Archive for December 2006

Point

December 30, 2006

And again, I point you to this week’s Pediatric Grand Rounds. There’s a great series on vaccines mentioned there, if you’re into that sort of thing (and I know you are).

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Squeak

December 26, 2006

Now up: this week’s Grand Rounds, into which I’ve again managed to squeak. This week: bloggers’ best-of.

True meaning of Christmas

December 25, 2006

I’m an M.O.T., so for me, Christmas, meh. It’s just kind of another day. I’m neither especially cranky about having to work nights through the holiday, nor is my heart filled with the dazzling light of yuletide joy.

But last night, a colleague reminded me of something that brought home the true meaning of Christmas: today, I am exactly halfway through my intern year.

Hallelujah!

We even had our own Christmas miracle: we got a kid with a huge neuroblastoma in his liver down to the CT scanner at 2 a.m….and he wasn’t bleeding into the tumor. (The real miracle is the first part.)

Huzzah! I shall celebrate by sleeping through the better part of daytime without showering first.

Home on paper

December 22, 2006

Yesterday, I discharged 5 patients from the hospital. Today, I feel dead inside.

For patients, hospital discharge is a happy moment. Leaving the hospital means leaving behind the unflattering gown, the interrupted sleep, the food that does not resemble itself, and the constant parade of people poking and sticking and looking at your business. Most inpatients eagerly anticipate discharge from the moment they are admitted.

For residents, hospital discharges are a little different. Patients leaving the hospital require instructions, follow-up appointments, outpatient testing, prescriptions, and sometimes, home care services. Their health care providers–all of them–require detailed information about their hospital course and about the plans for their medical follow-up. In my hospital, the responsibility for choreographing this administrative hoo-ha falls directly on the residents, and mostly on the interns.

Deep inside, in the part of me that is not an intern, I am happy for patients when they get to leave the hospital. But the rest of me–especially the part that operates computers and makes phone calls–seethes. Yesterday, after spending hours navigating a web of bitchy clinic receptionists and printing, then reprinting, this time on the right paper and on the right printer, I came to an unpleasant realization: I had spent more time discharging these patients than I had cumulatively spent face-to-face with all of them during their hospitalizations.

In theory, it is my job to treat people’s illnesses in order to get them medically ready for discharge. But yesterday, I spent so much time doing paperwork that I wasn’t able to think about or really, take care of, any of my patients who were still in the hospital. Getting patients home on paper left me no time to get patients well enough to go home in body. 

There is a light. Someday, when I am an upper level resident, I will ask my interns how their discharges are coming along. Oh, they will say, we are beginning to feel dead inside. And from my perch at a patient’s bedside, where we are together reviewing the nature of their disease process and the elements of their management, I will say, Let me help you with that. Which printer are you using?

But enough about me

December 19, 2006

Most of you know I’m not the only one writing about the medical profession out here in the blogosphere. This week, I’m honored to be in the company of many excellent medical bloggers at two weekly, appropriately named anthologies: Grand Rounds and Pediatric Grand Rounds. Please have a visit and view the greatness that surrounds me!

I also made it into WordPress.com’s A-Blog-A-Day column the other day. They called me “interesting,” which, as I recall, is fairly synonymous with “not interesting.” Whatever. It’s exposure.

But enough about me: anyone with an interest in verse should get their hands on this newly published poetry anthology called Body Language. The poems are written by and about the medical profession, and the few entries I have read so far are complicated and beautiful in the best of ways.

Now back to our irregularly scheduled programming.

It can’t just be me

December 15, 2006

I just started a rotation on the adolescent wards, and about half of our patients have eating disorders. They are all girls, and they range in age from 12 to 17 years old.

Every day, they have group therapy meetings in the recreation room at about noon. They file by our work area in flannel pants and pony tails, wearing shirts from cross-country teams and field hockey teams and basketball teams, slapping their slippers on the floor. They are all somewhere between 60 and 80% of their ideal body weight for height.

As they walk by, I think to myself, “Man, they are so pretty.” And I am not proud.

At first, I thought, it can’t just be me. Something has to be reponsible for making these women want to be thin, and it’s probably the same thing that’s squeezed my feminist brain into finding pointy chins and saucer eyes attractive. Right?

Well, not really. During a group session with our patients the other day, I began to understand that although societal norms might initiate dieting and body image problems in people with eating disorders, it’s compulsion and control that make them continue in the long term. After the thighs are gone and the belly is flat, it’s about seeing the scale needle continue to move downward; demonstrating how much control you really have; putting one over on your stupid parents; proving yourself a winner at something. Yes, the girls in our program do think they’re fat–but that’s not where it ends.

Where does it end? As one girl said, “There is no lower limit that would make me happy.”

Yes, women in all forms of graphic media have gotten thinner, on average, over the last 100 years. But it’s hard to demonstrate unequivocally that eating disorders have become more prevalent over that time. (See citations 6-17 in this paper.) One could (and I do) conclude that there’s a disease process at work in these patients that we do not provoke or mitigate with culture.

By these calculations, I’m the only one in the doctor-patient relationship whose viewpoint is much influenced by the thinness of the ladies in the magazines.

As ornithology is to birds

December 11, 2006

Today, in another of her cantankerous and directionless “interviews,” Deborah Solomon of the New York Times at least got something right. This time, the subject of her bullying is Louann Brizendine, a professor of neuropsychiatry at the University of California, San Francisco (UCSF). Brizendine, who in her picture insists on the heeled ankle bootie, just came out with a book about why all women are catty bitches. (Finally!)

Near the end of the interview, Solomon notes that while Brizendine draws on other scientists’ research in writing her book, she hasn’t done any research herself. In response, Brizendine delivers this gem:

I don’t like doing clinical research because of placebos. In a “double-blind placebo-controlled study,” as they are called, neither the doctor nor the patient knows what the patient is taking. I don’t want to give patients a placebo. It’s cruel.

I am not a neuropsychiatrist, and UCSF isn’t exactly tugging at my sleeve to offer me a job. However, I cannot understand how a person with any exposure to medical science can comprehend this little about its advancement.

When a scientist constructs a study testing a new therapy against a placebo, the driving assumption is that it’s unknown whether the therapy is better or worse than the placebo. Unless this ambiguity can be proven to an institutional review board, the study won’t be approved. If we already know what’s best, why risk study subjects’ health–and spend money–to study it?

We don’t always have to wait until studies officially end to find out whether placebos are better or worse than therapies under investigation: In many double-blinded placebo-controlled studies, investigators “break” the blinding at intervals in order to analyze existing data. They do this to identify cases in which either group is actually sustaining harm by being involved in the study. Sometimes, this results in the study ending early to prevent treatment group patients from getting a therapy that’s actually worse than the placebo. (Remember the Women’s Health Initiative trial of estrogen and progesterone? It was stopped early when it turned out that the therapy increased the risk of invasive breast cancer.) Sometimes, studies with a clear benefit from the therapy are stopped early so that the placebo patients can have access to the better therapy as soon as possible. (This happens all the time in studies of blood pressure medicines.)

In placebo-controlled trials involving ill patients, patients in the placebo group do not just get sugar pills instead of anti-cancer drugs or CT scans or whatever’s being studied. They get the standard of care for whatever illness they’ve got, while patients in the treatment group get the standard of care plus whatever therapy is being studied. Generally speaking, a study that provides less than the standard of care to its placebo group will not get past an institutional ethics committee.

My point is, placebos are not cruel. Often enough, they’re better than the new therapies we try out on people, and there are mechanisms to stop studies early when they’re worse. Moreover, without them, we’d have no way of measuring the effects of new therapies–we wouldn’t know what really works. 

My dad likes to quote Richard Feynman’s saying that “the philosophy of science is about as useful to scientists as ornithology is to birds.” I’m not saying this woman is a philosopher. But what she’s saying here isn’t useful to science, and it verges on being harmful to patients.