Thursday, November 29, 2007

Some of the things I don't know

This week we began our "Physical Diagnosis" sessions. This is when they'll teach me to do all of the things that doctors on tv do: listen to stuff with a stethoscope, grope people's internal organs (though we've already been told to use the verb "palpate" when talking to patients), tap on a belly with my fingers, rub up against some lymph nodes. You know, doctor stuff.

So when the day came for my first session, I packed up my bags, grabbed my passport, and joined three of my classmates for a journey over the East River and across the border into Brooklyn. When we arrived at our designated hospital, we met up with Dr. F who herded us into a conference room and began to outline the physical exam on a white board. Now, we've had virtually no meaningful instruction regarding the physical exam, so this brief outline - which contained little more information than can be discerned by an attentive bout with Hasbro's "Operation" - was riveting. But I didn't want to just hear about spleen groping, I wanted to watch it up close. So when Dr. F announced that we were going to hit the wards to meet some patients, I leaped from my chair. I'll get to watch Dr. F listen to stuff! And palpate stuff! Just like they do on tv! And when she finds a patient with an upside-down spleen, Dr. F will turn to us and say, "Now Medical Students, come palpate this upside-down spleen." Then we'll all shuffle over to the bedside to fondle that spleen while we solemnly nod to one another and mutter things like, "that's assuredly upside-down."

So out we walked into the corridors of the hospital, imagining all of the great anatomical oddities that Dr. F would reveal to us. But when we stopped at a patient's room, Dr. F looked at me and one of my classmates and told us, and I paraphrase here, "to go on in there and get us a physical exam." Then she turned around with the other students and left.

"Shit. Do you remember where the liver is?"

So my partner and I walked into the room and found Mr. S sitting on his bedside. He was a thin man with neatly trimmed hair and a quick smile. He was delicately folding his clothes and placing them in a drawer at his bedside. Mr. S was more than happy to discuss his case with us, and generously allowed us to examine him. Unfortunately, neither of us were familiar enough with the physical exam to really learn much from that component of the visit. However, we were both well-versed in taking a good history, and the story Mr. S had to tell was certainly a memorable one. It goes something (but not exactly) like this:

Mr. S had been diagnosed with diabetes decades ago, but he wasn't all that good about taking his medication. He tells us that he always felt alright, so he didn't think it was necessary to pop all those pills. After failing to control his condition for about 20 years, his peripheral nerves and blood vessels started falling apart, and doctors were forced to amputate his foot. Now, some years later, Mr. S is back. He hasn't been taking his medication, and he's had his second foot amputated.

Mr. S had worked as a paper pusher in an office before his first surgery, and had been put on disability shortly thereafter. I never asked whether he had been insured during those first 20 years, so I don't know whether his personal finances played a role in whether or not he took his medicine before he lost his first foot. However, he has been eligible for Medicaid since his first surgery, and the pattern hadn't changed. In fact, he continued to smoke two packs of cigarettes each day.

Recently, we've had a series of lectures on the economics of health care. One of the lectures was delivered by the President and COO of GHI in New York, Dr. Aran Ron, MD, MPH, MBA. GHI has recently merged with HIP to become the largest health insurer in New York. At one point in his presentation, Dr. Ron referenced studies that illustrated one of the problems that insurance companies - and the health care system at large - are confronting. When a patient with insurance walks into a hospital, they have no reason whatsoever to curtail spending. I can imagine that if I were lying in an emergency room with an excruciating pain in my back and a doctor says to me, "I'm 99.9% sure you've got a kidney stone. I've seen thousands of these things and you've got all the classic signs. But you MIGHT have something else. The only way I can know for sure is to order a very expensive CT scan for which you will pay precisely nothing." At that moment, I would be gasping incredulously while trying to muster the strength to punch the guy in the nuts for wasting all of that time talking to me when he could be wheeling me to his very expensive scanning machine.

Dr. Ron's claims were echoed during another lecture by Dr. Sheri Glied, Ph.D., who is the Chair of the Division of Health Policy & Management at Columbia's Mailman School of Public Health. Just to avoid anyone misinterpreting the reason for me writing about this, Dr. Ron, Dr. Glied, and I are all proponents of universal health care (though Dr. Ron can't have the GHI higher-ups finding out about this, so please, Mom, Dad, and Dan, don't tell Dr. Ron's bosses). Much of our health economics lectures centered around elucidating the profound challenges involved in implementing universal health care in America - not just politically, but in terms of controlling costs and ensuring high quality care.

During Dr. Glied's lecture, she referenced other studies that claim to show, not surprisingly, that people who are insured visit the doctor more often than those who aren't insured. Consequently, she said, if the 47 million uninsured Americans suddenly became insured, our health care system wouldn't be able to handle the surge in demand. This argument didn't sit well with some of my classmates, one of whom became particularly vocal. This student believed that it was absurd to believe that anyone would go to the doctor for any reason other than that he or she was sick. Nobody would take time out of their day - often several hours - to go sit in a waiting room if they didn't think they really needed it.

A medical curriculum is based primarily on repetition. We hear the same stuff over and over again to be sure that we remember it when it matters. And one of the things that I've learned over and over again is this: "there are lots of people who show up in hospital beds who don't think about the world the way I do." I agree with my classmate that it would be absurd to take three or four hours out of my day to see a doctor for a headache when I could much more easily wash an aspirin down with a cup of coffee. But I fully believe that there are plenty of people who would be lining up outside the MRI scan to rule out brain cancer before returning to work.

And what can be done about patients like Mr. S? Is there any way to put the onus on him to take care of himself? It's one thing to spare no expense to keep someone healthy, but is there any alternative to keeping someone alive while he fastidiously tears himself apart?

Thursday, November 15, 2007

When closets risper

In my seventh grade french class, my teacher would try to come up with the most absurd mnemonics to help us remember french vocabulary. For the most part, it worked. To teach us the word for "lobster," she suggested imagining coming home from school one day to find that your mother had been turned into a giant lobster madly flailing around on the floor. You would almost certainly yell, "oh, Ma!" Which is the way the french pronouce "homard" (because the french pronounce things incorrectly).

I've been doing very little learning over the past year. Primarily, I've been memorizing. So it's no surprise that I've come across my fair share of mnemonics. What is surprising is how truly awful these mnemonics are (with the exception of the very memorable, sexually-explicit ones which I won't be sharing on this site). For instance, to teach us that the deep cerebellar nuclei, from lateral to medial, are the dentate, emboliform, globose, and fastigial, our textbook suggests, just remember DEGF!

It sometimes even seems like these text books prefer the useless mnemonics to the memorable ones. All of our books and lectures constantly refers to "SIG E CAPS" as a way to remember the diagnostic criteria for depression. Those are:

1. Sleep disturbances
2. Loss of interest
3. Guilt or feelings of worthlessness
4. Loss of energy
5. Loss of concentration
6. Change in appetite or weight
7. Psychomotor retardation or agitation
8. Suicidal ideation
9. Depressed mood

Notice that #9 doesn't even play into the SIG E CAPS criteria for depression.

A much more accessible mnemonic is "Depression is worth studiously memorizing extremely greuling criteria. Sorry." Which correlates with: depressed mood, interest, weight, sleep, motor activity, energy, guilt, concentration, suicide. I've only read this mnemonic once in any text.

Today, I was studyig the atypical antipsychotics (the first generation of these antipsychotics are now called the "conventional antipsychotics", and the most recent iteration of these drugs is called - I kid you not - the "atypical atypical antipsychotics"). Three of the more important atypicals are clozapine, olanzapine, and risperidone, and next to a list of these drugs in my review book is the mnemonic "It's not atypical for old closets to RISPER."

That's right. Normally closets risper. Specifically when their old. Don't forget!

In the opening weeks of this year our course directors overwhelmed us with labels for parts of the brain and told us to memorize them. To our untrained eye, none of these parts looked any different than any other parts. The brain's just a big ball of wrinkly mush, and we were expected to remember the names of the wrinkles. In an email to the class, one of my classmates wrote "I always had a tough time remembering where the calcarine sulcus was until I realized it was right between the cuneus and the lingual gyrus." I thought the sentiment was funny enough to repeat to other people, and now, ironically, I never forget where to find those three parts of the brain.

So here's my new plan. I'm looking for the most nonsensical, useless mnemonics to compile into a list that I can routinely look over and make fun of. As these nonsensical strings of letters vie for the title of the most useless string of letters, hopefully, in the end I'll at be able to remember the battle and, by extension, the relevant medical knowledge.

Saturday, November 10, 2007

New year, new body parts, new patients

The last time I posted, I was just a first year medical student, naive to the ways of the world and ignorant of the practice of medicine. Much has changed since that last post. Specifically, two things have changed. First of all, I'm now a second year medical student which means I'm allowed to shove first years into their microscope lockers or slip cholera bacteria into their drinks in the cafeteria. The second change is that I've almost completed our Brain and Mind course. So, while I'm still entirely ignorant of the practice of medicine, I'm only largely ignorant of the way a healthy head is supposed to work.

Last year, most of my patient contact was with patients from a small general practice. These folks were typically getting checked up to make sure their diabetes or hypertension was under control. Later in the year, I hung out at the lymphoma clinic at the cancer hospital next door. While lymphoma can be a serious and life-changing diagnosis, the patients I worked with weren't acutely ill. More often than not, I would spend my time chatting with them about their medical, social, and family history then watch the doctor glance over a few charts and say something along the lines of, "I see no reason to begin treatment now. How about you come back in six months?"

Over the course of the year, I became very comfortable taking a patient history, so I didn't think much would change this year when we started interviewing our psych patients. It's just an interview, right? I ask questions, write down answers, smile when it's appropriate, frown when they frown. Piece of cake, right?

So there are a couple of reasons why my interviews with psych patients have been difficult. The first is that some of my patients have had fairly profound cognitive deficits. Before my first interview, I had assumed that the course administrators would start me off slowly. Maybe a patient with a mild mood disorder that's in remission. Maybe someone with hypomania and I'll diligently write down that "the guy talks fast." But, no. My first interview with a psychiatric patient in a clinical setting was with a schizophrenic patient with a string of suicide attempts on her record. The interview was not much like the medical histories I'd taken before (and, of course, the details I'm about to provide are changed from the patient's actual story, but the gist is there). The patient, who was bandaged up pretty well and confined to a wheelchair, told me that she was brought to the hospital after she fell off a subway platform and was hit by a train. Her expression didn't change, but I frowned anyway. It seemed like the right thing to do.

"So, can you tell me what happened before you fell off of the platform?"

"I needed to get away. I needed to get away to join the army, but I couldn't get on the train because I'd get caught and taken back to the hospital, so I jumped into the tunnel."

You know what's not an appropriate follow-up question in a medical interview? You're about to find out.


I was rarely able to elicit both a relevant and decipherable answer from this patient. The rest of the interview involved tangential and nonsensical discussions of whatever she wanted to talk about.

The second reason that I've found these interviews so difficult is because the information is so unreliable. This isn't because psychiatric patients are unreliable (though, obviously, there are some conditions that impair cognitive function to a degree that the history you get is clearly untrue). Rather, the information is unreliable because the interviews focus on the one subject that elicits the most guilt or embarrassment from the patient. If I spent forty minutes talking to a hypertensive patient about his salt and cholesterol intake ("Oh doc, I've been eating real good. Last night I had this, like cauliflower gratin with capers, it was DEE-lectable!"), I guarantee you that the meals he describes would all come from Weight Watchers commercials he watched while eating potato chips and licking sticks of butter.

Psychiatric patients often know exactly what would concern their doctor, and if they're not concerned about it, their doctor's not going to hear about it. Often, it's not until I get back to the nurses station and read reports from other clinicians or family members that my questions get answered. Like all those questions I had about the kindly, older woman who thinks I have "just the most beautiful smile!", who houses stray dogs, and who told me that she never drinks and didn't even touch alcohol until she was 28. It turns out that woman has about a half dozen drinks a night to wash down her benzodiazepines.

Accordingly, most of our patients don't think they have anything to discuss, but they'll chat with me to help me complete my school assignment. And at the end of the interview, I have to determine exactly what it is that the patient is most worried about. That thing, their chief complaint, is listed first our reports. Last year my reports started like this:

CC: Patient has had a productive cough lasting two weeks


CC: Patient is experiencing acute lower right quadrant abdominal pain

This year the chief complaints look different. Like this one for the homeless, alcoholic who believes the CIA is watching him from cameras in traffic lights:

CC: "The nurses won't give me a second cup of apple sauce."

Or from the woman addicted to an enormous list of prescription drugs:

CC: The doctors here are too young, and "lack the sophistication to understand me."

I graduated college with a double major in english and psychology. By the time I completed my psychology coursework, I had become one hundred percent certain that I didn't want to pursue it as a career. But many of my closest friends and family members have been treated by a psychologist or a psychiatrist, and I've always been aware of the profound impact a psychiatric disorder can have on a person's life. The science behind psychiatry is only now starting to catch up with the theoretical component of the profession. For that reason, I've heard lots of doctors and future doctors scoff at psychiatry, saying that it's make-believe, not a science. But over these last 10 weeks, I've found it hard to imagine a more important area of study.

Schizophrenia affects more than 1% of the adult population, a figure that I find absolutely staggering. Now I understand that, unless schizophrenia drives you to suicide (and teens with schizophrenia have approximately a 50% risk of attempted suicide), you're not going to die from a psychiatric disorder. But I suspect that if you had to wake up tomorrow morning with schizophrenia, an unremitting major depressive disorder, or lung cancer, you probably wouldn't mind rolling the dice with surgery and some chemotherapy. For precisely that reason, I believe we need our best minds researching treatments for psychiatric conditions.

Fortunately, mine is just a mediocre mind, so I can do whatever I want.