RSS

Advice for Aspiring Physicians

Tonight I spoke with UT’s Plan II Pre-Medical Society, answering their questions about what it’s like to become and be a doctor. Here’s some of the advice this old man shared with the youngsters.

Embrace Your Gifts and Passions

Early in his career, the late physician and author Oliver Sacks badly wanted to be a neuroscientist. The only trouble was he just wasn’t very good at it. After a number of mishaps in his attempts to do research, his supervisors firmly told him his future was not in the lab. Instead, he was sent to work with patients with severe degenerative neurological diseases living in a long-term care facility. While his contemporaries saw this kind of work as a dead-end, Sacks found it very much to his liking. At the nursing home, he was able to spend long hours with patients learning their stories.  Out of this experience, he discovered his gift for writing about what it’s like to live with a serious neurological condition. Sacks’ books and articles have evoked empathy and interest in people who would otherwise be overlooked. He has drawn medicine’s attention to the patient’s experience of illness, rather than simply studying and addressing disease. As Nobel Prize-winning scientist Eric Kandel wrote, Sacks “transformed the view of the mind for millions of people in a way that is both insightful and entertaining.” Imagine how much the world would have missed if Oliver Sacks had insisted on being a neuroscientist instead of embracing his gift for hearing and writing patients’ stories.

Be Curious

I recently saw a patient with symptoms I simply could not make sense of.  As I asked her questions about what she was feeling, more and more interesting details about her life came forth. I followed my curiosity and soon we were discussing changes in her most important relationships and transitions that were taking place. And then the cause of her symptoms became clear. Just by following my curiosity, rather than directly trying to figure out what was wrong.

It is also important to be curious about systems, customs, and institutions. Medical students should embrace the naivete they bring to their work. Medicine’s pedagogical method of apprenticeship leads it to honor tradition and hierarchy. It is slow to embrace change and question itself. While students are learning the culture and methods of medicine, I encourage them to also respectfully question why things are the way they are.  This is how breakthroughs and innovation happen. The disciplines of hospice and palliative care emerged when people looked at how patients were spending the end of their lives and asked if there could be a better way.  Was it really necessary to die in an intensive care unit connected to tubes and wires, surrounded by strangers and beeping machines? Or might it be much better to die at home in your own bed with family at our your side?

Seek Balance

There is more to life than medicine Keep up your relationships with your friends and family. Exercise. Take time to do what recharges your battery–music, books, writing, sports, travel, being outdoors. What good is it if you become a doctor, but in the process are transformed into a miserable, boring person?

Anyway. I hope the students gained something out of our time together. I enjoyed being with them and sharing what I’ve learned.

 

 

Seek Balance

 
3 Comments

Posted by on October 15, 2015 in Uncategorized

 

Curiosity

In a wonderful essay, physician and educator Faith Fitzgerald writes about the importance of curiosity in health care. As dean of students at UC, Davis’ School of Medicine she sometimes heard complaints from politicians about medical students being “insensitive, mechanistic, technocratic, inhumane brutes.” After a good deal of research, she asked herself, “What is kindness as perceived by patients?” Her answer was

“Perhaps it is curiosity: ‘How are you? Who are you? How can I help you? Tell me more. Isn’t that interesting?’ And patients say, ‘He asked me a lot of questions’; ‘She really seemed to care about what was going on with me.’ Is curiosity the same, in some cases, as caring?”

Fitzgerald writes that

An endowed lectureship at my medical school allows us to invite Nobel Prize-winning scientists to visit and lecture for several days. What impressed me most about my conversations with these luminaries was their extraordinary broad range of interests, their enthusiasm, and their thought patterns. One thinks science has a sequential and controlled pattern of logical ideas, firmly grounded in antecedent principles and constantly cleansed of intellectual debris by the abrasion of skepticism. Listening to Nobel laureates in medicine was revelatory. . . The scientists seemed oblivious to intellectual constraints and unconcerned about seeming naive or unknowledgeable. . .”

She then asks

What does curiosity have to do with the humanistic practice of medicine? Couldn’t it just convert patients into objects of analysis? I believe it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients–to empathize–one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.  Both the science and art of medicine are advanced by curiosity.”

Fitzgerald writes that efficiency and time often undermine curiosity. For instance,

One senior resident once presented a patient in morning report and, as part of the physical examination, mentioned a scar in the patient’s groin. When I asked how the scar had been acquired, she said, ‘He told me he was bitten by a snake there.’ ‘How did that happen?’ I asked. ‘I don’t know,’ she said.

How could that be? How could one not ask? The imagination runs riot with the possibilities of how this man got bitten by a snake in the groin. But the resident was too busy (or not curious enough) to ask!”

Fitzgerald asks

“What is the reward of curiosity? To the patient, it is the interest and physical propinquity of the physicians, which is therapeutic in and of itslef. To the physician, curiosity leads not only to diagnoses, but to great stories and memories, those irreplaceable ‘moments of medicine’ that we all live for.”

You can read the entire essay through the link below, and I recommend you do–especially because the story she ends it with is very good.

Click to access Fitzgerald_AnnInternMed_1999_130_70_Curiosity.pdf

 
Leave a comment

Posted by on August 4, 2015 in Uncategorized

 

Aid in Dying in Belgium

As I’ve written elsewhere “physician-assisted suicide (PAS) laws in Oregon, Washington, and Vermont permit doctors to prescribe a life-ending medication to adults who are found to have decision-making capacity and a terminal illness that will lead to death within six months. But now groups such as the Society for Old Age Rational Suicide (SOARS) are advocating that people without terminal conditions also be granted means for committing suicide.” A recent New Yorker article describes how this is already happening in Belgium. With the Britney Maynard case sparking a movement to give people more autonomy end to their lives, it’s worth examining how this is playing out in the European countries that are doing so. Here’s the link to the New Yorker article. http://www.newyorker.com/magazine/2015/06/22/the-death-treatment

 

 

 
3 Comments

Posted by on June 18, 2015 in Uncategorized

 

The Week in Medical News: PPIs and Heart Disease

I’m resolving to keep this blog alive with at least 1 post a week. An easy way to do this is a brief comment on a medical study that’s been in the news that week.

Today, I read about a study about a class of medications called proton-pump inhibitors (PPIs). Millions of people take a PPI such as Prilosec, Prevacid, or Nexium to treat heartburn and other complications of gastroesophogeal reflux disease (GERD). Now a group of researchers from Stanford are raising the possibility that PPIs might increase people’s risk of having a heart attack. The investigators reviewed more than 16 million clinical documents on 2.9 million individuals and found that people with GERD who took PPIs had a 16% higher risk of having a heart attack.

Although researchers acknowledge that PPI usage may be serving as a marker for a sicker population, they believe this is unlikely since people taking antacids such as Pepcid and Zantac didn’t have a higher heart disease risk. The studies authors theorize that PPIs might increase the risk of heart disease by inhibiting an enzyme called DDAH that is necessary for cardiovascular health.

Dr. Nicholas Leeper, lead author of the study states that “we’re not recommending that people stop the drug (PPIs) at this point.” But he did suggest that patients reconsider their need for the specific class of medications as well as their individual risk.

To clarify if PPIs truly increase the risk of heart disease, we will need a prospective, randomized study. In the meantime, I will reassess if people with GERD truly need to PPIs or if they could get sufficient symptom relief through lifestyle measures or another class of antacids such as Zantac or Pepcid. I will be especially careful about recommending PPIs to people with vascular disease or at a high risk of developing it.

 
Leave a comment

Posted by on June 11, 2015 in Uncategorized

 

Our Own Personal Rainforests

Here’s a link to an article I wrote on the microbiome, the one hundred trillion bacteria that live on or in the human body. I focus on possible links between the microbiome and obesity, immune disorders, and mental illness.

http://www.worldmag.com/2015/04/inner_life

 
3 Comments

Posted by on June 6, 2015 in Uncategorized

 

Vaccines

With measles and the whole issue of vaccinations in the news, I thought I’d share a basic primer on the subject.

What is a vaccine?

Our immune system is constantly protecting us against us bacteria, viruses, parasites, and fungi. That’s why people receiving treatments that suppress their immune systems are very susceptible to infections. The idea of vaccinations is giving a person a component of an infectious organism to stimulate his or her immune system to act against it before it causes harm. It’s training your immune system to be on guard against particular invaders.

The history of vaccines

Edward Jenner was a country doctor living in England who in 1796 performed the world’s first vaccination. He took pus from a cowpox lesion on a milkmaid’s hand and injected it into an eight year old boy named James Phipps. Six weeks later Jenner injected two sites on Phipps’s arm with smallpox, yet the boy was unaffected by this as well as subsequent exposures. Based on twelve such experiments and sixteen additional case histories he had collected since the 1770s, Jenner published a volume called Inquiry into the Causes and Effects of the Variolae Vaccine. Jenner came up with his idea by the observation that milkmaids infected with cowpox, visible as pustules on the hand or forearm, were immune to subsequent outbreaks of smallpox that periodically swept through the area.

Since Jenner’s discovery, governments have invested in vaccines. Initially vaccines were considered a matter of national pride and prestige. In the twentieth century, a standard battery of childhood vaccinations were developed and eventually required for public school attendance.

Some Diseases Vaccines Prevent

Polio

In this disease, people develop muscle weakness and the inability to move. The weakness can extend to the diaphragm, the muscle that moves our lungs so that people have to be placed on a ventilator to support breathing. Historically, a ventilator called on iron lung was used to artificially maintain respiration until a person recovered sufficiently to breath independently.

Rubella

When pregnant women become infected with this virus, it can cause serious birth defects such as heart problems, hearing and vision loss, and intellectual disability.

Diphtheria

This bacteria causes a membrane to develop in the oral cavity which can block the airway, causing people to suffocate to death.

Measles

This virus can cause cough, inflamed eyes, sore throat, fever, and red, blotchy skin. In about 30% of cases complications such as blindness, inflammation of the brain, and pneumonia occur.

The Impact of Vaccines

A little more than a century ago, before vaccines the U.S. infant mortality rate was 20 percent, and the childhood mortality rate before age five was 20 percent.

Are Vaccines Safe?

In the vast majority of cases, vaccines are effective and cause no side effects or only mild reactions such as fever or injection at the vaccine site. In 1998, the medical journal Lancet published a study linking the measles vaccine to autism. The study was subsequently found to be fraudulent so that the journal retracted the paper and the study’s author Andrew Wakefield lost his medical license.

Why Get Vaccinated?

Vaccines presented outbreaks of infectious diseases and save lives. When a certain portion of a community is vaccinated against a contagious disease, most members of the community are protected against it. Even those who aren’t eligible for certain vaccines, such as infants, pregnant women, or immunocompromised individuals are protected. This is called herd immunity. So when you get vaccinated, you are not only protecting yourself. You are also protecting the most vulnerable among us from getting sick.

 
3 Comments

Posted by on February 10, 2015 in Uncategorized

 

An Inspiring Story

The first two years of medical school are traditionally when students learn the scientific knowledge that serves as the basis of medical practice and research. Most students are more motivated to acquire this knowledge when they see how it connects to human health. Accordingly, many medical schools now teach at least some of their basic scientific concepts through illustrative clinical cases.

As part of a team helping to create the curriculum for the new UT Dell Medical School in Austin, I was recently given the assignment of writing about retinoblastoma. Since this is a cancer that occurs in childhood and I see exclusively adults in my practice, I do not have experience treating patients with retinoblastoma. When I set about researching actual cases of the disease, I came across the story of Ben Underwood. When Ben was two years old, his mother Aquanetta noticed that his right eye had a peculiar glow. After an examination by an ophthalmologist, Aquanetta was informed that Ben had a tumor called retinoblastoma in both of his eyes.

If left untreated, retinoblastoma will spread backward from the eye socket into the optic nerve, and then into the brain. Ben began chemotherapy, but after two months his right eye was consumed with cancer that it was removed. This was followed by an additional eight months of chemotherapy and then six weeks of radiation in attempt to save the left eye. When this treatment did not work, Aquanetta made the agonizing decision to have his left removed in order to save his life.

When Ben awoke from his second surgery, he said, “Mom, I can’t see anymore. Oh, Mom, I can’t see.” Aquanetta writes that “after praying for strength, I said, ‘Ben, Yes you can see’ and I took his little hands and put them on my face and said, ‘See me, you can see me with your hands,’ next, I put my hand to his nose and said, ‘Smell me, you can see me with your nose,’ then I said, ‘Hear me, you can see me with your ears, you can’t use your eyes anymore, but you have your hands, your nose, and your ears.’”

Ben’s mother and siblings worked hard to help him adjust to life without vision. Around age six, Ben began making clicking sounds with his tongue that enabled him to make sense of his surroundings by listening to the echoes bouncing off of objects. This process, known as human echolocation, is similar in principle to the sonar and animal echolocation employed by bats, dolphins, and toothed whales. Over time, Ben became so skilled at echolocation that he could accomplish such feats as playing basketball, riding a bicycle, rollerblading, and skateboarding. He was featured on the Ellen DeGeneres and Oprah Winfrey shows and was the subject of a program called The Boy Who Sees Without Eyes aired on the Discovery Channel.

I encourage you to watch the video I’m linking here. It’s a beautiful story of love, courage, hope, resilience, and faith.

Sadly, in 2007, a tumor developed in Ben’s sinus cavity and despite intensive treatment, he died two years later at age 16. This year, his mother Aquanetta released a book she wrote about Ben called Echoes of an Angel. It just arrived in the mail and I look forward to reading it.

 
1 Comment

Posted by on November 29, 2014 in Uncategorized

 

Cholesterol and Heart Disease

I’m enjoying a brief lull between a number of demanding projects. So I thought I’d dust off the old blog and share some articles on medicine and health I find interesting. Here’s one on cholesterol and heart disease.

Back in 1995, a study was published showing the benefit of a cholesterol lowering-medication called pravastatin. Over a period of 5 years, 6,595 men aged 45-64 with high cholesterol who were either given a placebo or pravastatin. The study showed that treatment with 40 mg of pravastatin for 5 years significantly reduced the risk of having a heart attack or dying from cardiovascular causes by 31% compared with placebo. After the study was published, researchers followed the men for another 20 years. And at this year’s American Heart Association’s Scientific Meeting the results of that additional 20 years of study were presented. They showed that the risk of heart-related deaths was 27 percent lower among the men who took pravastatin for those first five years rather than dummy pills. They also found a 31 percent lower risk of heart failure and a 13% lower incidence of death in the group initially assigned to take pravastatin. Furthermore, no adverse effects from taking pravastatin, such as cancer, were detected. What’s interesting is that once the initial 5 year study ended, the men went back to their regular doctors, and about one-third of both groups kept or started taking a statin such as pravastatin. So any differences seen 20 years later were probably is due to whether the men took pravastatin during the initial five-year study.

Coronary heart disease is the leading cause of death in the U.S. and the world as a whole. So a study showing such an effective means of preventing and treating this condition is very good news. Yes, yes, I’m aware of the possible side-effects of statins like pravastatin. About 1 in 10 people get muscle aches. But these usually resolve quickly once the medication is stopped and may not occur at a lower dose or on an alternative statin. Statins tend to cause a slight increase in a person’s glucose level, but that is far outweighed by the decreased risk in heart disease these medications cause. There have been rare reports of people feeling less mentally sharp after taking a statin. But in these cases, such side effects quickly resolved upon discontinuing the medication. Furthermore, this kind of neuro-cognitive side effect seems to be quite rare. I’ve never observed it in my practice and a recent, comprehensive review of multiple studies failed to find evidence that statins cause memory loss. In fact, some studies suggest that statins may even have memory-protective effects. By the way, the medication pravastatin used in the study I’m citing is generic and very inexpensive.

Here are links to a couple of articles on the study.
http://www.medscape.com/viewarticle/789649
http://hosted.ap.org/dynamic/stories/U/US_MED_CHOLESTEROL_DRUGS?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2014-11-19-15-20-07

 
Leave a comment

Posted by on November 27, 2014 in Uncategorized

 

Interesting Articles

The scientist Bert Vogelstein played an important role in understanding how cancer occurs. He is now working on developing what he calls a liquid biopsy. It is based on the fact that nearly every type of cancer sheds DNA into the bloodstream. By analyzing a sample of a person’s blood, a liquid biopsy would indicate whether a person has a cancer in his or her body. The hope would be that by detecting the cancer at an early stage, effective treatment could be started in time to result in a cure.

An article on the concept of a liquid biopsy explains that “making such screening a routine practice in medicine will be challenging. One difficulty is that while the test may detect the presence of cancer DNA in the body, physicians might not know where the tumor is, how dangerous it is, or even whether it is worth treating.”

You can read the entire article in MIT Technology Review here.

Robbin Williams’ tragic suicide has resulted in a proliferation of articles on depression and mental health in general. Last month’s Atlantic contained a fascinating article on the link between creativity and mood disorders such as anxiety and depression. The author Nancy C. Andreasen is a psychiatrist, neuroscientist, and a PhD in literature who has spent many years studying the brains and minds of creative people. Her study found that “80 percent of (the creative people she studied) had had some kind of mood disturbance at some time in their lives, compared with just 30 percent of the control group” she used. You can read the entire article here.

 
Leave a comment

Posted by on August 18, 2014 in Uncategorized

 

Listening

Doctors employ many means and methods in their effort to promote health and alleviate suffering. They ask questions and order tests to arrive at accurate diagnoses. They prescribe medications and perform surgeries. But I’ve sometimes found that the most healing thing I can do is simply listen to a person tell his or her story. The internist Rita Charon writes, that

Once, a young woman came to see me with severe and relentless abdominal pain. She was fidgety, spoke in fragmented speech, seemed clearly to be suffering. She had already seen a gastroenterologist, a gynecologist, and an expert in colitis, all of whom had found no abnormality to account for her symptoms. Since this was my first meeting with her, I asked as a matter of routine about the health of her family members. Her father, I learned, had died of liver failure. As she spoke of his horrible suffering—his abdomen swollen with fluid, his muscles spent, his mind clouded—she put both her hands, fingertips interlocked, almost protectively, over her own upper abdomen. I told her that she used the same gesture to discuss her own symptoms as she had to describe her father’s illness. For the first time in the interview, she became still. She looked down at her hands, now in her lap. We were both silent. And then she said, ‘I didn’t know this was about my father.’

 
3 Comments

Posted by on August 11, 2014 in Uncategorized

 
 
%d bloggers like this: