have a disease, don't trust the doctor, don't have the requisite willpower to change their habits, or just don't really care as it doesn't affect their lives immediately. These people come to the hospital commonly and have limbs amputated, are put on dialysis, have heart attacks, and are going blind. It's sad to walk into a room and know that a person will be dead within a year or two from a disease that is very preventable and controllable.

This is a strange parallel, but I worry that our society is heading down the second track in regards to climate change. It doesn't bother us currently, therefore we don't believe we have a problem, don't technically understand that we have a problem, don't have the requisite willpower to change, or just don't really care as it doesn't immediately impact our lives.

Climate change is different in that it is well established what is going to happen to a diabetic if they don't control their blood sugar. We have no idea what is going to happen to our planet as it warms. It could just be mild warming and secondary homeostatic mechanisms kick in to compensate, or it could generate a positive feedback loop that turns our planet into Venus within a century. We really just have no idea. The similarity is that there is something we can do right now to help prevent this problem, but we aren't doing it because we don't really believe that we have a problem. Sure hope we don't end up on that hospital bed in couple decades.

Just Say No to Drug....reps

2009-08-27T15:26:00.000-07:00

Third year of medical school is a glorious time. You have absolutely no responsiblity because you have hardly any competence. Therefore, you can sit and talk with patients for hours and get to know them. Third year is this idealistic time where you have all the time in the world with patients and their families. This is how medicine is supposed to be. In holding with that idealistic tenor, I am endevouring to avoid all gifts and influence by drug reps this year.

This is really hard. These little vermin are everywhere. They permeate our medical system with their free lunches, pens, clipboards, mousepads, notepads, and other assorted Chinese junk. They come in the middle of lecture with their steaming hot bags full of Panera Bread, or Chipotle or some other chain restaurant and slowly lay it out on the table in the back. The smell drives you partially mad with hunger and you can't listen to anything the presenter is saying. Then they stand there in their perfumed business-skirts and 5 inch heels and greet you with sparkling teeth as you pass by and grab the food before you have too much time to contemplate just how much of your medical integrity you sold.

I do get some enjoyment out of though. Their large, thickly makeuped eyes rise a little in shock when I sit down and pull out my peanut butter and jelly sandwich and carrots. They look at me with a mixture of confusion and fear like I am some rabid, anti-social lunatic for refusing their generous hospitality. I just sit there placidly listening to the doctor on the speakerphone, secretely seething inside that a fellow medical professional could stoop so low as to become a peddler of drugs. Albeit a sophisticated peddler, but a drug peddler nonetheless.

I know, I know...it's more complicated than that. The researcher has to get his funds from somewhere. If the drug companies didn't do these studies no one would...blah blah blah. It still doesn't change the ethical implications of a medical practictioner selling a drug and funding his research into that drug.

It sucks to have so much anger and loathing built up inside you for someone. Since I don't enjoy those feelings, this discipline is slowly teaching me to stay away from these drug lunches altogether. I think if I can keep it up for the rest of the year, then I will easily be able to avoid future lunches as I will find them a waste of my valuable time.

Controlling Health Costs

2009-08-01T18:05:00.000-07:00

A fellow medical professional stops by this blog every once and a while and leaves his thoughts. He's a smart fella and it's fun to read his stories, but we are on opposite sides of the political spectrum and have a rather abusive relationship if you really get right down to it. Maybe that's par for the course with bloggers :)

Anyway, he peaked my interest when he left a comment on my last post about controlling medical costs. The ironic thing was the example that he used was about medical helicopters. Medical helicopters are probably one of the most visible examples of medical waste and why our system costs so much. Do they save lives? Yes. But they also transport many people who don't need to be transported by a helicopter. My father was an ER physician for 23 years in one of the busiest ERs in the country and in that entire time he only transported 1 patient to a tertiary center by helicopter. It was a young man with a subarrachnoid hemorrhage and my father, the helicopter (and the brain surgeons on the other end) surely saved his life. It worked out well for that patient and it makes a great story, but the vast majority of patients transported by medical helicopter don't really need it

I went on a helicopter ride once because I thought it was cool. We transported a patient with preterm ruptured membranes 60 miles to our hospital. I'm not saying ruptured membranes isn't bad, just saying she more than likely would've survived the hour ambulance ride and didn't need the 20 minute helicopter ride at almost twice the cost. These kinds of stories are shockingly common. I'm sure if you did a cost/benefit analysis of helicopter transports in the US, it would be a high number. This also doesn't even factor in the stupidly high risk of crashing the helicopter before it ever reaches the hospital.

Back when my father first started practicing medicine, there weren't any air ambulances. These evolved after the Vietnam era and were popularized and glamorized by shows like MASH. Our state had one of the first air ambulances. It barely got off the ground (pun intended). There just wasn't much use for it. Now there are three air ambulance services in my state, all competing with each other to carry critically ill patients from hospital or roadside accidents. They are literally competing with each other. They have turf battles and run sophisiticated marketing campaigns, and this situation exemplifies what is wrong with our medical system.

These kinds of services are reimbursed because they are big, visible, sexy and look like they take a lot of work. They are all those things, but they really don't add value to the overall health system. In other words, it may look like it, but you don't get a lot of bang for your buck. For the $20,000 it took to take that lady with ruptured membranes to the hopsital, we could've provided vaccines to 70 kids. For the $120,000 it takes to give an 87 y/o man a new heart and two more years of life, you could get a primary care doc to work in a underserved area for a year and take care of hundreds of kids and their parents.

Sanitation, vaccines, preventative care, and good primary care are the key to an effective health system at the population level. Unfortunately, we are not reimbursing any of these things. I think we believe that we have these things already pretty well figured out and we're more focused on the next big thing. The helicopters, brand-name pharmaceuticals, medical robots, specialist consults, amazing imaging, and surgeries have all replaced primary care as the backbone of our medical system, and that's why it's so expensive. Do we need all these things? Yes. Do we need as much of them as we are using right now? No, and it's not where the money should be focused.

I finally have stories again

2009-07-21T18:14:00.000-07:00

The first 2 years of medical school make you an utterly boring person:
"What did you do today?"
"I studied."
"What did you study?"
"I don't really remember, something about the kidney"
"Anything else?"
"Nope"

Nothing interesting happens to you. You sleep, eat, study, go to class, and work out. You hang out with your friends some weekends, but only if there isn't a test coming up. You learn a hell of lot of information, but it is all cerebral and none of it is practical yet.

Now I finally have stories again. Getting the crazy patient who hears voices and asks if you do too, having my cell phone go off in the middle of my first pap smear, seeing interesting patients with benign diseases that you can help and horrible diseases that you can't do anything for. It's a breath of literary air after 2 years drowning under textbooks.

I saw something today that really struck me. I spent the day with the social worker, and we saw several sad cases of people who were not naturalized citizens, but really needed the healthcare benefits that naturilized citizens are entitled to. A wheelchair bound man of 34 and a man going blind were scrambling to find any medical resource they could that would help them. That wasn't the part that struck me though. A woman with four children in tow came to the clinic to have her diabetes checked. While she was in the lab, she left her stroller outside in the waiting room and when she came back, the stroller was gone along with her cell phone which was in a pocket in the stroller. She eventually arrived at the social worker's office and he immediately set out on a mission to find money to help this poor woman buy a stroller.

He wandered from room to room, looking in drawers and cabinets until he found an envelope in the drawer labeled "jean money." He explained to me that this was money that the clinic workers donated in order to wear jeans on Fridays. That made me smile, but the smile quickly evaporated when he opened the envelope and only $35 fell out. He counted it meticulously and then quickly pulled out his own wallet and added another $5 to the stack to make it $40. It was a touching gesture seeing a man who dedicates his life to helping people donate some of his own money.

Think about $40 for a second. Most of us stop by the ATM and pull out at least that much every other week or so to buy small things like food or gas. But, this little clinic with one social worker had struggle and scrape to come up with $40. These are the places we should be trusting our money to. This is why it makes me angry when we talk about million dollar bonuses to executives and then they complain that their taxes are too high. Real people are struggling to find $40 to give to a poor mom with four children who just had her stroller stolen. Where is the justice in that?

The Definition of Irony

2009-02-05T12:32:00.000-08:00

While studying about different viruses that can infect humans, said medical student contracts said virus and is now at home typing up some blog entries and posting pictures to facebook.

Trickling down- you gettin' kinda thirsty?

2008-08-23T17:01:00.001-07:00

Why Trickle-Down Economics Doesn't Work.

I'm no economist, but I've been getting in a lot of conversations lately about the state of the economy and basic economic theories. I am of the opinion that trickle down economics doesn't work. I think it's a construct made up by the rich to help them hold onto their power and influence and I give them credit that they've managed to convince so many people so that it works. If enough Donald Trumps say that the only way to economic growth is relentless (and reckless) tax cutting, then eventually people are going to start to believe it.

The theory (as I understand it) is that if we cut taxes for the richest members of society, then they are going to have more money, and they are going to spend that money and that spending is going to "trickle down" to us as sales, jobs, and giant bonuses. Unfortunately, it doesn't really work like that. Rich people don't get rich by spending money. They get rich by investing it and saving it. Maybe the theory would hold up if rich people were really investing a much greater percentage of their money, but mostly they are just accumulating it and holding on to it.

This is shown by the huge gap that we have right now between the have's and the have-not's. Rich people just keep on getting richer and resting on their laurels of the past few years, while middle class people keep getting poorer as their wages remain the same and food and gas inflation eat into their paychecks.

I have nothing against rich people. I admire them for taking enormous risks and having them pay off. Who knows, I might be an entrepreneur someday. They are the people who really drive progress and economies forward. But the theory I don't subscribe to is the one where people who earn more don't have more of an obligation to pay for services in our government (i.e. taxes). If you earn more than $100,000, you are in a much better position to help pay than someone who makes 20,000 a year. Trust me, you're not really going to miss that $30,000 as much as the low-income earner is going to miss $5,000. One is whether you can take that trip to the Florida this year, the other is whether he can put enough food on his table to feed his three kids.

Another consequence of this relentless tax cutting is how short-sighted it is. We are accumulating trillions of dollars in debt...for what? So we can have cheap plastic toys from China. So we can wage war in a country that doesn't want us there? Where is the long-term investment in the money we are spending right now. I am spending a lot of money right now, but it's with the idea that it will pay off in a couple years with a good job and income. I don't see that strategy being employed by our government or our society in general. People around the world are starting to see this and it has lead to the decline in the dollar. The rest of the world is losing confidence that we are a good long-term investment. We are just spending right now and not investing. This is bad for our long-term prospects and for our children's.

The element that makes a really strong economy is a strong middle class that has a good income and upward mobility. Why do you think China's economy is growing so fast? Their middle class is surging upward as all the factory workers bring home a good income and want to spend it. There are rich people in China and there will be a lot more, but their middle class will be the biggest factor in the coming decade. Meanwhile, our middle class is declining. People are falling into the have or have-not category and that is eventually going to be bad for everyone.

There is one candidate that is talking about helping the middle class and the other is talking about continuing the current economic policies. I think we all know the current policies aren't working very well.

6310

2008-07-22T10:53:00.001-07:00

There are many people who see God everywhere. They see God's action in all things, and in all of creation. But, I have trouble seeing God in all these things. When I look at life I zoom down to the smallest cell and wonder at it's intricacy, but never really believe that it was created. When I look at the stars I wonder at how far they are, but don't really see the need for a creator. When I go to church, I see people getting in touch with a spiritual need that we all feel, but I don't really see God.

The place I really see God is in the hospital. That nexus of humanity that swirls with grief, joy, rage, pity, and all other shades of human emotion. Weird things happen that don't seem to make any sense at first, but then a pattern emerges that just screams out for an explanation beyond coincidence. I'll give you an example.

I was getting off my shift in the ER and strolling lazily behind a bed being taken into the hospital. I don't know if it was idle curiosity or just boredom that made me ask where they were headed.

"6310," replied the tech who was pushing the bed. I turned down another corridor and started to walk away without saying anything else when the patient in the bed called out,

"Why, you gonna come and visit me?"

I turned around and smiled at the lean, black girl in the bed. Her hair was disheveled her teeth were a little crooked. Like most hospitalized patients she looked like she was having a rough day. But, she had an infectious smile and I couldn't help but grin too.

"No, I just had to find out," I said. I turned around and continued to walk away wondering why I had said that. Technically, it wasn't a lie, but I felt kind of awkward saying it because I really had no reason to find out what room she was going to. I kept walking and my mind shifted gears to something else.

I was just about to unlock my car in the student lot when another car pulled up and huge lady leaned out the window.

"Excuse me, do you know where we can find visitor parking around here?"

I had never had that question before but I felt like I should know where it is. I stood there in a mental fluster trying to think of where they could go for parking.

"My daughter was just admitted from the ER for a sickle cell attack and we can't seem to find parking anywhere," said the lady. The image of the grinning girl flashed into my head and before I even thought about it I blurted out,

"6310!!"

"Huh?" Said the huge lady in the car.

"6310, that's where they are taking your daughter. I just saw her. Pull right around here and check that big parking garage there and then go to room 6310 and you'll find her. She looked pretty good."

"Thanks," said the lady as she pulled away with a puzzled look on her face.

I don't know if they ever found visitor parking, but 6310 is now firmly engraved in my memory as my prescient number. Experience cries out for explanation.

Civics 101

2008-07-18T13:27:00.000-07:00

This makes me mad.

Why Karl Rove should go to Jail

It should make you mad as well. I don't care if it is political posturing by the Democrats, under article 1, section 8, clause 18 of the Constitution of the United States of America:

"The Congress shall have Power - To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof."

Sounds like a bunch of legal mumbo-jumbo, but it basically grants congress the power to issue subpoenas and investigate anything it chooses. This has been established by legal precedent over and over again and the law is quite clear that if a person is issued a subpoena from the Congress of the United States then they are COMPELLED to show up....period, end of story, no excuses, no choice. Karl Rove is very clearly breaking well-established law.

What's the Bush response when they break a law? Let's change the law. Let's try to rewrite the Constitution so it says that Congress can't compell ANY member of the Executive Branch to appear before it because that would violate the separation of powers. Any honest reading of the Constitution leaves the reader with the knowledge that, yes, there is separation of powers, but the executive branch and the judicial branch are designed to be checks on Congress. Congress is the big kid on the block and gets to make all the decisions. They design the law and the president's job is to either veto it or carry it out faithfully. The court's job is to decide whether that law is constitutional. Notice there's nothing in the Constitution about the Supreme Court checking the president. The branches aren't designed to be entirely equal. They are designed so that Congress is the ultimate authority with the president and the courts checking that authority.

Bush doesn't see it this way. He sees himself fully as powerful as Congress. He thinks that when congress passes a law, he can use a signing statement to disregard whatever part of that law that he dislikes. He thinks he can declare war. He thinks he can violate the law (torture, habeas corpus, and subpoenas are just a few examples). He thinks he has the power to override a congressional subpoena.

Bush is way overreaching his authority here and I think (I hope) the average American is starting to notice and get angry.

Snowed In

2008-04-30T20:00:00.000-07:00

I had one of the most painful experiences of my life today. I thought I was interested in psychiatry before I went and followed an older medical student around today. The first patient we went to was ok. He was a little "snowed" but could answer questions and generally seemed optomistic about the prospects for his future and that he would get out. He had some moderate dementia but was still pleasant to work with. The second patient was half awake and answering our questions with single word answers like "yes, no and mmmm" The last guy was really the icing on the cake. He had all kinds of medical problems and it was clear that he didn't know what was going on with him, but the main thing was just how freakishly slow he was. He was eating lunch when we walked in and my med student asked him a preliminary question. It literally took him 15 seconds to respond to the question. And when he did, it was with some kind of non-sensical, mono-syllabic whisper. Now, you may be thinking "15 seconds, that's not bad." So the next time you have a conversation with your significant other, I want you to count to 15 before you answer any question that they put to you. I guarantee they'll dump your ass or file divorce the next day. It took us 20 minutes just to get out of him that he didn't feel like killing himself. Add to that fact that it was sweltering inside the room and I was sweating through my white coat and it pretty much made for the worst experience ever.

I understand he's depressed and that it's a very sad case and I wish we could help him, but he was like a black hole sucking my energy, patience, and empathy. I think I empathized too well. I was genuinely depressed after the encounter. I couldn't interact with my friends normally. I had to eat a relatively large meal and then go take a two hour nap before I even felt a semblance of normal. It was actually kind of scary that my emotions could be affected so easily. I can see why doctors now say you need to be able to distance yourself from experiences like that. We want to pull them out of the black hole, but have to be careful that we don't get sucked in ourselves.

My Walk to School

2008-03-26T17:53:00.000-07:00

There is a graveyard on the way to school. I've driven past it every day for the last 7 months. I glance over every now and then as a name and a cross flashes by, but it never really registers. Since the weather has warmed up, I've begun walking to school. Now I pass the graves much more slowly.

In fact, I've even started to walk through the cemetary. It's much more peaceful and I can be alone with my thoughts. I pass the graves and read the names and wonder who the people were. I think about what death will be like and I think that if it's as peaceful as that cemetary then it won't be bad at all.

There is a certain irony in the passage of a student physician through a place of death every morning and afternoon. Death no longer holds the fear and revulsion that was there before. I've been up close and personal with death in order to learn how to heal the living and the passage through the graveyard is more peaceful than unnerving.

The saddest part of the journey is right before I leave the graveyard. I pass small graves with teddy bears and flowers. The peace is broken and I have to avert my eyes. The death of children is still reserves that fear. It drains my spirit but it reminds me why I am doing what I am doing. Why death is a worthy adversary and why the fight against it is such a noble pursuit.

Bush is a War Criminal

2007-12-25T09:24:00.000-08:00

I don't know why it took this article for me to see the truth. I have been hearing the news for the last several weeks and I don't know why I couldn't connect the dots.

Facts:
1). Torture is a war crime under both US law and the Geneva Convention.
2). Waterboarding is torture.
3). The Bush Administration has been purported to use waterboarding in several instances.

Ergo, the Bush administration has committed a war crime. I think that qualifies as "high crimes and misdemeanors" that is the requirement for impeachment.

Now, all the evidence of a particular war crime has been destroyed. Hmmm.....

On this most special day in our culture, one has to wonder what Jesus would think of waterboarding. Would he call it torture?

Merry Christmas.

It's time

2007-12-07T13:34:00.000-08:00

Senate Rejects Energy Bill

I think the vast majority of the American people can think enough in geopolical terms to realize that it is time to wean ourselves off this addiction to oil. Hell, the President said it himself in his State of Union address last year. Everyone now realizes that the safe money is not on oil. There are a number of imminently logical reasons for this:

1). Oil will become perpetually more expensive.
Since we are effectively burning the last billion or so years of organic carbon that has existed on this planet, we are eventually going to run out of oil. This fact is indisputable as the fact that the sun is going to explode in 9 billion years or so. We have absolutely no idea when we are going to run out of oil, but I'm guessing that it will be sometime in the next hundred years. And, as the resource gets more and more rare, it will get more expensive. Supply and demand. Wouldn't it be nice to run our economy on a resource that is only gets cheaper as we figure out newer, cleverer ways to produce it. Imagine America as an energy exporter!

2). We hate the people who have the vast majority of the oil.
Don't deny it....Saudi Arabia, Iran, Iraq, Sudan, Venezuela, Russia. These countries just suck and their shitty govenments are only in our sphere of thought because they receive copious amounts of money from the US, Europe, and China. Let's invent something else and send them all back to the stone age where they should be. Unless you think that women being sentenced to death by stoning for admitting to being raped is an example of an "enlightened country." You want a war on terrorism. Let's make them so poor they won't be able to afford to buy a can of beans let alone a bomb.

3). Global Warming
Even if you don't buy the science, you have to admit to yourself that we can't keep dumping carbon into the atmosphere forever. Eventually we are going to have some kind of global impact. Might be ten years or a thousand but we'll eventually have an impact.

I actually can't think of any good arguments to use oil other than the fact that it is the cheapest thing going right now. Chemically, it's a very good carrier of energy. It is very stable and can form all kinds of cool polymers that we use a lot, but there are other ways to form those compounds and there are better carriers of energy than oil. It's the cheapest and easiest thing right now, but we all know that is going to change someday. We're being penny wise and pound foolish and that's not good business. It's time to change and the only way to do that is with government policies that promote the technologies and encourage economic development of the technology. It's time to change our priorities.

Bush's Boastful Bluster

2007-12-03T18:52:00.001-08:00

Bush Scolds Congress

Doesn't this sound an awful lot like a little kid on a playground. "You better give me my candy or my daddy is going to come and beat you up." It's a shame and an embarrassment that this little brat is the leader of our country.

Hospital Image

2007-12-03T16:42:00.000-08:00

Words (at the risk of sounding like a portentous English professor) are the most powerful tools in a doctor’s considerable arsenal. Wielded like a surgeon’s precisely held scalpel, a single word can peel back the layers of a person’s life. A deft question can open the floodgates of an amazing torrent of emotion, truth, and pain. An awkward insult can cleave a gaping canyon between two people while a comforting word can bridge any gulf. There are no descriptions of these events. There are only words that bring images, colors, and a small amount of the actual experience to this page. These are one student's words of one day in the hospital following a chaplain.

Let the mind stream
Let the truth flow
Let your soul slow
Let your light gleam

Computer Terminal
Colorful Images flash on the screen
Depicting the lives of people who suffer
People who don’t fit into small, white, blinking boxes
But who are put there because of expediency

Lives laid out under a rainbow.
One man far from home
Described with cold words and abbreviations
Knowledge and facts with little information

2nd floor
Hunting amid a frenzy of colors
Cubicle to windowless cubicle
Brightly colored nurses flash past
Help!
A man is reaching from the hallway as we walk past
He is crying for explanation behind smiling eyes
Alone with listening ears he asks for retreat
But the family arrives and the mask resumes
No explanation suffices as the conversation slides to normal.

Follow a proud, pole-toting lion into his den
Slow and deliberate with his words
The probing questions just brushing the surface
But with a superficial question
A blinding pain explodes and silences
A lion cub was lost
We leave a torn heart
That no amount of surgery can fix

6th floor
Noise and activity surround a small woman
She is sleeping entombed in her bandage
The family is there and awkward platitudes are exchanged
There is coughing she peers out through long suffering eyes
A stumbling prayer is better than no prayer at all

The contrasts strike with visceral force
The entrance in a light room
Filled with smiling, healthy people
Around a patriarch cheering for football

Our destination is not this light, but the dark
Across the curtain is a dark space with a darker individual
He is totally alone in the darkness
But he is happy to see us.

His stories are of very long suffering
Loss, pain, unbearable pain
His dark eyes appear dead as the sun sinks
But there is life in him and the pain confirms it
He talks of life, friends, love
The things we all want

The listeners treat
The lonely man tells his stories
His eyes become more animated with each passing minute.
We leave only slightly drained with the darkness complete
But a happier man for all that.

From this...you exist

2007-11-22T12:25:00.000-08:00

Click To Play

More Biology love from my homies over at MIT. This is a picture of new research on the chemotactic factors that allow axons (those lovely little things that are growing) to follow certain paths, or to even grow at all. The cell on the right is a mutated cell that doesn't express the Ena/VASP proteinsthat appears to be necessary for the growth of the axons. Cool stuff.

My 20 Favorite People

2007-11-20T18:26:00.000-08:00

Prompted by yet another story on NPR about Oprah's 20 Favorite Things Show and how well it promotes certain products, I've decided to make a list of the 20 things that are the most important to me this holiday season.

20. Greybeard (even though he pisses me off sometimes....ok most of the time)
19. My Little Special Friend
18. My First Love
17. My Med School Mentor
16. My Awesome Little Sister in Small Group
15. The Ritmos and Med School Salsa Crew
14. The God Squad and Potluck Crew
13. Hispanics - thanks for all the culture and food
12. My childhood friend out on the East Coast
11. My old roomate and constant source of comedy
10. My Free Spirit Mountain Town Roomate
9. My Awesome Little Sist"a" in Small Group :)
8. Chuck Norris (had to throw it in there)
7. The sweetest little Inuit you'll ever meet
6. My Med School Roomate
5. My adopted Ma and Pa
4. My High School Best Friend and Mentor
3. My Wonderful Family
2. Mom and Dad
1. She Knows Who She Is

You are all precious to me (including you Chuck). Have a happy holidays

Physicians at Gitmo

2007-11-18T10:19:00.000-08:00

I was listening to a story on NPR the other day about conditions down in Guantanamo Bay. They were doing a report on the medical facilities down there which naturally peaked my interest. It started off fairly tame with Dr. GMO (general medical officer) talking about the new cardiac catheterization unit that they had flown down to take care of a patient. The doctor was complaining that it cost a lot of money to fly the unit down here and now the patient was refusing to allow the procedure to be done on him.

Then the reporter asked about the hunger strikes that were occuring. Apparently there have been as many as 50 prisoners on a hunger strike at any one time. With a tired tone in his voice, the doctor described the procedure. After 8 days without food, the prisoners were put on a "medical watch" and if they still refused to eat, then they were brought into the clinic, strapped to backboard, drugged, and a tube was threaded through their nose, esophagus, and into their stomach to start enteric feeding.

I listened with horror and revulsion as this doctor described the procedure being done on someone who was perfectly competent to make their own decisions and would obviously resist if given the choice. There will probably come a time in my life when I'll have to strap somebody down and perform a procedure on them because they are out of their minds or an immediate danger to themselves or someone else. But that threshold will be pretty high. The prisoners pose a danger to themselves, but they are not hunger striking because they are crazy or drunk, they are hunger striking because they have no hope of ever escaping from their prison cells. They have no hope, no recourse, no trials, no friends and family to come and visit them...in short no reason left to live and nothing that attaches them to any scrap of what makes us human. But these physicians are keeping them alive, locked up in their holes, with no control, no hope, no joy, living but not really alive.

This is an immensly powerful education that I am receiving. I will always endevour to use it for good, but imagine the horror a doctor would be able to inflict if he turned his education toward pain and suffering. Picture yourself strapped to a table, IV in one arm, a slow drip of paralyzing medication leaving you completely immobile. But you can still sense, you are able to feel the air forced down your throat every time the ventilator compresses air into your chest. You can feel the hole the monster has poked in your abdomen to insert the feeding tube that is keeping you alive. You can still hear and he stokes your fear and anguish with chilling words. How long before you would want to just die?

The Stress

2007-11-15T16:05:00.000-08:00

There is no doubt that medical school is stressful. There is no way that any human being could absorb this much useless information as fast as we are being taught it. It's how people handle that stress that says a lot about their person. I think this is a general rule and applies to everyone. How you handle stress reveals the most about your inner character.

People are so rarely severely stressed that it's difficult to see that true character. I think that's why I like the people I encounter in medicine so much. I would say the vast majority of people become monsters when they are severely stressed. They get angry, petulant, whiny, and are just generally people that you would not want to hang out with. They might be the nicest people in the world when you encounter them anywhere else, but in a stressful situation, they just suck. I woudl say I actually fall into that category too, but I am working on it.

Then there are the people who seem to somehow rise above the circumstances and realize that there are not really that many things in life that are worth getting stressed out about. Every once in a great while you will encounter a patient whose illness seems to have transformed them into an angel. These are people with life-threatening illness (the ultimate stressor) who seem not to have a care in the world. They are kind, patient, and willing to help in any way that they are able. These are the people that I latch onto in my environment. I am constantly trying to learn from them how to combat stress, and to learn how to be a better person. They have forged their soul into something beautiful and strong and I would like to emulate it.....

But since I am still a little snot who likes to complain, here is my rant against the characters that have emerged from the pressure cooker that is med school:

1). The Vampire
These people stay up until the ass-crack of dawn studying because they think they can cram the information into their heads simply by staring at it for a pre-determined number of hours. They also like to brag about how late they stayed up to make everyone think that they know so much simply because they were stupid enough to stay up all night. This places more stress on students that are dumb enough to fall for the ploy and like the bite of a vampire, they transform into more vampires. The only way to stop these creatures is to stab them through the heart with a wooden stake.

2) The Bitches
These are the girls (and some guys) that you knew would inevitable crack under the pressure. They have these really high, whiny voices and walk around bitching all day about how unfair the last quiz was, or how unfair it is that we have to learn all this info, or how they don't have time for anything anymore. They tend to get really angry almost all the time about the stupidest things. "What!!! The anal sphincter is going to be tagged on the test? That's so unfair." The only way to stop these creatures is to stab them through the heart with a wooden stake.

3) The Stress Balls
These people have STD (Stressful Test Disorder). They walk around talking really fast and asking all kinds of questions without really waiting for a response. They are very pushy and seem to hover around the teacher at all times asking really annoying, pointless questions. Unfortunately, their disease is contagious as I have seen perfectly normal students go into a group with a Stress Ball and come with STD. They come back saying, "OMG I don't know that. I need to learn that. Do you know that? Where can I find that? What are the attachments? What innervates it? OMG!! OMG!!" You get the idea. I have no idea how to stop the spread of this terrible disease. We might have to quarantine it. That would actually be an interesting experiment. Put a bunch of Stress Balls in a room and see how long it takes before all of them have heart attacks.

4). The Geniuses
Somehow these people seem to hold it completely together and yet know everything about everything. It is pretty funny to watch the Stress Balls and the Bitches bounce off them.

5). The Slackers
These are the people who waste a valuable hour the night before the test typing a rant against their fellow students. They are impervious to STD and vampirism although they can still be bitches. Long live the slackers.

Bush's Economy

2007-11-12T21:27:00.000-08:00

Economic Look at Bush Policies

What $611 Billion could buy

I'll give it that it's a little baised, but it's all true, and it's time for America to wake up and realize just how stupid we are acting. We are headed for an economic crisis of biblical proportions. I'm not talking about just the Iraq war or anything like that. Medicare is going to double it's rolls in about 10 years and we're going to be so far in debt that there's nothing we're going to able to do about it. The rest of the world knows this...hence the plummeting dollar. The prospects don't look good for the American economy. Let's elect somebody next year with a little saner economic policies and a little more decision making acumen.

Update:

Warren Buffet agrees with me.

He just says it a little more eloquently and with a lot of decision making acumen backing him up.

Mercenaries

2007-10-24T20:32:00.000-07:00

I should probably be studying for my upcoming test, but there are much bigger issues that are worrying me right now than some stupid test. We now have the largest, most highly trained, highly funded, ruthless, and ambiguously controlled mercenary army ever assembled running around over in Iraq. We've all heard the name Blackwater USA because it's been circulating around in the press as they get themselves in more and more trouble. My concerns are not so much their goings on in Iraq as much as the idea of having such a mercenary army.

There is a reason that armies have traditionally been composed of idealistic, patriotic, loyal young men and women. These people are the ultimate arbiters of the peace and stability in a country. They are trained to be absolutely deadly and our enemies and criminals all know this, and this ensures that our country is stable and prosperous. We don't have a new dictator seize power every 10 years because these deadly weapons are placed under the control of a democratically elected government. Congress actually despite the President's strenuous insistence that he is the "decider in chief." Now, those democratic controls are starting to erode with a president and vice president who are clutching at more and more power, and we have a deadly mercenary army whose sole motivation right now is money (i.e. power).

These are very ominous ingredients for destabilization of this great country of ours. Right now, the power grabbers and the mercenaries are aligned and occupied in a distant war. But what would happen if these powers decided to make a grab for power here? I know that it sounds ridiculous and I might just be fear mongering, but just imagine the situation for a second. Next year, during this most important of elections, there is some kind of shocking event. Let's say it's a bombing, or some kind of large terrorist attack. Doesn't really matter what it is as long as it creates fear and confusion. Let's say President Bush declares a state of emergency and starts to hire Blackwater mercenaries to "come back and defend the homeland." Now every member of Congress is guarded by Blackwater. The President gives himself vast powers to listen to "terrorists" and postpones the elections.

This would be the pivotal moment. It's not a far step from this point to a position where Dick Cheney makes a backroom deal with Eric Prince for ultimate power and Blackwater is now in the pocket of the Bush family. And whap bam, civil war. But the most deadly and insidious civil war ever visited on a country.

It's a lot of steps, but I've been right on the money about how events would unfold in Iraq and this is a very dangerous situation for our democracy. I really hope I'm wrong. Even if you don't buy my hypothesis, think about what these men are going to do when they get back from Iraq. Are they just going to go back to their day jobs? These men are trained killers and probably have no desire to watch their lavish salaries disappear. Do you think they will really want to be security guards or body guards if they could make a legitimate grab at ultimate power? That's a lot of faith in the honor of mercenaries.

Dealing with Death

2007-10-17T06:14:00.000-07:00

Every doctor must become intimately involved with death. Just by choosing this career they meet death countless times and struggle against his ever-present vigilence. I have personally never been very close to death. I have been fortunate enough to not have too many people who were close to me die. But I am not entirely unaquainted with death. I have felt fear to my bones when I realized that I was almost 500 feet up a rock face and not tied into anything. Or when I heard the engine of our little Cessna sputter as it struggled to climb over the mountains. I've glimpsed his face, but have never actually known death.

Now we are up close and personal. Every medical student must undergo a right of passage called Gross Anatomy. This is where a very special person who donated their body to medical science becomes our personal laboratory to figure out how the most incredible machine ever conceived is put together. Sounds very noble until you take a bone saw to the spinal cord and hack the guy in half.

The everyday experience of anatomy is kind of chilling. Here we are surrounded by 30 dead bodies in a room that smells of formaldehyde and we are indescriminately cutting them open and trying to figure out what goes where. "Oops, sliced through that nerve". If this guy was alive he just lost all feeling in upper shoulder and use of his deltoid...oh well. The class is difficult on multiple levels. First it is difficult to actually dissect. Dissecting is a skill that requires a lot of patience, and a good understanding of where everything is and some technical skill. The class is also difficult by the sheer volume of information we absorb. Imagine trying to learn every bone, muscle, nerve, artery, and vein in the human body in 10 weeks. It's impossible, we're going to forget and miss something. It is also very difficult on a personal level as you are wondering who this person lying in front of you was. What were his dreams? Who were his friends? What did he do for a living? How did he die? Was it painful? It's tough to separate the machine from the man.

I have found that I am able to ignore the dead person in front of me pretty effectively and focus on the anatomy. But I have realized I do have some vestiges of doubt about what we are doing. There are a lot of people in the lab who work on the cadavers without gloves. They do this because gloves are kind of expensive and they don't want to have to change pairs every time they switch cadavers and because they handle the tools more effectively without gloves. I cannot do this. There is just something about touching the inside of a human being without some sort of barrier between me and that body that I can't handle. It's completely illogical, but it exists in my mind and anchors me in the unusualness of what we are doing.

So that's my anatomy experience so far. I'll write again when I start having the zombie nightmares. If you can tell me the nerve that I sliced through that innervates the deltoid, then you get extra points.

Ethical Case

2007-08-30T18:26:00.000-07:00

One gets to learn all kinds of interesting things in medical school. Some of the most interesting for me are the ethical dilemmas one encounters. I think it's because I always think I have the right answer. I know what I would do in this case. But it rarely turns out to be the right answer (if there is a right answer).

Today's case concerns a 48 year old woman who presents to her neurologist with a complaint of abnormal, jerky, involuntary movements. The physician suspects a diagnosis of Huntington's chorea and confirms this suspicion with genetic testing. He explains to the patient that Huntington's disease is an incureable neurological condition which involves the gradual development of uncontrolled abnormal movements and eventually progresses to irreversible dementia and death within 10 years of diagnosis. He also explains that the condition is inherited in an autosomal dominant fashion with the result that there is a 50% chance her children may carry the gene for the condition although at this point it would asymptomatic. The patient refuses to give permission to the physician to inform her two daughters of the diagnosis, despite the fact that they are both in their early twenties and one of them is planning to get married and start a family within the next six months.

What would you do?

The essential dilemma is the physician's obligation to inform the daughters about their potential risk, versus the right of the mother to keep her information private. My immediate, gut reaction is to look out for the well being of others and inform the daughters. A more thorough analysis reveals why this might be a mistake. I learned to analyze dilemmas like this with a three tiered approach.

The first question you have to ask is what would I want in each of their places? If I were the daughters, I personally would want to know, but as a physician I can't say whether or not they would want to know. If I was the mother, I wouldn't want to admit that I may have caused something that will eventually hurt them, but I would want them to have the information to plan with. This analysis comes up pretty empty

The second question is: what is the greatest good for the greatest number of people? This one is a little more obvious. The greatest good usually comes from having as much information as possible. Not much good has ever come from keeping important secrets, especially of a personal nature. The mother might suffer if the information comes out, but more people including daughters and future generations will benefit from that suffering. This one comes down on the side of informing the daughters.

The third questions is: What would you want to become a universal principle? In other words, if you could write a law as how everyone would act in this situation, what would that law say? If a doctor was confronted with the same situation where he knows the patient's diagnosis but knows that information will bring lots of suffering, what does he do? This one is tough to use because it's such a personal nature. A doctor would be obligated by the profession to tell the diagnosis to the patient. But is a mother required to tell her daughter? I feel like maybe universal honesty and disclosure might cover it, but it's a little shaky.

Using that analysis, the principles lean toward telling the daughters and I feel like that is the right thing to do. The next thing to do is examine the literature and precedent for cases like this to see if something like this has happened before. There are two articles that seem pertinent.

JAMA; Between a Rock and Hard Place
Pediatrics: Physician's Duty to Warn Third Parties About the Risk of Genetic Diseases

From Pediatrics

In Pate v Threlkel, the highest state court in Florida unanimously held that a physician has a duty to warn a third partyabout a genetically inherited disease.⁴ The plaintiff was receivingtreatment for medullary thyroid carcinoma and sued the physicianswho had previously treated her mother for the same condition,but with whom the plaintiff had no patient-physician relationship.The plaintiff alleged that the physicians failed to warn the motherthat her condition could be genetically transmitted and that herchildren should be tested. The court stated that a duty to warnthe patient of the genetic nature of the cancer is determinedby expert testimony. If such a duty exists, it is also applicableto the children. However, the court, citing state confidentialitylaws, held that the duty was satisfied by warning the patientabout any genetic ramifications of the disease.
In Safer v Pack, an intermediate appellate court in New Jersey unanimously ruled that a physician has a duty to directly warnthose third parties known to be at risk of avoidable harm froma genetically transmissible condition.⁵ Safer involved a suitby a plaintiff against the estate of a physician who had treatedthe plaintiff's father for multiple polyposis with adenocarcinomaof the colon >30 years earlier. At the time of the father's deathin 1964 caused by metastatic cancer, the plaintiff was 10 yearsold. At age 36, the plaintiff was diagnosed with cancerous blockagebecause of multiple polyposis of the colon with evidence of metastaticdisease. The cause of action against the physician was for professionalnegligence, alleging that multiple polyposis is a hereditary conditionthat, if undiscovered or untreated, invariably leads to metastaticcolorectal cancer. The appellate court held that the physician'sduty to warn those known to be at risk of avoidable harm froma genetically transmissible condition extends to members of theimmediate family. The highest state court in New Jersey refusedto consider the case on appeal.

These cases are always kind of scary. They expected a doctor to remember the son of a man he treated for colon cancer almost 30 years ago. Did we even know what colon cancer was back then? That seems like quite a stretch. But these cases come down firmly on the side of informing the patient if there is a great risk to that patient. But only if there is an immediate or great risk. Otherwise, side with the privacy side. So that was really no help. The articles go on to describe the ideal situation.

Ideally, the physician would convince the mother to tell the daughters herself. He/she would be there for support and for infomation, but the obligation to tell lies entirely with the mother. In this situation, I would sit there and talk to the mother for as long as it took to get her to see that it's right to tell her daughters the diagnosis. That they need to know for their kids' sake and that the consequences of not informing them are so much greater. What if one of the daughters had a child and later found out that her mother didn't tell her the diagnosis and that her child now has the potential disease. She would fret about her child her whole life and she might never forgive her mother for not telling her. Honesty is always the best policy, but it's the patients who need to be honest.

Medical School

2007-08-26T20:35:00.000-07:00

Here we go

I've been waiting for this moment for the last two years and it's strangely anticlimactic now that I'm here. There was no grand entrance, no fireworks, no huge party, no bells and alarms going off in my head. There's just amazing people, new surroundings, and a quiet acceptance that this is going to be a defining time in my life. Med school is going to change everything from what I wear to work every day to the basic way that I interact with people. It's has already started to change my choices with what I want to do with my life, with what I hold most dear and sacred, and how I will choose between right and wrong.

In four years of hard work, sacrifice, determination, and life, I will hopefully emerge a better man and prepared to be a great physician.

100!!!!

2007-05-09T09:58:00.000-07:00

That`s right, this celebrates One Hundred Entries of Premedpilot. Didn`t think I`d ever get to One Hundred of anything. Felicidades!

Peru

2007-05-05T18:46:00.000-07:00

It`s been a while since I`ve posted on here. It`s going to be at least another two months because I am in Peru learning Spanish before I head to Medikal Skool. I will try to be even more offensive and politically annoying when I get back. Vaya con dios.