We were talking today about opportunistic infections (infections you get when you’re immunocompromised, due to HIV, on steroids, or you’ve received a transplant), and specifically about the effects of anti-retroviral therapy on changing the course of disease in patients with HIV.

Our lecturer, Dr. Montoya, mentioned something that I don’t think I’ve ever heard from another lecturer: he said that during the 1980s, the staff would meet once a month to mourn the loss of their AIDS patients, and to remember them. Rarely do we ever hear mention of patients dying, and even more sparse is the admission from a doctor that their patients affected them. That we’re not robots of information and treatment. We’re people, our patients are people, and that medicine is a human interaction. It was really refreshing to know that there’s emotion involved-or at least, there should be. All too often physicians are noted for their detachment, or at least, their ability to detach-to be objective in a time of crisis or emergency. But I think if you don’t let your patients get to you-or at least some of them-you lose something key to what drives you to continue practicing to the best of your ability.

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Us young folk are hot on your trail .

While I must agree that the tech changes even in the past 10 years of medicine have revolutionized the practice of medicine, I’m not so willing to give up on an older’s doctor’s level of experience. I may know the latest guidelines, and practice more evidence-based medicine, but until I’ve got a couple thousand patients under my belt, I’d much rather see someone older than a bright-eyed, bushy-tailed just-out-of-residency hooligan like myself in half a decade.

But now here’s the question: will it be easier for my generation to keep up, or harder? Now that we’re being trained in a computer and tech-aware world, will it be easier for us to a) keep up with change, b) learn faster and easier, or c) understand the new lab data and treatment options? That is, will we be just making more different types of antibodies, or will treatments become even more novel and hard to learn the second time around?

I’m hoping, of course, it’ll be easier. It’s like computers; we grew up with them, so we’ll (hopefully) always we able to understand the interface. Then again, I grew up with a Nintendo, and I can’t play anything more advanced than that worth a damn.

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We talked about diagnostic testing in our biostatistics/epi class yesterday, and I really think it was the first time that I realized how important statistics can be. It was probably the first time that I really saw how statistics affect patients–individuals–not big masses of people.

We talked about prevalence, pre- and post-test probabilities, predictive values, and likelihood ratios. Reading it now, it sounds pretty dry and boring, but it absolutely affects how likely a patient is to have a certain disease. It’s these kind of decisions and analyses that are absolutely vital to medical decision-making, and vital to being able to provide the most information and the best information to a patient; they also say a lot about how efficiently we spend health dollars in the US.

The big boom in “spiral CTs” or “whole body scans” can be pretty worthless if there’s no clinical suspicion of illness. Even a test that’s sensitive and specific 95% of the time will be a worthless test if the prevalence of a disease is extremely rare; one may increase their risk of some disease from 1% to 2%, but 98 times out of 100 you won’t have the disease, and you’ve just spent $6,000 to tell you that.

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When you study diseases and cancers and other terrible things all day long, you start to formulate the most invalid of hypotheses: this is pathology that affects other people . I will not get cancer. I will not have a risk of dying. I will go on my merry way, helping my patients. I will remain 24.

We need to know these diseases and their symptoms and complications to help our patients, never us. Maybe it’s an “us versus them” mentality, or maybe it’s just a psychological defense mechanism, but either way, I’m constantly reading about some disease and thinking to myself, “Man, that would really be awful to get that. I feel so bad for what they must have to go through.” But then a moment later, the reality hits me-and it’s frightening. I’m assuming that these awful cancers with awful prognoses and awful survival rates and awful treatments will somehow skip me. I’m just as likely to develop some of these cancers or diseases. I don’t get a “by” just because I’m going to be a doctor.

Perhaps that’s why doctors are more likely to smoke, drink in excess, or do recreational drugs than you’d expect. Less likely to get a regular checkup and physical. These aren’t diseases that affect all people. They affect other people.

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A Stanford physician at the student health center used code 5150 to send a student to Stanford’s psychiatric ward for 3 days, according to The Stanford Daily . There’s obviously two sides to the story, but I would assume the student must have done something to seriously concern the physician. Still, it doesn’t sound like the student’s stay was a pleasant one.

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Dr. Charles has a nice writeup of his experience with a transsexual patient, and I really respect him for trying to be sensitive and respectful. (When’s Stanford gonna start showing gay pr0n?) He did the right thing; above all, listen to your patient. And it’s okay to be ignorant (I don’t think doctors do it enough). The point is to have the willingness and interest to learn.

Just two notes: some people prefer transgender to transsexual, it just depends on the person. And a drag queen is not the same thing as a transgender person.

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We saw a physician where we’re rotating yesterday, and it presented a whole other level of uncomfortable challenges to face. My classmates went into her room (we’ll call her Maude) to take an initial history and practice the physical exam, and they were done within three minutes. Maude had a friend visiting, but they only got a few questions in before Maude politely said “It was nice talking with you,” promptly ending the exam. As we’re still preclinical students, and not responsible for Maude’s care just yet, my classmates took it as a sign and said goodbye. (Our preceptor later pointed out to us that you have to press on; you have to know all of the patient’s problems if you want to help them, or see if they’re getting better or worse under your watch.)

When we went back with our preceptor, it was a slightly akward experience. Maude had fallen, and clearly had some neurological deficits (memory and attention problems), and it seemed strange to try to elicit things on the history and physical exam with Maude as a physician–she would know exactly what we were doing. If we had tried to do a mini-mental on her, she’d know what to expect. It’s not that we trick patients on exams, but we do certain tests to try to elicit certain responses to check if things are within the range of normal (whatever that is). Physicians would generally know why we ask patients to sah “Ahh,” or stick out their tongue, or raise their hands above their head.

I didn’t realize how secretive I’ve been interpreting the history and physical until now. With other patients, they don’t generally know why I’m asking certain questions or listening certain places, but with Maude, she may have known exactly what we were doing (with or without the neurologic deficit). Part of it was concern that she’d know if I was doing something wrong, or asking the wrong questions, but part of it was that she could feasibly evade, dodge, and parry. I’ve got to learn to think of the history as getting answers, not revealing secrets or details that patients wouldn’t normally tell me if they knew what I needed to know.

An interesting aside-our preceptor told us to be vigilant when caring for other physicians; it’s easy for either physician or patient to minimize symptoms and disease, as they’re “one of our own.” Physicians are also more likely to be smokers and drug-abusers, lead more stressful lives, and don’t get regular checkups, so their disease may be more severe by the time they present for care. Heal thyself!

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What a great read about the changes in medicine currently taking place. As always, balance is the key.

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It sure was nice not to know anything. Those days are long gone.

Before medical school-or even just last year-I didn’t know a thing about disease. What makes you sick, how you can die, how your body can fail on you. And now that I do, it’s a frightening knowledge.

With every new organ we study, I basically learn more ways that I can die. More things that can go wrong, more ways that I can get sick, more complications and symptoms I could have in the future. First with the heart, you can have a heart attack. Duh. But you can also have sudden death-your heart just stops . Or you could have a clot that you have no clue about go to your brain or your lungs or anywhere else and kill you. Then with the lungs, there’s a ton of really nasty diseases that end up in honeycomb lung . Or you can get a number of respiratory infections that’ll do you in. Then onto the kidneys. Plenty of ways those can just stop out of nowhere. And now with the GI, there’s cancer everywhere. (What’s worse, a significant number of these diseases are what medicine likes to call “idiopathic.” That basically means no one has a freaking clue what causes them.)

The funny thing is, for those first 23 years, my risks were always the same, my chance of developing any of these conditions never changed. It’s only that my understanding of them has changed. Hell, my risks have probably decreased now since childhood-I eat better, I get more exercise, I’m much more hygenic-but I still feel like all of them are just waiting to get me. Any inkling of a sore throat jump-starts the thought-process quite well: “Is it strep? If so, am I going to develop acute post-streptococcal glomerulonephritis and start peeing blood? Or maybe I’ll get post-strep endocarditis. Listen. Do you hear a murmur?” This is contrary to the fact that I get maybe one or two sore throats a year anymore, and before that I had so many so frequently as a child and young adult that I got my tonsils out.

There’s some good sides to this, of course-every classmate I talk to washes their hands much more frequently. And I think once I see how rare most of these conditions are, I’ll be less concerned that I’m going to develop Goodpasture’s any time soon.

It must be scary as hell to try to raise a child being a physician though–worrying about Wilms tumor and rotavirus and what have you.

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A short-but-excellent piece on NPR discusses the trend of medical students changing their preferences for specialties . It’s worth the 8 minutes.

I think the piece is right–my generation has very different priorities than my parents’ generation. While we’re just as hard-working and driven, we want to have a more of a life. We want balance. Or maybe we just want it all–seeing patients, of course–but also families, social lives, and hobbies. I also think it’s unfortunate–and dangerous–to be pumping out such a small number of primary care doctors. But we clearly reward specialists with higher pay and, in many cases, better “hours.” We’re in big trouble in 20-30 years, when the millions of baby boomers need primary care, but all we’ve got is specialists.

I believe I’m ultimately very priveleged to be granted the opportunity to pursue a career in medicine–to receive more education than 99% of the rest of the world–and along with that comes a responsibility. Sacrifice. But ultimately, I want what everyone else wants: time to spend with my family and friends, and time to do the things I enjoy. We’re so focused on the scientific and causational in medical school that religion seems further and further from the truth; if we really only get one turn in this thing called life, I don’t want to miss out on it all. As always, it’s finding the balance that’s the key.

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