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.

Tuesday, April 18, 2017

The Burden of Medicine on Mt. Kilimanjaro

The imposing mountain of Kilimanjaro in the East African country of Tanzania stands alone amidst the surrounding flatlands and swallows up the horizon with its snow-capped peaks. At once alluring and intimidating, its enormous size provides the kind of thrill and sense of wonder that a child must feel when it becomes conscious of the seemingly infinite universe. This impression, I imagine, drove explorers a hundred and fifty years ago to try to climb the mountain’s approximately 19,000-foot peak. In 1861, for example, Baron Karl Klaus von der Decken, a German explorer, attempted to summit Kilimanjaro with English geologist Richard Thornton. Poor weather prevented the completion of their trek. A year later, von der Decken tried again, but once more the weather stymied his ascent. Others made further unsuccessful efforts in the decades that followed, but in 1889 a German geologist, Hans Meyer, and an Austrian gym teacher and mountaineer, Ludwig Purtscheller, became the first to reach Kilimanjaro’s highest peak.

Since then, thousands have traveled to Tanzania to brave the altitude and sub-zero temperatures and to climb the mountain. A friend and I, during our last year of medical school, were two of those people. We wanted to do something truly unusual, a trip that would take us as far as possible away from the hospital to a world we might never get a chance to see again. It is not unusual for fourth-year medical students to take a trip like this — a last hurrah of sorts before graduation. And, of course, one hopes that after separating oneself from medicine one would return to the hospital world refreshed, motivated, and ready to begin the grueling process of residency.

My friend and our guide, about two days before reaching the summit of Mt. Kilimanjaro.
Photo: Aaron Rothstein

One of the most notable aspects of climbing Kilimanjaro is of course its high altitude. Because the partial pressure of oxygen in the air decreases as one ascends, tissues within the body require higher volumes of blood to get the same amount of oxygen. For comparison, at Mount Everest Base Camp on the Nepalese side (at 5,360 meters or 17,600 feet elevation), the partial pressure of oxygen is half of what it is at sea level; Kilimanjaro stands at around 5,900 meters or 19,300 feet. At these heights the body must adjust to compensate for the drastic decrease in oxygen availability. During the earliest stages of exposure to high altitude, the respiratory rate increases to take in more oxygen, the heart rate goes up to deliver more oxygen to the tissues, and the blood concentrates oxygen-carrying hemoglobin by getting rid of excess fluid (this is called altitude diuresis and it is why one urinates more at higher altitudes). Then, if one spends several months at high altitudes, the body further adjusts by increasing the number of red blood cells through the release of erythropoietin, a hormone that acts on the bone marrow to increase red blood cell production.

The way exposure to high altitude manifests itself on a step-to-step basis is remarkable. As my friend and I ascended, it became more and more difficult to hike. Shortness of breath plagued us at slight inclines or fast-paced walks. Eventually, at the top, the slow slog felt like a sprint, our bodies desperately crying out for air. But it wasn’t just this odd sensation that was new to us. Climbing at these altitudes comes with certain risks, some of which can be deadly and which we got to experience up close.
The night we began our hike we awoke close to midnight, unzipped the tent, and stepped out into the bitter cold night air. The stars playfully glistened in the clear sky reaching out in all directions. We drank hot tea, ate some porridge, and headed on our way. Despite the brightness of the moon, we needed headlamps to see the details on the path before us, especially as ice covered every inch of ground. In the distance we saw other trekkers only by the small lights of their headlamps, tens of them slowly ascending, enveloped by darkness.

But there was one light that seemed to be getting closer rather than farther. And it seemed to be trembling, its owner unsteady. It was an unsettling sight, but we couldn’t keep looking as we were in the midst of trying not to fall, while also sipping water from our backpacks almost continuously so that it wouldn’t freeze. When we finally managed to look up again, the light was much closer and we made out two people in the pitch black: one was a Tanzanian guide and the other was a Caucasian hiker leaning on the guide for support. As they passed us the hiker slipped, barely able to stand on his own feet. We turned around and asked what had happened: “He fell and hit his head and a team is on the way to come help him down,” the guide answered. It seemed unusual that a head injury would make a patient this unsteady. But there were no medical supplies, no places for a med-evac to land, and no oxygen tanks. The only option for the hiker was to get down to base camp as quickly as possible. So the patient’s guide continued on, supporting the man as they descended the mountain.

What had actually happened was something far more serious. The hiker had High Altitude Cerebral Edema (HACE). People who live at low altitudes and suddenly ascend are at risk for this particularly affliction and it can occur at altitudes anywhere over 8,200 feet. Symptoms initially include altered mental status, unsteadiness or dizziness, nausea, vomiting, headache, and drowsiness, progressing over hours to days. With decreased availability of oxygen, there is an increase in the body’s stress response leading to vessel dilation and increased blood flow to the brain. Pressure increases within the vasculature of the brain as autoregulation of pressure is impaired. Fluid leaks out from the cerebral vessels, creating higher and higher pressures within the fixed compartment of the skull. With no place left to go, the brain herniates downward through the foramen magnum (the hole in the base of the skull through which the spinal cord connects with the brain). This will cause death.

The best treatment for HACE is to descend as quickly as possible to lower altitude. Supplementary oxygen can help, as can steroids (to decrease swelling), but these are merely temporary fixes to a deadly problem. And that night, the climber, with no oxygen, no steroids, and no chance of descending in time, died from HACE shortly after we passed him. On our descent we found out the news and even saw his body. A blanket covered the outline of a human form, still, silent, with no chest rise or fall.

The moment, in some respect, tainted our trip. Was there more we could have done? It appeared to be a hopeless situation and, in the thick of that night, gasping for air in the freezing cold as we let the man and his guide move on, we wondered if there was more. Nevertheless, short of helping him down, which would not have happened in time to prevent his demise, there was no equipment, no medication, no treatment we could have offered.

Mt. Kilimanjaro, about one day before reaching the summit. Our path took us around to the other side of the mountain before our final ascent.
Photo: Aaron Rothstein
In the 2015 New York Times article Is There a Doctor in the Marriage?, the writer Anya Groner discusses her husband’s grueling hours as a doctor. After he assists with a medical emergency during a plane ride, she realizes that he is, in some sense, always on call. Work is ever present. Whether there is turmoil in one’s thoughts about a patient or whether one is being asked advice by friends or family, the profession demands constant alertness and preparedness. Even on the slopes of Kilimanjaro, which only a century and a half ago hardly anyone dared to climb, medicine followed us. If we have any sort of conscience, there is no escaping the practice of medicine. This is why we must love what we do, but it is also why we must be prepared to live with it wherever we go.

Friday, March 17, 2017

The Face and the Person

I carry the plenum of proof, and everything else, in my face.
Walt Whitman, Leaves of Grass

The importance of the face in human interactions from the day we are born cannot be overstated. Infants, even if they are blind, communicate their feelings to their parents in large part through facial expressions. For children and adults, so much of what we comprehend about people’s feelings involves interpreting a glance, a smirk, or raised eyebrows. And there has been research suggesting that our own facial expressions can affect how we feel — what is called the “facial feedback hypothesis.”

I didn’t fully understand the importance of facial communication, though, until I met patients with illnesses — such as Parkinson’s Disease (PD), depression, and schizophrenia — that drastically alter a person’s ability to express thoughts and feelings through small movements of facial muscles. When meeting patients afflicted in this manner, I don’t know how they receive my questions or explanations. I don’t know if they’re upset. I can’t tell what they’re going to say next. The emotionless face, so empty and devoid of character, can be frightening; a person seemingly unaffected by emotion is capable of almost anything. Of course, these patients experience emotions of all kinds. Their faces just don’t exhibit them.

Leon Kass writes in Toward a More Natural Science about the importance of emotions expressed through the face, for instance in blushing. This can help us to think about patients with limited facial communication.

Blushing, like many facial expressions, “is not under our control.” Moreover, blushing is the “involuntary outward bodily manifestation of a very complex psychophysical phenomenon.” Mental states induce blushing: shyness, modesty, embarrassment, shame. Many of us blush when we’ve done something wrong, know we’ve done something wrong, and are scolded for doing so. It is, in certain respects, a public proclamation of shame. Similarly, the furrowing of the brow, a smile, and a frown are also public manifestations of mental states. All this indicates that we are social beings and cognizant of those around us. To wit, Kass argues that blushing requires a notion of the self, a concern of how one appears to others, and an “awareness that one is on display.”

The same is not always true about every facial expression, but it is certainly applicable in most circumstances. When we laugh at someone else’s joke, or cry when wronged in some way, we can do so alone. But more frequently we do so in front of others and in response to others. In the case of crying, we may try to be alone when we sob because we are concerned about appearing fragile or weak. With smiling or laughing, we are recognizing that someone else said something funny. These are social reactions that require cognizance or acknowledgement of other human beings, and many of our facial expressions take place within the context of social relationships. “The face,” Kass writes, “is not only the organ of self-expression and self-presentation, the source of our voice and transmitter of our moods; it also contains the chief organs for beholding other selves.”

Because of the significance of the face in our social interactions, it is “most highly regarded, both in the sense of most looked at and in the sense of most esteemed.” Attention, wanted and unwanted, centers on the face. Yes, some superficial aspects of ourselves can reveal much beneath the surface: our deepest worries, fears, and joys. Such an understanding ought to give us new appreciation for the kinds of difficulties patients without facial expressions confront. They are handicapped in their interactions with others. They inadvertently block a vital mode of communication. They cannot indicate how they feel without using words. As physicians we treat the symptomatic aspects of diseases like Parkinson’s, but we cannot change someone’s face; even while patients are on their PD medications, their facial deficits persist. It is one of those debilitating aspects of illness that one can easily forget when thinking about people who suffer from these illnesses but that one cannot ignore when facing them in person.

Friday, February 3, 2017

How Doctors Choose a Specialty

People sometimes assume that every doctor feels a calling or has a special skill for one area of medicine or another. But the truth is very different for most doctors.

Old operating theater in London
Wikimedia Commons (Mike Peel, CC BY-SA 4.0)
When students begin medical school they don’t actually know what medicine entails. Maybe they’ve followed physicians around or worked in a lab. But that is completely distinct from being in a hospital for twelve to fourteen hours a day writing notes, calling consults, rounding on patients, operating, or delivering babies. And even when young students do see these things, they usually watch from afar and don’t fully understand what’s going on. The hierarchy, the language, and the rapid exchange of information remain a mystery.

Nevertheless, matriculating medical students still have ideas about what specialties they want to practice. Walk around an auditorium during an orientation and most budding physicians will say they’re interested in one field or another. This is completely understandable; something motivates people to apply to medical school. I thought seriously about becoming an emergency-medicine doctor. I had worked as an EMT in New York and loved the excitement of emergencies, the rush of adrenaline, and the range of patient presentations. But I didn’t really know what it was like to work in an emergency room for a twelve-hour shift.

Once medical school starts, things slowly change. As they study the biological systems and dissect in the anatomy lab, some students realize that they now feel dispassionate towards what they once loved. Suddenly, the eye or the heart or the skin is not as interesting as the lungs or the brain or the intestinal system. Granted, this is all still theoretical — it is early, and the students have not been inside the hospital yet. But inklings arise and ideas take hold. I enjoyed many of the educational blocks during medical school and even had a particular affinity for hematology and gastroenterology, while taking a dislike, surprisingly, toward neurology (I am now a neurology resident).

It is during the third year of medical school when professional ambitions take shape, as students work in the hospital and clinic. They rotate through general surgery, psychiatry, emergency medicine, and neurology, among other specialties, getting a quick but deep sense about how these areas work. They participate in surgeries, clinic appointments, and hospital codes. Decisions about a future specialty often form during these samplings.

But there is often much more to those decisions. I liked nearly everything during third year. I found the operating room fascinating. You stand at the operating table and assist the surgery residents and attending as they open up the patient and take out parts of the intestine or the gallbladder. You peer into a living human body in real time. You see the problem; you fix or remove it; and then you sew the patient’s skin back together. Other specialties are similarly awe-inspiring. On my obstetrics rotation I delivered babies. In the emergency room, I participated in trauma codes and watched the effects of treating drug overdoses. There is so much to marvel at in medicine that each rotation is appealing in some way. How can a student settle on one specialty?

When faced with this impasse, another deciding factor is often a teacher or mentor. After all, the word “doctor” comes from the Latin verb docere, which means “to teach.” The degrees we receive when we graduate from medical school read M.D., or Medicinae Doctor — “teacher of medicine.” So when we speak of a doctor’s purpose it is implied in the word that the purpose is not just to heal the sick but to teach the next generation of doctors, and also one’s patients. Notice this passage from the Hippocratic Oath:

I swear by Apollo The Healer.... To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.

Image via Flickr
These lines that deal with the doctor-student relationship come before the parts about the doctor-patient relationship. It is one of the few professions left in this country that still functions as an apprenticeship (somewhat similar, in a few respects, to being a Ph.D. student under an adviser). One studies a specific topic very intensely for an extended period of time with a group of professionals who teach you how to do what they do. This means that who teaches you matters as much as what you’re taught.

When I rotated through neurology, the subject area excited me, but I was particularly impressed by everything about the doctors. They took the time to explain things to students, which in the busy context of the hospital and clinic isn’t always a priority. They treated patients with great respect and kindness. They knew an impressive amount about the subject and beyond. I felt inspired. Though many other physicians in internal medicine, pediatrics, and elsewhere were similarly impressive, my experiences were more mixed in those departments. This at least was my unique experience; colleagues of mine reached different conclusions.

The physician teachers also affect the culture of each department. For example, emergency medicine doctors are frequently seen as adrenaline junkies. They love going rock climbing, bungee jumping, racing in triathlons, and so forth. This is not true across the board, but one likely finds a higher proportion of people who have those hobbies in emergency medicine. Specialties fit certain personalities or interests. I found that more neurologists shared my interests — many of them study human consciousness, autonomy, and free will, which tie into my fascination with the humanities.

The last element that helps medical students choose a specialty is lifestyle, or how much time one has outside of the hospital. Surgeons seemingly live at work even when they’ve graduated from residency programs. Surgeries can be long and tedious; unexpected disasters occur during operations; patients need emergency surgeries; and many post-operative patients need close monitoring to make sure there are no complications. Pediatricians, by contrast, tend to have much more normal lifestyles. They can work in an outpatient clinic from, say, 8 a.m. to 5 p.m. Any child with an emergency goes to the emergency room, not to the outpatient clinic, and pediatric patients tend not to have as many chronic, difficult-to-manage illnesses as adults (like heart disease or high blood pressure). Pediatricians focus more on preventative measures, such as well visits and vaccines. As a pediatrician it is much easier to keep up with family or hobbies outside of medicine. I loved surgery, but I could not see myself putting in the hours to do it every single day for the rest of my life. Neurology, on the other hand, like pediatrics, often involves a more balanced lifestyle.

And this is how we choose: subject material, mentor and teacher experiences, department personalities, and lifestyle. But the truth is that many of us who go into medicine could be happy in a number of specialties, which is an important perspective to have. It means that we love, broadly, the subject and practice of medicine, and that our curiosity about disease processes and treatments does not start and stop in one specialized silo or another, just as most diseases do not stop in one body part or another. It’s what makes medicine such an enthralling and difficult field.

Tuesday, December 13, 2016

The Distortion of “Death with Dignity”

I recently wrote a short essay for Public Discourse about the “death with dignity” movement. In the piece, titled “All Death is Death Without Dignity,” I compare the palliative-care movement — which seeks to alleviate the physical pain of death, often in the context of hospice care — to the physician-assisted suicide movement and find the differences in their respective descriptions of death telling. I quote somewhat extensively from the piece here, in order to then offer some additional thoughts on why the phrase “death with dignity” is a problem.

It has become common to talk of “death with dignity” in the policy world. There’s a Death with Dignity Act in Oregon, which permits physician-assisted suicide. There’s a Death with Dignity Act in Washington, which also legalizes physician-assisted suicide in certain circumstances. A Death with Dignity National Center exists in Portland, OR, a nonprofit that advocates for patients to “make their own end-of-life decisions, including how they die” — its website is plastered with images of smiling faces. The message, it seems, is that if one can control how one dies or when, the dying process is somehow less disturbing, awful, and humiliating. Instead, it can be dignifying.

Conversely, when dealing with end-stage cancer patients and palliative-care physicians in the hospital I rarely hear the “death with dignity” phrase used; more often I hear a palliative-care doctor say, “we want him (or her) to be comfortable.” It is a marked difference between the palliative-care movement and the assisted-suicide movement. In hospice, there is a resignation to the uneasiness and difficulty that comes with any death. With palliation, nurses and doctors can only free the patient from pain but not from the indignity of dying.

And why does choosing the way one dies have no relevance to whether or not a death is dignified?

Death is not simply a part of life but the end of human life — the end, in some sense, of an entire world. It is the transformation of a living member of our species into an immobile mass of flesh with no potential for life again. Rabbinic Jewish authorities recognized this in the Mishnah, an extensive commentary on Jewish law, when they wrote, “anyone who destroys a life is considered by Scripture to have destroyed an entire world; and anyone who saves a life is as if he saved an entire world.” Thus, not only are the physical manifestations of death ignoble and viscerally disturbing but, in principle, the end of an individual is tragic, too….

Death and dying detract from life by ending it. There are more or less disturbing ways to pass (you can die while someone is breaking your ribs doing CPR or you can die without that), but none of them is truly dignified. And choosing to preempt death using physician-assisted suicide doesn’t change this. In truth, there is no such thing as death with dignity. There is only somber tragedy, as your body lies exposed to the world’s Hobbesian bacteria and insects.

I think there is an important debate to be had about whether assisted suicide should be available in certain, very rare circumstances. But that is a separate discussion from the point I am making here, which is that the term “death with dignity” is inaccurate and misleading. The phrase changes our whole concept of death — it is a change that puts a positive spin on dying, a change that detracts from the somber aspects of the end of life.

Wikimedia Commons
This deceptive use of language reminds me of George Orwell, who focused some of his sharpest criticism on the use of language and how it changes our perception of events and ideas. In his famous 1946 essay “Politics and the English Language,” he condemns the “tendency of modern prose ... away from concreteness.” Specifically, Orwell exposes the misuse of euphemisms common in war propaganda — for instance talking about sending people to prison and death camps as the “elimination of unreliable elements.” Euphemisms can obfuscate the gravity and odiousness of an action, thus creating a false appearance so powerful that it can become tolerable, even appealing.

In 1984, Orwell offers a similar warning. The totalitarian government of Oceania uses its own language called Newspeak, destroying most of the English language to make way for abbreviations and vague terminology — “cutting the language down to the bone.” As one character explains, “the great wastage is in the verbs and adjectives, but there are hundreds of nouns that can be got rid of as well.” By manipulating the language, the government of Oceania manipulates the way people think, specifically the political and moral decisions they make. One of its most effective tools is the creation of catchy slogans that utterly distort reality: “war is peace,” “ignorance is strength,” and so forth.

I am not saying that the “Death with Dignity” movement is an attempt at mind control, like in the police state of 1984. Nor am I arguing that there is only one right way to express an idea. But when it comes to framing an argument or the context of a debate, we should be very careful when we use language that assumes certain principles that subtly distort reality. In this particular case, the phrase “death with dignity” assumes that death can be dignifying. At its core, however, death is nothing less than awful:

Indeed, the concept of “death with dignity” is a euphemism for what is one of the most heart-wrenching, difficult, unsettling, and undignified events of human existence. I think of that patient who chose to make his death comfortable and the image is disturbing rather than heartening. Where is the dignity in lying in a bed with flies buzzing around one’s head, vulnerable and lifeless?

Monday, September 26, 2016

Should Computers Replace Physicians?

In 2012, at the Health Innovation Summit in San Francisco, Vinod Khosla, Sun Microsystems co-founder and venture capitalist, declared: “Health care is like witchcraft and just based on tradition.” Biased and fallible physicians, he continued, don’t use enough science or data — and thus machines will someday rightly replace 80 percent of doctors. Earlier that same year, Khosla had penned an article for TechCrunch in which he had made a similar point. With the capacity to store and analyze every single biological detail, computers would soon outperform human doctors. He writes, “there are three thousand or more metabolic pathways, I was once told, in the human body and they impact each other in very complex ways. These tasks are perfect for a computer to model as ‘systems biology’ researchers are trying to do.” In Khosla’s vision of the future, by around 2022 he expects he will “be able to ask Siri’s great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get today from the average physician.” In May 2014, Khosla reiterated his assertion that computers will replace most doctors. “Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by statistical science.”

The dream of replacing doctors with advanced artificial intelligence is unsurprising, as talk of robots replacing human workers in various fields — from eldercare to taxi driving — has become common. But is Vinod Khosla right about medicine? Will we soon walk into clinics and be seen by robot diagnosticians who will cull our health information, evaluate our symptoms, and prescribe a treatment? Whether or not the technology will exist is difficult to predict, but we are certainly on our way there. The IBM supercomputer Watson is already being used in some hospitals to help diagnose cancer and recommend treatment, which it does by sifting through millions of patient records and producing treatment options based on previous outcomes. Analysts at Memorial Sloan Kettering Cancer Center are training Watson “to extract and interpret physician notes, lab results, and clinical research.” All this is awe-inspiring. Let us generously assume, then, for a moment, that the technology for Khosla’s future will be available and that all knowledge about and treatment options for medical problems will be readily analyzable by a computer within the next decade or so. If this is the future, why shouldn’t physicians be replaced?

There are several errors in Khosla’s way of thinking about this issue. First of all, modern health care is not “like witchcraft.” Academic physicians, for example, use evidence-based medicine whenever it is available. And when it isn’t, then they try to reason through a problem using what biologists know about disease presentation, physiology, and pharmacology.

Moreover, Khosla mischaracterizes the doctor-patient interaction. For Khosla, a visit to the doctor involves “friendly banter” and questions about symptoms. The doctor then assesses these symptoms, “hunts around ... for clues as to their source, provides the diagnosis, writes a prescription, and sends you off.” In Khosla’s estimation the entire visit “should take no more than 15 minutes and usually takes probably less than that.” But the kind of visit Khosla writes about is an urgent care visit wherein quick and minor issues are addressed: strep throat or a small laceration requiring a stitch or two. Yes, these visits can take fifteen minutes, but so much of medicine does not involve these brief interactions. Consider the diabetic patient who has poorly controlled blood sugars, putting her at risk for stroke, heart attack, peripheral nerve destruction, and kidney failure, but who hasn’t been taking her medications. Or consider a patient addicted to cigarettes or on the verge of alcoholism. Consider the patient with Parkinson’s disease who wonders how this new diagnosis will affect his life. And what about the worried parents who want antibiotics for their child even though their child has a viral infection and not a bacterial infection? I can go on and on with scenarios like these, which occur hourly, if not daily, in nearly every medical specialty. In fact, fifteen-minute visits are the exception to the kind of medicine most physicians need to practice. One cannot convince an alcoholic to give up alcohol, get a diabetic patient to take her medications, or teach a Spanish-speaking patient to take his pills correctly in fifteen minutes. In addition, all this is impossible without “friendly banter.”

As Dr. Danielle Ofri, an associate professor of medicine at the New York University School of Medicine, wrote in a New York Times blog post, compliance with blood pressure medications or diabetic medications is extremely difficult, involving multiple factors:

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots — on top of remembering to take the morning pills and then the evening pills each and every day.
Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations.

Because of the difficulties involved in getting a patient to comply with a complex treatment plan, Dr. John Steiner argues in an article in the Annals of Internal Medicine that in order to be effective we must address individual, social, and environmental factors:

Counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. ...[F]ront-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in ways that exemplify the underlying principles of health care reform.

Therefore, the interaction between physician and patient cannot be dispensed with in fifteen minutes. No, the relationship involves, at minimum, a negotiation between what the doctor thinks is right and what the patient is capable of and wants. To use the example of the diabetic patient, perhaps the first step is to get the patient to give up soda for water, which will help lower blood sugars, or to start walking instead of driving, or taking the stairs instead of the elevator. We make small suggestions and patients make small compromises in order to change for the better — a negotiation that helps patients improve in a way that is admittedly slow, but necessarily slow. This requires the kind of give-and-take that we naturally have in relationships with other people, but not with computers.

This kind of interaction also necessitates trust — trust regarding illicit drugs, alcohol, tobacco, and sexual activity, all of which can contribute to or cause certain medical problems. And a computer may ask the questions but cannot earn a patient’s confidence. After all, these kinds of secrets can only be exchanged between two human beings. David Eagleman, a neuroscientist at the Baylor College of Medicine, writes in his book Incognito that when we reveal a secret, we almost always feel that “the receiver of the secrets has to be human.” He wonders why, for example, “telling a wall, a lizard or a goat your secrets is much less satisfying.” As patients, we long for that human reception and understanding that a physician can provide and use to our advantage in coming up with a diagnosis.

Khosla neglects other elements of medical care, too. Implicit in his comments is the idea that the patient is a consumer and the doctor a salesman. In this setting, the patient buys health in the same way that he or she buys corn on the cob. One doesn’t need friendly banter or a packet of paperwork to get the best corn, only a short visit to the grocery store.

And yet, issues of health are far more serious than buying produce. Let’s take the example of a mother who brings her child in for ADHD medication, a scenario I’ve seen multiple times. “My child has ADHD,” she says. “He needs Ritalin to help his symptoms.” In a consumer-provider scenario, the doctor gives the mother Ritalin. This is what she wants; she is paying for the visit; the customer is king. But someone must explain to the mother what ADHD is and whether her child actually has this disorder. There must be a conversation about the diagnosis, the medication, and its side effects, because the consequences of these are lifelong. Machines would have to be more than just clerks. In many instances, they would have to convince the parent that, perhaps, her child does not have ADHD; that she should hold off on medications and schedule a follow-up to see how the child is doing. Because the exchange of goods in medicine is so unique, consequential, and rife with emotion, it is not just a consumer-cashier relationship. Thus computers, no matter how efficient, are ill-fitted to this task.

Khosla also misunderstands certain treatments, which are directly based on human interactions. Take psychiatry for example. We know that cognitive behavioral therapy and medication combined are the best treatment for a disease like depression. And cognitive behavioral therapy has at its core the relationship between the psychiatrist or therapist and the patient, who together work through a depressed patient’s illness during therapy sessions. In cognitive behavioral therapy, private aspects of life are discussed and comfort is offered — human expressions and emotions are critical for this mode of treatment.

To be sure, Khosla is right about quite a lot. Yes, technology ought to make certain aspects of the patient visit more efficient. Our vital signs may one day easily be taken with the help of our mobile phones, as he suggests, which would save time checking in to a clinic and could help give physicians constant and accurate measurements of blood pressure in hypertensive patients or EKG recordings in patients with heart disease. Technology of this sort could also indicate when an emergency is happening or how a patient ought to alter medication doses.

Furthermore, Khosla correctly identifies some of the limitations of human physicians: “We cannot expect our doctor to be able to remember everything from medical school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth.” True, the amount of information accumulated by modern medical research is beyond the capability of any human being to know, and doctors do make mistakes because they forget or are not up on the latest research. In a 2002 study in the Journal of Neurology, Neurosurgery and Psychiatry, investigators found that 15 percent of patients with a diagnosis of Parkinson’s disease do not necessarily fulfill criteria for the disease and 20 percent of patients with Parkinson’s disease who have already seen medical providers have not been diagnosed. These are large percentages that have profound implications for people’s lives. And this is exactly why physicians must use technologies like Watson to do a better job, not necessarily abdicate the job altogether. Most of us already carry smartphones or tablets on rounds, to look up disease processes or confirm our choice of antibiotic.

Lastly, Khosla wisely points out that physician bias can negatively affect a patient’s treatment. As he writes, “a physician’s bias makes all these personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what ‘preferences’ are being incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing countries, in my estimation.” Undoubtedly, this dilemma is real. I have spent many of my posts on this blog writing about the issue of remaining unbiased or level-headed in the face of difficult patient interactions. A study published in Obesity in 2013 found that physicians “demonstrated less emotional rapport with overweight and obese patients ... than for normal weight patients,” which may “weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.” And as Tara Parker-Pope remarks in the New York Times, “studies show that patients are far more likely to follow a doctor’s advice and to have a better health outcome when they believe their doctor empathizes with their plight.” If bias exists in lieu of empathy, it makes sense that patients have worse outcomes. What makes doctors most valuable, their humanity, can have negative consequences.

But people can learn from studies, alter their behavior, and remain human. Computers or robots can learn from studies and alter their behavior, but they will always be robots. They will never earn the trust of the chronically ill drug addict. They will never be able to negotiate with the most difficult patients who demand specific treatments but may not be entirely sure why. An ideal system would not be one built solely on fallible human doctors but one in which new tools significantly augment human physicians’ skill and knowledge. A measured combination of these will put all the information at a doctor’s fingertips while keeping the art of medicine alive.