Thursday, November 12, 2015

Beauty, Biology, Music, and Math

As physicians, we rarely consider the healthy human body. We learn about normal human physiology during our first year of medical school but soon afterwards are exposed solely to pathology. In the hospital we almost always inquire, “What is going wrong here?” but rarely ask, “What is going right here?” It is worth taking a moment to examine well-functioning human biology. Let’s start with a deep breath.

Your diaphragm contracts and pushes downward against your liver, spleen, and stomach. Your chest expands and sucks in molecules of oxygen, nitrogen, and other gases through your nostrils and mouth. These airway entrances humidify and warm the gases while filtering out foreign bacteria and dirt. Air travels deep into the lungs along a system of progressively smaller passageways until it reaches the alveoli, compartments at the termini of the lung lobes. Here, red blood cells passing through adjacent vessels pick up oxygen from the alveoli in exchange for carbon dioxide, a waste byproduct of the energy exchange in each cell in the body.

Next, the red blood cells carrying oxygen travel through the pulmonary vein to the left atrium of the heart. During diastole, a period of relaxation of the heart, the left ventricle expands like a sponge and fills its chamber with the blood from the left atrium. This muscular left ventricle subsequently contracts and forces blood into the aorta, the main artery of the body. The aorta squeezes and moves the plasma forward. Then, it splits into two different pathways — some of it ascends into smaller arteries that move up into the arms and the brain and some of it descends into smaller arteries in the abdomen, legs, and toes. Either way, the flow is highly pressurized and continues to be guided along by the muscular arteries. Each artery further branches off into arterioles, or small arteries. These arterioles also decrease in size and eventually become capillaries, which are so minuscule that red blood cells have to move through them single file.

In the capillaries, another exchange takes place: the red blood cell offloads oxygen and picks up carbon dioxide. Cells from other tissues, like muscles and the gastrointestinal tract, pick up the oxygen and use it for aerobic respiration, a complex biochemical reaction that creates energy for all kinds of cell tasks and thus for everything that human beings do. You can digest food, speak, and read because of energy. And you have energy because of oxygen.

The red blood cells continue their single-file journey. But, something begins to change. This time, the vessels enlarge as they coalesce and converge. They become venules and then veins. Unfortunately, veins are not muscular in the way that arteries are. Blood, then, is pushed forward because of the back pressure from more and more blood that builds up. Additionally, one-way valves within the venous system prevent backflow, ensuring that the deoxygenated blood continues to move forward. And even as we walk or stretch, our contracting muscles push against the veins and coax the red liquid’s movement.

Finally, blood arrives in the Superior and Inferior Vena Cava, large vessels that lead into the right atrium of the heart. During diastole, blood enters the right ventricle. During systole, a period where the heart contracts, the right ventricle squeezes blood into the pulmonary artery and eventually into the lungs where the process repeats itself.

There is beauty in this cycling system. It repeats itself with every heartbeat, over sixty times a minute, every hour, every day, for one’s entire existence. The efficiency, the speed, the different parts — the whole thing is stunning. And as we delve even deeper into how this whole system works we uncover more relationships that demonstrate our impressive biology.

The volume of blood that the heart pumps out is called cardiac output. We can calculate the cardiac output by multiplying the heart rate and the systemic vascular resistance, or the resistance that must be overcome to push blood through the vessels. The mean arterial pressure, or the average pressure in the arteries during one heartbeat, can be calculated by adding two-thirds of the diastolic pressure (the pressure while the heart is relaxed) and one-third of the systolic pressure (the pressure in the arteries when the heart is squeezing). Alternatively, multiplying the cardiac output and the systemic vascular resistance and adding the central venous pressure, the pressure of the blood in the veins as it returns to the heart, can also give you the mean arterial pressure. As one can see, elements of the whole system are related to each other mathematically. These relationships allow for push and pull: change one side of the equation and the other side changes to maintain balance. Increase heart rate and the systemic vascular resistance may decrease in order to maintain cardiac output.

In addition to the mathematical relationships between our internal organs, there are musical relationships, too. Like the percussionist, the heart maintains the rhythm and slows or quickens pro re nata (as needed). Using musical terms, we might say that during exercise the heart beats in presto or allegro; during the moments before sleep, perhaps andante. Our breathing coincides with the beating of the heart. Our lungs whoosh as they fill up with air and suddenly deflate as air rushes out. This, too, is rhythmic and audible. The intestines and stomach churn and rumble as they break down food and move waste through the long gastric tunnel.
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In his beautiful book Emblems of Mind (1995), Edward Rothstein, critic at large for the Wall Street Journal — and, full disclosure, my father — examines the relationship between music and mathematics. Reading it from a medical perspective, one immediately notices how integrated mathematics and music are in human biology, beyond the superficial examination we gave these relationships above. Let’s take our discussion of the musical aspects of human physiology, for example. Rothstein explains,

A rhythm is not like a sequence of numbers at all; it is closer to our experience of continuous time. When we feel rhythm subtly, it is not like the thumping of a mechanical drum machine, with accents calculated and then routinely repeated; it is more like the movement of a conductor’s baton or Fred Astaire’s feet. The model for rhythm is not the goose step but the breath — the inhale and exhale — or the heartbeat, with muscular contractions of interior chambers. This sort of rhythm slides and elides.

There is something beyond just mechanics in the musical ensemble of our bodily rhythms. The beatings of our heart and contractions of our bowel muscles are continuous despite the pauses or rests in between them. Pauses mean just as much to our efficient functioning as the muscular contractions themselves. If there are no rests in between heartbeats, for instance, the heart cannot fill with blood and thus cannot pump oxygen to the rest of the body.

Rothstein continues:

Music’s great energies derive from the creation of continuity out of discontinuity — a sort of inversion of the calculus, interested not in the infinitesimal and the instantaneous but in the ways they combine into the gestural and fluid that resembles some inchoate way our inner life.

As with music, our body changes and moves such that at any instant something new is happening. But physicians are not as interested in the instantaneous as in the trend. Is there consistency in the heart rate? Is there consistency in the blood pressure? Is it low or high over an extended period of time? What does this tell us about the relationship between the cardiovascular, pulmonary, and nervous systems? We want to know how these measurements combine to create the clinical picture of a fully functioning and continuous human life.

And what about the mathematical relationships between our blood pressure and heart rate that I described and that are so integral to our cardiovascular system? In a section on the subject of topology Rothstein writes,

Differences and similarities are established through mappings, which can even link objects that at first appear to be drastically different. These mappings can themselves become the object of intense scrutiny. “Mathematicians do not deal in objects,” PoincarĂ© [Henri PoincarĂ©, a French mathematician] observed, “but in relations between objects; thus, they are free to replace some objects by others so long as the relations remain unchanged.”

Now let’s go back and consider the heart’s relationship to blood pressure. The heart beats and the vessels contract and relax to increase or decrease pressure. As the blood pressure decreases, the heart rate increases in order to maintain cardiac output — to keep the same amount of blood flowing through the vessels and reaching our brain, liver, and kidneys. These mathematical linkings or mappings allow us, as physicians, to make hypotheses about what is going on inside the body. We can place variables in the system and draw conclusions because these mathematical relationships are constant. For instance, giving a patient a medication that increases blood pressure may cause the heart rate to decrease. Like mathematicians, physicians deal in relationships between things that may not always seem like they are related.

By sharing fundamental principles with music and mathematics, human biology is certainly a thing of great complexity. But it is also beautiful. In thinking about our circulatory system, its sounds, its relationships, there is no doubt that, as Rothstein describes in a passage about the sublime, it is “tremendous, awful, and humbling, yet also elevating.” He notes,

The sublime is linked to limitlessness and the infinite, yet it also has its effect because that limitlessness is somehow grasped and experienced at once, as a single whole.... It makes the imagination seem inadequate while giving our understanding an almost ecstatic sense of having apprehended what should be beyond its containing powers. The effect of the sublime is not out there, in the world of objects, but in the experience of the subject. The sublime is part of inner, not outer life.

Think of the circulatory system again and its millions of cells carrying and distributing oxygen, picking up carbon dioxide, squeezing single-file through capillaries — all this occurring constantly as we rest, move, and eat, and on such an infinitesimal scale and in such a limitless fashion. Imagine trying to invent or create such a system. One’s imagination may be inadequate. Nevertheless, we can just barely grasp these repetitive events, which are happening as you read and as I type. Our cells “echo up and down the line, in all our caverns.” They die and are replaced. They work and seem never to rest. They perpetuate the indefatigable to and fro of the circulatory system and the life of the human being, “knowing that the end of one journey is just the beginning of another.”

Thursday, October 15, 2015

The Problem with the New Patient Autonomy

The neurology team shuffled single-file into the patient’s small room. The patient, probably in his 30s, had black hair, brown eyes, and an unsettling demeanor. He glared icily at us from his bed, the blankets covering him up to the neck. His pale brow furrowed even more noticeably as all nine of us intruded on his privacy. In a scene out of a futuristic movie, EEG (electroencephalogram) leads on his scalp connected his head via wires to a screen showing squiggly lines representing brain activity; a small video camera attached to the screen monitored the patient’s movement. He had come to the hospital overnight after falling and shaking, a story worryingly suggestive of a seizure.

Brain waves on EEG
Image via Shutterstock

An electroencephalogram records neuronal signals in the brain and is used by neurologists to diagnose seizure activity. When a patient has a seizure, which can manifest as full-body convulsions, a family member in the room pushes a button on the machine which starts the video camera recording the patient’s movements. Then, neurologists examine the movements in the video and the waves tracked by the EEG to see if they are consistent with seizures.

There are different kinds of seizures depending on which part of the brain is affected. Symptoms range from a loss of attention for a few seconds (absence seizures) to full-body convulsions which we typically associate with seizures (generalized tonic-clonic seizures). Different conditions can cause these events — for instance, high fever as a child (febrile seizures) and brain tumors can induce hyper-excitability in the brain. If the seizure does not stop, a patient can enter status epilepticus, a state of prolonged epileptic activity that can cause permanent damage.

Having a seizure, then, can be very serious business. Physicians must perform a medical work-up to ensure that the patient is not at great risk. In addition to an EEG, our patient’s neurologist ordered labs and a CT scan of the brain. However, these tests were all negative. Even overnight, when the patient and his mother both claimed that the patient seized, there were no abnormal electrical discharges on the EEG.

Indeed, not all physical manifestations of seizures indicate the presence of legitimate seizure activity in the brain, which is why the EEG is such a valuable diagnostic tool. It turns out that certain patients may believe they are having seizures when they are actually having pseudoseizures or psychogenic non-epileptic seizures. To most observers, pseudoseizures look exactly like generalized tonic-clonic seizures. Patients shake, tense up, and flail violently and frighteningly. However, certain differences exist that distinguish them from each other. During pseudoseizures, EEGs show no abnormal brain activity, patients do not bite their tongues (this can occur with real seizures), and patients do not respond to anti-epileptic or anti-seizure medications. It’s not that patients undergoing pseudoseizures aren’t sick, it’s just that their sickness has nothing to do with neurological pathology or seizure activity.

Frequently, patients who experience pseudoseizures do have underlying psychiatric disorders, like anxiety or PTSD, but not always. Other risk factors and triggers include interpersonal conflicts, childhood abuse, and past sexual abuse. Seemingly, then, a pseudoseizure is a symptom of a psychiatric illness. Another factor that distinguishes pseudoseizures is that patients are conscious during the events. I’ve seen one attending push down hard on a patient’s hand during a pseudoseizure while telling the patient he was going to do so. The patient suddenly awoke before the attending pushed hard enough to hurt the patient. (If the patient was having a generalized seizure, he would not have felt anyone pressing on his hand nor would he have heard anyone giving him a verbal warning of it.)

In explaining the concept of pseudoseizures to a patient who has them, one must take great care. If a physician tells a patient, “these are not real — it is in your head, so grow up,” no one will benefit. Psychiatric illness cannot be fixed with a stern rebuke. One must explain that these are not seizures and that it will take time to fix whatever is happening, but anti-seizure medications will not help. (While there are no medications for pseudoseizures, behavioral therapy can be efficacious.) Through this conversation, one hopes the patient will seek help from a psychiatrist.

The patient we saw that morning did have pseudoseizures rather than seizures, as the EEG and the video of his body movements indicated. Additionally, and tragically, he had a horrific childhood and had been physically abused by his father. The attending explained all this very gently in the course of nearly twenty minutes. When he finished, the patient and his mother both burst out indignantly: How could this physician ignore the symptoms? How could he be so callous as to dismiss this disease? Why wouldn’t he prescribe medications? Why did he not order an MRI of the patient’s brain (an expensive type of imaging) to further investigate the cause of this? In the patient’s words: “I’m not believing any of this bullshit.” Although the physician calmly tried to explain everything again, the patient refused to listen and eventually the team left to continue rounding. Still enraged, the patient called the customer-service department of the hospital and continued to argue with the team throughout the day. Eventually, after numerous disputes, our attending physician caved (and who could blame him given that there were nineteen other sick patients on the service who needed his attention?): the patient got what he wanted, an MRI study which showed nothing abnormal.

Unfortunately, this is a weekly if not a daily experience in hospitals across the country. Patients frequently make inappropriate requests of physicians, which are subsequently granted. What has brought our system to the point where a patient issues orders and the physician must about-face from a medically sensible course?
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In ancient times, patients had very little, if any, autonomy, as R. Kaba and P. Sooriakumaran point out in their 2007 article, The Evolution of the Doctor-Patient Relationship in the International Journal of Surgery. Doctors decided what was good for patients and what wasn’t. There was no informed consent — a doctor told a patient what the patient needed and expected him or her to comply.

This interaction may have evolved from the ancient Egyptian “priest-supplicant” relationship, in which magicians and priests with access to gods conjured up cures for various medical disorders. The patient, without a modicum of holiness, had to supplicate to the priest, or father figure, in order to get well. Even for the Greeks, who developed slightly more scientific ways of approaching disease and more ethical ways of approaching the patient (see the Hippocratic Oath), the doctor was a paternalistic figure granting “hard-line beneficence” to the patient. All this was akin to a parent-child relationship, a model for the doctor-patient interaction that was considered normal even in the mid-twentieth century, as I wrote in my essay on vaccines for The New Atlantis:

The unchecked authority of medical experts in those days allowed doctors to trammel the rights of both patients and research subjects. Many of those whose research laid the foundations for modern vaccines, such as Jonas Salk, Maurice Hilleman, and Stanley Plotkin, tested their vaccines on mentally retarded children. Starting in the mid-1950s and continuing for about fifteen years, the infectious-disease doctor Saul Krugman fed hepatitis virus to severely disabled residents of the Willowbrook State School in order to study the virus. The enshrinement of patient autonomy in the 1970s was in part a response to these very serious ethical problems.

Recently, though, things have changed:

Over the past few decades, however, the boat has tipped to the other side. Now, patients rate doctors online at sites like Healthgrades or Yelp or Vitals the same way one rates a restaurant. This puts pressure on physicians to give patients what they want rather than what they need in order to garner more business. The government bases Medicare reimbursements, in part, on patient satisfaction scores, putting further pressure on physicians to make patients happy [In fact, patient satisfaction score surveys play a significant role in determining how much money hospitals receive from Medicare.] Dr. Richard Smith, former editor of the British Medical Journal, has explained that the increasing power of patients is bringing us to a point where “there is no ‘truth’ defined by experts. Rather there are many opinions based on very different views and theories of the world.” If a patient wants a test or procedure, he or she can have it. The same goes for refusing it, even against the advice of doctors.

This modus operandi of allowing patient satisfaction to dictate medical care is becoming more and more common. It is even encouraged. Kai Falkenberg, a journalist, notes in a must-read 2013 article in Forbes,

Nearly two-thirds of all physicians now have annual incentive plans, according to the Hay Group, a Philadelphia-based management consultancy that surveyed 182 health care groups. Of those, 66% rely on patient satisfaction to measure physician performance; that number has increased 23% over the past two years.

And that’s not all, according to her article. These metrics encourage physicians to do things that are not always in the best interests of the patient:

In a recent online survey of 700-plus emergency room doctors by Emergency Physicians Monthly, 59% admitted they increased the number of tests they performed because of patient satisfaction surveys. The South Carolina Medical Association asked its members whether they’d ever ordered a test they felt was inappropriate because of such pressures, and 55% of 131 respondents said yes. Nearly half said they’d improperly prescribed antibiotics and narcotic pain medication in direct response to patient satisfaction surveys.

Satisfying patients and practicing good medicine are not always the same. Data on this abounds. A 2013 study by physicians at Johns Hopkins demonstrated little evidence that patient satisfaction corresponds to the quality of surgical care. Furthermore, in a 2012 study, physicians at UC Davis found that increased patient satisfaction scores were associated with higher health care expenditures and even increased mortality.

Of course, I’m not arguing against patient autonomy or patient satisfaction. People ought to have a voice in their healthcare. But attributing excessive importance to patient satisfaction scores stymies medicine and encourages confusion among patients who don’t necessarily know what is and isn’t medically appropriate, thus putting them at risk. This is borne out in the story of our pseudoseizing patient, and in the data from studies. If we, as physicians, merely do what the patient asks of us, we are no longer practicing medicine; we are technicians for hire, something I pointed out in a previous post on the purpose of medicine. Evidently, then, the push for patient autonomy can hurt both patients and doctors.

Indeed, the solution is not to incentivize the physician to give the patient what he or she wants. Nor is it to force the patient to do only what the physician demands. What we need is balance. As suggested in a 1996 article in the Annals of Internal Medicine, what we need is not a consumer model but a model that promotes “an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician’s experience.” Doctors don’t have a monopoly on medical truth but they have years of education and experience and they must help patients to make a reasoned choice.

Physicians need to provide patients with information, evidence, and guidance. They need to negotiate with patients, just as patients need to negotiate with doctors. And sometimes physicians need to draw a hard line. If a doctor encounters a patient who demands something a physician is not comfortable with or if the “chosen course violates the physician’s fundamental values” despite negotiations and conversations, “he should inform the patient of that fact and perhaps help the patient find another physician.”

Yes, final choices belong to patients and not doctors. But both must invest a lot in order to allow patients to make informed decisions. We should not let the mistaken primacy of satisfaction surveys and radical autonomy obstruct this negotiation — there is more at stake for all of us than just an extraneous MRI.

Tuesday, September 15, 2015

CPR in the Hospital, Part 2

With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.
—Sir Thomas Browne, Religio Medici

I wasn’t the first to arrive in her room. The resident had already started the code, and nurses, physicians, and medical students crowded around her bed, performing CPR. The patient, a woman in her sixties, bore the physical scars of many life-saving interventions for deadly issues ranging from heart attacks to strokes to blood clots in her lungs. Six different IV bags with medications hung on poles on either side of her bed. A tube stuck out from her neck and was connected to a breathing machine. Otolaryngologists (specialists in conditions of the nose, ear, and throat) created a tracheotomy for her months ago, cutting an opening through her neck because she could not breathe properly through her mouth.

This was all I knew when I walked up to her bed, where ten physicians and nurses ran through the protocol necessary for restarting the patient’s heart. In addition to defibrillation to shock the heart back into rhythm, physicians give epinephrine to augment the effects of CPR. Epinephrine raises blood pressure by constricting blood vessels, thus increasing the flow of blood into the brain and the heart. And, it binds to beta-1 receptors in the heart, improving the heart’s ability to contract.

A well-run protocol, or code, has a rhythm: Epinephrine is given every 3 to 5 minutes, chest compressions are performed thirty times for every two breaths, the heart is shocked at the stop of compressions, and then we start over from the beginning. If there is a competent leader, then despite the chaos of human bodies crowding around the spectacle of death, opening drawers for medications, and thumping on the patient’s chest, there is still order, a pattern, a method, a purpose.

Wikimedia Commons
When the resident doing chest compressions tired out, she shoved me to take her place the next time around. Chest compressions are intense, both emotionally and physically, and one tires easily. So we cycle in and out — we compress for as long as our bodies allow and then make way for a colleague who is next in line. I stepped up and began my compressions. The compressor must replicate the beat of the patient’s heart. If you go too fast, the heart does not have time to fill and you don’t pump blood to the brain; too slow, and the brain is deprived of oxygen and your compressions are useless.

The patient’s eyes looked up at me as I pounded my palms onto her sternum rhythmically and her whole body shook. Still open, a thin glassy film covered her eyes, clouding the stuff of life that normally emanates from a human’s gaze. Feeling uneasy as the object of her empty stare, I looked up at the TV: two pop singers were apparently at war on Twitter.

At some point — I can’t remember how early or late in the process this occurred — the patient seemed to gasp for air. She growled and gurgled, desperately reaching for the elemental gas which we take for granted every time we inhale. This may have been her agonal breathing, a process that some experience on their way to death. The late Dr. Sherwin Nuland, a surgeon and writer, described this in his book How We Die: “The adjective agonal is used by clinicians to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer.” He continues,

The apparent struggles of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce. In the ultimate agonal moments, the rapid onset of final oblivion is accompanied by the cessation of breathing or by a short series of great heaving gasps.... (p. 122)
Indeed, this is what the patient seemed to be experiencing. But was it? One resident tore open a drawer, found a thin, long, hollow tube and connected it to the suction machine on the wall. Perhaps, he theorized, the patient had a mucus plug in her airway. In patients with tracheotomies, the air bypasses the mouth which normally cleans and moistens the air we breathe. In response, the patient’s body produces more mucus, which accumulates and blocks the flow of oxygen into the lungs. This could be an easily reversible cause of the patient’s sudden deterioration.

The resident pushed the suctioning tube into the patient’s trachea while a nurse called the otolaryngologists who had placed the tracheotomy and were better trained to deal with it. The resident retrieved small bits of mucus out of the patient’s airway, but we still needed to continue CPR. Eventually, after many attempts to revive the patient, the attending physician looked at the clock and, realizing it had been 25 minutes since the code started, asked: “Does anyone have any other ideas as to how we can save this patient?” Met with silence, he nearly declared the time of death to be 3:32 in the afternoon. But the otolaryngologist shouted that he had finally gotten something. A long, viscous, and yellow-brown piece of mucus shot up into the suction tube and the patient gasped for air. Her heart began to beat appropriately again; her respirations normalized. Within five minutes she was back to her old self again, sick, yet alive and aware, conversant via hand motions and mouthing of words. She could now let us know that she existed. The glassy film retreated from her eyes as she was pulled back from death.

This is an uncommon circumstance. In a study in The New England Journal of Medicine in 2009, researchers studied Medicare patients 65 years of age or older who underwent CPR in U.S. hospitals from 1992 through 2005. They found that only 18.3 percent of these patients survived to discharge. Over the course of this time “the proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased.” It seems that CPR has not gotten better, and the authors express “significant concern” that CPR has increased “during a time of more education and awareness about the limits of CPR in patients with advanced chronic illness and life-threatening acute disease,” like the patient we revived.

And yet, who can argue with the results that day? I wrote in my last post on CPR that “we rightfully value human life above all else and thus owe the patient every weapon in this battle. While the rapidity of the process may seem callous, it is essential in a last-ditch effort to stave off eternal rest. After all, what if she had been revived?” In this patient’s case she was fortunate. Yes, she was still critically ill, but perhaps this gave her more time to be with her husband, who had been visiting her for months. Maybe now she could have the conversations with her family about whether she wanted CPR done in the future if her condition worsened (she and her husband eventually decided they didn’t want any further CPR measures — this one experience was traumatic enough). Alternatively, perhaps this revival would change nothing about how she would use her time on this earth. It is not for physicians to say how she ought to use her new-found days; it is only for physicians, when appropriate, to help her grasp them.

Monday, August 10, 2015

A Tour of the Intensive Care Unit (ICU)

I have a rendezvous with Death
At some disputed barricade,
When Spring comes back with rustling shade
And apple-blossoms fill the air—
I have a rendezvous with Death
When Spring brings back blue days and fair.

It may be he shall take my hand
And lead me into his dark land
And close my eyes and quench my breath—
It may be I shall pass him still.
I have a rendezvous with Death
On some scarred slope of battered hill,
When Spring comes round again this year
And the first meadow-flowers appear.

God knows 'twere better to be deep
Pillowed in silk and scented down,
Where Love throbs out in blissful sleep,
Pulse nigh to pulse, and breath to breath,
Where hushed awakenings are dear ...
But I've a rendezvous with Death
At midnight in some flaming town,
When Spring trips north again this year,
And I to my pledged word am true,
I shall not fail that rendezvous.

—Alan Seeger, I Have a Rendezvous with Death

The Intensive Care Unit is an uncomfortable place. It is where the sickest patients in the hospital reside. Because many of the patients require emergency medical interventions or close monitoring, the layout resembles that of the emergency department (ED). Patient rooms encircle a nurse’s station where computers sit on a long table. As in the ED, each room is filled with machines projecting vital signs, EKG tracings, IV fluid rates, and other information towards the physicians and nurses. And the nurses in “the unit” (as it’s commonly referred to) are always active, checking in on patients throughout the day and night.

There are many different types of intensive care units: some for patients with heart issues (cardiac ICU), others for patients with neurological issues (neuro ICU), pulmonary or general medical issues (medical ICU), surgical issues (surgical ICU) and cancers (oncology ICU). What we see in each unit, however, is equally disturbing. And what follows are the some of the things one might see (and which I have seen) in different ICUs over the course of a day.

Image via Shutterstock
In the neuro critical care unit, one patient lies unconscious with a massive and deadly brain bleed. In another bed across the room, a patient with a rapidly expanding brain tumor cries out in searing pain from a headache. In the cardiac intensive care unit, a patient, hours after receiving a ventricular assist device (VAD), a device which helps the heart’s ventricles pump out blood after being weakened by disease, receives chest compressions from a nurse as he goes into cardiac arrest. Another unconscious patient in the far corner of the room is on ECMO, or extracorporeal membrane oxygenation, after having massive heart and lung failure. ECMO takes blood out of the venous system, oxygenates it in a machine and then pumps it back into the arterial system, thus bypassing the heart and the lungs. In the normal circulatory system, blood goes from the veins into the right side of the heart and subsequently to the lungs where it is oxygenated, flows to the left side of the heart and is pumped into circulation to nourish the body’s tissues. ECMO temporarily maintains circulation until the patient’s heart and lungs can function on their own.

In the oncology unit, a middle-aged cachetic patient lies face-up in the bed, staring at the ceiling while fungal and bacterial infections cause his blood pressure to drop and heart rate to increase. Despite the medications used to prevent these infections in cancer patients with very low white blood cell counts, sometimes the microbes sneak by. And because chemotherapy used to treat cancer destroys white blood cells, the cancer patient has nothing left with which to fight off the infection. Even the most minor bacterial invasion can be fatal for these patients, as it eventually was for him. Meanwhile, in the next room, another patient had just passed away and her family crowded around her bed sobbing and mourning their loss while holding the expired patient’s hand, hoping for the return of warmth.

Unusual sounds percolate from room to room in these dank areas of the hospital. Most noticeably, IV poles beep constantly as they run out of their fluids or medications. Cardiac monitors sound alarms as patient heart rates dip too low, rise above a normal level, or register abnormal rhythms. Some patients moan and scream, losing all sense of time and of themselves. Or, perhaps they curse and threaten nurses while withdrawing from alcohol. Others vomit and pass gas. Some patients demand the impossible: “get me out of here!” or “leave me alone!” Sometimes patients need to be strapped down to the bed because they pull out their IVs as they wail and moan and thrash about. During the day, minimal light shines into the unit and it is tainted by the sickness and suffering which pollute the air and tint the windows. Foul smells, which I wrote about here, are most potent in the ICU. Many ICU patients, though washed by nurses, have not bathed in weeks. The stench of sweat, stool, and blood permeates the unit when nurses change patients’ diapers, suck accumulating mucous out of patients’ mouths, and clean up blood-stained sheets.

And if you think it’s bad for providers, imagine what patients experience. The ICU must feel like a kind of hell on earth. Sleep is rare when your neighbors expectorate, choke, vomit, and shout, and nurses and physicians constantly wake you up, draw blood from your veins, and examine you to ensure your mind still functions correctly. Some patients can’t eat or drink because they need surgery (it is safer to put patients under anesthesia for surgery when they have not eaten because food will not come up from the stomach and choke the patient or travel into the lungs while they are unconscious) and so they go to bed hungry and thirsty. A patient may even go to sleep not knowing whether he or she will wake in the morning. You may be one of those who has a rendezvous with death tomorrow; you may be one of those who survives; you may hang on by a thread for weeks. Who would ever want to end up in an ICU?

And yet, it is in the ICU that patients receive the most fastidious care. Nurses watch over only one or two patients and thus can keep a close eye on them. Physicians trained in the art of emergency procedures, like intubation, are always around and watchful. Nobody will be more attentive to your medical needs than an ICU team, which monitors every sign of life you emit: breaths, heartbeats, skin color, blood pressure, electrolyte levels, blood counts, infectious disease cultures from your urine to your spinal fluid. The advantage of being in the ICU is that you receive the care that you need even if it is in a frightening environment. I hope I never have to be there, but if I am severely ill at some point in my life, the ICU is the place I would choose to be.

Tuesday, July 28, 2015

Vaccines and Their Critics

This year we witnessed a lot of contentious debate in newspapers and on television shows about the safety and efficacy of vaccines. Recently, for example, the actor and anti-vaccine activist Jim Carrey spoke out against a new law in California that eliminates personal-belief exemptions from mandatory vaccination. Carrey tweeted: “California Gov says yes to poisoning more children with mercury and aluminum in manditory [sic] vaccines. This corporate fascist must be stopped.” Carrey received Twitter support from other celebrities including Kirstie Alley, Selma Blair, and Erin Brockovich. Meanwhile, a woman from Washington state died of measles in June, reportedly the first measles death in the United States in a dozen years. And, in Seattle, only 81 percent of kindergarten students have been vaccinated against the polio virus, a rate “lower than the 2013 polio immunization rates for 1-year-olds in Zimbabwe, Rwanda, Algeria, El Salvador, Guyana, Sudan, Iran, Kyrgyzstan, Mongolia and Yemen, among other countries.”

In a 2014 post on this blog, I told the story of a child in the hospital who nearly died from whooping cough. I pointed out that vaccine critics today make similar objections to vaccine critics from the eighteenth and nineteenth centuries. But why has this criticism persisted such that outposts of communities still refuse to vaccinate their children? Why does the vaccine controversy continue to resurface?

I have since followed up on this subject with a full-length essay in The New Atlantis, now available online: “Vaccines and Their Critics, Then and Now.” If you’re at all interested in the topic, or if you’re interested in history and public health policy, this piece worth your time. I argue that vaccine criticism has a long and robust history. And historical vaccine criticisms repeat themselves today, though they are voiced by new anti-vaccinationists and shaped by cultural trends like feminism, environmentalism, and radical patient autonomy.

What exactly do these critics say? And how do we confront such a persistent and unyielding group of arguments? It’s all there in the essay. Here is a taste:

It is true that high vaccination rates are important for public health, and when people make false claims about the dangers of vaccines it is the responsibility of scientists, journalists, and politicians to criticize and refute them. But calls to ostracize and ridicule vaccine critics may be as likely to harden hearts as they are to persuade. For example, in a recent article in the journal Pediatrics, researchers studying the effects of different communication strategies reported, somewhat counterintuitively, that giving vaccine-hesitant parents more information about the safety of vaccines, or telling them about the risks of vaccine-preventable disease, whether through scientific information, dramatic narratives, or arresting images, were not effective at persuading them to vaccinate their children. And yet, another recent study in Pediatrics suggests that parents are less likely to vaccinate their children if physicians ask them what they want to do about vaccinations (as opposed to taking a presumptive approach and asserting that the children will receive their shots).

Given this impasse, where ought we to turn? Perhaps what is needed is a better understanding of the long history of vaccine critics’ objections, going back to the very origins of vaccination. This will help us not to bemoan, accuse, or fight but to educate, persuade, and vaccinate.

The whole essay is online here.
Image via Shutterstock

Tuesday, June 23, 2015

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will “make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health” in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her golf swing, or a family physician might administer amphetamine injections to people who want to feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed, doctors daily witness death and terminal illness. If we know CPR, do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine, is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism ... composed of parts. It is a structure and not a heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes, “large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine and we would be remiss if we didn’t study this purpose carefully. Without a purpose, medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

Tuesday, June 2, 2015

Empathy in Medicine

“You’ll h-h-h-have to... excuse m-m-m-me. I’m a little slow because I had a stroooooke,” he told us before we explained to him what his wife’s treatment would be. His voice was nasal and his speech deliberate as he slowly and poorly enunciated each word. He wore sweatpants and a long-sleeved shirt with a blue and white hat pulled down over his eyes. Stubbornly refusing to stay tucked away, gray hairs peeked out the sides of his chapeau and covered his ears. He looked to be in his seventies. His wife lay on the bed in a hospital gown, slippers still on. She wore a winter hat that concealed a bald scalp, one of the many side effects of potent cancer medications. Her eyebrows were gone and her sinewy frame was exaggerated as cachexia set in. She needed extra rounds of chemotherapy for metastatic cancer.

Image via Flickr: Tim Hamilton (CC)
That afternoon, I ran into the husband in the hospital lobby. He had just bought food and was going to bring it back to his wife, but he was heading the wrong way. He asked a fellow student and me (he recognized both of us) how he could get back to his wife’s room and we pointed him in the right direction. We watched him shuffle towards his wife in the cancer ward. This couple was neither wealthy nor well-educated; they were suffering and attempting to navigate the healthcare system as well as the overwhelming size of an academic hospital. They seemed helpless together.

It’s in such moments, as in many others, when empathy wells up in medical practice. I could clearly imagine myself or my family members in their position. Their emotions became all too familiar and upsetting to me. I wanted to do everything in my power to help them and to fix their situation. But this strong sense of identification seemed odd given how brief my interaction with them had been.

In reality, however, such a feeling is not so unusual. Robert Louis Stevenson, the famous nineteenth-century Scottish writer, co-authored a short story called The Ebb-Tide. It is an account of three criminals who steal a ship and the deeply troubling moral situation they subsequently encounter. When one of them falls sick, Stevenson describes the healthy comrades’ feelings:

A profound commiseration filled them, and contended with and conquered their abhorrence. The disgust attendant on so ugly a sickness magnified this dislike; at the same time, and with more than compensating strength, shame for a sentiment so inhuman bound them the more straitly to his service; and even the evil they knew of him swelled their solicitude, for the thought of death is always the least supportable when it draws near to the merely sensual and selfish.
Image via Shutterstock

Given the power of this selfless commiseration shouldn’t we cultivate it in medicine? No doubt it will help us to act altruistically even when we see the worst in patients or colleagues, thus leading to a better bedside manner and better patient care. Jean-Jacques Rousseau, the Genevan philosopher, saw such feelings differently, however. In Emile, or On Education, Rousseau points out that empathy is really an outlet for selfish passions, even if its effects can be positive. Rousseau writes that,

if the enthusiasm of an overflowing heart identifies me with my fellow-creature, if I feel, so to speak, that I will not let him suffer lest I should suffer too, I care for him because I care for myself, and the reason of the precept is found in nature herself, which inspires me with the desire for my own welfare wherever I may be.
Such cynicism about the underlying nature of empathy still has its advocates today. In the September 2014 Boston Review, Yale psychology professor Paul Bloom questions our high regard for empathy. I recommend reading his essay and his exchange with other scholars, including Peter Singer, Sam Harris, and Leslie Jamison. Bloom points out the dangers of unchecked empathy: “Strong inclination toward empathy comes with costs. Individuals scoring high in unmitigated communion report asymmetrical relationships, where they support others but don’t get support themselves. They also are more prone to suffer depression and anxiety.” And this is especially the case, Bloom points out, in the medical field in which a doctor can lose a sense of objectivity and a cool head in an emergency. Bloom distinguishes between cognitive empathy, which is empathy tempered by rational feeling, and emotional empathy, which can be dangerous. Bloom writes of an older relative of his in the hospital:

He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect.

This makes sense. I can imagine how exhausting it must be to feel so strongly about every patient. It would cause burnout and depression. But the psychologists Lynn O’Connor and Jack Berry respond to Bloom in the following way: “We can’t feel compassion without first feeling emotional empathy. Indeed compassion is the extension of emotional empathy by means of cognitive processes. Only if we have the capacity to feel empathy toward loved ones can this sentiment be generalized by the imagination and extended to strangers.” This addition to Bloom’s argument is absolutely vital. Both types of empathy are important.

Such balanced empathy keeps the physician honest. There are many times when, in a rush to complete the work of the day or under the pressure to see every patient, physicians take their frustrations out on patients. Empathy tames our impulsivity and gives us pause. It forces us to consider the actions we are about to take. And we can project empathy using reason and emotion. If an elderly woman is being difficult, instead of reacting with frustration and annoyance we can step back and ask ourselves, “What if is this were my grandmother or my mother? How would I want her physician to behave?” To do this is not easy, but it can make an immense difference in how one interacts with a patient.

Empathy may or may not spring from selfishness, and too much of one aspect of it (like too much of any emotion) can be a bad thing. But physicians do need empathy, both the emotional empathy that we feel towards some and the cognitive empathy that we can extend toward all. In the cogs of an impersonal medical system, it leads to the dignified treatment of a suffering patient.

Thursday, April 9, 2015

Three Years Left to Live

What would you do if you only had three years left to live? I remember, in middle school, discussing a version of this question with my friends. Sometimes we presented each other with a timeline of three weeks, sometimes just three days, but the scenarios all had similar preconditions: you have no obligations and it doesn’t matter if you spend all your money. Our answers were all similar. We proposed travelling to exotic places, tasting unusual foods, and performing daredevil tricks like bungee jumping or skydiving. Indeed, the question did not really concern death’s imminence. It was more about what one would do with a lot of money and a limited amount of time. We were so young, we didn’t fully grasp that such a situation could ever truly exist.

It began with a fall. The patient, a fifty-eight-year-old woman, was not usually clumsy. She kept everything neat around the house and remained active, walking daily with her husband and their dog. She brushed it off as an aberration. Then, she fell again the next week; a third time the week after. The falls slowly became more frequent. Once she began to experience clumsiness in the right arm as well, she and her husband agreed something was not right — it was time for a visit to the doctor. Her doctor diagnosed her with ALS.

Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, begins for most people like it did for this patient. It starts so subtly that it is almost impossible to diagnose when symptoms first appear. Neuroscientists and neurologists know very little about what causes the disease but its effects are well-understood. It leads to slow and progressive death of motor neurons (nervous system cells that carry signals which allow our muscles to contract) in the anterior horn cell body, a portion of the spinal cord containing the origins of motor neurons. In fact, peripheral nerves from the spinal cord innervating muscles (often referred to as lower motor neurons) and central nerves from the brain which send signals to the spinal cord (upper motor neurons) both die off, causing two different sets of symptoms. The loss of lower motor neurons leads to muscle atrophy: the muscles look smaller, are weaker, and have diminished reflexes when a neurologist uses a reflex hammer. The loss of upper motor neurons exaggerates reflexes and causes uncontrollable muscle firing, leading to muscle stiffness and spasms. Very few diseases combine these symptoms; polio and ALS are two of them. Because of this, whenever a neurologist finds upper and lower motor neuron symptoms in the same patient, he or she immediately considers ALS as a possible diagnosis.

ALS spares certain functions, though. Patients retain bowel and bladder control, tactile sensation, and eye movements. Additionally, cognitive abilities are frequently untouched. Unlike in Alzheimer’s disease, where patients are not fully cognizant of their march toward death, ALS patients know all too well what is happening. ALS drags the helpless patient, with no ability to kick or scream, toward his or her end. There is no therapy to reverse ALS. Treatment involves medication for depression, muscle spasms, and anxiety. Riluzole, an NMDA inhibitor, may extend life by a short period of time.

Patients eventually require a tracheotomy, a surgical windpipe for a breathing tube, and a ventilator as respiratory failure ensues. The example of Stephen Hawking, the famous physicist who has lived with the disease for more than a half century, is an extreme outlier: the median survival time with ALS is just three years from the onset of clinical symptoms. About 80 percent of people with ALS die within five years of their diagnosis.

Our patient wanted a second opinion about her diagnosis from an academic physician at a large medical center, which is what brought her to the office. She stoically retold her story to us and further described her symptoms. Her motions were so clumsy and uncoordinated that she could no longer sew as efficiently as she used to. She fumbled when turning a doorknob, inserting a key into a lock or using a spatula. Walking was a struggle, too — she leaned on her husband to avoid falling.

After a thorough physical exam, the second opinion offered by the attending physician merely confirmed the first opinion the patient had received. She had upper and lower motor neuron symptoms and no evidence of any other cause for them besides ALS. There, in the office with her husband, she began to sob. At fifty-eight years old and a few years left before retirement, she was going to die. Her husband teared up, too, and sat with his arm around her. We responded with silence, perhaps the best response to such tragic news. After about thirty seconds, she looked up at us, bleary-eyed, and asked what would now happen. Physical therapy, riluzole, antidepressants — yes, she would start all of these. But I’m not sure that’s what she really wanted to know. What should she, a wife and mother of three with a newborn grandchild, do with her last three years?

Images via Shutterstock

Monday, March 23, 2015

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital. Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified? How should we view the place of the mentally ill in our society?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place of medical students within the medical field. This piece discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I explained how a trauma code works and the horrors that trauma patients face. The kidney-failure patient also faces difficulties, but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

Monday, March 16, 2015

Becoming Cynical, Part 3

The problem of physician burnout, which in a previous post I defined as a “loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment,” increasingly plagues the American medical profession. In an article in the Archives of Internal Medicine in 2012, researchers found that U.S. physicians suffer more burnout than other American workers. This year, a Medscape Physician Lifestyle Report found that 46 percent of all physicians who responded had burnout, “a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40 percent of respondents.”

The consequences are deleterious: burnout negatively affects patient care and is associated with higher rates of suicidal ideation. In two earlier posts (here and here) I offered a couple of reasons why physicians become cynical. In this post, I expand on my previous entry suggesting this phenomenon is partially due to the “patient population one deals with.”

Let me start with a story.

One night, the general medical team admitted a patient with severe hyperglycemia, or high blood sugar, who had a history of IV drug abuse, alcoholism, diabetes, and hepatitis C, a viral disease that can destroy the liver. The patient drank so much hard liquor that he got dehydrated, neglected to take his insulin and went into a hyperosmolar hyperglycemic state. Patients with diabetes develop this condition when they have an infection, preceding illness, or dehydration. In diabetics, physiological stresses like these reduce insulin, a hormone which normally regulates blood sugar levels, causing unmitigated hyperglycemia. The blood becomes hyperosmolar due to the excess sugar and draws more fluid into the intravascular space leading to dehydration of cells within the body and increased excretion of water in the urine — which in turn worsens the pre-existing dehydration. As urine is excreted there is also a loss of electrolytes like sodium and potassium. Severe hypotension (low blood pressure) ensues and patients can die. Treatment involves IV fluids, insulin to correct the hyperglycemia and continuous monitoring.

After recovering overnight, our patient declared that he would start a new life and give up drinking — he was ready to make a change. As his symptoms improved and his labs normalized the medical team worked toward this goal. We arranged for follow-up appointments with a primary care physician, an infectious disease physician, and a psychiatrist. The pharmacist managed to get him insulin through a hospital-assistance program. And the social worker arranged for him to go directly to an intensive alcoholic recovery program gratis. In order to get there, he was offered transportation from the hospital. The hospital ate the cost for treating him because he was uninsured. It is both wonderful and incredible that all these resources, given freely, go towards helping a patient get back on his feet.

However, on the day of his discharge, the patient left the hospital but did not take the ride or his insulin. He drank two bottles of vodka and came back that evening in a drunken stupor and a hyperosmolar hyperglycemic state. He cursed at his nurses and the female resident who admitted him. Because he also threatened them, the hospital staff put him in restraints in his bed so he wouldn’t violently swing at those giving him medications. The medical team repeated the previous day’s actions — but two days later, the patient did the exact same thing. And for the third time, the medical team readmitted him.

This sequence of events elicits all kinds of thoughts and visceral reactions pulling us in two different directions. Surely, this patient has an illness (alcoholism) and so we need to be understanding even if we hold him responsible for his actions. And yet, the hospital gave him multiple golden opportunities to attempt to turn his life around and he declined to do so. At what point does the hospital turn him away and refuse to pay for his medical care? Would it be ethical to do so? The money can be better spent on destitute patients who will take their medications but can’t pay for them. Given the limited resources of any system, shouldn't we at least entertain the idea?

Unfortunately, doctors face this conundrum on a weekly basis. Some diabetics refuse to take insulin; other patients refuse to give up an unhealthy diet; some don’t take their blood pressure medications. Statistics back this up: in one particular review article in the Journal of the American Pharmacists Association in 2000, 43 percent of the general population and 55 percent of the elderly population were found to be nonadherent to their medications. Approximately 125,000 deaths per year have been attributed to nonadherence to treatment for cardiovascular disease. Finally, the direct and indirect costs of nonadherence to medications are estimated to be $100 billion per year in the United States.

Physicians want patients to get better, and this is more than just a matter of prescribing medicine. They spend time talking to patients about their illnesses and treatments. They call consults from specialists who then take time to figure out a plan for a particular aspect of the patient’s ailment. Social workers arrange for affordable medical services, transportation, and institutional and governmental help. Physical therapists and occupational therapists see patients who need to regain strength. All this requires logistical tasks that aren’t always intellectually stimulating or exciting and may not even be compensated for at all.

Of course it is true that the doctor can fail the patient, but it is also true that the patient can fail the doctor. In the Medscape survey I referenced above, physicians cited “too many difficult patients” as one of the reasons for their burnout. This reaction is completely understandable. After seeing patients make poor choices again and again, a general malaise can set in. At some point, physicians ask themselves, “why should we care?” Doctors may start to go through the motions of writing notes, coming up with a plan, and making arrangements for these patients but with an emptiness of spirit. We may become embittered, both toward the patient and toward some of the annoying tasks involved in the work. A sense of futility and even detachment can follow.

Let’s not forget that the practice of medicine is a very human enterprise. Indeed, as healthcare professionals, we ought to recognize the problem of nonadherence even after putting aside the issue of limited resources. However, it is useless to just complain about uselessness — to throw our hands in the air and ask “Why even bother?” In every field there is work that does not bear fruit; entrepreneurs, for example, fail 80 percent of the time when starting a new business. Why expect a profession that relies on the Sisyphean task of changing a human being’s behavior and habits will be exempt from this fact? Patient failure, just like physician failure, is an integral part of our fallible medical system.

Wednesday, February 25, 2015

What Doctors Can Learn from Sherlock Holmes

I remember reading Sir Arthur Conan Doyle’s Sherlock Holmes detective stories as a child. I tore through each page of each book, relishing Holmes’s crime-fighting abilities and dreaming that I could replicate them. I even would have settled for the opportunity to work alongside Holmes like his loyal ally Dr. Watson, sharing in adventures and assisting the great investigator. Today, when I return to stories like The Sign of the Four, I am just as enthralled and entertained as I was then.

Sherlock Holmes sculpture by John Doubleday,
at Meiringen, Switzerland, near the Reichenbach waterfalls,
where Holmes faces his nemesis Professor Moriarty
in “The Final Problem.”
Image via Shutterstock

Holmes’s power of observation is his most impressive trait. He observes his surroundings more carefully than any of the professionals at Scotland Yard. He notices the way a man dresses, the way someone walks, different types of ash from pipes, and unique types of handwriting. Holmes succeeds as a detective using this unmatched faculty. As a budding physician, I am beginning to realize how relevant this ability is to the practice of medicine.

Indeed, Conan Doyle based Holmes off of his teacher in medical school: Dr. Joseph Bell, a professor of medicine at the University of Edinburgh. The author wrote to Dr. Bell in 1892: “It is most certainly to you that I owe Sherlock Holmes.” Though Conan Doyle never pursued medicine as a career, he assimilated much from his mentor. He describes his encounter with Dr. Bell in the book Memories and Adventures (1924):

For some reason which I have never understood he singled me out from the drove of students who frequented his wards and made me his outpatient clerk, which meant that I had to array his outpatients, make simple notes of their cases, and then show them in, one by one, to the large room in which Bell sat in state surrounded by his dressers and students. Then I had ample chance of studying his methods and of noticing that he often learned more of the patient by a few quick glances than I had done by my questions.

From Dr. Bell’s perspective, teaching students to use their eyes as well as their textbook knowledge was of paramount importance. Deflecting his former student’s praise, Dr. Bell explained in the Strand Magazine

Dr. Conan Doyle has, by his imaginative genius, made a great deal out of very little, and his warm remembrance of one of his old teachers has coloured the picture. In teaching the treatment of disease and accident, all careful teachers have first to show the student how to recognize accurately the case. The recognition depends in great measure on the accurate and rapid appreciation of small points in which the diseased differs from the healthy state. In fact, the student must be taught to observe. To interest him in this kind of work we teachers find it useful to show the student how much a trained use of the observation can discover in ordinary matters such as the previous history, nationality, and occupation of a patient.

An example of Bell’s acumen tells us much about his prowess as a physician. Conan Doyle recounts the following conversation between Bell and a patient:

“Well, my man, you’ve served in the army.”
“Aye, sir.”
“Not long discharged?”
“No, sir.”
“A Highland regiment?”
“Aye, sir.”
“A non-com. officer?”
“Aye, sir.”
“Stationed at Barbados?”
“Aye, sir.”
“You see, gentlemen,” he would explain, “the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilian ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British.” To his audience of Watsons it all seemed very miraculous until it was explained, and then it became simple enough. It is no wonder that after the study of such a character I used and amplified his methods when in later life I tried to build up a scientific detective who solved cases on his own merits and not through the folly of the criminal.

Dr. Bell further explained his methods in the Strand Magazine:

And the whole trick is much easier than it appears at first. For instance, physiognomy helps you to nationality, accent to district, and, to an educated ear, almost to county. Nearly every handicraft writes its sign manual on the hands. The scars of the miner differ from those of the quarryman. The carpenter’s callosities are not those of the mason. The shoemaker and the tailor are quite different.

It is tempting to think of Dr. Bell’s and Sherlock Holmes’s skill as the stuff of history. How many of us handcraft shoes these days? Also, these methods seem useless in the age of labs and imaging. We can track liver enzymes, look at cells from biopsies, get blood counts, and perform full body scans showing us much of what we need to see. Nevertheless, to rely on labs and imaging and other recent techniques to dismiss Dr. Bell’s method would be a mistake.
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During an outpatient clinic week, one woman came in complaining of a “racing heartbeat.” The resident and I interviewed her together and asked a series of questions that most physicians ask a patient during a visit: When did this start? What does it feel like? Do you have any shortness of breath with it? Does it happen while you’re active or at rest? Does anything make it better or worse? Is there any pain associated with it? Is it constant or does it wax and wane? Do you have any other symptoms with it? Have you had any sick contacts recently?

From what we gathered, she, her two children, and her husband all had pertussis, or whooping cough (That a whole family has a disease for which we have a vaccine is distressing — see my post on vaccines here.) She had been coughing hard for months and was taking Robitussin to mitigate her symptoms. But at random times during the day, she felt like her heart was racing. She denied an association between the cough and any activity and claimed that she wasn’t taking any medicine other than Robitussin. None of us could figure out why she was having these symptoms. We ordered an Electrocardiogram (EKG), which demonstrated a fast heart rate but no abnormal rhythms.

As we walked out of the room we noticed an inhaler of albuterol hanging out of the patient’s purse. An inhaler is used by asthmatics to control wheezing. It is one of the first-line treatments for asthma and it allows patients to breathe in medication, thus making sure the medicine gets into the lungs. We asked if she was using it. She admitted to taking it seven to eight times per day. Her son had asthma and she used his inhaler to help with her cough.

Albuterol acts on beta-2 receptors in the lungs. These receptors, when stimulated, cause relaxation of the muscles that control the airways. In asthmatics, the airways clamp down and cause shortness of breath and wheezing. Albuterol reverses this effect. Unfortunately, there is minor cross-reactivity between beta-2 receptors and beta-1 receptors. Beta-1 receptors can increase the heart rate and cause cardiac arrhythmias. This particular patient was using the inhaler so often that she was getting a lot of cross-reactivity and consequently felt like her heart was going to jump out of her chest.

We explained this to her and told her to stop using the inhaler. She left without any prescriptions — an unusual outcome for a clinic visit. In this case, even though we had taken a thorough history by asking the patient careful questions and getting an EKG, we were flummoxed. Only by observing not just the patient but her belongings were we able to figure out what was going on.

A doctor’s success depends both on the ability to elicit information from the patient and to watch carefully for signs of unusual behavior or circumstances. Observation is and remains, as it was for Dr. Joseph Bell, integral to the accurate recognition of a patient’s illness. It requires levels of attentiveness that only the expert observer could describe as “much easier than it appears at first”; while being foundational, it is by no means elementary.