Tuesday, September 27, 2016

Green

“Never doubt that a small group of concerned citizens can change the world. Indeed, it's the only thing that ever has.” – Margaret Mead

We live in a world of stuff. We are consumers, buying things, using them up, discarding them, acquiring more. As I look at the next generation of cell phones and computers, contemplating upgrades, I start worrying about our preoccupation with having things. It's not that I find this hobby superficial or silly (though in a way, I do), but it's because I worry it's ruining our world. Like health care, our resources in this world are finite. Our consumer-driven culture will end up consuming those limited resources. Even if we recycle all that we buy, the cost of manufacturing the new goods and reclaiming the resources of the old worries me. I've been thinking about carbon footprints, global warming, and other environmental issues recently, and I worry that the legacy we are leaving to future generations is more problem than solution. While reducing waste, improving our commuting routines, eating less meat, and composting all make a difference, I think we need to overhaul our cultural disposition to consume. I also struggle with the itch to use stuff up and get more, but I'm trying to curb that. It is our responsibility to rein in waste, to protect our world.

Monday, September 19, 2016

Anesthesiology and Critical Care

"Love. You can learn all the math in the 'verse, but you take a boat in the air that you don't love, she'll shake you off just as sure as the turning of the worlds. Love keeps her in the air when she oughta fall down, tells you she's hurtin' 'fore she keels. Makes her a home." - Serenity (2005).

This will be my last post about medicine. I might have some lingering thoughts about other facets of this strange life we live, but for now, I think I have accomplished what I wanted to with this blog, and it's time to step back. I started writing here on September 1, 2006, when I knew nothing of this ship I was boarding. It was the day before orientation for medical school. Ten years later, I have written over twenty two hundred posts, most of which are essays on becoming a physician, musings on the inner workings of medicine, reflections on the emotional and subjective experience of medicine, and stories of my life during medical school, residency, fellowship, and (hopefully) the beginning of a career. There is no way to summarize this, and while I want to make grand sweeping statements on what this means with flowery and literary-device-laden language, it's really not necessary. Someday, I might highlight those blogs that I am most proud of, but for now, I let this website speak for itself.

This is the path I chose, from the many I could traverse. It has been harrowing, lonely, exhausting, dangerous, frightful, upsetting, and profoundly sad. But it has also been enlightening, inspiring, heartening, beautiful, transformative, and dare I say it, fun. As a career, I am so happy to be an anesthesiologist and intensivist. My day-to-day and week-to-week work life is filled with moments of sheer wonder, great pride, meaningful connection, poignancy, and growth. I can think of no other vocation I would instead choose.

I thank all of you who have read this blog, and I apologize that it is coming to an end. I hope I have shared some glimmer of the magical and miraculous world I see every day. I hope to continue writing in the future and contributing to the literature of medicine in different forums and settings. Like every other incredibly difficult decision in my life, I have very mixed feelings about this, as evidenced by my lollygagging in saying good night. But here it is: please contact me (you can always post a comment) if you'd like to continue the conversation on medicine. I greatly appreciate your patronage, and I hope you have enjoyed reading. I have loved every facet of this. Good night.

In ancient Greece, the Asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The rod of Asclepius is a roughhewn branch entwined with a single serpent.

With respect, love, and passion,
Craig

Sunday, September 18, 2016

Last Words

I make little notations to myself about blogs I want to write. I jot them down on scraps of paper, saved emails, and notepad documents titled "temp." Some of them make little sense to me when I find them again (kind of like trying to write down my dreams). Some feel so big and important that I want to set aside dedicated time to write conscientiously. Unfortunately, the window of opportunity is closing. For a lot of reasons out of my control, this blog is making its last rounds.

One note I wrote to myself was, "Anesthesia is not easy; discuss risk taking and dependence on surgeons." I don't specifically remember what stimulated that idea. There's a great deal that I could say (and have said in the past). Anesthesia is one of the few specialties that depends heavily on the skill of another professional. The doctor on the other side of the drapes affects almost everything I do. For the same surgery, two different surgeons may require very different anesthetic plans. Whether the surgeon is speedy or slow, loses a lot of blood or loses nothing, requires deep anesthesia and paralysis or manages with little - it all affects my decision-making. I have written before that anesthesiology is protecting the patient from the (necessary) surgery and surgeon, and I really believe that. It's no small thing to cut into someone, and my job is to safeguard the patient while that happens.

Of course, the skill of the anesthesiologist affects the surgeon. What I do can profoundly change the surgical conditions from whether there's excessive bleeding to how much the brain swells. I can think of very few other symbiotic medical specialties; perhaps obstetrics and neonatology, but not much else.

It's easy to underestimate how difficult anesthesia is. There is a metaphor of the Stanford undergraduate being a duck; on the surface of the pond, she appears serene and relaxed, but under the water, she is paddling furiously to stay afloat. Sometimes, that's how I feel with anesthesiology. Although we show a calm demeanor above the drapes, we may be working tirelessly to mitigate risk and optimize every single aspect of the perioperative period.

Thursday, September 15, 2016

The Impact of Anesthesiology

I hadn't seen this when it came out almost four years ago, but the New England Journal of Medicine for their 200th anniversary (such an impressive milestone) asked the question, "What has been the most important article in NEJM history?" This blog concluded that the first description of anesthesia in 1846 by Henry Bigelow was the most significant report, surpassing even articles on aspirin for heart attacks, tPA for stroke, and development of vaccination. Indeed, the field of anesthesiology allowed advancement of surgery and the surgical subspecialties. Before anesthesia, no one would even consider an elective procedure; it would be terrible to put someone through pain and agony for a disease process that was not life-threatening. But with inhaled ether, and later similar compounds, we made possible so many other advances in improving human health.

Monday, September 12, 2016

2200


On a trip to Prague last year, I saw this building and managed to snap a photo. Ten years ago, when I started this blog, I picked this URL, but I don't remember why. Nevertheless, I've grown to like it.

Friday, September 09, 2016

Personal Identity

When I studied philosophy as an undergrad, one topic that really fascinated me was personal identity. How do we know we are the same person we were yesterday? What defines us? Is it causality, physical identity, some kind of metaphysical "soul," or something else? The philosophical literature on this is quite dense and less interesting to me now. But sociological ideas about identity still captivate me.

Many health care workers, I think, identify very strongly with their profession. If you were to encounter them in the supermarket and ask them what they do, they might reply that they are a doctor or nurse or therapist. We are proud of what we've accomplished, and our jobs have taken up so much time in terms of years of education and our daily lives. Our professions also carry such emotional weight, give us such deep satisfaction, and involve such close interpersonal interactions. It is no wonder that our profession, role in society, and vocation are tied to our sense of personal identity.

Over time, I have found that my sense of identity is less and less tied to my profession. This surprises most people, even those close to me. At work, I am very much a physician, anesthesiologist, and intensivist. I enjoy my work, I take pride in doing it well, and it defines me for sixty hours of the week. I am really quite present.

But once I leave the hospital, that part of me fades. My identity is only loosely tied to being a physician. I spend most of my time, energy, and effort pondering other things - writing, books, music, dance, cooking, travel. So it always surprises me when friends (and family) tell me that I'm a good doctor. I'm glad for such affirmation, but it feels strange to me to hear that from the world outside the hospital.

Part of this dissipation of a medical identity, I think, is the reason why I'm winding down this blog. It has always been my firm intention to keep this blog medical in nature. I think focus is important in writing, and writing broadly about medicine has yielded me thousands of posts. I think it's also earned me a reputation of someone who thinks, reflects on, and writes about medicine all the time. Perhaps that was true in medical school and residency when medicine was the whole of my life. But as that part of my identity softens a bit, I am less wont to continue blogging.

In any case, this is a rambling post that stems from me pondering my own identity, who I am, and who I'd like to be. As a doctor, I am proud of what I have become and where I'm going, but I tire a little of all those who assume that is mostly who I am. My departure from writing regularly here is a personal stimulus to broaden my sense of personal identity. I am understanding how much people change, and how important it is to discard the detritus of identities past.

Tuesday, September 06, 2016

The Cost of Medicines

One of the biggest challenges we face in the coming years with regard to health care is reining in costs. I recently read a great synopsis on why prescription drugs cost so much in the United States. This JAMA article is definitely worth perusing. It explores concisely and clearly why normal supply-demand economics don't apply to prescription medications. By looking at protected monopolies created by patents, restrictions on government negotiation for Medicare drugs, tactics used by the pharmaceutical industry to delay generic drugs, and physician prescribing practices, it sheds a lot of light on why we are here now. The article also addresses a lot of counterarguments relating to the cost of medications in the U.S. such as research and development investments and cost-sharing with patients. It proposes several reasonable and well-supported measures to decrease the burden of prescription medications on health care cost in America. I don't often write a blog that points to a separate article, but I really believe this paper summarizes the problem in a more comprehensive, accessible, and thought-provoking manner than I could ever achieve.

Saturday, September 03, 2016

Quality of Life II

I feel that relationships and passion are at the center of quality of life. When I meet with a family of a dying patient, I often ask them to tell me about the patient. They almost always tell me about the patient's personality, his relationships with others, or his passions in life. In our conversations, these characteristics seem intertwined in creating meaning and value for that person (or least, the family's interpretation of it). And indeed, when it becomes clearer that the patient is losing his personality, unable to maintain his relationships, and will never recover to pursue his passions, the conversation about the end of life follows.

For me, at least, many of the decisions I make stem from my relationships with those around me and the values, interests, and commitments I have. I am proudest of these things, most creative with them, and happiest when I delve into them. Whether it is holding a board game night or learning a new dance or reading "Harry Potter 8" or crafting a new poem, I am energized, sometimes exuberant. When I reflect on curtailed relationships, lost hobbies, disinterest, I find little substance and joy. My mood and indeed my quality of life follows the robustness of my relationships, the devotion I give to my passions.

Although medicine is not aimed at such lofty goals, I do think we can make small differences in helping patients achieve these goals. We center our patients in their universe of relationships; we ask about their spouse, kids, friends, family. We help them bridge estranged relationships. We encourage their support network to buoy them up. We ask them what they love doing. As they recover from illness or cope with disease, we orient them in their world of passions, helping them engage as best they can in the things that give their life meaning, quality.

Wednesday, August 31, 2016

Quality of Life I

Although quality of life feels incredibly fuzzy and subjective, I think it's important to contemplate. It is perhaps the truest and least-spoken goal of medicine. And along with passing on our genetic makeup, it may be our most fundamental want as people. We don't talk about it enough. In all the lectures of medical school, studies and articles in journals, and posts on this blog, it represents a tiny fraction of what we discuss in medicine. In the same way that death and the dying process is glossed over, the ephemeral phrase quality of life usually earns only hand-waving and idealism.

Although there are quality of life measures taken with psychometric tools and surveys, I like to think it is in the "I know it when I see it" category (originally attributed to Supreme Court Justice Potter Stewart). Yet I'm not sure it really is. Outsider (physician) impressions of the quality of a patient's life often differ greatly from the patient's assessment of his own life. We all have our own ideas of whether we would want to go to dialysis three times a week or be wheelchair-bound or not be able to eat or suffer constant pain. But if any of us were actually in any of those situations, we might change our mind.

Nevertheless, I will talk about quality of life as if we knew what it was. The reason we allow surgeons to cut into people, prescribe medications with side effects, and hospitalize patients is because we think it'll improve their quality of life or length of quality life. But we never think of it that way. It's almost a rote reaction; we diagnose a patient with hypertension and prescribe hydrochlorothiazide; we find appendicitis on CT scan and book the operating room; we witness a suicide attempt and place the patient on an involuntary hold. We do so hoping or imagining that as a result, the patient will live longer and/or have a "better" life.

Why is it that medicine's boundary stops there? Should we actively participate in enriching a patient's quality of life? Or is that out of our scope of practice, someone else's responsibility? Sometimes, I think our social workers who find shelters for our homeless patients, reunite families, and help patients cope with their illness have a more direct impact on quality of life. I think of our physical and occupational therapists who help patients get back to their sports or climb the stairs in their house or use a prosthetic limb. Why is it that doctors are concerned only with the disease and its treatment? Is medicine nearsighted this way? Or is it simply a division of labor; we cure disease and defer a patient's happiness to someone else? I'm really just rambling, but I figured this is an important topic of conversation, and I wanted to open the door.

Monday, August 29, 2016

The Future of Medicine

I was asked recently what I thought the next breakthroughs in medicine would be. I have no idea. Although I like to read about where science is going and although I used to participate in research, now my career has greatly diverged from that. Nevertheless, sometimes you get asked a question and you just have to hypothesize.

We've been talking about personalized medicine for (it seems like) forever, but I think it's going to happen. President Obama launched the Precision Medicine Initiative and that helps funnel NIH funding to those areas of research. We are definitely getting more knowledgeable about how all the "omics" (genomics, proteomics,, metabolomics, gut microbiomics) affect disease and health. Despite this, it hasn't translated to everyday clinical application. For example, though whole genome sequencing has become cheaper and more readily available, genetic testing is not widely used by physicians to make clinical decisions. Only a few tests are standard of care (such as testing for an HLA gene before starting someone on the HIV medication abacavir). I believe physicians are just late adapters of technology. Once genetic testing becomes a more commonplace clinical tool, I think personalized medicine will really hit its stride. This will almost certainly increase costs. We just await to see if that translates to better outcomes.

To me, personalized medicine comes in flavors beyond the interaction of genetics and diseases. One form of personalized medicine is the use of feedback loops and technology to achieve our health goals. For example, insulin pumps for type I diabetics can almost work on autopilot. They can test a person's sugar, adjust the dose of insulin, and check to see if it worked in an entirely automated algorithm. Will anesthesia move in that direction? Will we end up having machines that can detect the level of anesthesia for a patient and automatically adjust the medications to achieve a target? (This was attempted with a robotic sedation system which never caught on; it's now off the market). To me, these individualized therapies also represent a kind of personalized medicine.

With regard to areas of medicine that will blossom, I think immunotherapies and treatments for neurodegenerative diseases will become a big focus in the coming decades. We must focus our resources on diseases like Alzheimer's which currently doesn't have effective treatments but will become a growing burden on society and our health care system. These are, at least, my predictions; who knows where things will go in the next few decades.