Adherence

Medical adherence or compliance (the less PC but more commonly used term) is the concept that patients don't follow through in filling prescriptions and taking their medications as recommended by the physician. When I first thought about this, I thought, "Who would ever do that?" After all, many drugs have double blind random controlled trials showing their effectiveness in reducing mortality and morbidity. After memorizing the pharmacokinetics and mechanisms of action and indications of each drug, I thought, "That's all I need to know." You figure out what the patient has, you prescribe the treatment, and you're done.

I have realized it's not all that easy. After being sick for the past few days, I realize that no one wants to take drugs. There are lots of reasons, most I probably haven't even fathomed. However, I didn't want to medicate (even just over-the-counter) for several reasons. It's an admission that you're sick. It's inconvenient. There are side-effects. Now, I know I will be fine whether or not I take NSAIDs. And I would assume that if I had something life threatening that could be cured with medication, then I would comply. But I can already see that it is not as easy as I originally assumed.

Drug Delivering Robots

I have to say one of the coolest experiences in Clinical Interlude was going down to the pharmacy in the basement. We got a tour by one of the managers who described the process of filling a prescription. In Moffitt, drugs are delivered by these cool air tubes. But in Long, drugs are delivered by R2D2-like robots. These robots are fairly big, with speakers, a monitor, and motion sensors. They can even sense when you are nearby, and they will talk to you. In the basement, pharmacists will load up the robots with drugs and give them instructions. Then the robots move about the hospital completely autonomously. They will locate the elevators and command down an elevator. (Since I have been asked this by multiple people, they control the elevators through some sort of electromagnetic frequency, not by actually pushing the buttons). Then they will navigate into the elevator and tell all humans to exit. They go to the correct floor and dispense the drugs for that floor at the nurse's station. It's really nifty.

Clinical Interlude II

I found that the team was structured to teach the least experienced. When a question came up, the medical student first described what she knew. Then the intern would add or embellish the answer. The attending or resident would only step in if necessary to revise the answer (or to throw in a completely random trivia fact: guttae in Latin means drops, so sometimes prescriptions have the abbreviation gtt).

The pace was fast and busy. On the first day, our team was on call and received an admission during morning rounds. The third year and an intern rushed down to the ED to admit her while the rest of us rounded on the other patients. During rounds, pagers would go off, people would make phone calls, and others would hunt down a computer to show an X-ray. Sometimes, less than half the team was paying attention to the person presenting the patient. Of course, everyone on the team was already familiar with the patient, so I was not alarmed.

The culture of medicine struck me as highly intellectual. While surgeons and anesthesiologists seem to favor procedures, the medicine service enjoys standing around and figuring out odd cases through discussion. Being able to do an effective differential and explain it was very important. The chief residents stood out during the noon conferences because they clearly knew the most. It was important to some members of the team to be able to pull out an article from JAMA or cite relevant clinical research.

Clinical Interlude I

Clinical Interlude is a nifty three-day event that happens right before winter break. In order to introduce us to hospital in-patient medicine, the school assigns the first-year students to different ward teams at UCSF affiliated hospitals. This allows us to gain a context for the material we're learning in the classroom. We also get to practice our patient-doctor skills by taking a medical history and doing a physical examination on a patient. We observe team dynamics within the hospital and interact with non-physician members of the health care team. Perhaps most importantly, we acquire some stories about being in a hospital to bring home to our families for winter break.

I was assigned to Med Team G at Moffitt (the main UCSF teaching hospital). Other students were assigned to disciplines as diverse as emergency medicine and psychiatry to neonatal ICU and labor and delivery. I loved being on the medicine team. It was a lot of fun, and I did not feel completely bewildered. I tagged along with a third-year student who was great.

I was most surprised by how easily I was integrated into the team. I felt that I was considered a member, if only for a short while, rather than an outsider observing the dynamics of the medicine service. For example, I was encouraged and perhaps even expected to contribute to the intellectual discussion of the issues facing our patients. This was a lot less intimidating than I expected. I didn’t feel bad or ashamed to say I did not know anything about the subject. The team was delighted when I would say something, and then they would politely correct whatever egregious mistake I had just made.

Happy Holidays

Warm wishes to everyone for a lovely holiday season.

Clinical Ethics

You are a transplant surgeon faced with an ethical dilemma. There is a 16-year-old child in kidney failure who needs a kidney transplant. The mother asks you to take a kidney from the father and give it to the daughter. However, the father has already donated a kidney to the daughter before (and after many years, that kidney was rejected). Taking the second one would require him to go onto dialysis and severely decrease his life expectancy. He is in jail, and the jail agrees to pay for medical expenses. The father, who is divorced from the mother, consents to the procedure, saying that he is willing to sacrifice years from his life in order to improve his daughter's quality of life. It is important to note the daughter will not live substantially longer with the kidney transplant, but she will have a much better lifestyle.

The principle of autonomy grants patients the right to make decisions (even bad ones) about their health care. The principle of beneficence compels physicians to act in their patient's best interests. Yet the principle of non-maleficence says to "do no harm." (One should point out that nearly all procedures do harm, but we weigh the benefits with the costs. A blood draw harms the patient by causing pain, breaking the skin, etc., but benefits outweigh the costs).

What do you do? The mother and the father both consented to the procedure (and the daughter assented). You want to act in the patient's best interest and do no (unjustifiable) harm. Yet who is the patient? In a transplant, both the father and the daughter are patients. You would be taking years from the father to improve the quality of life for the daughter. Is that morally praiseworthy or blameworthy?

It's a complex case, further complicated by biological reasons (if the daughter rejected the first kidney, wouldn't she reject the second?). No surgeon would actually take this case. Luckily, this is based on a true story; a relative was found to be a match and underwent the kidney transplant without complication.

"If the father wants to run into a burning building to save his daughter, he can do so, but I cannot hold the door open for him."

Patient Simulator

At the end of the cardiovascular block, we had a session with a patient simulator at San Francisco General Hospital (SFGH). The patient simulator is a "souped-up" CPR dummy. It can breathe, has pulses, has pupils that react, and talks. You can listen to heart and breath sounds and do a fairly comprehensive physical exam. They put us in groups of seven as a team to treat the patient.

I was one of two history takers. It was a little nerve-racking. Something was definitely wrong with the patient. He was very light headed, had a pulse of 120, and a blood pressure of 60/40. It was hard to concentrate on which questions were pertinent - clearly, we would not care about where he lived ("social history"), but we might care about whether he had shortness of breath. My peers did a physical exam, set up an EKG, and got the vitals on the monitor. One first-year was the fake resident who supervised us.

We took a quick time-out to discuss a differential for the patient. We came up with a plan of diagnostics and treatment, and began to administer the plan. Afterwards, we gathered in a conference room where a fourth year explained the pathophysiology of the condition. It was highly educational. In a real situation, would we have been as successful? I don't know. Though we pretended the mannequin was a real person, it's hard to picture what we would do if a real person was dying on us.

Denying Medical Care

What do you do with a patient who does not want medical care? On the one hand, he/she (as long as he is older than 18) is in control of his body. He can sign out "AMA" (against medical advice), which means that you covered your legal grounds by telling him what you suggest as a doctor, but he declines following that advice. Jehovah's witnesses are free to refuse blood and blood products, and then you do the best you can with things they might accept like saline or erythropoietin (EPO). In these situations, the patient decides what kind of care he would like.
But on the other hand, a physician can detain a person seriously contemplating suicide. We won't let him kill himself. He does not have control over his body. And if we aren't sure whether someone wants medical care, we treat him as aggressively as possible, assuming that's what's in his best interests.

Clearly, this post brings up many emotion-laden and difficult issues. Are there cases when not-treating is better than treating? How do we approach those cases? Where are demarcations to be drawn?

EMTALA

EMTALA was an act passed by Congress in 1986 which requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status, and ability to pay. This was created in response to concern that emergency departments were turning away patients because they could not pay. So now all emergency departments are required to do a basic screen of anyone who walks into the ER. In principle, this sounds like a wonderful thing. Everyone should get medical attention, especially for illnesses that can be life-threatening.

Unfortunately, this is an unfunded mandate; there are no reimbursements. As more and more people take advantage of this act (by coming into the ER without any particular problems or with minor symptoms), hospitals have sustained increasing financial costs to the point that they have to shut down their emergency departments. Waits have greatly increased in length, jeopardizing those who do have medical problems. Those without health insurance turn to the emergency department as their primary care because they cannot get health care elsewhere; however, the ER is not a primary care facility. In practice, EMTALA seems to have hurt emergency departments as well as patients requiring those services.

It's a hard line to walk. You can't deny a basic screen for someone who may have a life-threatening illness. After all, that's what emergency departments are for. However, when people start misusing such resources and when such a mandate is unfunded, it creates an incredible strain on resources to the point that the hospitals have to close their ER. I am unsure whether there is a good solution for this problem, but it is certainly something that we should be aware of.

Asymmetry

A patient has the right to choose the kind of doctor he or she sees. That is, a woman can ask for a female (or male) gynecologist. For cultural reasons, a patient may request to be seen by a doctor of a particular ethnicity. That makes sense. A patient's body, health, and illness are incredibly private things, and they should have some control over who sees them.

On the other hand, a doctor cannot refuse to see a particular kind of patient. We cannot limit our practices to a particular religion or gender or race. That makes sense too. Discriminating based on such divisions would be highly unethical. Everyone deserves medical attention and care regardless of their demographic labels.

Both of these arguments seem sound and nearly incontrovertible. Yet they create this dynamic of asymmetry which is very interesting to me. Can we find some philosophic justification of first principles for this? That is, can both these ideas in medical care be derived from one higher level principle? I haven't put too much thought into this, but it is certainly worth contemplating.

Opthalmology

For my opthalmology elective, we finished with a dissection and practicum session. It was a lot of fun. We dissected sheep's eyes, going through the motions of taking out the lens in the fashion of old cataracts procedures. It was the first time I'd ever done microdissection. The tools were really nifty. The microscope was controlled by foot levers, allowing you to move it around, focus, and zoom. We used actual surgical tools which were highly complicated. I don't think I'm particularly proficient. It took a while to get a feel for the tools and the movements necessary to make incisions or extract a lens. The professor and a resident were both incredibly helpful and encouraging. We then sutured up the incision, which was definitely the hardest part of the procedure. Everything was so small it was difficult getting the sutures through the tissues and pulling the thread through. All in all, I learned a lot. I didn't realize I'd like microsurgery so much, though I am painfully aware of how lacking I am in skill.

For the practicum, we learned to use our opthalmoscopes to visualize the retina and the slit lamps. It was tough. It was the first time the first years had ever picked up an opthalmoscope, so we really didn't know what we were doing. But with some eye dilation and trial and error, we managed to learn a little about the equipment used in the eye exam.

PBL

Over the last two weeks, we worked on a problem based case in FPC small groups. It began with a standardized patient who came in to talk about a family member's medical problem. I was the interviewer for that week. I won't actually go into any detail about the case since it's probably going to be used in future years (and we are supposed to treat it as if it were a real patient, preserving confidentiality). However, the interview was interesting for several reasons. I was talking to someone about her family member, rather than to the person himself. I had to break bad news. And the patient reacted very emotionally and was not happy. It was difficult, but I enjoyed it greatly. It was an incredibly fun and educational experience. When I was talking to the standardized patient, I really got absorbed in obtaining a good medical history; I forgot we were in our classrooms with my peers and small group facilitators. It was just me and the person I was building rapport with.

The case unfolded over the next week. In these cases, we get information about the present illness, physical findings, family history, etc. We begin to form our differential of what's going on and also discuss labs and diagnostic tests. At the end of the session, we each decide on a learning issue to research for the next week.

On the last FPC PBL, like many others, I wikipedia'd my answer. However, we had a special library session to learn to use the resources available here. I was very apprehensive at first. Not only was it a Friday afternoon, but it was about things like PubMed. Even if you hadn't used PubMed, it's easy to figure out (especially for this generation of medical students, though I will say that PubMed doesn't have the best user interface). But I actually enjoyed the session a lot. There are a good deal of other resources available through the university. Many medical texts and references can be accessed, and these will become essential throughout my training here.

In the end, we came back and solved the case. It was fascinating. While a curriculum based strictly on cases may easily leave stuff out, I feel that a curriculum without PBL lacks a connection between lectures and what a doctor actually does. Here, they equip us with many skills. We learn to work as a team, to learn from and teach each other, to answer questions ourselves, and to think independently as well as with others.

Yet Another Exam

The dearth of blogs recently can be attributed to yet another exam. Exams, unfortunately, will become a routine part of my life. While UCSF has fewer exams than many other schools, they continue on through our clinical years, through boards, and then through recertification during our careers. I am unsure how good tests are at estimating one's aptitude for medicine. Clearly, some form of standardized evaluation is warranted. However, through many, many years of test-taking, I have realized that learning to take a test is as important as knowing the answers. Raised in an exam-taking culture, you sort of realize what kinds of questions are likely to come up, what kinds of traps are usually set, and what kinds of answers will satisfy the reader. Since all we have to do is pass with a 70%, by now most students have found a good balance to our studying. I think many of us found preparing for this test to be a lot less stressful than preparing for our first one. Rest assured, we will learn everything we need to become good doctors.

A Zero Sum Game

Knowing nothing about economics, I can't say whether "zero-sum game" is technically the right phrase here. What I mean is that nearly everything done in medicine comes with a cost. In studying for my exam tomorrow, I'm looking at laboratory medicine where "shotgun screening" is not encouraged. You can't just order all the tests for every patient and see what happens. Each test is a drain on resources: money, time, reagents. Tests should only be ordered if they will change the diagnosis or alter patient care. It's easy enough to do a blood draw and send it in for "the works," but is that really cost-efficient? Is it really the best thing to do for your patient and for health care in general? Furthermore, even if all tests are 95% accurate, if you order 20 tests, one of them will come back a false positive or a false negative. I guess I wanted to point out that you can't order all the labs "just because." You have to use medical acumen to determine which tests are useful. I think many times, we automatically overestimate what we need to cover our bases, and this is not a good use of resources.

Big Pharma

Drug development is a complicated, expensive, resource-intensive process. Though pharmaceutical companies invest about a billion dollars for a single new drug (Wikipedia), the pay-off is worth it. Drugs like Lipitor (atorvastatin) and Plavix (clopidogrel) have made many billions of dollars in global sales (12.9 billion for Lipitor). However, the patent on these drugs start ticking once they are discovered, and after patents expire, cheaper (equally effective) generic drugs are allowed.

To delay the flood of generic drugs lowering the market price of the moneymakers, big pharma has entered into agreements in which they pay generic drug makers to drop challenges to patents. By offering generic drug companies perhaps a hundred million dollars, they can keep generic versions of their blockbusters off the market, effectively extending their patent by several years. In the end, the cost is transferred to the consumers. The FTC has tried to block such agreements, but last year, it was ruled that the FTC was beyond its jurisdiction.

While I cannot say legally what ought to be the case, I think this is a very interesting question and brings up one side of pharmaceutical companies that I had not considered before.

Lesson

This is a poem I wrote and submitted to the online Tabula website, part of Synapse (the school newspaper).

Lesson
By Craig Chen

To read the EKG, you have to examine
the ST elevation – that means there's an MI.
With acronyms, you can convince anyone
you know what you’re talking about, even me.

The nurses here wear make-up,
and all the doctors are available.
When patients seize, swimming up from their beds,
you wonder if they, too, have a crush on the intern.

We learn medicine from our couch
paying TIVO tuition, watching thrice married
surgeons save their ex-wife's ex-husband in time
for Southpark, another Great American Show, at 10.

You never miss an episode; in fact,
I know about the notebook with the love letters
to Dr. Cameron, jotted with suture-supple
hands, starving for validation.

You can do this, you think, as the patient
waits patiently on the screen. The only
motion in the room: the buzzing of the lights,
the sterile surfaces staring back.

How to be a Doctor

You don't have to be a genius to be a doctor. That sometimes surprises people. True, we are in school for forever. There's a lot of material to learn. Most of us are pushed to our limits in mastering all the information. You have to be not only a jack of all trades, but also a master of some. There are so many disciplines that one cannot find them all easy. But despite that, you don't have to be brilliant. Many of my classmates are, but I also have peers here whose strengths lie elsewhere: in leadership, dedication to service, the compassion necessary for a patient-doctor relationship. Doctors need to have many different skills, talents, and abilities; in some cases, photographic memory and amazing critical thinking are not the most important of these. The more I think about it, medical school is not difficult in that there aren't any concepts I'm afraid I won't get. Instead, it's the volume of information that pushes my mental organizational skills.

Shadows

After my midterm, I arranged an anesthesiology shadowing experience in the operating rooms here at Moffitt-Long Hospital. It was a great experience. The ORs here have really amazing and high-tech equipment. I saw one of the great GI surgeons Dr. Way do a laparoscopic surgery. It was impressive. With a few small incisions, the doctors inserted a camera and several tools into the patient. Guided by several screens, he pulled out part of the intestine that had herniated into the chest cavity. It reminded me a lot of video games with the sophisticated controls, the video screens, and the equipment as he used heat cauterization to prevent bleeding.

The anesthesia side was just as impressive. The anesthesiologist explained a lot of the equipment they use in the OR. I got to see many of the different physiological monitors and drugs available. He explained what anesthesiologists do to prep the patients for surgery. Anesthesiologists worry about the big picture while surgeons do their thing. They play a vital role in resuscitating patients in the case that something goes wrong. All in all, I think the OR is not a bad place to be. The complexity of procedures and cases there along with the sophistication of tools makes it quite an alluring place.