Archive for the ‘Medical Musings’ Category

Articles

Reflection on Medicine, Rotation 1.

In Medical Musings on June 22, 2012 by David

It’s amazing how many things happen in the hospital and how much responsibility that I have, even as a medical student. I told a patient with metastatic renal cell carcinoma that he was going to die. I closed at the end of brain surgery for a patient I admitted and talked to everyday for more than week. I interpreted for a mandarin speaking patient who came in with nonspecific chest pain, and left with a CABG, and developed a stroke and became aphasic. It’s a sign of how sick our healthcare system when you know your patient has less than a year to live, but it’s her insurance status rather than her prognosis that guides what tests we order and what procedures we do. It’s hard to talk to Utilization Review, even at one of the strongest safety net hospital of one of the most affluent counties in the United States.

But what’s most shocking to me, and what I have the hardest time struggling with, is how quickly lives can change. It’s amazing how one day, you can come into the hospital with no complaints, minor fatigue and just feeling under the weather, and leave a few days later after brain surgery and a prognosis on the order of weeks to months. Or you can come in with nonspecific chest pain, a normal EKG, one borderline troponin, and what can be described just as well as the prodrome of viral gastritis, and be sent for a CABG. It’s especially hard to think that you are doing the best for your patient, offering invasive but life saving procedures to patients who have no insurance, when you call to follow up and find out your patient who you advocated for to get a CABG developed a stroke postop, become aphasic, and stayed in the ICU for a week.

Mr. Y was a monolingual mandarin speaking gentleman who went to the ED with some non-specific chest pain after two days of the stomach flu. He wasn’t the most cultured gentleman, but he reminded me of my dad. He was a rather loud gentleman, with no sense of an indoor voice. Like my dad, he was a smoker. I still remember discussing with the team, whether he needed to be admitted – with some nausea and vomiting (perhaps because of the viral gastritis?), some exercise intolerance, and some nocturnal orthopnea, but with negative troponins, a normal EKG, and more concerned about his nausea and vomiting than about his chest pain. His chest pain seems to be chronic – perhaps an outpatient stable angina work-up would be enough?

As the only mandarin speaking member of our cardiology team, I spent a lot of time talking with him. We had long conversations on why smoking cessation is important and what it means to eat well. To me he complained about the hospital food, and I laughed in his face when he told me that he got the nurse to get him a hamburger and fries from the hospital cafeteria. I sat with him during his catheterization, and I translated for the cardiology fellow as he told Mr. Y that he had bad triple vessel disease, that there was nothing interventional cardiology can do for him as his coronary arteries are too bad and the plaque too diffuse for stents, and would probably need a CABG. I laughed at him again when right after he heard the news, and then told us that he was hungry because he was NPO for the entire morning and asked if someone could get him McDonalds now that we are done.

As a physician, there is so much responsibility. The idea of informed consent is hard, who can truly understand the implications, ramifications, advantages, disadvantages, challenges, and harms of an invasive procedure. It was especially hard for a patient like Mr. Y. Monolingual and poorly educated; Mr. Y was a migrant worker working as a masseuse in a mall in South Bay as the rest of his family was in China. When I asked for an emergency contact, repeated as the likelihood of CABG became greater, he could not name anyone. He was alone, in a country that does not even speak his language. Although I sat down with him and described to him in detail the surgery, he was almost indifferent, almost resigned in his trust of the medical team. Asking him to explain concepts back to us, all he would say is “I don’t really understand, but whatever you say I need, I’ll do.”

He asked me if a CABG was dangerous, and I looked him in the eye. “This is a very invasive surgery, they will need to open your chest and perform major surgery. There is the risk of complications, but we believe that this surgery can help you and we recommend you get the surgery.” I thought we were doing a good job. SGFH doesn’t even have a cardiothoracic surgeon – we called Moffitt/UCSF, got carotid ultrasounds, and PFTs, and kept him inpatient until the following week. I thought it was a triumph, an expensive surgery for a poor patient – an egalitarian use of resources and a good advocacy on our part.

One of the assignments for the medicine clerkship was to call a patient after discharge to help us think about discharges and to assess patients understanding and management after they went back home. During my last week, I finally got around to this assignment. I called his phone three times during the last week. Only on the third call did someone finally pick up, but it wasn’t Mr. Y. It was a nurse at Moffitt/UCSF. Mr. Y was still in the hospital so many days after the surgery? The nurse was actually an ICU nurse. Mr. Y suffered a stroke after the CABG, and this was his 5th day in the ICU. He was now no longer able to speak, aphasic and needing to be transferred to back to SFGH – potentially for a long stay before long term placement.

It’s always said that life is fragile, and that we should cherish each and every moment, but is so hard to know and truly internalize this bitter and cold truth. It is hard to be an advocate for people who depend on you when in there is so much uncertainty, so much risk, and so much danger behind every choice. As physicians, our job is to provide predictability, stability, and comfort. To explain, reassure, manage, care for, and love our patients. Even that alone is hard.

Articles

My Greatest Fear

In Goals,Medical Musings on March 7, 2012 by David

This past week, we had our last FPC session of the year. In our small group this past year, we have talked about a lot of the most important issues, like our experiences with death, that we don’t have time to talk about during the clinical curriculum. As we transition to the clinical curriculum,  we were asked “what is our biggest fear/worry as we start on the wards?”  It’s hard to imagine that almost two years have gone by, and I will soon be starting in the hospital. As I am about to start on the wards, my greatest fear is unintentional change.

During first year, in FPC one of my classmates talked about her older brother. Now a transplant surgeon, she recalled how he’s changed throughout the course of medical training. He was recently divorced and now just throws himself at his work, without much to his life outside of this. She still remembers him as the kind, gentle, and intelligent person he once was, but her heart breaks for the kind of person he has now become. When his parents are sick, he is a great resource – able to consult to chair of the GI department when they have a medical problem – but over his caring core is an abrasive shell. Being an attending surgeon, in command of surgical field, one comes to develop an expectation of how the people around you will treat you – and this expectation bleeds through into the other, more important, relationships. For better or worse, medicine is a very hierarchical culture. You can be treated poorly by the people above you, especially as people are busy, tired, end frazzled, unfortunately, this normalizes this kind of behavior when you advance, and can affect how you act in other aspects of your life.

That is my greatest fear. To one day, look into the mirror and not recognize the person I have become. Third year will most likely be a busy year, and be over in just a blink of an eye, and I don’t want to wake up next year and wonder how did I get where I am. As we grow older, no one intentionally becomes arrogant, aloof, cold, or impatient, yet these are adjectives that we find can too often describe adults. If we are being honest, these are traits that can especially describe physicians.  In medical school, we hear stores of surgeons throwing temper tantrums when the smallest of things go wrong. A rock’s natural tendency is to roll downhill –  to go with gravity and slide in the path of least resistance. It is just too easy be complacent and without intentional direction, to slip up.

And unfortunately, that is my natural tendency. I am arrogant, too confident in my achievements and accomplishments, even as in my heart I recognize that it not by my ability alone. I am impatient. The past two years, to my dismay, I have felt that my tendency is to be impatient. I am rushing for place to place to study.  I am too easily annoyed when I have to wait on others, yet ironically I am habitually late – making other people wait. Although I usually enjoy talking to people in passing, I find myself avoiding eye contact so I don’t waste time making small talk. As the next year to be even busier, I will need to consciously prioritize relationships and keeping up with people.

Ultimately, I think that my solution. To have meaningful change, I will need to prioritize and have goals. Next year will be the most challenging, the most tiring, and the most important year of my life so far. But in addition to all that, it will also be the best year of my life yet, the culmination of so much of what I have worked for so long. I will see, learn, and do so much in the next year. The next twelve months, as I study for the boards and then go off to the hospital, will be a stressful experience, but it is precisely this stress that is our impetus to improve, grow, and learn.

Originally written on 02/26/2012

Articles

Protovis

In Medical Musings,Statistical Analysis,Statistics on June 14, 2011 by David Tagged: , ,

Just started playing around on Protovis, WordPress doesn’t allow Javascript, so will just post some .png of graphs I’ve made. It’s a shame, b/c some of them are interactive. Owell!

http://dl.dropbox.com/u/13118678/Protovis/Age.html

Articles

Liver Transplant Donor Run

In Inspiration,Medical Musings on April 6, 2011 by David Tagged: , , ,

Sunday night, I had the rare opportunity to go on a donor run. We flew into Fresno and I got to scrub in to help in a liver and kidney procurement. It was an amazing experience – awe-inspiring to realize what was happening and overwhelming in knowing what a rare and unique opportunity this was. Out of the tragedy of one person’s loss, multiple individuals are helped – in this particular case, the heart, liver, and kidneys were collected. It is truly an amazing system, where the anonymous generosity of one individual can galvanize an entire support network and bring together physicians from all over the country to most efficiently help people in need.

On the scientific and medical level, transplant is just as amazing.The very idea of transplant, the practice of moving and implant another individual’s organ to help prolong another individual’s life, underscores a deep fundamental understanding of physiology, cell biology, and biochemistry. Physicians build upon a tremendous body of knowledge of physiology – an understanding of how each organ functions and what purpose each tissue serves. For a successful transplant, physicians need to identify the signs of what organ is failing, surgeons need to perfect the technique of resecting an organ while minimizing ischemia and preventing blood clots, and a large body of knowledge must be available to understand how to perfuse the organ and minimize the immune response of a foreign organ.

The play-by-play:
At around 8:30PM, I got a call from Alexandra. I did not have the pager and she had just gone to a procurement earlier that day, so she asked if I wanted to go. I had just gotten home from preceptorship and was making dinner. Having been in the ED the entire day, I was rather tired, but really excited for this opportunity – particularly when I heard that it would be in Fresno.9:45PM, I got into an unmarked van in front of Moffitt Circle. I met up with Alex, the transplant coordinator, Stephen, R3 from Fresno on transplant rotation here at UCSF, and Ingo, the transplant fellow. We drove to SFO and got on a private jet to Fresno. An anesthesiologist from the transplant network met us at the airport and we headed off.

11:45PM We got to Community Medical Center, changed into their scrubs, and began preparing for the surgery.  There was a little bit of downtime, where we got some coffee (bad idea, I was trembling a little when closing) and the fellow went through all the paperwork.

12:15AM. The surgery began. The nurses were super helpful – I don’t have too much experience scrubbing in, but they were really nice in helping me pick out gloves and put on the gown and gloves.

It was an amazing process, with the cardiac team working in parallel with the abdominal team. I won’t go into too many details, but it always astounds me the amount of finesse involved in surgery. Great delicacy is used to maintain the blood supply of the organs, and I could tell the

3:00AM The surgery began to wind down. The R3 and I got to close up the donor, while the fellow focused on the actual organs. I helped tear down the surgical field and package the organs.

4:00AM Back to the Fresno airport, which was then only a skip, hop, and a leap back to SF. I couldn’t sleep the rest of the night, and stayed away the rest of the time until I got back home.

This was truly an amazing experience, and really highlighted the joys of surgery. Through finesse and technique, there is an unparalleled opportunity to make a great impact and impact someone’s life. The task before you is directly tangible and the responsibility is directly on your shoulders. It is truly a different experience, and I really felt the rush of adrenaline in helping out and knowing what I was doing would make a difference.

Articles

Cargo Cult Science, Medicine, and Science Fatigue

In Medical Musings on March 7, 2011 by David Tagged: , ,

Part One: Cargo Cult Science

During the Second World War, American and Japanese forces fought over a large swath of territory across the Pacific Ocean. This area including many previously unexplored islands and archipelagoes and many indigenous cultures inhabited these distant lands. Isolated by large jumps of distance and previously unknown, these indigenous cultures were exposed to modern technology for the first time during the war. Imagine their amazement as, for the first time, they saw the metallic glare of fighter jets and battleships and heard the deafening roar of jet engines.

Food rained from the skies and the new arrivals literally changed the landscape, as both American and Japanese soldiers used airdrops and created landing strips and airports. To these indigenous cultures, the new arrivals must have seemed to be Gods or, at the very least, demons. Introducing the indigenous cultures to canned foods, medicine, clothing, and other manufactured goods, this outside intervention must have seemed incomprehensive –completely changing their world view and turning their lives upside down as they stood in the middle of a battle between two technological powers.

But then, after the conclusion of the Second World War, the soldiers left as quickly as they had come. Without a war to fight, there was no longer the same incentive to stay at these remote islands. For the indigenous cultures, it must have been quite confusing. Where did all the nice clothing, tools, and medicine go? How come food no longer dropped from the skies? Not fully understanding the reason why the soldiers came to their land or the mechanism behind the new supply of food and supplies, some indigenous cultures became cargo cults. They wanted access to the benefits and tangibles of technology without truly understanding how it worked. Mimicking the soldier’s actions and creating the outward signs of complexity, cargo cults sought to recreate the conditions required for attracting the cargo. Creating life-size replicas of airplanes, building control towers made of wood and thatch, and even clearing land to recreate runways, cargo cults mirrored the conditions of a technological society without fully understanding the reasoning and mechanism of their actions.

Richard Feynman famously used the term cargo cult science to describe research that is done without a full understanding of the underlying mechanism and using “reason” to justify the results post-mortem. Although these imitations can be quite accurate – Feynman mentions that the straw antennas of these make-shift airplanes were strikingly close to the length of actual antennas – without having any kind of result. Although mimicking the routine of developing hypotheses, using controls, and performing experiments, cargo cult science describes work that seeks to create results while lacking the fundamental understanding of what is actually happening. Cargo cult science is the justification of empirical observations without a true understanding of underlying processes.

 

Part Two: Medicine as a Cargo Cult

By this definition, medicine is a cargo cult science. This says nothing of medicine’s efficacy or its ability to help people, but 21st century medicine is ultimately an empiric science. As much as we understand cell biology and systems physiology, the human body is still an incredible mystery, full of individuality, complexity, and beauty. With the level of current understanding and knowledge, biology (especially human biology) is a black box. As a first year medical student, this is the fundamental challenge in learning medicine – the knowledge gap between physiology and pharmacology.

As much as we understand human organs (the heart is a pump, the kidneys are a set of filters, and etc), with the current level of understanding, it is still fundamentally impossible to deduce the efficacy and the side effects of pharmaceutical agents. We can conceptually think about what happens when we increase or decrease blood flow, but it is still very difficult to determine a drug’s effect given its molecular structure or even what protein it targets. As an example, different approaches are needed to learn physiology and pharmacology in medical school. We want to understand how to body and various organs works in physiology, but we are forced to memorize the characteristics, half-lives, toxicities, and efficacies of drugs in pharmacology.

Yet despite its status as a cargo cult science, I find partial assurance because medicine is an empiric science. We choose what pharmacological therapies to give because it worked for the last hundred thousand people with your illness, and while we might not understand completely the mechanism of its effect, we can be reasonably confident in its efficacy for you. In fact, if you think of it this way, the FDA is the simply the clearinghouse of cargo cult science. The FDA does not simply ask pharmaceutical companies what the mechanism of their drug is (actually it does, but if you follow my logic of medicine as a cargo cult science I’d say that’s misguided.), but actively seeks to test and validate its efficacy.

But more than an effect on clinical outcomes, medicine as a cargo cult has great implications on the speed of medical progress and how medicine will progress in the future. Despite the rapid pace of basic scientific discovery, the difference in attitude and perspective between medicine and science will only widen the gap between scientific knowledge and clinical treatment. The next part will try to explain what I hypothesize will happen and why that is.

 

Part Three: Science Fatigue in Medicine

Unfortunately, it is far too easy for smart people to think of explanations and justifications of what they observe –regardless of whether or not it is true. Anecdotally, I can remember quite a few instances where I was asked to explain a concept, and while I wasn’t completely sure, was able to describe a reasonably sound explanation. Then, in retrospect, the explanation turns out to be completely wrong. Prior to Galileo’s claim that the Earth revolved around the Sun, humans lived normally and comfortably for hundreds, if not thousands of years. Prior to Galileo, there were many scientists, astronomers, and great thinkers – yet were they not troubled with what we now recognize as errors and fallacies of critical thought? Intelligent people, if set in a particular framework of thought, are especially difficult to persuade.

A prime example in medicine would be the recognition that Helio pylori, bacteria in the stomach, can cause ulcers. The scientists were initially ridiculed and scorned – “How can bacteria grow in the acidic environment of the stomach?” – before overwhelming evidence was obtained. It took the efforts of a brave scientist to ingest the bacteria and give himself ulcers before the scientific community could access the truth of his statements. With such a discovery, the entire framework of treating stomach ulcers was changed and Barry Marshall and Robin Warren won the Nobel Prize – but before this discovery, when haven’t other physicians and scientists recognized this link? Hindsight is 20/20, but the question of stomach ulcers is a large part of gastroenterology.

I can think of two main reasons, why medical advancement lags behind scientific understanding. There are undoubtedly more, but I think there are two main causes in relation to perspective and the framework of research. First, medicine works. This gets back to the initial idea that medicine is an empiric science – despite all its shortcomings and gaps in understanding, medicine is highly efficacious and we are at a point in history were previously fatal diseases and symptoms are routinely treated and cured. Just as Galileo was focused on something that seemly had no direct bearing on day-to-day life, many of the problems of medicine are not focused on the day-to-day treatment of patients. If someone has a heart attack, there is a standardized protocol and all in all, it works well. There is a standard of care for most diseases that guide how physicians treat patients. When things work, there is much less of an incentive to figure out why it works and how it works. This is a simplification, but I feel like this especially true when people are overworked, fatigued, and worrying about hundreds of other concerns (such as patients health, regulation, and even healthcare reform).

For the second reason, I would like to suggest a new phrase: Science fatigue. The idea of compassion fatigue is a concept that argues that the media has caused cynicism and lack of initiative in society by saturating newspapers and news shows with decontextualized images and stories of suffering. This inundation of similar images has been cited to cause the public to become cynical, or become resistant to helping people who are suffering – I would argue that this is same case with science. The general public, and physicians in particular, are flooded with so much news of scientific breakthroughs and innovations that seem to never materialize in concrete advances or meaningful change in care. We are always hearing about the latest device and the newest therapy, but the standard of care has changed so slowly that it is difficult to not become cynical about the marketing and showmanship now pervasive in medical science.

 


Part IV: Conclusions

The combination of relative efficacy and inundation of information is especially noticeable in medical education. In medical school, one is expected to learn and understand a large and ever-growing body of knowledge related to basic science and treatment. We are flooded with a huge volume of information – more than enough to occupy us for 24/7 for the next four years – and thus we need to prioritize what is important and what we choose to be curious about. The standard of care is undoubtedly important (medicine first and foremost has to work), so treatment is often emphasized. Science and the basic mechanisms often seem more nebulous and intangible. There are still many aspects of medicine that we do not understand, and the mechanisms we understand are sometimes barely better than the educated guesses of intelligent people. To reiterate, it is far too easy for smart people to think of explanations and justifications of what they observe – and without true understanding of the underlying mechanism, is medicine much better than a cargo cult? With the pressing urgency of patient care and the great body of knowledge expected of every physician, is it possible to function above the level of a cargo cult scientist?

A great clinician once told me that the most important skill to learn in medical school is the ability to deal with uncertainty. When we treat patients, we can never truly be completely certain that our diagnosis is correct or our therapy is the most efficacious. Physicians need to be comfortable with the uncertain variability in disease presentation, drug response, and even human physiology. This uncertainty begins even at the level of molecular mechanisms. Even as basic science pushes our understanding of biology, science cannot be the only force that drives the practice of medicine. Patient needs, cultural barriers, and pragmatic considerations all divide the worlds of medicine and science.

Since coming to UCSF, I have realized that many of the greatest challenges of medicine come not from the science, but from quality of care and from access to care. The most intractable problems of global health and health within our own community come from deciding how and where to deliver care that is currently already available. Healthcare reform seeks to answer the questions of how we can improve our quality of care without bankrupting the economy. Learning to deal with people is an incredibly important issue –  even though we have incredibly efficacious drugs for treating hypertension, asking people to take pills (with noticeable side effects) for a disease that is subtle, often symptomless, is tremenendously difficult. There are many questions that cannot be answered from the benchside and while I still greatly admire and respect science’s ability to alleviate suffering and cure disease, much good can be done in improving the potential we already have in front of us now. For better or worse, medical is truly different from science.

 

 

 

 

Articles

Thoughts on Cancer

In Medical Musings on November 3, 2010 by David Tagged: , ,

I don’t know enough about cancer to understand its treatment, but I had an curious thought. Would appreciate any thoughts on why it wouldn’t work, how its currently done in current medicine, or just opinions/suggestions.

In my mind, it seems like cancer treatment is equivalent to the endgame in chess. There’s only a limited move set (only so many drugs that are available and efficacious), and there are only so many ways that the cancer can respond. Sometimes, the treatment forces the cancer’s hand, selecting for more resistant and virulent genotypes and quickly leading to either success or failure. My analogy to chess is that with only a limited number of moves (cancer is often determined at late stages), can we anticipate and plan the best course of action. In some ways, this is already done with frontline therapeutics used before secondary treatments. Clinical trials have been run testing the efficacy of using one drug first vs. using another drug first, but I have the following questions:

Are late stage cancers uniformly harder to treat and more lethal? I am reminded of my undergrad biology class, where we learned about dynamic equilibriums. In a population of different organisms, or cells in this exam, although we can imagine one group would theoretically “more fit” and overrun the entire ecosystem, there can be dynamic equilibriums where unique environmental pressures would allow each organism to create its own niche and allow for coexistence of multiple organisms.

Can there be a similar example in cancerous cells, where more invasive, metastatic cells are held in check by less invasive, but perhaps faster growing cells? If the less invasive cells are more susceptible to exogenous cancer treatments, the therapeutic can ultimately select for the more deleterious cell type and speed up cancer progression?

Is there any situation where delaying treatment can improve patient outcome?

Are there any ways to homogenize cancer cell populations prior to treatment?

Articles

Synthetic Biology: Engineering Biological Systems

In Medical Musings on May 12, 2009 by David Tagged: , ,

by: David Ouyang and Dr. Jonathan Silberg

from: Snapshots in Research, Volume 2 (Spring 2009) —
Abstract

Recent advancements in molecular biology and biochemistry allow for a new field of bioengineering known as synthetic biology. Using biological parts discovered in the last thirty years and mathematical models grounded in physical principles, synthetic biology seeks to create biological systems with user-defined behaviors. The major focus of research in this emerging field is the characterization of genetic regulation and the abstraction of biological systems to clearly defined logic circuits. With the abstraction of individual DNA sequences to known biological functions, synthetic biologists seek to create a standard list of interchangeable biological parts as the foundation of this emerging field. Through genetic manipulation, these parts are expected to be useful for programming biological machines that process information, synthesize chemicals, and fabricate complex biomaterials that improve our quality of life.

http://catalyst.rice.edu/archives/43