Change in Pace

I've just started my four week neurology rotation at San Francisco General Hospital. It's a big change from psychiatry. The hours are longer, the atmosphere is more intense, the expectations are higher. The teams are made up of a senior and junior resident and the three medical students and we manage a significant ward census and patient turnover. The attending is fantastic and has a strong dedication to good teaching. The bread-and-butter cases here are mostly stroke and substance abuse.

The day begins with pre-rounding on our patients at around 5:30 or 6. Work rounds begin at 7 with the residents seeing every patient and deciding on the to-do list and orders. Attending rounds are at 10 when the attending card-flips and then sees new patients or discusses a particular case in depth. The afternoon consists of getting all the work done for our patients, admitting new patients, and discharging old patients. We usually end from 5-7 in the evening. Call is every fourth night and goes until about 10pm. The structure is really similar to medicine and brutal.

Current Events

"They just out-lawed trans-fats. That's strange. It's cis/trans prejudice...a new meaning to stereoselectivity." - my friend Rev.

Ψ

I learned that Ψ is a quick abbreviation (at least at SFGH) for psychiatry. My experience in this four week rotation was fantastic. Like family medicine, I did not go in with expectations that I would love it, but I did. My attendings and resident really made the experience. They spent a remarkable amount of time teaching me, watching me interview, helping me work up a plan for my patients. Perhaps because they are psychiatrists, they kept asking me how my experience was, whether I was learning and meeting my expectations, and whether I had too many or too few patients. The team cohered well and I think that makes a huge difference. I also really liked the consult-liaison role, and it was hard to say goodbye to my patients on my last day. I was able to spend a lot of time learning about their lives, desires, and problems. I felt that I got a broad spectrum view of psychiatric diseases.

As a specialty, psychiatry has gone up on my list, mostly because consult Ψ is not isolated from the rest of medicine. I like having more time with patients, working on a therapeutic relationship, and being able to connect with people other physicians don't have time to deal with. I think the patient population really needs advocates and that's important to me. Unfortunately, Ψ has this feel of voodoo; we don't know how our drugs work or how diseases come about. This may change in the future. Psych is also the least hands-on of specialties. So although it has gone up on the list, it's not at the top.

Poem: Done

Done

When you’re done, the leftovers
are in the fridge. I’ve put Sammy in bed,
said goodbye and taken the trash out
along with the photos from the album.

Why People Travel

I never did the post-college whirlwind travel of the world: carefree backpacking through Europe, trekking around Asia, or mingling with locals. In some ways, I wish I had; I see pictures of my friends in exotic locations, seeing astounding wonders of nature, eating foods I've never heard of. They seem to be swimming in human experience, breaking out of bubble after bubble, driving after the unknown and miraculous.

Perhaps this is merely a compensatory attempt at justifying my life, but medical school is not so different than traveling. We see a different reflection of the human experience, and I think it really extends beyond that of simply illness and disability. We see how people cope, we see how families band together, we see how the human body perseverates. I've seen grief, elation, deception, anger, acceptance. The breadth and depth of the human mind and body in this respect is only recognized by those who go through it and their caretakers.

Not everyone cares to chat with the woman who finds out she is pregnant (which can lead to shock, disbelief, or relief), convince the transgender to share some of his or her personal life with a stranger, or listen impartially to a victim of abuse or even the perpetrator. But I love it. Health is the great equalizer. I've met high-powered Stanford MBAs struggling with mental health issues and illegal immigrants whose sprained ankle may mean they can't feed their families.

And on the other hand, I've seen residents awake after delivering a dozen babies, still working up another patient. I've seen professors delve into complex patients, security guards subdue schizophrenics, therapists get someone bed bound for months back on their feet. I've seen nurses respond to a witnessed seizure in the hallway, emergency doctors rush a gurney being wheeled in, chaplains making their rounds from patient to patient.

The hospital may not have beautiful monuments or breathtaking landscapes, but it is a travel of sorts, the kind that wades deep into human emotion, that challenges human experience, and that ultimately reaffirms some sort of meaning to our living.

The image is a picture of the Radcliffe Camera and All Souls College at Oxford. I took it in England, fall of 2004.

A Day in the Life of Psych C/L II

Four people in a car playing hot potato (or Russian roulette) with a lit firecracker. It is passed to the driver when it blows up, destroying his entire dominant hand.

A man who, in the morning, claims he is a state assembly person from Texas, listing people who could be contacted to verify his political career. In the afternoon, he is completely bewildered why he would say that; he's never even lived in Texas.

A MUNI bus driver who was assaulted with a lead pipe, possibly causing PTSD. She also has a cluster B personality disorder (like borderline) and has alienated nearly the entire staff on her ward.

A man who can't remember where he lives, how he got to the hospital, even what he enjoys doing. He can name his family members but has no idea when he last saw them or where they are.

A man who presented floridly psychotic, claiming he was a doctor and part of the FBI, talking to empty spaces in the room, disoriented to time, place, and person. He later develops chest pain, and the question is whether he can consent to an invasive procedure or whether it would even be beneficial given his psychiatric conditions and unlikelihood of taking medications correctly.

Countertransference

Countertransference is the concept that a therapist or clinician develops strong emotional reactions to a patient unconsciously. I sort of think of it as the feelings I get when I see a patient. I feel pity when I see a young person in a car accident or satisfaction when I talk to a patient who has finally gotten an exercise routine. But this is taken to a whole new level in psychiatry, especially since much of psychiatry depends on the therapeutic alliance. How one interacts with patients greatly affects whether patients will share personal details of their life, be willing to work on maladaptive behavior, and adhere to medications.

In this rotation, I've had patients threaten to kill me, call me a liar, and ask if I'm the FBI hunting them down. Even though I understand that these patients may be paranoid or borderline, it elicits an involuntary emotional reaction. I've found myself scoping out these patients before I see them to see if they are in a good mood or not. I brace myself before I go in, knowing that they may be furious and yell at me to get out. I have to dig deeper to find the empathy and patience to work with them and tell myself not to take what they say personally. It's emotionally weary to go through all that, but it's a prominent part of psychiatry.

Behind the Scenes

My classmate and co-blogger Stephanie commented on this a while back, but it is amazing how much work is done for patients behind the scenes. We might only see patients for 30 minutes or so (at least in psychiatry; on other services, maybe 5 minutes) but we spend an impressive amount of time researching those patients, writing up recommendations, carrying out orders, presenting at rounds, thinking about diagnosis and treatment, blogging about them (just kidding). I think this is just a doctor's role in the hospital.

Accessories

There are a host of other conferences, meetings, and lectures on this rotation. Indeed, I could spend the bulk of my time listening and learning without even leaving the hospital. Of note, we have a humanities discussion group where we read short stories, discuss nonfiction (Gawande's "The Itch"), and practice meditation to give us insight into non-medical aspects of psychiatric and neurological illnesses. We have didactics oriented to medical students as well as grand rounds targeting faculty; topics range from adult to child and adolescent psychiatry. Occasionally, we even have evening conferences. Though I've always been tired, I found the night-time neuroscience review and case conference to be fantastic (they're lead by some of my favorite faculty). I like this mix of structured and unstructured learning.

Poem: Countertransference

I wanted to write a poem about my psychiatry experience. This is really rudimentary and still needs a lot of work.

-

Countertransference

On the elevator I unclip my pager
slip it into a bag where I stow a stethoscope I never use
Running my finger along the rim of the bell
I decide to thin out my belongings
The scope is marred with dust
but I set it in my ears anyway
curious what a psychiatrist hears

A man certain homeless shelters are for homeless people
but when he steps into one it is filled with normal people
pretending to be homeless
following him

A victim of a motorcycle accident
transected spine leaving him motionless
who finds me a best friend one day
a liar the next, depending on the pain

The pain, that was all she could say
this woman my age, who had fallen two stories
fracturing dreams of school.

This much school, I think, looking at the stack
of books overflowing the shelves, piling the ground
This much school to accept the stories these people offer
to justify returning the stethoscope to the bag.

Time

It is disappointing and humbling to wonder how much time gets wasted in the day. We spend a good deal of effort, energy, and thought on activities with very little yield in meaning or productivity. How much of one's time is spent reading news articles that have no lasting impact, surfing the web mindlessly, shopping for things one doesn't need, or writing blogs for the sake of doing so? We whittle our lives away on Facebook or driving a car or waiting for elevators. Some of these activities are necessary and some may be worthwhile even if their worth cannot be measured. But perhaps others, the things we do selfishly, the things we do without knowing why, those things, can and should be discarded.

This thought occurred to me as I was pre-rounding on patients, faithfully copying down lab values. Indeed, that itself should be questioned. What laboratory tests are relevant to psychiatry? Certainly, some are vital on the consult service such as B12 levels or TSH or RPR. Some may be occasionally relevant like WBC or electrolytes or liver function tests. But a lot of what I was looking up and copying down never got used and never contributed to patient care.

The Pareto or 80/20 rule states that for many events, 80% of the results come from 20% of the efforts. Most of what we do contributes very little to our productivity. Our best successes can be attributed to a small percentage of our time. This has been empirically shown in many arenas: most of the wear on our carpet occurs on a fraction of the surface area; most of the profits for a business come from a minority of customers; most of the money in a society concentrates within a limited number of people; most our time is spent with only a few of our friends. Not all of our time is equally useful; not all of our work is equally productive. This has been widely applied in business and quality management, but I think it could be used in everyday life.

We should accept that some of what we do will be "waste" and as long as the fleeting pleasures or necessity of doing those things justifies them, that's fine. But we should wean ourselves off other pursuits that just don't seem time-efficient. We should spend less time with useless pre-rounding, more time with the patient; less time with online social networking, more time talking to those we care about.

Image is Rene Magritte's "La Trahison des Images," owned by and exhibited at LACMA, shown under fair use, image from Wikipedia.

Unsung Heroes

I have found that the truly underestimated workhorses of the wards are the non-MDs. Everyone is aware that the whole system depends on nursing and that they provide a wealth of experience and knowledge when it comes to patient care. But I've also found that social workers are amazing people who track down lost family members, call other health care facilities, contact community resources to figure out where a patient goes when he leaves the hospital. We can handle the medical aspects, but we know nothing when it comes to social work stuff. Physical and occupational therapists, too, make a world of difference in the patient's lives. Indeed, not many people know the difference (PT deals with gross motor ability such as gait; OT deals with fine motor movements and activities of daily living). Doctors worry about what kind of infection is happening and what antibiotics are needed; patients worry about whether they need a walker or if they can go up stairs. Lastly, today we relied on an interpreter who did an exemplary job acting as a neutral intermediary. And I'm sure there are other key players (phlebotomists, even custodial staff) who nobody sees but make the hospital run smoothly.

Lesson Learned

Today's lesson: dispo / sign off on patients as soon as you can, or else you'll get swamped.

Freud and Psychodynamics

An interesting question is how much Freudian theory or psychodynamics we use. Psychodynamics is the study of conscious and unconscious forces that underlie human behavior. We don't use very much of that clinically as psychiatrists. However, one of my attendings is very interested in psychodynamic theory and likes to conjecture on unconscious motivation. For example, we saw a patient who was somewhat hostile to us. In his garbled history, he noted a past conflict with child protective services over the treatment of his daughter. The attending suggested that the patient's hostility could have stemmed partly from the resident being a woman at the approximate age of the daughter. This could have stirred unconscious emotions related to that conflict.

It is fascinating to conjecture on what possible strange forces affect our behavior without our knowing. What causes our emotional lability? Why do certain people affect us more than others? Can you rationally explain emotional outbursts or episodes of depression? How come some minor suggestions trigger such powerful responses? I probably should never admit this, but I do like pretending to psychoanalyze my own behavior and those around me.

What is a Consult?

I think one of the more valuable general things I've learned on this rotation is the nature of consult services. It's useful to know when to get a consult and what a consultant does. At least for psychiatry, we get consulted when patients on the general medical wards have mental status changes, suicidal or homicidal ideation, behavior issues, pre-existing psychiatric conditions, legal status problems (such as a psychiatric hold), or questions of informed consent. Consult services expect the consultee to ask a specific question. Sometimes this is general, frustrating, or inappropriate ("she has interesting behavior, go check it out for us"), but usually it gives us a place to start. We then see the patient and assess general psychiatric issues, focusing particularly on the consult question. This allows us to make a recommendation on what to do with the patient; the primary team can choose to accept or reject those recommendations.

Legal Aspects of Psychiatry

Interestingly, the domain of psychiatry includes a lot of legal medicine and ethics. On consult service, we are sometimes asked to assess a patient's capacity, whether they have the ability to make an informed consent decision. Ironically, psychiatry has the fewest procedures so we rarely consent patients ourselves (electroconvulsive therapy is one exception). But we are considered knowledgeable of a patient's ability to consent because we spend a fair amount of time assessing cognitive capacities.

Psychiatry can also place legal holds on patients (along with general physicians, law enforcement officers, and others). That is, we can detain a patient against their will if they meet certain criteria such as being a danger to self, danger to others, or gravely disabled due to mental illness. These "5150s" are an interesting example of how individual rights are subsumed by paternalism (preventing suicide, grave disability) and societal safety. While many people can initiate the 5150, usually only psychiatrists really pursue the longer term holds such as the 5250 or putting a patient on a conservatorship.

Because of this intersection between medicine and law, psychiatrists are often involved in hearings that take place in the hospital by the bedside. They act as expert witnesses to argue whether someone should be held against their will or given medications involuntarily. To me, this is a fascinating aspect of medicine I hadn't thought about before.

Poem: Affidavit

One of my favorite poems is "No Second Troy" by W.B. Yeats. The amount of ground he covers in this 12-line poem is breathtaking and his use of sound, syntax, and imagery is unparalleled. Here is the original Yeats poem and one I wrote in response.

No Second Troy
W.B. Yeats

WHY should I blame her that she filled my days
With misery, or that she would of late
Have taught to ignorant men most violent ways,
Or hurled the little streets upon the great,
Had they but courage equal to desire?
What could have made her peaceful with a mind
That nobleness made simple as a fire,
With beauty like a tightened bow, a kind
That is not natural in an age like this,
Being high and solitary and most stern?
Why, what could she have done being what she is?
Was there another Troy for her to burn?

-

Affidavit

I confess I craved a second Troy to burn.
Not for the tyranny or maritime seduction
or the heroes that arise when they recognize
duty as passion, but simply to know
Beauty commands. For why else would women
court clostridium but for the basilisk gaze
to hold reason enthralled, drive waterfalls off cliffs?
Little do they know my misery, the temptation I rein,
that I learned something from those little streets:
Nobility is not free will, and responsibility leashes
my splendor from destroying your jury of weakness.

Challenges in Psychiatry

Psychiatry is often viewed as a soft specialty; it's touchy-feely and its vital signs include such things as mood and whether someone is feeling suicidal. Our bread-and-butter is someone's family support or occupation or marital status or education. We ask where our patients grew up, how they got to San Francisco. We don't physically examine the patient. Our trade involves things the public knows (or thinks they know): depression, psychosis, paranoia.

But after two weeks of this rotation, I realize this is not an easy specialty at all. We deal with the hardest patients: the manipulative, the uncooperative, the narcissistic. We deal with the hardest people: victims of abuse, murderers, schizophrenics. We have few diagnostic tools; there's no brain scan or lab test that can diagnose bipolar disease. We have to carefully evaluate someone's history, behavior, speech, and thought process to decide whether to label someone with a potential stigma. We can't even count on our patients communicating coherently. We run the risk of asking a sensitive question that turns the patient against us. We are often emotionally drained by those we see. Our patients have chronic, progressive, debilitating diseases.

Watching a good psychiatric interview done by one of the attendings is an amazing experience. I really see the remarkable finesse, the careful wording, and the planned organization of the interview to ally the patient and convince him to share deeply personal aspects of his life such as history of trauma or the delusions no one else will believe. It takes as much skill as conducting a good physical exam to conduct a good interview with an uncooperative, psychotic, or suicidal patient. It's often very difficult to "put oneself in the patient's shoes" when they are threatening to hurt others or hallucinating or delirious.

A Day in the Life of Psych C/L I

A paranoid and disorganized schizophrenic who does not recognize when others are in the room, constantly mumbling self-dialogue and flailing all four extremities. If you listen closely, you realize he's plagued by demons and spends his life trying to exorcise those foul spirits.

A man in his forties who crashed his motorcycle after an 80mph high speed chase, drunk and high on cocaine, now nearly completely paralyzed. A family who bands together despite previous estrangements to visit his beside in the ICU daily.

A woman in her 20s, pregnant in her second trimester, who has lost weight from 104 to 86lbs.

An HIV positive man, antagonistic towards those around him, completely convinced that parasites travel within his body, migrating between his ears, and crawling under his skin. In severe renal failure, he's been kicked out of enough dialysis sites that he has nowhere to go.

A man who tried to commit suicide with turpentine, alcohol, GHB, and cocaine, now saying that he wants a pen to stab himself in the heart. When asked about suicidal thoughts, he says "why? Will you try to stop me?"

A woman who is refusing a life-saving pacemaker because it is against her religious beliefs as a Christian Scientist. That's usually okay, but we were called to assess her capacity to refuse this treatment. To see if she understood what was going on, we asked her to explain a pacemaker and she said it is "an envelope that sees my heart."

Outpatient Psychiatry Clinic

We have an outpatient psych clinic for all eight weeks of the block (including through neurology) to promote continuity care and exposure to ambulatory psychiatric complaints. I think it's a great idea as inpatient psychiatry is skewed towards severity. The clinic also breaks up the long week. My clinic is at the Walden House, a non-profit substance abuse treatment center which has an amazing array of resources from education for clients to get a GED to computers to work on resumes for jobs to community groups fostering social support.

I really enjoy it; it feels like family medicine with the community setting, the types of patients, and the role I play. However, the patients are complex. The first patient I saw started crying about ten seconds into the interview. I talked to her for over an hour (which before psychiatry, I would not have thought possible) but got such insight into her childhood, social stressors, problems with the law, substance use. At the end of the interview, she told me she felt an incredible relief and thanked me for merely listening. Just yesterday, I met my first transgender patient (male to female) who was struggling with depression. She had a fascinating mental status exam and we had a great conversation.

Psychiatric Emergency Services

We take one night of call with Psychiatric Emergency Services from 6pm-11pm. Psychiatric emergencies often involve 5150's (involuntary holds) for suicidal attempts, homicidal ideations, or grave disability (such as inability to provide food or severe alcoholism). Patients may self-present to the emergency room, but most are brought in by police, security, or case managers. The range of patients is stunning; there are those who are constantly shouting, those with active psychosis, those who honestly are just looking for a place to stay for the night. The emergency department has interview rooms where security can watch, panic buttons in case staff is threatened, and seclusion rooms (not padded, but close).

I interviewed a patient who was having suicidal thoughts, but the story became extraordinarily complicated with diagnosis of breast cancer subsequently leading to a broken relationship (the boyfriend left because the patient had a lumpectomy) and loss of housing. We also saw a patient with borderline personality disorder, a diagnosis of an incredibly volatile mood. He wanted to kill his father and then he threatened us when we refused to let him do so. It got to a point where he wouldn't even communicate with us, telling us that he would only talk and listen to the "nice nurse." It was a crazy evening.

Poem: Stack

This is another poem written about a photo I took. Still too rough for my liking, but here it is.

Stack

Warned by masters who would find this unbecoming,
I paid no heed and the stack has grown.
Seeded by wanderlust journals
haphazardly lounging on this wayward chair
the party spirals into a stairstep -
Where does it go? I do not know.
To unearth the originals, I slide out the bottom rung
careful not to send the tower toppling,
each attempt a greater effort
as it grows like a child whose appetite
cannot be satiated.

Psychiatry 110

I'm doing a month long psychiatry rotation at San Francisco General Hospital. We get to pick between working in the inpatient wards and the consult liaison (C/L) service. Interestingly, the inpatient wards are ethnically separated with focus groups in Latino health, women's health, African American health, Asian American health, and LGBT issues. I'm not sure why they do that. The inpatient wards deal with acute psychiatric symptoms in patients who don't want to be there: schizophrenia, depression, bipolar, personality d/o, PTSD, substance abuse. The consult-liaison team responds to psychiatric consultations from other services. The patients are medical and surgical patients who develop or have psychiatric problems that the primary teams can't handle. C/L assesses conditions like depression, delirium, dementia, personality d/o, substance use, and assessment of capacity for informed consent. I decided to work with consult-liaison; though the really interesting stuff is inpatient, I figured learning how a consult service works would be very useful since I'm leaning toward a medicine-y field. Differential diagnosis is tougher with C/L because you have to consider all the organic stuff too.

The instruction is awesome; the attendings on my service are completely dedicated to medical student teaching. They take a lot of time out of their day to help us get as much as we can out of the rotation. There are some formal didactics: psychopathology, pharmacology, adolescent and child psych, grand rounds, case presentations, and humanities conferences (one of the attendings enjoys reading psych-related literature). But a lot of it is learn on the job also.

Lung Cancer Screening Project

For family medicine, we had to do an evidence based medicine project. The residency director publishes an online newsletter "FP Revolution" and included this article based on what I found. Some of the wording is a little stronger than what I originally had, but here it is.

Does Screening for Lung Cancer Make Any Kind of Sense?
Craig Chen
General Background:
Approximately 160,000 Americans die each year; these are more persons than who die from colon+breast+prostate+melanoma cancers all put together.
Thus the disease burden is substantial and treatment for lung cancer that is clinically diagnosed is usually ineffective. Of patients who present with symptoms due to advanced local or metastatic disease, 75% are not amenable to cure; their 5-year survival rates are <> 8mm, with less than 3.3 mSv dose of radiation (slightly more than annual exposure from natural sources)). In the recent and surprising ELCAP Study [Early Lung Cancer Action Project] baseline screening with low-dose spiral CT (n=1000) in smokers with >10 pack-years and age > 60, spiralCT detected malignant nodules in 2.7% vs. 0.7% with chest x-ray only.
In the International ELCAP Study with 31,567 subjects; CT scans found cancer in 13% of the positive CT scans (484 of 4186 abnormal CTs) including 412 stage I cancers. Estimated 10 year survival rate was 88% for stage I. If resection is performed within 1 month of diagnosis, the estimated 10 year survival rate was 92%. All lung cancers were estimated to have over 80% 10-year survival rate. The cost of low dose CT was < $200. The investigators concluded that lung cancers detected through CT screening are early stage and resectable; routine CT in asymptomatic smokers yields high prevalence of lung cancer. These optimistic comments must be tempered by certain obvious problems including observational cohort study type introducing lead-time bias and problems of overdiagnosis and absence of actual mortality data available from long-term follow-up. Also, extremely noteworthy, are the objections of Welch et al. who a year later wrote in the NEJM: “Last year, the New England Journal of Medicine ran a lead article reporting that patients with lung cancer had a 10-year survival approaching 90% if detected by screening spiral computed tomography. The publication garnered considerable media attention, and some felt that its findings provided a persuasive case for the immediate initiation of lung cancer screening. We strongly disagree.” Furthermore, other critics uncovered the following sources of systematic bias--undisclosed economic interest in the products being tested. The authors of the ELCAP study, Henschke and Yankelevitz, have since acknowledged that their widely cited 2006 article in The New England Journal of Medicine, for one, should have disclosed that they received royalties from their patented “methods to assess tumor growth and regression in imaging tests”—inventions that have been licensed to General Electric (GE), a maker of CT machines. 27 patents, royalties from 1. -In addition, they acknowledged that “virtually all” of the money from a foundation listed as a sponsor of their research actually came from an “unrestricted gift by the Vector Group, the parent company of Liggett Tobacco, which manufactures cigarettes.” $3.6 million improperly disclosed. These putative results must be thrown out completely because the authors are basically crooks, aided and abetted by the lax standards of the NEJM. Finally, another Mayo Clinic CT Study (5-years) with 520 current or former smokers over age 50 with > 20 pack years of smoking, found that 51% of these subjects at baseline had non-calcified nodules, and 1.7% had primary lung cancer. After 3 years of annual CT, 73.5% had non-calcified nodules, 95% were benign (15 underwent surgeries), 68 had primary cancers, of which 61% stage I. There was, however, no difference in mortality relative to historic benchmarks (2.8% vs 2.0%).
Crestanello et. al studied thoracic surgeries done on participants of Mayo Clinic CT screening study (1999, n = 1520, age > 50, >20 pack-year hx); they found 3130 nodules found in 1112 participants (73%). 55 participants underwent surgery (3.6%). Benign disease was found in 10 (18.1%) and lung cancer in 45 (81.9%), of which 28 were stage IA. 27% experienced complications, including 1.7% operative mortality. No reduction in mortality has yet been demonstrated.

Cost-Effectiveness Considerations:
Computer simulated model of annual helical CT vs. no screening for current, quitting, and former heavy smokers, age >60, 55% men. They used a parameter of 50% stage shift with screening leading to 50% fewer advanced-stage cancers and more early stage localized cancers. The model takes into account biases (overdiagnosis, lead-time, etc) The positive outcomes include absolute and relative difference in lung cancer specific deaths; harms include false positive tests and surgeries.
Result: Over 20 years, 13% lower disease-specific mortality, and 1186/100,000 false positive tests. The cost per quality-adjusted life year (QALY) for current smokers is $116,300 [probibitively expensive even though this is the group with the highest yield], $558,600 for quitting smokers [also prohibitively expensive], $2,322,700 for former smokers [also very, very prohibitively expensive even though this is the group that we might most be interested in screening in compassion for their having changed their lifestyle.] If all parameters occurred as maximally favorable (adherence, bias, quality of life, cost of CT, anxiety), the best-case cost would be $42,500/QALY, which is just at (and slightly over) the upper bound of what most would consider cost-effective. [Craig Chen, MS III, UCSF]
COMMENT: There simply is NO reasonable case to make to screen smokers for lung cancer. All smokers should be told to quit. All screening should stop. All industry participation in further research should be banned. Drs. Henschke and Yankelevitz should go to jail.

Intersession Fun

There were a few fun events during intersession. Some of the Nigerian students in our class put together a traditional(ish) Nigerian dinner which was delicious. The food involves lots of spices and really robust flavors. They also had some Nigerian music (soon they ran out and played salsa) and the talented chefs wore traditional clothing. We also had a reception at the interim Dean's house which I really enjoyed. A lot of the faculty were there and it was good catching up with my classmates over hors d'oeuvres and drinks.

Intersession

Our third year is interspersed with four weeks of "intersession" when the whole class gets back together in between rotations. The objective is to teach us clinically important concepts that are rarely formally addressed like ethics, health policy, translational science, and epidemiology. In practice, it's a somewhat relaxing classroom week that allows us to catch up with friends, finish errands, and recuperate. Our last intersession focused heavily on epidemiology, evidence based medicine, and the role of research in medicine. Notable lectures include Don Ganem describing the scientific thinking about HIV in the early stages of the AIDS epidemic. We had small groups discussing meta-analysis and in depth basic science papers. There was a "master clinician" rounds discussing a case of recurrent headache as well as an FPC session. That was good; we debriefed on trying episodes that occurred during our first rotation as well as our growth and learning on the wards.