Sunday, December 31, 2006
I have realized it's not all that easy. After being sick for the past few days, I realize that no one wants to take drugs. There are lots of reasons, most I probably haven't even fathomed. However, I didn't want to medicate (even just over-the-counter) for several reasons. It's an admission that you're sick. It's inconvenient. There are side-effects. Now, I know I will be fine whether or not I take NSAIDs. And I would assume that if I had something life threatening that could be cured with medication, then I would comply. But I can already see that it is not as easy as I originally assumed.
Saturday, December 30, 2006
Thursday, December 28, 2006
The pace was fast and busy. On the first day, our team was on call and received an admission during morning rounds. The third year and an intern rushed down to the ED to admit her while the rest of us rounded on the other patients. During rounds, pagers would go off, people would make phone calls, and others would hunt down a computer to show an X-ray. Sometimes, less than half the team was paying attention to the person presenting the patient. Of course, everyone on the team was already familiar with the patient, so I was not alarmed.
The culture of medicine struck me as highly intellectual. While surgeons and anesthesiologists seem to favor procedures, the medicine service enjoys standing around and figuring out odd cases through discussion. Being able to do an effective differential and explain it was very important. The chief residents stood out during the conferences because they clearly knew the most. It was important to some members of the team to be able to pull out an article from JAMA or cite relevant clinical research.
Wednesday, December 27, 2006
I was assigned to Med Team G at Moffitt (the main UCSF teaching hospital). Other students were assigned to disciplines as diverse as emergency medicine and psychiatry to neonatal ICU and labor and delivery. I loved being on the medicine team. It was a lot of fun, and I did not feel completely bewildered. I tagged along with a third-year student who was great.
I was most surprised by how easily I was integrated into the team. I felt that I was considered a member, if only for a short while, rather than an outsider observing the dynamics of the medicine service. For example, I was encouraged and perhaps even expected to contribute to the intellectual discussion of the issues facing our patients. This was a lot less intimidating than I expected. I didn’t feel bad or ashamed to say I did not know anything about the subject. The team was delighted when I would say something, and then they would politely correct whatever egregious mistake I had just made.
Sunday, December 24, 2006
Saturday, December 23, 2006
The principle of autonomy grants patients the right to make decisions (even bad ones) about their health care. The principle of beneficence compels physicians to act in their patient's best interests. Yet the principle of non-maleficence says to "do no harm." (One should point out that nearly all procedures do harm, but we weigh the benefits with the costs. A blood draw harms the patient by causing pain, breaking the skin, etc., but benefits outweigh the costs).
What do you do? The mother and the father both consented to the procedure (and the daughter assented). You want to act in the patient's best interest and do no (unjustifiable) harm. Yet who is the patient? In a transplant, both the father and the daughter are patients. You would be taking years from the father to improve the quality of life for the daughter. Is that morally praiseworthy or blameworthy?
It's a complex case, further complicated by biological reasons (if the daughter rejected the first kidney, wouldn't she reject the second?). No surgeon would actually take this case. Luckily, this is based on a true story; a relative was found to be a match and underwent the kidney transplant without complication.
"If the father wants to run into a burning building to save his daughter, he can do so, but I cannot hold the door open for him."
Thursday, December 21, 2006
I was one of two history takers. It was a little nerve-racking. Something was definitely wrong with the patient. He was very light headed, had a pulse of 120, and a blood pressure of 60/40. It was hard to concentrate on which questions were pertinent - clearly, we would not care about where he lived ("social history"), but we might care about whether he had shortness of breath. My peers did a physical exam, set up an EKG, and got the vitals on the monitor. One first-year was the fake resident who supervised us.
We took a quick time-out to discuss a differential for the patient. We came up with a plan of diagnostics and treatment, and began to administer the plan. Afterwards, we gathered in a conference room where a fourth year explained the pathophysiology of the condition. It was highly educational. In a real situation, would we have been as successful? I don't know. Though we pretended the mannequin was a real person, it's hard to picture what we would do if a real person was dying on us.
Tuesday, December 19, 2006
But on the other hand, a physician can detain a person seriously contemplating suicide. We won't let him kill himself. He does not have control over his body. And if we aren't sure whether someone wants medical care, we treat him as aggressively as possible, assuming that's what's in his best interests.
Clearly, this post brings up many emotion-laden and difficult issues. Are there cases when not-treating is better than treating? How do we approach those cases? Where are demarcations to be drawn?
Friday, December 15, 2006
Unfortunately, this is an unfunded mandate; there are no reimbursements. As more and more people take advantage of this act (by coming into the ER without any particular problems or with minor symptoms), hospitals have sustained increasing financial costs to the point that they have to shut down their emergency departments. Waits have greatly increased in length, jeopardizing those who do have medical problems. Those without health insurance turn to the emergency department as their primary care because they cannot get health care elsewhere; however, the ER is not a primary care facility. In practice, EMTALA seems to have hurt emergency departments as well as patients requiring those services.
It's a hard line to walk. You can't deny a basic screen for someone who may have a life-threatening illness. After all, that's what emergency departments are for. However, when people start misusing such resources and when such a mandate is unfunded, it creates an incredible strain on resources to the point that the hospitals have to close their ER. I am unsure whether there is a good solution for this problem, but it is certainly something that we should be aware of.
On the other hand, a doctor cannot refuse to see a particular kind of patient. We cannot limit our practices to a particular religion or gender or race. That makes sense too. Discriminating based on such divisions would be highly unethical. Everyone deserves medical attention and care regardless of their demographic labels.
Both of these arguments seem sound and nearly incontrovertible. Yet they create this dynamic of asymmetry which is very interesting to me. Can we find some philosophic justification of first principles for this? That is, can both these ideas in medical care be derived from one higher level principle? I haven't put too much thought into this, but it is certainly worth contemplating.
Thursday, December 14, 2006
For the practicum, we learned to use our opthalmoscopes to visualize the retina and the slit lamps. It was tough. It was the first time the first years had ever picked up an opthalmoscope, so we really didn't know what we were doing. But with some eye dilation and trial and error, we managed to learn a little about the equipment used in the eye exam.
Wednesday, December 13, 2006
The case unfolded over the next week. In these cases, we get information about the present illness, physical findings, family history, etc. We begin to form our differential of what's going on and also discuss labs and diagnostic tests. At the end of the session, we each decide on a learning issue to research for the next week.
On the last FPC PBL, like many others, I wikipedia'd my answer. However, we had a special library session to learn to use the resources available here. I was very apprehensive at first. Not only was it a Friday afternoon, but it was about things like PubMed. Even if you hadn't used PubMed, it's easy to figure out (especially for this generation of medical students, though I will say that PubMed doesn't have the best user interface). But I actually enjoyed the session a lot. There are a good deal of other resources available through the university. Many medical texts and references can be accessed, and these will become essential throughout my training here.
In the end, we came back and solved the case. It was fascinating. While a curriculum based strictly on cases may easily leave stuff out, I feel that a curriculum without PBL lacks a connection between lectures and what a doctor actually does. Here, they equip us with many skills. We learn to work as a team, to learn from and teach each other, to answer questions ourselves, and to think independently as well as with others.
Tuesday, December 12, 2006
Sunday, December 10, 2006
Thursday, December 07, 2006
To delay the flood of generic drugs lowering the market price of the moneymakers, big pharma has entered into agreements in which they pay generic drug makers to drop challenges to patents. By offering generic drug companies perhaps a hundred million dollars, they can keep generic versions of their blockbusters off the market, effectively extending their patent by several years. In the end, the cost is transferred to the consumers. The FTC has tried to block such agreements, but last year, it was ruled that the FTC was beyond its jurisdiction.
While I cannot say legally what ought to be the case, I think this is a very interesting question and brings up one side of pharmaceutical companies that I had not considered before.
Monday, December 04, 2006
By Craig Chen
To read the EKG, you have to examine
the ST elevation – that means there's an MI.
With acronyms, you can convince anyone
you know what you’re talking about, even me.
The nurses here wear make-up,
and all the doctors are available.
When patients seize, swimming up from their beds,
you wonder if they, too, have a crush on the intern.
We learn medicine from our couch
paying TIVO tuition, watching thrice married
surgeons save their ex-wife's ex-husband in time
for Southpark, another Great American Show, at 10.
You never miss an episode; in fact,
I know about the notebook with the love letters
to Dr. Cameron, jotted with suture-supple
hands, starving for validation.
You can do this, you think, as the patient
waits patiently on the screen. The only
motion in the room: the buzzing of the lights,
the sterile surfaces staring back.
Saturday, December 02, 2006
Friday, December 01, 2006
The anesthesia side was just as impressive. The anesthesiologist explained a lot of the equipment they use in the OR. I got to see many of the different physiological monitors and drugs available. He explained what anesthesiologists do to prep the patients for surgery. Anesthesiologists worry about the big picture while surgeons do their thing. They play a vital role in resuscitating patients in the case that something goes wrong. All in all, I think the OR is not a bad place to be. The complexity of procedures and cases there along with the sophistication of tools makes it quite an alluring place.