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.