Studying, Advocating, Consoling...so much to do

Well, spring semester has been coming on fast and furious - been extremely busy. Have also had tests every other week, essentially, and our first Block exams of the semester are next week. We have had two standardized patient encounters with our small group - where we must take histories and perform a physical exam. It's amazing the things you notice yourself and your classmates doing when interacting with patients - strengths and weaknesses, the importance of listening... We have also practiced doing SOAP note write-ups (subjective, objective, assessment, plan) and worked on differential diagnoses. The ailments of the patients are in line with what we are learning, so we can apply what we learn clinically.

Tomorrow we get to explore a new aspect of the physician-patient relationship - breaking bad news. We will have 12 minutes to break bad news to a standardized patient who has been trained on how to react convincingly to the news, including shouting or crying. We will be faced with one of these: a son whose father unexpectedly died, a woman with a suspicious breast lump who needs a biopsy, a man with inoperable pancreatic cancer, a childless woman who just had a miscarriage, and a man with an STD from an affair. Should be interesting and nerve-wracking - but I imagine it will be more difficult for some of my colleagues than for me. Working in the lab, I definitely got to deal with very angry patients, and one woman I drew as a trainee had just learned her husband was going to die - that was a difficult one. You really don't know what to say to a stranger who suddenly starts crying, especially when they're still holding back so much pain and you know almost nothing about their situation. I almost cried myself that time - but sometimes all you can do is squeeze a person's hand to let them know you're there with them, even if it's for just a moment. I'm usually someone who insists on a 3 foot personal space bubble and never hugs people unless they're family (and even then not so much), but somehow I was able to recognize that at that moment, she really needed to feel physically that someone was there with her. If you're really with them, and not just going through the motion, time almost seems to stand still for you both in a good, or at least meaningful, way. They say, "You can touch patients during a bad news situation if you think they would be okay with it," and you kind of wonder, "How will I know if they would be okay with it?" Well, that was one of those moments, and I could definitely tell even with no experience - though my rule is that if in doubt, it's better NOT to touch.

On a more positive note, last Thursday we were bussed by the Osteopathic Physicians and Surgeons of California (OPSC) to the state capitol to speak with assembly members and fellows about the recent merger between the Doctor of Osteopathy and Doctor of Naturopathy boards. Essentially, bill AB X4 20 merged the boards because the governor wanted to make it look like he was cleaning up the government - busting excess bureaucracy and saving money. However, both our boards are funded by those in the profession, no tax money is involved, and they approve licenses as well as oversee malpractice issues. NDs do not prescribe medications without supervision (and even then, no category 2 drugs) nor do they perform surgeries - so having them oversee us, or even have us oversee them, is not fair to either profession. I was the designated group leader to the assembly member whose fellow we spoke to because apparently I live within the district (14). Definitely nerve wracking, but everyone seemed to think I made a very eloquent case. The fellow we spoke to seemed very supportive of our cause. One of the senators (Lee) has submitted two goldenrod bills to his boss for approval, which we need in order to get numbers on them, support, and signatures. It was really enlightening to see how the process works in state government, and that people in the offices actually will listen to you and you can make a difference. We also got to speak to one of the governor's aids right before he was going to a meeting with Mr. Schwarzenegger himself, with the promise of at least mentioning the issue with him, so that was exciting. There were a bunch of school children outside of the governor's offices as we walked in and they were all asking us to say "Hi" to the governor for them, ask for more money for schools, it was adorable. All in all, a very exciting day - here we all are in front of the capitol building!

Also, on one final note, the founder of Touro University, Bernard Lander, last night at the age of 94. All the Touro campuses were closed out of respect. I don't really know what to say about it, as I never met him or knew much about him before now, but I am kind of wondering how it will affect the universities. At the least, I was productive and used the day to get more caught up on classes.

Relishing the News

I have gradually grown to oppose dietary supplements, culminating in my history of medicine paper documenting the history of the industry (which is quite interesting). I rarely do double posts on the medical blog, but felt compelled to share a recent article. In this article, it has been found that those who take vitamin C and E supplements do not receive some of the benefits of exercise, such as increased resistance to oxidation and better control of insulin production. To spare the nitty gritty, it stems from vitamin C and E neutralizing the oxygen radicals produced from muscles respiring. As a result, the body does not receive damage from the radicals and therefore does not launch a response to the oxidation - the vitamins took care of the problem. This is not to say that antioxidants are bad, but just that megadoses of vitamins C and E is not a good option.

This is just one of many recent studies disproving the long-term health benefits of vitamins C and E in preventing heart attacks and cancer, as well as the lack of long-term benefits from taking a daily multivitamin. Like with weight loss, people always want fast, easy solutions to difficult problems, and the artificial solutions are almost always worse than the natural solution. Want to lose weight? Take ephedrine or hydroxy-cut and get a heart attack. Want to eat what you want without gaining weight? Binge and purge, while your teeth rot out. Want to eat more junk food and less fruits and vegetables? Pop a multivitamin and lose money and the benefits conferred from actual food. When it comes to one's long-term health, there is no magic solution, and people seem to refuse to acknowledge that. In an age of instant-gratification, perfect health is still unattainable at the click of a button.

Obesity

There are times when I feel like medical research is somewhat unnecessary, such as when it proves something already widely acknowledged as true. With obesity, the number of "studies" about the health and social effects of obesity is quite staggering, and the results unsurprising. Here is a sampling of the recent findings relating to obesity.

Being obese will...increase the chance a child will have allergies, lower a man's marriage chances, decrease one's productivity, worsen asthma symptoms, lower chances of receiving a raise or promotion, increase women's chances of pelvic disorders and decrease quality of life in old age, increase the chance a child will suffer lower body injuries, hide fetal abnormalities during an ultrasound, and raise the chance of being disabled in general.

This is supposedly new data, compared to the old data linking obesity to breast cancer, high blood pressure, shorter life span, cardiovascular disease, heart attacks, diabetes, sleep apnea, gastroesophageal reflux disorder, back problems, and steeper decline in mental faculties after the onset of Alzheimer's or dementia. I don't understand why we need more proof that being overweight and obese is a serious health problem. If being told that they will get their feet amputated if they don't lose weight does not motivate them, then how will information about pelvic disorders sway them more? We also do not need data to prove that being obese makes one less desirable in general, everyone already recognizes that fact. It is mostly a superficial problem, but it is hardwired in our being to be repelled by the unhealthy. Unfortunate and discriminatory from a humanistic stand point, but logical and fair from an evolutionary view, where the population, not the individual, is most important.

To play devil's advocate, knowing definitively that something is caused by a person being obese could help physicians treat problems - they could abstain from prescribing medications they would give a non-obese person, if the potential benefits of the medicine would certainly be curtailed by the person's obesity. After all, a non-obese person may have an underlying cause for a disorder which is treatable, while the obese person may have the problem simply because of excess weight. I have been tempted to write about obesity before, and finally felt compelled by the many unnecessary "studies" posted in Yahoo!'s Weight Loss News. If nothing else, one can at least be impressed by the sheer number of health complications from being excessively massive.

Who can become a doctor?

Sorry about the lack of posts, but not much of interest relating to my going to medical school has happened lately. No news from Western U yet, they still haven't sent my official alternate list letter. And Touro still hasn't withdrawn a thousand dollars even though I gave them the credit card form weeks ago.

On another note, I came across an interesting article which brings up the question of who should become doctors. Now, if you asked someone, "Can anyone become a doctor?" then usually they would respond, "Of course! If you want something and work hard enough, you earned it! This is America after all." Then you have to ask, "What if that person molested a child, or killed a Jew in a neo-Nazi hate crime?" You usually don't picture a person like that aiming to become a doctor, but in many countries, most recently Sweden, such cases have occurred.

This article describes a current problem at Sweden's most prestigious medical school - they admitted a Nazi-sympathizing felon who was convicted of murder and served for 6.5 years before applying for medical school. In Sweden, it is almost always illegal to require a criminal background check, and apparently the screeners and interviewers did not seem concerned about the 6.5 year gap in this student's record. They have managed to make it nearly impossible for him to graduate and become a practicing physician by restricting him from clinical experience, but the issue still remains.

Being a physician, like being a school teacher or a priest or in any other position in which you have a mentor-like power status, includes certain standards of behavior and morality. Would you want your fourth-grader being taught by a physically abusive alcoholic? Would you want your priest to be an ex-child molester? Just the same, you would not want your physician, someone you trust when you are at your most vulnerable, to be a convicted rapist or murderer. I believe in equal opportunity as much as anyone, but you have to draw a line at some point in the interest of protecting people. We usually want to think that the only criteria for a job is a person's academic background, work experience, and recommendations, but there is a host of personal qualities that are equally, sometimes more, important. I know there is always the question of whether a person can change, learn from what they did, etc. I understand forgiving "mistakes" but maliciously murdering someone? I think some "mistakes" teach best by prohibiting a person from achieving their dream. If after raping or murdering and thoroughly destroying the lives of others they can spend a few years in jail and then live the rest of their life as if nothing happened, that is a crime in itself.

Difficult Patients

I was able to access the study from work, but now that I am home I cannot access it. It has been written about in newspapers, blogs, and magazines across the country. The main gist: doctors who see more "difficult" patients are also more burned out, more stressed, and tend to be younger-than-average female physicians. The article does not make any attempts to establish causality, though the relationship between seeing difficult patients and stress levels would seem directly proportional to common sense.

What I found more interesting were the most common attributes of patients that made them qualify as "difficult." Over 1/3 of the difficult patients were so categorized for insisting on an unnecessary medication. Another ~10% were difficult for having unrealistic expectations for their care, and ~10% were unsatisfied with the care they were receiving. I have complained before, but the US is only one of two countries (the other is either Australia or New Zealand) which advertises prescription-only drugs in the media. It is creating a culture in which people who know nothing about medications and physiology of the body to demand new, expensive name brand drugs despite their doctors' medical opinions. When a physician has a full waiting and exam rooms, he is pressed for time and often does not feel he has the time to explain why the advertised drug is not as good as the currently prescribed medication, or why the drug is not needed at all. It has gotten to the point that dangerous surgical procedures like gastric bypasses are being advertised on television!

I admit that if a patient has a physician who has not kept up-to-date with the ever growing field of medicine, then bringing new medications to his attention could do some good. However, over half of the "new" drugs released each year qualify as "Incrementally Modified Drugs", in which a different but equally potent version of the same chemical is being advertised as a new drug. Honestly, I think pharmaceuticals should not be advertised through any media PERIOD.

Artificially Extending Life

It seems most people have very mixed views on extending a person's life artificially with respirators, feeding tubes, and the like. My personal opinion is one of individual liberties, that each person has the right to determine his or her own fate, whether by dictating in a will to be on a respirator indefinitely or by ending life prematurely with assisted suicide. Personally, I want to live as long and healthily as possible. Of course, anyone seeking assisted suicide should first seek counseling and explore all options, but ultimately it should be their choice. Better for them to do it safely and with certainty while they are able, than attempt it and become handicapped for life, becoming even more miserable and unable to make a second attempt.

This topic was inspired by today's Dilbert, which was surprisingly funny with Scott Adam's take on extending life:

I understand that people object on moral (primarily religious) grounds, but I do not think other people should be able to prevent others from taking control of their own life or death. The Terry Schiavo and Karen Quinlin cases are the prime examples, where parents or spouses fight the state, doctors, or other family members for the right to prolong or end the person in question's life. I really feel for the doctors trapped in those situations, and hopefully if I face one of those cases the players will be relatively rational.

Put Down Those iPods!

I always objected to the bud earpieces on a comfort level - I just could not get those little things in my ears comfortably. Looks like I dodged a bullet. Most people listen to those buds with the volume so loud I can hear them from a few feet away. In my youth, I always sprang for the huge DJ headsets, which felt like they made sound easier on the ear. I used to listen to music pretty loudly, despite my parents telling me I was killing my ears. Somehow, those warnings never felt very finite - I might have a slight buzzing in my ears after an hour or two of listening, but it always went away. Even though I have since stopped pounding the music into my ears, most of the damage is probably done - at least I never stuck those buds in my ears. I always thought those smoker's lung vs. healthy lung ads were particularly convincing, so perhaps these images will be convincing to a few (c/o my CogSci class):

The first image is pristine, healthy cochlear cilia, or in simple terms, "the hairs in your inner ear that interpret sound for your brain." The second image is cochlear cilia with mild-moderate damage, and the third image is cochlear cilia with a lot of damage. Unlike lungs, which take a long time to recover but do to a certain degree, damage to cochlear cilia is PERMANENT. I seriously expect half the people in my generation to have significant hearing loss by the time they are 40 years old on account of the mp3 player/bud headset craze. Do your ears a favor - if you want to listen to music for more than half of your lifespan, turn down the volume.

Dietary Supplements

To preface this entry, a new study came out disclaiming the medical benefits of taking multivitamins, adding to the message from the November studies disclaiming the benefits of Vitamin C and Vitamin E. I have never been a big fan of dietary supplements, in fact I wrote a paper explaining why the industry is so unregulated and able to make such fantastic health claims, but many people are self-medicating with vitamins, minerals, etc. This is one of my favorite clips summing up my view on the subject:

Yes, indeed, they really are no better than placebos. Unless a person has an actual vitamin deficiency, there is no real reason to take dietary supplements. You may think you are taking steps to prevent cancer by popping that Vitamin C every day, or that your memory will improve by downing Gingko Biloba, but the odds are good that you're just producing expensive urine. As a side note, make sure you're not also taking birth control pills, since Gingko Biloba affects liver enzyme activity and you may end up getting pregnant or extremely hormonal. I am very glad that these decade-long studies are finally coming to their conclusion and proving that there are no long-term health benefits to taking dietary supplements. Maybe the hubbub will die down by the time I am practicing, and I won't have to listen to a speech by a patient enlightened by Wikipedia about the benefits of taking Selenium or Echinacea each day.

Marburg Fever

With global travel, diseases uncommon in the developed world are increasingly being seen. I am fascinated by infectious diseases, one of my favorite movies being "Outbreak," so ID news tends to catch my attention. One that recently made headlines was Marburg hemorrhagic fever, contracted by a tourist in Uganda. He likely caught it when he visited a python cave and encountered fruit bats. The virus, a member of the filovirus family which includes Ebola, was only discovered in 1967 - ironically, it was transmitted by African green monkeys imported for research and to prepare polio vaccines. Check the CDC page for more details on the background and symptoms.

It's pretty scary to think how unprepared the medical field is for rare, contagious diseases from the third world. So many viral infections start out with flu-like symptoms that the person would not be treated or quarantined, and it would be easy to transmit the disease to other people. With an incubation period of 5-10 days, plenty of people could become infected.

With global warming, in addition to global travel, I'm confident we will begin seeing more tropical diseases, particularly those carried by insect vectors. The range of mosquitoes capable of transmitting Dengue has spread across the southern United States, the Hemipteran responsible for Chaga's disease may be able to spread north from Mexico, and West Nile Virus is already found across the country. Cases of Dengue fever have occurred endemically in Texas. It will be interesting to see how the geography of tropical diseases continues to evolve.

Extreme Measures

Bill Gates has just gone up a few notches in my book - I can forgive the sleazy early Microsoft tactics and the bugs in every Windows release. Anyone who unleashes mosquitoes to try to make people feel malaria is an urgent issue gets points for unconventionality and creativity.

Gates makes some important, obvious statements: "There is more money put into baldness drugs than into malaria," and "the market does not drive scientists, thinkers, or governments to do the right thing." The first point he makes is unfortunately just the tip of the iceberg - pharmaceutical companies will make as many expensive drugs as possible for people who can afford it. Rich white men afflicted with AIDS, cancer, hair loss, or erectile dysfunction will pay huge sums for treatment. AIDS cocktails and chemotherapy drugs are so unbelievably expensive and require so many doses, it seems obvious from a pharmaceutical company's perspective why it is more profitable than investing in curing malaria or tuberculosis, which are most prevalent outside the US. It is easy to criticize pharmaceutical companies...because they're so crooked and their business so engrossed in making money. Only in the US and New Zealand are prescription-only drugs advertised to the public, and our pharmaceutical companies are consistently at the top of the Forbes list with profit margins up to 10x as high as other companies. As for the second point, yes, the market does not drive companies or people to do the right thing. I disagree that it does not drive scientists or thinkers to do the right thing; rather, it drives the companies and money wielders away from scientists and thinkers who want to do the right, but unprofitable, things. Whether the businessmen of pharmaceutical companies will ever yield to their role of creating significant treatments and cures, only time will tell...