Scary

Happy Halloween! The venomous lizard shown above is the Gila monster which has an interesting place in the history of medicine. One of the newer medications for Type II diabetes, exenatide, was derived from a hormone found in the saliva of the Gila monster. This molecule is similar to a human protein that regulates glucose metabolism but the version found in the Gila monster lasts a lot longer. Although now exenatide is made directly through chemical synthesis, it demonstrates how new drugs can be found in nature. Indeed, a great example of this is premarin, estrogens derived from horse urine (the name comes from pregnant mare urine). Perhaps sometimes, it is better not to know where our medicines come from.

Image is in the public domain, from Wikipedia.

Learning

Knowledge, it seems, occurs in ebbs and flows. By the end of college, we are overflowing with facts and formulas; we can demonstrate the right hand rule, navigate the photosynthetic transformation of light into chemical energy, and describe the Wittig reaction (aldehyde + triphenyl phosphonium ylide = alkene + triphenylphosphine oxide). Then we reach medical school and realize all that memorization must be neatly stored away in file cabinets labeled "foundation." We spend the first two years of medical school filling our heads with new facts until we are brimming with eponyms and images of cells and names of drugs we've never seen. Flying through exams, we imagine we cannot possibly learn more, and no more knowledge could possibly exist. Indeed, looking at multiple choice vignettes, we see the world as clear cut and distinct; medicine is easy, we say.

Then, we shed our backpacks and don our white coats to enter the clinical realm. The third year of medical school comprises of learning a new kind of practical knowledge. How do we interact with nurses, pharmacists, clerks, therapists, and ancillary staff? How do we call primary physicians, and how do we present real people with complex diseases in several minutes? Oh, certainly in college, we understood the chemical structure of bicarbonate, and in early medical school, we learned its use and toxicity, but now, only now, do we face a blank order sheet and realize we have no idea how to write the order. We learn how to learn, where to get information, how to teach ourselves, how to glean what we can to help those we serve.

And in the last few months, I encountered the turn of the fourth year. As a sub-intern responsible for patients, I realized how little we know. Sure, I know the mechanics of diseases and the treatments. But why do two patients with the same disease have different outcomes? Why are we so unsure how long a patient with a terminal illness will live? Why are there first line and second line drugs; what causes one treatment to fail and how can we prevent that? Why do medical mistakes happen? How can we miss such devastating diagnoses as domestic violence or child or elder abuse? How do we approach ethical dilemmas in practice? How do our subconscious biases affect our thinking? How can we anticipate unanticipated outcomes and unforeseen events?

The more I learn, the less I know. If real life were textbook, we would be healthier, medicine would be cheaper, and the vagaries of judgment and instinct would no longer persist. But textbooks hardly encompass all of medicine. When applied to the real world, theory can be flimsy and our fund of knowledge a dearth of practicality. This is why research is critical. To remain stagnant is to concede that we don't know what is always the best for our patient and we aren't trying to find out. A doctor who doesn't ask questions cannot remain at the forefront of his field and does not avail himself of the toolbox that medical school has given him. This is what I've learned in medical school: learning is lifelong and there will be a point in time when we have to teach ourselves; we investigate, we think, we learn, and we teach. Research is not for everyone, but to forget its place in medicine is to lose the humility that makes good physicians good.

Back

I'm back to blogging regularly now. In the last week, I took both parts of the Step 2 licensing exam and went to my first interview at UCLA for anesthesiology. It was quite a tiring week. The clinical portion of the exam involved 12 patient encounters with patient actors; we had to do a history and physical and write a brief note. I felt that UCSF prepared us well for this exam as interspersed through the curriculum, we had standardized patient encounters simulating common chief complaints. Nevertheless, seeing twelve patients was exhausting; it felt like a long clinic day. The fund of knowledge exam was also quite involved, but I am glad to be finished.

Going on interviews is both exciting and tiring; the logistics of travel, navigating a new place, dealing with sleep deprivation, and at the same time learning about programs and interviewing well is challenging. But I am really looking forward to seeing different programs, their emphases, their strengths, and their styles of training. I won't blog specifically about any programs, mostly because it would not be a prudent decision. The residency selection process (which will probably earn itself a blog sometime) involves a somewhat obscure and precarious match (though the match was implemented to improve clarity and equality). The mechanics behind it are such that publicly formalizing my opinions about each program would hinder me. Furthermore, as I learned on the medical school interview trail, rumors about every program abound. I don't find them useful and would not want to start or perpetuate anything. Lastly, the word "match" really describes the process well; each program and applicant has its personality and style and no program is for every applicant; it really is about finding the best fit for oneself.

Michelangelo

This was sent out as an advertisement for an anesthesia research project by the Bickler lab at UCSF. I am very amused by it. Shown under fair use, from Paul Au.

I am going to take a one week break from this blog for Step 2 preparation. USMLE Step 2 is the second of the three-part licensing exam and involves a two-day test including a practical portion and a fund of knowledge portion. I'll return to blogging in a week.

Health Policy II

From the California HealthCare Foundation, health care was 16.2% of the GDP in 2007, $7421 per capita. 31% was spent on hospital care, 21% on physician and clinical services, 10% on dental and other professionals, and 10% on prescription drugs. Only 7% was spent on administration.

Who pays this? Private insurance covers 34.6%, out-of-pocket payments cover 12%, and other private monies cover 7.2%. The federal government foots the bill in 33.7% of payments (19.1% Medicare, 8.3% Medicaid) and states and local governments fill in the last 12.6%.

This is a problem. Though in recent years, we've tried to curb costs and spending, health care still outpaces inflation; growth rates of the consumer price index are consistently several points below national health spending growth rates. Our costs are out of control.

Cost containment fails, I think, because we're Americans. Our consumers demand. We resist limited choices, we love the power of industries (device manufacturers and drug companies), our political system acts as a glacier. But we need to control costs; there's no alternative. Each dollar that's spent on health care is a dollar less from schools or the environment or jobs. Without cost containment, we can't insure more people; without cost containment, people will still find themselves bankrupt from emergency appendicitis. Yet our system hangs around because it seems "good enough"; too many special interests groups exist that are afraid that change will hurt them so they stick with what we have now.

Things will change; they may be at the brink of change now. But what I've come to understand is that our system now is unjustifiable and unsustainable. With medicine's focus on evidence-based practice, where is the evidence here? We're spending all this money, and our outcomes are not very good. What went wrong? Can we fix it?

Health Policy I

By the usual standards, the United States does poorly in health outcomes; we rank 19-25 among OECD in infant mortality, maternal mortality, and life expectancy from birth (but we do a lot better with life expectancy after age 65). Many reasons have been proposed to explain these differences such as the heterogeneous population in the U.S. or the prevalence of resuscitation of premature infants, but the hard outcomes still trouble me. Furthermore, race-stratified outcomes are even worse; African American men have very poor life expectancy compared to Caucasians or women. Many of our gains in life expectancy are in upper socioeconomic status groups (and many from decline in tobacco use). While we're making improvements, these are not equitably distributed.

Yet the costs of our medical care is stunning. Our health expenditures were 16.2% of the GDP in 2007 (California HealthCare Foundation); with the recent economic recession, the % of GDP is even higher since healthcare is more insulated than other industries to recession. Projections for healthcare % of GDP are hard to make but uniformly, estimates suggest larger and larger proportions of the GDP will be spent on health without clear benefits (since our outcomes haven't changed much). Indeed, compared to other nations, our expenditures are staggering.

Why do things cost so much? We seem to have much more specialists, but not more doctors. Perhaps our payment valuations (fee for service) are wildly unreasonable. Compared to other countries, our doctors are paid more; there's a larger gap between physician and non-physician salary in the United States. From a hospital standpoint, we have more ICU beds, expensive procedures, and technology even though hospital stays are shorter.

Costs vary a lot; states like Minnesota spend the least on health care while states like Florida spend a staggering amount. We have a good bit of administrative overhead, but estimates seem to hover around 14% of health care expenditures, suggesting that increased efficiency would save some but not a whole lot of money. Many doctors claim defensive medicine (especially with imaging) drives up costs. You'll also hear practitioners complain about the aging population, but other countries have an aging population as well. Economists will cite lack of cost competition and market forces; I really don't know enough to comment. The government will claim it is a lack of investment in information technology.

Costs are tied to everything. Nearly all students favor universal health care, but I heard a recent insightful comment. We can't even pay for Medicare for those who have it now; how can we talk about expanding Medicare to everyone? Things aren't even working now, without universal health coverage; how do we expect to get universal health care to work?

Revision: Hangman

Hangman

I remember when it was black and white,
you were living or you were dead, and the in-between
belonged to Michael Jackson music videos
and occulteers in dark alleys, when
there was no controversy; if you had a knife in your head
or the cough of consumption, we dragged in the box;
not this ridiculous business, shining lights at pupils,
insulin pumps clicking like the return of a typewriter,
an octopus sprouting from a dead man's mouth.

I remember when you'd kill a man
and he'd be dead; it was civilized that way,
but now diverted in transit, they end up
on my chopping block, in my glass coffins,
more machine than man in each of these rooms.
I make my executioner rounds every day
and the culling is always the same,
euphemized as family discussion for goals of care.

I don't want to kill them, but
they're already dead, I tell myself.
My hair falls out in clumps.

The white coats, we pat ourselves on the back since
this is the closest we've gotten to resurrection itself.
I tried rolling in a three-day boulder
but the nutritionist stopped me, said
"You can't do that, we need to give him tube feeds."

He never came back, this gentleman,
we didn't think he was Jesus anyway.
I filled out the paperwork, scheduled a time,
1600, as if death were too busy in the hospital
to come without an appointment.
Even though he aspirated at 1400,
a blooming pneumonia, an old man's friend
we continued full steam for another two hours
until morphine came waving down the caboose.

Pediatric Skills Session

I went to an open pediatric skills lab run by one of the pediatric ICU attendings, and it was a lot of fun. I spent most of my time practicing intubation on pediatric mannequins. I found it especially useful to try different laryngoscope blades just to see the practical differences with size and Mac vs. Miller blades. I had a lot of time to just troubleshoot with the models. I also practiced phlebotomy, IVs, and arterial lines on the pediatric models. It was very productive and worthwhile.

Image is in the public domain, from Wikipedia.

Trepanation

This is a fascinating skull from ~3500BC from a female girl who survived trepanation, shown at the Natural History Museum, Lausanne. Trepanation is the practice of drilling a hole into the skull, presumably to relieve pressure. Evidence of trepanation has been found in prehistoric human remains, possibly to cure seizures, migraines, and head trauma. Furthermore, there is evidence that people to whom this has been done survived the procedure. Who knew one of the oldest surgical practices would involve the skull?

Image shown under CeCILL license, from Wikipedia.

Frequent Flyer

Some patients are known as frequent fliers to the emergency department. The ones I've seen come in regularly for drug-related problems: alcohol intoxication, alcohol withdrawal, cocaine, amphetamines, opiate withdrawal. As an idealistic medical student, I try my best to persuade them to change their habits knowing it takes more than a scolding. We send them out, and they come back, pretty much the same.

When I was on my ICU rotation, I took care of a patient who stroked from cocaine hypertension. Looking at her past ED records and discharge summaries, I gathered that she had been to the emergency department a dozen times, admitted several times, and each episode was due to cocaine. All the discharge summaries emphasized the substance-use counseling given and the importance of quitting. Yet she kept on coming back, until her latest admission for a severe hemorrhagic brain bleed landed her in the ICU. She had several kids, all under 10. None of us thought she was likely to recover, but because of her family, we pushed on.

This is frustrating. What can we do to prevent frequent fliers from coming back to the emergency department? Although some patients have exacerbations of asthma or congestive heart failure, most of the frequent fliers I've seen have been due to drugs and alcohol. The nonchalance they have scares me, and the power of addiction they face controls them. One of these days, they won't be lucky enough to leave the emergency department to get another drink or high. So each time I see someone like this, no matter how futile the situation, I do my best to get him to change.

Information Economy

One of the ideas that Freakonomics touches upon is that of an information economy. For the most part, doctors deal in an information economy. When a patient goes to their physician, they want to know what is causing their rash or cough or fatigue. The doctor, a veritable repository of facts, deduces from the history, physical exam, imaging, and laboratory tests an answer, and they can proceed to treatment. We go to four years of medical school and three to eight years of residency to develop such a fund of knowledge as well as the tools to know how to ferret up knowledge we don't have. The "thinkers" in medicine such as internal medicine doctors deal with this information economy.

This is changing. The Internet is here to stay. Patients google their symptoms, peruse websites, post on message boards, and find support groups online. The vast information gap between physician and patient is closing, at least for the educated patient. Frequently, I see patients who have already done their research and come up with conclusions.

What does this mean for medicine? I'm not sure. Patient empowerment is a good thing, but we will have to see how empowering the Internet will be for consumer understanding of medicine. Information gleaned from the Internet may be biased, out-of-date, incomplete, false, esoteric, or too complex but this may not be readily apparent to the general public. Doctors will have to struggle with convincing patients that they know better, or on the other spectrum of things, conceding that they know less than the well-researching patient. This is somewhat disconcerting. The information economy of medicine is crumbling, and doctors that I have spoken to vary a lot in their reactions. Some don't like it. Others welcome it. Most adapt.

Patient / Doctor

One of my close friends from college who is also a medical student recently had surgery. Talking to him about his hospital stay was enlightening. You would think that being in medical school would cushion the experience as a patient. But he said that though he walked the same halls with confidence in his white coat, when the roles were reversed, he found it a scary and foreign experience. From the pre-operative clinic visits to the surgery to an ICU stay to the floor, he was never comfortable, never at ease. Despite understanding more medicine than most, he still found everything emotionally challenging and frightening. The role of the patient comes with undeniable vulnerability, no matter how prepared one is. Perhaps knowing more about the medical system makes the experience even harder. Those of us in the medical field know that the system is hardly perfect, that unforeseen events and errors happen, that some complications may not be avoidable. We're all very grateful that he made it through his eight hour surgery safely and well.

What is it like to be a patient? What is it like not to speak English, not to understand medical vocabulary, not to know what each pill is for, not to know what a surgery or procedure entails? What is it like not to know who your doctor is, or how the system works, or the plan for the day? What is it like to wonder whether you'll make it out of the hospital?

I underestimate how scary the hospital is. It's foreign, mechanical, imposing, gray. The patient experience of illness and health extends far beyond the medicine he takes or the doctor he sees for fifteen minutes each day. The patient experience encompasses emotion and fatigue, physical and spiritual challenge, an eclipsed understanding, a willingness to trust that things will be better. Relinquishing that self-determination, giving one's free will to a surgeon, hospital, institution, that's what makes being a patient hard. Unfortunately, I feel that no matter how much I try to understand this feeling, I won't fully know it until I find myself fully immersed in it as a patient.

Poem: Pinata

Pinata

String them up, lasso and haul them to a tree,
burros and zebras and primitive horses,
nooses around necks. We shake them in the air.
We beat them, and they give sustenance,
confetti like colors, fireworks of dismemberment
decapitation, singing and dancing.

Blindfolded, I spot on your voice.
You, to whom I've only spoken two words:
Hello and a splutter, some travesty of love.
You, for whom I spin, a moon about a planet,
you call out and I wish it were for me
when really, you are asking for another burger.

Facing the direction of your voice I swing
throwing my entire weight into this bat
beating a poor pig into a pulp
until the others jump on me, pull me back
as if from a fistfight in which I keep swinging.

Freakonomics

Freakonomics by Levitt and Dubner has been on my reading list for a long time, and I finally got around to it. It reads as a collection of essays with a casual conversational tone similar to that of Atul Gawande or Malcolm Gladwell. The authors examine disparate fascinating topics from sumo wrestling to children names to drug dealing in an economic and statistical light to draw fascinating sociological conclusions about motivation, incentive, family, and occupation. Do teachers cheat? How are real estate agents motivated to sell your house for more? Can we be good parents? I highly recommend this is a non-fiction read. Understanding that people act on incentive has changed how I view much of what I do now. At 6pm, it's probably better for patients if I stopped by their room to check in and see how they are doing. Even if it is merely a social visit, it builds rapport and strengthens the therapeutic relationship. But the incentive to go home at that time, driven by hunger, fatigue, stress over an exam makes such an act of charity hard to accomplish. Can doctors really be selfless?

Image shown under fair use, from Wikipedia.

Caffeine III

This post is a continuation of the story from the last two posts.

Over the next few days, her creatine kinase peaked and returned to normal. As a healthy 35 year old woman, her kidneys did well in excreting all the caffeine. But her troubles extended to her relationships with the staff. She loved some nurses, she hated the others. She opened up to me, but wouldn't say a thing to my resident. She expressed both love and hate for her mother and step-father. She wanted them to vacate her life and then wanted them to visit and when they visited, refused to talk to them. She said she was suicidal any time we brought up the possibility of sending her home, but the staff claimed the more they interacted with her, the happier she seemed to be.

I met her parents. I was afraid given all I'd heard, but they struck me as perfectly normal people. I learned that they had adopted her at age 5. Since age 16, she has had difficulty getting along with others (though the patient insisted that the voices and paranoia began at age 8). They denied any maltreatment of the patient despite the patient's allegations of harm and rape. Since the patient brandished a knife at them, they needed to call 911 every few months for psychiatric emergency services. The family went through counseling and multiple psychiatrists to no avail. "We just don't know what to do anymore," the mother said. "Her schizophrenia is so severe and it's ruined my husband's and my life. But nobody believes us. One psychiatrist says she's a paranoid schizophrenic and another says she's not. One says she's schizoaffective bipolar and another says she's just bipolar and another says there's nothing wrong at all, she simply has a borderline personality disorder. But I've taken care of her since she was little. She hears voices. She can't sleep at night without her step-dad in the room, then claims her step-dad wants to rape and kill her. She thinks she has special powers. She's never held down a job. She just can't function."

"Wow," I said. I'm not sure if that's what I should have said, but it's how I felt.

The mother continued. "We need you to make this diagnosis clear. She tried to kill herself. She drove out to the store, bought a bottle of pills, and swallowed them all. She's suicidal, she has a mental illness, and she needs help. We need you to transfer her to the psychiatric inpatient facility. Otherwise, she'll continue ruining her life and ours as well."

The psychiatry resident finessed the situation with the patient. The patient didn't deny any of this, but the psych resident was just a little skeptical. He talked to the outpatient psychiatrist, who also had his reservations. The outpatient psychiatrist felt that the patient and her parents exaggerated the symptoms and demanded medications; when medications failed, the patient wasn't complaining of the usual side effects. He had been trying to minimize medications and work on cognitive-behavioral therapy.

When the patient was medically "cleared" after the caffeine overdose, I asked psychiatry whether she should be admitted to the inpatient service. Both she and her parents demanded this. But psychiatry was reluctant to do so. They felt that the patient's mental illness was compounded by both a component of Munchausen syndrome and Munchausen-by-proxy. In the psychiatric factitious disorder of Munchausen syndrome, patients will feign illness or psychological trauma to draw attention or sympathy to themselves. They want to be in the role of the patient, dependent and comforting; this psychological need drives them to hurt themselves or fake illness. Munchausen-by-proxy is a similar syndrome in which a parent fakes or afflicts a disease on their child to get them medical attention. This is a form of child abuse, but I'd never heard of it described for someone in their 30s. In essence, the thought was that both parent and patient had a psychological need to be in the "patient role" and thus fabricated or deliberately induced medical and psychological illness to get us to see her.

The patient had been seen by the same outpatient psychiatrist for three years and been seen at that office for six years, and the outpatient physicians strongly felt there was a component of a factitious disorder. She had chosen to overdose on caffeine, something that is not very lethal but dangerous enough to get her hospitalized. Her parents were irrationally committed to hospitalizing her at a locked facility. Her borderline personality disorder fed off of attention in the hospital. The psychiatry consult team reviewed notes from past hospitalizations which were all consistent with factitious disorder. They recommended discharging her with close outpatient follow-up to balance feeding her psychological addiction to attention with the possibility of suicide. This was one of my most interesting patients as a medicine sub-i.

Caffeine II

This is a continuation of yesterday's post.

I was a medicine sub-intern, fresh into my fourth year of medical school, about a year out from my psychiatry rotation. I scrambled to recall how to do a psychiatric interview and realized the simplest thing to do was listen.

"I started hearing voices when I was 8," the patient said, "My step-father was drunk and threatening to kill my mother and me, and maybe rape us, and the voices, they told me he was coming. Ever since he moved in, the voices have always been talking to me, warning me and threatening me, and I never feel safe."

"Have you ever been hit or hurt or been forced to have sex?" I asked.

"No, he always got away with it," she replied.

I didn't know what she meant, but she couldn't clarify. She started looking around her, over her shoulder, around the corner. "What's going on?" I asked. She didn't answer, but when I asked if she was hearing voices, she nodded.

This is how our conversation proceeded; in between every few questions, she would look around, eyes wide, hugging her pillow. I learned that she had over a dozen visits to psychiatric emergency services and half a dozen psychiatric diagnoses, from depression to bipolar disorder to schizophrenia. She'd tried too many medications to recall and was taking two antipsychotics. She had been jailed once for threatening to kill her mother and involuntarily detained many times for threatening suicide. She had a special power: she could tell whether someone was good or evil simply by looking at him or her. Surprisingly, her thought process was fairly goal directed and linear. However, she had no insight that she had a psychiatric condition.

She insisted that she only took the pills to quiet the voices; she didn't intend to kill herself. Yet I could not contract her to safety; she would not promise that she wouldn't overdose again when she went home. I called psychiatry consult and though it was nighttime, they were kind enough to come by and do a quick assessment. We got collateral information from the mother who insisted that her daughter was mentally ill, threatening to kill herself and the mother and step-father. She begged us to hospitalize her and then transfer the patient to the inpatient psychiatry ward. The psychiatry consult resident decided to 5150 the patient (involuntarily detain her) for danger to self.

Caffeine I

This is based on a patient I saw back in May. I have been meaning for a while to write this into a short story.

She was inconsolable. Normally, inconsolable is a word we use in pediatrics, a "red flag" to note a child who simply won't stop crying. Inconsolable is a foreboding adjective, triggering a reflex that tells me something's wrong, this child is sick. But instead, this patient was 35, in a gurney in Zone 1 of the emergency department.

She was loud. Huddled in the fetal position, she writhed and cried out, clutching her bald head and convulsing. Nobody paid any attention. Nurses with blood pressure machines walked past, volunteers pushed patients along in wheelchairs, doctors hurried by to write orders. Only medical students, in unease and fear, glanced at her. The atmosphere was palpable.

Her clothing surprised me. She was disheveled, with a large brown stain in her cream colored blouse and a hole at the knees of her jeans, but her shoes were fancy. Black and shiny with two inch heels, they registered as dressy causal. She wore a black leather choker. She held her face in a pillow, wailing.

I introduced myself, and when she didn't hear, I spoke louder. The emergency department rang with rumbling beds and overhead pages and alarms. Finally, I set a hand on her shoulder and she looked up, leaving a damp make-up impression of her face in the pillow. She was on her side, and a pink bucket lay beneath her.

"I took a bunch of pills," she said. "I'm scared I'm going to die."

I wished I could promise her that she wouldn't die.

"It was caffeine. I drove to the store and bought a bottle and swallowed them all."

She told me she had taken about 50 pills of Nodoz, 200 mg of caffeine each. A quick visit to Wikipedia told me this was equivalent to about 40 Starbucks tall coffees. The patient had taken them because of the voices. I clarified. She overdosed because she couldn't take the voices anymore, not because the voices were commanding her to kill herself. This flight of impulse was followed by some nausea, vomiting, and lightheadedness, prompting the patient's mother to call 911.

In the emergency department, they had done the usual work-up for an ingestion. Poison control did not recommend charcoal and there was no antidote. She was started on fluids, her electrolytes were repleted, and she was being monitored for any unusual heart rhythms. But a laboratory test for muscle breakdown - her creatinine kinase - kept rising, and so the emergency department called the medicine service to admit her to the hospital.

Technology and Medicine

Image from xkcd.com, drawn by Randall Munroe, shown under Creative Commons Attribution-NonCommercial 2.5 License.

Revision: Poem of Lies

This week's writing prompt is write a poem with 31 words. This is a revision of one of my older poems. It's really abstract, but I heard a few poems in the Writers' Conference this summer that had a certain riddle-like quality and I wanted to capture that. Unfortunately, the spacing is not what I intended (there's more white space), but here's the text.
-
Poem of Lies

There is always some measure of a lie
in telling the woman I love
she's beautiful
so when I tell you
you're beautiful
I mean really beautiful
you know I mean it.

Clinical Therapeutics

This month I'm taking a lecture-based course called clinical therapeutics. Focusing more on treatment than diagnosis, it covers a wide base of topics from angina to contraception to anesthetics to geriatric pharmacology to pediatric medications to antipsychotics. It's a pretty ambitious task. Each session is accompanied by evidence-based articles and most sessions are case-based seminars. I'm looking forward to this course because much of medicine so far has focused on diagnosis rather than treatment, and before I become a house officer next year, I want to get a better sense of medications. It's also very nice to see classmates again; this is my first non-clinical rotation and though I miss patients, I am able to focus more time on learning. Hopefully this will also be a good time for Step 2 Boards preparation.

Moral Standards

Should doctors be held to a higher moral standard than the general population?

This fascinating ethical question was proposed by an article I read lately about professionalism. Specifically, it commented on medical students posting images online of unprofessional behavior: drinking, partying, dressed inappropriately. While the article didn't outright condemn this behavior, it suggested that physicians and medical students be held to a higher moral standard; although it may be okay for the general population to make public such activities, it is certainly not permissible for a doctor to do so.

Interesting. Why should this be? On the one hand, a person's public and personal lives should remain separate. Perhaps there are some professions in which this is less the case (such as a publicly elected politician) but in general, a physician's life need not be under public scrutiny. As long as what we do at work is appropriate, what we do at home ought not to matter. Furthermore, freedom of speech protects what doctors choose to put online or say in public; it is, if I may use the medical ethics term, a matter of autonomy. Why should a need for a doctor's image to be doctor-ly override his or her personal choices?

On the other hand, doctors have greater moral responsibilities than other people. In many other professions, people act selfishly; they are out to maximize profits and minimize expenses without regard to the customer. In medicine, the physician ought to serve the patient's best interests, not his own. And here lies the rub. There may be some therapeutic motivation for a physician to appear professional even in his personal life. Perhaps we want our doctors to fit a certain mold; we want them to be reading the medical literature or playing golf or attending charity events in their spare time rather than going to salsa clubs, bar-hopping, and throwing costume parties. Maybe. And if this is true, one could argue that professionalism outside one's professional life is crucial to the patient-doctor relationship. This could be a case for holding doctors to higher moral standards even outside the direct purview of medicine.