True meaning of Christmas

Posted December 25, 2006 by signout
Categories: Uncategorized

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.

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Home on paper

Posted December 22, 2006 by signout
Categories: Uncategorized

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

Posted December 19, 2006 by signout
Categories: Uncategorized

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

Posted December 15, 2006 by signout
Categories: Uncategorized

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

Posted December 11, 2006 by signout
Categories: Uncategorized

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.

Assign a value of zero

Posted December 4, 2006 by signout
Categories: Uncategorized

During my first week of medical school, we watched a video that documented the life and death of a child diagnosed in utero with neurologically devastating spina bifida. The girl’s parents had been aware of her prognosis long before her birth, but chose not to terminate the pregnancy; they cared for her until her death at 8 years of age. Speaking several years afterward, they regretted nothing. They saw her, and the opportunity to take care of her, as a gift from God.

I distinctly remember sitting in the lecture hall and thinking to myself, you people are out of your fucking minds. I grew up with a disabled sibling, and I was pretty sure that disability had not been a gift, either to my brother or to my family. Disability ruined birthdays, strained family gatherings, and doubled the expectations of parents. Disability brought my family together only in that we together questioned my brother’s quality of life, and in the face of the way we responded to his limitations, the quality of our own lives. When disability united us, it was usually in grief.

Despite some significant personal progress, it remains difficult for me to see disability outside this framework, which has made working in the NICU (the neonatal intensive care unit) challenging at times. After all, the NICU is a bit of a disability factory: we keep alive babies whose chief challenges at birth are often the same challenges that predispose them to long-term, global impairment.

That’s not to say that we keep every baby alive. In our NICU’s work area, there’s a corkboard full of bar graphs demonstrating the likelihood of various levels of neurodevelopmental impairment based on a child’s gestational age at birth. When very premature births occur, we use these data to help guide parents toward resuscitation or palliation for their newborn.

Even with well-studied odds, there are many, many times when determining the likelihood of disability is a bit of a crapshoot. In these grey areas, the decision of whether to resuscitate or palliate hinges on a deeply personal calculation: Whether a family will sustain a net gain or a net loss by having a disabled child. Families like the one in the video sustain a gain. Other families, especially those comprised of a single parent under financial and emotional strain, sustain a loss.

In the discussions I overheard during my NICU rotation, the focus was uniformly on the impact of a child’s disability on a family’s quality of life, and on the ability of a family to provide for the needs of a disabled child. But in my own mind echoed a question I was ashamed of even thinking: are we sure that all NICU graduates are grateful they were kept alive?

I was relieved to hear that others—legitimate scientists, even—have asked the same question. For nearly 30 years, a group of Canadian investigators has been following a large group of kids born at extremely low birth weight (ELBW) and comparing them to a control group of kids with normal birth weights. (ELBW babies comprise a very large proportion of NICU admissions.) In a publication in October of this year, these investigators demonstrated something fascinating: although there were major differences in health status between the two groups of young adults, there was no difference in self-perceived health-related quality of life. Moreover, within the group of ELBW subjects, those with neurosensory impairments (like blindness or cerebral palsy) reported the same quality of life as the subjects without neurosensory impairment.

Only 5 people in the study said they’d rather be dead—3 in the ELBW group, and 2 in the normal birth weight group. Four of those 5 had mental health problems without any other impairment, suggesting that it’s depression more than a neurodevelopmental disability that’s behind their unhappiness.

These results include the proxy scores of 10 parents who responded on behalf of their severely disabled children, ranking their health-related quality of life on a scale between zero and one. And although scientific papers aren’t usually geared to pull at heart strings, I found this part especially poignant: only when the investigators substituted the parents’ scores with scores of zero was the average quality of life of the ELBW subjects significantly lower than that of the normal subjects. Put another way, it was only by the investigators’ calulations–not the patients’ or families’–that these lives seemed less worth living.

What you see depends on the lens through which you view it. Both scientists and sisters can assign a value of zero to the quality of life of people who, viewed through their own lenses, are doing just fine.

If disability is more uncomfortable to me than it is to people with disabilities, who of us needs more therapy?

Sleep ethic

Posted November 22, 2006 by signout
Categories: Uncategorized

 

I was drinking my coffee unawares the other morning when I somehow got roped into a rather unpleasant exchange. 

 

“I don’t know if anyone’s told you yet,” said the blonde-haired senior resident who comes from money, “but your role in the NICU is to stay awake. Don’t ever, ever go to sleep when you are on call. You need to be available to answer questions about the patients you’re covering.”

 

“That’s bullshit,” said the brown-haired senior resident with the eating disorder. “It’s not like anyone ever comes to us with questions about our patients—they go straight to the nurse practitioners, who rarely have any interest in teaching us, anyway. And there really are long stretches of time when nothing happens. Sleep whenever you get the chance.”

 

The blonde ignored her. “As an intern,” she insisted, “staying awake is the least you can do.” She indicated in her way that this was the end of the conversation, and I went back to drinking coffee. But I thought to myself, the least I can do? In what sense is being awake actually doing anything?

 

It’s a pretty common thing for residents on call to stay awake in order to stay awake, with the endpoint of saying to their colleagues, “I stayed awake.” I suspect they are confusing their sleep ethic with a work ethic, and responding to an institutional trend toward mistaking alertness for actually caring about anything, especially patients.

 

I bought into the ethic for about five minutes. The first night I was on call, I accidentally slept 4 hours, and felt terribly guilty the next day. I stayed awake the next call night, after which I decided I was being ridiculous. On my third call night, with absolutely nothing to do, I slept for four hours and woke up at 4:30 a.m. Before I left that morning, one of my sicker patients took a turn for the worse, and I stuck around for an extra hour past my work-hour limit to round on him with the team and explain his situation to his parents. I was aware at the time that I felt able to do this because I wasn’t dead to the world–because I had slept when I could.

 

A few days later, my attending pulled me into his office. “Dr. Signout,” he said, “I really appreciate your commitment to Baby Totally-Gonna-Die. When you stayed past work hours the other morning to help take care of him, it showed the kind of commitment to learning and patient care that we love but are not allowed to encourage any more.”

 

I didn’t tell him that it hadn’t been that bad because I’d been pretty well-rested. I didn’t want my having slept to somehow diminish what he saw as good patient care.

 

Of all the things to be secretive about doing at night, I never imagined sleeping would be one.