What they don't tell you before med school: Choosing where you work

Each year medical schools in Canada are flooded with more and more hopeful applications from students who are praying for the chance to wear a white coat and introduce themselves as "Doctor". These students have put forward superhuman efforts to achieve: they have great grades and solid MCAT scores; they have resumes polished with extracurricular activities showing their leadership, determination, and compassion; and they have spent hours on end crafting essays describing exactly why they want to enter the field of medicine. The competition is so steep in Canada that thousands of students are rejected time and time again, causing many to go off to international schools in the Caribbean, Australia, and Ireland.

Unfortunately there are many negatives to being a doctor that you just don't hear about when you are applying to medical school. One major drawback is the limitations placed on where you can live when you finally graduate. Medicine is touted as a very stable profession in Canada, one that is "recession proof". This stability is due in part to the major physician shortage we have in Canada. However, this shortage is not ubiquitous in location or profession.

If you want to be a family doctor, you're set, you can basically work in any city and you will be able to find patients and establish a practice. However, if you are a heart surgeon, you may complete your residency without a job available. Imagine that, finishing 4 years of med school and 6 years of residency without a job to show for your efforts. The lack of employment is simply because there are only so many facilities that can offer cardiac surgery and there are more graduates than there are retiring surgeons whose spots need to be filled.

Even if you are interested in a specialty that does provide employment opportunities for its graduates, you may still have little say in where you are employed. For instance, I was talking to an ENT surgical resident who was complaining that he will definitely not find work in Vancouver when he graduates because everyone wants to work here; thus, only the most experienced and capable surgeons are hired (good news if you have an ENT problem in Vancouver).

Some may argue that this problem is not unique to medicine because many occupations force people to relocate to where work is available. However, this is especially unfortunate in medicine because many people go into med school without being aware of this reality. Going tens of thousands of dollars into debt, slaving through med school and then residency, to realize that you have to move far away from your family and friends to find work can be a rough fact to deal with...so try to deal with it before you apply to med school. Either that or be comfortable entering a specialty with more flexible options...

An Untold Fact About The GP Shortage

General practice is in a bad state in Vancouver, and probably most of Canada, because of the well known shortage in general practitioners. Many people can't find a GP and those that have one hesitate to visit their doctor because they know that they're doctors are overbooked and appointments need to be made far in advance. Somewhat nonsensical because most of us can't predict that we will be sick two weeks ahead of time. This leads to obvious problems because if patients don't see their doctors regularly, their doctors cannot catch their illnesses early and control their disease before it becomes more harmful to the patient and more expensive for the system.

Doctors, educators, and public health officials often discuss these issues when they publicly debate the GP shortage. However, an aspect of the problem that is not discussed as often are the unnecessary mistakes made by physicians who are overwhelmed with an unrealistic schedule. Doctors know that there is a GP shortage, so they often find it difficult to turn away a new patient who has nowhere else to go; thus GPs tend to have too many patients.

Next, consider the fact that these GPs develop very close relationships with their patients and feel obligated to see them as soon as possible when they become ill.

Having a large patient population and wanting to ensure no patient is turned away means that GPs will have many patients to see each day.

Then realize that these doctors have lives, families waiting at home, and that they can't stay in the office all day. They would stop time for you if they could, but they can't, really.

Many patients + wanting to see all of them + time is finite = 10 minute visit

The 10 minute visit is an attempt to maximize efficiency while minimizing any potential harm to patient care. However, any time you speed up ANY process, you risk making silly mistakes. These errors are often easily correctable, but sometimes they aren't. Compromising patient care is something no doctor ever wants to do, but it is something that will happen. Even in a perfect system, doctors will make mistakes (sorry, they're human too), but in an imperfect system, doctors will make more.

There are two ways to resolve this problem:

1) We can improve the system. This would mean improving general practice and luring more med students into the field so that there will be fewer patients per general practitioner and then each doctor can spend more time with their patients.

2) We can make perfect doctors. That means they would have to be robots. Getting a DRE sucks now. It'll probably be a lot worse if it's done by a robot.

Malpractice: Don't Rush The Surgery

Take a look at your palm. Now make a fist as tight as you can. Chances are you can now see two seperate tendons running over the middle of your wrist. One of these tendons is the tendon of palmaris longus. 10% of the population will NOT see this tendon when they make a fist because they were born without it. It's not a big deal, the tendon is pretty useless functionally. Thus, when a patient tears an elbow ligament, surgeons often scavenge the palmaris longus tendon and reattach it to the elbow in place of the torn ligament.

We were told an unfortunate story about a surgeon who rushed a surgery and cut into a patient's wrist, hoping to scavenge the palmaris longus tendon. Turns out that this patient was in the 10%, he did not have the tendon. Guess what is usually underneath the tendon? The median nerve. This surgeon cut clean through the nerve controlling the muscles of the patient's thumb, index, and middle finger. These fingers are now non-functional for this patient. A really tragic case and a reminder to all physicians not to rush their surgeries.

Reminder: Wrist Bone Pneumonic

So Long To Pinky Here Comes The Thumb

Scaphoid, Lunate, Triquetrum, Pisiform. (Proximal)
Hamate, Capitate, Trapezoid, Trapezium. (Distal)

Data Storage Laws and Electronic Medical Records

Rules surrounding data storage are becoming more and more important as we become a more digital society. The BBC reports that Microsoft senior vice-president Brad Smith is calling for international trade laws around data storage.

Apparently different countries have different rules around how long data must be stored and when it must be destroyed. This can become a confusing issue to navigate for companies offering data storage to an international market. Should they follow the data storage laws of the country that the consumer inputted the data from or the country the data is being stored in?

Rules around data storage also complicate electronic medical records, which some hail as the next technological revolution in medicine. Medical data is completely confidential, so many would argue the idea of storing the data outside of the country is preposterous. This takes away the complexity of having two sets of laws around the storage of the data; however, it means that we cannot take advantage of cheaper rent and maintenance fees found by establishing data centers in foreign countries. Keep in mind that having these data centers within our borders does not really make the data more secure. Hacking only requires accessibility and if the data center is connected to any kind of network on the internet, its physical location has no influence on its security. So does it really make sense to demand that medical data is stored within the country?

Considering laws regarding how long medical data must be stored, we currently have rules around how long paper medical charts must be held by a physician. Would these rules be the same if/when we move to digital records? Digital records are much easier to manage than their paper counterparts, so it may make sense to store them indefinitely, or at least for a longer period of time. This would certainly be of added benefit in research. We could learn a great deal if we had over 40 years of patient data to study. Of course, this is only true if researchers gain patient consent to view the data.

As data storage becomes a more frequent point of discussion in politics, I think we will see health officials begin to weigh in on data storage policy, at least with regards to how data storage affects health care.

Patient Trust

Nanos Research reports that physicians are the most trusted professionals by Canadians. 77% of respondents considered medical doctors' standards of ethics and honesty to be "high" or "very high". These results aren't terribly surprising considering physicians know they must carry themselves in a manner that elicits trust. After all, they ask you very personal questions, make you to strip naked for examinations, and occasionally anaesthetise you before cutting you open and placing instruments inside your body. If they didn't have your trust, they would be unemployed.

What does constantly surprise me is how much trust patients have in me, a medical student. When I first started seeing patients last year, I assumed most of them would be unwilling to see me and tell me that they came in to talk to an actual doctor. This never happened, not once, patients were more than happy to talk to me. In fact, most of them were happy to play a part in training the next generation of physicians (which I and all my classmates are of course grateful for). Of course, in the beginning all I did was perform a medical interview, but still, these patients were willing to answer personal questions asked by a complete stranger with less than two months of training.

Now in second year, I have a better understanding of how to perform a medical interview and several clinical exams (read: "I can actually do stuff"); yet, this year has been even more astonishing than the last. A few months ago, a family allowed me to examine their seven day old daughter. They let me place a giant microphone to her chest (also called a stethoscope), shine a bright light into her eyes (looking for the red reflex), palpate her head (feeling for fontanelles), and feel her abdomen for any abnormalities. These parents didn't know me, but because I'm a physician (in training) they trusted me with their new child.

That's a lot of responsibility. I better go study...

Nanomedicine Begins Changing the Face of Medicine

"Sir, you have glioblastoma multiforme, a brain cancer with a very poor prognosis. Normally your chance of survival would be very low..."

"Normally?"

"Don't worry, we're sending in the robots*..."

Nanomedicine is the use of nano (meaning very very small) technology in health care. Nanomedicine is an exciting new field that will probably change management options for a wide array of diseases. Of course, I say this as an electrical engineering graduate, who worked at Microsoft, and is now in med school...so my passion for the topic may not be representative of the general feeling in the medical community. However, I recently came across two articles that show how nanotechnology is truly moving medicine forward.

First, an article recently published in h+ discusses a recent study demonstrating nanotechnology fighting brain cancer. This nanotechnology seems to be far more effective than chemotherapy and radiation therapy, and safer than surgery, which are the current treatment options. Nanoparticles were used to target cancerous cells. Once they were bound to the cancerous cells, a light beam activated them and made them toxic, kill the attached cell. These nanoparticles can clear 80% of a brain tumour in 5 minutes!

Second, not only can nanotechnology fight existing cancer, but it is being used to detect cancers earlier than current technology allows. Detecting cancer early makes treatment more effective and reduces those cancer related complications we all hate, like death.

Nanotechnology has amazing potential to increase patients' quality of life and reduce their disease burdens. In an attempt to emulate Nostradamus, I predict that there will be a vast array of new developments within nanomedicine in the next 5 years and after that we will start seeing the use of nanotechnology as a common option in every physician's medical toolbox.

Emergency Rooms and Sick Children, Not a Waste of Time

The Vancouver Sun has an article wherein ER doctors can be found encouraging patients to come in with their children if they have even the smallest concerns about their childrens' health. I found this surprising because many of the ER doc bloggers are constantly complaining about parents who come in with their children who have nothing worse than a bad cough.

I wonder if the physicians in the article meant what they said or if it was the only statement they could make considering it really wouldn't be acceptable to say "stop wasting our time with your kids' runny noses". The difference in opinion could also be attributed to a difference in Canadian ER docs from American ER docs (who are certainly more avid bloggers), or perhaps a different opinion coming from this ER doc who is in a quieter hospital than most metropolitan ER docs.

Reminder: Low Volume vs. Low Osmolality

When the kidney is faced with low intravascular volume and low serum osmolality, low volume wins, ADH is released.

The kidney plays a key role in regulating intravascular fluid volume and osmolality. When volume is low, water is preserved and ADH is released. When osmolality is low, ADH is not released. However if volume AND osmolality is low, volume is considered more important and ADH is released.

Reminder: What are Reminders

Posts titled "Reminder:" are made to help me remember specific medical information that I think is important, but I keep forgetting. I'm putting these up on my blog because I figure if I forget them, other med students will too. The info may be of interest to lay readers too; however, these posts aren't meant to teach anything, so the details will not be explained.

Langara's Energy Healing Program

Here is an article discussing the Integrative Energy Healing program at Langara College, a well known college in the Greater Vancouver area.

I very much agree with Chris Macdonald, the author of the post, Langara is ripping off their students with a course based in pseudoscience. Supporters of energy healing may claim that doctors (read medical student in my case) are so wrapped in modern medicine that they are not willing to consider the possibility of alternative therapies, but, in this case, nothing could be further from the truth. I welcome the potential benefits of alternative therapy. However, I believe there should be substantial research supporting "energy healing" before it is packaged as a certificate program and sold to students. Until then, can we really trust a graduate of this program with our health?

There is No Doctor Shortage, Only a Sleep Surplus

I recently came across an article describing how Australian doctors are made to work longer hours. Apparently the health authority has decided that doctors can work 80 hour work weeks if they just drink 6 cups of coffee a day.

Of course, this health authority wants to assure everyone that they are not in their ivory tower creating esoteric advice that doesn't apply to real world situations. They add that they realize drinking that much coffee is "not always feasible or realistic"; their solution: physicians should take caffeine pills instead.

Seriously? There is a health authority in a respected, developed country that thinks the answer to a doctor shortage is to force doctors awake with a stimulant so that they can work longer hours? What's next? I mean, cocaine is a better stimulant than caffeine...if they still have a doctor shortage maybe the health authority can strike a deal with a Colombian cartel?

Oh, and side effects of caffeine can be anxiety, insomnia, and agitation...the exact qualities I'm looking for in my physician...

Vaccine Misinformation

There have been a number of stories in the media for the past few years about the vaccine conflict. The pro-vaccine group is all for vaccinations and wants to ensure the entire population is immune to diseases like diphtheria and pertussis. The anti-vaccine group believes that vaccines are bad and cause problems, like autism. If you are considering vaccinations for yourself, or your children, I strongly suggest discussing your concerns with your doctor. There is a lot of misinformation and fear mongering out there that distract people from the facts.

The truth is that vaccines are not 100% safe, but wait!!!!...Nothing really can be 100% safe. Even drinking water can be dangerous...if you suddenly lose coordination of your swallowing reflex...water could get into your lungs, and you could drown, but does that mean you're going to run off to the Sahara and never drink anything...ever? No, of course not. Obviously the vaccination issue is a much more complex issue than drinking water, but we all need to realize that many good ideas/important activities come with associated risks. Just remember, we need to weigh those risks against the potential benefits gained.

I recently spoke with a friend who has hand, foot, and mouth disease (HFMD). A very infection disease caused by a virus. She got HFMD from her little cousin who was recently vaccinated for MMR (Measles, Mumps, Rubella). Her cousin picked up the HFMD a few days after receiving the vaccination. Now her entire family believes that the MMR vaccination directly gave this little boy HFMD. That didn't happen! Measles, mumps, rubella, and HFMD are all different diseases. The MMR vaccine does NOT contain HFMD virus. The MMR vaccine could not have directly infected this boy with HFMD! It didn't happen! To get HFMD the boy needed to come into contact with the HFMD virus. Please consider the possibility that getting HFMD shortly after the vaccination was a coincidence, not causation! If a child is vaccinated and then gets straight A's on his report card, you shouldn't assume that the vaccine made him smarter! (Well, you could...because if the vaccine prevented him from being sick...he probably went to class more...leading to him learning more...resulting in the good report card...)

It is the media frenzy attacking vaccinations that is causing people to fear irrationally. I'm not discouraging caution, but I am encouraging critical thinking. As I mentioned earlier, if you are considering vaccinations for you or your child, discuss your concerns with your doctor. You don't just have to take your doc's word either, you can ask your doctor to provide you with evidence. There have been many studies looking at the effects of vaccinations.

Just in case you come across peer reviewed articles written by Dr. Andrew Wakefield claiming that MMR vaccines are linked to autism...please check out this article, which states that the link between MMR vaccination and autism is extremely unlikely and that Dr. Wakefield's work is being discredited.

Why INR is Important for Coumadin Users

Your INR (International Normalized Ratio) is a measurement of how quickly you clot (stop bleeding). It is an important measurement if you are using coumadin (warfarin) a drug that "thins your blood", reducing how quickly you clot. Patients are given coumadin because they have a clotting problem; for example, they may have suffered from pulmonary embolisms or strokes. A pulmonary embolism occurs when a clot blocks off blood to your lungs and a stroke is a similar problem, but it affects your brain.

If you are on coumadin, you will undergo a bleeding test to determine your INR. Ideally, your INR should be higher than normal (normal is around 1), but not TOO high. If your INR is too high, your blood is too thin and you are at risk of bleeding out.

For example, if a healthy person gets hit hard enough in the arm, they will get a bruise. A bruise is a sign that the person was bleeding underneath his skin, but the blood clotted and he has began healing. Now, if your INR is too high, you may take significantly longer to clot because your blood is very thin (clotting factors are missing).

The reason I mention this is because a gentleman was telling me about a time when his INR was high and although he was told he needed to come in to see his family doctor, he didn't. I don't know if the doctor didn't clearly convey the danger of the situation, or if he just ignored his physician's warning, but he didn't bother to make an appointment. Later that week, he went to his chiropractor who did some work on his back. He ended up having a sore back the next day; he thought he broke his back because the pain felt the same as when he broke his back years ago. Turns out that the pressure the chiropractor put on his back caused him to bleed internally because his blood was so ridiculously thin. The blood didn't have anywhere to go because his skin was intact, so it pooled in his lower back. Blood pooling into a restricted space increased the pressure in his back and caused the pain.

This man was very fortunate that the blood pulled in a relatively safe way. If he bled into his chest cavity, for example, this could stop your heart from beating and be fatal.

What Are The Chances?

I was told a story about a person who was watching House and saw a case where a patient had heart palpitations when anyone put pressure on his abdomen. The patient on House had a pheochromocytoma.

This person went into her doctor's office and claimed that she too had a pheochromocytoma and described her symptoms and how they were similar to the case she saw on House.

I'm guessing 99% of the time when a patient presents at their doctor's office with a diagnosis they came too while watching a fictional tv show...they are wrong. This is even more likely when the diagnosis is as incredibly rare as a pheochromocytoma. There are endocrinologists who go their entire career without seeing a SINGLE case of pheochromocytoma.

Turns out this woman was right and she did have this incredibly rare disease. Seriously, what are the chances?

Hackers Guide to H1N1

I came across a guide to hacking influenza. It creates an impressive analogy comparing DNA to hard disk memory, RNA to RAM, and amino acids to pixels.

The guide discusses how to theoretically hack influenza, making the current strain of H1N1 substantially more dangerous. The post goes on to describe how influenza may well figure out how to perform the aforementioned hack on itself. However, I suspect that if that particular genetic modification made influenza more infectious, it would have already happened by now. If influenza was more infectious, it would infect more people (obviously!), and this would make it more evolutionarily fit because it would be passing on its genes at a higher rate. Thus, since we don't see the hack in the real world, it may be because that particular genetic change makes the influenza less infectious. This same phenomena is seen in HIV. HIV can become resistant to medication, which seems like a genetic advantage, but sometimes when medication is stopped, the HIV infection loses its resistance to the drugs. This is because the non-resistant HIV strain is more evolutionarily fit than the resistant strain and out-competes the resistant strain if it is not hampered by medication. (If this makes you want to stop your HIV meds...DON'T...Go talk to your doctor first!!!)

The guide describes how influenza is made up of genetic compartments and co-infection of a host by two strains of influenza can lead to the creation of novel influenza strains.

Consider what happens when a host is infected by two types of Influenza at the same time. If the genes were stored as a single piece of DNA, there would be little opportunity for the genes between the two types to shuffle. However, because Influenza stores its genes as 8 separate snippets, the snippets mix freely inside the infected cell, and are randomly shuffled into virus packets as they emerge. Thus, if you are unlucky enough to get two strains of flu at once, the result is a potentially novel strain of flu, as RNA strands are copied, mixed and picked out of the metaphorical hat and then packed into virus particles. This process is elegant in that the same mechanism allows for mixing of an arbitrary number of strains in a single host: if you can infect a cell with three or four types of influenza at once, the result is an even wilder variation of flu particles.

This mechanism for genetic variation leads to the most dangerous influenza outbreaks. Imagine two strains of influenza, strain A infects humans and pigs and strain B infects pigs only. Strain A is relatively harmless to humans because we have been exposed to it for a long time and our immune systems have learned how to fight it. Strain B is harmless to humans because it does not contain the required proteins to infect us. However, if a pig was infected by strain A and strain B and the strains shared genetic information, then a new strain, strain C, may be created sharing genetic components from both strain A and strain B. Strain C can be especially dangerous because it may have proteins from strain A that make it infectious to humans, but the proteins from strain B are completely unrecognized by the human immune system, meaning we have little immune defence against strain C. This is what happened with swine flu, avian flu, and the Spanish flu.

Another interesting point brought up in the guide is using influenza as a biological weapon. Theoretically a very scary and dangerous possibility. However, it would be ridiculously difficult to control a weapon like that. Influenza can rapidly spread across the globe, even when the entire world is prepared and trying to stop it. A "surprise attack" with influenza would probably be very difficult to contain and the attacker would be putting himself in grave danger too!

Can You Recognize Primary Care When You See It?

Wired has an article discussing the market advantage of cheap, simple solutions over more expensive, feature rich products. The thesis of this argument is that we consumers prefer the quick, easier option most of the time and only rarely desire the more detailed, fancy choice. Their first example describes how photography enthusiasts may demand the more powerful DSLR cameras, but the average person prefers the simple point and shoot cameras for their ease of use and lower price point.

Another example they describe is the new Kaiser Permanente "microclinics". Kaiser Permanente is described as

the largest not-for-profit medical organization in the country, Kaiser has long relied on a simple strategy of building complete, self-sustaining hospitals—employing 50 doctors or more—in each region it serves.

These microclinics are run by two doctors and set up in strip malls. They share electronic medical records with larger regional Kaiser Permanente hospitals, but do not contain a radiology department, pharmacy, or any additional features you would expect from a hospital. The wired article reports that

What they found is that the system performed very well. Two doctors working out of a microclinic could meet 80 percent of a typical patient's needs. With a hi-def video conferencing add-on, members could even link to a nearby hospital for a quick consult with a specialist. Patients would still need to travel to a full-size facility for major trauma, surgery, or access to expensive diagnostic equipment, but those are situations that arise infrequently.

This microclinic is being heralded as an amazing step to reducing costs and simplifying health care for patients. However, I don't understand how this is different from primary care? Aren't these "microclinics" simply doing the job of a family physician? Family physicians are easeier to access than specialists in the hospital (or at least they should be!). They provide preventative care and establish a long term relationship with their patients. They treat the average patient's needs and consult with specialists in the scenarios that are beyond their professional scope. This is the role of a general practitioner. They are vital to our health care system, but I don't think the general public sees their importance. Patients sometimes even view their family physicians as obstacles to reaching specialists who are the "real doctors". This could not be further from the truth.

I strongly believe that strengthening primary care will reduce overall costs of health care, but I think primary care needs to do a better job of marketing themselves so the public understand their value. Otherwise, you get articles like this, that praise Kaiser Permanente for re-inventing the wheel.

Need Up-To-Date Research...Now?

The Public Library of Science has released a new website, PLoS Currents, to rapidly share research pertaining to influenza in response to global fears regarding H1N1.

The website is a joint venture with google that allows researchers to present their results to the world while side-stepping the lengthy publishing process. The research articles are looked over by expert moderators; however, the articles are not peer-reviewed in detail (peer-review is usually the rate determining step for publishing). Peer-review allows fellow researchers in the same field criticize the methodology, analysis, results, and conclusions of a research project. It is a check and balance in the scientific community. Peer-review ensures that an unjust conclusion that may incite unnecessary fear is not released to the general public.

However, the peer-review process certainly delays the distribution of scientific knowledge. A delay that may have disastrous consequences in the presence of a global pandemic.

I'm interested in seeing if the lack of a peer-review process results in PLoS Currents doing more harm than good with regards to rapidly spreading scientific knowledge. The PLoS openly states that results on their Currents website should be considered preliminary and they do point out that the articles have not been peer-reviewed, however, readers may not heed this warning. I believe that a hybrid publication system, involving immediate publication and peer-review, would be a huge win for everyone; I just hope it works.

Ice Water Recovery

Ice water recovery is a method of exercise recovery used by many elite athletes. UFC fighter, Tito Ortiz, and Jenna Jameson provide an example in this video.

A good discussion about ice water recovery and the scientific theory behind it can be found in this article at Shark Fitness. To be honest, I haven't gone through the sources cited in the article, but some of the logic doesn't make sense at first glance. For example, the article states that ice baths are thought to,

Constrict blood vessels and flush waste products, like lactic acid, out of the affected tissues

How does that make sense? The ice bath will surely constrict blood vessels, but how does it "flush waste products"? If the blood vessels are constricted, then the blood will have a harder time leaving the tissue. The blood transports the waste through your body, so if it can't leave your muscle tissue, the waste won't leave either.

Discrepancies like this make me very skeptical about the recovery value of ice baths. As the article says, most studies regarding ice water recovery offer inconclusive or contradictory findings. I would really hate to go through all that if it doesn't really help!

In Response To "Is it fair to compare American health care with systems in Europe or Canada?"

I found an interesting article on KevinMD written by Ralph Silverman, a colorectal surgeon who blogs at The Colon Doctor.

Dr. Silverman discusses his thoughts on comparing American health care with systems in Europe and Canada. He attributes America's lower life expectancy, compared to Canada and Europe to a lack of healthy living, as opposed to a broken health care system. Saying,

American patients...are more obese than patients in other countries. We eat a diet high in fat and carbohydrate content. As a population, we smoke like there’s no tomorrow. We drive everywhere we go and don’t get any exercise. Instead of exercising to control our blood pressure or diabetes, we sit on the couch and take a pill. We eat ice cream and cake, and then take some insulin to bring down our sugar levels

I agree with Dr. Silverman because preventative care has been shown to be the best way to improve patients' quality of life. However, earlier in the article, Dr. Silverman explains that American's shouldn't expect universal health care just because Canadians and Europeans have universal health care,

It is true that those countries [Canada and Europe] do have universal health care, but is it a fair comparison?

Who does Canada rely on to defend its borders? When the Germans invaded France in World War II who stormed the beaches at Normandy? The point is, these countries rely on the United States for security when peace is compromised. America allocates trillions of dollars to defend both itself and the rest of the world. No other country does this. That money could easily be used for universal health care.

Discussing the "these countries rely on the United States for security when peace is compromised" issue would taint this post with a political slant that has nothing to do with the fallacy of Dr. Silverman's argument, so I will leave it alone. However, the crux of Dr. Silverman's argument in the above quote is that America could easily provide universal health care, but it must spend that money on other expenditures, like defence. Thus, American's should not expect the same health care that Canadians and Europeans receive because Canadians and Europeans have fewer financial burdens, allowing them to spend more on universal health care.

Reuters illustrates the argument against Dr. Silverman's statement quite nicely.

Here is a comparison of the United States' health care costs versus those of selected other countries in 2006:

UNITED STATES: 15.9 pct of GDP, $6,657 per capita

BRAZIL: 7.9 pct of GDP, $371 per capita

CANADA: 9.7 pct of GDP, $3,430 per capita

CHINA: 4.7 pct of GDP, $81 per capita

FRANCE: 11.1 pct of GDP, $3,807 per capita

GERMANY: 10.7 pct of GDP, $3,628 per capita

INDIA: 5.0 pct of GDP, $36 per capita

ISRAEL: 7.9 pct of GDP, $1,533 per capita

JAPAN: 8.2 pct of GDP, $2,936 per capita

MEXICO: 6.4 pct of GDP, $474 per capita

SOUTH AFRICA: 8.7 pct of GDP, $437 per capita

SWEDEN: 8.9 pct of GDP, $3,598 per capita

RUSSIAN FEDERATION: 5.2 pct of GDP, $277 per capita

UNITED KINGDOM: 8.2 pct of GDP, $3,064 per capita

America probably does spend much more money on defence than Canada and Europe. However, that does not help the argument against universal health care. The countries that offer their citizens universal health care (e.g. Canada) spend significantly less per capita on health care than the United States. The American health care system is broken and needs to be reorganized. People aren't lobbying for more money to be thrown at the problem. They are lobbying for a more intelligent system.

Again, living healthy is paramount and pushing Americans to clean up their diets and improve their attitudes about exercise is very important, maybe even more important than health care reform. However, claiming that America can't offer universal health care because it spends so much money on defence just doesn't add up.

The Unfortunate Truth About Developing New Treatments

Our health has improved significantly due to advancements in medicine. We now live longer, better lives than we ever did before; however, most of these improvements took advantage of the sick and desperate.

Whenever a new drug, therapy, or treatment is developed, it must go through several phases of testing to ensure that it is effective, safe, and we understand its side effects. To achieve the most accurate results possible, we perform double blind testing. This form of testing involves at least two drugs, the new drug being tested and either the drug that is currently used to treat the disease or a placebo. Multiple drugs are required to provide a comparison to judge the new drugs efficacy.
Double blind testing avoids biased result because neither the patient nor the physician know which drug the patient is taking.

Thus, once a patient decides to participate in a clinical drug trial, there is approximately a 50% chance that the patient will be given either a placebo or an old drug that is known to be ineffective. With more pathogenic illnesses this can severely reduce a patients quality of life or even result in their death.

Normally the results of these studies are closely watched and if the investigators notice that one treatment method is significantly better than another they often switch all patients to the superior treatment. However, the patients on the inferior treatment will have already suffered significantly.

This means that many advancements in medicine required taking advantage of the desperation of very ill patients. If these patients were not desperate enough to go through clinical trials (wherein they may have been given a placebo), then the treatments would never have been tested and thus never approved for general use. Unfortunately, this is still the best method of treatment approval available to us today. Hopefully one day we will be able to perform robust drug testing without requiring patients to suffer phase 3 clinical trials...but that doesn't seem possible in the near future.

An Important Malpractice Precedent

The Vancouver Sun has an interesting article about a recent malpractice case. The article discusses the case of Shawn Kahlon, who had a bout of lower back pain ten years ago. Mr. Kahlon had spinal tuberculosis; however, the diagnosis did not occur until a full year after he started having the back pain. By then, the TB had already spread to his brain and caused severe damage.

In 1999, Mr. Kahlon went to a physician who ordered a CT scan in the hopes that it would provide insight into the back pain. The radiologist noticed some abnormalities and wanted Mr. Kahlon to come in for a follow-up scan with contrast dye. Scans using contrast dyes do have risks associated with them (as does EVERY procedure you do in the hospital...or even life...seriously, even walking up stairs has associated risks, so don't think any hospital procedure is completely safe); however, most patients go through contrast dye scans without any complications (as always, you should ask your physician if you are going through a contrast dye scan and you have any concerns). The article states that Mr. Kahlon's physician had noted in his chart that Mr. Kahlon seemed hesitant about undergoing the scan.

Unfortunately, two key speakers were not able to provide testimony for this trial. Mr. Kahlon's TB meningitis had left him with cognitive impairments so he could not take the stand. Also, Mr. Kahlon's family physician had died a year earlier, so he too could not take the stand. Thus, a considerable number of assumptions must have been made throughout this trial.

The issue that I found most interesting about this trial is that it set a very important precedent for future malpractice cases. The judge cleared the physicians of any liability and found that the hospital and health authority were 70 percent liable, and Mr. Kahlon was 30 percent liable. This was an important precedent because it protects the physicians. Finding the physicians liable would have been similar to telling every physician in Canada that they need to chase their patients to ensure they followed through on the advice they were given, a task that does not need to be put on our already over-worked doctors.

Unfortunately, the article did not really go into detail about how the hospital was responsible. It seems to me like Mr. Kahlon was told he needed a contrast dye scan and he decided not to do it. If that is actually what happens, then it seems to me that Mr. Kahlon is 100 perecent liable. Regardless, this was a very unfortunate case and hopefully Mr. Kahlon will be able to make a partial, if not complete, recovery.

Bad Pharmacy Tech or Bad Training?

I'm going to start this post with a disclaimer to ensure that you don't misinterpret what I'm saying. I am commenting on pharmacy technicians that are bad at their job. I am not saying all pharmacy techs are bad at their job, in fact, I'm sure many are very well trained and professional.

The other day I went to a local chain pharmacy. I want to tell you the name of this chain, but I'm too poor to afford council if they decide to take legal action. I went to the pharmacy to fill a prescription for a couple of vaccines. Normally, when you fill a prescription for medication, the pharmacist gives you the drugs, explains how to take them and any possible side effects or drug interactions. With vaccines, however, it seems that the pharmacy tech is deemed competent enough to sell the vaccines to the client without pharmacist assistance.

This particular pharmacy tech brought me the vaccines from the back of the pharmacy. She then billed me over $100 for the vaccines. I asked her why the bill was so high because I have a fairly good extended health plan so I was surprised the vaccines weren't covered. She explained that many insurance plans do not cover the cost of vaccines and that my insurance "probably" didn't cover them either. I insisted she double check and it turned out that she was wrong. This pharmacy tech should have done her due diligence and investigated whether my insurance covered vaccines instead of assuming it didn't, but if this was her only mistake I wouldn't have any grievance with her.

After she adjusted the price, I paid and she said goodbye. Being a medical student I knew that some vaccines need to be refrigerated if they aren't being administered immediately, so I asked her if I needed to refrigerate these vaccines. She confirmed that they did need to be stored in a fridge. What if I didn't know that some vaccines needed to be refrigerated? I don't think that vaccine storage procedure are common knowledge, are they!? What kind of training did this pharmacy tech have? She shouldn't be assuming that I have up to date knowledge about vaccine storage; in fact, she shouldn't assume I know anything. Even if I had told her I was a med student, which I didn't, even then she shouldn't assume I know a thing about vaccine storage! We aren't taught that kind of thing in class, at least not in first year.

My final problem with this pharmacy tech occurred when I asked her if I had to wait two weeks before the vaccine's protective effect was active. I asked because I remembered from class that the adaptive immune response takes about two weeks to develop memory cells to specific infectious agents, but I wanted to double check that this was also true for the adaptive immune response to vaccines. The pharmacy tech said that she didn't know. Now, if you are going to give me a vaccine, you should probably know how it works. Maybe knowing about vaccine activation delays isn't part of a pharmacy tech's job description, but if that is the case, they shouldn't be the ones giving the vaccines to the customer. I feel the onus is on the person selling the vaccine to tell the customer pertinent information regarding its storage, activity, and any other information that may affect the customers health. To make matters worse, the pharmacy tech, after saying that she didn't know about the activation delay, didn't even bother to ask the pharmacist. She just walked away. I had to insist she find the information for me.

The situation I went through was only a small hassle, but the problem is that I wasn't given important information. Since I've been taught about vaccines, I was able to ask the right questions, but what happens to the customer who doesn't have a background in health care? I'm not sure if this was a case of poor training or an irresponsible employee...either way, it's a problem.

Remembering the Patient Perspective

Being a med student puts you in the unique position of understanding both the patient's side and the physician's side of a hospital visit. We are not yet comfortable enough with the medicine to think that the diagnosis, treatment, or prognosis are routine everyday occurrences, but we understand some of the physiology and consequences of illnesses.

This perspective often allows us to see flaws in the way physicians, who have much more experience than we do, interact with patients. Physician experience breeds complacency as broken bones, surgery, and even death become "part of the job". On top of that, many doctors are overworked, exhausted, and running on very few hours of sleep. With such a combination of exhaustion and fatigue, it is not surprising that the quality of a physician's bedside manner may be reduced. However, I think there is a basic standard that must always be met.

Yesterday, I was in the emergency room with a friend who had injured her shoulder. She was in pain and very concerned that her shoulder may be broken. The emergency room physician that came to see her was very direct and concise. He did not indulge her in any small talk and, thus, did not build any rapport with her. When he began to examine her, he pulled the chair I was reaching for away from me without saying a word, so that he could use it himself. Now, this physician was not particularly friendly, but I don't feel that he did anything wrong in this physician-patient interaction (even though the guy stole my chair!). He was efficient, he got the job done, he explained to his patient everything that he was doing to her and he also explained what she should expect to happen during her next hour in the hospital.

The next physician that saw her was an orthopedic surgeon. He introduced himself, explained to the patient that she had broken her clavicle, and presented her options. She could elect to have surgery to repair the bone immediately, which would mean she would have to stay in the hospital for the next day or two, or she could wait to see if the bone healed on its own over the next two months. If the clavicle proved unable to heal on its own, she would have to have the surgery anyways. Due to hospital policy, if she wanted to have the surgery immediately she had to decide while she was in the hospital, otherwise, she would have to wait the two months.

This orthopedic surgeon did the bare minimum that was expected of him. He answered all of the questions that were asked; however, he did not even attempt to convey any additional information that could be important to the decision at hand. I think he should have mentioned how either decision would affect the range of motion in the shoulder, any potential complications if she chose to wait two months and found she still needed the surgery, or how her short term quality of life would be affected if she chose to wait two months. He did answer all of these questions when asked, but what if they had not been asked? It's hard to make an informed decision if you aren't informed! While talking to me, she mentioned several times how she did not like the idea of having a foreign object in her body. He just sat there pretending he didn't hear anything, instead of providing his insight as an orthopedic surgeon and perhaps mentioning the evidence based data that supports inserting a metal plate into a person's body.

Worse of all, he kept mentioning how he was in a hurry because he was "off the clock". He explained that he started his shift at 1:00 pm, it was 12:00 am at the time, and he needed to get home to sleep because he had to be back at the hospital at 7:00 am. He pushed for a decision over and over again saying things like, "once I'm done this paper work you've got to decide", "we're on my time, I need to go home", and "listen ma'am, I don't know what is taking you so long". In short, the guy was douche. For him, surgery to repair a broken clavicle might be as normal as warming up leftovers for dinner, but for the patient, this was the first broken bone she had experienced, it was a big deal. Pushing her to make a decision in five minutes is not only incosiderate, it is unethical. He hadn't taken the time to teach her enough about the surgery to consider her decision informed.

I understand that he was tired, that he wanted to go home, and that he doesn't control hospital policy, but all he needed to do was take off his douche-bag-doctor-hat and wear his normal-human-being-hat to see that he should have explained everything. All it would have taken was a "look, I'm very sorry, but hospital policy states you have to give me your answer before you leave and unfortunately, I'm at the end of my shift. I've been here since 1:00 in the afternoon and I'm due back at 7:00 this morning, so I need to go home and get some sleep to be able to do my job properly. I really do apologize, but this means you are going to have to make a decision in the next ten minutes, which is really tough. Is there anything I can do to make that easier?"

If he would have spoken like that his patient would have been more comfortable with him and probably trusted him a hell of a lot more. In fact, she probably would have agreed to allow him to perform the surgery on her. Instead she thought he was a jerk and didn't want him to touch her, a response I'm sure he is used to from his experiences clubbing at a younger age...

Smoking Leads to Cancer?!

Sometimes med students, physicians, and everyone else involved in the health care industry forget that our knowledge about health and medicine isn't all common knowledge that we can expect everyone to know. Apparently, not everyone knows that St. John's Wort is actually a medication and it has many drug interactions you need to be aware about before you fill a prescription if you are taking St. John's Wort. However, there are some things that I think the general public should be expected to know. One of those things is that smoking leads to cancer! Seriously, people NEED to know this! Lung cancer is a terrible way to die and you need to be aware that smoking greatly increases your likelihood of lung cancer. If people knowingly risk lung cancer and continue to smoke, that's one thing...but people who start, or advocate, smoking without knowing how fatal smoking can be...that really shouldn't happen in this day and age!

Calling Out the Boy Who Cried Wolf

Munchausen syndrome by proxy is a scary form of Munchausen syndrome. In Munchausen's the patient fakes an illness to get attention from physicians. In Munchausen's by proxy, a person, usually a parent or caregiver, makes a patient, usually a child, sick or injured to get attention from physicians. The parent or caregiver can even fabricate the child's illness, making the child believe that he is sick and that he needs to see a doctor when he is actually completely healthy.

This is a difficult diagnosis to make because if it is incorrect, the child will not be getting the treatment that he needs.

Admitting Ignorance is OK

It is not OK for a patient to have sinus congestion for an entire year. It is not normal for a patient to develop a recurring fever for a day or two almost every month. When these symptoms occur simultaneously with the onset of joint pain, maybe there is something actually wrong with your patient. I don't know, maybe your patient is actually ill? Running a gamut of tests that return negative results and then telling your patient, that it is just her allergies, is not proper patient care. She has had her allergies for her entire life and she has only had the aforementioned symptoms for the past year. Something doesn't add up here.

I think doctors should be comfortable with saying that they do not know what is going on. Referring a patient to a different specialist or to another colleague for a second opinion doesn't mean you are a bad physician; it just means you want someone with a different perspective and a different set of experiences to take a look at your patient and help you figure out the problem. That is how medicine is supposed to be practiced.

Maybe you're right, maybe her allergies have just progressed and the symptoms have become worse over the past year. Even if that is the case, you should probably tell your patient why you are not modifying her allergy medication and its dose because, otherwise, it seems like you are saying her allergies are getting worse and she just has to live with that. Maybe that is also true, and there is nothing medicine can do for her new symptoms, but TELL her that, don't make her guess. I feel like I'm just asking for basic patient care that every physician should provide...it seems to ME like all of this is just common sense.

In the end, your patient is confused, suffering, and thinks her doctor is incompetent and a bit of a jerk (the latter two points may or may not be true...I have no idea, I've never met you). She is so desperate for decent medical advice she has resorted to asking a first year student what she should do and then exclaimed that I gave her better advice than you ever did. That is embarrassing. Relatively speaking, that is like a dog providing better relationship advice than your best friend...seriously, us first years are idiots (for now...).

Do Patients Really Worry About How They Are Addressed?

Throughout our first year, we have been taught asking a patient how they would like to be addressed is an ESSENTIAL component to the beginning of a medical interview. For instance, a normal opening to an initial interview with a patient might be: Hi John Doe, my name is William Abbott, I'm a medical student and I've been asked to interview you, is it alright if I call you John, or would you prefer Mr. Doe?

Do patients really care whether you call them by their first name or their last name? The last time I remember anyone being upset with me for using their first name was when I was in grade 3 and I learned my teacher actually had a first name, so I couldn't help but use it. I would also think that a patient would correct me if they didn't like how I was addressing them. I really don't see much value in asking a patient how they would prefer to be addressed, not that it is too much work or anything, I just don't like doing pointless things. However, the faculty REPEATEDLY demands that we do ask patient's how they prefer to be addressed. It is even incorporated into both of our first year clinical exam evaluations. Hopefully one day I'll understand what value this brings to my clinical interview.

P.S. Next time you're in the hospital...ask to be addressed as Batman, at the very least you'll give your doctor/resident/med student a good laugh. Although, I probably wouldn't do that if the physicians suspect you may have a psychiatric illness.

Researchers Should Learn How To Program

Throughout most of my first year in medical school, and by most I mean the entire time, my background in engineering was useless. Sure, I could figure out how to plot the inverse of a graph without breaking a sweat, but surprisingly, that isn't an important skill to have as a doctor...doesn't really help with picking up the ladies either, seriously, Dr. Madden is a liar!

Anyways, this summer I'm doing research and I've finally been able to take advantage of my background in electrical engineering. I've found my experience in programming to be priceless. In our lab we collect our data in excel spreadsheets and then analyze them. Excel, and most other Microsoft Office products, have a scripting language called VBA. VBA is an easy language to learn, particularly if you have programmed or scripted in another language before. Using VBA, I am able to automate data analysis. For example, instead of having to calculate the mean of a column, I can write a script that will do it for me. Not that impressive when you look at a simple example like that, but you can imagine that if you have ten thousand columns per spreadsheet and you have 500 spreadsheets, then it would be nice to be able to write a ten line script just once to be able to calculate all the column means you need.

Anyways, being able to automate the analyses of the excel data has been incredibly valuable. I spent maybe a day writing scripts, but I will save at least two weeks in the end because the scripts will take me about two minutes to analyze the data collected from each patient.

Automating analyses can be a huge time saver. The time you invest in learning how to script will payoff in the end, especially if you find that you can reuse parts of your scripts in multiple studies (which is often the case).

Med School Finals vs. Undergraduate Finals

Practically everyone knows that med school is difficult and that the exams are fairly intense. People even joke about how med students become intimately attached to caffeine during exam season just to survive (funny because it's true I guess...).

One of the first things you should realize as a med student is that these exams are different from any exams you have taken before in undergrad. I did my undergraduate degree in engineering, another degree that is universally considered to be difficult, but even though I had up to 9 courses in a term, those exams were much easier. The difficulty in medical school exams comes from the amount of content, not necessarily the difficulty of the material. The key difference from undergrad is that you can review an entire undergrad class in 3 days if you have kept up throughout the year and you can buckle down and focus during crunch time. After those 3 days, you can known EVERYTHING that you are expected to know for that course.

In med school, you can spend three weeks, theoretically, studying for a single course and still not memorize everything you need to know (I say theoretically because you also have several other courses you need to study for at the same time so you can't actually devote three weeks to a single course). The best thing you can do for yourself as a med student is to accept that you won't know every detail of every subject that you can be tested on. Coming to terms with this fact will help you study effectively without stressing out. Many of our exams are multiple choice, so if you focus on understanding basic principles you can often do a good job of narrowing down the correct answers.

Nice Guys Might Finish Last...But A Heart Attack Will Kill You

I don't care how tough you are...if you wake up because you feel a weight on your chest, see a doctor. If you develop chest pains that radiate to your left arm, see a doctor. If you feel heart palpitations ever, even if you think they're happening because you're with the love of your life, see a doctor. If, when you're driving, you press on your break pedal but your car doesn't stop, well in that case see a mechanic, your doctor isn't going to be able to help with this one.

Point being, chest pain is a big deal. Your heart is kind of essential for living. Don't be the guy who waits a week before coming into his doctor because you aren't going to like hearing you have permanent cardiac damage that could have been averted if you only saw us earlier.

What does H1N1 mean?

As you probably already know, pig farmers and Jewish and Islamic interest groups have finally convinced the WHO (World Health Organization) to rename the swine flu virus to the influenza H1N1 virus, but what does H1N1 mean?

Every strain of influenza has an H protein, hemagglutinin, which allows the virus to attach to human host cells, and an N protein, neuraminidase, which destroys mucous. There are multiple types of hemagglutinin and neuraminidase, so the numbers that follow H and N describe the specific type of hemagglutinin and neuraminidase found on that strain. Hemagglutinin and neuraminidase are important because they are essential proteins that allow the influenza virus to infect us. For example, influenza causes a soar throat by clearing the protective layer of mucous usually covering the throat cells with neuraminidase, it then binds to the uncovered cell with hemagglutinin, and finally the virus injects itself into the cell and destroys it.

Swine Flu: Lose-Lose for Politicians

This swine flu virus (now H1N1 flu virus) is bad news for politicians across the globe. If government officials do not handle the flu outbreak promptly and properly, they will allow a global pandemic. Obviously, their voters will rally around this inaction as an example of government ineptitude. However, if they do handle the outbreak properly and prevent a pandemic, many voters will probably forget about the swine flu and only remember the large number of tax dollars that were used to fight a problem that never happened.

I think that there are a good number of people that, paradoxically, can only appreciate the potential devastation of an outbreak if they see it happen, and obviously, if the outbreak is prevented, it won't be seen. Of course, I think the politicians should and will act in the best interest of the general public and contain the virus; I just think that their work will not be adequately appreciated.

Masks DO Help Against Swine Flu

I heard a bit of irresponsible journalism on the radio today. A reporter stated that people should wash their hands regularly to prevent infection/transmission of swine flu, but that masks were useless.

Now I agree that hand washing is probably MORE important than wearing a mask, but a mask can still help! I'm specifically concerned that someone who thinks that they are infected with swine flu may decide to fore go a mask because they think it doesn't make a difference. If you are infected, wearing a mask is of utmost importance if you are going out in public, which you hopefully aren't, because a proper mask will prevent the transmission of your germs to everyone around you.

If you aren't infected, wearing a mask can help stop germs from getting into your body, but unless you are in an environment where you are in close proximity to infected individuals (like you work in a hospital) you probably are at a lower risk of infection. Most infectious agents do not remain in the air for long after they are expelled by their host (i.e. after a person sneezes). Of course if you want to play it safe, why not put the mask on. Better yet, get the mask companies to make designer masks that make you look like a superhero.

Baby Formula Made Wrong!

We were told about a case today where a mother mixed up her portions when she was making formula for her newborn. Instead of mixing 1 part formula powder with 2 parts water, she mixed 4 parts formula with 1 part water. The baby ended up dying with a blood sodium level above 200 mmol/L (normal levels are around 140 mmol/L).

The poor baby was basically poisoned by salt...

Insurance vs. Diagnosis

Imagine a scenario where you suspect you have a debilitating illness. You have had scary symptoms, like shaking uncontrollably and randomly losing your balance, for almost a year. You have never seen symptoms like this before and you are scared. Your latest symptoms provide more insight into your disease and the doctor says that he finally has an idea what may be the diagnosis.

To confirm the diagnosis he must do some imaging. However, if he does the imaging and the imaging supports the diagnosis, then your medical record will show that you have a chronic condition. Your doctor advises you to get disability and health insurance before you get the imaging done because it will be much easier and cheaper if you get the insurance while your records say that you are healthy. However, this means you will have to wait for several more months before you know if you actually have the disease.

Did the doctor do the right thing in this scenario? He is giving his patient the opportunity to acquire affordable insurance before he confirms the diagnosis. If I was the patient, this is the scenario I would prefer. However, there are patients out there that are very anxious and want to know what their illness is immediately. For them, that anxiety outweighs the potential benefit gained from getting their affairs in order.

As usual, the right answer in this scenario is to present all the information to the patient and let them decide...even if it seems like the patient may be making life harder for themselves with their decision.

What Makes Swine Flu So Dangerous?

Unless you've been disconnected from the global news for the past few days, you've heard of swine flu. Swine flu is basically the flu in pigs caused by a specific strain of influenza. The influenza viruses are a family of viruses that infect mammals (including people) and birds.

There are multiple strains of the influenza virus. Different strains have slight differences in their genetic code, which result in massive differences in the virus' features. Different strains are often specific to different species and some are better at hiding from their hosts immune system than others.

Influenza viruses are most dangerous when they are first able to infect a new host species. For example, our bodies have seen human influenza for years and our immune system has learned how to fight it. This is why most of us only have flu like symptoms for about a week after we are infected with human influenza. However, our bodies have never seen swine influenza because we aren't pigs (feminists may disagree with half of that statement). Thus, when swine flu is first able to infect humans, the virus is incredibly good at making us sick because our immune systems don't know how to fight it.

Swine flu has the potential to be a pandemic because it may be difficult for our immune systems to fight, which means it would be able to easily spread from person to person.

A very important point to remember is that all the infected patients in Canada have had mild symptoms, so this virus may not be as dangerous as we are fearing. However, it is responsible for over 150 deaths in Mexico, so health authorities are justified in their concerns about swine flu.

Listen To Your Patients...Even If They Seem Crazy

We learned a valuable lesson in patient care last week. We were told about a patient who was visiting a city on business and wound up in the hospital. He was waking up from general anesthesia to hear his doctor order him a course of heparin (heparin is a blood thinning agent). Upon waking up and hearing the order the patient demanded not to be given heparin, stating there was an article about how heparin was contraindicated in his condition in some journal from the 1980's. When asked how he knew about this article, the patient said he know about it because he wrote it. This was how the story was told to us; however, I do suspect that since this patient was waking up from anesthesia, the language may have been more colourful and a shade more disrespectful because the attending physician completely ignored the patient. My guess is the doctor thought the patient was still hopped up on the drugs he was given and his comments were just lunatic ramblings.

Turns out this patient was our professor and a doctor himself. Also turns out that he actually did write that article and knew what he was talking about. He almost bled to death because his doctor ignored him.

Why Male Medical Students Get The Shaft

Believe me, I'm thankful I'll never have to push a tiny person through my genitalia after growing it for 9 (really 10) months, I'm also happy living without a monthly hormonal cycle, but sometimes you miss out on good learning experiences being a guy.

At my school, we work with family doctors once a week throughout the year. Most of us go in pairs, often one guy and one girl. Almost every girl who comes in for anything uniquely feminine (yeast infection, pap smear, breast exam, etc.) will only see a female student. This double standard does not cross genders because male patients seem to be more than happy to talk about erectile dysfunction or drop their trousers in front of either a guy or a girl.

This dichotomy does not affect most of us because we will eventually deal with these illnesses in the hospitals when we are 3rd year students; however, it would probably be better for everybody if we gained some practical experience sooner rather than later. If you reach the point where a urinary tract infection has put you in the hospital, do you really want a medical student who has never talked to a female patient about anything "feminine" before?

The students who are really hurt by this discrimination are the male students who are interested in OB/GYN. There aren't many, but those few miss out on clinical experiences that may decide their future careers.

Hemoglobin is Proof of God II: Carbon Dioxide Transport

If you came to this series of posts hoping to find a rigorous theological debate regarding the existence of an omnipotent power...I'm sorry to disappoint (not really).

Carbon dioxide (CO2) is a metabolic byproduct of aerobic metabolism. Aerobic metabolism is our bodies' primary method of energy generation and it produces a large amount of CO2. This CO2 is released from our bodies into the external environment through our lungs, which will be discussed in a later post. This means that our blood has to transport CO2 from our tissues (e.g. your calf muscle) to our lungs.

There are 3 methods of CO2 transport:

1) CO2, like oxygen, is transported as a dissolved gas in blood plasma. This accounts for 2-10% of our blood's total CO2.

2) CO2 can bind to hemoglobin (and other blood proteins) and be transported to the lungs with the hemoglobin. A single CO2 binds to a single hemoglobin molecule (remember this is different than oxygen, 4 oxygen molecules bind to 1 hemoglobin molecule). This accounts for 5-10% of our blood's total CO2.

3) CO2 can be converted to bicarbonate (HCO3-) by an enzyme called carbonic anyhdrase. The chemical equation for this reaction is: CO2 + H20 -> H2CO3 -> H+ + HCO3-. This reaction is reversible. 80-90% of our blood's CO2 is transported as bicarbonate.

Note: An important concept to understand for future posts will be Le Chatelier's principle
, with regards to concentration, and how it applies to the above equation.

The next post will discuss how gas is exchanged in the lungs.

Hemoglobin is Proof of God I: Oxygen Transport

If you came to this series of posts hoping to find a rigorous theological debate regarding the existence of an omnipotent power...I'm sorry to disappoint (not really!).

Hemoglobin is a protein found in red blood cells. Hemoglobin consists of four subunits and each subunit can bind to a single oxygen molecule. This is the main method of oxygen transportation in our bodies, 98% of our blood oxygen is bound to hemoglobin. If we didn't have hemoglobin, we would die because our organs would suffocate, they would not get enough oxygen (at least you would leave a pretty corpse).

The remaining 2% of the oxygen in our blood is dissolved in the blood fluid (note: if the idea of gasses dissolved in fluid confuses you, think pop (soda for the americans), the bubbles in pop are created because carbon dioxide is dissolved into the drink at the manufacturing plant).

Hemoglobin is, in a sense, a perfect protein. It has several properties that make it an optimal molecule to help with gas exchange. This series will cover several background topics, culminating in a final post explaining these optomized properties.

The next post will discuss carbon dioxide transport in the blood.

Before You Give Medical Advice...Look At The Patient....or Atleast Their File!

I saw a patient who told us that she had been drinking as much V8 as she could because her dietitian suggested it as a good source of nutrients and electrolytes. Now, it's true, V8 is a great source of vitamins and minerals. I mean vegetables are good for you and V8 is just a can of liquefied vegetables more or less, but that doesn't mean it's harmless.

The dietitian, who suggested that our patient double fist V8 because she was eating less and needed to keep her nutrient levels up, apparently thought it wasn't necessary to ask about the patient's primary illnesses. Even though it would take two minutes to ask and then see that the patient had tremendous peripheral edema and her legs had swollen up to 3x their normal size.. Oh, and why read a patient's file if you're suggesting a simple over the counter drink. Not even medication! Just a drink! Sure the file says the patient is on a diuretic...but who cares?!

Well, V8 is loaded with salt...if you've ever had it, you know it tastes like it was made with ocean water...salt, or sodium to be more precise, is an element the body uses to retain water. Peripheral edema is swelling that is due to an accumulation of water. A diuretic is a pill that helps the body get rid of water. The dietitian basically increased the severity of the edema and undid the work the diuretic pill by ordering the patient to ingest so much salt. This all happened because looking at a patient or reading her file wasn't apparently worth the dietitian's time...

Keep in mind there are plenty of dietitians out there that do a great job. The one that this patient saw is definitely not one of them.

Electronic Health Care: Engineers != Doctors

For those of you who aren't programming nerds, in the C++ programming language "!=" means "not equal to".

I was in the ER last week and noticed a significant problem with the software the hospital was using to triage, order tests, and discharge patients. The doctors and nurses, regardless of age, were having difficulty using the software. The user interfaces were not intuitive to them and they couldn't navigate their way around the program. They would try to look at test results and they couldn't figure out how to display lists of x-rays. They couldn't look at notes from a patient's previous discharges. The program they were using was new, supposedly better than their old program. However, after the staff had finally learned how to use the old program, they were struggling to find their way around this new interface.

I took a look and the program seemed incredibly easy to navigate and I ended up showing the physicians how to use the application. Think about that, a first year stduent was showing these full-fledged doctors how to use the application that they use to care for their patients.

The problem was that the software was very intuitive to me because I've spent 6 years as an engineer and only 6 months as a physician (the student version). Engineers, or computer people in general, have a different set of needs for their program. We want our applications to be streamlined so that we can use the fewest number of mouse clicks possible to get the results we need. We like keyboard shortcuts to access menus quickly. We care less about a pretty interface (not always true), as long as we can maximize our efficiency. The average user doesn't think about this and they are generally willing to replace efficiency with ease of use. The hospital staff don't want to learn shortcuts, they want everything they need displayed in front of them. They don't want to click through a set of options to make sure their layout is optimized, they just want an application that does what they need 90% of the time without being told. If they have a need that falls in the 10%, they are generally willing to wait for the IT guy to come out and show them how to do it.

If software companies want widespread adoption of their applications for use in health care settings, they really need to make sure a health care professional is involved in their interface design and user experience development. Otherwise, you get a hospital with a frustrated staff who are less efficient and the already high patient wait times increase.

Why your nose runs when you cry...

If you've ever seen someone crying, I mean really crying, you'll notice that often they have a runny nose too. Normally you don't see this when your girlfriend is shedding a couple tears when the guy in He's Not That Into You is proposing. Nor do you see a runny nose when you're shedding a couple tears because you realize you were dragged out to see the most convoluted, soap opera-esque movie...ever. You do however, see the runny nose if you see someone really bawling. Just find me if they ever make a sequel to He's Not That Into You.

You see the runny nose because our eyes are connected to our nose through a nasolacrimal duct. Tears flow from the lacrimal gland, which is in the upper outside corner of our eye, and flow downwards. Some flow out of our eyes and down our face, but a large majority flow into the lacrimal sac, which is that red, ball shaped sac at the inside corner of our eyes. That lacrimal sac is connected through lacrimal cannaliculi (canals) to the nasolacrimal duct, which is connected to our nose through paranasal sinuses. And that's the path tears take to run through your nose.

This anatomy is a two way street and explains how some people can snort milk up their nose and squirt it out their eye (seriously!).

I really hope they don't make a sequel...

ER Etiquette

The media has no shortage of stories describing the extended waits patients face when they arrive to the emergency room. However, following simple ER etiquette will help your visit be as short as possible.

Upon arrival, explain your symptoms to the nurse as accurately as you can. This will help them triage you and decide how quickly you need to see the doctor. Unfortunately, patients are often motivated to exaggerate their symptoms because making their illness appear worse will result in them skipping ahead in the line. We then see an instance of game theory where every patient is motivated to exaggerate their symptoms to prevent any other patient from skipping ahead of them in the ER queue.

I don't really have any advice on how to deal with this dilemma. However, I will tell you that exaggerating your symptoms too extremely can result in a barrage of unnecessary tests. This testing can be dangerous because every test has some associated risks, whether they be exposure to bugs or radiation. The testing will also extend your stay because waiting for equipment to become available can take a long time, especially if everyone is exaggerating their symptoms.

Once you get admitted into the ER, be polite but be heard.

First, be polite. Do not talk to the staff rudely, especially the nurses. If you are frustrated with their work or attitude, you can let them know if you really want to, but talk to them like they are colleagues, not the hired help. For example, if you were promised breakfast at 8 and it's already 8:30 and you haven't got your oatmeal. When you see the nurse, you can say "Hey, I know you're really busy, but I was told I'd have breakfast at 8 and it's already 8:30, can I get you to help me out, I'm starving." This is the preferred response over, "Hey, you told me I'd get my breakfast at 8, it's 8:30, can't you do your job right?"

Seriously, be polite, I'm not trying to teach you manners, this advice will help you if you're ever in the ER. I have seen quality of care deteriorate because patients have been disrespectful. At best, the health care staff will try to admit you to a different department and your stay at the hospital will be extended longer than it needs to be. At worst, you may be discharged quicker than you should be because you are an ass. The ER staff will obviously not intentionally harm you, but it is human nature to not be as eager to help someone who is treating you like dirt.

Secondly, be heard. The ER gets VERY busy and if you are too quiet the staff may forget about you. Or worse yet, mistakenly assume that your illness isn't as serious. Though I have yet to see the latter, I have seen a girl who was forgotten because she was too quiet. She came to the ER because she had a severe bout of diarrhea, but after the doctor saw her he decided that she had passed through the worst of it and that she should be discharged. Unfortunately, he was sidetracked because there were 20 other cases that all came in at once and the girl, who was sitting quietly in her bed, spent an extra 4 hours in the emergency room before the doctor got around to ordering the discharge.

The White Whale of Endocrinology

Some time last term an endocrinologist was lecturing to us about the autonomic nervous system. He brought up a hypothetical scenario where a patient had overdosed on a sympathetic stimulant, which would cause tachycardia (fast heart rate), bronchodilation, pallor (paleness), diaphoresis (sweating), etc. Turns out this situation rarely occurs from an overdose of drugs because we don't give people many sympathetic stimulants. However, patients can have a pheochromocytoma, a tumour on their adrenal gland, which causes excess adrenaline to be secreted throughout the body. These episodes of excess adrenaline are often on and off, not constant. Adrenaline is a sympathetic hormone which causes the aforementioned symptoms. This illness is VERY rare, yet doctors, especially endocrinologists, cannot stop talking about it. I have heard 6 different doctors tell me about pheochromocytomas, but none, not a SINGLE one, had ever seen one before. They all ended the discussion with some variation of "remember, if you ever see one while you're on the wards, give me a shout if I'm at the hospital".

The pheochromocytoma is the white whale of endocrinology. Endocrinologists keep chasing after this rare disease and, it seems, they will not be fulfilled with their careers until they see it. I'm sure that through the years I will go on to learn about the white whales of other specialties.

Oddly enough, last week, a patient came to talk to my class about his pheochromocytoma. Turns out he had been having regular bouts of panic attacks when he was stressed and went to his family doctor to see what was happening. A cyst was found above one of the patient's kidney in the past, but he had been told that many people have them and that these cysts are entirely normal. The family doctor ran a blood test and measured his blood pressure and saw that everything was normal, so he thought the problem was entirely emotional. Then a few months later, things got worse. The patient would be climbing a set of stairs and have the same "panic attacks". He would also be having these panic attacks more often.

Finally, his doctor sent him to an endocrinologist who began piecing the puzzle together. The patient had panic attacks. Panic attacks are a "fight or flight" response. When you have a panic attack, your heart rate rises, your skin becomes pale, and you sweat...you are having a sympathetic response. The blood test ordered by the patient's family doctor did not alarm the doctor because the pheochromocytoma had episodic bouts of adrenaline secretion and the patient was not having an episode when his blood was tested. Finally, guess what is sitting right on top of the kidneys, where these "cysts" were...the adrenal glands. Those cysts were actually adrenal medullary tumours.

Surprising how a disease that is mentioned in med school so often (6 times in 5 months!) can go unnoticed because it is so rare in the population. Fortunately, the tumours were removed and the patient has made a full recovery.

Scary that he went undiagnosed for so long because a pheochromocytoma can easily be fatal. Too much adrenaline can cause heart failure. I guess the lesson is that you should always look out for the white whale.

Migraines Lead To Temporary Blindness!?

Follow up on a case I discussed earlier this month. The patient went to the opthamologist and he told her that her eyes were healthy. The patient then came back to see my preceptor, who suspected that the symptoms could be prodrome for migraines.

Turns out that the patient used to have bad migraines 10 years ago and a day after she saw us she had them again.

I had no idea that migraines can induce temporary blindness! Apparently this is relatively common in migraine sufferers.

Freaky!

Vision Acuity Test

In my latest post I talked about doing a vision acuity test, so I thought it might be a good idea to explain how the test actually works. Most people have seen an eye chart in either their doctor's or their optometrist's office. It's a standard white chart with black letters in rows. From the top down, each row has more letters and the letters in the row are smaller than the letters in the row above them. Beside each row you see a score, the top one is usually 20/200, the next one is 20/100, and so on. The numerator refers to how far in feet the patient is when he or she is doing the test. The denominator refers to the farthest distance, in feet, that a person with normal vision, 20/20, can be and still be able to read that row.

During the test, the patient usually stands 20 feet away from the chart and reads aloud the smallest row of letters that he or she can. The score beside the letter represents their vision acuity. The patient usually does the test once with the left eye covered, once with the right eye covered, and then with both eyes uncovered.

Warped vision -> Blindness -> Out Of My League

As I've mentioned before, at UBC we start working in a family practice clinic from day 1. In our first term, we spend the majority of our time in the clinic interviewing patients because we don't really know anything about medicine. In second term, which we are currently in, we begin learning the fundamentals of medicine and we begin to develop our diagnostic skills.

Since January, I've been seeing a variety of patients who have mostly had infections, sprained ankles, and needed vaccinations. Most of the patients have been fairly straight forward and I am already able to predict the course of action the doctor I am working with will take with these cases.

There are some cases that are a little bit tougher though. Last week, I saw a woman whose chart stated that she wanted to see the doctor because she was feeling dizzy. I was thinking I'd see her, do an interview, take her blood pressure, check her ears, and everything would move along smoothly. Instead, as soon as I start asking her about her presenting complaint, I find out she temporarily lost her vision. She was talking to a friend and all of a sudden her vision started to warp and then she went completely blind. A few minutes later her vision came back but it was cloudy. Then, she went to lie down, and the back of her head started to twitch. That may have been a coincidence, but it was interesting because your visual cortex is located in the rear portion of the brain. After the twitching, she made her way to the clinic and now she was feeling dizzy but her vision was fine. I just sat there thinking...she temporarily went blind, and she told the office assistant that she wanted to see the doctor for her dizziness?!

Her blood pressure was fine, a little low maybe, but nothing that would set off any red flags. The problems with her vision, and by "problem with her vision" I mean the disappearance of it, made me give her a vision acuity test. She said that she had glasses but only needed them for driving. I gave her the test and she had 20/20 vision in her left eye. Her right eye, however, was 20/100. That's pretty bad! Afterwards, surprise surprise, she told me that she wears her glasses to correct the vision in one of her eyes, but she wasn't sure which one. I'd put my money on it being the right eye ;)

Anyways, after all this...I had no idea what the cause of her symptoms could be. This one was completely out of my league. Apparently 5 months of medical school doesn't make you knowledgeable enough to be a doctor. All I could do was try to comfort her because she was understandably shaken up by the whole ordeal. I am fairly certain, however, that she should be wearing her glasses at all times. Relying on her left eye all the time will put excessive strain on it.

My preceptor wasn't sure what the diagnosis was either, so we decided to refer her to an opthamologist.

Cold Sores = The Kiss of Death

In PBL last week we learned about the kiss of death. Apparently, if you have a cold sore, you are a very serious risk to newborns.

Cold sores are caused by the herpes virus. The herpes virus has the ability to travel through nerves and infect the brain, which is called herpes encephalitis. This normally doesn't happen because healthy people have an immune system that is strong enough to prevent the virus from entering the brain. However, a newborn's immune system is still developing, which means that babies are extremely vulnerable to herpes encephalitis (among other things).

We were told the story of a resident who had a cold sore and kissed his 2 week old son. Within the next two weeks the baby had herpes encephalitis and died.

Many people carry a herpes infection; however, they are normally do not spread the infection because the virus is not actively replicating in their bodies. Cold sores are indicative of active, replicating herpes virus. Moral of the story, don't kiss a baby (or anyone really) if you have a cold sore.

No You Can't Leave...I'm Not A Real Doctor

I'm writing this post to beg everyone to remember that a 1st year medical student is NOT a real doctor. Make no mistake about it, you are doing US a huge favour when you let us see you in the clinic. You are helping us learn how to interview, give shots, perform a head and neck exams, etc. The most we can do for you is give you pleasant conversation and maybe a laugh.

This week in the clinic, I saw a man who was diagnosed with bronchitis during his previous visit, he wanted to know if he was getting better. I took his history and listened to his lungs. I haven't been formally taught how to do a respiratory exam yet, but my preceptor told me to give it a shot. How hard can it be? I know both where the lungs are and how to use a stethoscope. Anyways, I took my best guess and his lungs sounded fine to me. Unfortunately, I have no idea what they would sound like if they weren't fine, so my opinion is relatively worthless at this point and I made sure to let the patient know as much. I would hate to make him think that he was getting better only to have the preceptor see him and tell him that he needs to go to the hospital immediately.

Anyhow, I left the patient in the exam room and waited outside for my preceptor, who was seeing another patient. Eventually, my patient got tired of waiting and tried to leave. He told me that I checked him out and that was good enough.

No, it really wasn't good enough. I had to twist the guy's arm to get him to stay. Maybe next time I should tell the patient I think they have SARS, that way they'll probably wait to hear an opinion from a real doctor.