!

I'm not sure, but I think I may have just seen Oregon's first confirmed case of H1N1.

Finally, something applicable in class...

...as opposed to the differential for green urine, for crying out loud.

If you're really old, you might remember Marcus Welby, the old-timey father-knows-best kinda doc who you'd trust with your cold-war era life. That's very different from TV doctors today, and frankly, it's different from real doctors.

It's hard to append a date to the demise of what became known as “paternalistic medicine,” but we can be sure that it ushered in a change in the patient physician relationship. The common indicators are well known – in 1953, 69% of physicians reported not informing patients of a cancer diagnosis (Fitts & Ravdin, 1953). By 1979, that number had fallen to 3% (Novack, et al., 1979). Similar numbers apply to physician attitudes toward compliance and legal developments delineating informed consent.

We recently read a case (described in Carrese, J.A. Refusal of care: patients’ well-being and physicians’ ethical obligations. JAMA. 2006; 296:691-695) which detailed the ethical dilemma faced by a patient and her multidisciplinary care team. As the term implies, a dilemma literally denotes a “double proposition,” and the two faced by the team are unfortunately mutually exclusive:

1.     A physician has an obligation to protect a patient from harm.

2.     A physician has an obligation to respect a patient’s wishes (when competent).

The article is all very fancy and technical, so here's the Cliff's Notes: In this case, the patient is a competent (28/30 MMSE, about the same as you or me) elderly woman who seeks to be discharged to her home with a condition that will almost certainly become more complicated in that setting. The alternative involves discharge to a skilled nursing facility, sort of a extra-medical retirement home, where her condition can be monitored more closely. The care team eventually convinced the patient to relocate to a long-term nursing facility by suggesting that “her care was not complete and that she needed continued treatment in an institutionalized setting.” The institution’s ethics committee supported this decision.

The case described in the present article reminds me of one I encountered at with my preceptor (I changed a few details to keep it legit). The patient, an otherwise healthy elderly gentleman, only one day into a new anti-epileptic medication had developed profound mood swings and massively inappropriate behavior (including the, um, propositioning of every person he encountered, regardless of age or sex). However, these episodes were punctuated by long periods of relative normalcy. It was during one of these normal periods that the patient was brought to our clinic by his daughter, who was his temporary caretaker.

It was clear to us that this patient would have to discontinue his medication, but the severity of his epilepsy was so great that such action would risk a pretty serious seizure. The patient, who was completely mentally competent (29/30 MMSE), did not wish to discontinue the medication for fear of complications. He expressed that his mood “was simply a matter of adjustment,” and would subside. His daughter worried that his behavior was disrupting her household.

While this isn’t a dilemma in the strictest sense, conflicting obligations were at play. We had to balance the needs of two patients, both of which were in opposition. Furthermore, we had a duty to the emotional health of the patient and his family. Ultimately, we decided to switch the patient’s medication and suggest that he consider an inpatient psychiatry service during the transition. “The job we’re doing in treating your epilepsy,” my attending argued, “isn’t finished.” This line of reasoning seemed strangely familiar in the context of the Carrese article.

At its core, ethics is an attempt to define “the good.” Physicians established that full disclosure and truthful reporting is “good.” Thus it may be that the course of action taken by this care team or my preceptor was not ethical. I find it misleading to suggest that a patient’s “care is not complete,” as it may be interpreted as acute care for the present illness as opposed to long-term care for the patient. That distinction was not made, and to argue that there is no difference is to say that no patient’s care is ever “complete.”

On the other hand, both patients probably underwent the course better suited to the preservation of their health (despite themselves). In a utilitarian context, then the “good” course of action was taken, in the sense that the ends justified the means. Whether physicians should value Socrates more than Bentham is a topic beyond the scope of my small-town degree, but it does throw into question the ability of any physician in any context to truly provide what we know as informed consent.

The scenario of a subspecialist physician patient (like a cardiologist) receiving care with which he or she is familiar (such as a CABG) is exceedingly rare, but may be the only example of truly informed consent. So basically, we have to strive to present a case for or against therapy as journalistically as possible. Then again, when the journalist is also the headliner, there's a conflict of interest. Similarly, how can a physician who already possesses a medical opinion truly present an objective case? Or is a biased presentation the correct one – after all, it's no more appropriate for a physician to argue for outdated therapies than it is for a journalist to argue for outdated moral codes.

I'm rambling (which I'm allowed to do, so shove it), but I think I just made an argument for WebMD. Oops.

The z-pack: a lesson in humility

I am the world's biggest hypocrite.

A little background: it's important to realize that we're all going to die. Sooner or later the Large Hadron Collider will engulf us in an enormous black hole, making the study of medicine completely moot. But likely to occur before that death (but maybe not this one) is the eventual nullification of antibiotics as we know them.

The principle is basic. Antibiotics work by stopping bacteria from doing what they need to do to survive (synthesize proteins, replicate DNA, build a cell wall, etc). Every microbe, though, is different. Some of them are more susceptible to medicines than others. Therefore, if you give someone an antibiotic, you in the long run select for survival the cells that can resist the drug. Over time, more and more microbes develop mechanisms to protect themselves from antibiotics until eventually the medicines become ineffectual.

This sort of stuff is great evening news fodder, and often shows up on posters in front of Trader Joe's. But what most people don't know is how real it actually is - physicians get bulletins biweekly detailing the latest resistances to each drug. Some drugs work sometimes, is the deal, and it's important stay on top of the arms race developing between microbes and the companies that develop new (and expensive) drugs to kill them.

It's particularly bad in Asia (China has the highest rate of microbial resistance). In Hong Kong, treatment of a simple middle ear infection requires IV vancomycin - a harsh administration route for a serious therapy.

Anyway, the next part of the story takes place in my maxillary sinus, where an infection has been brewing for about a week. I'm pretty sure it came from a patient in clinic, and I'm equally sure this is the second time this has happened. So I waited it out, as you're supposed to do when you catch a cold, but just found myself getting sicker, watching my symptoms progress into productive coughing with mild fever, chills, and night sweats. All of this points to a viral infection - the kind that isn't affected by antibiotics. Ironically, that fact was covered ad nauseum in lecture this week, where we're conveniently covering antibiotics and pulmonary physiology. 

And finally, just to drive the point home, the internal medicine talk I went to this week was on "Community-acquired infections and antimicrobial resistance," where we were told not to give patients thoughtless macrolides, but to lecture them on the growing threat of superbugs.

Naturally, I went the next day to get a z-pack, because I'm great like that. I showed up at the doctor's office with the usual litany of symptoms. I didn't like his style at all - no meticulous history taking, just a quick feel for lymph nodes and a scribbled prescription: "Azithromycin 250mg." The z-pack.

[Side note: The z-pack is a devious marketing plot that prepackages azithromycin for people with cold symptoms. They instruct you to take 2 pills at 250mg each on the first day, followed by one 250mg pill for the following four days. In this way, manufacturing companies have designed a convenient method to sell people medicine for diseases they don't actually have.]

The doc made a half-hearted attempt at convincing me that my symptoms were viral, and suggested I wait 2 weeks before filling the prescription, just to see if the symptoms go away. So he gets an A for effort, but does that line work on anybody? If someone lands in your clinic, they're probably ready to be done with their problems. To be fair, what are you supposed to say to a patient who wants antibiotics for their cold? "Sorry, you'd just be contributing to a global epidemic of resistance and therefore must suffer in silence [or find another doctor]" doesn't seem so convincing. But that's what we're told to say.

Anyway, I knew I was morally bankrupt at this point. I had taken time out of my day to get checked out for viral symptoms and had managed to acquire a knee-jerk prescription for the very medicine I had learned so much to hate. I decided to go for broke. I filled the prescription, popped the two pills for the loading dose, and felt placebic surge of azithromycin course through my bacteria-free veins.

Interestingly, I felt a bit better by the evening. Maybe it was the thought that I had done everything I could do. Maybe the drug actually was working, and I was one of the lucky few who actually did have bacteria in their sinuses. I'm pretty sure it's the first theory, though.

And insurance covered most of the $10 cost. Unfortunately, my dignity was part of the copay.

Take home message: When you've got a cold, don't go to the doctor. Even if you manage to finagle a z-pack out of it, you know better and ought to be ashamed of yourself. But if the pyrrhic victory of assuaging your baseless fears at the cost of global health wins out, at least take the full course.

Duel

It's really silly, but somehow the inexplicably-hyped Jon Stewart interview/thrashing of Jim Cramer has been made into something of a recession-era Guy Fawkes Day for disenchanted investors. It's pointless to try to throw any more cents into it than the world already has (especially here, here, and here).

It's therefore way more interesting to think about the implications of this, well, duel. People's love of modern sport surely taps into a more primal desire for competition, but by and large the only varieties of this that make it into the public arena (pun intended) are football games and presidential elections. It was great to see a duel of ideas receive as much publicity as this.

I'm not saying this never happens. Presidential debates are among the most televised events nationwide, but they're less debatey than sound-bitey. And it's not like this was a two-way exchange by any means (if anything, it was a steamrolling). But for people to get worked up about an issue like the role of journalism in a privatized economy is refreshingly sophisticated.

After a presidential debate, people generally slip comfortably back into their original ideologies. But nobody really thinks about the philosophy of journalism much these days, and because it brings a critical issue to the fore, I give this spectacle a thumbs up.

Beep beep beeeeeeeeeeeeeeeeeeeeeeeeeeep.

An interesting thing happened this week, but as is increasingly and lamentably the case in my life, I can't really share it without a little explanation.

An EKG (or ECG) is an electrocardiogram, a simple way to measure the basic rhythm of the heart. It was figured out in 1911, when Augustus Waller attached electrodes to a patient's arms and legs to see if the body elicited any electronic changes. Interestingly, the biggest changes in the body are in the heart, so that's what shows up overall. If you plot these changes on graph paper, you get a pretty interesting waveform that looks something like this.
Each wave means something different about the heart, and one can really devote their entire life to decoding it. But your average doctor can read one generally pretty well - you can see how fast the heart is pumping, where it is, what parts are/aren't working, and detect myriad complicated diseases of almost any bodily system. Basically, if something is seriously wrong with you, there's a good chance it'll show up on this test.

As a result, medical dramas love to show off EKGs and their propensity to flatline and do any number of other mercurial things. The reality is that most EKGs are rather droll. When I first saw them in use to monitor intensive care unit patients, I nearly jumped out of my seat when I heard the alarm go off. "VENTRICULAR TACHYCARDIA" the machine read. I rushed over to the offending room to see nothing but a smiling patient, happily eating a peanut butter sandwich. It turns out, EKGs are notoriously sensitive to movement.

At this point, we just know the basics of decoding these maniacal beasts: what each wave means, how to decipher the flow of electricity, and a few disorders of the heart. We know what it's supposed to look like, and that when it doesn't look like that we should flip out and call Cardiology. So when I saw this, I nearly fell out of my very nerdy seat.



Unfortunately this is going to really only appeal to a terribly antisocial audience (so if you're looking to do something interesting right now, read something relevant), but this is the strangest EKG I've seen so far. Generally, when people have been inactive for a long time and have various cardiac risk factors, it's a good idea to indulge your doctor (and his dorky medical student) in an EKG. It's a cheap test that can rule out any major problems, making everyone (especially the insurance company) a little more comfortable. Most of the time, it's absolutely normal. But every now and then, we get one that looks like this - one that nobody can figure out.

At first glance, it looks like the machine is broken. There's erratic behavior everywhere, and it's hard to pick out a pattern. But with the help of a non-PhRMA endorsed pen, we started to notice certain regular peaks. Essentially, the large deflections on lead II probably represent ventricular depolarizations, but they're entirely in the wrong direction. And that doesn't explain the rest of the extra waves.

It doesn't take an expert to notice that this doesn't look right (don't worry, we already flipped out and called Cardiology). But it's not recording artifact, and the leads are on correctly. Nobody could really figure this out. What happened to my waves? What's the rate? And why isn't this patient currently dying?

Needless to say, it was eerie. Not in the "ooh-a-scary-ghost" kind of way, but in a "everything you thought you knew could be completely wrong and you'd still owe medical school exorbitant amounts of money" kind of way. It was like telling a kid "there is no easter bunny," or a Portlander "that's not soy in your latte."

Ailing patients, ailing states

Along the course of our treatment of epidemiology, I reencountered the term “relative risk.” This concept, which assesses the risk of an event relative to its exposure, was something I had encountered before, but in a very different context.

In international relations analytics, a commonly cited reference is the State Failure Task Force Report (Esty, et al., 1995), a collection of analyses produced by the intelligence community that identifies instability factors and their influence on the failure of a state (defined as adverse regime changes, genocides, politicides, etc). Like any classical epidemiologic study, the report assesses exposures and outcomes. It has even been controlled to reduce “false positives” (states that exhibit risk factors but don’t fail, as in Morocco and China) and “false negatives” (states that do not exhibit risk factors but do fail).

These factors are not as predictable as one might think. For example, a negative per capita annual change in GDP represents a relative risk of 2.0 for state failure. Other factors include soil degradation (RR = 1.8), below-median imports+exports/GDP (RR = 1.9), presence of autocracy (RR = 11.0), urbanization-GDP ratio (RR = 4.9), and even French colonial heritage (RR = 0.3).

For example, the central African state Chad exhibits a declining GDP, high rates of soil degradation, low ratio of urbanization to GDP, suggesting a high risk of state failure.Indeed, most analysts place the current regime in Chad among the most corrupt in central Africa.

Therefore, US policymakers ask analysts strikingly similar questions to the ones patients ask of their doctors. In this framework, “what are the chances of regime change in Kazakhstan this year?” becomes a strangely similar question to “what are the chances of a stroke in Mr. Jacobsen this year?” By no coincidence, the answer to both of these questions required roughly identical thought processes. While in Kazakhstan the answer requires assessment of economic data and reports from political dissidents, in Mr. Jacobsen (a patient from my clinic whose name I changed) it required assessment of prevalence data and reports from clinical physicians.

Mr. Jacobsen is a 68 year-old man with a history of hypertension, hyperlipidemia, and type-2 diabetes. He smokes half a pack of cigarettes per day, drinks 3-5 drinks per day, but exercises regularly. He eats a diet of mostly whole grains and lean meats. His father and most recently his brother died of fatal cerebral ischemic events brought on by complications from atrial fibrillation. Although he has not developed this condition, he showed up at my preceptor’s clinic (internal medicine) two weeks ago concerned that he might suffer the same fate as his father and brother.

After a brief physical exam, my preceptor agreed that his risk factors disposed Mr. Jacobsen to an increased chance of having a stroke. After making medication adjustments, my preceptor turned to me and asked me a simple question. “What are the two most effective interventions we can do for Mr. Jacobsen right now that would decrease his risk of having a stroke?”

I thought about this for a long time, and was later tasked by my preceptor with coming up with some “good epidemiologic data” supporting his advice to Mr. Jacobsen to reduce drinking and smoking. As it happens, these are significant risk factors for stroke. Regular consumption of 60g of alcohol represents a 1.64 relative risk for cerebral ischemia (Reynolds, et al., 2003), and regular cigarette smoking represents a 3.7 relative risk (Wannamethee, et al., 1995). Therefore, assuming that Mr. Jacobsen successfully ceases his cigarette and alcohol intake, he may decrease his chance of suffering an adverse cerebrovascular event.

Nevertheless, this still doesn’t answer the patient’s question. For that, we have to consider broader population data. In American adults above age 65, the incidence of stroke is 8.1/100 (Neyer, et al., 2007). However, this data doesn’t account for men, who may be affected by stroke at a different rate from women (in fact, estrogen is neuroprotective in circumstances of cerebral ischemia). Furthermore, it’s necessary to include Mr. Jacobsen’s many risk and resilience factors. While I already acquired data for relative risk increases due to smoking and alcohol consumption, the effect of his hypertension, diabetes, hyperlipidemia, family history, diet, exercise habits, and even place of residence (a “stroke belt” exists in the southeastern United States) factors into this calculation. It became quickly apparent to me that a complete assessment of every risk – both known and unknown – was impossible, or at least extremely impractical.

This created a dilemma in addressing Mr. Jacobsen’s question. While it would be impossible to provide him with a perfect number of his risk for a stroke, he still wanted an answer. Thus, the best my preceptor and I could do was to provide him with a ballpark estimate. Though I wasn’t present for the patient’s follow-up, I imagine the conversation went somewhat like this: “Mr. Jacobsen, your chance of having a stroke in your lifetime, now that you’re 65, is 8.1%. However, due to the fact that you smoke and consume alcohol regularly, that risk is significantly higher.” This is unfortunately dissatisfying to both the patient and the physician.

Maybe some day a company will cash in on the incredible potential market for analysis software that computes risk factors to produce clean predictive numbers. It wouldn’t be that hard – one could acquire risk data from epidemiology studies, and write a simple program that factors them into a Bayesian probability formula. However, until that time, patients will have to settle for relatively vague explanations from their physicians. 8.1% is a nice number, but it is of little practical value.

Nevertheless, this does not undermine the importance of competence in statistics and epidemiologic literature for physicians. Whether counseling patients on their use of glucosamine chondroitin for arthritis pain relief (wherein we informed the patient that an ongoing randomized clinical trial has found statistically miniscule improvements in pain when compared to placebo therapy in the GAIT trial), or using number needed to treat data to convince a patient to maintain her metformin therapy (NNT = 14 for 10 years, Van de Laar, et al., 2006), epidemiologic data has proven a powerful tool for me in this week alone. It is startling to consider the frequency with which it will be invoked throughout my career.

In fact, the proper use of this data underscores the differences evidence based practice from folk therapeutic traditions. As such evidence is brought to bear on alternative therapies, which as many as one-third of Americans utilize (Barnes, et al., 2002), the interpretation (and misinterpretation) will increasingly affect our consumption of these interventions. Because some of these will be accepted into common practice and others will be rejected, one could make the argument that epidemiologic evidence is the principal factor in defining sophisticated medicine as we know it.

Therefore, the use of statistics may pivotally influence people’s lives on a scale as broad as transnational politics to one as personal as their health. We can only hope that these statistics will be interpreted pragmatically and without intent to deceive, as the stakes are higher than ever before.

Still not kicked out

Almost two feet of paper sits on my shelf - the remains of my course outlines for the material we've covered so far (not including textbooks). A testament to how for we've come. Also: A monument to caffeine.

We just finished the second class of our rotation, Cell Structure and Function - notorious for its brutal load of information. And I have to admit that fighting through it each and every day in the midst of the cold, dark winter was pretty trying. But despite the hundreds of reactions and concepts we were forced to internalize, it's over.

The next class on the docket is Systems Processes & Homeostasis, a round-up of physiology and pharmacology. This finally seems a bit more like what I signed up for.