Wednesday, February 26, 2020

The Absent Oncologist

We admitted the patient to our service from the emergency room to treat her for thrombocytopenia (an abnormally low platelet count) and spontaneous bruising. The patient, in her fifties, was otherwise healthy. True, she had been treated for stomach cancer nearly seven years ago, but it was in remission and had been for a while. She had no issues eating or drinking, no problems going to the bathroom, no blood in her stool, no vomiting, no bloating, no severe acid reflux. In other words, she had no residual gastrointestinal symptoms.

Over the next two days, we ordered other labs, and their results concerned us. Not only were the patient’s platelets low and getting lower, but other blood markers were abnormal, too. Her fibrinogen, a protein that circulates in the blood and helps the blood clot, was also dangerously low. Her INR (international normalized ratio), which measures the time it takes for the body to create clots, was high. These aberrations indicated disseminated intravascular coagulation (DIC). In this disorder, the bloodstream rapidly forms clots, thus exhausting the body’s platelets and clotting factors. With fewer available platelets and clotting factors, patients also experience bleeding. DIC induces a terrifying, circular, and deadly process of clotting and bleeding. As one study showed, if the underlying cause of this brutal pathology is not controlled, mortality is over 20%.

A plethora of disorders, including bloodstream infections and malignancies, cause DIC. But the patient did not have a bloodstream infection — all of her blood cultures were negative and she had no symptoms of an infection. On day two of her hospitalization, we obtained a CT scan of her abdomen and chest, looking for a malignancy. Tragically, metastatic gastric cancer lesions riddled her liver while a recusant growth consumed her stomach leaving little normal tissue in its wake. Unfazed, she calmly stated she understood and asked what her next options were. Though her husband seemed more shaken by the diagnosis, he, too, wanted only to know what came next. This was a diagnosis she had faced and survived before. She believed strongly she could survive it again. We told the patient and her husband that we would contact her oncologist, the same one who had treated her gastric cancer originally. She would, we explained, help us figure out what treatment options existed. It was as if there was a transient release of pressure in the room; they trusted the oncologist and were glad that we were getting her involved. Since it was late in the evening, we promised to reach out first thing in the morning.

On the third day, I called the patient’s physician. Because she was busy seeing patients in clinic and unavailable to take my call, I left a message with the secretary asking that she call me back as soon as possible. The secretary also took down the patient’s information so the oncologist could at least look at the scans and laboratory results to get an understanding of what was going on. When we rounded that morning, I let the patient and her husband know of this development; all of us expected the oncologist would reach out to our team later in the day. But by the end of day three there was no word. I spoke with my attending physician about our dilemma. Since we were not oncologists, we could not prescribe chemotherapy and we didn’t know what the appropriate treatment should be for the patient. All we could do was treat the DIC by transfusing platelets and control the patient’s pain and nausea. Suspended in a kind of medical purgatory with our patient and her husband, we waited for some direction. Our attending physician reached out to the oncologist that evening via email. Perhaps a fellow faculty member’s missive would indicate the urgency of the matter.

But day four brought more of the same. None of us had heard anything from the oncologist after three calls that day. The patient and her husband became understandably more frustrated and their future seemed much more opaque. The patient’s husband pulled us aside and sternly rebuked us. How could we let her sit here like this with no treatment? What was our plan to help her? How were we going to deal with this resurgent cancer diagnosis? With no good explanation we deferred and equivocated, stating that we were doing our best to get in touch with the oncologist who would hopefully give us some guidance soon.

On day five the patient’s mental status deteriorated. She drifted in and out of sleep. Three meal trays came and went untouched. We called another oncologist and asked him to see if he could get in touch with the patient’s primary oncologist or at least recommend some kind of treatment — later in the day he told us that perhaps there were some options but it was not his area of expertise. Not to worry, he assured us, he had spoken with the primary oncologist and she would be in touch with us soon. But she never called. The patient’s husband expressed more and more frustration and anger. Why did the oncologist, someone they had known personally for years, not even come to the bedside to see them? Why did her office not return even the husband’s calls, let alone our own? It was not just a personal affront to them but a professional affront to us. We felt helpless.

Finally, on day six, our attending got in touch with the patient’s oncologist and during a phone conversation asked about possible chemotherapy options. She replied, “What chemotherapy? There is no chemotherapy option! There’s no treatment option whatsoever.” By this time our patient was more somnolent, more often unconscious than conscious. She labored to breathe as her pale and gaunt face withered away. She was dying. I spoke with the husband and told him that we had finally heard from the oncologist: no chemotherapy options existed. We could only make her comfortable as she passed from this world. It was as if he knew this was coming, throwing his hands up in the face of this tragedy and walking out of the room in tears.

At the end of the week, the patient died.

We were indignant. Clearly, the oncologist abandoned her patient. Despite the close relationship they once had, she had not come to see the patient nor reached out to her or her husband to explain the situation. Anger permeated our team’s discussion that evening as the two residents on my team and I packed our bags and headed out of the hospital. We swore we would never do that to our patients.

One cannot know for certain what was going through the oncologist’s mind as her patient’s illness evolved. And it is difficult to malign such behavior without knowing all that was happening at the other end. Did she feel overwhelmed by the grief of her day-to-day job? Because of her closeness to the patient and the patient’s husband, did she want to avoid telling them the prognosis and outcome? Whatever the case may be, it was wrong of her to vanish when the most trying time came. Yet it is worth exploring what may have occurred.
In his book Thinking, Fast and Slow, Nobel laureate Daniel Kahneman, an economist and psychologist, explains that psychological literature supports the concept of familiarity breeding comfort. Repetition, he states, “induces cognitive ease and a comforting feeling of familiarity.” He describes how, in an experiment run at the University of Michigan and at Michigan State, psychologist Robert Zajonc and his team placed Turkish words in ad-like boxes in the student newspapers. Different Turkish words were shown at different frequencies, some once, some up to twenty times. The investigators then sent questionnaires to the students asking about their impression of the words. Kahneman writes, “The results were spectacular: the words that were presented more frequently were rated much more favorably than the words that had been shown only once or twice.”

Medical training is nothing if not a long series of repetitions, of exposures to similar diseases and situations. An oncologist sees cancer and its morbid consequences every day. This may not breed the kind of positive reactions that Kahneman describes, but it likely elicits an increasingly tepid and nonplussed response from the physician. Poor outcomes or test results shock less than they would most others. Perhaps our patient was one of ten with similar diagnoses witnessed by the oncologist in the last month, and one of a hundred in the last year. And maybe that led to a dismissal of this fatal and unconquerable diagnosis. Why invest time in another situation like this when failure is guaranteed?

Danielle Ofri, a clinical professor at the NYU School of Medicine, thinks about this slightly differently. In her book What Doctors Feel, she references a 2012 study on the nature of grief and patient loss in the lives of oncologists. The oncologists in the study attempted to compartmentalize their sadness and grief in order to keep them separate from their work and their personal lives. But they failed terribly. Dr. Ofri writes,

The pervasiveness of death often led to a relentless sense of grief among the oncologists, not just for the patients who had died but for the patients who they knew would be dying soon.... Grief ate at these doctors, distracting them from both their families and their patients. Many reported withdrawing from emotional involvement with their patients and that their patients had noticed they weren’t fully present.

The problem, in Dr. Ofri’s eyes, is an overwhelming amount of grief thrown at the physician on a day-to-day basis. It is certainly possible, in the particular circumstance I described, that the oncologist felt too sad and too upset to come see the patient.

Interestingly, both of these theories are rooted in the same etiology: overexposure. It is a conundrum of our nature as human beings. Repetition either exhausts us or anesthetizes us. Do we need to limit physician hours or days worked? Do we need to limit physician obligations during the day to allow for these kinds of important conversations? I don’t know the answer. Until we figure out a solution, reason and empathy must keep watch over our conditioned responses, lest we abandon those most in need of our help.

Tuesday, June 4, 2019

Why I, a Physician, Write

“One would never undertake such a thing if one were not driven on by some demon whom one can neither resist nor understand.”
 – George Orwell, “Why I Write”

I remember my first encounter with great literature. Before bedtime, my father would read Great Expectations to me, using different voices for different characters. I remember Pip and Miss Havisham, though I don’t think I fully understood Miss Havisham’s peremptory and eery commandment to Pip to love Stella. I remember the stygian scene with the convict in the graveyard. I also remember reading Sherlock Holmes under my covers, enamored with his brilliance and the game that was afoot. I remember tearing through the Lord of the Rings books and the first few books of Robert Jordan’s The Wheel of Time series. Great stories left a large impression on my childhood. The thrill of diving deeply into an engrossing world still makes me a bit giddy. Even when I read books far more socially complex now, books I would never grasp as a young reader, like Thomas Hardy’s novels, I am reminded of the initial excitement I once felt discovering new stories.

As a child, these stories didn’t remind me of my own life or people in my life, they were just thrilling. I fantasized about writing my own stories one day. I created comic books with different monsters, though my drawing was appalling. I once sat down to hand-write my own epic fantasy story – I don’t think I got very far. I suspect, then, that my desire to write and tell stories was present at a young age. But I lacked the sedulousness to work on my drafts. I would write an essay for school or a story at home and immediately hand it in or toss it aside, assuming that was the end.

Since then, of course, I have written more and learned more. The process certainly has not gotten any easier, especially as time spent writing crowds out time for other things in life like music, friendships, reading, TV shows, and family. Indeed, the time invested has not been trivial. Just as an example, I was covering the intensive care unit one night during my first year of residency and during the few brief quiet moments of the night I was reading a book about the psychology of the Nazi war criminals for an essay for the Jewish Review of Books.

Why do I attempt this seemingly crazy task? It is a question prompted by a recent fellowship interview, when an interviewer asked me: Why do you write? And what drives a physician (and there are many physician-writers) to write?

In 1946, George Orwell explored the reasons for his own writing in an essay entitled “Why I Write.” Orwell explains that there are four great motives for writing: egoism, aesthetic enthusiasm, historical impulse, and political purpose. Writers, he argues, “desire to seem clever, to be talked about, to be remembered after death…. It is humbug to pretend that this is not a motive, and a strong one.” Because of this, serious writers are “vain” and “self-centered.” Of course, there is an element of solipsism in writing. No writer, physician or otherwise, writes without anticipating some kind of audience. It does help give our writing purpose, to know that it affects or influences others. But such an aspiration is not unique to writers, as Orwell concedes. All professionals – scientists, artists, politicians, etc. – desire, to some extent, to be remembered through their research, art, or deeds. No ambitious citizen can deny that this plays some role, large or small, in what he or she does. But the entire writing motive is not necessarily self-aggrandizing: Writers appreciate beauty, “pleasure in the impact of one sound on another, in the firmness of good prose or the rhythm of a good story.” An author, no matter what his or her topic, attends to “aesthetic considerations.” And the content matters, too. Essayists, novelists, political journalists all “desire to see things as they are, to find out true facts and store them up for the use of posterity.” In other words, they aim to portray the world as it is, to draw away the curtains. And there is also a “political purpose” to this. Though writers do want to see things as they are, they also want to imagine the world as it might be or “to alter other people’s idea of the kind of society that they should strive after.” Orwell does not argue that one of these is more important than the other: “These various impulses must war against one another,…fluctuate from person to person and from time to time.”

Most of what Orwell says pertains to physician-writers. For some of them, for instance, politics drives much of their work. Atul Gawande, a surgeon and public health researcher, is a good example. Gawande’s books, like Being Mortal or The Checklist Manifesto, both agitate in some way for reform of our medical system. In Being Mortal, he urges us as a society to rethink the way we take care of the elderly and those closest to death such that we provide them with more independence and choice and less invasive care. In The Checklist Manifesto, he discusses the importance of checklists for the safety of patients in a hospital, in particular during surgeries.

For most physician-writers, however, I suspect that the primary purpose is to reveal to the reader what the world of medicine is like – a world that contains the kinds of riveting stories that fiction offers.

Physician-writers face unpleasant facts; or, rather, unpleasant aspects of life. Most of the stories I relate on this blog are tragic in some way – some of this comes out of a frustrating sense of injustice, but a lot of it comes out of a sense of the inevitability of tragedy and the beauty and rare success coupled to that struggle. Thomas Hardy reportedly said, “The business of the poet and the novelist is to show the sorriness underlying the grandest things, and the grandeur underlying the sorriest things.” The physician-writer shows the sorriness and grandeur underlying our physical life. In that sense, I write with a historical impulse, “to see things as they are.” What is medicine really like? What does it mean to be sick and helpless? What does it mean to be sick and poor? How do physicians react to all of this?

Perhaps the thrill and romance from childhood stories has faded somewhat, but the hunger for nonfiction as a grounding tool has taken their place. This blog provides, among other things, a way to impart the great complexities of medicine and diseases, which are often only understood by other physicians and the victims of those diseases.

I wish I could write a novel with the same flair for storytelling and the same talent for diction and the same eloquence as Dickens or Hardy. That I cannot is unfortunate. But stories about medicine are powerful and the most I can offer. And I am “driven on by some demon” to write about them; a purposeful struggle to put to the page these stories that are filled with meaning, and that might otherwise disappear.

I will never retire this task, whether it’s through this blog or elsewhere. But as my career advances I ought to give myself space to breathe. I start my fellowship in neurovascular disease this summer and have an important specialty board exam this year, both of which require, I think, all of my intellectual energy. So things will be quiet on this blog for now, but look for more in the coming year.

Monday, March 11, 2019

What Makes a Great Physician?

At this blog’s inception nearly five years ago, I asked myself the following question: “When you watch impressive doctors at work, what is it that most impresses you?” In other words, what makes a great physician? I was a third-year medical student at the time and I couldn’t answer the question. At the beginning of training one can hardly keep up with the incoming information, let alone consider the characteristics that make a great physician. I liked and disliked certain doctors depending on the way they treated residents, medical students, or patients. But beyond kindness, their traits varied widely. During residency I have been fortunate to work with many admirable doctors, and consequently my sample size has grown. Seeing what I’ve seen thus far, I think curiosity and humility are the two most impressive characteristics of a great physician.

Galen of Pergamum (AD 129–ca. 216), the Greco-Roman doctor, wrote extensively about how to make physicians great again in his treatise That the Best Physician Is Also a Philosopher. He bemoans the lost art of medicine and the corruption of the profession. He advocates for a temperate lifestyle, arguing that if a physician puts virtue above wealth, he or she will be “extremely hardworking” and will therefore have to avoid “continually eating or drinking or indulging in sex.”

A doctor must also be “a companion of truth.” “Furthermore, he must study logical method to know how many diseases there are, by species and by genus, and how, in each case, one is to find out what kind of treatment is indicated.”

He continues,

So as to test from his own experience what he has learnt from reading, he will at all costs have to make a personal inspection of different cities: those that lie in southerly or northerly areas, or in the land of the rising or of the setting sun. He must visit cities that are located in valleys as well as those on heights, and cities that use water brought in from outside as well as those that use spring water or rainwater, or water from standing lakes or rivers.

Notice that Galen does not endorse brilliance as a required characteristic of a physician. No, he advocates for the intelligent use of one’s faculties. Indeed, he seems to favor curiosity about the surrounding world as a necessary quality for a doctor.

Curiosity, a desire to discover and a desire to know, is inseparable from a great physician. In residency we are often told by our attending physicians that we must be “lifelong learners.” Curiosity naturally creates lifelong learners. Medicine, after all, is not confined to what one learns in medical school or residency. If it were, our doctors would not be very good. One does not see every disease process in residency, one often forgets certain things, and the evidence and guidelines are forever changing and improving. Thus, we must always be looking up the latest evidence on the diseases we see.

Moreover, there isn’t always a clear diagnosis or treatment, and physicians must scour scientific literature for the answer. When, as so often happens, there is a diagnostic mystery, curiosity works against our inclination towards laziness and forces us to stay on our toes, question what we believe and why we believe it.

Curiosity also aids the clinician-researcher. Physicians since Galen’s time have participated in various forms of research, attempting to answer questions that have not yet been answered. For many of our predecessors the questions were quite basic, given the general ignorance about the world of biology. Yet there are still vast areas of medicine for which answers are needed. The most obvious examples in the specialty of neurology concern brain tumors or diseases like Parkinson’s. The lifespan for patients with certain brain tumors is a year and a half – how does one improve treatments for these virulent neoplasms? For Parkinson’s disease, we can only treat symptoms but cannot slow the disease down – what treatments might reverse this pathology or at least stop it in its tracks? Curiosity drives physician-researchers to make discoveries and to seek answers to these questions.

But there is another characteristic, too, necessary in order to be a great physician. The sheer volume of material one must know and understand about medicine as well as the natural world is enormous and infinite. Because of the infinite knowledge they cannot possibly possess, doctors must also confront this world with humility, humility about how much one must truly know and understand in order to be great.

What was true in Galen's life is doubly true today: There is a vast world of knowledge in the realm of medicine. Humility, like curiosity, provides doctors with a sense of the struggle to accumulate a vast amount of knowledge. It helps them confront the possibility of being wrong. And as I’ve written on this blog, doctors are often wrong. Humility makes us more likely to double-check ourselves, to re-examine the patient when we’re unsure, to look things up when we feel insecure in our diagnosis. It makes us more thorough. It urges us to listen to the opinions of other doctors, of nurses, or even of patients.

What, then, when I watch doctors at work, most impresses me? What, then, makes a great physician? Curiosity and humility are necessary characteristics. There is not a single physician I look up to who does not have both of these qualities. These alone may not be sufficient but I have also noticed that other remarkable characteristics tend to accompany curiosity and humility: kindness, self-discipline, intellectual rigor, equanimity.

William Osler
In his valedictory address to the University of Pennsylvania School of Medicine in 1889 (also known as the essay Aequanimitas) Dr. William Osler, one of the original four physicians at Johns Hopkins Hospital and a legendary professor of medicine at the Hopkins medical school and later at Oxford, discusses the quality that he thinks is most integral to being a physician – imperturbability or equanimity. He writes:

A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions.

What lies behind Osler’s idea of equanimity is an acknowledgement of uncertainty in medicine. And such an acceptance arises first from a humble and inquisitive outlook. Curiosity and humility acknowledge this uncertainty and the need to prepare for it, with equanimity.

Wednesday, January 2, 2019

Medicine as a Vocation

“Hey, doc, come over here!” the patient shouts at me and gestures with a quick wave of his hand as I walk by his room. “I need to show you something. Take a look at this.”

Without waiting for me to ask him what is wrong, he takes out his member and testicles and points at them.

“One of my testicles is swollen. Look! And it’s painful, doc. There’s this shooting pain going up into my stomach. I feel nauseous. Can you get me something for the pain?”

I look at his testicles and feel both of them with my gloved hand. One is certainly larger than the other and the patient winces in pain when I touch them. Though it is close to the end of the day, perhaps ten minutes or so before I sign out to the nighttime physician, I run through the possible diagnoses: testicular torsion (the testicle twists on itself, reducing blood supply and causing intense pain and eventual infarction of the testicle), epididymitis (an inflammation of a certain part of the testicle usually caused by a sexually transmitted disease), a varicocele (the veins of the testicles enlarge due to malfunction of valves within the veins, causing increased pressure and pain), and other, less common pathologies.

At this point, the best next step is to get an ultrasound of the scrotum. This imaging study, which is fairly quick and cheap, gives the physician a sense of the pathological process. Of course, this has to be ordered rapidly because if the patient does have testicular torsion, he needs to be seen immediately by a urologist.

After examining the patient, ordering the test, and calling down to the ultrasound technician to make sure the patient had the imaging study done, it is time for sign-out. But I am in a bit of a bind. It is my responsibility to make sure the patient gets the treatment he needs, but I also have plans with a couple of friends all the way across town. If I leave now, I can make it but will surely be late. If I wait for the study, I will never make it.

I stop by the night physician’s room and let her know that it will be a little bit of time before I sign out because I’m going to follow up on this study. She, understanding my conundrum, tells me to leave and kindly volunteers to take over. Frequently, residents cover for each other in these situations, for we know, given our hectic schedules, how hard it can be to find time to keep up with friends, date, and attend weddings, religious ceremonies or graduations. I jet out of the hospital and just make the crosstown bus in order to show up twenty minutes late.

At the bar my friends and I discuss our respective days at work. And then comes the dreaded question, directed at me: “How was your day?”

I pause as I do when people ask me this question, not because I don’t know what to say, but because there is so much to say I really don’t know where to begin or what is appropriate. Do I tell them how only an hour ago I was examining another man’s penis? Do I tell them about the patient I admitted to the hospital and watched die over the course of five days because his metastatic cancer was so bad that there were no treatment options? How about the time a patient walked into the hallway, pulled his pants down, and pooped on the floor by the nurse’s station?

If I’m honest about the events of my day, I now know the look I’ll receive in return: the eyes widen, the eyebrows go up, the mouth twists in slight disgust and the jaw drops ever so slightly. “Why,” their shocked facial expressions seem to say, “are you telling me this?” The problem is that these stories and experiences not only are a part of work; they become a regular occurrence and a part of life. Resident hours are so long and so intense that, frequently, there isn’t much else to talk about. Anything outside of the hospital feels unnatural to residents; we no longer fit in. Our singular experiences mark us in a sometimes Hester Prynne-like way among our friends and significant others outside of medicine.

Sometimes, too, we mark ourselves not outwardly but inwardly. When I am with friends at a bar or at an apartment sipping on a beer, it will suddenly occur to me that three hours prior, a patient was vomiting on me or dying as I pumped on his chest. The juxtaposition between these two very close moments in time is bizarre.

But even beyond these occasional strange realizations and awkward interactions is something much more expected. When I describe to acquaintances what neurologists do, a typical response goes something like this: “My grandfather is losing his short-term memory — could this be Alzheimer’s?” Or, “my grandmother has Alzheimer’s, are there new discoveries being made on how to cure it?” Some of this is about making conversation related to my job. However, what becomes clear is that you cannot escape the profession. For better and for worse, it follows the doctor everywhere.
In February 2017, Dr. Farr Curlin, the Josiah C. Trent Professor of Medical Humanities at Duke University, wrote a wonderful essay in Big Questions Online about medicine, titled “What Does It Mean to Have a Calling to Medicine?” In it, he explains his hopes that young physicians see medicine as a vocation: “To practice medicine as a vocation is very different [from other professions]; it means putting oneself forward not merely as a physician but in order to become a physician.” And becoming a physician takes “a lifetime of effort.” He compares it to the theological concept of vocation, in which one is summoned or called by God to a certain task. His purpose, I think, is not to portray doctors as gods or medicine as the holiest of professions, but to make clear how absolutely consuming medicine is if taken seriously.

To practice medicine as if it were just another 9-to-5, Dr. Curlin observes, “is akin to play-acting.” One attempts to keep the role at a distance. This is a fool’s errand, as no serious physician can manage it. Any serious approach to the profession necessarily leads to a consuming embrace. I think even of physicians I know who have reached the highest levels of their field, but who still respond to patients’ emails at night after they’ve come home from work; they must be available by phone day and night when they’re on call; they still have to keep up with new research, which they read on their own time; and many even do medical research outside of work hours. This is not to mention the incredible and unsettling statistic that physicians have one of the highest suicide rates of any profession, a rate more than twice that of the general population.

Anton Chekhov via Wikimedia
Dr. Siddhartha Mukherjee, a physician-writer, has considered this dilemma, too. In a stunning essay for The New Yorker, he writes about Anton Chekhov, the great Russian playwright. Chekhov gave up his medical practice to travel to Sakhalin Island, a Russian island in the North Pacific Ocean. At the time it was a penal colony, packed with the destitute and hardened criminals of the Russian Empire. Why would Chekhov travel here? What purpose did this trip serve? Mukherjee argues that Chekhov used Sakhalin “as an antidote.” Chekhov, he claims, had become desensitized to his life as a physician, numb to human suffering as well as to the greater corrupt political struggle in Russia. And it is here, among the detritus of society, where Chekhov discovered sensitivity. This story poses the question faced by all physicians, Mukherjee writes: “What will move me beyond this state of anesthesia? How will I counteract the lassitude that creeps over my soul?”

In one sense, Mukherjee’s essay serves the purpose of encouraging the discouraged, angry, numb physicians. But in another sense it illustrates the point that medicine is a vocation. When patients’ suffering becomes just another task to deal with, physicians falter not just as physicians but as people. Medicine reaches beyond its worker bees and into the hive. It claims physicians as human beings. It claims a part of their souls.

This is not all bad or all good. But it is nearly impossible to dissociate the personal life from the professional life as a physician. Medicine practiced well must be a vocation.

Wednesday, October 31, 2018

Bigotry, Medicine, and Pittsburgh

“You’re one of them wealthy people, from that wealthy family — what are they called? The Rothbergs?”

“You mean the Rothschilds?” I asked.

“Yeah they’re the ones. You’re related to them?”

“No, sir. My last name is Rothstein — different family but same religion.”

Most of the time I don’t hear about race or religion in medicine but often enough I do have interactions with patients about my religion that make me wince. In another instance I saw a patient after a large surgery. I introduced myself and asked him how he was doing. “I’m okay,” he responded. Then, after a pregnant pause, he looked at my ID badge, then my face, and asked, “You’re Jewish, right?”

“Yes, I am,” I responded.

“I have great respect for the Jewish people. You know Jesus was Jewish, right?”

“Yes, I did know that.”

“But you don’t believe Jesus was the Messiah, right? You know, Jesus is our Lord and Savior and he performed incredible miracles while he was alive. Did you know that?”

“Yes, I’ve read some of the New Testament and I’ve spoken with Christians about their beliefs.”

“Well, then, why not believe in Jesus? He built on Judaism. His thinking revolutionized religion. It is the latest prophecy, the latest and truest Word of God. Would you be interested in seeking out Jesus?”

“I appreciate the offer but I’m comfortable with my own religion.”

“Well, you should convert. It’s the only way to seek the real Truth. Jesus is the Messiah and if you don’t convert you won’t be going to heaven.”

“Thanks, but I’m okay. Now, how’s your surgical site doing? Are you still in any pain?”

Sometimes it even goes beyond this. There was a patient I saw regularly in the hospital who would intermittently get aggressive, annoyed, or anxious. The nurses called me to talk him down. One evening he was particularly upset about being in the hospital. I entered his room as the nurse was leaving. “Tell that n***er to leave me alone!” he shouted.

“Excuse me, that is inappropriate. We do not use that kind of language.”

He looked at my name badge and shouted, “Well guess what? I’m Hitler, so I think you should leave.”

This is not to mention a co-resident who was told by a patient, “You’re such a Jew.” Or another patient who told a Jewish co-resident, “All you want from me is a pound of flesh” — a reference to The Merchant of Venice, where Shylock, a Jew, lends money to a Christian and demands a pound of his flesh as security.

These experiences and others I’ve had run the range from threats of violence to humorous to uncomfortable, but there is a theme behind them. Unfortunately, my experiences are not unique. All physicians take care of racist or bigoted patients. In January 2018, the Wall Street Journal published a piece on racist patients, quoting doctors discussing their experiences. In a 2017 blog post by the American Academy of Family Physicians, multiple physicians retold their stories of interacting with bigoted patients. Dr. Lachelle Dawn Weeks, a resident at Brigham and Women’s Hospital in Boston, wrote a short 2017 essay for STAT News chronicling her experience with racism. She concludes that

in an ideal world, hospitals would categorically disavow cultural and religious discrimination. Hospital administrators would publicly refuse to cater to culturally biased demands and express a lack of tolerance for derogatory comments towards physicians and staff as a part of patient non-discrimination policies.

Dr. Dorothy Novick, a pediatrician, wrote in a 2017 Washington Post op-ed that “When I treat racist patients but fail to adequately address the effect of their words and actions on my colleagues, I not only avoid teachable moments; I condone hate.” Dr. Farah Khan wrote in 2015 in The Daily Beast, denouncing bigotry she’s faced in the hospital. She asserts, “We should be taking strides within the medical community to break down unfair judgments and racist ideals.” Moreover, “Of all the things that I had imagined brown could do for me, I never really expected it to make me feel out of place both inside and outside of the hospital.”

These interactions do make a physician’s job difficult. Patients refuse treatment from a particular physician or verbally abuse him or her on the basis of race or religion. A physician cannot offer an argument against this to assuage the patient. And it is difficult to hear or experience these insults and epithets after years of training to help others.

What, then, ought to be done? Many of the physicians I cited above offer condemnation and resolve not to tolerate racist behavior. But in practicality these are non-specific, anodyne proposals. Of course hospitals, and we, should condemn such behaviors. But what does that mean in terms of our conduct in the hospital?

In an earlier post, I’ve written about the more general difficulties physicians regularly experience because of frustrated patients, who may swear at, insult, or even slap us, and since writing those words I’ve been punched or swung at by patients multiple times. I’ve been accused of not caring about my patients, of being a bad physician. This is part of the difficulty of the profession. Physicians and nurses bear the brunt of patients’ frustrations or hatred. And while we can tell patients that their language is inappropriate, part of being a physician is offering our services when they are ill, despite how we might feel about them or they might feel about us.

This is nowhere more true than during war. As I’ve previously written about the role of the Hippocratic Oath in wartime, “The physician ... is responsible only for the good of the patient no matter what uniform that patient may wear. The Oath makes no exception for wartime or for the treatment of an enemy.”

Tree of Life synagogue in Pittsburgh / CTO HENRY (Creative Commons)
One of the most recent and heartening examples of such principled medical practice was after the attack in Pittsburgh this past week, where an anti-Semitic gunman killed 11 Jews in a synagogue, screaming “All Jews must die.” After being injured in a gunfight with police officers, the gunman arrived at a hospital where Jewish doctors and nurses took care of him.

Yes, there are bigots and racists who not only insult those who are different but murder them. However, in the face of such hatred we must continue to offer the patient treatment. To treat patients in their time of acute need despite what they’ve done or said is part of our professional responsibility.

This may strike some as a deeply unsatisfying conclusion. Where is justice? Where is the punishment for these people? Why shouldn’t they face consequences for their hatred? But we see these patients for a brief moment in their lives. Distributing punishment is not our purpose, nor will a refusal to treat them change the way they feel or act. In fact, a physician is far more likely to change such behavior and to make an impact by treating the patient. After that, we trust our legal system to distribute punishment, and hope the prejudiced patients figure the rest out themselves.

Wednesday, September 12, 2018

Is More Medical Testing Better?

“I think this patient needs a CT scan of her chest,” the consulting physician said to me over the phone. “Her lungs sound bad, and given her history, we need to make sure she isn’t developing pneumonia.”

The patient, though only thirty-five, had been through a lot during her hospitalization. She came in a week prior with some shortness of breath, an abnormally high heart rate (tachycardia) and chest pain. But her heart checked out just fine. An EKG was normal and her troponin, a protein that spills into the blood with damage to heart, was undetectable. Because of her tachycardia and chest pain we tested her for a pulmonary embolus, or clot in the lungs, with a CT scan. It was positive. The potentially deadly clot blocks off blood flow coming from the right side of the heart into the lungs causing heart strain and disrupting oxygenation of blood and the functioning of the heart.

We admitted the patient to the intensive care unit where she received IV medication to thin her blood. She recovered but continued to experience residual chest pain that would clear in the months ahead. As we prepared to discharge the patient, the consulting physician, a cardiologist, told us he wanted her to get another CT scan of her chest. She had not had a scan since the initial stages of her workup. What if she developed pneumonia in the interim? Her white blood cell count, often a crude marker of infection, was not elevated. She did not have fevers. When asked, she felt well enough to go home and wanted to leave. Then again, being in the hospital made her susceptible to infection. Moreover, on her physical exam, we heard crackles in her lungs – this sometimes indicates an intrapulmonary pathology. The cardiologist’s concern gave us pause and we ordered the imaging study.
Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover, patients sometimes ask to see a specialist in the hospital: “Can you call the neurologist to come see me?” or “We’d like you to call a cardiologist to see our father while he’s here.” Because consultants share a different knowledge base than the team primarily caring for the patient they may ask for more tests to rule out other serious pathologies that the primary team neglected to consider.

The patient’s repeat CT scan merely demonstrated small collapsed alveoli. These terminal branches of the lungs often collapse when we draw shallow breaths or lie flat for a long time, a typical finding in many hospitalized patients. Given the benign nature of this finding, we discharged the patient. Yet she had received an extraneous dose of radiation and her hospital bill would be hundreds of dollars more. Did she absolutely need this? This common story raises other questions, too. Do patients do better with more specialists seeing them? Do patients do better with more testing?

In a 2012 post for the New York Times Well blog, Tara Parker-Pope pointed out that “overtreatment – too many scans, too many blood tests, too many procedures – is costing the nation’s healthcare system at least $210 billion a year, according to the Institute of Medicine.” And the stories she tells about astronomical hospital bills due to overtesting are disturbing.

In a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk heart failure and cardiac arrest among patients was lower in teaching hospitals during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr. Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced physicians?

Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:

We – both physicians and patients – usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less – even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

When specialists like neurologists or cardiologists see a patient, they approach the bedside from a unique perspective. The pathologies they know and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to recommend workup for a disease potentially related to their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail. This does not always happen, but by nature there is a bias when a consultant approaches a patient – and that bias is toward ordering another test, toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs something and when the best approach is to do nothing at all. Our patient at the beginning of the story did not really need a repeat CT scan. To be sure, the cardiologist didn’t recommend it simply to radiate the patient or increase the hospital bill. But none of us wanted to miss something.

A conservative method of practice can come with experience, but as evident from the JAMA study referenced above, that’s not necessarily the whole story. Some of this, I think, requires thinking regularly about how well the patient in front of the doctor is doing and how a test will change the course of the patient’s treatment. “Will this change our management?” is a question our attending physicians always ask us before we order a test. And it is a question all doctors must ask themselves.

Thursday, April 26, 2018

Reflections on Treating the Poor

It is altogether curious your first contact with poverty. You have thought so much about poverty — it is the thing you have feared all your life, the thing you knew would happen sooner or later; and it is all so utterly and prosaically different. You thought it would be quite simple; it is extraordinarily complicated. You thought it would be terrible; it is merely squalid and boring. It is the peculiar lowness of poverty that you discover first; the shifts that it puts you to, the complicated meanness, the crust-wiping.

- George Orwell, Down and Out in Paris and London

George Orwell’s 1933 memoir, Down and Out in Paris and London, relates the clear-eyed experience of being homeless and penniless. The novel’s protagonist lives in Paris giving English lessons and eventually experiences a stroke of bad fortune and loses his job; money slowly but surely disappears. He is overcome with “a feeling of relief, almost of pleasure, at knowing yourself at last genuinely down and out.”

Imagine, Orwell asks of us, what this bad fortune means. You cannot send letters because stamps are too expensive. At the baker, an ordered pound of bread weighs in slightly more and thus costs slightly more — and you cannot pay for it. You avoid “a prosperous friend” on the street so he won’t see that you’re “hard up.” And you’re hungry. Wherever you walk there are inescapable reminders of this: bakeries, restaurants, coffee shops. “Hunger,” Orwell writes, “reduces one to an utterly spineless, brainless condition, more like the after-effects of influenza than anything else.” Months pass by in between baths. Clothing is pawned. In the midst of this scramble to live, however, one forgets that there is, indeed, a lot of time with nothing to do at all: “you discover the boredom which is inseparable from poverty; the times when you have nothing to do and, being underfed, can interest yourself in nothing.”

Orwell based such descriptions largely on personal experiences. In 1927 he spent time in the company of tramps and beggars in London, dressed in worn-out clothing and sleeping in poor lodging-houses for two or three days. He subsequently moved to Paris and subjected himself to similar experiences. In doing so, he eventually brought attention to the plight of the poor, providing an honest, unvarnished look at what it was like to be down and out.
Rereading the book reminds me of Bellevue Hospital, New York City’s flagship public hospital. Bellevue, or its progenitor, was originally an infirmary in Manhattan in the 1660s and became the most well-known of the public hospitals in the country (I have written about it for Public Discourse). Here physicians treat the uninsured, the undocumented, and the homeless. It is a rare day when a physician at Bellevue does not interact with New York’s poorest residents.

Jim Henderson (Creative Commons)
Sometimes they come in search of medical care and sometimes they come in search of a meal. They stumble in from homeless shelters or from street corners, inebriated, withdrawing from drugs or alcohol, psychotic, suicidal, deathly ill or sober. Occasionally they unknowingly enter the emergency room with lice or bedbugs and nurses delouse them with multiple layers of permethrin, an insecticide. The physician must approach these infested patients with a hairnet, gown, and gloves — the lice crawl on the patient’s head, chest, arms and bed sheets. The smell sometimes overwhelms the doctor or nurse, too. It may have been months since the patient has bathed, and the odor percolates throughout the room and the hallway.

As I wrote in my Public Discourse piece, the patient presentations are frightening and remarkable:

Ride the elevator down, and you will stare in horror as an agitated drug addict with an infection tries to punch a physician while bolting out of his hospital room with security guards and nurses in pursuit. Next door, a homeless patient lies in bed with heart failure. Next to him is a patient who’s visiting New York from Africa with a raging AIDS infection. Peer into another room down the hall, and you can watch patients withdrawing from alcohol or heroin, thrashing about and screaming.

Physicians have the unique privilege at Bellevue to see poverty up close, which so rarely occurs in upper and middle class professions. But as close as we are, we don’t really understand the poor the way Orwell did. We don’t live amongst them or feel the curse of extended hunger or the uncertainty of when the next meal will come. We don’t experience that odd sensation of boredom, where there is nothing to do because one has nothing to do it with. And we cannot fully empathize with their fragile health.
This is why Orwell’s book is so enlightening. At least we get a description of what some of Bellevue’s patients may go through; at least we get a glimpse. It creates a little less space between the comfortable and the impoverished.

But Orwell wasn’t wholly right about the poor. He wrote in Down and Out:

The mass of the rich and the poor are differentiated by their incomes and nothing else, and the average millionaire is only the average dishwasher dressed in a new suit. Change places, and handy dandy, which is the justice, which is the thief? Everyone who has mixed on equal terms with the poor knows this quite well. But the trouble is that intelligent, cultivated people, the very people who might be expected to have liberal opinions, never do mix with the poor.

True, there is a closeness between “intelligent, cultivated people” and the “poor” simply by virtue of being human. However, there are deep differences that would not disappear if the two simply switched jobs and clothing. For instance, in 2016, four percent of U.S. adults experienced a “serious mental illness.” This did not cover patients without fixed addresses — the homeless. And      approximately one fifth of the homeless in the United States suffer from a severe mental illness. Even if the definitions of “severe” and “serious” don’t match up precisely, the difference between mental illness among the homeless and other US adults is huge. And these differences matter both to policy analysts and to physicians.

Two epidemiologists, Elizabeth Bradley and Lauren Taylor, have written a thoughtful book dealing with the issue of rising health care costs entitled The American Health Care Paradox. In it they argue that our skyrocketing health care expenditures (we spend more than double the share of GDP of other developed countries on health care) and poor outcomes (we are in the high 20s or low 30s in rankings among OECD developed countries for maternal mortality, life expectancy, low birth weight, and infant mortality) are not due to overspending, but rather to underspending by the United States on social services — affordable housing, education, access to healthy food, and so forth.

Bradley and Taylor explain how this happens:

Several studies have demonstrated the health toll of living on the streets; more than two-thirds of America’s homeless population suffer from mental illness or substance dependency, while nearly half have at least one additional chronic condition such as diabetes or hypertension. The high costs of health care provided to people who are homeless have been well documented. For instance, in one five-year period, 119 people who were chronically homeless and tracked by the Boston Health Care for the Homeless Program incurred a total of 18,834 emergency room visits estimated to cost $12.7 million.

This makes sense. Many of our homeless patients deal with chronic diseases like diabetes, mental illness, or congestive heart failure. We stabilize them in the hospital and send them back to a shelter or the street. Often they return the next week with exacerbation of their heart failure or sky-high blood sugars or psychosis, even when medication is provided by the hospital without charging the patient.

Thus a chasm separates our world and that of the poor, yet they are entangled. How can you get someone to start eating vegetables and fruits and whole grains in order to mitigate the effects of diabetes if they don’t have money to buy these foods? How can you control a child’s asthma if a family does not have money to clean their apartment and rid it of the vermin, bugs, and dirt that pervade the nooks and crannies? How can you ensure a psychotic patient takes his medication when he can barely feed himself? The homeless face a very different and more intimidating set of difficulties than the wealthy. And these translate into challenges for physicians, who do not have the time or skill to be both doctors and social workers.

We, as physicians, care for the patients until they are ready to leave the hospital. Then they face their poverty on the street. Our view is but a brief and skewed snapshot. In our myopic hospital world, the hospital stretcher is detached from daily life. And this is necessarily so, to a certain degree. Physicians can only do so much to fix societal ills — they cannot create a job, a safe home environment, or a loving family for the patient.

Nevertheless, both wealthy patients and poor patients succumb to cancer, strokes, and heart attacks. Both undergo the humiliating process of death and dying. In this sense, death and disease are often great equalizers. Neither the poor nor the rich can escape them. They rapidly close the chasm between the two classes. And at least in that vein, Orwell was right.

Tuesday, February 6, 2018

Locked In: What It's Like to Be Fully Paralyzed

On Friday, December 8th, 1995, Jean-Dominique Bauby, the 43-year-old French editor of the fashion magazine Elle, suffered a major stroke. He was behind the wheel of his BMW after picking up his son, and suddenly felt as though he were “functioning in slow motion.” His vision blurred and he broke out in a cold sweat. He barely managed to get himself and his son to the home of his sister-in-law, a nurse, who promptly took him to the hospital. At this point, Bauby could not speak or move his body. He slipped into a coma and woke up twenty days later to find that he was completely paralyzed except for his left eyelid. He could hear, see, and feel but could not move or speak — a condition known as locked-in syndrome.

Bauby’s once vigorous and ambitious life was reduced to a hospital bed in a rehabilitation facility at Berck-sur-Mer in northern France. Despite this fate, Bauby managed to “write” a book using eye blinking, The Diving Bell and the Butterfly (1997; adapted for the screen in 2007). His assistant slowly listed the letters of the alphabet and Bauby blinked his left eye to indicate the letter of choice. And so he wrote the book, letter by letter. Two days after its publication, Bauby died of pneumonia.

The French editor experienced a rare stroke in a relatively small area of the brain. In most cases a stroke, or death of brain tissue, is due to the blockage of an artery (ischemic stroke), but strokes can also be due to bleeding (hemorrhagic stroke). In Bauby’s case, a clot likely wedged itself into the basilar artery, a vessel supplying blood to the cerebellum and brainstem. This caused an ischemic stroke in an area of the brainstem called the pons. Because the brainstem connects the spinal cord to the brain, all of the motor fibers from the body converge here as they move up into the cortex. Given the relatively small size of the brainstem, it is unfortunately possible to knock out nearly all of these motor tracts, leading to Bauby’s clinical presentation.

I thought about the book and its author after encountering a patient experiencing a similar tragedy. Like the French editor, she was relatively young. She was a writer, too. She had collapsed in a supermarket and opened her eyes to the cold and dark reality of complete paralysis, relying on a ventilator to help her breathe. I saw her every morning for two weeks. I listened to her heart and lungs or drew her blood. When she opened her right eye on a regular basis, we asked our speech pathologists to help her communicate. They trained the patient to look up for “yes” and down for “no.”

There were days when the patient was too exhausted to participate in these exercises or when she had an infection, or seemed to decline and failed to answer or understand basic questions asked of her. Her mother sat at bedside each day conversing with her and encouraging her. In these situations we typically speak with family members about the goals of care for their loved ones. What would the patient say if she could speak? Would she want us to do everything we could to keep her alive, such as cutting a hole in the throat, a tracheostomy, so she could breathe without a breathing tube? Or would she want us to withhold surgeries? These are always difficult discussions for doctors and family members as we all attempt not only to predict what the patient would want but also to separate ourselves from what we want. The mother, however, did not hesitate — she asked us to do everything to keep her daughter alive.

What, indeed, would the patient say if we asked her? And what was she experiencing at that very moment? Fortunately, Bauby left behind a view into the world of locked-in patients. They are very much aware of the world around them even if they cannot demonstrate it. Some of this occurs within the imagination, as Bauby writes: “You can visit the woman you love, slide down beside her and stroke her still-sleeping face. You can build castles in Spain, steal the Golden Fleece, discover Atlantis, realize your childhood dreams and adult ambitions.” These fantasies can bring relief to patients:

For pleasure, I have to turn to the vivid memory of tastes and smells, an inexhaustible reservoir of sensations.... Now I cultivate the art of simmering memories. You can sit down to a meal at any hours, with no fuss or ceremony. If it’s a restaurant, no need to call ahead.... Depending on my mood, I treat myself to a dozen snails, a plate of Alsatian sausage with sauerkraut ... or else I savor a simple soft-boiled egg with fingers of toast and lightly salted butter. What a banquet!

But rumination can turn to tragic thoughts as well. Bauby thinks of his ninety-two year old father who can no longer descend the staircase of the apartment building. Bauby used to shave his father; now someone needs to shave Bauby. He watches his children play and feels them embrace him without being able to respond.

Such helplessness leaves one vulnerable to the outside world, too. An ophthalmologist examines Bauby without his consent — Bauby cannot tell this physician to stop. He is aroused by the terrifying sight of a doctor standing over him while sewing up his non-functional eye. After all, when a patient lies in bed without speaking, it can be tempting to see him or her as a specimen rather than as a human.

What is most disturbing, though, is the way life seems to march on without Bauby. He writes,

I am fading away. Slowly but surely. Like the sailor who watches the home shore gradually disappear, I watch my past recede. My old life still burns within me, but more and more of it is reduced to the ashes of memory.

When doctors bring him to Paris for more specialized examinations, Bauby notices the building where he used to work and people he used to know, all engrossed in the day-to-day business of life, while he is seemingly frozen in time: “The treetops foaming like surf against glass building fronts, wisps of cloud in the sky. Nothing was missing, except me. I was elsewhere.”

Jean-Dominique Bauby’s book is tremendous and beautiful not simply because his story and words are so affecting. It gives voice to the patients we are often tempted to brush off — there is a person within the heavy immobile flesh. And if there is a book inside the mind of one, of course there are books inside the minds of others. (However, as I’ve pointed out elsewhere, great accomplishments are unnecessary to demonstrate the value of a human life.)

Thankfully, locked-in syndrome is not a death sentence; nor is it necessarily a fate worse than death. Patients can recover after such a devastating injury. The Guardian published a story in 2012 about a patient who regained most of his motor function after being locked in. A 1995 study of 11 patients with locked-in syndrome found that all of the patients regained enough control of fingers or toes to use a digital switch. In a 2003 study, authors concluded that five- and ten-year survival rates for patients with stable locked-in syndrome were 83% and 83% respectively (that number dropped to 40% at twenty years). Of the patients in the study, only one wanted to die, but seven of them never even considered euthanasia, while six did but rejected it.

To become locked-in is not the end. This should give us pause about withholding aggressive treatment from these patients. They are still very much with us, and with luck and modern medicine perhaps we can bring parts of their bodies back.

Wednesday, December 20, 2017

When Doctors Are Wrong

As medical students and resident physicians gain experience they also gain knowledge and confidence. Consequently, young trainees eventually reach a level of comfort in speaking with families and patients about prognosis and disease course. This is part of the purpose of training, as these conversations happen so often that they are an integral part of practicing medicine. But it isn’t certain that with experience and confidence also comes accuracy.
Soon after finishing sign-out on a night shift I received a page. The nurses told me that a patient’s daughter had arrived and wanted to speak with me about her father. The patient was an elderly but relatively healthy gentleman who had been admitted with abdominal pain. Multiple imaging studies had shown little to account for his discomfort. But the pain was so intense that he could not eat anything. Even going to the bathroom was difficult — he held in his stool to avoid the agonizing act of defecating. As a result, he became constipated, which then exacerbated the pain. Thus, the medical team administered anti-inflammatory treatments, stool softeners, and IV fluids as they searched for the etiology of this troublesome symptom.

The patient’s daughter asked me about the latest imaging studies and labs as she sat holding her father’s hand. Buried to his chin under the covers, the patient participated in the discussion, asking when he would be able to eat and go to the bathroom easily again. I explained that all the tests had been negative so far and we were unsure of what was going on. I then left the room, and the daughter caught up to me in the hallway. She seemed worried, speaking hurriedly and pleadingly: “How long do you think my father has left to live? How much time do I have left with him? Should I start making funeral arrangements?”

The questions took me aback. I had seen plenty of patients in the intensive care unit who were on the verge of death and they looked so different from her father — a profound pallor, somnolence, lethargy, disinterest in conversation and food. But this patient wanted to eat again, he wanted to see his family, he wanted to watch basketball on TV, and he was interactive and conversational. His cheeks certainly did not exhibit the deathly pale hue of those crossing over to the other side. I assured the daughter of this: “I don’t think you have to worry about that. The most important thing right now is that we figure out what is going on. I can’t tell you how long he’s going to live but I would be shocked if he had only days or weeks left.”

This interaction repeated itself for the next three nights, always with the same diagnostic uncertainty. On further imaging there was evidence of some abnormal fluid in the abdominal cavity. Interventional radiologists extracted the fluid to test it for any cancerous or infectious cells, but it would take perhaps a week or more for definitive results to come back. In the meantime, the patient’s pain improved and he moved his bowels without issue. Even though we didn’t yet have a diagnosis he seemed to be doing incrementally better each day.

On the fourth night I again saw the daughter and she asked: “You don’t think I should be planning the funeral for my father, do you? He’s not going to pass in the next few days?” I understood why she was asking the question — any child ought to be concerned for the well-being of a parent. But I was also surprised because her father was on the mend. I told her that if he continued to improve he would leave the hospital, and his primary care doctor would follow up the lab results and see him in clinic.

At around 2 a.m. that same night, a voice over the hospital loudspeaker echoed throughout the halls as I jumped out of my chair: “Code blue, 7th floor, code blue, 7th floor.” There was a patient in cardiac arrest. I ran out of the workroom and met up with another resident. Which patient was dying? On my way to the code I ran through the patients on the coverage list that evening; I did not expect anyone to pass away. As the other resident and I ran down the hall I saw the code cart containing all the medical resuscitation equipment necessary to treat cardiac arrest outside of the room I had visited every night for the past four nights. My heart leapt out of my chest; I pleaded with some higher power that it not be that patient. But it was.

The resident, nurses, and I immediately began CPR. The anesthesiologists burst into the room and stuck a tube down the patient’s throat and into his trachea to protect his airway as the respiratory therapist attached the tube to a ventilator to help the patient breathe on his own. After multiple rounds of CPR, his pulse returned. We wheeled the patient — attached to tubes, and poles filled with intravenous fluids — to the ICU for closer monitoring. He didn’t respond to our questions or poking and prodding, but he was alive.

Alas, as soon as we got to the ICU, his heart once again stopped beating and his IV line ceased working — his veins (which can happen as we age) were friable and brittle, and the small vein carrying the volume and force of the IV infusions burst. Without an IV we could not give medications. We turned, then, to an intraosseous (IO) line. This entails drilling a hole into the bone and infusing medications through that hole. It is a proven method of administering medications when physicians and nurses cannot obtain IV access. I opened the IO kit and attached the drill to the IO needle, placing it on the shinbone and drilling. It slid into the bone, I detached the drill, and hooked up the IV tubing to the IO line jutting out of the patient’s bone. At this point, the code had been going on for nearly 15 minutes and the patient’s family had arrived. They watched as we furiously attempted to revive their loved one. At some point a family member shouted “Stop, please, enough!” Time of death: 2:45 a.m.

I sheepishly held my head down, avoiding eye contact with the family as they sobbed. The medical team and nurses quietly left the room, leaving the patient in peace. As I passed by the daughter, I could only say “I’m so sorry” — little else would have sufficed. Not only did we not save him, but night in and night out I had given the daughter a false impression that he wouldn’t die. Perhaps, I wondered, I had been disingenuous in some way. Either way, I was wrong.
Alas, physicians are wrong relatively often, and there is ample evidence for this. In a systematic review in the British Medical Journal in 2012, researchers found that each year up to 40,500 adult patients in American ICUs die with a misdiagnosis. The Journal of the American Medical Association published an analysis in 2009, concluding, among other things, that “while the exact prevalence of diagnostic error remains unknown, data from autopsy series spanning several decades conservatively and consistently reveal error rates of 10% to 15%.” The American Journal of Medicine published a separate analytic review article in 2008, concluding that diagnostic error occurs up to 15% of the time in most areas of medicine. The authors further theorized that overconfidence often accounts for at least some of the errors. These reports have reached a wide audience in the laymen’s press as well. In 2015, the Washington Post published an article indicating that diagnostic errors affect 12 million adults each year. The impacts of errors, as we see in the story above, don’t just involve the patient but the patient’s families, too.

Though these statistics are shocking, it is almost impossible, from the patient perspective, to look at them and subsequently be skeptical of everything a doctor says. After all, we are not only practically but also emotionally dependent on them: We want reassurance from our physicians and we want definitive answers. As a patient, it is frustrating to hear “It may or may not be cancer and we can’t be sure” or “I don’t know how much longer she has left.” Indeed, when the path ahead of us is no longer clear, we turn to physicians for answers because of their experience. We want them to be the kinds of people none of us can be — always right, always knowledgeable, always calm and composed. But they are fallible, despite the impossibly difficult and long road they’ve traversed.

And what can we as physicians take away from this? Doctors want to be the kinds of people their patients expect them to be. But the statistics of medical errors are the reminders of how impossible that is; how many years of studying and experience are necessary even in order to be competent; how difficult, despite the many exams we take and pass, it is to apply knowledge appropriately. Not only are we fallible, but the science we rely on is not always helpful either. Indeed, the best studies are useful merely for inferring what will probably happen — they do not tell us definitively what will happen to the patient in front of us. Moreover, scientific evidence does not exist for every treatment in every situation or every diagnosis in every situation. Once again in medicine, our ideal does not match with the real, and our preconceived notions are sometimes shattered in moments of frustration and uncertainty. Perfection is unattainable, but we must constantly seek it out, always aware of how out-of-reach it lies.

When patients and their families now ask me questions about prognosis or treatment I always preface what I say with: “Nothing is 100% in medicine.” Though I will be wrong again in my career and will, hopefully, learn from my mistakes, I never want to give a false impression. We often tend to ignore uncertainty or wish it away, but we must always remind ourselves, whether as patients or doctors, that no doctor and no science is perfect.

Monday, November 27, 2017

A Biopsy

There are certain patients who never fade from a doctor’s memory — they make an indelible imprint on one’s training. Thinking back on these patients and their respective hospitalizations is like gazing through a pristine window pane on a clear, sunny day. Often they stick in our memories because one becomes emotionally invested in them or because there is some interesting disease or singular clinical outcome. The former patients usually affect us more deeply.
Blood cells from a patient with Leukemia
(Prof. Erhabor Osaro via Wikimedia - CC)
I can tell you her name, age, and favorite foods to eat and cook. I recall, without difficulty, how many children she had, her religion, where she grew up, traveled and met her husband. I can even recreate her hospital room in my mind — family pictures across from her bed, a knitting kit on her nightstand next to her laptop computer, a plastic storage bin with clothing and candy.

She was in her fifties and had been diagnosed with leukemia, a cancer of the blood. There are different types of leukemia, but in general, patients with leukemia have bone marrow that overproduces certain infection-fighting cells, or white blood cells. Some of these cells function normally, but many do not. They overcrowd the marrow, preventing it from making red blood cells and platelets. If there is a high enough number of them, they clog up blood vessels. And eventually, the cancer kills you.

Treatment of leukemia involves rounds of chemotherapy, potent drugs that arrest cell growth or division by acting on a specific stage in a cell’s reproductive cycle. Each of these drugs targets different aspects of quickly dividing cancer cells. But they also wreak havoc on the body’s normal cells, causing nausea and vomiting, hair loss, heart damage, kidney damage, and liver damage. Unavoidably, the therapies for leukemia have serious, sometimes intolerable side effects.

The goal of prescribing such potent medications is to wipe out all of the cancer cells. But it is especially important to wipe out the “stem cancer cell” — that is, the original cell or group of cells causing this tempest. If you can’t kill those cells, you cannot cure the cancer; they divide and produce more defective, parasitic, and deadly neoplasms. For certain patients a bone marrow transplant is the best hope for a cure. Chemotherapy wipes out one’s own bone marrow and cancer cells to make room for the transplant, which does not contain the same cancer progenitors. The donor’s marrow must match the patient’s marrow; the cells produced from the transplant must be sufficiently genetically similar to the patient’s or the white blood cells from the donor tissue will attack the patient’s own body.

Our patient had gone through multiple rounds of chemotherapy, all of which failed. She had found a match for a bone marrow transplant, though, and was going to try a new combination of chemotherapeutic drugs to wipe out her bone marrow in preparation for the procedure. This process takes weeks. Thus, she lived in the hospital, receiving family along with friends from church. During the afternoons, after rounds, I would come by and chat with her if she wasn’t too exhausted or sick. Our conversations wandered from religion to food, travel, and family. We talked about history, too. She was a Civil War buff and had no trouble discussing her favorite historical figures from that era and her favorite speeches.

She possessed a seemingly infinite amount of patience and kindness given the circumstances. I never once heard her bemoan her situation. She wanted, I think, to be treated as she had always been treated, even as the reality of her prognosis set in. If she hadn’t had children, she once mused to me, she would have given up after the last round of chemotherapy failed and opted for palliative care. But her children were too young to lose their mother, and so she hoped to live on. So we hoped with her, attempting just once more to extend her life.

At a certain point towards the end of the chemotherapy regimen, we extract bone marrow from the patient and look at the marrow under the microscope with a pathologist. A hematologist aspirates the sample using a large needle and spreads it onto an approximately three-inch-by-one-inch slide. The oncologist, pathologist, residents, and students look at the small sample of tissue. Ideally, there are very few cells and almost no cancer cells. Otherwise, the chemotherapy has failed and the transplant cannot be done. As the pathologist moved the slide of our patient’s marrow around, large dysmorphic cells popped into view. There weren’t a lot of them, but they were noticeable and they were cancerous. I heard the pathologist offer up a disappointing, “Hmmm.” No, as it turns out, the chemotherapy had not killed enough cancer cells to make the bone marrow transplant worthwhile. Tragically, the patient would soon die.

It is strange, is it not, that this human being’s outcome depended on an inch-wide sample of bone marrow? We do not think of people as bundles of organs and cells but as whole, complete beings. We think of people abstractly or even holistically — character or personality, physical and mental abilities, age. Who cares about the cells in their marrow? What bearing does that have on the life to be lived? But it matters much more than it seems. This small sample ends a life or gives fresh winds to a sick life. It is counterintuitive to the way we think, but it is how we make decisions in medicine. We treat the person but we also treat the disease. If the disease still exists and runs rampant within the body, the person, no matter how admirable, familiar, and recognizable, will perish.

Friday, August 4, 2017

The Case for “Pimping” in Medical Education

Illustration by William Sharp (National Library of Medicine)
“What are some common causes of pancreatitis?”

The attending physician looked at me as we stood outside of the patient’s room. It was as if she had turned a stage light on over my head while medical students and residents silently waited at my flanks, watching with bated breath. I stammered and said, “alcohol.” 

“And what else?”

This time the question was directed at another medical student. I breathed a sigh of relief. It was my first time experiencing what everyone in the medical field calls “pimping.”
On rounds in the hospital, attending physicians “pimp” — that is, publicly interrogate — medical students and residents about various aspects of disease and disease treatment. Physicians have practiced this method of teaching and testing for years.

Dr. Frederick Brancati popularized the term in “The Art of Pimping,” a 1989 article for the Journal of the American Medical Association that satirized the practice. He humorously (and seemingly apocryphally) tells us how the word was first used in the seventeenth century by Dr. William Harvey, the physician who discovered the circulatory system. Harvey allegedly said of his students:

They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!

Brancati continues with his satirical history by relating how William Osler, the father of modern medicine, used the method and its moniker in the United States. Abraham Flexner, an educational reformer and eponymous author of the Flexner Report, which detailed the failure of American medical schools to teach science properly, supposedly described Osler’s method in his diary:

Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.

(For what it’s worth, neither the Oxford English Dictionary nor Merriam-Webster list this usage of the word. But one irked respondent to Brancati’s article offered an alternate etymology, arguing that pimping is actually a malapropism of pumping, meaning “to question persistently.” The writer insisted on correcting the record, “Lest this word, possibly used as a sensational catchword, become a neologism.”)
Pimping, though used often in the hospital, does not comprise the bulk of medical education. Prior to the third year of medical school, a student’s knowledge is tested with a plethora of multiple-choice exams. Some of these are higher-stakes than others. For example, one must pass Step 1, the first of three exams comprising the medical licensing process, in order to apply for residency, and one’s score determines where one trains.

It might seem, then, that pimping takes a back seat to such exams. But in reality they complement and build on each other. Given that Step 1 is a multiple-choice test, if you can recognize the answer then you can get the question right — you don’t have to be able to recall it from memory.

But pimping takes medical education to a different level. Not only does one have to recall the precise answer from memory when being pimped, but one has to do so in a kind of theater, in front of the whole medical team and, occasionally, the patient.

To answer these unpredictable questions correctly, one must know a great deal and demonstrate that knowledge under great stress. This is very difficult indeed. The cellular and sub-cellular aspects of human biology are dizzyingly complex. Proteins, hormones, cell membranes, hemoglobin, acids, bases, and many more players all interact with each other in different ways. The biochemical and cellular processes merge together into systems like the cardiovascular and nervous systems. One could study these systems for years and still not be comfortable with them. And they all affect each other. The kidney can compensate for a respiratory issue. The respiratory system can change because of a musculoskeletal issue. One has to understand these interactions to treat disease. Consequently, a medical education must be broad and deep.
How does one memorize or even recognize all of this information? One method involves creating mnemonics or poems. This is a perennial trick used not just by medical trainees but by religious groups as well.

In an article for Aleph, Maud Kozodoy explores this technique within the medieval Jewish tradition. Medieval Jewish scholars used poetry to memorize religious and medical facts. As Kozodoy writes, “versification facilitates memorization.” Moreover, “verse preserves the integrity of a given text or, putting the point negatively, reduces the possibility of its corruption.” Galen, the famous Greek physician of the second century AD, recognized this:

drug prescriptions in verse form are more useful than those written in prose with a view not only to memory, but also to the accuracy of the proportion in the mixture of ingredients.

Kozodoy offers another example, translating from the Hebrew a verse by Yannai, an Israelite poet circa the sixth century AD, “based on the rabbinic dictum that the 248 limbs/organs of the body correspond to the 248 positive commandments given at Mount Sinai”:

Then, two hundred and forty-eight limbs / You fashioned in man and attached to him. // You chose thirty for the soles of [his] feet / accustoming them for good and for evil. // You decreed ten for [his] feet / so that they would not the receiving of the ten commandments.

Modern medical education draws from this rich tradition of versification. Though we don’t typically memorize poems in medical school or residency, we do come up with short phrases that allow us to retain important information. Take, for example, the side effects of an anticholinergic medication like diphenhydramine (Benadryl), which blocks acetylcholine receptors in the nervous system. Most students and physicians memorize the overdose effects using the following short mnemonic:

Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter.

When you overdose on anticholinergic medications your body temperature increases, your pupils dilate, your skin dries up and flushes, and you can become delirious. We try, whenever possible, to find mnemonics like these when studying for exams, as they often make memorization easier.
Another method that helps us memorize information, though it sometimes goes unrecognized by its victims, is being the target of pimping. This makes pimping both a way to test knowledge — as in the story that opened this post — and a way to accumulate knowledge.

An attending physician once pimped me about the treatment for a pulmonary embolism, a clot that has migrated to the lungs and cut off blood supply, leading to rapid deterioration and death. One of my answers was to use nitroglycerin, a drug that causes vasodilation.

But I was very much wrong. The attending immediately said to me in front of the whole team, “you’ve just killed your patient.” Because nitroglycerin dilates vessels, it decreases the pressure of blood being pushed into the heart, and consequently decreases the force with which the blood is pushing into the pulmonary circulation and bypassing the embolism. If you do this, the body can no longer push blood past the clot, and you can die.

I will now never forget this fact. It was a stark reminder of how much more I had to learn, especially given how terrifying the consequences of my treatment would have been had I used it on a real patient.

Pimping is equal in potency to poetry and mnemonics in searing facts into one’s memory.
Recently, there has been some controversy over pimping as an educational method. Dr. Dhruv Khullar, a physician at NewYork–Presbyterian Hospital, wrote in a post for the New York Times’s Well blog that this style of teaching, in which we are only expected to demonstrate how many facts we know, “encourages us to learn to show, not grow — to project confidence, and dismiss uncertainty.” Suzanne Gordon, a medical journalist, wrote in a blog post for the British Medical Journal that pimping discourages health care providers from admitting mistakes:

If a fundamental communications skill learned in medical training is to confidently communicate knowledge that one does not actually possess, never express doubt, and avoid at all cost embarrassing a medical superior then patient safety truly becomes a mission impossible.

But this seems to miss the point. Pimping, if not done maliciously, is an effective exercise in testing and teaching. After four years of medical school and two years of residency, I still get pimped and there is still much that I do not know. Every question directed toward a student or resident is also a lesson in humility, about how much there is to learn.

What we need instead, as Dr. Khullar argues, is a shift in attitude about what it means to get something wrong.

As part of the learning process in medical school, students should be encouraged to fail, and to learn from those failures so that they better succeed as physicians. As a 2012 study in the Journal of Experimental Psychology: General demonstrated, children actually perform better in school if they are told that failure is a normal part of the learning process. They have a better working memory and are more effective in solving difficult problems.

Failure also teaches us to adapt because we remember what to do when the same situation arises again. When I face a real patient with a pulmonary embolism, I am certain I will not give that patient nitroglycerin.

There is a relatively small and brief price to pay for getting a question wrong while being pimped. But the stakes are far higher when you are the one making the decision about a real human being. And to learn from such failures as a medical student is in the best interests of both the budding physician and of his or her future patient.

Editor’s Note: This post has been updated to clarify that the poem by Yannai was not specifically written for use in medical education.