Patients

Over the last few weeks, I've met quite a few patients with neurologic and psychiatric problems. It's been really fascinating for me. For some reason, the symptoms and signs associated with disorders of the mind captivate me more than those associated with other systems; diagnosing sciatica, while important and interesting in its own way, just doesn't compare to trying to understand florid hallucinations. Patients with mental illnesses have not only distorted perceptions of the world, but also distorted perceptions of their own illness; you can't always take what they say at face value.

Two weeks ago, we saw a patient who had previously been sick with a psychiatric disease. She heard voices, had hallucinations and delusions, and attempted suicide once. Her story really made an impression on me, but I'm struggling to explain why. I think it's because I'd never really heard what a person with delusions sees, hears, and feels. It's something I couldn't understand until I placed myself in her shoes. From the outside, it seems ridiculous to think that someone would believe things that aren't real. But when you hear the patient talk, you find their story spooky, compelling, and intriguing.

For FPC, we saw a patient last week who had her right occipital lobe removed because of intractable epilepsy; as a result, she has no vision in her right visual field. However, as I walked with her, I could not tell she couldn't see half the world. Over 30 years, she'd learned to adapt without a significant portion of her cerebral cortex. At preceptorship, I met a patient who was experiencing hallucinations, but did not realize it. Her daughter came in to tell me about the hallucinations; the patient thought they were undeniably real. In taking a mini mental status exam, she told me the year was 1907.

I guess the patient presentations of a lot of disorders of the brain and mind make this block incredibly fascinating. A lot of it is trying to understand a patient's subjective experience from an objective point of view.

Followup

So on bmj.com where the last image (algorithm for choosing a specialty) is drawn, there are a few responses asking about family medicine, ob/gyn, and preventative medicine. I propose another condition: Independently wealthy? -> preventative medicine.

Choosing a Specialty

Exams

Life as a student involves exam after exam. This weekend right before the exam is full of cramming. We can relax the weekend after the exam. Here an anatomy practical, there a clinical skills assessment. There's the neurologic exam, the mental status exam. Our lives are structured after such things.

Neuroanatomy II

In the third lab, we dissected the neck, confirming my belief that the neck is one of the most difficult structures for me. Even though the neck, for the most part, is just a gateway for nerves and vessels to and from the head, the anatomy is fairly complicated. We then dissected the orbit, the related structures of the eye. To enter the orbit, we actually crushed the skull from the inside; this was a little alarming, but the best way to reach the nerves and muscles of the eye. The eye is an amazingly concerted structure when you examine the intricate muscles and their innervation. Lastly, we dissected the face. This was quite scary as it really brought to light the fact that this was a person we were taking apart. I am certain that I would not have been able to do this at the beginning of the year; I suppose this shows how much I have changed with regards to anatomy over the last 9 months.

This concludes our formal laboratory dissections for the year. That's a really tremendous thought. While I never craved anatomy lab, I have learned an incredible amount and realized that the human body is a fascinatingly structured system. So much can be learned from studying the physical organs, their innervation, their musculature, and their blood supply. I have an overwhelming sense of gratitude and awe for the person who donated his body for us to learn from it. I suppose we have passed one major milestone of medical education.

Here is a youtube clip on neuroanatomy, taught by Pinky and the Brain: http://www.youtube.com/watch?v=snO68aJTOpM

Neuroanatomy I

The first two weeks of Brain, Mind, and Behavior are really packed with anatomy labs. We have 5 anatomy labs dissecting the brain, the neck, the skull, the orbit (eye), and the face. It's been really intense. Before starting this course, I didn't know much of brain anatomy. Despite the prototypic picture of the brain, a lot of structures are really nebulous: hypothalamus, thalamus, basal ganglia, pons. I hear about these things, and I might have some sense of what they do, but I really don't know where they are in the brain. The head also has twelve cranial nerves which are fundamental to understanding neurology; we have to locate and identify the cranial nerves from several different perspectives. The brain is just such a black-box organ that I've learned an incredible amount over the last ten days in anatomy lab. I never really thought about how it sits in the cranial cavity or what sections look like or how the blood vessels work.

In the first lab, we looked at all sorts of specimens: whole brains, brains cut down the middle, skulls, dura (outer covering of the brain), and spinal cord. It's a fairly overwhelming feeling to be holding a brain and thinking, here lies all the memories, thoughts, experiences, emotions of this person. Unlike the kidney or liver, the brain really tugs on your feelings.

This became very apparent when we did the second lab. In this lab, part of the skullcap of the cadaver had been removed, leaving an intact brain. We used a tool called a brain knife to actually section the brain, cutting out slices and examining the tissue. It was amazing. It's a strange feeling, cutting into someone's brain, and I don't think I'd call it a good feeling, but it was certainly a mindboggling one. I learned a whole lot.

Crime and Punishment

One argument in philosophy is that moral responsibility is contingent upon the presence of free will. Indeed, the ability to freely choose someone's action is necessary for her to be morally responsible for them. If I rob a bank, I have committed an ethically blameworthy action. Yet, if I am forced to rob a bank because some particularly manipulative person has a gun to my head, then I am less morally responsible for robbing the bank; if I did otherwise, I'd be dead. Simple enough.

The question, raised on the first day of lecture, is whether a psychiatric condition which predisposed someone to a terrible act of violence absolves him to some extent of his actions. Say someone has overwhelming urges to commit acts of violence due to a disease. He recognizes this in himself, and realizes he is a danger to those around him and turns himself in to an emergency room. Yet the ER eventually releases him, and he never sees a psychiatrist. Finally taken by these urges that have a distinct biologic basis, he murders someone. How bloody are his hands? Is he a modern day Macbeth, driven by circumstances out of his control to do something he tried his best to avoid and wished he had never done? Obviously, he's held accountable to some degree. But should a psychiatric disorder play a role in our moral assessment of his actions? In our condemnation by the justice system?

Brain, Mind, Behavior

There are many people who absolutely love our last block for the year, Brain, Mind, and Behavior. I have to say I am one of them. This is a much-anticipated course. In fact, 100 days before the course would begin, one of the course directors Dan Lowenstein came in to tell us to begin the countdown. He popped in when it was 30 days before the start of the block, and then again at 15 days. There's certainly been a lot of hype and expectation!

It's really been an awesome experience. You can tell that everyone involved in the course from the course directors to the administrators to the lecturers feels passionately about both the material and the way it is delivered. Even the introductory lecture, usually filled with logistics and routine, was fascinating. Dr. Lowenstein quoted Lao Tzu, had a clip of a ballet dancer, and showed artwork to describe how intricate and powerful the nervous system is. On the first day, they brought in a patient who had suffered a stroke. In interviewing the patient and demonstrating key examination features, we were drawn into the captivating yet bizarre things that can happen to the mind - an ability to comprehend language but not produce it, to flex one's hands but not extend them, the increased tendency to show emotions. We got to hear about his recovery since the stroke, about his family involvement, about the role of neurology.

There are several contests this block. Every day, we begin class extra early with a case of the day - several challenging questions involving a neurology or psychiatry case; we've had strokes, hydrocephalus, alien hand syndrome, and others so far. According to Stephanie, the person who wins gets a shirt saying, "I am a HUGE NERD." (Or something to that effect). The cases are quite interesting indeed.

Then there's a contest called the "Syllabus Perfectionism Award" which awards points to students who catch mistakes (content, grammar, typographical, anything) in the printed course reader (>1000 pages). When I took computer science from Eric Roberts, he was just putting out his book "Art and Science of Java" and he did the same thing for that course. Every mistake got you a ticket in a raffle at the end of the quarter, and the winner of the raffle got an automatic perfect score on the final. He got free labor of four hundred editors out of that class. I did manage to win a coding contest to net the automatic perfect score, so I got to sleep in on the morning of the test anyway. In any case, I am OCD enough that typographical errors in printed material really annoy me (and content errors are even worse), but I also procrastinate too much to catch any mistakes for the syllabus perfectionism award before someone else notices.

Ciaconna

An article came out in the Washington Post describing an experiment in which they got world famous violinist Joshua Bell to play as a street musician in the subway of Washington D.C. He played for 43 minutes as over a thousand people passed by trying to get to work during rush hour. The instrument was a $3.5 million Stradivarius; the pieces were some of the most amazing classical pieces ever composed. The article mentions the Bach "chaconne" from Partita No 2 in D Minor. This is a really spellbinding, thrilling piece; it's beautiful. For some reason, the piece struck me most about this whole situation; though I may not have recognized Josh Bell and I certainly wouldn't have believed the violin was a Strad, this 14-minute piece is the stuff of masters.

The results were shocking (to me). Only one person recognized him. Only a few people stopped to listen. He made about $32 in time he played. This really raised a lot of questions for me. What is art? Do you have to be trained to listen to classical music to appreciate it? Perhaps, but every child who passed by wanted to stop and listen. The article mentions poet laureate Billy Collins (who I heard speak when I was an undergrad) who comments that all babies are born with a knowledge of poetry, because the lub-dub of the mother's heart is in iambic pentameter. But, somehow, we lose it. This music is gorgeous, and people are simply rushing to work. How much does context play into this whole situation? How much passes us by because we are too focused on where we need to be and what we need to do? Why are some things aesthetically pleasing while other things are less so?

Perhaps this is all unrelated to medicine, but as we move into our brain, mind, and behavior block, I begin to think of these questions more and more.

Link: Washington Post - "Pearls Before Breakfast"

Litany of Words

We finished our metabolism and nutrition block last week. The pace of the class really amazes me; we're moving so quickly and covering so much ground. I think I enjoyed GI and endocrine a lot more than I expected, though perhaps this is because I've found my natural rhythm and groove for studying the material. The block was very internal medicine oriented; most practitioners on a daily basis deal with issues like stomachache or abnormal growth or diabetes. I did not think the biochemistry was too intimidating, and it was nice that the second half (endocrine) had less focus on anatomy, histopathology, and radiology.

At the end of each block, we have to fill out course evaluations. While they are certainly tedious, I guess it's important for course directors to have an idea of the things that are working and things that need improvement. However, I've become increasingly lax about giving specific feedback; I remember at the beginning of the year, I would write paragraphs commenting on the presentation styles of the lecturers, the organization of material, the supplemental online things. Now, I just fill in the bubble for "very good" or "excellent" and move on. Oh well.

Virginia Tech

Whoever thought there was absolution through murder never felt the collective impact of a world's horror, pity. Would such torrid emotion penetrate the impassive face if it were not disfigured and marred in suicide? I would imagine there would be some human remnant, some whisper struggling to overcome hoofbeats and rage, some delicate tether to reality, but maybe he lost that long ago. Some characterize it by ethics - it's wrong to unconditionally inflict pain on another; others by logic - what would society be like if this were the norm?; others by emotion - that's just a repulsive idea; yet others by plain common sense - why would you do such a thing?

How does one lose it? Is there a biologic basis? Did society fail him? Was it destined? But how could someone resign that so many innocent people were destined to pass on a day that wore a mask hiding its obsequies with a facade of normalcy? The entire philosophic notion of free will encompasses the very strong feeling I have that my actions are mine. I can refrain from doing something; I am responsible for my actions. Did he have such free will? If so, why did he choose to do what he did? Was there a possibility that such sadness could have been averted? How are victims and their families supposed to think about this "fateful" day. Destiny is only such insomuch as we concede our individual metaphysical tethers to some metaphoric spider weaving intricate webs between disparate people and events.

My sincerest sympathy to the members of the Virginia Tech community and all those affected by this terrible incident. My thoughts and prayers go out; may mother's embrace welcome the victims home. I honor the inestimable courage and sacrifice of those who put themselves in the way of danger to help others. I may know my cranial nerves and the treatment for a pneumothorax and how to diagnose hemochromatosis, but all I really have is compassion, and that from the greatest depths I can find.

Sick

This is to remind myself that the subjective feeling of being sick, what the person actually experiences, is always unpleasant. Even if the illness is minor - just an upper respiratory tract infection - it sucks to have it. Symptoms like fever, cough, sore throat, headaches on paper are just words, but the subjective experience is painful and uncomfortable.

Obesity

Obesity is an incredibly important issue that we touched on at the end of the last block. It's an epidemic that is sweeping across Westernizing nations, targeting young and old, and increasing morbidity and mortality. So many diverse factors play into the equation: genetics, nutrition, exercise, hormones. And it's a problem that is so resistant to change. Here, I am going to focus on two obesity-related issues that fascinated me.

The first is the identification of the fat hormone leptin and its receptor. These were experiments done in the 1950s on mice with mutations that caused them to be severely obese. I think the experiments were very elegant for their time. Researchers used a technique called parabiotic pairs, connecting two mice so that they share the same bloodstream (it's a little strange, and I don't know the details). If you take a parabiotic pair of a normal mouse and an obese ob/ob mouse (image above), then the ob/ob mouse will lose weight to a normal weight. The researchers concluded that something in the normal mouse "rescued" the obese mouse, and this hormone traveled through the bloodstream. If you take a parabiotic pair of a normal mouse and an obese db/db mouse, then the normal mouse will lose weight, but the db/db mouse will remain obese. Researchers deduced that the receptor for the hormone was knocked out in the db/db mouse so the db/db mouse had elevated levels of the hormone, which caused the normal mouse to lose weight. So they were able to characterize two mice with separate etiologies of obesity, one involving the hormone and one involving the receptor. Pretty cool.

The other interesting thing about obesity is that not all fat is equal. Visceral or intra-abdominal fat ("the beer belly") is harmful to the person's health, but subcutaneous fat is not. This presents itself strikingly in Japanese sumo wrestlers. Sumo wrestlers eat and exercise. So they build up an incredible amount of weight, but all that fat is subcutaneous. As a result, sumo wrestlers don't get type II diabetes, no matter how heavy they are. On the other hand, a huge percentage of obese people in the U.S. develop type II diabetes because they have visceral fat. Interestingly enough, when sumo wrestlers retire and stop working out, the rate of obesity-related morbidity and mortality shoots up.

Wrapping Things Up

I never was any good at wrapping presents. I just can't estimate the surface area of irregular polyhedrons. In any case, we finished up the endocrine unit. We had a lecture on the ethics of artificial nutrition (feeding through a tube). I'm not interested in writing about the specifics of artificial nutrition, but one thing struck me. Withdrawing artificial nutrition is ethically and legally equivalent to withholding artificial nutrition. It's definitely a lot harder (emotionally) to take someone off tube feeding, but it's the same as not giving it to them in the first place. The patient is not dying because he's not eating; he's not eating because he's dying. The underlying disease is killing the patient. A feeding tube does not stop, and may not even hinder, the inevitable. In any case, this is the conclusion that contemporary philosophy tends to side on, though we didn't really delve into the issues. I thought that was interesting because I pondered this topic in a February post on "Some Dilemmas."

We also had patients come in to talk about their diseases. One was a woman with type 1 diabetes. It was really amazing to hear her speak about the impact of the disease on her life. As a medical student, we learn about the disease presentation, diagnosis, epidemiology, complications, and treatment. We're taught that diabetes is treatable with good insulin management. But we never really see the impact of the disease. Patients have to learn to count calories and carbohydrates in the foods they eat, to calculate the dose of insulin they need, to plan out their day from snacks to exercise. There's social stigma and parental involvement and the looming threat of diabetic ketoacidosis. It's scary. It's not easy to have good glycemic control. I learned a lot from hearing the patient's perspective.

The Difference

(Click on the image to enlarge it. Linked to xkcd, a comic strip licensed under Creative Commons)

History Lesson

Apparently, diabetes has a rich history. Sushruta of 6th century BC India was a surgeon who discovered that diabetics had glucose in the urine, and he furthermore distinguished between Type 1 and Type 2 diabetes. That's pretty amazing to me. (In other news, he's also known as the father of plastic surgery because he invented rhinoplasty, the repair of a disfigured nose because criminals at the time were punished by nose amputation).

In trying to characterize diabetes, Oskar Minkowski and Joseph von Mering in 1889 removed a pancreas from a dog and discovered that it got diabetes. The professor giving the lecture remarked that this was "gene knockout technology of the day; you take out organs and see what happens." Funny way of looking at things.

I finally managed to wade through all the biochemistry. I have to admit, the abridged version is not as fun. We only cover the key points in each metabolic pathway. Medical school doesn't have the time (nor would it be justified) for us to delve into the biochemistry and organic chemistry principles. So this time around, things feel like a lot of memorization for me.

(Image: Sushruta performing plastic surgery)

Descartes' Folly

The pineal gland is an endocrine organ in the brain which secretes melatonin. It always fascinated me because of its fundamental and incontrovertible significance in the history of western philosophy. Nearly every novice philosophy student reads Rene Descartes' Meditations on First Philosophy. In fact, I read that slim book in at least four courses as an undergrad. In Meditations, Descartes proposes his theory of dualism, that mind and body are fundamentally distinct substances. The main problem of dualism involves how mental phenomena interact with physical phenomena if they are fundamentally distinct. How does food satiate my feeling of hunger? Well, Descartes had an answer. He proposed the pineal gland as the "seat of the soul" where mental and physical substances interact. This has, since the 17th century, been debunked, but it was a nice try anyway.

Wallet Biopsy

I don't have the time or background to explore this topic in any amount of depth, though it is an extremely important one. I thought of it when I heard the term "wallet biopsy," a procedure done to see whether a patient is eligible for an expensive treatment or health insurance.

Hospitals are businesses. They need to make money to stay afloat. There isn't a way around it. The people that run a hospital and manage it are concerned with the bottom line. They are not doctors, they're businessmen. However, revenue isn't guaranteed. Some patients can't pay, some insurance companies won't pay. Yet the service we provide can't be negotiated. If a motorcyclist gets in an accident, he needs a CT regardless of financial situation. The hospital may or may not be reimbursed, but the man is dying; the physician isn't thinking about money, until he gets slapped on the wrist by the hospital administrators. Restaurants reserve the right to refuse service to anyone. At some level, hospitals relinquish that right.

How do we reconcile finances with health care, especially in this age of defensive medicine (which I may address in the future)? Who makes the final decisions? I really think clinicians should call the shots about what a patient needs. If I'm ever in a place where some guy with an MBA and without an inkling of medicine tells me what I can and cannot do for my patients, things need to change.

Pictures

This is a gorgeous picture of Half-Moon Bay last weekend.

This is a comic I got from an AMA newsfeed. It reads: "You need more fiber and less cholesterol in your diet. Throw out the eggs you bought and eat the carton they came in."

Study Habits

It's a bit fascinating looking at study habits of medical students. Though at UCSF, there are far fewer ultra-competitive cutthroat students, they do exist. I'm not being critical. If it works for them, that's fine by me. A pass-fail grading system smooths out the extremes of Type A personalities. There are students who pre-empt lectures far in advance, who consult books upon books, who orient themselves to exam questions. They do fine in medical school, and I assume they do fine as doctors too.

On the other hand, some students fall in my camp. We don't pick up our syllabus (course reader) until an exam is imminent. I don't worry about preparing for anything other than small groups. I don't worry about reviewing lectures. I attend all my classes, and that seems to be pretty good for me. I can read through the syllabus in the week or so prior to an exam and do fine. Despite this, I don't neglect medicine. I love medical school. I just spend a lot of my time reading journal articles, pursuing projects, thinking about issues that make this discipline so dynamic and exhilarating. The curriculum is great, but thinking outside the box is what interests me.

Most people fall somewhere between the two extremes. It's nice to be in an environment where not everyone is focused solely on exams, school, and career. I suppose it's also nice to be in an environment where not everyone is as lazy as I am.

UTEACH Revisit

Back in January, I wrote a few posts about my experience with an elective where I was paired with an expectant mother and helped deliver the baby. Just last week, I met the family for the baby boy Dashiell's two month pediatric appointment. It was wonderful! He was developing well, and I got to see some of the routine things he needed done, including immunizations. He was very cute, happy, and interactive; he especially liked faces with glasses. He wasn't too thrilled about the shots, but did really well with them. I also got to talk to the family about how they were adjusting to a new face in the household. Raising an infant is definitely a full time but very fulfilling job. They were all very happy to see me, and having the continuity of the experience was great.

I also spent some time this afternoon playing with my friend Mika's daughter, who is one and a half. That was a lot of fun. Kids are so adorable, happy, and enjoyable. They really make my day that much brighter.

Endocrine

We just started the endocrine portion of "Metabolism and Nutrition." The endocrine system (hormones) was always a pretty nebulous topic to me because it's spread throughout the body without any distinct organs. When you mention the circulatory or pulmonary or gastrointestinal systems, you generally have an idea of where the key components are. But endocrine? Not so much. Even though there are discrete structures like the pituitary gland, I honestly didn't know where that was before medical school. (It's found in the "Turkish saddle" or sella turcica, a depression in the sphenoid bone at the base of the skull). And indeed, hormones are secreted by a whole host of random organs, from the thyroid gland to the heart to the adrenals to the placenta.

Furthermore, many of the diseases are "named" diseases like Addison's disease or Cushing's disease or Graves' disease. This means there's an unfortunate amount of memorization. But the endocrine system is incredibly important, regulating functions as diverse as growth, lactation, glucose homeostasis, and blood pressure. It's also fairly interesting because all the different regulatory mechanisms are very logically connected, meaning that the different diagnostic tests make a lot of sense.

GI Exam

So a little over a week ago, we had our exam for the gastrointestinal block. It was a pretty intense test. In the morning, we had four hours of multiple choice questions. In the afternoon, we had two practical exams. The first was a histology/pathology practical where we were given 6 slides. After examining them under a microscope, we had to determine the disease. This was tough; I have enough trouble identifying normal tissue (they just look like cells to me), let alone pathology. But it was really fun because it felt like detective work, putting a clinical story together with a slide. We also had gross specimen identification; they would give us a liver or pancreas or colon, and ask us to figure out what was wrong with it. Even though I didn't do fantastic on that section, I enjoyed it. Then we had an anatomy practical, which was similar to the ones we had at the beginning of the year; there were cadavers open with organs, vessels, tissues, or nerves marked for us to identify. Though some of the questions were tricky, it wasn't as harrowing an experience as it was in the past. And yes, yesterday's post was an April Fool's joke.

This Space for Rent

I have gotten a monetary offer from another medical school requesting to link this blog as a suggested reading for their course "Transformation as a Medical Student." We're currently discussing the exact terms, but they have requested some topics for me to write about. This means you might anticipate posts on the Proper Use of the Ophthalmoscope, the Side Effects of Viagra, and Curing Smoked Ham. The program funding this is associated with several pharmaceutical companies, so I will be adding unobtrusive advertisements on treatments for intractable bloody diarrhea. Please click on them. April showers bring pilgrims.