Pediatric Cardiology Pathology Specimens

We just had a lab on pathology of congenital heart defects. It was really cool! They had these amazing specimens of unusual diseases. On the one hand, it was really sad to see pediatric pathology specimens (as it indicates the child died and had an autopsy), but on the other hand, I learned so much from seeing actual hearts. The pediatric cardiologists and surgeons helped guide us in examining the specimens (we can't use wall thickness to locate left ventricle anymore since so many defects have right ventricular hypertrophy). I really enjoyed trying to guess the pathology: Ebstein anomaly, tetralogy of Fallot, ASD, VSD, truncus arteriosus, transposition of the great vessels, coarctation of the aorta, pulmonary valve atresia. The pulmonary atresia specimen even had a surgical Dacron shunt from the pulmonary artery to the aorta; that was crazy. I was impressed; these are lesions that I probably will never see again (unless I decide to go into peds cards, which has moved up on my list of interest). The hearts were so incredibly small (the size of an almond), but it was a great exercise following the flow of blood through all the different chambers.

NEJM Clinical Problem-Solving

The New England Journal of Medicine put a collection of interesting clinical vignettes into a book titled Clinical Problem-Solving, editors Sanjay Saint, Jeffrey Drazen, and Caren Solomon. Basically, it is a compilation of previously published cases on NEJM. I found it really educational in thinking about how experts approach difficult unknown diseases. How do you take a good history? What do you look for on exam? How do you interpret labs? I love looking at the differentials and how they're formed. The most obvious way is to list diseases by likelihood, but experts also think about the things that are most serious and dangerous in the patient (even if unlikely). These cases are oddball cases: usually rare presentations of common diseases, and sometimes common presentations of rare diseases. They're written for practicing physicians, and as such, they are not good for Boards prep (in case this post is misinterpreted as such). But they are very cool and probably useful for the wards when we might be called upon to explain our clinical reasoning.

Image from Amazon UK, shown under fair use.

Ethics

A lot of ethical issues come up with perinatal and neonatal care. For example, how do you treat a pregnant woman if the standard of care is a drug whose effects on the fetus are unknown? How much are you willing to endanger a mother's life to save the fetus? Can you compel a mother to undergo something as invasive as a C-section because you feel obligated to save the life of an unborn baby? What happens when a mother denies her fetus important life-saving treatments or tests, such as antiretroviral drugs because she has HIV? Issues around genetics are just as dicey. What are a physician's obligations to a patient's family after diagnosing a patient with a potentially genetically transmissible disease? Can you balance confidentiality of the patient's condition with an obligation to warn children if it is preventable? Can parents force their children to undergo genetic testing? How about genetic testing for a carrier condition?

There are so many interesting ethical dilemmas and I actually enjoy these small groups where we try to flesh out how to apply general principles of autonomy, beneficence, non-maleficence, justice. I'm not sure we can come to very strong conclusions, but I do think discussion of these issues helps us understand the impact of these real-world situations.

Review Books for Boards

I haven't yet started studying seriously for Boards, but I have started collecting review books. As I'm starting to look into how to study for the USMLE, I've become sickened by the ridiculous amount of commercial prep materials out there for this exam. I really dislike this aspect of high impact standardized tests. Money should not be able to buy a better score on an exam. I'm not sure whether there's strong evidence that this is the case, but regardless, people think it is, feeding into this burgeoning industry which takes advantage of vulnerable (rich?) students. When I see thousand dollar courses run by professional companies and piles of review books and boxes of flash cards, I wonder whether I am shortchanging myself by refusing to splurge. I'm the kind of person who believes (naively?) that the coursework of the last year and half should be sufficient, that textbooks are the best source of learning, that the goal of these basic science years is to lay a foundation for understanding medicine, not for acing yet another exam. I think right now, my focus will be on using materials at the library as well as less high yield resources (texts, syllabi). We'll see.

Rain

It is days like this that make me glad I am not made out of cotton candy.

KA

There was a Chancellor's reception yesterday, but I decided not to go, partly because it was raining, and partly because I think how he handled the situation with Dean Kessler was unsatisfactory (I wrote a post about that several weeks ago). It then occurred to me that this situation finds an interesting parallel with Dumbledore's dismissal by Cornelius Fudge.

"... but Dumbledore is gone, Harry. He's gone."
"He will only be gone from the school when none here are loyal to him," said Harry, smiling in spite of himself.
(JK Rowling, Harry Potter and the Half-Blood Prince)

Not that I knew Dean Kessler well or anything, but it would be cool to start a "KA" and practice dueling charms.

Pilots and Models

One of the things they've really pushed for clinical rotations are "pilot" or "model" programs. These programs encompass 3 or 6 blocks, emphasize a theme, and take place all at one site. For example, there is a longitudinal VA experience with internal medicine, surgery, and neuro/psych focusing on the veteran population. An SFGH model targets underserved communities by integrating internal medicine and family medicine at the county hospital. Those wanting to try Fresno can do a combined six month experience in family medicine, ob/gyn, and pediatrics there. There are more interesting ideas. Some students may do a set rotation schedule, starting with medicine, then neuro/psych, peds, surgery, ob/gyn, and finally family medicine. This is intended to outline a logical order in which to do rotations; having surgery experience may enhance ob/gyn, and knowing ob/gyn issues will help with family medicine. I think the concept is cool, but it sounds like few people want to brave medicine first. Lastly, the most radical model program involves a complete integration of all the blocks in a year at Parnassus. This is a heavily outpatient based program. Students have their own cohort of patients to follow throughout the year; when they go to surgery, you go to surgery with them, and when they go to outpatient clinic, you follow. In theory, it seems very neat, but I feel like it requires a very particular person with a lot of initiative and independence to get the most out of it.

While I think the principle behind model and pilot programs is fantastic - an integrated approach for a more longitudinal experience, focusing on certain populations of patients, more time spent at a particular setting - I don't know if any are particularly for me. While SFGH and the VA program are most appealing to me, I don't know if they have exactly what I'm looking for. I think perhaps I prefer the flexibility of the traditional system, being able to rank what I would like to do, where, and when.

We've been having a lot of lunchtime or dinnertime talks from the different clinical core clerkship directors. It's been pretty interesting, though they really like emphasizing that all sites are about equal and there's no bad time to do a rotation. What's interesting to me is the rumors that are floating out there, and whether they should or can be debunked or not.

Third Year Rotations

A new, fun, and daunting task looming over us right now is figuring out our third year rotations. The third year is modularized in a pretty convenient fashion. There are six blocks, eight weeks each. The required rotations are divided into 8-, 6-, and 2-week segments that can be sort of interchanged. These include internal medicine (8), surgery (8), neurology/psychiatry (8), obstetrics/gynecology (6), pediatrics (6), family and community medicine (6), anesthesia (2), and surgical subspecialties (2). Each of the rotations is offered at a panoply of sites, from university academic hospitals to community practices to rural settings (as far as Fresno). I'm pretty excited about it. It's interesting how they decide which rotations to require; we're one of the few schools that require anesthesia, but when I heard a talk from the anesthesia clerkship director, he said that the focus is on learning skills such as IV placement, monitoring a patient, and securing an airway that are useful in any field rather than on convincing people to go into anesthesia. We also have to do two weeks in a surgical sub like opthalmology, urology, head and neck, neuro, or ortho, and that's pretty cool. It's interesting to see how other medical schools differ (Stanford requires critical care; Harvard, I think, does a month in radiology). In any case, people lately are in a flurry trying to figure out how to order their clerkships and where to do them.

Shenanigans

Over winter break, some of my high school friends called me up to see if I wanted to hang out a bit. We were meeting at Barnes and Noble. So I head over and see my friends Alex (UCSF-Berkeley) and Chao (Harvard), both second year med students. They were sitting in the cafe with review books and highlighters and notes spread all around them, preparing for Step 1 of the USMLE. Ouch. This was not a party I wanted to be at (though, it could have been worse: one of my other friends who came isn't a med student at all). But they called me over and said, "Go get a book, we'll study together."

I came back and started reading this:

Alex replied, "I hate you."

Image from barnesandnoble.com

Pregnancy

The physiology of pregnancy really fascinates me. I've heard somewhere the strange comparison between a fetus and a parasite. And no matter how distasteful this analogy is, it's an interesting idea. The embryo or fetus siphons away nutrients from the mother, and the placenta secretes various hormones that favor the developing organism at the expense of maternal health. Indeed, if something goes wrong, there can be drastic adverse consequences for the mother: ectopic pregnancy outside the uterus, molar pregnancy as cancerous growth, placenta previa or accreta causing life-threatening hemorrhage. To me, it seems like a scary risk for such a normal process.

But even in the progress of normal pregnancy, the mother is at risk for developing gestational diabetes because of placenta-induced insulin resistance, pre-eclampsia leading to stroke or seizure, pulmonary embolism causing death. Not to mention all the less severe but annoying symptoms like morning sickness or lower back pain or stretch marks. The incidence of domestic violence increases in pregnancy (paradoxical? it certainly doesn't favor the species). Even after the baby is delivered, mothers may suffer from postpartum depression, or worse, psychosis.

Ignoring all the things that can go wrong, the physiology of pregnancy is still an astounding feat. The mother - and her heart, lungs, kidneys - accommodate for a 5L intraabdominal mass. Tidal volumes are increased 40%, cardiac output 30-50%, GFR 50%. That's significant. Pregnancy is really a unique and impressive physiologic state.

Where's the guy in all this? (Well, males do produce a tremendous amount of sperm - ~1000/heartbeat, but still, I don't think it quite compares).

DevBio

There's a lot of developmental biology and embryology in this block. I'm pretty weak on this stuff; I never took a course on it in undergrad. I don't particularly like developmental biology. I think its difficulty lies in the steep learning curve. Embryology has its own complicated vocabulary: syncytiotrophoblast, morula, gastrulation. There's really no a priori way of understanding what those words mean. So a lot of devbio is just getting a grasp of the terminology. It's also complicated because it requires a lot of 3 dimensional visualization to picture the developing cavities and migration of cells and folding of tissues. Very little of it is intuitive; indeed, tissues develop then involute, cavities form then disappear, structures bear little resemblance to the eventual organ they become. But there are some redeeming aspects to developmental biology. It really does give insight into anatomy, explaining the orientation, innervation, and structure of our bodies. It is also a hot topic in investigation of cell signaling, cell differentiation, and tissue biology. Lastly, embryology is actually an amazing integration of complex changes whereby two cells develop into a baby. It astounds me when I think about the intricacy and tremendousness of in utero development. I don't know how practically useful embryology is as very little diagnosis or intervention can be done on a developing embryo or fetus. But this may change in the future.

World Clock

I thought this was pretty cool.

http://www.chippynews.com/worldclock.htm

Death and Dying

We had several lectures and discussions about death and dying. How do you tell patients they are dying? How do you deal with dying patients? It's one of those "fuzzy" topics that I happen to really like and write about. In a morbid way, I am attracted to it. Encountering death is one of those pivotal moments in one's life with such gravity and emotion that it is easy to run away. But I really think that meaning, art, intrigue, and respect can be found in thinking about and immersing oneself in death. Sort of strange, and hard to put into words. We heard a very poignant panel today of clinicians telling us stories of how they dealt with critically ill and dying patients. In a small group, I wrote about the question, "If I were to die in a few years, how would I like to die?" Terribly morbid, but how interesting! After hearing the panel today, I've thought more about what a perfect death would be (I've written in the past about the medical ethics definition of a good death but mine may be different). For me, I'm not really that afraid of death (perhaps it's residual teenage invulnerability or a lack of realism). But if I were to die a "premature" death, I would love it if my organs could be donated to different recipients. I'm not sure how that would change if I were to die older (a priori, it doesn't seem to matter, but I have a nagging feeling it might). In any case, I would hope for something good to come out of my death; death, no matter how serious and grave (pun intended), can also be curious, meaningful, thought-provoking, and reflective. The purpose of most things, it seems, is for the living. To think otherwise of my own death would be selfish.

Epilogue

The first block of medical school was Prologue. How apt (or corny?) then, that we finish with the Epilogue block. Epilogue happens every Friday during Life Cycles. Its purpose is integration and consolidation of the material we have learned in the last year and a half as well as preparation for the USMLE. I like this set-up with just four days of new material a week and a day of general review. Unfortunately, it makes Fridays really busy. The lectures consist of preparation for the wards (reviewing likely medical conditions we'll encounter such as diabetes and sepsis) as well as Boards prep; often the two overlap. I've realized so far that I have a lot of anatomy and pharmacology to review (especially musculoskeletal), but perhaps I remember more than I thought I did. The instructors are the best from all the blocks we've had. We also had a cool lab in which we rotated through 35 stations in partners solving Boards-style questions with specimens to examine. While some questions were fairly easy, others were pretty tricky. It was really fun (I enjoyed the rapid pace) and educational.

Life Cycles

The last block of our "essential core" classes is Life Cycles, a ten week course that catches us up on "special" populations. We begin with the male and female reproductive systems, fertility, reproduction, and developmental biology. We then do perinatal care, pediatrics, adolescence, and finally geriatrics. It's an interesting set-up, following a person from before conception to old age. While most medical schools do embryology early to explain anatomy, we instead cover embryology at the very end and use it to review anatomy. Indeed, the past week has involved several pretty intense sessions in the lab dissecting the pelvis and perineum. It's been a long year and a half since Prologue when we last saw the pouch of Douglas or tracked the ureter going under the ductus deferens. An odd feeling, being back in anatomy lab, but this stuff really deserves another look. This block has a lot of social issues such as domestic violence and child abuse, gender and cultural issues, and ethics (especially with prenatal care). I like using our knowledge of "normal" physiology and applying it to different physiologic states such as being a newborn or being pregnant. This is not my favorite block, as I have trouble with developmental biology, but it is certainly one in which I will learn a lot and hopefully enjoy. It will be practical for our rotations in Ob/Gyn and Peds.

Kooza

On the first weekend of the quarter, a bunch of us went to see the Cirque du Soleil show Kooza. It was awesome, sort of residual holiday fun spilling over into the beginning of school. While the day was gloomy and rainy, I couldn't help but smile when I saw the big top circus tent. They had clowns doing a hilarious pre-show show with slapstick humor (vacuuming popcorn as someone was about to eat it, checking the bald guy's wig). I loved the atmosphere; the costumes were bright and fun, the live music was fantastic, the circular stage was like an old-time circus. The acts were unbelievable and entertaining; they started off with jaw-dropping contortionists, a little creepy and breathtaking, like something out of a dream. I can't understand how their bodies are able to make such shapes, but it was very artistic. The other acts were just as remarkable: a trapeze, a unicycle, a highwire (with jump-roping and leapfrogging). They had the most amazing juggler, doing beautiful and mindboggling patterns with bowling pins, rings, and balls. I really enjoyed the pickpocket, a stunning performance of showmanship, trickery, and humor where he managed to take an audience member's watch, wallet, and even necktie without him realizing. I'd seen the watch steal before, but this took it to another level. The ending was this catapulting extravaganza with people flying through the air. The plot made no sense, but that's okay. It was cool. The group was awesome (thanks to Steph for organizing!) and it was a really fun evening.

Image shown under fair use, taken from Wikipedia.

With Gratitude

I appreciate it. And on the second Friday of the month, too.

Y

Things To Do

I posted a link to Gawande's Harvard address last year:
http://asclepion.blogspot.com/2007/03/atul-gawande.html

He proposes 5 simple things that all physicians should do to better their practice. I wanted to list them here to remind myself.
1. Ask an unscripted question.
2. Don't complain.
3. Count something.
4. Write something. (Well, here it is.)
5. Change.

Performance

The last section of Gawande's book discusses the issue of performance in medicine. How do we measure ourselves? How do we know if we're doing a good job? This is not as straightforward an issue as it seems. He brings up how the Apgar score was developed in obstetrics so that the performance of a hospital could be compared to others. He raises the issue that a lot of things in medicine don't have evidence-based justification; there are no randomized double-blind controlled trials for much of what we do (especially if it was developed decades ago). Gawande has a really inspiring chapter on a center that works on cystic fibrosis and has unbelievably improved the lives of patients by implementing different treatments than the standard of care at the time. He also discusses the very scary idea that different hospitals have different track records; not every doctor's performance is the same, even though we'd like to think that every surgeon is competent, every physician equal. Lastly, Gawande tells of a remarkable experience when visiting hospitals in India, seeing how they could accomplish so much with very limited resources.

"'What is your preferred technique for removing bladder stones?' one surgeon in the city of Nagpur asked me.
'My technique is to call a urologist,' I said."

I really enjoyed this section of the book. It makes many points. We are by no means the best doctors in the world because we are trained at a great U.S. hospital. There is always room for improvement, and always opportunity to learn from colleagues elsewhere. Bettering ourselves does not take genius; it merely takes diligence, an ethical drive, and ingenuity.

Lethal Injection

Atul Gawande also discusses lethal injection and the doctor's ethical obligation in his book. He says, "there is little doubt that lethal injection can be painless and peaceful, but as courts have recognized, ensuring that it is requires significant medical assistance and judgment." However, many people (including the AMA) think the ethical obligation of a doctor bars him or her from participating in a lethal injection. This is a very charged topic, and not one I am well-versed in. The AMA Code of Medical Ethics only permits physicians to provide a sedative to calm anxiety and to sign a death certificate after someone else has pronounced death. A physician cannot even pronounce death, because if the prisoner is found alive, the physician would not be able to resuscitate him.

Gawande interviews several health professionals that participate in administering lethal injections. Often, the physician is only asked to monitor the patient; he does not deliver the drugs. But when difficulties happen, the physician may be called upon to insert IVs, take more responsibility, nearly play executioner. On the other hand, some health care professionals argue that if a lethal injection has to happen, then it should be done by doctors. That is, they may approach the situation thinking that if they do not participate, then the lethal injection may have complications, and by omission, they contribute to greater suffering. This is an interesting stance, and I think it has some merit. Indeed, a death-penalty patient "is no different from a patient dying from cancer - except his cancer is a court order [...if] a patient dies, are you not going to comfort him?" The inmate is going to die. Are doctors shirking their responsibility of solace at that moment of death by not participating in the execution? This is a tough topic, but one that deserves thought and discussion.

Legal Medicine

One chapter in Atul Gawande's Better addresses medical malpractice. I don't know much about medical malpractice, but I will. Most doctors face some sort of litigation against them in their careers. "The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy percent of the time, the suit is either dropped by the plaintiff or won by the doctor in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars." I found this chapter fascinating. Gawande interviews a doctor who became a malpractice lawyer, and the lawyer's attitude is striking. He takes only cases he can win and only cases that offer him a substantial monetary reward. This makes sense from the lawyer's point of view, but it serves the lawyers, not patients or doctors. The stakes are high, and lawsuits attempt to cherry pick the most lucrative cases. The system does not work; "ninety-eight percent of American families that are hurt by medical errors don't sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted [...] In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology." Indeed, because of fear of litigation, doctors do not apologize for errors and play defensive medicine, running unnecessary tests to protect themselves. This is not a climate conducive to efficient or effective patient care. Furthermore, lawsuits ruin doctor's careers. Many times, insurance companies will have doctors settle even if they did nothing wrong because it is cheaper to settle than to take the case to court. Even if doctors are exonerated from blame, there is a huge psychological hit. The antagonistic, adversarial nature of medical malpractice needs to be fixed. In my mind, we need a system that does three things: compensates a patient for damages due to a physician's negligence, acts as a safeguard to prevent grossly negligent doctors from practicing (licensing boards are the current mechanism), and is an economically sustainable structure that prioritizes doctor-patient relationships.

:)

You smile is the worst euphemism for the USMLE.

Better

I'm a big fan of Atul Gawande's writing; he has a very readable manner, approaches difficult topics, and offers insights into those tough issues. His writing is clear and his arguments are solid. He's inspiring. His book Better addresses the problem of how to improve medicine, a field where mistakes cannot be tolerated and yet unforeseen complications crop up all the time. How do we reconcile these two conflicting aspects of medicine? "This is a book about performance in medicine [...] in medicine, as in any profession, we must grapple with systems, resources, circumstances, people - and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve." He approaches this problem by looking at diligence, ethics, and ingenuity. By analyzing the washing of hands, eradication of polio, delivery of medicine in war, he shows how monumental changes in health care have happened. In any case, I really enjoyed this book. Unfortunately, a lot of the chapters are essays previously published in The New Yorker, so I had read a few of them. But if you're new to his writing, this is a good book to start with.

Image from npr.org, shown under fair use.

2008

This blog has survived through another lap around the sun. Journaling is an interesting concept. Traditional journals are written merely for the writer and the exercise of putting down thoughts, reflections, and events on paper. Now, blogging has made it a performance of sorts. But I don't really have a concrete audience or an overarching theme. So it's writing for myself and letting everyone else peek into my strange and curious thoughts.

In any case, resolutions! The problem is that with upcoming boards and rotations, the future of this blog looks slightly bleak. I think I'm aiming for five posts a week (slightly less than usual) but it'll probably drop when the critical time of USMLE and rotations rolls around. I think early this year I'll have more posts about issues in medicine, personal reflections, thinky-thinky type stuff, but after that, it'll be more of a "what's going on these days." Especially for the wards, I want to record exciting, memorable, and scary stuff as it happens.