Book Review: The Mind's I

I finally got around to reading a long-standing book on my shelf: The Mind's I by Hofstadter and Dennett. This is a philosophical collection of essays, short stories, and excerpts to create a journey through fascinating topics in philosophy of mind. It is the kind of book I love given my background in philosophy. I'd been introduced to nearly all the ideas in my undergraduate curriculum, but I found this book a well-crafted, well-designed overview that captures intellectual curiosity without being bogged down in jargon. It's readable, interspersed with commentary and reviews by the authors. The book contemplates problems like the mind/body dilemma (what is mind, what is body, and how are they related?), artificial intelligence (can computers really think and what would that mean?), personal identity (what makes me me?), consciousness (what does it mean to think and to be self-aware?), and other philosophical conundrums. It's a little dense for the layperson but challenges us to consider ideas I think are central to our being human that we do not otherwise ponder.

Image shown under Fair Use, from goodreads.com.

Introduction to Open Heart Surgery

One of the benefits of the echocardiography rotation is that I get to see cardiac anesthesia and surgery without the stress of having to do it. Since I'm an extra hand, I can take time getting echo images, following the surgery, and helping out with the anesthesia. This is great for me because the set-up for anesthesia is more complicated and involved than any surgeries I've done this far. There are more medications, drips, machines, and monitors to prepare. The start of the case has a series of steps to get adequate intravenous and arterial access. By helping out, I get exposed to the pace and general steps leading up to and including the surgery. I get to think of cardiovascular physiology and pathology in a safe context, watch the surgeons sawing the sternum and preparing the heart for bypass, and see the coordination in putting the patient on bypass. Hopefully when my cardiac rotation comes around in a few weeks, I'll be ready.

Images shown under Fair Use, from www.stanford.edu.

Airport

There is often a comparison between the airline industry and the operating room environment in terms of culture of safety, teamwork required, and process management. As I find myself making this analogy for patients in the pre-operative area, I realize it's more and more apt. There's a certain behind-the-scenes mayhem that occurs daily in airports and operating rooms. There is a rush to get all the surgeries going and all the planes into the air, often around the same time. If one case or flight gets delayed, it affects the subsequent schedules. Each instance involves more than the pilot and passenger or surgeon and patient; the right equipment and staff need to be available. Length of flight or duration of procedure is important as well as destination; if a plane bound for San Francisco takes off, there had better be a gate available on the other end, and in the same way, if a surgery starts, there needs to be an appropriate bed available for the patient post-operatively. I suppose big service industries based on throughput must have similar structures.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Assignments

Unlike medical school, residency has a paucity of assignments. We no longer have tests or projects or presentations; our evaluations are based primarily on our clinical performance. Yet in medical school, I became accustomed to doing a presentation every few weeks, studying for an exam every other month. Now when I am asked to do a journal club presentation or put together a short powerpoint, I find it so onerous. It's not that I don't want to learn, but that my priorities have shifted, and I don't expect to or want to spend so much time on something like this. I hope this changes, as I don't like this about myself. I should be happy to learn more outside the hospital and share it with my co-residents.

Perception

It is very easy for physicians to dismiss things like "the common cold." Symptomatic treatment, rest, hydration; "it's nothing severe," we say. But now that I am suffering from a stuffy nose, rhinorrhea, cough, and sneezing, I have to say that no matter how insignificant we consider rhinovirus, it is an eminently persistent nuisance. I will have to keep this in mind the next time I see a patient with something I think is unimportant but is causing the patient, his family, his work a great deal of grief.

I am a Giant Fomite

A fomite is the medical term we use for something (usually inanimate) that can transmit infectious organisms; often, neckties, white coats, and stethoscopes are blamed for being fomites. Unfortunately, I've come down with the common cold, but in circumstances like this, it strikes me as strange that doctors are so unwilling to call in sick. We see illness all the time, work with immunocompromised patients, understand the epidemiology of infectious disease, and yet we are reluctant to take care of ourselves when we are struck by the same illnesses. At least I'm on a rotation without direct patient care; on my echocardiography rotation, I don't put patients at too much risk and I can take shorter days when I need it.

But this is a culture that we need to change. Sick people (at least with transmissible diseases) in the hospital should be patients, not providers, especially when most infectious. The system needs to have resources in place such that residents feel that we can take time off without putting too much burden on others.

Length of Training II

The premedical curriculum ought to be changed. The courses required are so extensive and onerous that it locks in biology majors and dissuades humanities majors, a composition of applicants which might not be ideal. Although medical students need to have some grounding in basic science principles, it always seemed excessive to me that the premed curriculum requires two years of chemistry, a year of biology, and a year of physics. Although there are pockets of medicine in which we do use a microscope or consider chemical structures or apply fluid dynamics, these are not requirements of being a good physician. Indeed, the basic sciences taught to undergrads are designed to train those who will go into academic, research, or industry careers, not those who will end up as doctors. I would advocate minimizing undergraduate requirements because I found that I learned and enjoyed my non-science courses the most. This would also allow premeds to graduate sooner if desired and reduce overall debt burden.

Similar ideas translate to the basic science years of medical school; there's a lot to learn, but the key is to train students to think critically and study independently, not to teach them everything in the textbook. Medical knowledge is changing so rapidly that it only makes sense to teach young physicians to teach themselves. However, I would not curtail the clinical years; unlike everything else so far, stepping into the hospital, learning a new environment, and seeing the practice of medicine - that's crucial for training. Even with two clinical years in medical school, there are facets of medicine I have not seen. As for the length of residency, I don't know the optimal timing, but I don't think research should be required. Residency should be designed to teach clinical competence but not force everyone down a track of academic leadership. Those who want it should have the opportunity to pursue it. It would be ideal to eliminate wasted time for trainees, but we don't want to streamline the process so much that trainees don't get to pursue their own interests and develop their own expertises.

Length of Training I

In a recent article in the Journal of the American Medical Association, there was a proposal about shortening the time of medical training. The argument for these changes is that excessive training creates waste; it is costly to society, hospitals, as well as the trainees themselves. Furthermore, with an anticipated shortage of providers, changing the length of training could help with skewed supply-demand problems. The paper cites programs in which training is shortened; indeed, there are combined undergraduate-medical school programs (and the British system) which curtails the undergraduate years. University of Pennsylvania medical school and Duke medical school shorten the traditional 2-year basic science curriculum to 1.5 and even 1 year in length. Harvard medical school shortens its required clinical clerkship months. All of these programs produce outstanding residents. Even in residency, the author contends that residents in specialties like internal medicine, family medicine, and pediatrics are ready for independent practice after two years of training rather than three. The author argues that surgical residents should not be required to do research. Overall, they felt that training could be reduced by 30%.

I think that shortening the time to produce physicians is a worthy task so long as it does not compromise newly trained physicians. As residents, we do feel that the bulk of our 20s and early 30s - the time that others dedicate to burgeoning careers, new families, and solidification of identity - is unfairly absorbed by medical training. A lot of what we learn and do does not directly apply to our ultimate practice of medicine. But I'm not sure we can really reduce medical training all that much. I'll try to outline some of my thoughts in the next few posts.

3D Visualization

One of the challenges of echocardiography is the visualization of a three dimensional structure with a two dimensional imaging modality. The heart, its valves, chambers, and great vessels sit on a tilted axis within the chest, rotated, and asymmetric. Furthermore, with transesophageal echocardiography, the probe is within the patient's esophagus or stomach, forcing the clinician to picture in the mind's eye the location and rotation of the ultrasound beam.

I was never very good with 3 dimensional visualization and construction. When I was little, I liked abstract math and numbers, not geometry. My toothpick-and-marshmallow bridges wobbled, and I never tried building a house of cards. So this is tough for me. But with online applications that allow the viewer to rotate models of the heart, apply labels, and take cross-sections, I'm slowly wrapping my head around everything.

Image is in the public domain, from Wikipedia.

Echocardiography

I am now on a short echocardiography rotation. Echocardiography is a burgeoning tool that uses ultrasound to look at the heart. Transthoracic echocardiograms are commonly done in general medicine; a sonographer applies the probe to the chest to look at the heart's chambers, valves, and other parameters. This can guide diagnosis and therapy by helping the clinician understand how well the heart is squeezing, look for past heart attacks, measure pressures in the lungs, and grade the severity of diseased valves.

Transesophageal echocardiography uses the same modality but in a different manner. The ultrasound probe is placed into the esophagus in a sedated patient, and this allows the clinician to look at the heart from behind. It is better at assessing certain disease states like infected valves or clots in the atria, but it can also be used by an anesthesiologist during a surgery.

I am currently on a rotation designed to teach anesthesia residents how to place the probe, obtain basic views, and interpret them to guide our intraoperative management. I tag along in all the cardiac rooms where transesophageal echocardiography is a staple. I've seen lots of fascinating pathology: a valve the surgeon wants to replace, a bypass for a poorly functioning heart, a tumor in the atrium. Videos, a simulator, and a textbook round out my learning. It's a really fun, useful, and interesting experience.

Image of echocardiographic image is in the public domain, from Wikipedia.

Anatomy

Andreas Vesalius was a Flemish physician and anatomist who wrote De humani corporis fabrica. Anatomy is one of the first subjects any medical student takes, the first time we really examine the human body, our first encounter with death. Many of us forget the details learned in the long quiet hours of the anatomy lab, and indeed, I thought I was finished until this year. Anesthesia, it turns out, requires a fairly thorough knowledge of human anatomy, from the vasculature of the extremities to the division of pulmonary lobes to congenital anomalies. But this time, I open my anatomy book with a little more focus, direction, and interest.

Image is in the public domain, from http://special.lib.gla.ac.uk.

The Match

I want to wish a wholehearted congratulations to all my friends who matched! The Match, of course, is the ever-confusing, always-stressful enigma that determines where every medical student is going to do residency. Well done to my friends for finishing medical school and uncovering the next stage of their academic lives. And congratulations to all the people who matched to Stanford for anesthesia; I look forward to meeting and working with you!

Opinions on Medicine

It's fun and fascinating to read different viewpoints and opinions on medicine; I scroll through most news items on topics related to medicine, I glance through blogs written by physicians, and most recently, I'm looking at a few chapters of a book proposal. The diversity of things people write about and the opinions expressed is really amazing. Some articles provoke a vein of indignation, some articles express ideas I've already blogged about, some articles I can't understand. Frequently, I look at the same evidence as the writer but come up with very different conclusions. I balance what I read with my personal experience in medicine, but what scares me is that the layperson does not have that ballast. What if the public latches onto some extreme view of medicine? What if the opinion expressed is one-sided? What if it's a straw-man argument?

I write this simply because this blog, like everything else, is only a lens through which I capture bits and pieces of my life as a resident. I may be completely wrong, biased, or skewed. So take what I say with a grain of salt, and feel free to comment on any post with your thoughts.

Weekends

Weekend efficiency is really quite disappointing. I've written about the drive for efficiency and improved turnovers during the normal workweek, but none of this applies on the weekend. Part of it is due to cases being add-ons. They may not have had adequate pre-operative workup and planning. The anesthesia team needs to get to know the patient. There are only one or two rooms running so if there are multiple cases, we need to triage the order. But I wish things moved faster. Working on one weekend, I realized that there was a shortage of transport staff so it was faster for me to get the patient and bring them up myself; on a normal weekday, we expect patients to be readied before the prior case finishes. On one of the cases, there was no request for neurologic monitoring even though this was recommended by neurosurgery consultants days before; we had to call in our neuromonitoring technician, wasting half a morning. It took a lot longer to get equipment prepared and turnover operating rooms. And I understand all this; we're running at a much reduced staff. But it still frustrated me that a set of cases that should have been finished in half a day kept me up until midnight.

The Long Case

One day as a "late call" resident staying until midnight, I got assigned to the longest case I've had so far. A patient with BRCA positive breast cancer was scheduled for bilateral mastectomies, a salpingo-oopherectomy, and breast reconstruction with abdominal tissue flaps. The anesthesia was unremarkable, but the surgery was interesting. The gynecologists started by removing the uterus and ovaries (due to the increased future risk of cancer). Then, two simultaneous surgical and nursing teams started. Above the arms (which were out by the patient's side), the surgical oncologists were removing the breasts (first the healthy one, then the diseased one to avoid contamination). Below the arms, the plastic surgeons were dissecting out the abdominal tissues with which they would reconstruct the breast. There were two scrub nurses and two circulating nurses as well. After several hours, the breast surgeons had finished and the pathologist confirmed negative cancer at the margins. Then the plastic surgeons got to work. The length of the surgery was really a result of the microdissection required; the plastic surgeons had to hook up the tiny arteries and veins from the abdominal tissue graft to the ones in the chest wall. Then they had to optimize symmetry and appearance. The procedure took a total of around 16 hours from start to finish. The anesthetic challenges for this sort of case include fluid management and positioning. The incalculable fluid losses from an open surgery of this length are considerable, yet too much fluid can cause tissue swelling that will impede the plastic surgeons. And for positioning, anyone leaning on a cord or having a joint at an odd angle for 16 hours will wake up uncomfortably. Luckily, the patient did well.

Test

Anesthesiology for exams is quite different than anesthesiology for everyday cases. On the day-to-day basis, most cases proceed smoothly, as expected, routinely. On tests, every case probes a specific disease, disorder, malfunction, injury, complication, calculation, etc. In real life, patients have common medical problems: hypertension, diabetes, arthritis, coronary artery disease. On tests, there is a preponderance of systemic lupus erythematosus, anticardiolipin antibody, diabetic ketoacidosis, and tracheo-esophageal fistulas. Each day in the OR, I concentrate on practical issues: improving turnaround time, preparing following cases, getting my lines untangled. Tests address none of these but instead ask mechanisms of action of drugs, interpretation of statistical calculations, and obscure medications we no longer use.

In taking our yearly in-training exam, I realized anesthesiologists have to know other fields of medicine pretty well: I have to be able to calculate GCS in trauma, Apgar scores in newborns, and Child-Pugh classes in cirrhotics. I have to understand the process of labor and complications of delivery, changes in physiology after gastric bypass, vital signs of small children, anatomy of nerve plexi, interactions of psychiatric medications with anesthetics, ventilator settings in the ICU. This is really hard; some of these subjects I haven't contemplated in over a year. But even more than just medicine, we also have to know physics, engineering, biochemistry, pharmacology, statistics, and ethics.

Taking the test is a humbling experience and reminds me that though I may feel comfortable managing the anesthetic for a straightforward simple case, I have a great deal more to learn to fully master anesthesia.

Spring Break

I'm going to take a week-long break from the blog. We have our in-training exam coming up, a yearly half-day written test to make sure we're keeping up with our studying. I'll be back next weekend.

Pain and Anesthesia II

Some of the hardest patients to anesthetize for surgery are those with chronic pain. Similar to the patients I saw on my acute pain rotation, these patients take a whopping amount of opiates, and their bodies are tolerant and resistant to them. And yet, as anesthesiologists, we are asked to ready these patients for a surgery where skin, muscle, tissues, and bones are cut and rearranged, and then to wake them up afterwards with minimal discomfort. This is a challenging if not impossible situation.

I had a patient who was taking handfuls of Vicodin a day and needed a hip replacement. He refused a spinal or epidural, but we tried our best to use as many pain adjuncts as we could. We gave large amounts of opiates: 500mcg of fentanyl, 4mg of hydromorphone. We used ketamine as an adjunct. We ran the patient on a lidocaine drip during the surgery. We avoided acetaminophen given the amount of Vicodin he was taking preoperatively. With all of this, we achieved a satisfactory and yet suboptimal post-operative status. The patient was sleepy and snoring - side effects from all the pain medicines. Yet when you woke him to examine his hip and leg, he was in excruciating pain. When you left, he went back to snoring. Sometimes this behavior is interpreted as patients seeking pain medicines, but its not the case. As patients take more and more opiates, the therapeutic window - that is, the sweet spot where they get analgesia but don't have overwhelming side effects - gets smaller and smaller. Sometimes it disappears so that the patient is either "snowed" (sedated, asleep from the opiates) or in severe pain. It's a challenge, but we do as much as we can to tide patients through comfortably and safely.

Pain and Anesthesia I

Astute medical students sometimes ask: why does the anesthetized patient need pain medications? After all, under general anesthesia, patients aren't conscious, they aren't aware, they shouldn't be feeling any pain, they shouldn't remember the surgery. It's an interesting question, and I'm not sure I have a fully satisfactory answer. Most of our anesthetics don't provide analgesia; that is, they don't quell that unpleasant sensation of hurt we feel when we are cut. They simply make it so patients aren't aware of what they're feeling, if that makes any sense.

And patients under anesthesia do respond to noxious stimuli (our euphemism for pain). An unconscious patient may breathe faster, increase their blood pressure, and have a higher heart rate on incision. Although the brain is blissfully unaware, the rest of the body reacts, and stress hormones pour out, perhaps at higher quantities since the patient cannot react. We often use these measures as indicators of how much pain a patient experiences and how much analgesia they may need. Working in pain medications protects the other organs by alleviating the stress response of surgery and allows for a smoother wake-up at the end of the case as we know how much the patient needs.

All of this is fascinating to me; it seems to suggest that pain is not solely a subjective experience because even if you take away that experiential aspect, we think patients have pain. Are there objective ways to measure it? Why is our understanding of this phenomenon so limited?