Thursday, March 1, 2012

Breath



N.B. This post may be considered, um, politically incorrect. Let's just consider it in a clinical context.

I am jewish, well, my mitochondria is. And if I'm right, my oral microbiome, rather, my breath, is as well. I call it "Jew Breath". It resembles mothballs(note: this is not my breath all the time, only occasionally!). I've noticed it a lot at Temple and had it independently confirmed by an old jewish roommate:

"You know what I'm talking about" I said to A. "Jew Breath is real!". A put his face in his hands, smiled, and nodded slowly, admitting the painful truth. I could smell it on him too.


As an SGU'er, with my school's majority Indian population, I also noticed among some a certain "Indian Breath" (or more offensively: Desi Breath). I can't quite put into words what it smells like, but I prefer it to Jew breath. Anyways, a fellow (caucasian/goyim) med student who is dating an Indian women actually had that breath... which means either the smell is not associated with the subcontinent OR she transferred some of her oral flora to him through excessive make out sessions (how long and how many remains a subject for further study).

There is some clinical relevance to this, however. Analyzing the myriad microbiomes of the gastrointestinal tract is a hot research topic,implicated in everything from Chron's disease, type 1 diabetes, failure of anastomeses in surgery (from a grand rounds lecture pre-pub) to development of pancreatic cancer. And it turns out, some research has found a difference in the oral microbiome of different ethnicities.

So maybe there is something to Jew Breath after all...

Sunday, January 29, 2012

Maple Syrup

The tapping of trees for maple syrup was practiced in north america for thousands of years before the arrival of the immigrants. The French adopted its use early on and it's a tradition that has had a noticeable impact on the St. Lawrence River valley. Maple syrup also has a history as one of the earliest examples of socially responsible purchasing. Slavery lords of the south produced much of the sugar in the United States in the early to mid 19th century. For abolitionists, maple syrup became an alternative source of sweetener to divert funds from the economic clout of the slave owners, as were other agricultural products similarly boycotted as part of the Free Produce Movement. Interestingly, the Free Produce Movement began in the 1790's and lasted until the 1850's. Somewhat parallel to today with fair-trade and organic goods, the "Free Produce" products never were able to compete economically with slave labor products. Though, one could say "Free Produce" is finding a more enlightened market in the 21st century, ultimately people have to value their ethics of human rights and environmental responsibility more than saving money...

Tuesday, January 24, 2012

Round, Cut, Eat, Sleep

Alarm slap at 4:45, got 20 miutes to get ready. It starts with a cold bike ride through the dark park, and suddenly I have coffee and Ins & outs. The parade of patients then flies by, soon back in the OR and the ritual scrub in begins. Inside the abdomen now, presurized camera port view - like a reverse submarine periscope. Hiding spleen and adherant umbilicus, don't forget the internal hernias. We're out and grabbing an Oxygen tank, wake up - you did well, well your GIT did, now it's up to a duel b/w your WBCs and disturbed microbes. Pass off at PACU, go grab something for $3.26 - surgery makes you hungry. But at the end of the day sometimes, you're more tired than hungry - wake up at midnight wiht the light on, turn it off - rinse and repeat.

Thursday, January 12, 2012

Competitive Specialties

Entering clinicals, I never expected to like the more "procedural" specialties. But ever since I scrubbed into my first C-Section in OBGYN, I've been drawn to the OR. The excitement, the atmosphere, the sense of accomplishment, the work of having a few, long, nice projects to work on for the day and the ability to see a difference in a patient after surgery are all very attractive to me. I can see that much of my pre-clinical work was also project oriented, even if it had little to do with surgery.

If only things were so simple. I decided to take SGU up on there clinical academic advising services (something I made good use of in basic sciences with the great Dr. DB). I sent in my CV, GPA, Step 1 and goals of matching in Surg or OBGYN. I will say Dr. PB (the clinical advisor) gave me some needed advice and gave a great critique of my resume. But he basically said I have less than a coin flip's chance of matching in either specialty. Not a 0 chance, but not great either. It's tough news, but I'm thinking about what I can do to change my chances and think hard about what I like about the OR.

But it got me angry and thinking about WHY certain specialties have cut offs. Does someone need to be that much smarter to go into General Surgery than to go into Family Medicine? Is the academic training of Dermatology really more broad than Primary Care?

From my experience in medicine: No. In fact, general practice is in many ways more challenging intellectually - you really have to know the subtle signs of sickness to catch the deadly diseases early among the sea of worried well. No, there is something else at play, as DJ Shadow once alluded to...

The most competitive specialties pay the best. Lifestyle is a part of this, which is why EM - a midrange compensation - is becoming highly sought after. This is not surprising if one is a cynic, but it's disheartening if one is kinda typical on stats paper but wants to follow their interests and make a difference in a field. We live in a capitalistic society, so I guess I shouldn't expect things to be different - it's just always startling when the brutal reality of it stares you in the face. I just wonder what the distribution of Derm vs. Family vs. Surgery vs. Psych would be if all of them paid the same and had the same hours. And what that would do to the delivery of healthcare in this country. Considering how many physicians I've hear complaining about compensation cuts, I'm guessing it would be a bit different than today :)

F/U post comparing specialty distrubution in other healthcare systems (europe, canada, india) to follow...

Tuesday, September 6, 2011

Fully formed

(Paul) Farmer entered Harvard med school in the fall of 84. He was only twenty-four. He told me once, "I was fully formed at twenty three." He meant, I think, that by then he had his philosophy and worldview in order, and he knew he wanted to marry them to action..."
From Mountains Beyond Mountains

How many students enter med school with an independently formed world view?
Sure, many have goals, mainly around specialty, lifestyle, etc. But in many ways the med school admissions process selects more for students who can have the world view of their institution imparted onto the next generation of doctors than for those who have their own ideas about what they want with medicine. Ideas that, in many cases, take time away from the pre-med grind in order to formulate.
I am seeing the validity of my original goals with medicine the more I get into the grey fog of action, indepenence, and socio-politics that is clinical practice. A validity that was much harder to see in the cold facts of mcq memorization that was basic sciences.

Thursday, August 25, 2011

This is clinicals

Have reached the stage of exhaustion where I am a complete neurotic, overly sensitive, giggling monstrosity. I am so toasted yet still oddly wired and excited to get up and go to the hospital and explore brooklyn and i dont even know. This is clinicals.

Friday, April 29, 2011

When Normal is Abnormal

In the last week of my Introduction to Clinical Medicine course, we had a middle aged women patient with hypothyroidism. She had a bought with Grave's disease and ended up with radioactive iodine therapy which, though it cured her hyperthyroidism, left her with hypothyroidism. She was later put on levothyroxine but ever few years they needed to increase the dose. I remember asking if this was typical to our clinical professor that day, Dr. R, and he said that this is quite common with hypothyroid patients.

--

My friend B also has hypothyroidism. B also developed hypothyroidism as a result of radiation, but this was for her Hodgkin's Lymphoma, which she successfully beat. B initially went undiagnosed until her Oncologist, and the best Doc she's ever had, noticed her sweating too much when she came in once, and immediately ordered a TSH test. Since then she was placed on 50ug of Levothyroxine and her TSH was typically around 1.1 (reference range 0.4 - 5, though there is some debate about this).



Sir Charles Robert Harington, discovered the structure and synthesis of levothyroxine



Over the past year or so, B started to notice her hair falling out. At first she thought it was due to two surgeries she had within a few months of each other (both for unrelated conditions). Her previous Endocrinologist took a job in another city and so she saw a new one at a prestigious university last June. After looking at her TSH (2.2) and examining her rather quickly, she told her "your hair is not going to all fall out" and rather rudely dismissed her concerns.
Dismayed by this for a while, B continued to watch her hair fall out for the next several months and then started to get some painful acne. After this she made an appointment with a Dermatologist in November. Her PCP signed off on the referral, though he didn't have much insight into her hair loss either. The Dermatologist examined her and drew some blood. Before she got any results back she prescribed spironolactone, presumably for its anti-androgenic effects to counter the acne and hair loss. She ran her own tests and noticed she had a slightly elevated aldosterone, called B and told her to take the spironolactone.
The spiro at first stopped the hair loss but didn't induce much regrowth. After a month on it without any complaints, the Derm doubled the dose to induce regrowth. Within a few weeks B started to notice some strange side effects, though not entirely uncommon. She stuck through this (she is a very compliant patient) but then started to just get plain lethargic over the end of winter and into spring. She also stopped working out and couldn't seem to keep her apartment organized. B thought perhaps it was the long, cold winter but then she started to get salt cravings and gain some weight. Again, possibly spiro side effects, at least the salt craving.
Since spiro is a potassium sparing diuretic, one must be careful about potassium intake. One day in March, B ate a bit too much broccoli and appeared to get symptoms of hyperkalemia. It could also have been just bad broc, but after that she was scared off eating anything with a lot of potassium - cutting out some of the fruit staples of her diet such as bananas and juices. After this, she started to feel insatiable hunger and, as a cancer survivor, started to get paranoid about the constellation of symptoms of tired, hunger and generally feeling ill.
Just this past week she had her yearly check up with her Oncologist. After reporting how she felt to the interns and doing some blood work, they came to a rather obvious conclusion: B needed to increase her dose of levothyroxine. It turns out that at this appointment, her TSH had risen to 3.3, while still in the "normal reference range", her oncologist knew her history and that B's typical range for proper thyroid treatment was a TSH of around 1. She prescribed a dose of 75ug and explained that her hair loss, weight gain, and lethargy were all likely due to the hypothyroidism.

--

Looking back on this, there are a few interesting lessons. First, the reference range does not always tell the whole story. References ranges are in fact based on the population mean for a lab value, +/- 2 standard deviations. This helps us see pathological outliers, but it doesn't always tell the most accurate story for an individual. It reminds me of another story where a fellow med student, and former nurse, said someone could have a blood sugar of 40 be not outrageously low (though we're taught <60 is low) because he could just be someone who has low sugar. While I have not had enough clinical experience to appreciate this, it seems to make sense and was certainly analogously true for B.
Also, I know my own personal clinical judgement got warped when trying to help B figure out what was wrong. Makes me wonder how much physicians can really get emotionally vested in their patients before we start to see what we want rather than what is really taking place.
However, the most disturbing aspect of this whole endeavor was the fact that 3 separate, board-certified physicians completely missed what was going on. Not only were her symptoms dismissed (endocrinologist), completely missed (primary care doc) but she was also misdiagnosed and given an unnecessary treatment (dermatologist). A year of distressingly losing hair and the psychological consequences of that, gaining weight, rising blood lipids and also some inflammation on top of it all, could have been avoided if someone had just put together her symptoms with her #1 chronic condition and what is "normal reference range" for her, individually.
It raises many questions about the coordination of care, the role of medical records, and even the attentiveness (perhaps overworked, perhaps not) of the physicians in our US healthcare system. I just wonder how typical such cases truly are... and will certainly do my best to keep this in mind on my clinical rotations later this year.