one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.
From the editor: Health care is nearly 20 percent of our GDP. The surest way to be a full participant in this massive and growing sector of the economy is to get an MD. But it is a substantial commitment for a young person to prepare for, enter, and complete medical school. What is it like day-to-day? To help young people (and old people advising young people) answer this question, I placed a mole in one of America's medical schools. We pick up the story in the middle of 2017.
To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous.
We gathered at a Sunday barbecue before our first day of the second year. We won't expect to see too much of Awkward Allen because he married a business consultant who works two hours away and moved in with his wife. Although several students toiled away in our research labs over the break, most people took at least a short vacation. The young father whose wife is in law school jetted off to Europe: "our first vacation since the baby was born eight months ago." Baby was parked with the grandparents for two weeks. Two classmates coincidentally were both on separate vacations with parents and siblings to Peru. They took different approaches to anthropology. One camped in the mountains among the Inca ruins. The other reported, "the alcohol is so cheap there. Our family's whole tab for a week was seventy bucks!"
We're nervous about this block, covering clinical microbiology (everything that can cause an infection: bacteria, viruses, fungi, parasites, autoimmune disorders). All of last year's blocks were centered around a single physiology textbook. We'll be using a diversity of materials, many self-selected, for microbiology. About a fourth of students started researching textbooks and studying during the break. The general consensus of upperclassmen, based on the class Facebook and Group-Me chat, is to use Sketchy Micro. These are a video series of narrated progressive illustrations. For example, they will draw a cat for bacteria that are catalase-positive, or draw a van for bacteria that the recommended antibiotic treatment is vancomycin. In our new small-groups, some students close their eyes to imagine the illustration. It seems odd, but it works for them. So far I'm just using a textbook: Medical Microbiology by Murray.
Reflecting modern education's prioritization of bureaucracy over academics, M2 opened with an hour-long orientation led by two deans, experts on paperwork for the LCME. This year will be clinically-focused in comparison to last year's emphasis on basic science. This will prepare us for the rotations of M3 and M4, our "clerkship years." We need to be able to conduct a full history and targeted physical exam, then present this to our attending or resident with our differential diagnoses. Most lectures will be conducted by practicing clinicians, instead of PhDs, requiring scheduling flexibility on our part.
Our first lecture began on Monday at 9:00 am, right after the orientation. An Emergency Medicine physician in his mid-thirties specializing in the management of sepsis kicked off what promises to be a jam-packed two weeks of bacteriology. Our textbooks give the illusion that the moment you send a sample (e.g., blood, stool, urine, or sputum) off to the "Lab", the identity of the bacteria is immediately ascertained. "When I have a potential septic patient in the ED, I do not have two days to wait to grow a culture. Instead, I will get back a few key findings in maybe two hours before the full report. The prelim report will give me Gram-staining. If the identified bacteria is Gram-positive they will also run a quick catalase enzyme activity." I was excited to check the Google Calendar and see that he is returning for two more lectures this week. My female classmates were also excited, characterizing our lecturer as "dreamy."
Afterwards, a 45-year-old lab technician from Quest Diagnostics came in with three boxes of samples to lead a workshop. He explained how he runs 10 of the tests that we might order. He opened with a colony of methicillin-resistant staphylococcus aureus (MRSA), the bacteria that causes pneumonia, sepsis, endocarditis, and skin infections, and ran a quick catalase test. The petri dish had small transparencies in the agar gel demonstrating MRSA's ability to lyse red blood cells. He took a swab, swiped a colony on the petri dish and put some hydrogen peroxide on the swab. We saw it start bubbling up. "Now you know it is MRSA, and not Strep." He showed us two McConkey growth plates where a colony of pink lactose-fermenting, harmless E Coli contrasted with a dull-yellow strain of Salmonellae. Students afterwards commented, "He knew a lot, and this was a perfect complement to the theory, but I wish he would stop waving that swab around. I don't want to catch MRSA!"
Lectures afterwards delved into the main categories of bacteria defined by the Gram stain. Gram-positive bacteria have a thick outer peptidoglycan (sugars cross-linked with short peptide bridges) cell wall outside its cell membrane; Gram-negative bacteria have an additional outer lipid membrane covering its thinner cell wall. This key difference, specifically the presence or absence of a second cell membrane, will affect the virulence (ability to cause disease) and susceptibility to various antibiotics.
We learned that there is a fine line between hosting normal bacterial flora and being on the verge of death from infection. For example, Streptococcus pneumoniae, the most common cause of bacterial pneumonia, is a normal component of the oropharynx and throat. Pneumonia ensues when oropharynx secretions are aspirated (entry into larynx and respiratory tract) and the protective mucous lining of the upper respiratory tract is diminished by IgA protease secretion. The "flesh-eating" bacteria, Streptococcus pyogenes is also the culprit of the common strep throat in children. S. pyogenes produces many virulent proteins that enable its spread but induce a strong immune response. M-protein on its cell wall prevent phagocytosis, but elicits a strong antibody response. Sometimes, S. pyogenes release streptolysins and pyrogenic exotoxins that lead to Scarlet Fever or potentially Toxic Shock Syndrome from systemic activation of the immune system. The surge of antibodies produced during a S. pyogenes infection can lead to Rheumatic Fever (involving heart inflammation) and Post-Strep Glomeuruloar Nephritis (inflmmation of kidney from small immune deposits). According to the American Academy of Family Physicians, "Although antibiotics have been shown to reduce the severity of acute symptoms and shorten the duration of the illness by about one day, more than 90 percent of treated and untreated patients with acute pharyngitis are symptom-free by day 7. Therefore, the primary reason for treating uncomplicated streptococcal pharyngitis is to markedly reduce the incidence of subsequent rheumatic fever" and other serious complications. Many people, especially if they work in healthcare, host Staphylococcus aureus in peaceful colonies on their skin. A small cut or abrasion in the skin can let Staph in where it will usually cause a benign skin infection, but sometimes can lead to release of Staphylococcal Toxic Shock Syndrome Toxin. This toxin, called a superantigen because it can lead to activation of twenty percent of T-cells, endothelial cell dysfunction, and shock. If the strain is methicillin-resistant (MRSA), treatment is vancomycin to kill the bacteria, and fluids, vasopressors, and blood transfusions to address the life-threatening symptoms of shock.
Our best defense against harmful bacteria seems to be other bacteria. Our body realized that we cannot beat them, so instead our immune system attempts to supervise the ecosystem. Numerous surfaces – skin, oral cavity, gut, urogenital canal – are colonized with competing bacteria that prevent any single one from domination (most antibiotics are copies of compounds secreted by one bacteria to inhibit the growth of another). Some of the worst infections occur when the entire ecosystem is wiped out after administration of a broad-spectrum antibiotic. Babies are vulnerable due to immature flora and immune systems, which is why women in the 35th week of pregnancy are screened for vaginal colonization of Streptococcal agalactiae (group B strep). If the baby picks up S. agalactiae during delivery, it could lead to bacteremia (bacteria in the blood), pneumonia, and meningitis.
The EM physician emphasized that the physiological response to an infection is not necessarily indicative of the degree of colonization. "Infection is just one component of septic shock." Septic shock occurs from the immune system's overreaction to an unwelcome guest. In fact, gastroenteritis can even be caused without eating a food infected with staphylococcus. If staphylococcus had ever been colonized in the food, it could deposit toxins that are resistant to heat and cold. "The bacteria could be long gone from a contained piece of food and cause severe gastroenteritis even if nothing is colonizing the gut. Simply the immune system reaction is enough." Antibiotics do not help against toxins.
Our patient case: Ellie, a 30-year-old female, was vacationing with a group in the Caribbean a year earlier. Ten group members got diarrhea after eating ice cream. After three days of symptoms, she and her husband went to a clinic where they waited briefly until the doctor showed up on a moped. The doctor explained that they didn't normally give meds for these symptoms, but the husband insisted and Ellie received a single dose of an unknown antibiotic. Her GI symptoms improved after three days, but four days later she developed general malaise, 102-degree fever, myalgia (muscle pain), petechiae (small diffuse red specks on the skin) and hemoptysis (coughing up blood). Ellie made it home, but these symptoms persisted for two weeks. Her primary care doctor referred her to an infectious disease (ID) specialist for further evaluation.
The ID physician, who did his residency in Ghana seeing nasty infections every day, explained, "This case really perplexed me. It was not a typical presentation nor clinical course." She was put on a seven-day course of levofloxacin for suspected Typhoid fever. A blood culture came back normal, but her stool sample revealed a non-typhoid fever strain of salmonella, a bacteria that infects the gut immune system. Typhoid-causing salmonella is distinguished by a short DNA piece. This gene island allows the bacteria to hitch a ride with macrophages to infect organs beyond the gut. Despite the antibiotic treatment covering salmonella, her symptoms did not improve. "I was convinced I had dengue fever. There was a CDC warning about it," explained Ellie. This fear was compounded because the ID doctor was uncertain about his diagnosis. "It can take up to a week after this treatment for symptoms to get better. Throughout the whole experience I was not sure her constitutional symptoms were due to the salmonella infection. Typically a non-typhoidal strain would be constrained to gastroenteritis which according to HPI [history of present illness] resolved quickly." On day seven, when he was going to re-evaluate her diagnosis and start her on another antibiotic treatment, her fever resolved. The ID physician hypothesized that the initial antibiotic dose may have caused Ellie's more serious problems by disrupting her ordinary bacterial flora.
The most surprising aspect of the case was that Ellie told us that she'd just returned from the same Caribbean island: "I did not go to the same ice-cream shop."
Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 2 days. Example fun: Jane and I joined Lanky Luke and his PA wife Sarcastic Samantha for a late afternoon beach-music concert followed by burgers at their pristine apartment. Samantha, in her final rotations at PA school, recently returned from her eight-week ED rotation in two nearby counties. "What shocked me about my ER rotation was that the docs are paid per patient and PAs are salaried. To maximize profit, all time-consuming procedures (e.g., central lines) are done by PAs. The result is that doctors tend to see the green triage patients [the least serious cases] while the PA is working with the yellow triage group. It just didn't make sense."
Three marathon 4-hour lecture sessions with infectious disease (ID) specialists. Some would cover over 10 different diseases caused by a specific bacterial strain in a mere hour time. Most of the information went in one ear and out the other, especially with the PhD microbiologists. About two-thirds of students stopped attending lecture after the first session. "I have to study this material on my own over several days to not suffer from information overload. I do not find getting bombarded at lecture is efficient use of my time." They missed a few clinical pearls from the more lively ID clinicians.
One ID doctor delved into the disease-filled, gram-positive, spore-forming, anaerobic genus Clostridium. Spores enable a bacterium to lay dormant, surviving external pressures such as extreme temperatures, pH, and sanitation chemicals. C. difficile is able to survive hand sanitizer and many hospital disinfectants. "Only thorough hand washing will get C diff off your hands. Hand sanitizer does nothing to it." C diff jumps from bed to bed in hospitals, causing terrible gastroenteritis. Although C. diff is not able to thrive against normal gut flora, after a broad-spectrum antibiotic that decimates the normal flora, C diff will overtake the gut leading to pseudomembranous colitis and the release of toxins that cause life-threatening rice-water diarrhea similar to cholera. The genus Clostridium also contains C. tetani and C. botulinum two related species that cause tetanus and botulism, respectively. C. tetani produces a neurotoxin that destroys inhibitory neuron activity producing a spastic paralysis, typified by lock-jaw. Why are rusty nails and dog bites associated with tetanus? The skin typically seals over a deep penetrating wound before it is fully repaired. Sealed off from the destructive power of oxygen, anaerobic bacteria such as Clostridium tetani thrive. C. botulinum produces a similar neurotoxin, classified as a Tier I bioterrorism agent, that destroys neuromuscular junction activity, producing a flaccid paralysis. Otto Warmbier, the University of Virginia student imprisoned by North Korea, contracted botulism, which lead to respiratory arrest and coma. (The same Botulinum Toxin, "Botox," can be harnessed to extend the expiration date of the Hollywood elite.)
A 35-year-old overweight unkempt ID pharmacist and an internal medicine resident led a highly effective two-hour lecture and workshop. Unlike the pharmacist at your local Walgreens, pharmacists who work in hospitals must complete a residency. Our lecturer said that his job was to eliminate any bug that comes into his hospital. He went over the clinical impact of antibiotic resistance: "the never-ending arms race." "My job is to make you good stewards of antibiotics. Now, this can seem like a daunting task, especially when Cipro [broad-spectrum antibiotic] is OTC in Mexico, but let's give it a shot." The ID pharmacist added his opinion that there are few new antibiotic classes in the pharmaceutical pipeline because it is difficult to make a profit: "In addition to costing millions to bring a new drug to market, once it is in market, bacteria develop resistance so fast that it doesn’t have a long shelf-life. Further, the medical system reserves new antibiotics as a last line defense." A student shared a Harvard-Technion experiment on the class GroupMe illustrating the rapid generation of antibacterial resistant genes. Escherichia coli with a fluorescence probe was plated on one end of a giant agar plate with steps of increasing concentrations of the antibiotics trimethoprim (Bactrim) or ciprofloxacin A time-lapse video depicts bacterial colonies traversing onto each step and completely covering the sheet by 12 days.
The 27-year-old internal medicine resident, reminded us that Group A Strep (strepococcal pyogenes) is one-hundred percent sensitive to penicillin. "Don't be a jerk and give your poor patient a Z-pack," she cautioned. [Azithromycin is a broader-spectrum antibiotic.] We were also informed that hospitals in different regions have different antibiotic schedules: "MRSA is much more rare in rural Idaho than in NYC. I would be terrified to get hospitalized in NYC."
The workshop culminated in using iPads to play "Heads Up". One student would put the iPad on his or her head and, based on hints from other group members, try to guess the bacterium or antibiotic displayed on the screen, e.g., 1st-generation cephalosporin or Clostridium tetani.
My favorite lecture was by a 35-year-old emergency medicine physician on the management of sepsis, a systemic immune response to infection. The immune response causes blood vessels to dilate, thus reducing blood pressure (hypotension), leading to multiple organ failures ("septic shock"). Patients who show up in the ED with septic shock have a mortality rate of twenty-five percent. "I like how he made you feel like you were in the ED. He gave so many different clinical cases," commented a student after class.
The physician explained, "If a patient is in shock, I immediately conduct a RUSH (Rapid Ultrasound for Shock and Hypotension) exam. I am looking for what is causing the shock. Is it an internal bleed causing blood to pool in Morison's Pouch [between kidney and liver] or around the rectum? Is it cardiac tamponade [fluid in the sac of the heart restricting its motion]?" Once he has determined septic shock, he starts the patient on antibiotics even without any confirmation of bacterial infection. He then determines if the patient is fluid-sensitive, i.e., if cardiac output would improve with IV saline. The Starling Curve describes cardiac output as a function of End Diastolic Volume (blood volume) for a given heart contractility and vascular tone. The physician continued, "We used to just give the standard 30mL/kg. [2 L for a 70 kg person.] Now electrical engineers have given us the NICOM [Non-invasive cardiac output monitoring] device to determine if someone is fluid-sensitive or insensitive." NICOM device uses two pairs of electrodes to measure the change in impedance across the chest to the abdomen as a bolus of fluid is injected into the patient. He concluded, "No idea how it works, but we use it everyday. It is pretty neat to see the Frank Starling Curve appear on the NICOM screen and watch the physiology we learn in medical school actually be applied."
Our patient case: A young ED physician describes his treatment of Abigail, a 26-year-old waitress attending community college for interior design. She presents to the ED for a worsening blood-tinged productive cough, fever, syncope (fainting episodes), and back pain. Over two months she has been to the ED twice and been prescribed different antibiotics for a productive cough and myalgia. With blood pressure of 80 over 55 and heart rate of 110, she is immediately recognized to be in shock and is transferred to the ICU. The RUSH exam reveals left ventricular dysfunction suggestive of distributive shock (leaky blood vessels from suspected sepsis infection decreasing blood volume). Even after a total of two liters of IV saline, she requires pressors (norepinephrine) to maintain a MAP (mean arterial pressure) above 65 mmHg.
"Her entire course changed from a simple question: 'Do you use drugs?'," explained the ED physician. Abigail confirmed she regularly injects oxycodone into her veins. "We immediately suspected septic shock with endocarditis [infection of heart tissue] likely from Staph aureus, which has a proclivity to infect the tricuspid valve after getting injected into the blood." Blood and sputum cultures grew methicillin-resistant Staphylococcus aureus (MRSA). She is immediately started on IV vancomycin (a non-penicillin-based antibiotic reserved for serious gram-positive hospital infections). Echocardiography reveals substantial vegetation on the tricuspid valve. The colonies were releasing small particles into her pulmonary circulation causing septic pulmonary emboli. In addition to heart and lung colonization, she developed osteomyelitis (bone infection) in her vertebrae. The immense immune response due to the bacteremia (infection in blood) and Staph aureus toxins caused glomerulonephritis (kidney inflammation) and hematuria (blood in urine).
"Although the bacteria is the cause of her sepsis, the infection was not the immediate concern," explained the EM physician. Intensive support therapy including blood/plasma transfusions, fluids, mechanical ventilation, and vasopressors were given throughout her two-week ICU stay. "I've rarely seen someone recover completely in medicine after septic shock with tricuspid valve endocarditis. It truly amazes me. Heart, lung, kidney—all fully recovered except for lower back pain." Abigail was transferred to a "step down" unit [in between the ICU and the general ward] and discharged to rehab.
When we returned to lecture, an ID physician introduced diseases of the spirochetes such as Syphilis and Lyme Disease. "Always note the presence of rash on the palms or soles." This can help narrow down a broad differential as not many diseases cause a rash there. Syphilis, caused by Treponema pallidum, begins with formation of a chancre, a characteristic painless ulcer, on the penis or in the vagina that lasts for four-six weeks. "I can never understand how some males do nothing about this quite obvious lesion." Patients then develop a generalized lymphadenopathy (enlarged or sensitive lymph nodes) with a diffuse rash on the palms and soles that resolves. After a multi-year latency period (typically within 5 years of primary infection or 15-20 years after primary infection), some patients enter a serious tertiary phase that involve syphilitic aortitis (inflammation of the aorta potentially causing an aortic aneurysm ), neurosyphilis and gummas (red protrusions of the skin with a necrotic core).
Lyme disease, caused by Borrelia burgdorferi, requires an infected tick to be feeding on the human for at least 48 hours for the bacteria to change membrane proteins in preparation for human cell infection. The feeding ticks are typically less than two millimeters in size, so they are easier to miss than a syphilis chancre. Lyme-infected ticks and diseased humans are most common in the Northeast and upper Midwest, coinciding with large deer populations.
Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 2 days. Example fun: Our class held a Game-of-Thrones watch party. Straight-Shooter Sally: "Game of Thrones unites multiple generations under one roof. My parents love this show just as much as I do!"
Virus week. Long days of lectures followed by three hours of studying old material on infectious bacteria in the evenings.
"The more I study, the less I know," reflects Gigolo Giorgio, the class alcoholic frequently found on the dance floors of downtown clubs. One classmate asked Giorgio, "Is Campylobacter jejuni gram-positive or negative?" We were all impressed when Giorgio responded, "Gram-negative." We were stunned: "How did you know that!" He answered, "Well I haven't heard of it, and I've only studied gram-positives."
This block is particularly challenging because the material doesn't build on previous lessons. I feel more behind each day. "I'm still on gram-positive bacteria! I have not even started gram-negatives!" wails a classmate as we begin virology.
If you model a physician as an information processor, the result of this block is a database that is indexed in only one direction. For example, we study by investigating the properties of each pathogen one at a time. We can reliably regurgitate information from yesterday about a single bacterial species. However, when we attempt to develop a differential based upon symptoms, we have difficulty identifying potential culprits. For example, both S. pyogenes and an acute HIV infection can lead to sore throat. There were many blank faces when we were asked, "What are the common causes of sore throat?" Fortunately electronically implemented databases can be indexed in multiple ways. This is what gives clinical-assistance programs, e.g., UpToDate.com, their power to boost physician efficiency, especially in regions where ID doctors are scarce.
A 60-year-old internist who specializes in herpes and whose two children are also practicing physicians at the hospital introduces virology to us with four hour-long lectures. The Internist introduced infectious disease: "ID is not rocket science. It's an approachable field if you have the interest and dedication to learn a lot of diseases." Jane actually shadows the son and mistakenly thought he would be teaching us.
There are three types of viruses: RNA, DNA, and retrovirus. RNA and DNA viruses hijack host cell machinery to produce proteins of their own design. Retroviruses actually insert their own DNA into host cells.
A basic virus is a small particle containing genetic information (DNA or RNA) that encodes for its infective vector (the proteins that enable the virus to get into cells and reproduce). These proteins include the structural capsid protein(s), the polymerase(s) used to replicate the genome, and critical docking proteins to allow access into the host cell. The mode of transmission is restricted if the virus is enveloped in a lipid bilayer. "Enveloped viruses have an easier way to get into cells, but are much more susceptible to drying out on a surface. Non-enveloped viruses can last for days on a surface."
The internist asked the class, "What is the difference between herpes and love…? Herpes is forever." Herpesviridae is a large class of enveloped DNA viruses that include herpes simplex (genital warts and labial cold sores), varicella zoster (chickenpox and shingles), and the college-drag epstein-barr ("mono"). "Sixty to seventy percent of the population is infected with HSV1 [herpes simplex 1, mouth cold sores]," said our lecturer. "Most people do not have reactions, but some people have outbreaks, particularly under stressful conditions. Does anyone want to tell their story about cold sores?" Two students volunteered that they have outbreaks, particularly around exam week. They both have a prescription for the antiviral drug acyclovir, which can reduce symptoms if administered during the beginning of the outbreak (typically a tingling or burning sensation). Herpes viruses remain latent in sensory nerves until the immune system is weakened. Reactivated virus will travel to the skin to cause an outbreak.
Shingles, caused by the latent varicella, will typically infect only a single dermatome (region of skin innervated by a single spinal nerve). We also learned about flaviviridae, which causes several nasty tropical diseases, including Dengue, Zika, and Chikungunya. "Each of these is transmitted through the same Aedes mosquito, so it is possible to get multiple outbreaks simultaneously. I've had patients with two at once."
A number of students thought the viral lectures would have been more effective after a dermatology block (scheduled in two weeks). The early symptoms of viruses are typically nonspecific, with the exception of some characteristic rashes. For example, we looked at pictures for the common rash-causing diseases of childhood (measles, scarlet fever, rubella, slapped cheek and roseola) without having an understanding of what pathophysiological mechanism is causing these lesions.
The ID physician spent about 30 minutes on the hepatitis viruses. "There is now a ninety-five percent cure rate for all genotypes of Hep C. It's truly unbelievable the surge in drug innovation. Five years ago we had almost nothing. Now there are over 12 drugs." He commented how the first Hep C drug recently dropped in price to remain competitive as it only covers a few genotypes compared to the newer drugs.
Why are there are so many genotypes and viruses? Some viruses purposefully use an error-prone polymerase (enzyme used to replicate DNA/RNA) to accelerate their mutation rate. For example, influenza pandemics occur when a "genetic shift" arises that is sufficiently different from previous strains so that past exposure provides no immunity. This also means the influenza viruses make up to 10 percent null copies, incapable of infecting, but that is okay for an organism that is expending someone else's energy.
We also learned that many cancers are thought to be a result of past viral infections. For example, cervical and anorectal cancer are almost entirely attributed to sexually-transmitted human papillomavirus (HPV) infection. This is a DNA virus and the cancer-causing strains are primarily HPV 16,18,31, and 33, which are covered by the Gardasil 9 vaccine (ideally administered to both males and females at age 11-12). Viruses typically induce a cell growth state to increase DNA and RNA replication. Some viruses even encode proteins that suppress growth inhibitors such as tumor-suppressor gene p53.
Wednesday and Thursday featured lectures on HIV led by a quirky, cynical ID physician specializing in HIV patients and speaking in a voice that was a bit like Brian Boitano's. "Do you think he is gay?" a student asked after lecture. Type-A Anita quickly responded, "Of course he is gay. He treats HIV patients."
HIV is a retrovirus with machinery to integrate its viral genome into the host genome. HIV's genome encodes for (can produce) only nine proteins. Gp120 is a glycoprotein inserted into the cell membrane envelope that allows the virus to bind to CD4, a protein found on specific white blood cells. When bound, the hidden Gp41 aggregate to bring the viral envelope closer to the host membrane and eventually fuse allowing access to the host T cell. Other host proteins are necessary for viral fusion, including CCR5. One student sent a case report to the class GroupMe about an HIV-positive individual inadvertently cured of HIV when he received a transplant of bone marrow that lacked this protein. (http://www.nejm.org/doi/full/10.1056/NEJMoa0802905).
Two lectures were dedicated to managing HIV. The ID physician began: "My patient was diagnosed with HIV around age 40. She was confused until her husband admitted that for decades he would go on business trips and have unprotected sex with men. She got a divorce." A student whispered, "I wonder if health insurance survives after divorce?" (Answer: depends on the state; see Real World Divorce)
The ID physician continued, "You are now supposed to prescribe antiviral drugs to anyone with HIV as opposed to those below a CD4 count threshold. Europeans still wait for a low CD4 count to develop, probably because of the cost of these drugs." HIV antivirals, if taken regularly, are able to wipe out detectable virus particles in the blood and return CD4 count to normal. "There was a study conducted in West Africa where married individuals with one HIV-positive partner was treated. They evaluated how many HIV-negative partners contracted HIV over several years. Almost no one who adhered to the medication regiment passed the HIV to their partner. Some partners tested positive for HIV, but it turned out to be a different genetic strain. The partner had to have caught it from someone other than the spouse."
We also learned about HIV prophylaxis treatment. At-risk individuals, such as healthcare workers in a high-risk region, or high-risk sexually-active individual, are prescribed HIV antivirals to prevent transmission. "If you are stuck with a needle from an HIV-infected patient, TELL SOMEONE. If you get started on prophylaxis drugs within 48 hours, we can basically guarantee a zero percent transmission rate. You have to hit the virus before its genome is integrated into CD4 T-cells." One classmate asked, "Are there certain regions of the country where all gay people should be on prophylaxis?" The lecturer was slightly confused, but responded, "No. Assess the risk. If someone is having unprotected sex with two-three different partners a week, yes. If they are in a monogamous relationship, no. Also it depends on what insurance they have."
A few classmates discussed afterwards if medical education weights HIV too much compared to more common viral infections. Less than 1 percent of the world is infected with HIV. In the US, 1.1 million individuals are HIV-positive, about 0.3 percent of our 325 million population.
Our patient case: Taylor, a 41-year-old black female, presents to the ED in respiratory distress. She reports worsening shortness of breath and persistent cough over the past 4 weeks. Chest x-ray shows glassy white highlights on the normally black air-filled lungs. This suggests diffuse intralobular infiltrates (infection in numerous spots within the lungs; a typical pneumonia is just one big spot). She is admitted and placed on antibiotics. However, her pulmonary function continued to deteriorate and she is transferred to the ICU. Her CBC revealed elevated lymphocytes with a CD4 T cell count less than 100. She is immediately started on antifungal medication to address a suspected Pneumocystis jiroveci infection. HIV test is positive.
Her two-week hospital course is challenging. Because of her low immune function from the HIV, she arrived at the hospital coinfected with several viruses. Then once in the hospital she acquired a conventional pneumonia from intubation and urinary tract infection (UTI) from the foley catheter. She makes a full recovery and is discharged for outpatient follow-up.
Taylor, now 55, is energetic and recently became a grandmother. "At the time of the diagnosis, my three children were 14, 16, and 21. I was in complete denial. I went to four doctors in town to get another HIV test. I finally accepted it while talking on the phone with my internist. I dropped the phone and wept. My children came into the kitchen and asked what was wrong. It felt impossible bringing this up with them." Once Taylor acknowledged her HIV, she quickly began antiviral treatment without serious side effects. Her CD4 count has improved to normal, and she has not been hospitalized since the above episode.
How did your friends and family react? "I was severely depressed for several years. I've been on every single antidepressive that you can think of. You never know who will be there when you are most vulnerable. My best friends were the first to flee. Three of my siblings still do not speak with me. My sister will occasionally visit me, but she refuses to hug me, or let me see her children. People, especially in my community, remember the 1980s epidemic. They think if they touch, or even come near someone with HIV they will get infected."
"I told my oldest son a few months after my diagnosis. He asked, 'Do you know who did this to you?' I told him the truth. 'Yes. The man knew he had HIV, but still slept with me. When I found out and confronted him, he moved far away.' I was scared my son would search him out and attack him. I fortunately calmed him down."
How about coworkers? "I do not tell my coworkers about my health. I get my work done and get home for my kids. No socializing for me."
The last question asked by a student was, "If you could go back, would you not sleep with that man?" The whole class put their heads down in shame. Taylor seemed a little taken aback, but responded, "Yes, I regret getting HIV." Several students went up afterwards and gave her a group hug.
Back in lecture we were treated to three 2.5-hour sessions led by an experimental psychologist who studies human engineering in medicine: cognitive-biases, leadership and systems engineering in healthcare. She explained that she had worked at another institution on applying human engineering principles to the cardiac OR and had been recently hired into a newly created position at our hospital and school. "I am by no means an engineer. In fact, my former boss who was an engineer would always get frustrated when we had a meeting. We just think different." She now conducts studies evaluating the use of checklists, standardized communication protocols, team meetings before and after surgery, and sleep schedules.
"Healthcare systems are not engaging in improvement by pinpointing individuals anymore. Instead, they are trying to improve the system in which actors engage," she noted. "There were three occasions at the hospital where different nurses administered a full vial of insulin [about 300 cc; triple the correct dose]. The problem was that the nurses were used to getting insulin shots in a pre-formulated syringe with the dosage measured out instead of a whole vial. We implemented a standard insulin dispensary protocol."
Lanky Luke, a conservative-leaning 25-year-old, vented his spleen after the third session: "What a complete waste of our tuition dollars. We have already had that lecture about respecting other professions [working in the hospital, such as nurses and technicians]. I am all for sitting down and figuring out ways to minimize errors but you have to maintain individual responsibility or the whole system shuts down. I don’t need an overpaid psychologist who knows nothing about medicine to teach me that. Why don’t you just bring in an experienced PA or nurse who can tell what it is like getting talked down to by a PGY1 [intern year]." Another student added, "Why are we discussing how to improve team communication when we don't even know how to diagnose strep throat?"
Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 1 days. Example fun: Jane and I joined Luke and his wife Samantha for beers downtown followed by a space-themed Escape Room. Luke and Samantha had successfully completed one before. Three medical students and one PA student were not able to escape in the one-hour time slot. Let's hope that we do better when solving medical mysteries.
This week will cover mycology (study of fungi) and parasitology.
Our professor, a 70-year-old ID doctor with thick grey hair, used to go overseas six months of every year to treat rare disease outbreaks, including the 2014's Ebola outbreak in Sierra Leone. He is celebrating his forty-fifth year of teaching medical students! When he went to medical school, Latin was an admission requirement. This would have been quite helpful in memorizing the 70+ pathogens covered during the previous three weeks as well as in pronouncing medical terminology. Instead of using textbook images for these diseases, he uses pictures of his own patients. During an investigation, he goes to the patient's house and workplace to investigate potential exposures. One student's summary: "He's basically Dr. House!"
Dr. House likes to look at the big picture. "We think history is all about human actions. False. Two-thirds of the cells in our body are bacteria. We are the Uber for bacteria. Genghis Khan was about to conquer all of Europe. His army caught Yersinia pestis in Turkey. The Russians did not stop Napoleon's army. Napoleon caught dysentery from Shigella outbreaks." Several students are planning to read Guns, Germs and Steel on his recommendation.
Fungi are dimorphic organisms. At colder temperatures, fungi grow as the familiar mold, creating small inhalable spores. At body temperature, these spores convert into a circular yeast structure. Lectures detailed the three categories of fungi: dermatophytes (fungi that love keratinized tissue such as skin, nails and hair), systemic (fungi that can result in body-wide infections), and opportunistic (fungi that do not cause infections unless the patient is immunocompromised). Only dermatophytes are transmitted from person to person.
This block tends to evoke exotic diagnoses from students. "I'm going to get histoplasmosis [systemic fungal infection]!" exclaimed Straight-Shooter Sally after she removed an unwanted bird's nest from her potted plants. "As I was throwing it in the trash, the nest broke in half. I inhaled all the bird poop and dust!" After class it is not uncommon to hear, "Do I have a rash on my hand? Do I have syphilis?" One student after class asked Dr. House to inspect his foot. Dr. House had commented, "People who get athlete's foot just on the nail, not the foot, are more likely to have diabetes." The student asked, "Do I have diabetes?" Dr. House replied, "You'll be fine. Remember to never treat your own children. I was convinced my kids had meningitis when their first 103 degree fever occurred." He ended with a joke: "If athletes get athlete's foot, what do astronauts get…? Missile toe!"
Parasites are divided into protozoa (microscopic eukaryotic single-celled organisms) and helminths (macroscopic eukaryotic multicellular organisms). With only two days of lecture, we focused on the most common parasites, especially malaria. A common theme of this block is that many symptoms of disease are not caused by the pathogen-killing cells. For example, the watery diarrhea of Clostridium Difficile and Cholera are caused through a toxin-mediated mechanism releasing water into the lumen of the gut. The nonspecific flu-like symptoms of most viruses are not caused by cells dying but the systemic host immune interferon response. Malaria, caused by the protozoa Plasmodium, is an exception to this rule. Plasmodium infects and lyses (ruptures) red blood cells after replicating inside them. Different plasmodium species have different lysing rates giving a classical cyclical fever/anemia pattern ranging from 48 hours to months. Dr. House recounted how as late as the 1920s, syphilis was treated by giving the patient malaria (P. vivax)! The malaria would cause such a high fever it would kill Treponema pallidum. After the syphilis was cured, they would give chloroquinolone to cure the malaria.
We also learned about how the Rockefeller Foundation was founded to address the epidemic of Necator americanus (Hookworm) in the South (see http://www.pbs.org/wgbh/nova/next/nature/how-a-worm-gave-the-south-a-bad-name/). Hookworm is a helminth that latches onto the gut lumen where it produces eggs that pass out in the feces. When a human walks barefoot through a field of fecal-contaminated soil, larvae penetrate into the foot. "Farmers would use human feces to fertilize the field where children would play barefoot." Once inside, the worm travels through the blood to the lungs, travels up the trachea to the pharynx, and finally is swallowed into the gut. Each hookworm drinks 0.3 mL of blood per day. "The problem is you are not infected with just one hookworm, but thousands. Losing 30 mL of blood per day will cause severe iron-deficiency microcytic anemia." Over time, this produces lethargy and mental retardation. It is estimated that 40 percent of school-aged children were infected with hookworm in the early 1900s. The Rockefeller Foundation led a massive public campaign that focused on schools to eradicate hookworm from the South.
Dr. House described the waterborne parasite called Cryptosporidium . "Crypto is all through the DC water system. It is resistant to chlorine treatment." The immune system is normally able to contain the infection. However, some of my AIDS patients before HIV antivirals would have 60 bowel movements a day due to cryptosporidium. These people would live on the toilet, and die from dehydration and malnutrition." Dr. House couldn't end lecture without showing us live video, captured during a colonoscopy, of Ascaris ("Giant Roundworm"), which can grow up to a length of more than a foot in the human gut (https://youtu.be/HOaZCkA8Zvk).
Classmates were particularly interested in another waterborne parasite Naegleria fowleri, the "brain-eating amoeba." Naegleria is found in warm lakes, including in the U.S. It is thought to gain access to the brain through the cribriform plate (thin bone separating the brain from nasal cavities) under barotrauma or a pressurized injection of infected water, e.g., falling during water skiing. I was conversing with a female hematologist in the hallway later than afternoon. She commented, "I will never swim in a lake out of fear of getting Naegleria."
Our patient case: Grandma Martha, a 68-year-old female accountant with degenerative disk disease in her lower back. Her daughter brought her to the ED for worsening back pain, neck stiffness, and headache over the course of weeks. On physical exam, she showed diminished lower extremity reflexes. Dr. House explained, "Before you can order a lumbar puncture ("LP" or "spinal tap"), you have to rule out increased intracranial pressure which could cause herniation of the brain." An MRI revealed several inflamed lesions of the meninges without evidence of increased intracranial pressure. LP results showed decreased protein, decreased glucose, and the presence of neutrophils in the CSF. Gram stain on the cerebrospinal fluid was negative (no bacteria observed). "The LP results were suggestive of a bacterial meningitis. However, her presentation did not fit. Bacterial meningitis is typically a very rapid onset of symptoms." She was started on empiric antibiotics until culture results could be obtained. "I was driving home that evening listening to the news on the radio. They were reporting about an outbreak of contaminated steroids. I turned the car around. Not everything on the news is Fake News." Several chuckles were heard in the audience.
Back in 2012, Martha had been getting regular epidural steroid injections for back pain. At least one was supplied by the New England Compounding Center (NECC) and, due to a profit-motivated sloppy approach to sterility, had been infected with the fungus Exserohilum rostratum. "We didn’t know how to treat it. No one had ever seen this before." Dr. House added, "It is extraordinary how quickly the local health departments and the CDC responded. Within 48 hours of the first diagnosis, the CDC was calling patients." (753 patients were injected with contaminated steroid; 234 developed fungal meningitis and 64 died. See https://www.cdc.gov/hai/outbreaks/meningitis.html.)
Martha was started on an aggressive antifungal regimen including amphotericin (known as "amphoterrible" due to its severe side effects including kidney failure) and voriconazole. "The challenge with fungi and parasites is that our immune system does not do a good job of killing it. Instead, they typically wall off the lesion to contain it. We did not know if our drugs could reach these lesions. We also did not know about the risk of recurrence. How long should we treat the patient?" Martha was in the hospital for 70 days, and continued treatment for another two months. She has fully recovered from the ordeal.
"I was fortunate compared to several other people who live with long term complications from the meningitis. Or who died. I know several people who have dealt with recurrent meningitis episodes," explained Martha. A student asked about the recent 9-year prison sentence for the NECC co-owner and pharmacist Barry Cadden. "What would you say to him?" "Well, I wouldn't say anything to him. I would punch him the face," chuckled Martha. Her daughter jumped in, "I would punch him too."
I had lunch outside with six classmates. One commented that "Medicine was really the Wild West a few decades ago. Could you imagine discovering these unknown disorders like hookworm?" Straight-Shooter Sally added, "The best part would be getting to name all these symptoms! How badass would it be to name Toxic Megacolon [severe, potentially lethal, distension of the colon that can occur when an antidiarrheal agent is administered during an active C diff infection.]"
Our group then walked over to the hospital's SimLab, which is led by a retired nurse and EM (emergency medicine) resident. We practiced running a Code Blue where a patient was in cardiac arrest. The main purpose of the simulation was to introduce us to standard communication skills such as "call-backs" (acknowledging an order with a clear read-back) and SBAR (situation, background, assessment, recommendation) hands off. Lanky Luke had run EMS for all of his undergraduate career. The rest of us had no idea what we were doing. The first simulation round we were sent without any guidance to resuscitate a dummy. Over time we got the rhythm of running a code. Two people focus on chest compressions, one person performs breaths, one person runs the monitor and defibrillator, and one person records events. I learned that if you are performing chest compressions correctly you can actually feel a pulse from the compression in the femoral (leg) artery.
What do people who don't go to medical school do with $300,000 of college education and $300,000 of taxpayer-funded K-12? One of my undergraduate classmates on Facebook this week:
if you've been paying attention, you probably know I haven't been the same since November 9, 2016. things changed not only in this country but also in how I view myself within that context. i joked that if Trump won I would leave the country…
well, now it's time to follow-through on my promise. after weeks and weeks of trying to figure out what was next, I finally realized that I had no idea and couldn't figure it out while remaining in my last job and in my last city. so as many of you know, I left DC and my job [social media analyst for advertising agency] …
but now the time has come for me to say goodbye to what used to be my home and is now just the place I try to avoid claiming. i hope to find myself in the coming weeks and months and find what makes me truly happy, in both work and in my personal life.
to that end, I am saying goodbye to the US of A and hello to everywhere else! i do not know where I will end up and although it's a bit scary, I know I'll find my way by the grace of a god (and maybe just a little luck)! if you have an iPhone, nothing will change between us. if you don't, then you'll have to settle for Facebook Messenger if you'd like to keep in touch (starting tomorrow).
...
au revoir america, it was fun until it wasn't. for all those I'm leaving behind...fight the good fight, win back Congress and the WH, and maybe then I'll pay you all a visit in the future (!?)
until then, peace&love…
We had a 2.5-hour lecture from two physicians: "Motivational Interviewing: Eliciting Patients' Own Arguments for Change". A 2014 landmark study found that "Behavioral patterns contribute more to premature death than genetic predisposition, environmental exposures and health care errors" (Annals of Internal Medicine, March 18, 2014). The main message is that patients need to feel like they have autonomy. "Don’t give them orders, give them options." One internist described his patient who had been trying to quit cigarettes for a decade. "He told me, 'Hey Doc, I am down to five cigarettes a day from a pack-a-day.' I asked him, 'What's stopping you now?' He responded, 'If I give up now, my nagging wife will get all the credit.'."
On Friday, we were assigned our M1 mentees. A social committee of M2s, four women and one man, stalked the M1s for this entire week (online and offline) and concluded by matching the new M1s with M2s. The matches were announced using a "Tinder match" at the annual M1 welcome party, featuring a full keg and a SnapChat Geofilter. The M1s received folders with their mentors'' pictures and had to search for them in the house. Only one match was done with romantic hopes: Gigolo Giorgio and a cute sorority girl. Ten percent of the M1 class threw up during the party.
Statistics for the week… Study: 15 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun:
Jane and I unfortunately missed the M1 keg/Tinder party to attend a surprise party for her sister, an advertising executive. Thirty family members crowded into a bar to watch the boyfriend, a pharmaceutical rep, propose marriage. Jane's sister said yes.
Hematology and immunology. Immunology is one of the class's least favorite topics. Gigolo Giorgio: "I accept just taking a hit on the exam. It makes no sense to me."
An enthusiastic 44-year-old immunologist kicked off the lectures. She explained, "We need about 100 million unique antibodies to be immune competent. We have about 30 billion B cells in the blood. That means we only have 300 potential B cells that need to become activated if we are to mount an antibody attack against a given antigen. This is the key dilemma in adaptive immunity: How do you find them!"
Our first-year perspective on the immune system was cell-centric. This week we learn that the story is more complex and includes smaller-scale proteins from the complement system and larger-scale tissues such as the spleen filtering blood-borne pathogens.
Our current understanding of a typical bacterial infection:
The C3 protein is fundamental to the complement system and will bind to almost any biological molecule. How does the body avoid its own proteins being marked for phagocytosis? The liver releases anti-complement factors that bind to sialic acid, a component on human cell membranes. Streptococcus pyogenes, the bacterial strain causing strep throat and necrotizing fasciitis, expresses M protein to mimic sialic acid. The immunologist explained, "Although this molecular mimicry decreases the efficacy of the innate immune system, it is also Strep's greatest weakness." Our adaptive immune system readily produces antibodies that target M protein. The problem is that this antibody can cross-react with our own tissue causing a rare complication of sore throat: rheumatic fever (inflammatory disease that leads to skin rash, joint pain, and destruction of heart tissue).
If the innate immune system mechanisms are insufficient for clearance, the adaptive immune system will be activated. Resident macrophages will migrate to lymph nodes and present phagocytosed segments of foreign material on major histocompatibility complex (MHC) proteins to lymphocytes (T cells and B cells) that circulate among lymph nodes. Because the body can't anticipate all of the epitopes (protein shapes) we might encounter, we use a game of probability. The immunologist explained, "We are finally unlocking the adaptive immune system. When I was an undergraduate student in the late 80s, how our adaptive immune system generates this antibody diversity was still not accepted let alone in textbooks. MIT Professor Susumu Tonegawa won the Nobel Prize for discovering VDJ [variable, diversity, and joining] recombination. He showed that each B and T cell mutates its own DNA to rearrange the genes encoding the B cell's antibody or T-cell receptor. Each B and T cell clone has different DNA than your typical cell in your body! If this B cell antibody or T cell receptor recognizes a sequence presented on MHC, it will become activated. The activated cell will undergo clonal expansion [reproduction by division], and, in the case of B cells, will differentiate into a plasma cell secreting gobs of antibody against this specific antigen into the bloodstream."
Our patient case: Georgia, a 46-year-old female presenting to her internist for a routine physical. Medical history is unremarkable except for well-controlled hypothyroidism. She has swollen lymph nodes (lymphadenopathy) in her neck. Routine blood tests reveal elevated protein. Serum protein electrophoresis, a technique that separates proteins based upon electric charge, reveals an "M-spike" in the immunoglobulin (antibody) zone, suggesting an increase in concentration of a single clonal variant of immunoglobulin. "Georgia had a rogue plasma cell producing gobs of a single type of antibody. It is essential you understand the significance of clonal expansion to her condition versus the antibody response to an infection. During an infection, several B clonal species will get activated, each with a different antibody that binds to different sites of a pathogen. Infection causes a general increase in globulin concentration but not a spike." The risk is as this single clonal variant continues to expand, it could push out the normal functioning bone marrow cells.
Georgia was referred to heme/onc (hematology/oncology) for further evaluation for this monogammopathy of unknown significance. One of my favorite lecturers, the young redheaded hematologist, followed Georgia for one year during which she began to have anemia, proteinuria (protein in urine), and bone lesions on routine tests. George was diagnosed with multiple myeloma (MM) at the age of 47 and, based upon her genetics and stage, given eight years to live. (Type-A Anita uses the helpful mnemonic "CRAB" to remember the classical signs of MM: hyperCalcemia, Renal impairment, Anemia, Bone lesions.) After her diagnosis, she quit her job as a secretary for a law firm and went on disability.
Georgia underwent several weeks of intense chemotherapy and a successful autologous hematopoietic stem cell transplant (HCT) over the course of a month-long hospital stay. She explained, "I never considered that I would die during the treatment." She is now two years into remission and maintains an active life.
The HCT given to Georgia is the gold standard for MM treatment. "Why do we even give bone marrow transplants to MM patients?" asked the hematologist. She answered her own question: "The purpose of a bone marrow transplant is to be able to give higher doses of chemotherapy that would otherwise be lethal. We nuke the patient." The hematologist recounted how bone marrow transplants were first investigated after the observation that individuals exposed to radiation from Hiroshima and Nagasaki developed pancytopenia (low blood cell counts). Bone marrow transplants were thought up as a way to reverse this aplastic crisis. "Leave it to the DoD to advance science. Pretty quickly oncologists applied the research to cancer treatment."
"The scariest part of multiple myeloma is that you are never cured," explained Georgia, as she broke into tears. "It will come back every time. This tragic fact makes MM different from other cancers. I go to an MM support group every two months as opposed to a more general cancer group. It is such a different beast." Georgia grew up in a large mid-West family with five siblings. "My closest sister withdrew from me after the treatment. I think it is just hard for her to accept."
The hematologist added, "Plasma cells are the cockroaches of the immune system. They survive everything. The unfortunate truth is that the question is not if MM will relapse, but when. Further, the traditional chemotherapy we use causes the plasma cells that do survive to have more mutations. Drug resistance develops after successive relapses." She gave an impassioned speech on the importance of research. "The life expectancy for MM has increased dramatically. Maybe ten years ago, Georgia would have had to be maintained on melphalan [nasty chemo agent that acts via a similar mechanism to mustard gas] to contain her MM." She turned to Georgia: "Could you imagine being on melphalan, the drug used during your bone marrow transplant experience, routinely?" "Oh, God, no. My hair, the diarrhea, the sheer pain. Mostly my hair though." The class chuckled, and the hematologist continued, "This is changing because of the extraordinary advancements in targeted therapeutics. I love this field because it changes so quickly. Cancer years are dog years. A five-year-old article or clinical trial is thirty-five years old by my standards. Even the current issues of journals are a year late; you have to go to conferences to learn about the latest breakthroughs. It is frankly hard to stay up to date on every neoplasm [cancer]. The result is that oncologists convey out of date survival expectancy to patients."
Jane had a slight hiccup with her mentee: the day after their first meeting, rumors surfaced that her mentee had disenrolled for personal reasons. The whole class joked that Jane made the helpless M1 quit. "What did you do to her!?!" We never learned the truth, but this classmate was quickly replaced by someone from the waitlist who became Jane's new mentee: "Rebecca," who had majored in electrical engineering at a large public university. Rebecca had spent a week at a DO (Doctor of Osteopathic Medicine) school: "I got a call from an unknown number. When I heard I got into this school, I almost fainted. My legs went weak. I packed everything back up and drove the next day eight hours. I really want to call my undergraduate prehealth advisor who told me I would never get into medical school because of my grades. Suck it!" An M1 told Jane, "I like your new mentee better than your last. Thanks!"
Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: 1 day. Example fun: Dinner party with classmate and his wife, a marriage counselor. "My favorite patients at my old job were the couples with a schizophrenic." A classmate who worked on a psych ward before matriculating at medical schools said, "Wow! I was scared out of my mind. I had this one patient who would say, 'There is a woman standing behind you.' I believed her! I could never do psychiatry."
One week before exams.
"We are going back to preschool," said the young female dermatologist. "Dermatology is another language. We start with vocabulary." She spoke in a monotone voice and enjoyed sadistic humor. "It helps if you know Latin. How many of you took Latin?" Two students raised their hands. She chuckled, "Well... that is too bad." We went through several images, and described the lesion with the help of a handout with common terms: umbilicated nodule, erythematous maculopapular, scaly serpiginous plaque. The class was surprised to hear that erythroderma (diffuse erythema covering the body) is a "dermatological emergency". This massive inflammatory response can cause a drop in blood volume and hypotension.
A dermatologic pathologist gave two hour-long lectures on skin histology (study of the microscopic structure of tissues) with slides of normal and diseased skin. I enjoyed seeing how certain skin issues manifested themselves so clearly on histology compared to other organ systems where the pathological manifestation is more subtle. He ended: "Gastroenterologists and dermatologists always argue with each other about what is the largest organ. There is a huge amount of blood flow to the skin. Inflammation frequently leads to skin changes. Think of the skin as a window into the body."
"Dr. Joel", a brilliant pedantic rheumatologist in his late 30s with a heavy Jamaican accent, discussed infectious diseases of the skin and immune disorders that manifest with skin symptoms. Roseola ("Sixth Disease" or "three-day fever") is caused by human herpes virus 6 (HHV6). It is characterized by high fever, which can cause seizures in children, followed by a maculopapular (flat and raised erythematous dots) rash. Several of these childhood illnesses cause serious damage to a fetus if the mother becomes infected during pregnancy. A congenital rubella infection (German measles infection while pregnant) leads to the fetus having microcephaly and a patent ductus arteriosus (PDA). A male student commented, "Could you imagine living two hundred years ago before we understood the role of congenital infections? Your baby comes out as a dwarf or with microcephaly. Must be God's will."
These lectures should help us to answer multiple choice Board questions, but we are doubtful about being able to diagnose patients. Lanky Luke: "I feel much of medicine is getting the approval by society to witness disease. This ordained selection process entails paying it to the Man." Luke thinks that more of our medical training should be an apprenticeship rather than lecture-based.
He got his wish when we went in for an afternoon to the dermatology clinic. Four-person groups crowded into each small examination room to spend 15 minutes with a patient volunteer and a dermatology attending or resident. My group first saw a 30-year-old female who has suffered from neurofibromatosis since she was a teenager. Only when the patient took her gown off did we see the copious neurofibromas (benign tumor of nerve sheaths) covering her body with the peculiar exception of her head and distal extremities (arms and legs). She could walk around in a long-sleeve shirts and slacks without anyone noticing. The patient allowed each of us to palpate her skin. Neurofibromas are thimble-sized fleshy cylindrical nodules with a dark brown color that sag from the skin. They feel mushy, almost like a fluid-filled vesicle. The attending noted, "A lot of patients first try to scratch them off. They return much worse."
We rotated to the next room and a normal-appearing 50-year-old female. As we examined her more closely, we saw signs of scleroderma. She had sclerodactylyl (localized thickening of skin on fingers and toes) preventing full extension of her fingers. Her lips were permanently pursed with six or seven valley and ridges on the skin adjacent to her lips. "Before treatment with steroids, I could barely move any of my joints because the skin was so tight. I now live a normal life with my family." Our patient did not have any of the life-threatening manifestations of scleroderma, which can include pulmonary hypertension and pulmonary fibrosis.
We then rotated through a case of eczema and psoriasis. Eczema, also known as dermatitis, is characterized by pruritic (itchy), erythematous (redness that blanches with touch), oozing vesicles (fluid-filled sac) with edema (swelling) typically occurring on flexor surfaces. It is commonly caused by an over-reaction to an exposure such as poison ivy or the metal nickel (e.g., touching dime). Interestingly, eczema is more common in asthmatics. Psoriasis is an inflammatory condition without a known trigger characterized by acanthosis (keratinocyte hyperplasia; thickening of the skin) leading to scaly plaques on the extensor surfaces (e.g., the outside of the elbow). The attending confirmed the psoriasis diagnosis by eliciting the Auspitz sign, bleeding after a pinprick.
Our patient case: Fiona, a 42-year-old female elementary school teacher, presenting for bilateral stiffness and pain in her wrists, fingers, and knees that is worse in the morning. She had her thyroid gland removed (thyroidectomy) in her 20s after diagnosis of Graves' disease: antibodies that bind to thyroid stimulation hormone receptor causing excessive thyroid hormone release. Her condition is now well-managed with synthroid.
She has been to her doctor several times over the past few years for joint pain in her hands. "I was originally diagnosed with arthritis. I got frustrated with my doctor. He would take an x-ray, prescribe physical therapy, and never follow up." Over the last two months she has been unable to do several daily activities at work and the pain has begun to interfere with her sex life with her husband. Her proximal interphalangeal joints (proximal knuckle) and wrists are swollen and warm to the touch.
Fiona has rheumatoid arthritis (RA) defined by synovitis (inflammation of the synovium or fluid within joint capsule). The pathogenesis of rheumatoid arthritis is unknown, but some people are predisposed genetically and there are environmental risk factors, e.g., smoking, which increases the risk of RA up to 40 times in individuals with Shared Epitopes (SE) gene variants of MHC proteins.
Fiona never smoked, although she had the positive ACP titer (measure of antibody concentration in serum) that is typical of smoking-induced RA. She also had other hallmarks of chronic inflammation such as elevated C-reactive peptide (protein produced by liver suggestive of systemic inflammation). The Rheumatologist explained, "The ACP is helpful to know what kind of rheumatoid arthritis I am dealing with. However, once it is present I no longer care about it -- think of ACP as a pregnancy test. You can't get more pregnant once you test positive. Instead, I listen to Fiona's symptoms and follow her C-reactive peptide levels."
She was initially prescribed naproxen (nonsteroidal anti-inflammatory marketed as "Aleve"; similar to Advil) without any symptom relief. She currently takes methotrexate, a folate synthesis inhibitor used to treat several cancers and inflammatory conditions. "I will still get flare-ups if I over-exert myself, but I am able to be active. I even exercise three times a week on the elliptical."
Describe the pain before your treatment? "My joint pain was unbearable before I was referred to Dr. Joel. Our family goes to the beach once a year... my one break from teaching. We always have a crab leg feast. I had to stop eating the crabs because my pain would be terrible for several days afterwards. I was bedridden. Perhaps it is punishment for the gluttony."
Does anyone else in your family have immune disorders? "I know my mother had joint problems. She was never diagnosed with rheumatoid arthritis though."
How does RA affect your family? "I've learned my limits now and my husband and kids are truly great about understanding. In the beginning they were a little confused. I still sometimes hear my kids half joke, 'Oh, Mom isn't cooking dinner? She is so lazy.' Even with treatment I still have to be careful how much strain I put on my joints. Scrubbing or cutting too much will cause a bad flare-up that lasts for a few days."
Dr. Stein, an internist who has been in practice for over 40 years, followed up on the "Motivational Interviewing: Eliciting Patients' Own Arguments for Change" lecture from two weeks ago. "There are 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. We also no longer use the word compliance to describe the degree of a patient following prescriptions and medical advice. We now use the term adherence because it suggests an active role and collaboration of the patient with the doctor and treatment process."
After one hour and fifteen minutes of theory, Dr. Stein brought in one of his longstanding patients, an overweight female in her late 40s who quit smoking six months ago. She began smoking a pack a day when she was 14. "Smoking was a part of my life. I felt that I would not know what to do if I did not smoke. It helped keep peace in the house. It kept me calm during work." She described how Dr. Stein would bring up smoking "every single time" she went in. "He said all the right things, but I was just not ready up in the head. The key was I felt comfortable with Dr. Stein. He was not judging me, pointing a finger. When I finally was ready, Dr. Stein leveraged this motivation to help me." What made you quit smoking? "If you have a big enough why, you will figure out how to quit. I hated seeing my children grow up with me smoking. My father recently had a heart attack -- I am sure smoking all his life did not help. I had these two drivers in my mind and I just went cold turkey." We congratulated her for her smoke-free six months.
Afterwards we divided into four-person groups to present a patient from our clinical shadowing experience. We were fortunate to be presenting to Dr. Stein. Our goal was to practice how to present patients to attendings for Rounds next year and how to write a medical note. The general format of a note: chief complaint in the patient's own words, History of Present Illness (HPI), Past Medical History (PMH), Medications, Family History, Social History, Review of Systems (RoS), Physical Exam (PE), Assessment, and Plan. The transgender wave has reached daily Rounds: "Don't use male or female in HPI anymore," said Dr. Stein. "It's frowned upon." After Dr. Stein revealed his fondness for "complementary medicine" (accupuncture, yoga, etc.), Gigolo Giorgio said that Dr. Stein reminded him of someone who had a "midlife crisis and suddenly turned Zen."
We wrapped up the week by reflecting on a three-week prescription simulation. Students were divided into two groups: diabetics and HIV patients. The faculty gave us pill bottles filled with M&Ms. Our class president sent periodic GroupMe messages about various simulated issues. Example: "Update: your throat is burning and your chest is on fire! wait an additional 35 minutes after taking your pills before eating." Some students ate all the M&Ms the first day. Some abandoned the simulation. Everyone forgot to take at least one pill.
Straight-Shooter Sally recounted the awkward conversation after her new roommates, a nursing student and college-educated bartender, accidentally read a message: "You forgot to take your HIV antiretrovirals for today. Double up."
Mischievous Mary, a smart, petite jewish girl who dyed her hair pink last year because "it was the last time I could do something stupid before we start clerkships -- unlike a tattoo, this is reversible." She began school aspiring to follow in her father's footsteps as an internist, but is now determined to become a heart surgeon. Mary responded to Sally's story: "I realized this weekend that I have lost all sense of decency. I was in this quaint coffeeshop by my apartment studying STDs looking at pictures of penises on my computer, easily seen by the other patrons." Jane added, "I was walking with Giorgio on the Greenway. We somehow got on the topic of syphilis. It took us several minutes to understand why people were looking at us strangely."
Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: none (one week before exams).
Exam week with three exams.
The main three-hour multiple-choice NBME exam consisted of 100 microbiology questions and 50 immunology and dermatology questions. Lanky Luke: "This was the hardest block since the beginning of medical school." Several students complained about the emphasis on tropical diseases. "There must have been 10 questions on leishmaniasis. Every time I saw that as an answer, I would choose it." Another student added, "I just felt it was not representative of what we will see on Step I. There were so few on hepatitis." Several students reflected that they will never understand immunology. Type-A Anita: "I knew going in that I would take a hit on immunology. Oh well."
The case-based exam asked about five hypothetical patients. It tested appropriate use of antibiotics, and classical "alarm" signs of serious imminent danger, for example, patient with sore throat who has difficulty swallowing and drooling may have epiglottitis with the potential to close off the airway. The clinical exam tested adult immunization schedules, screening guidelines, and dermatology pictures. Type-A Anita: "I know we need to know these, but I crammed the day before for immunizations and screening. I've already forgotten them!"
The clinical exam consisted of interviewing standardized patients (paid humans recruited from the community as actors) presenting for pneumonia. We used simulated stethoscopes to hear abnormal breath sounds. The clinical exam tested the same immunization schedules and screening guidelines as the case-based exam.
Recall that we meet three times per week for two-hour "case sessions." Our facilitator is the redheaded hematologist/oncologist. This is the first time that our six-student group met off campus, sharing margaritas as a Mexican restaurant with our facilitator. We were joined by another case session group and their young emergency medicine facilitator.
Our heme/onc attending described the abrupt shift between fellowship and attending. "Even as a fellow, you have someone to bounce ideas off of, to confirm a diagnosis or treatment plan. It takes a little while to get confidence in yourself as an attending." She had just returned from her first vacation since becoming an attending. "My husband forced me to go on the trip to the Dominican Republic. It was scary leaving my patients. I remember sitting on the beach with a mamajuana [local drink] and feeling completely relaxed. I realized that I had not felt relaxed since beginning my residency six years ago. And probably not since beginning medical school too!" [Hurricanes Irma and Maria passed through the D.R. a few weeks later.]
The other facilitator brought his wife, an Ob/Gyn, and their three children, the oldest aged eight. When should physicians have children? "We made an active decision not to have children during residency. My wife knows all too well that it is best to begin having children by age 35. This can be a serious constraint for women if they start medical school late. Residency is your training and you need to dedicate yourself to it." The EM physician said he enjoys shift work. He can dedicate everything when he is there, and upon leaving the ER, "I am clear-headed and can focus on my children and wife."
"A lot of my residents struggle if they have children," continued the EM attending. "You will have to sacrifice something. Most of the time it means you will miss soccer games and friends' birthdays. I find it is especially hard if their significant other is not in the medical world. Nonmedical spouses do not understand that once residents are off their 12-hour shifts, they are not done. After your shift, you hit the books. You study. The one exception is a resident I have now. He will not sacrifice his time with his children so after work he plays with his kids. When they go to bed, he hits the books. He just does not sleep and seems to functions fine thus far... I am not like that."
After the facilitators left, Jane, Mischievous Mary, Deeva Debbie and I walked over to our favorite burgers and beer spot to work on our 100-beer card. After drinking 100 different beers at this restaurant, you are awarded with an embroidered mechanic shirt. Debbie is a a young Indian-American who dominates the class SnapChat story and Instagram. She journeyed to Portugal over the most recent break for a trip with two high school friends.
The women continued the conversation of children over beers. Debbie lamented, "I have no idea when I will be able to have children." Mary reflected, "I now understand why my parents got divorced. My father was a internal medicine resident when they had two children. He was always gone. My mom had to everything: feed us, drive us, discipline us. She always felt like the bad guy. When my father was home, he would just want to play with us. There was just no time for my parents." It always surprises me how many male physician lecturers in their 40s are not wearing a wedding ring. [Editor's note: Our young medical student might want to read Real World Divorce and learn about the world of sexual and financial freedom opened up by no-fault divorce to any plaintiff suing a physician.]
After a well-deserved nap, Jane and I attended our classmate's housewarming party. He and his wife, a marriage counselor, recently moved into a spacious new downtown loft. While people danced in the center, I talked on the sidelines with a 25-year-old classmate whose parents are Iraqi Kurds. His last trip to Iraq was in 2010, his freshman year of college.
I asked for his perspective on Iraq and the Kurdish people. "It's hard for me to say. Everything I know is from my dad. My family was comfortably settled in the US when it happened. I just remember my father being glued to the TV during the Iraq invasion. He would cheer the U.S. army every step of the way. Saddam gassed my people." Why has it gone so wrong for both the U.S. and Iraq? "I don’t know. It comes down to the Iraqi people as a whole were not ready for democracy."
He is eligible to vote in the upcoming referendum on independence (held September 25, 2017; result: 93 percent in favor). "I think now is the best time for independence. We are ready. The state institutions are there and the Peshmerga will defend us against any invader -- Turkey, Iran's militias. It doesn’t matter that we are dispersed in Iraq, Syria, Turkey, and Iran. Everyone might invade us. I am concerned about the state of elections in Kurdistan. Unfortunately the only politicians come from just two families, but it is now or never. I'm voting yes for independence."
Our block coordinator, a PhD in physiology, is attempting to execute a flipped classroom for the six-week cardiopulmonary and hematology block. We have about 3 hours of online lectures recorded by various physicians to watch at home every week before synthesis sessions with physicians going over cases. The coordinator assured the class that she has set it up to be the same amount of total class and lecture hours, consistent with LCME guidelines.
The main textbook resource for this year is Robbins and Cotran's Pathological Basis of Disease. Upperclassmen recommended that we purchase a $95 subscription to Pathoma, an online organ-based video atlas covering high-yield pathologies. Many of us are watching the lectures at 1.5x speed, pausing to replay sections that are confusing or to check Wikipedia. Lanky Luke surmised, "This is the future of medical education. There are so many educational resources now. Most of our class would give up lectures if it saved $10,000 of tuition." The five classmates at lunch immediately agreed. Gigolo Giorgio: "Half the class does not even attend lectures." Straight-Shooter Sally: "I think it would allow medical schools to focus on emerging technologies and practical challenges in medicine. We could use that money to invest in ultrasound, EMR training, and memorable patient interactions."
An internist specializing in viruses lectures on upper and lower respiratory infections. "I know it may not be politically correct, but the most common cause of immunodeficiency is pregnancy. Every month we have a couple 20-something-year-old pregnant women admitted requiring mechanical ventilation. They have another child in daycare that brings home RSV [respiratory syncytial virus] or the flu." He explained how the emergence of new influenza strains commonly originate in regions of the world where there are close living situations between humans and animals hosts such as birds in Southeast Asia. Flu strains in birds produce new viral proteins that can infect human respiratory cells (genetic shift) and cause a pandemic.
A PhD respiratory physiologist from the hospital, in his late 30s, leads a workshop on mechanical ventilation with example patient cases for COPD (Chronic Obstructive Pulmonary Disease) exacerbation, pulmonary fibrosis, and asthma. Three respiratory therapists, the oldest in his mid-twenties, joined for the workshop. They were helpful in offering patient examples for our questions. A student commented, "How did they know about this career growing up in high school?" (BLS shows that respiratory therapists need an Associate's degree and, in 2016, earned median pay of $58,670 per year.)
During a break, a classmate asks why the asthma case had normal oxygen saturation despite poor ventilation. "Hold your breath... Please don't pass out though. [student holds breath for a few seconds.] What is making your drive to breath is not your drop in PO2 [partial pressure of oxygen]. You have enough oxygen and a high enough pressure gradient in your alveoli to maintain your blood oxygen saturation for several minutes. It is the buildup of CO2. A patient even with status asthmaticus [severe exacerbation of asthma that no longer responds to brochodilators] should have normal oxygen saturation levels. If O2 levels drop, that patient is in really bad shape."
The respiratory physiologist explains why he got interested in physiology. "When I was a kid I had terrible uncontrolled asthma. I grew up on a farm in rural Iowa. My parents just took my occasional gasping for panic attacks. One time I had a really bad episode. Fortunately, we had come into town, and so they took me to the nearby family physician's office where I got an inhaler."
Before we arrived, he had connected mechanical ventilators to a dummy lung bag. In groups of three we learned about the different ventilator modes and settings. "When you place an order for mechanical ventilation, there are several things you need to include. The first step is specifying volume control or pressure control. For pressure control, you specify the peak inspiratory pressure, the rate, the fraction of inspired oxygen and the PEEP [positive end-expiratory pressure]." During inspiration from full exhalation, significant energy must be used to open compressed alveoli. Alveolar recruitment is maintained by holding the lungs at or above PEEP. "PEEP is your friend. Use it." He demonstrated PEEP by attaching a respiratory bag to the cut trachea of a fresh pig lung. "See how difficult it is to inflate the lung when it is collapsed. [5 cmH20 PEEP added.] Now try, much easier to inflate, right?"
We also learned about plateau pressure to ensure we don't "pop the lungs". Lung inflation requires overcoming the resistance of the airways and stretching the lung tissue (compliance of the lung comprised of the surface tension and lung tissue matrix). "It is okay to use high pressures to overcome obstructed airways. It is not okay to use high pressures to open alveoli. That will cause barotrauma of the lung." We learned how to measure the static lung compliance versus the airway resistance by measuring the pressure required to hold the lung at tidal volume at the end of inspiration. "If this pressure is close to the peak inspiratory pressure used to inflate the lung, most of the energy is being used to deform the lung tissue; whereas, if the plateau pressure is close to PEEP, most of the energy is consumed to drive flow through the airways."
The next day, the same respiratory physiologist gave a lecture on obstructive and restrictive lung disease. Obstructive diseases such as asthma and smoking-related chronic bronchitis and emphysema involve an increased resistance of the airways. Patients feel that air is trapped in their lungs. Obstructive disease can be treated with inhaled steroids and Beta-2 receptor agonists, e.g., albuterol, that cause bronchiole smooth muscle relaxation. Restrictive lung diseases are commonly caused by an occupational exposure such as to asbestos, silica, beryllium, or coal dust. These particles are inhaled into the lower airways where macrophages phagocytose the microscopic particles, but the macrophages are not equipped with enzymes to degrade these particles. Over decades, the inflammation leads to the deposition of extracellular matrix proteins that stiffen the lungs and make it harder to breathe in. The only effective treatment is lung transplant.
Our patient case: Nathaniel, a 68-year-old Air Force veteran, presents to his internist for an annual check up. He was diagnosed with emphysema following a 30-year history of smoking, and pulmonary fibrosis due to asbestos exposure working as a construction foreman after the Air Force. "My wife made me quit cigarettes 20 years ago, well before any of my lung issues. Beginning in my early 60s I started to develop difficulty breathing."
The pulmonologist explained, "Nate unfortunately has an obstructive and restrictive lung disease that combine to make his pulmonary function even worse." A normal individual is able to exhale at least 80 percent of his or her maximum inspired volume in the first second of expiration (typically 4 out of 5 liters of lung capacity). Nate is able to expire only 30 percent within the first second. Nate is treated with inhaled steroids, a long-acting Beta-2 agonist inhaler, and a rescue albuterol inhaler as needed. These medications alleviate symptoms. (The traditional age limit for a lung transplant is 65.)
"I get out of breath if I walk up half a flight of stairs. There are a lot of activities I am just no longer able to do," explained Nathaniel. "It makes me sad. I used to love to hunt and fish. I simply cannot do these any more. It is even difficult to take a walk with my wife."
This block we have weekly two-hour ethics lecture led by a psychologist, ethicist, or physician (frequently a geriatrician), followed by small group discussions led by a facilitator. This week: "Ethics in the Workplace," led by a female psychologist. When should a medical student speak up after noticing an error or unethical procedure? Should there be anonymous feedback in the medical field? The psychologist presented a peer-reviewed article that proposes a 5-step method by which a healthcare worker can determine whether to speak up:
The psychologist introduced the theory of "burdened courage" defined as a "system where there are rigid hierarchies, risky communications, and dysfunctional teams; and where unethical or unprofessional behaviors are ignored." The psychologist concluded: "We should design an ethical system such that individuals who speak up are not considered heroes. Courage should not be necessary for any health care professional to ask a question or make a suggestion regarding a patient’s care. It should be the norm."
Lanky Luke's summary: "Who gets paid for this? I want that job." Another student responded, "This field exists only because student loans subsidize these academics."
Statistics for the week… Study: 10 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Our class held a Floyd Mayweather and Conor McGregor Fight watch party. At least 25 students attended, including several M1s. "Much better fight than the Pacquiao fight. I think McGregor did really well. He got so tired at the end."
Classmates are enjoying the flipped classroom format, especially because class begins at 9:00 am instead of 8:00 am. Type-A Anita: "I do not even watch the online lectures. I prepare for lecture by watching the corresponding Pathoma videos. It solidifies the material when we go over cases in the workshops."
A tall Russian-immigrant pulmonologist in his late 50s introduces diseases of the pleura. Pleura is a thin membrane that runs along the inside border of the chest wall and outside border of the lung forming an air-sealed fluid sac called the pleural space. (Embryologically, the lung bud from the esophagus actually grows into this pleural sac like a fist going into a balloon). The pleural space links chest wall expansion to lung expansion. Chest wall expansion produces a negative pleural pressure that expands the lungs.
A pneumothorax occurs when air gets into the pleural space, thus destroying the negative pressure gradient that holds the lung expanded (-5 cmH20). This can occur spontaneously, typically in "long and thin" men, when a small section of lung parenchyma ruptures the visceral pleura, creating a connection between small airways and the pleural sac. It can also happen from trauma when the parietal pleural membrane is punctured. Tension pneumothorax, a life-threatening complication of a pneumothorax, occurs during trauma when the punctured pleura forms a one-way valve allowing air in on inspiration but not on expiration. The pleural pressure can get so high that it displaces the heart in the thorax.
A pleural effusion is a buildup of fluid in the pleural space. This causes increased intrapleural pressure and displacement of the lungs and potentially heart in the thorax. The fluid can be composed of plasma ultrafiltrate (transudate) suggested of inflammation or exudate ("a pus filled mess"). Pneumonia (infection of lung parenchyma) frequently leads to a harmless transudative pleural effusion, but the bacteria can migrate into the pleural space causing an exudative empyema. "Never let the sun set on an empyema. This is a medical emergency."
Mesothelioma, a rare complication of asbestos exposure, is cancer of the pleura. "Most of my asbestos-exposure patients were in the Navy, stationed either in shipyards or on ships. I ask them if they were exposed to asbestos. They respond, 'Oh yeah. I would go to the engine room and particles would be falling down.'"
"All of the data on the risks of asbestos exposure is from studying construction workers during the 1960s skyscraper boom in New York City." Asbestos exposure in the absence of smoking history is associated with a 6-fold increase in lung cancer. According to UpToDate, "asbestos exposure acts synergistically with cigarette smoking to increase the risk of developing lung cancer (not mesothelioma) 60 times over that of a similarly matched non-smoking, non-asbestos-exposed cohort." The pulmonologist: "The Board loves to test that mesothelioma is far less common than lung cancer or pulmonary fibrosis from asbestos exposure."
If lung cancer is a more common consequence of asbestos exposure, why so many commercials from plaintiffs' lawyers looking for mesothelioma patients? "Lawyers salivate over a mesothelioma case because it is no work. There is a one-one causal relationship between mesothelioma and asbestos exposure. Smoking is not a risk factor for developing mesothelioma. The defense cannot say it was lifestyle choices or smoking that led to the disease."
An invasive pulmonologist in her 50s discussed lung cancer for two hours. An invasive pulmonologist gets one to two years of training after a pulmonary fellowship and three-year internal medicine residency (i.e., there is no pulmonary residency, only the post-residency fellowship). With this additional training, an invasive pulmonologist can perform procedures such as a biopsy and bronchial thermoplasty (burning airway smooth muscle for non-responsive asthma). Symptoms of lung cancer are nonspecific. These include dyspnea, cough, cachexia (wasting, sudden weight loss), hemoptysis (coughing blood), and pleural effusion (from metastasis to pleura or to lymph nodes draining the pleura). "The most important aspect is to recognize the chronicity of the symptoms versus a more acute episode of pneumonia."
Smoking is the most important risk factor for lung cancer. She defines a non-smoker as "someone who has had fewer than 100 cigarettes in his or her lifetime." Smoking also causes the more aggressive forms of cancer: squamous cell carcinoma and small cell carcinoma (SCC). "SCC has a proclivity to metastasize to the brain. We treat SCC with prophylaxis brain radiation because by the time we can detect it in the brain it is too late."
She then went over the staging system for lung cancers. "Staging is important to be able to give the patient an estimate of his or her life expectancy. I would expect my fellows to be able to give an accurate stage. I just expect you to know the different components that go into staging." Staging incorporates the tumor size, nodal involvement, and presence of metastasis. "Lower stages are typically dealt with through surgical resection of a lung lobe and resection of any lymph nodes. Higher stages require chemotherapy."
Gigolo Giorgio asked the pulmonologist her thoughts on e-cigarettes. "E-cigs are such a new product. Each tobacco company uses a different formula. A new FDA regulation requires tobacco companies to release the full set of ingredients used in the vapor. I will withhold judgement until this information is analyzed." She did mention that she has noticed a rise in fungal pneumonia cases among e-cig smokers.
Gigolo Giorgio, true to his Los Angeles roots: What about pot? "That's also a tough question. There are no studies that show an increased risk of lung cancer that I know. When my patients tell me they smoke pot, I cannot tell them to stop for fear of getting lung cancer. Cancer patients? I say go for it."
She described how the second cause of lung cancer is radon exposure. Radon exposure increases the risk for adenocarcinoma, a less aggressive form of lung cancer compared to smoking-associated small cell and squamous cell carcinoma. "If you live in a high radon state, make sure you get a radon inspection. My house was off the charts. I had a radon mitigation system installed."
Our patient case: Beth, a 45-year-old spunky sarcastic mother of three, presents to her physician for worsening shortness of breath and joint pain. A chest x-ray reveals hilar infiltrates (enlarged lymph nodes of the lung). She was referred to a tertiary hospital for follow-up.
"I was diagnosed for three years with asthma. When I finally was referred to the university hospital for biopsy I was almost relieved." She drove three hours for her lung biopsy appointment. "When I was called back from the waiting room, the nurse grabbed my hand and started praying. I was like, 'Damn, Woman, what are you doing?' I did not realize I was in the OR. I did not sign up for this!" Her lung biopsy revealed non-caseating (no necrosis) granulomas diagnostic for sarcoidosis.
Sarcoidosis is a systemic inflammatory disorder that causes granulomas, a collection of immune cells formed in an attempt to wall off a substance. The soft-spoken Indian pulmonologist explained, "We have made incredible progress in understanding sarcoidosis. This mostly shows how little we knew ten years ago and how far we have to go. We still do not know what causes this immune response. It likely is an unknown substance that certain individual's macrophages cannot deal with." These granulomas can form anywhere in the body, but sarcoidosis almost always involves the lungs. "Patients are diagnosed due to shortness of breath from the pulmonary fibrosis or on incidental findings."
Beth has a lot to say about her physicians. "I cannot stand when the doctor comes in and says, 'So what brings you in today?' Look at my damn chart. Spend two seconds getting to know me. I once told a physician, 'Well I was learning to twerk on the kitchen table and fell. That's what causing my joint pain, not my sarcoidosis on my chart.'."
Beth is managed with glucocorticoids and methotrexate (folate synthesis inhibitor) to reduce her immune system response. These have greatly improved her joint pain and lung function, but have lead to significant weight gain. "Laugh all you want. Call me Fatso." She explained how frustrating it is that people around her, both strangers and close family members, attribute her weight gain to laziness. "It does not matter how much I eat or exercise. I will just keep putting on weight. It makes me depressed. I cope with it with humor, by poking fun at myself. I would not wish this even on my worst enemy... my ex-husband. And I hate him."
Beth has not had to increase her dosage for two years. Most patients will regress and require more intensive pharmacologic agents. "I am hopeful I can continue this lifestyle. I view my disease as that devil on your shoulder. He's always there, and I hope I can keep him silent for a little longer."
This week's ethics session: "Distributive Justice". Before the lecture and small group meeting, we read several papers and completed a quiz:
True or False: The Affordable Care Act can be viewed as an effort to mandate distributive justice in the United States? Lanky Luke had a field day: "I was going to put false. Then I remembered a liberal probably wrote it." [Editor: sometimes justice is not fully distributed; more than 30 million Americans were without health insurance in mid-2017, seven years after Obamacare was enacted.]
True or False: Distributive justice refers to the fair and equitable distribution of goods and services.
Which of the following strategies for eliminating healthcare disparities is the most difficult to implement? Answer: Collection of standardized data on patient and provider race and ethnicity.
One required paper was "Ushering In The New Era Of Health Equity" by Joseph R. Betancourt: (Health Affairs Blog, October 31, 2016):
several promising opportunities are on the horizon … activities focused on diversity and inclusion, and especially new conversations about racism, implicit bias, and stereotyping as root causes for disparities, are bubbling up now more than ever before. This is likely a direct consequence of the coverage of police violence against Black citizens, the Black Lives Matter movement, and the current and toxic political climate around race relations.
Luke: "My problem is not that they are making us read these articles. It is important to keep an open mind to new information. My problem is that they state their opinions as fact. Their job is not to indoctrinate us, but to provide the tools and resources for us to make our own opinions."
[Editor: Dr. Betancourt thought that the political climate was "toxic" in October 2016; imagine how he felt after Donald Trump was elected in November!]
Another article contained an interview with the physician president of a free clinic. He explained how they had planned to close down the clinic after the passage of the ACA. "Little did we know we would have more business than ever before from people with high-deductible plans not able to pay for small checkups and medications. Of the 4 million dollars in services we provide now, about 3 million go to the pharmacy."
An endowed university professor of ethics and member of the ethics committee at the hospital introduced the topic with a 1.5-hour lecture. He proposed that people agree on two principles:: (1) a decent minimum access for all, and (2) better or faster care for those who can afford it. [Editor's note: this is what most countries around the world, from Mexico to the U.K. to Russia, actually do provide. The public hospitals are free and can be reasonably good; private hospitals and doctors are available for the rich. They manage to do this while spending only a fraction of what U.S. society spends.]
He gave a personal story about Canada's attempt to provide gold-plated service for all: "I used to teach in Canada. My daughter went to an ophthalmologist where she was told she may have brain cancer and needed an MRI to rule this out. She was given an urgent 3:00 am appointment… in 6 months. Instead of waiting, we went across the border to get a $500 MRI that was emailed to her Canadian doctor. It was quite the spectacle. There are these lots near the border where MRI and CT machines are set up in trailers. The whole parking lot was filled with cars with Canadian license plates."
After the lecture we broke into six-person groups with a facilitator. Our group's facilitator was a 35-year-old female professor of ethics from our affiliated university. She had completed a Science, Technology, and Society (STS) PhD dissertation on "kind of the intersection of technology and how knowledge is generated -- ethics is my passion." She disclaimed having better answers to ethical issues than others, but felt that her training enabled her "to ask the right questions about an ethical dilemma." Gigolo Giorgio scoffed. She began the discussion with "I do not want this discussion to be political. However, being engaged in politics is important, now more than ever with the ongoing 'medical apartheid' [instituted by Donald Trump]. I am not saying how you should feel about it. But be engaged, and always reframe to the cultural context."
We started by watching a clip from Dallas Buyers Club, a movie about getting ddC and peptide T at a time when neither drug was FDA-approved. [Today, drugs related to ddC are used in standard of care combination treatment and used while peptide T is not part of any recognized treatment.] One student whose internist father has practiced in India and England added, "My father told me how grateful he is to have the FDA. There are some whacky treatments and patient requests in medical systems without the FDA framework." Capturing the spirit of current discussions regarding inequality and race, the ethicist framed the FDA's 1980s approval process for AIDS drugs: "Although the AIDS epidemic was primarily impacting African Americans, it was wealthy white men with AIDS who had sufficient influence to expand treatment options for AIDS patients. This was fortunate, but it serves as an example of the challenges different groups face." She was confident in her race- and class-based analysis, but did not explain why the government would ignore wealthy white men with AIDS in the early years of the epidemic and then begin to listen to them in the late 1980s. Nor did she explain what the government could have done in the early years of the AIDS epidemic when there was no scientific basis for treatment.
We discussed Boston REACH, a community program to address modifiable risk factors, particularly obesity and smoking, among African Americans living in the Boston metro area. Straight-Shooter Sally said, "This program is great. There are whole communities that are alienated from the healthcare system. My concern is a growing culture that blocks candid conversations. Healthcare workers have to say you are beautiful no matter what. It's difficult to convey to an obese individual that, yes, you are beautiful but you are fat and you need to lose weight. I mean you are literally a walking poster child for risk factors."
Can future generations of doctors be reformed via ethics discussion? Lanky Luke: "I kept my mouth shut the whole time… Time to go shoot a gun!"
Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 nights. Example fun: Jane and I joined Luke, Samantha, and Mary for drinks at our favorite burgers and beer joint. Samantha will be finished with PA school in a few months. She is almost as excited as Luke. "I married you for the money," exclaims Luke. "In a few months I get the money." Samantha recounted her two-month psychiatry rotation: "We worked with foster youth. I never was exposed to this. Several kids were sexually abused by their parents and now sexually assault their new foster siblings. The older children are so mentally screwed up they are forever dependent on social services. The government pays for housing, food, and all the medical care."
Cardiology week begins with a one-hour lecture and two-hour workshop focusing on interpreting electrocardiograms (ECG or EKG). An electrophysiologist with a Southern accent who is celebrating his 40th year reading EKGs implored us to "develop a systematic way to read EKGS. Don't just jump into the details." He commented on 30 slides of pathological EKGs. Afterwards, we broke up into seven-person groups and went through 20 example EKGs with a fellow. Straight-Shooter Sally was unimpressed with our fellow: "When asked why this is a LBB [left bundle branch], all she would say is, 'That's what a LBB looks like. It's pattern recognition.' That does not help us. Connect the physiology to the EKG."
We next traveled to the clinical room to practice on Harvey, a cardiopulmonary patient simulator, with a soft-spoken retired Navy cardiologist who had become a class favorite last year. "Studies show that it requires hearing about 200 murmurs to get decent at identifying one on a patient." Jane put her stethoscope on Harvey's chest while the rest of the students listened to the simulated heart sounds on wireless stethoscopes. "Enter number 24". The heart sound changes from a crescendo-decrescendo systolic ejection murmur of aortic stenosis to the holosystolic murmur of mitral regurgitation. Jane found it challenging to determine whether a murmur is systolic or diastolic. "It was really helpful to listen on Harvey while feeling for the pulse. If the murmur happens with the carotid upstroke, it is a systolic murmur."
Each group also rotated through two patient volunteers. Patient #1: accommodating 40-year-old female recently diagnosed with pulmonary stenosis after an enlarged thymus was removed. We felt a thrill (vibration felt with hand) under her left clavicle and a loud systolic murmur that radiated to her back. Patient #2: genial 75-year-old male with mild mitral regurgitation, typically a benign finding due to the changes accompanying an aging heart. The murmur was barely audible after concentrating for 45 seconds. The cardiologist asked, "How could we bring out the murmur?" After several blank looks from the group, Gigolo Giorgio proposed, "Make him squat?" "Yes!!," exclaimed the cardiologist. "Squatting would certainly work, but we'll just ask him to flex his arms together." With an increased afterload (blood vessel resistance), the left ventricle pushes more blood backwards through the mitral valve orifice. This accentuates the mitral valve regurgitation murmur. We asked the patient to stand up. The decreased preload (the total amount of blood returning to the heart) completely eliminated the murmur.
A pediatric cardiologist, recently retired from clinical practice, introduced congenital heart defects. She emphasized the cyanotic ("blue baby") defects including Tetralogy of Fallot (four heart defects combined) , transposition of the great vessels (left/right reversal creating two nearly separate circuits), and tricuspid atresia (closure of the tricuspid valve orifice). She referred to current events while looking at the swirling color doppler field of flow through an obstructed aortic valve: "Looks like [Hurricane] Irma." Fortunately for her, she's already retired because Generation Politically Correct was gunning for her. Pinterest Penelope: "It is inappropriate to make light of the suffering of those who have gone through Harvey, Irma, and Maria." Two classmates piled on.
The pediatric cardiologist continued regarding the importance of the ductus arteriosus in these "duct-dependent disorders." The ductus arteriosus is a short connection (right to left) shunt between the left pulmonary artery (carrying deoxygenated blood from right ventricle to left lung) and descending aorta that allows oxygenated blood from the uterine vein (from the mother) to bypass the lungs and mix with the systemic circulation. Compared to normal oxygen saturation after birth, the fetus survives on a lower oxygen saturation in-utero.
When baby takes her first breaths, the pulmonary vasculature opens up. Usually the ductus arteriosus closes. However, if the ductus arteriosus fails to close (patent ductus arteriosus or PDA) the shunt reverses direction, causing oxygenated blood to overload the pulmonary circulation. A reverse-flowing shunt isn't bad for everyone. Patients with an obstructed right ventricular outflow tract, such as babies with Tetralogy of Fallot or tricuspid atresia, require the right-to-left shunt PDA to get blood into their lungs. "A patent ductus is the only thing keeping the baby with Tetralogy of Fallot alive. Pump those prostaglandins. Do NOT let it close."
Tetralogy of Fallot was a lethal disease until the 1940s when a surgical procedure was developed to connect the right subclavian vein (part of systemic circulation) to the right pulmonary artery for oxygenation. This procedure is front-and-center in the identity politics of medicine, having been developed by Alfred Blalock, a white male surgeon, Helen B. Taussig, a white female cardiologist, and Vivien Thomas, a black male lab technician. People fight about whether the procedure should be called "Blalock–Taussig" (BT) or Blalock–Thomas–Taussig (BTT) and also how much credit should be assigned to the three collaborators. The discussion regarding the race and gender identification of the creators has outlasted the original procedure. Today a synthetic dacron shunt is placed between the right subclavian vein and right pulmonary artery. "Eventually the child will grow out of the BT shunt," said our pediatric cardiologist, However, the heart has grown enough so surgeons can perform a more complicated fix."
Our patient case: Becca, a female neurotrauma nurse, age 27 at the time, returned to work two months after giving birth to her second child. "It was just a normal day. I had two great patients, which means it was somewhat boring -- not stressful at all. I was pushing some meds to my patient when I had this odd sensation in my neck. It wasn’t a sharp pain, but a strong tingling sensation. I went over to the charge nurse who sat me down." Becca's heart rate was in the 50s (bradycardia). She felt a searing pain in her chest and was sweating profusely. "It felt like someone was stabbing me through the front of my chest all the way out the back."
Becca recounted how she was hauled down to the ED in a gurney. "Let me tell you something: patients remember what they hear in the hospital. My scrubs were soaked with sweat by the time I got to the ED. I started taking off my scrubs and even sports bra. I am sure people saw me naked through the makeshift curtains in the ED. Some ED nurse blabbered, 'What's wrong with her?' It was just rude." Her cardiologist, the retired Navy doctor who taught our simulator session (above), commented, "A lot of residents make offhand jokes about patients. Try to do it in the resident lounge."
The ED physician performed an EKG. "I turned my head to look at the screen. Those Tombstone T waves are still seared into my head." [Tombstone T waves suggest a myocardial infarction ("heart attack").] "This is when I was called down to the ED," explained her cardiologist. She was taken to the Cath Lab while a nurse called her husband, at home with the 2-year-old and 2-month-old. Becca: "I've sent several patients to the Cath Lab, some don’t come back. I was freaking out all alone."
"We inserted a catheter through Becca's femoral artery up to her heart. Pretty quickly we realized we were not dealing with a typical MI caused by a thromboembolism," explained the cardiologist. He showed several images of the catheterization. A student asked, "How could you tell this was not a thromboembolism?" The cardiologist responded, "This is why they pay me the big bucks." [Interventional cardiology is one of the highest paid specialties, if not the best with explanations.]
Becca had spontaneous coronary arterial dissection (SCAD) of her left anterior descending artery, the main artery that supplies both ventricles. From Wikipedia: "a dissection is a tear within the wall of a blood vessel, which allows blood to separate the wall layers. By separating a portion of the wall of the artery (a layer of the tunica intima or tunica media), a dissection creates two lumens or passages within the vessel, the native or true lumen, and the 'false lumen' created by the new space within the wall of the artery."
SCAD is a rare condition, accounting for fewer than 0.4 percent of heart attacks, but is more common during the postnatal period. This increased risk may be due to the the progesterone surge that weakens connective tissue to prepare for the baby traversing the vaginal canal. The progesterone also weakens connective tissue in blood vessels, thus enabling false lumens to develop.
Coronary dissections can be difficult to stent (putting a tube into the collapsed vessel, then inflating). "Sometimes it pays to be lucky instead of good." The cardiologist got the catheter through the true lumen instead of the false lumen. "I've only dealt with two coronary dissections in my lifetime. I knew I did not have my catheter through the false lumen because I did not have to put much force on the catheter to move it through the left coronary artery. If it had been the false lumen, I would eventually have gotten stuck where the lumen ended."
The cardiologist placed the first stent where the false lumen ended and worked his way back to where the dissection originated (working from distal to proximal). This required three stents total before perfusion normalized.
Becca's rehab included a psychology consult. "It was hard for me to not think about how close I was to dying. I would lie awake scared that this could happen again. I still see my psychologist periodically." The cardiologist: "Fifty percent of individuals experience depression during the first year post-MI." Becca returned to work at the neurotrauma ICU after 1.5 years and exercises regularly. She gets an annual echocardiogram. "One thing [the cardiologist] told me is that I cannot have another child."
During a brief intermission, our class joked about the weekly newsletter section on "How to Save Money". Recommendations submitted by former students included (1) Make your own laundry detergent pods, and (2) Take up offers for food from friends. The cardiologist chimed in, "Does anyone have a part-time job?" One of our classmates drove Uber five times per month during M1 year, but he has stopped this year. The cardiologist commented that one of his classmates paid for medical school by working as a cab driver while another worked as a part-time cop. "Getting shot at was his stress relief from studying. He is now a trauma surgeon." Classmates noted that tuition has gone up so much faster than wages that even paying for undergraduate tuition would be impossible today.
After the patient case concluded, the cardiologist summarized myocardial infarction complications. The danger of a MI does not end during the acute event. After the risk of cardiogenic shock or sudden cardiac death from an arrhythmia, there is significant remodeling of the necrotic tissue. Over the next few days, white blood cells infiltrate into the tissue to eat up the dead tissue. During this period there is a significant risk of ventricular wall rupture, in which blood flows from the heart into the pericardial sac. Blood filling the sac around the heart compresses the heart, preventing pumping (cardiac tamponade). "You die pretty quickly from a free wall rupture." Weakened tissue can also cause a papillary muscle ("heart strings") tear that holds the mitral valve from prolapsing during systolic contraction. Over months and years, remodeled scar tissue may develop arrhythmias and aneurysms. "An MI does not end after the two-week hospital stay. Patients need to be followed for life."
Our ethical group met for a 1.5-hour discussion on patient autonomy and veracity. Nervous Nancy, an attractive, intelligent female who asks great questions at the speed of sound, worked as a CNA and scribe for a large health system in the ED and orthopedic unit before medical school. She recounted, "Patients would come in on lawyers' directions to get a payday because they knew the hospital would settle rather go to court. We had this one woman purposefully fall off a bed that did not have the railing up. She got one million dollars."
Lanky Luke continues to scoff: "I want a talk from a malpractice lawyer and from a physician reflecting on their experience about getting sued by a patient. Not from some overpaid ethics professor. Why do we as physicians get to decide what is or is not ethical. We should first be taught the Law. Yes, sometimes there will be grey areas. Those situations should be highlighted and settled through the legislative process." (Luke hopes to go into politics after graduation.)
Classmate political activism continues with a Facebook post from Type-A Anita regarding Trump's Department of Education relaxing requirements that universities run sexual assault tribunals:
I think that taking what [Education Secretary Betsy DeVos] says at face value is dangerous. This administration doesn't care about sexual assault victims.
Do you have any idea how hard it is to file a sexual assault claim on most campuses? Or how degrading [sic] victims are made to feel during this process? … The students Betsy is looking out for here are rapists, who already have the entire system at their backs. … Even if the school does something, it will take forever and their rapist will most likely be allowed to stay on campus, finish their degree, or be given a slap on the wrist. It's laughable if you seriously think rapists on campuses are actually punished - the vast majority aren't dismissed from school.
… I do not care if rapists feel their rights have been taken away from them under these university Title IX programs. University's [sic] have professional Title IX coordinators, larger universities have whole departments. It's not asking for the sun and the stars for schools to pay professionals to advocate for sexual assault victims on campuses. These programs force administrations to listen to victims over fucking rapists, and still so many victims don't get any semblance of justice.
… And this isn't just about rape, it's about all forms of sexual assault, which by the way isn't a fucking bipartisan issue. Conservatives literally voted for a man who bragged about assaulting women...
Nearly half of our class clicked "Like" on Anita's post, roughly one third of which is reproduced above.
Jane and I went to the mall. A 40-year-old sales clerk asked what we did and then told us about having dilated cardiomyopathy (enlarged heart). "If my meds don’t start working, I have to get a heart transplant." He recalls his doctor saying something about a viral infection. We spent the drive home pondering the possible causes. Dilated cardiomyopathy is typically familial, but we both thought of Coxsackie type B virus and Chagas Disease (prevalent in Central and South America, caused by the Trypanosoma cruzi).
Statistics for the week… Study: 14 hours. Sleep: 5 hours/night; Fun: 2 nights. Example fun: Jane and I went to a concert with Jane's sister, a nurse on the neurotrauma unit, and her two friends, a fellow female nurse on the unit and an autopsy assistant at the hospital who doubles as a part-time stand-up comedian: "If I were stranded on an island after a plane crash I would know exactly what cut to take out of the the dead bodies. Tenderloin dinner for me."
Heart failure week begins Sunday evening. Jane and I watch (at 1.75x speed) three hour-long lectures on hypertension and ischemic heart disease (due to obstructed arteries the heart is starved for oxygen causing chest pain d). The lecturer is a 35-year-old cardiologist who comes in Monday morning for a two-hour case workshop. "I get excited when I see 30-year-olds with hypertension. I can change their lives. When I see a 70-year-old patient with three decades of uncontrolled hypertension, the damage is already done."
Hypertension is categorized by disease acuity. Malignant hypertension is a severe acute elevation of blood pressure that causes end organ damage, particularly in organs with dense capillaries, e.g., the kidneys and retina. Benign hypertension, over 95 percent of cases, is a progressive mild elevation of blood pressure. Our lecturer explained that Amazonian tribes with no exposure to Western diet typically show blood pressures of 80/50. Normal blood pressure for an occasional McDonald's customer is 120/80. Greater than 140/90 mmHg constitutes benign hypertension. Over 200/120 mmHg is malignant.
"The vast majority of benign hypertension is simply caused by chronic excess of salt intake," said the cardiologist. "Our bodies have evolved complex mechanisms to retain fluid by holding onto salt. Recommended salt intake is about 4 grams; most Americans consume about 10 grams per day." About 30 percent of the US adult population has hypertension compared to 45 percent of the Japanese adult population with their salt-heavy fish diet.
He explained that, although salt intake is a serious driver, "there are many risk factors that interplay with this volume overload state. It is well-established that African Americans have an increased risk of hypertension. The current theory is that there was an evolutionary adaptation to holding onto salt in Sub-Saharan Africa. These adaptations helped individuals survive as young children in a dry environment with little access to salt." He continued, "The unintended consequences of chronic hypertension that develop when you are 50 do not really matter from an evolutionary standpoint. Our genetics are most adapted to getting to reproductive age." There is nothing that humans can do after age 50 to increase their genetic success? "I would like to think there is some selection that occurs during your 50s as you take care of your child, perhaps even into grandchildren-rearing age."
Why is hypertension bad? "A misconception about hypertension is that the heart is at fault. Hypertension is not a disease of the heart, but a disease of the vasculature and kidneys. Cardiologists get stuck dealing with many of the serious complications." The endothelial cells and smooth muscle cells of vessels do not respond well to chronically elevated hypertension. Over time, the increased pressure within the vessels hardens and narrows both large and small arteries (atherosclerosis and arteriosclerosis, respectively). The increased resistance decreases perfusion to tissues and increases the risk for thrombus (clot) formation leading to embolic events such as heart attack and stroke. Further, the left ventricle undergoes hypertrophy (thickening) as it struggles to pump against an increased total peripheral resistance.
"For most of my patients, losing weight is the most effective method," said the cardiologist. "Unfortunately, only six percent of patients told to lose weight actually keep weight off at one year. I give HTN medications first and tell them that they can get off them once they lose the weight." What about reducing salt? "Americans are so far to the extreme that taking away the salt shaker will do nothing. Shake away. Chronic benign hypertension needs antihypertensive medications."
Where is HTN treatment going? "We are in the dark ages of hypertensive treatment and pharmacology in general. Most of us hope that in twenty years we will have a renaissance in pharmacogenetics to personalize treatment. Right now it is just black or white." (White patients may respond to single drugs, but certain monotherapies are contraindicated in African Americans due to poor response rates. Black patients will be started on lisinopril in combination with a diuretic.)
The cardiologist concluded: "On a brighter note, we are at a unique point in human history that we are no longer dying from microbes and predators. Instead, we are eating, drinking and smoking our way to death. Not bad."
The rest of the week was dedicated to the diagnosis and management of heart failure. First we learned multiple classifications:
Retired Navy Physician: "Cardiology is not rocket science. It is just common sense."
We were prepared for our patient case with a lecture on dilated cardiomyopathy, a systolic non-ischemic problem. The heart is enlarged due to growth of muscle cells, but the resulting thin-walled muscle is unable to pump enough blood. This can be caused by genetic defects, viruses (Coxsackie B), parasites (Trypanosoma cruzi causing Chagas disease), alcohol abuse, cocaine, and poorly understood autoimmune mechanisms.
For the most part, we're not working with cadavers this year, However, this week we go into the anatomy lab to dissect the preserved hearts that we removed from our cadavers last year. Several students expressed frustration that they had to resurrect their anatomy outfits. Pinterest Penelope: "I thought we were done with anatomy lab. Another pair of scrubs will be tossed." Our favorite trauma surgeon and an M4 helped with the dissection. We first weighed each heart and found that two-thirds weighed more than the normal 500 grams. The trauma surgeon attributed this to "pervasive hypertension".
We used a scalpel to open the right atrium. We used angled probes to identify the veins draining the body: inferior vena cava, superior vena cava, and the barely visible coronary sinus. We then opened the left atrium with its four pulmonary veins draining oxygenated blood from the lungs. One student found a patent foramen ovale (PFO) type of atrial septal defect (ASD). You could see a hole connecting the left atrium to the right atrium. (The trauma surgeon expected more: "I would expect to have several PFOs. It is expected to be present in 25 percent of the population. Look closer!" We then opened the left and right ventricles to observe the heart strings connecting to the valves. Afterwards we went over to the "Tray of Horrors," collected over multiple years. We looked at the severely dilated thin walls of dilated cardiomyopathy, a bicuspid aortic valve, and a heart with several stents in the left anterior descending coronary artery. "Good haul!, I am very impressed," said our trauma surgeon. She suggested that our class contribute to the school's archive: "Put the mechanical aortic valve and aortic dissection on the tray."
Our patient case: Jonathan, 53-year-old construction manager and father of two, presents to the ED for progressive shortness of breath and swelling in his legs associated with a 15-pound weight gain over two weeks. Lung auscultation (listening with a stethoscope) reveals bibasilar (base of both lungs) crackles. Heart auscultation reveals a S3 gallop, an extra heart sound that sounds like a horse's gallop, suggestive of rapid ventricular filling.
Feeling for the location of the heart under Jonathan's left nipple revealed a laterally displacement. Chest xrays showed an enlarged cardiac silhouette and bilateral infiltrates (pathy whiteness at the base of the lungs) with accentuated vasculature at the hilum (connective tissue where the pulmonary artery, pulmonary vein and bronchi pierce through the pleura). EKG shows sinus rhythm with a left bundle branch block, left ventricular hypertrophy, and biatrial enlargement. An echocardiogram (ultrasound of the heart) shows dilation with a 30 percent ejection fraction (normal > 55 percent). Jonathan is diagnosed with dilated cardiomyopathy secondary to viral myocarditis (infection of heart). ("Viral myocarditis and dilated cardiomyopathy," Kearney, et al. Post-Graduate Medical Journal, 2001 ).
Jonathan, his wife, and their 25-year-old son were joined by his cardiologist. Jonathan and the son rarely spoke; the wife, a middle school teacher, led the conversation. "We did not know what hit us. It came out of nowhere," explained the wife. "I did not know what to say to my children or husband for weeks." The son was clearly uncomfortable. When asked about his perspective on two separate occasions, he repeated: "I try to stay optimistic, and hope for the best. I just have to believe my father will pull through this."
Jonathan's symptoms rapidly deteriorated at the hospital to a point he underwent a LVAD (left ventricular assist device) implantation to improve his cardiac output while he waits for a heart transplant. "We would have liked to do the surgery at a larger hospital that does maybe 100 per year. There was just no time, he was on his deathbed," explained the wife. "The surgeon had done maybe two in his life. We put our faith in him, and it fortunately went great."
Jonathan has been on the heart transplant list for five years. He appears tired, worn out, although he still looks imposing in his burly 6'5" frame. "It is hard to find a heart that fits his size," added the cardiologist. His wife is convinced he will get one soon. She recounted the scariest day in her life: "I got a phone call from my husband telling me he got in a car accident. A truck veered into his lane, striking the car in front of him. He swerved off the road hitting a tree. "I believe God has a plan for him. He wouldn’t have come out of that car accident without any scars." Jonathan: "I am realistic. I have lowered my expectations." There is clearly a disconnect.
Jonathan's symptoms have improved remarkably from his deathbed with the LVAD. His progress has pushed him down in the transplant list for more urgent cases. He is maintained on diuretics and antihypertensive medications. He quickly gets out of breath from walking. He has had to retire on disability, while his wife has picked up hours working at Starbucks after her job.
A student directly asked Jonathan, "Are you depressed?" "I feel like a failure. My whole life I provided for my family. Now I just sit and wait." Several students went up afterwards to thank the family and look at the numerous batteries and charging devices for the LVAD. Mary asked to listen to his LVAD. "It sounded like a fish-tank pump."
Our ethics lecturer and facilitator returned this week to introduce the topics of beneficence and nonmaleficence (do no harm). Lecture opened with the classic ethics train dilemma. "There are five people on the track who will die unless you pull the lever to divert it to the side track where one person will die. Would you pull the lever?" Most students responded via the iClickers, "Yes". "Now you have five patients that need a transplant and a healthy tourist comes to town? Should you harvest the tourist's organs to save your five patients?" The class responded "No". Asked to justify the different answers, one student responded "The guy on the track got into his unfortunate situation, the tourist did not." Lanky Luke: "Is that victim blaming?"
In our small groups, we went over the Jesica Santillan case. Jesica Santillan was treated for anemia in her hometown of Guadalajara, Mexico with iron supplements, but over the years her conditioned worsened and a heart murmur was found. She was diagnosed with restrictive cardiomyopathy, a genetic disorder requiring heart transplant. She crossed the border illegally to stay with a family member living in North Carolina and sought treatment at Duke. After she was denied Medicaid coverage, a local business owner and the community donated $500,000 to pay for a transplant. A heart and lung transplant was performed at Duke in February 2003. Unfortunately, she probably would have been better off getting the transplant in her native Mexico. The American transplant surgeon, James Jaggers, assumed that the organ program would not have contacted him unless the donor and Jesica were a match. Her body rejected the new heart and lungs, with incompatible blood types, resulting in brain damage. Duke found a second set of donor organs and transplanted them, but it was too late to save Jesica, who died a day later at age 17.
Our group discussed whether Jesica should have been able to receive the second heart transplant. "She was promised a heart. It was not her fault Duke messed up." Type-A Anita: "We should go to an opt-out organ donation system." Six of the seven students thought it was "immoral" that "insurance" (i.e., American taxpayers via Medicaid) did not automatically cover the foreigner's transplant operation.
According to the required reading, "The Jesica Santillan tragedy: lessons learned" (David Resnick, The Hastings Center Report, July 2003), physicians and our organ donation system should operate without regard to immigration status:
The fact that Duke did not deny Jesica an opportunity for a transplant based on her immigration status also reveals compassion. Some people criticized Duke for allowing an illegal alien, or undocumented immigrant, to have a chance at receiving an organ transplant. The organ allocation system, according to these critics, should serve citizens first, and illegal aliens should receive an organ only when no citizen requires that organ. Indeed, the reasoning goes, the fact that Medicaid does not extend benefits to illegal immigrants reflects this country's collective decision to take care of its own citizens first.
There are several problems with this reasoning. First, immigrants, including illegal aliens, donate organs in the United States. Indeed, some evidence suggests that they may give more organs than they receive. Second, immigrants, including illegal aliens, make important contributions to the United States economy. The Santillans had lived and worked in the United States for three years; they were not on welfare. Third, immigrants, including illegal aliens, pay taxes. As an employee of Louisburg College, Magdalena Santillan probably paid taxes to social security. Medicare, the state government, and the federal government. Both of the Santillans probably paid gasoline taxes and sales taxes. Although they did not qualify for Medicaid, they were not seeking a handout: they were industrious people who made sacrifices to try to save their daughter's life. Thus, there were sound moral and economic reasons to offer them medical care, including organ transplantation, notwithstanding their immigration status.
The author of the article has a law degree and hypothesized regarding the difficulty of recovering cash from Duke:
Although Jaggers has admitted his fault, since he is an independent contractor and not an employee or agent of Duke, his negligence would not implicate Duke under the doctrine of "vicarious liability." To go after Duke's deep pockets, Dixon will need to argue that Duke was negligent. So far. Duke has accepted responsibility in the mishap but has not admitted that it made an error. For the last few years. Duke has asked patients to sign mandatory arbitration agreements as a condition of providing care. These agreements require patients to submit their claims against the hospital to an arbitrator instead of taking them to court. As of this writing, information about any arbitration agreement between the Santillans and Duke was not publicly available. If the Santillans had signed such an agreement, they would need to show that the contract was invalid before they could pursue malpractice litigation.
That's where the matter stood in July 2003, apparently, and we the surgeon, James Jaggers, being thrown under the bus by Duke and becoming the primary defendant in any lawsuit filed by the patient's mother. Students expressed sympathy for Dr. Jaggers: "He made a mistake, but there should have been other checks. He made one error. Think of all that training he has put into becoming transplant surgeon."
[Subsequent news articles found via a Google search make it clear that Duke paid a settlement to the patient's mother in 2004. Apparently when someone is listed on your web site as being a professor of surgery it is tough to escape liability for his or her actions! Illustrating the asymmetry between the stakes that patients and physicians have in our system, Dr. Jaggers continued to be a professor of surgery and pediatrics with tenure at Duke through 2010, and Dr. Jaggers was on the faculty at the University of Colorado's School of Medicine in 2017.]
Type-A Anita was also thinking about immigration this week. Her Facebook post, "liked" by about 20 percent of our class:
DREAMer's parents were never 'criminals', but working people displaced by NAFTA and US economic and foreign policy. Their parents did not 'break the law', but obeyed the the law of supply and demand that were shaped according to the wishes of US corporations. US policy united economics, destroyed peasant economics in Mexico and Central America, attracted laborers to the US, then branded these same migrants 'criminals'. Rather than recognize this history or take responsibility, we now criminalize the children of people that we displaced, cheated and exploited. The real criminals in this equations are corporations who profited from migrant labor yet never fought for their legal rights, and politicians who decided demonize immigrants for political gain. There is the law, and there is morality, and these are at complete odds with regard to US immigration policy. We are not a 'nation of laws' but a nation of lies, a nation of greed, a nation of racism, and a nation of violence.
Our school holds two shows per year featuring local art. This semester's show is on the interplay between medicine, veterans, and the military. The 50 pieces in the hallways at our school include paintings of soldiers, photos of veterans, an American flag, and two essays, one on how a Health Professions Scholarship Program medical student puts on two coats (his uniform and his white coat) and another on the role art played in healing a Iraqi war veteran. A week after the show opened, the Dean emailed all students and faculty:
Some of you have brought up concerns that the display is militaristic and can seem counterintuitive to the type of learning environment we try to create at the school. I understand your concerns, especially without the context of the show. Our goal is to pay tribute to the sacrifice of veterans and their loved ones while also showcasing the power of art to promote healing and reintegration…
Please let us know if you have further concerns. We would like to continue the discussion.
Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: doubleheader Thursday night softball game before the playoffs followed by burgers and beers. Our school put together a softball team for a community recreational league. We play two or three games per week with five males and five females. Pinterest Penelope grumbled over the league rules: when a male is walked, he goes to second and the female on-deck has the option to take first, whereas when a female is walked, she goes only to first. Jane said: "I should identify as a male." Gigolo Giorgio: "I should just identify as a female so we have enough ladies every match."
We lost 35-3 the first game to the "Masterbatters", a team of plumbers. We spent 45 minutes in the field during one inning while the Masterbatters scored 28 runs. We won 9-8 the second game against "Pitch, Don't Steal my Vib", a local restaurant team. Jane, having never put a mitt on before, appeared several times at bat as the MVP in a school-sponsored video.
Hematology week. Our favorite redheaded hematologist/oncologist: "Heme is a free-for-all. Oncology is more by-the-book. Our whole practice has no idea what is causing one patient's hematological abnormalities. We've been following him for 3 years. This is what makes hematology so exciting."
Blood is composed of cells and plasma (water, electrolytes, and proteins). As introduced in the Year 1, Week 7 and Year 1, Week 16 chapters, all blood cells are derived from a single hematopoietic bone marrow stem cell that can produce either the myeloid lineage or the lymphoid lineage. The myeloid lineage includes erythrocytes (red blood cells), platelets (for clotting), monocytes (white blood cells that consume particles), and neutrophils (the most abundant immune cell that responds to infections). The lymphoid lineage includes the immune system's T cells and B cells.
Platelets start as small cytoplasmic blebs (bulge in the cell) of megakaryocytes (large resident bone marrow cells) and eventually detach and drift away. Erythrocytes (red blood cells) mature in the bone marrow until they lose their nucleus. "If you see reticulocytes [immature red blood cells] in the blood, the bone marrow is working in overdrive producing red blood cells."
Our lecturer explained the complete blood count (CBC), the most common blood test. Normal CBC: 45 percent of blood volume is composed of red blood cells (hematocrit), 55 percent plasma (proteins, electrolytes, water), and less than 1 percent white blood cells and platelets. "Do not forget about the peripheral blood smear [looking at a drop of blood through a microscope]. It's vastly underutilized. You can catch iron deficiency before counts get low." The hematologist emphasized contextualizing a CBC: "Before you jump to pathological anemia, is this patient over-hydrated? If they are hooked up to IV saline, they are going to have lower counts even though the total rbc mass may be normal."
Anemia is divided into problems of underproduction or destruction. "Destruction anemias are caused by an intrinsic or extrinsic factor. Intrinsic anemia is caused by a defect in the red blood cell itself, such as the membranopathy hereditary spherocytosis or the oxidative damage from an enzyme defect such as glucose-6-phosphate dehydrogenase. Extrinsic anemia is due to destruction of the red blood cell from the outside." This can be due to an autoimmune reaction against red blood cell surface proteins or a platelet disorder causing small thrombi to form in the vasculature shearing normal red blood cells.
"Use the Coombs test to differentiate between intrinsic and extrinsic disorders." The Coombs test mixes the patient's blood with an antibody against human antibodies. If the immune system is attacking its own cells, the anti-Ig antibody will cause the red blood cells to precipitate out of solution.
When so many red blood cells are destroyed that the body demands more, immature red blood cells that still have nuclear material (reticulocytes) are released into circulation. "Always ask for the reticulocyte count if you suspect an anemia of destruction."
The next two lectures detailed hemostasis (clotting) disorders and the body's two systems for preventing bleeding. Primary hemostasis plugs the damaged blood vessel with platelets. Secondary hemostasis creates a more stable clot by using clotting factors, proteins released by the liver. Primary hemostasis disorders are associated with mucosal bleeding (gums, menorrhagia, epistaxis), whereas secondary disorders such as hemophilia lead to severe internal bleeding, especially in joints (hemarthrosis).
Our patient case: Gina, a 51-year-old secretary presented to her internist after gingival (gum) bleeding from a dental cleaning. She described bruising easily and itchiness after hot showers (aquatic pruritus). A CBC reveals an elevated hematocrit (extra hemoglobin) and a high platelet count. She was surprised to be diagnosed with polycythemia vera (PV): "I did not know I was sick until the doctor told me I was sick."
PV is a type of myelodysplastic disorder. A mutated myeloid stem cell, most commonly a JAK2 gain-of-function mutation, causes unchecked clonal proliferation of the myeloid lineage. This results in erythrocytosis (increased red blood cells), thrombocytosis (increased platelets), and leukocytosis (increased white blood cells, specifically of the the myeloid lineage).
Gina started with low-dose aspirin and biweekly phlebotomy (blood draws) to decrease her platelet function and hematocrit, respectively. Straight Shooter Sally: "Can she donate the removed blood?" The hematologist responded, "Great question, in many countries yes. In the US, the Red Cross will not accept anyone with an abnormal CBC. It is a shame because there is nothing abnormal about her denucleated red blood cells."
PV increases the risk of thrombotic events (clots, stroke, heart attack) due to the increased thickness of blood. According to UpToDate, the annual incidence of thrombosis in PV patients ranged from 2-5 percent depending on risk factors such as age and hematocrit management, which compares to annual stroke risk of 5.6 percent for a 75-year-old smoker with hypertension and diabetes.
PV patients have a 20-percent lifetime risk of their PV transforming into myelofibrosis and a 7-percent lifetime risk of acute myeloid leukemia. "PV overworks the bone marrow," explained the hematologist. "Myelofibrosis is what you get when you wear it out." Bone marrow becomes fibrotic with collagen (fibrous protein found in bone, tendons, and ligaments) deposition displacing the stem cells. This causes an abrupt aplastic anemia with extramedullary (outside the bone) hematopoiesis. PV turning into leukemia happens because rapid clonal proliferation increases the chance of an oncogenic mutation (cancer-producing mutation).
"When it rains it pours," recounted Gina. "I had left my husband. I was going through divorce, I had a new boss trying to cut costs at work, and my son was jobless after graduating from college. Now I have my doctor using all these fancy words and telling me I might have cancer. It was too much." A student asked: "Did you have any issues dealing with health insurance during the divorce." "No, I was the primary insurer." The heme/onc added, "I have issues with insurance and divorce all the time. Also, when the patient with insurance is diagnosed with leukemia and has to stop working. The family has trouble switching primary insurance to the other spouse."
[Editor: note Gina's description of being involved in a divorce lawsuit that she started as "going through a divorce." This is conventional for American plaintiffs, as though divorce litigation were a random weather phenomenon that they had stumbled into. See Real World Divorce.]
Could Gina describe the itchiness? "Every time I got out of a hot shower, I would have this uncontrollable itchiness for a few hours. It got so bad I would be afraid to shower!" The hematologist added, "There are a few theories out there to explain this phenomenon. One theory states the increased myeloid white blood cells cause increased histamine release. This doesn't make sense because patients can get the itchiness even without leukocytosis [high WBC]. The other theory is platelet aggregation after vascular constriction in the skin after a hot shower."
Gina, now 66, returned to her hematologist about a year ago due to acute left flank pain, fatigue, and poor appetite with a 15 pound weight loss over a two-month period. Physical exam revealed a palpable mass on her left upper flank. CBC showed pancytopenia (low cell counts across the board). A bone marrow sampling revealed diffuse fibrosis.
The hematologist explained that bone marrow sampling has two steps: "First a needle is inserted into the bone. A vacuum is created to suck bone marrow aspirate into the syringe. Then, a small sample of bone is extracted for biopsy. I am told that the aspirate step is the excruciatingly painful part." Gina interjected, "It feels like a lightening bolt traveling through your bone." Her bone marrow cells have been expelled from the fibrosed marrow and now reside in her spleen, liver, pleural cavity and peritoneum. The enlarged spleen is compressing her stomach, which makes her easily satiated and explains the weight loss [Editor: when will be able to buy one of these spleens on Amazon?]. She was diagnosed with myelofibrosis and informed that her life expectancy was just seven years.
The only curative therapy for myelofibrosis is an allogeneic (from a different person) stem cell transplant to replace the defective myeloid clonal population. Gina was not a transplant candidate given her age. She was started on Jakafi (ruxolitinib), a small-molecule inhibitor of JAK2. Jakafi may relieve symptoms of myelofibrosis, but does not improve survival [Editor: except for the survival of Incyte Corporation, which collects roughly $1 billion per year from this "ophan drug"].
The hematologist recounted Gina's Jakafi-induced anemic crisis: "Jakafi is a double-edged sword. It can improve symptoms, but it also risks causing an anemic crisis. We followed the drug's guidelines but Jakafi was such a new drug. We took her off the drug, but then she had withdrawal requiring two transfusions. We titrated her down [with smaller doses of Jakafi]. She finally has great symptom control with this lower dose." Despite all these ups and downs, Gina is happy with her treatment. Her symptoms are managed well, and she enjoys vacationing at the beach in her retirement.
A student asked, "I apologize if this is blunt: do you struggle with the cost of Jakafi? Is making Medicare pay for such a costly medication that just improves symptoms worth it?"
"The medication makes me feel much better. I was barely eating before I started Jakafi. The pain in my stomach [spleen] got better, it allowed me to sleep. My blood tests have improved. Jakafi had a crazy price tag when I first started taking in 2012. I am fortunate that my doctor enrolled me in a charity program that pays my share." According to "U.S. Probe Sheds Light on Charities’ Role in Boosting Drug Sales," (Wall Street Journal, June 2017), pharma companies are the primary donors to these "charities" because "every $1 million donated to charities can lead to up to $21 million in sales for drug companies." In other words, patients are more likely to continue having their Medicare prescriptions filled if they don't have to pay anything out of pocket.
Friday afternoon concluded with a practice clinical exam session. We interviewed a standardized patient with simulated heart failure (bibasilar crackles with S3 gallop). After the 30-minute encounter, we analyzed a (fake) electrocardiogram and chest x-ray, and then we spent 45 minutes writing a H&P (history and physical exam) note. Type-A Anita before the practice session: "I am so nervous. I do not know who we will have to write up. I don’t know if we should do vitals. I'm freaking out about having to read an EKG."
Students throughout the day were checking news about the Las Vegas shooting. Pinterest Penelope updated our small group from BuzzFeed: "Isn't that where Russian News propaganda is spread?" "Are you kidding, they have better live news updates than any other website." "That's because they don’t fact check anything."
The weekly email from our director of academic counseling:
... in this Wellness Weekly section, inclusive language will be highlighted. The following details were taken directly from the University of Massachusetts–Amherst transgender terminology guide [from The Stonewall Center, "A Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) Resource Center"]
She promises more information on the topic of transgender vocabulary in future editions, includes a recipes for Zucchini Parmesan Crisps (preheat oven to 450 and bake for 30 minutes), and advertises a yoga session taught by a full-fledged MD.
Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 nights. Example fun: Our social chair organized a 2:00 pm Saturday private wine tasting tour for $20 at a local winery attended by 15 students.
Leukemia/Lymphoma week. A spunky 40-year-old hematologist/oncologist hung up her phone as she arrived five minutes late for the first lecture. "Sorry! Sorry! My husband is incompetent at getting the children ready for school. I had to leave earlier than normal to get here. He can't find my son's shoes! The whole house is in chaos." (She rejected three additional calls from the husband during the lecture.)
Leukemia, a cancer of bone marrow blood cells, is classified according to (1) stem cell lineage (myeloid versus lymphoid), and (2) chronic versus acute. Disease severity is determined by symptoms and the percentage of immature cells (called blasts) in the marrow and blood.
She began the lecture with an impassioned speech on the advances in treatment of chronic myelogenous leukemia (CML). "This is the coolest story of the century! It is an amazing time to be in medicine. In the 1990s, CML had 100 percent mortality within five years." Dr. Brian Druker's lab linked CML to the Philadelphia Chromosome, a translocation between chromosome 9 and chromosome 22 resulting in the constitutively (constantly) active BCR-ABL fusion protein. Druker developed imatinib, a targeted therapeutic agent, that inhibits the function of BCR-ABL protein. "This is what bench to bedside medicine is all about. Imatinib was the first successful targeted therapeutic in cancer treatment. The trials of the drug that became Gleevec showed complete hematologic response in 94 percent of patients versus 55 percent for standard of care. We never see these numbers. The coolest thing is it is a small pill. This is Nobel Prize-worthy." The class, one week before exams and exhausted after three hours of lecture, showed little reaction. "Guys, come on, get excited!"
Imatinib is a nearly complete cure, with CML patients now as likely to live to a ripe old age as anyone else, but nobody wants to do a clinical trial investigating whether patients can stop taking Gleevec. "Would you sign up to be randomized to stop the drug that saved your life? Who is going to fund it? Not Novartis."
She continued with the childhood disease of acute lymphocytic leukemia: "ALL is a parent's worst nightmare. An 8-year-old falls on the playground and starts to complain of bone pain. When you go to the pediatrician, ALL is not on their radar. There is no fracture on x-ray, but the pain does not resolve." After several tests including an abnormal CBC, the child is referred to a pediatric oncologist who then performs a bone marrow biopsy to diagnose ALL.
Induction therapy (initial treatment) involves 30 days of intense chemotherapy (typically, methotrexate) to get the child into remission. Due to ALL's tendency to metastasize to the brain, chemo drugs are introduced via lumbar punctures every three days. "We fortunately have a fantastic prognosis for ALL. Children are resilient. We are able to use doses and treatment frequencies that are not achievable in adults."
Lectures conclude with an overview of common chemotherapy agents and a discussion of side effects: "An overlooked area of chemotherapy is managing nausea. I had a patient vomit when she saw me at the grocery store. These drugs cause such visceral reactions. We've developed much better antiemetics in the last few decades." She is a strong proponent of medical marijuana having trained in Seattle. "Even with the newer antiemetics, Marinol [synthetic THC] is one of the most effective agents I have seen to control nausea and appetite."
We need to memorize the major complications of several drugs. Doxorubicin has a 11 percent risk of developing acute dilated cardiomyopathy. This rises to 35 percent if higher doses are used. Vincristine, a microtubule inhibitor, can disrupt the highway system of the neuron. This can lead to peripheral neuropathy (sharp pain in the extremities), one of the most common side effects of chemo. Certain breast and ovarian cancers requires hormonal agents. "Some of the estrogen modulators and aromatase inhibitor makes the patient feel like he or she is going through menopause. Testosterone inhibitors for prostate cancer causes this similar menopause sensation with hot flashes and all." Straight-Shooter Sally: "All an oncologist does is hope the poison kills the cancer before the patient."
Our patient case: George, a 31-year-old owner of a small construction firm, presents for a painless mass on the right side of his neck he noticed showering a week earlier. He has lost 10 pounds over the last month, which he attributes due to training for an upcoming bike race. He reports occasionally waking up sweaty in the middle of the night, which he attributes to anxiety from his 100-hour work week. He has intermittent back pain, which worsens when he consumes two or three beers. Physical exam reveals a 4 cm x 3 cm mass in the right supraclavicular fossa (space just above the collarbone) and an unbeknownst 5 cm x 5 cm mass in the right axilla (armpit). George undergoes a lymph node resection (removal). Biopsy reveals pathognomonic binucleate Reed-Sternberg cells on histology. George is diagnosed with Hodgkin lymphoma (formerly "Hodgkin's lymphoma," but the trend is to get rid of the apostrophe S when a disease is named after a physician who discovered it, as opposed to being named after a patient).
Hodgkin lymphoma begins in a single lymph node and, unlike other cancers that can pop up in random locations around the body, spreads along continuous lymph drainage, spreading first to the spleen, then the liver and finally the bone marrow. Most lymphomas afflict the elderly, but Hodgkin patients have a bimodal age distribution, peaking around 25 and 65.
George is joined by his oncologist, a 60-year-old with a slight stutter. "Oncologists are stereotyped as two-faced. We are aggressive in attacking the cancer, but the moment we give up on beating the cancer, we switch to palliative care. It could be overnight the day after receiving chemo."
George: "I had chemo about once or twice a week for two months. Then I had a PET scan to re-evaluate." His oncologist commented: " George was a uniquely motivated patient. We discussed possible clinical trials. However, he wanted to preserve his lung function given his passion for biking. Clinical trials are not good for personalizing treatments. We customized a treatment regimen without standard-of-care Bleomycin." [Bleomycin causes pulmonary fibrosis in 10 percent of patients.]
George was asked to describe the chemo center. "Chemo centers are a depressing sight. You remember the faces of the person next to you. I would try to imagine the life of the person. You can tell who will not be there next month."
Mischievous Mary asked how George's family managed the diagnosis and treatment. "My wife was a rock," recounted a tearful George. "She would try to shield me. I remember one time I got up from the TV to do some task. My wife thought I would be away for 15 minutes. When I came back sooner, I found my wife and son scrubbing the whole room with bleach. I asked them, 'What is going on?' 'Oh, nothing…' they responded. I realized they were doing this out of fear I would get an infection." He continued: "I kept working during the early chemo. After a few cycles it got unbearable to work immediately after a dose. I would take a few days off and lie in bed, then be back later in the week. My brother and his family moved into our house to help manage the business. I was upfront with my employees and clients. I am proud that not a single employee left."
Type-A Anita asked what motivated George through his treatment. "I grew up without a father and did not plan to have children because I thought I wouldn't make a good father. I am a Christian, but talk a lot with my neighbor who is a rabbi. One evening he told me, 'Look at what you have accomplished.' After that, I promised myself I would always be there for my children."
Friday afternoon concludes with an introduction to intravenous catheters (IVs), the first workshop in our clinical procedure series to prepare us for clerkships. "Think of this as a little treat before you start exams next week," explained the physician coordinating the series. Students have been eyeing each other's veins all week, especially Buff Brad's, a stereotypical class "orthopod" (aspiring orthopedist) who played baseball in college.
An ER nurse demonstrated IV insertion on a student. "The hardest part is getting the feel of advancing the catheter while retracting the needle. Access the vein by inserting the needle at 45 degrees. Once you see the flash [of blood], level out, inch forward with the needle and advance your catheter. If you lose the flash, pull the needle back and adjust."
Students paired up and began. We adjusted... a lot. Gigolo Giorgio practiced on Particular Patrick, a fastidious and fashionable student from California. Giorgio did not level out enough and punctured the vein. He was moving the needle around aimlessly with a grimacing Patrick shaking under his dyed blonde hair ("flow" in California parlance, apparently). The ER nurse told him to just practice advancing the catheter. Patrick was not happy. "You are just shoving the catheter into my connective tissue!" Jane and I partnered. Neither of us got it. When I retracted my needle, blood gushed out. She now has a 3 cm diameter bruise from my handiwork. I snagged two unused IV kits to practice on at home under the guidance of Jane's sister. Patrick: "We must look like heroin users."
Our director of academic counseling emails a recipe for Goji Berry Trail Mix, including an explicit "place all ingredients in bowl and mix together" instruction in case any aspiring interventional radiologists are in doubt. We also learned about seven ways to calm our minds, e.g., reduce caffeine. Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: none. Jane and I prepared for the weekend studying sprint by stopping at a craft beer and wine shop with a bar. We'll be concentrating on lymphoma histology and the endless list of cancer drugs. Exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam. Interviews with "patients" are done solo with a faculty member observing and grading in real-time via video. My first "patient" presented for shortness of breath and 15 lb. weight gain over one month. I heard heard Bibasilar inspiratory crackles listening to the lungs, and an S3 gallop listening to the heart, suggestive of congestive heart failure. After the exam, I confirmed the diagnosis by reading a chest x-ray showing bibasilar infiltrates and congestion in the hilar vessels. The diagnosis was further confirmed by interpreting a difficult EKG with Q waves (prior MI), RVH (right ventricular hypertrophy), biatrial enlargement, and right axis deviation with potential hemiblock. Each of us then had 45 minutes to write a one-page H&P (history and physical) note. Nobody reported finishing the H&P note early and, in fact, some students said that they ran out of time. The second patient presented for pneumonia with pleurisy (inflammation of the pleural membrane). While listening to her lungs with the wireless simulated stethoscope, I heard the classic sound for pleurisy: "walking on fresh snow" on inspiration and expiration. The 50-question clinical multiple choice exam included 35 questions on EKG interpretation and pediatric cardiology findings. For example: "There were a few poorly worded questions," said Jane, "but nothing to get uptight about." As I walked out, a horde of students led by Type-A Anita were complaining to the clinical coordinator (administrative assistant to the physician-director) about the questions and the quality of the images. The 3-hour 120-question NBME exam featured numerous questions on heart failure and chronic obstructive pulmonary disease (COPD). I should have studied the basic physiology from last year as there were several easy questions that I struggled with. I will study this for Step 1. The questions on cancer and hemostasis disorders were straightforward, e.g., a patient with sudden weight loss, night sweats, and an enlarged lymph node mass biopsy revealing Reed-Sternberg cells (diagnosis: Hodgkins lymphoma). The class agreed that this was easier than the last block. Straight-Shooter Sally: "Microbiology was the hardest." On Thursday we started at 8:00 am with a case-based exam presenting H&P notes, test results, and images for four patients: COPD exacerbation, CHF, dilated cardiomyopathy, and an anemic elderly woman presenting to ED after she fell down. The elderly woman was the most challenging for the class. Pinterest Penelope: "It caught me off guard. I was not thinking about MSK []musculoskeletal] material." Most people finished the three-hour exam early, so eleven of us headed over to our favorite burger-and-beers spot for the 11:00 am opening. Composed Catherine, a short, intelligent Catholic with long black hair, was the center of attention showing off pictures of her new shepherd-mix puppy, who is being cared for by her new husband, a work-from-home engineer. We spent the afternoon conducting a financial intervention with one of Jane's sisters. She takes home $2,500 after taxes each month working as a neurotrauma nurse. [Editor: she needs to come to Boston; nurses at Tufts went on strike in 2017 to protest wages that averaged, pre-strike, $114,500 per year and topped out at $152,000.] Although she graduated debt-free from a state university, she has accumulated $4,000 in credit card debt at 20 percent APR, a $15,000 car loan with a $350 monthly payment, and a $10,000 Lowes loan in her name for improvements of her ex-boyfriend's house. She has paid nearly $5,000 in interest payments over the past year towards the Lowes loan, but has not touched the principal. "I feel like I am struggling to stay afloat in a dark ocean. What do I do?" Jane has been in the U.S. military's Health Professions Scholarship Program, which pays for all tuition, fees, and health insurance. Last year she got a $20,000 signing bonus and started receiving roughly $27,000 per year in cash. Jane agreed to dip into her "war chest" to loan her sister $4,000 interest-free to pay off the credit card debt. "You have to promise me that you will talk to [ex-boyfriend] about dealing with this Lowes loan." Criticism of President Trump's condolence phone call to Myeshia Johnson, widow of fallen soldier La David Johnson, energizes several classmates. Type-A Anita wrote on the class GroupMe: "For anyone who has a military family, I am so sorry." Pinterest Penelope: "Such a sad time to be an American." Grades are released on the school's Blackboard website on Friday at 11:00 am only if all class members have completed evaluations of the block and each lecturer (see Year 1, Week 28). This takes about an hour, especially if you're careful to avoid generating false alarms via the forced "inappropriate conduct" boxes (four for each lecturer). I've been careful with evaluations ever since the first exam week of M1 year, I awoke at 10:45 am on Friday morning after an evening of downtown bar hopping. My phone showed several emails from the examination coordinator reminding me to complete the evaluations. However, the power had failed in my apartment and I had to walk to the nearest Starbucks. I am waiting until graduation to admit to classmates that I was the reason they had to wait until 2:00 pm before leaving campus for their vacation (students who fail will stay an extra week and take an exam again). Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 night. During drinks and dancing on Thursday night to celebrate completion of this block, I spoke with the Kurdish classmate who was excited about the independence vote (see Year 2, Week 7). What was his reaction to media reports of the Iraqi military re-taking Kurdish territory? "My family in Kurdistan and their neighbors don’t care about the prospect of war. They are used to it." Those of us who passed the last block's exams on our first try are back from a week of vacation. Wildflower Willow, a free-spirited outdoors enthusiast from Oregon and founder of our school's wilderness club, went on a three-night solo backpacking trip. Pinterest Penelope spent the week in Banff with her family. Gigolo Giorgio crashed his parents' trip to Europe. "I was planning to go home, but my father had a last-minute business trip to London and Brussels. He called me up to cancel my trip. I asked if I could come along for the ride. He reluctantly agreed. I think he had been excited to spend quality time with my mother." Jane and I skipped the Monday morning lecture, so our GI pathology week begins with a new 8-person "small group." "You look too happy to be medical students" remarked a gentleman in a wheelchair as Jane and I take the elevator to the third floor. The 57-year-old retired orthopedist is our facilitator. Five years ago he had a bike accident that left him paralyzed from the waist down. "I expect a comprehensive differential. Don’t just blurt out syndromes. Tell me why you are thinking that. Do not expect to be leaving early with me." Geezer George, a 32-year-old Boston native who is our oldest classmate, commented "It is refreshing to have someone hold us to high standards. Most of the facilitators have been more casual." Our group discussed celiac disease and common GI pathogens. Celiac disease, an autoimmune disease due to hypersensitivity reaction against gliadin (component of gluten), is most associated with Northern European ancestry. Type-A Anita: "White people have to pay somehow." The immune reaction produces IgA that frequently cross-reacts with proteins in the dermal papillae (junction of dermis and epidermis) creating the characteristic dermatitis herpetiformis (grouped fluid-filled sacs, named after the similar appearance to a herpes outbreak). The IgA antibodies do not lead to GI pathology, but serve as a useful biomarker for diagnosis. Geezer George brought up a norovirus outbreak while discussing common GI pathogens: "I was at ground zero in Boston. I lived across the street from the Chipotle where half our school got lunch." (the illness was traced to a sick employee and it was unrelated to an earlier E. coli outbreak at Chipotle) A student replied, "Chipotle gets a bad wrap... no pun intended. You do not have an increased risk of getting a GI bug at Chipotle compared to any other restaurant, just so many people get meals there. It's like the Toyota brake scandal." A student described getting a Staphylococcus aureus enteritis characterized by profuse vomiting and diarrhea: "It's like you don't know whether to sit on the toilet or to stand next to it." A 45-year-old gastroenterologist specializing in hepatology (liver) gave Tuesday's lecture on GI pathology: gastroesophageal reflux disease (GERD), peptic ulcer disease, Boerhaave syndrome, and inflammatory bowel disease (IBD). She explained that "36 - 77 percent of Americans experience GERD throughout their life. The severity of the symptoms do not correlate with the severity of GERD. Patients are not faking the pain. Some just have more sensitive mucosa than others. Avoid caffeine, smoking and late night meals." She detailed how the use of proton pump inhibitors (PPI), such as Prilosec (omeprazole) has gone through cycles. "Patients and providers have become skeptical about the use of PPI. The problem is that we overprescribed them for some time and they started to be linked to everything without evidence. I had a patient post-MI [heart attack] with a peptic ulcer. The CCU staff took him off the PPI out of fear of reinfarction. [Once off the PPI] The ulcer bled so much he required transfusion. The link has been proven false." Peptic ulcer disease, ulcers that form in the stomach and duodenum (proximal small intestine), is associated with nonsteroidal anti-inflammatory (NSAID; aspirin and ibuprofen are examples) use and chronic Helicobacter pylori infection. "20 million people take NSAIDs daily including 70 percent of people over 65. As long as people use NSAIDs, I have a job." Why do doctors ask if the abdominal pain gets better or worse after eating? "Gastric ulcers worsen after eating. Eating stimulates acid production in the stomach. Duodenal ulcers become better after eating. Eating causes release of bicarbonate in the duodenum that neutralizes irritants." Boerhaave syndrome, a condition where intense vomiting leads to esophageal rupture, is caused by binge drinking. "Chronic vomiting such as in alcoholics and bulimics typically does not rupture through the esophagus," she explained. Boerhaave syndrome is associated with a 35 percent mortality, "the most of any GI perforation." Gigolo Giorgio: "I'm surprised that none of my college friends got Boerhaave syndrome." "Do not get IBD [inflammatory bowel disease] confused with IBS [irritable bowel syndrome]. Much different. IBS comes and goes and is not as severe as IBD," she explained. The two most common IBD conditions are Crohn disease and ulcerative colitis (UC). Nervous Nancy has Crohn disease. "My doctor is convinced I am Jewish. I keep telling him I am not. Infliximab [tnf-alpha inhibitor] has been a Godsend. I usually let my roommate inject it into me every three weeks. It's like ripping a band-aid - easier if someone else does it quickly. He was trying to impress his new female friend by winding up before stabbing me. He ejected prematurely, wasting half the dose. I am freaking out. That's like $4,000. My insurance won't give me another prescription so I am going to try to make the next few doses last longer. I can already feel my hands and legs swelling and getting hot." Crohn disease, a transmural (entire thickness of gut tube) granulomatous inflammation of the GI system, usually occurs in the ileum [terminal small intestine]. Because Crohn Disease is transmural inflammation it can lead to performation and fistualization (connection between two tubes). If the colon ruptures it can create a connection to the bladder, called a colovesical fistula. Gigolo Giorgio: "Could you imagine peeing feces?" Our patient case is Rebecca, a high-school swimmer who began seeing our gastroenterologist/hepatologist lecturer when she was 15. Rebecca presented for bloody diarrhea with mucous, fatigue, and a seven-month history of crampy abdominal pain. Over the preceding week she has experienced sharp right-upper quadrant (RUQ) pain. On physical exam, Rebecca appears pale with an enlarged liver palpable six centimeters below the costal margin and a palpable spleen. No scleral icterus (yellowing of the sclera) is noted. CBC shows pancytopenia (low red and white blood cell count) with a normocytic anemia (normal red blood cells, but not enough of them) and high reticulocyte count. Stool sample tests positive for white blood cells, red blood cells, but negative for pathogens. After a colonoscopy, Rebecca is diagnosed with ulcerative colitis. What is causing her enlarged liver and spleen? Ten percent of patients with UC develop primary sclerosing cholangitis (PSC). PSC is an inflammatory reaction that causes fibrosis of the biliary tree connecting the liver to the duodenum. Over time this causes incurable cirrhosis (hardening of the liver), which clogs portal circulation of blood returning to the liver. "The treatment of PSC is liver transplantation. That is how serious a disease it is. Liver transplant is not even a cure," explains her doctor (our lecturer). Rebecca is placed on the liver transplant list. Patients on the liver transplant list are ranked according to the Model for End-Stage Liver Disease (MELD) score, which predicts three-month mortality among liver failure patients based on three lab values: creatinine (kidney function), bilirubin (liver's ability to breakdown and excrete heme), and the international normalized ratio (liver's ability to synthesize clotting factors). Rebecca was at 12 out of 40. "PSC patients are screwed over by the MELD score," explained our hepatologist. "Their lab values do not reflect their deterioration. I told Rebecca's family that she would not make it to the expected donation time." Her family and doctor petitioned the UNOS (United Network for Organ Sharing) to no avail. Pinterest Penelope whispered, "This story reminds me of Denny from Grey's Anatomy losing the heart transplant by 17 seconds." Her mother described searching for a living donor. Live donor liver transplant (LDLT) is a procedure where a liver section from a living donor is removed for transplantation. The liver is able to regrow to normal function over time. LVLT has several ethical dilemmas. Who gives consent for a pediatric donor? A cousin or uncle who matches may experience immense family pressure to donate, compounded by the fact that many liver transplants require immediate decisions. Pinterest Penelope whispered again, "This is just like Grey's Anatomy! Remember that episode where the son of an abusive father has to decide to give him part of his liver?" Rebecca's real-life situation was more serious, but less dramatic. There was no abusive father and nobody in her immediate family was a match. Rebecca waited three years for a liver while enduring serious complications such as hyperammonemia (high serum ammonia causing mental status changes). One evening she presented to the ED for severe hematemesis (vomiting blood). The dilated veins in her esophagus ruptured. (Esophageal hemorrhage is the most frequent cause of death in liver cirrhosis patients.) Rebecca underwent banding endoscopy (put rubber bands around the veins) to stop the bleeding. After these episodes, the family and doctor petitioned UNOS, who increased her MELD score. Rebecca underwent a domino liver transplant the summer before her freshman year of college . The first domino was a cadaver (dead person) whose liver is transplanted into a patient with a genetic disease such as familial amyloidotic polyneuropathy (FAP) or Maple Syrup Urine Disease (MSUD). The second domino is the liver removed from that patient, which can be installed in Rebecca's body and then function normally. We saw a picture of the domino family smiling next to each other: the widowed wife of the cadaveric donor, the mother holding an 8-year-old daughter with MSUD, and Rebecca. Rebecca's PSC returned three years later. Her mother said, "We knew the system better the second time around. We listed at a transplant center that did not have a national reputation and in a state with high donation rates." Rebecca showed us her scars. The scar from the first transplant was roughly 4 inches long on her right side. The scar from the second liver transplant went across her entire abdomen. Her transplanted liver had enlarged to cover her spleen. The extensive fibrosis also adhered parts of her liver to the diaphragm making it difficult to remove. As a result, she experienced pain for several months requiring high dose IV opioid painkillers and neurontin. Two years out she is dealing with opioid tolerance and withdrawal symptoms as she tapers off. Rebecca, now a rising senior at college studying chemistry, plans to return to school after a semester break. "I hope to get back in the water next month. It symbolizes, sort of, returning to normalcy." After Rebecca and her mother left, a student asked the hepatologist, "Given that there is such a long waiting list for transplants, what are your thoughts on a single patient receiving two livers?" She passionately responded: "Rebecca deserved this liver. I just came back from the AASLD [American Association for the Study of Liver Diseases] conference. UNOS just approved liver transplants for alcoholics who are three months sober [Hepatitis C from IV drug use is another common reason for requiring a transplant]. I have never met someone who is more motivated and wants to be a productive member of society. Throughout her first transplant recovery she kept going to college. Can you imagine the drive that requires? A lot of potential liver transplant patients just sit at home on disability. What do they do after the transplant. They continue to sit at home on disability. No, she deserved this second liver." For each of the next six weeks we will write a two-page single-spaced ethics essay. "I am really excited about doing this ethics course with you," explained our former ethics facilitator, who is now the class lecturer. She explained that we would be preparing for 30-minute lectures by reading the same materials as her undergraduates, then break into 10-person groups for one hour. This week's topic is pain and readings include essays by sociologists, peer-reviewed ethics journals, poems by Sylvia Plath and Elizabeth Dickenson, and three paintings. Jane had a higher pain tolerance than I did and got through all of them in two hours. We read a journal article on pain treatment differences between blacks and whites summarized in "U.Va. report: Med students believe black people feel less pain than whites" (USA Today): The survey ... asked 222 white medical students and residents to rate on a scale of zero to 10 the pain levels they would associate with two mock medical cases — a kidney stone and a leg fracture — for both a white and a black patient, and “to recommend pain treatments based on the level of pain they thought the patients might be experiencing.” The survey also asked them whether they believed certain statements about whites and blacks were true, e.g., black people age more slowly than whites, black people have less sensitive nerve endings and black people’s blood coagulates more quickly. Surprisingly, over 100 students believed these fallacies to be factual. Those who believed that information to be true rated black patients’ pain lower than they did white patients’. We read "Pain Sensitivity: An Unnatural History from 1800 to 1965" (Joanna Bourke, Journal of Medical Humanities, 2014): In 1896, a second-year medical student simply known as “E. M. P.” was working in a surgical-dressing room at The London Hospital. … His account —which was published in The London Hospital Gazette, an in-house journal for hospital personnel— epitomized a particularly nasty strand in British chauvinism. Implicit in E.M.P.’s narrative was the belief that not every person-in-pain suffered to the same degree. While certain patients were regarded as “truly hurting,” other patients’ distress could be disparaged or not even registered as “real pain.” Such judgments had major effects on regimes of pain- alleviation. At the end of the nineteenth century, E.M.P.’s condescension (if not outright contempt) for destitute, “foreign,” and other minority patients was not aberrant. [Wikipedia says that the author "describes herself as a 'socialist feminist'"] Our group agreed that there is inequality in pain management for black and white patients, though it was difficult to separate socioeconomic factors. Geezer George wasn't persuaded by the study: "Who cares what medical students think. We know nothing. I have read other more reputable reports that link decreased opioid prescription rates for blacks versus whites with the same discharge diagnoses. I took a public health course that analyzed articles in USA Today and such. Journalists know less than nothing and are just trying to get clicks. Something like 9 out of 10 articles were simply inaccurate representations of the data in the report." Straight-Shooter Sally: "I agree. They should have presented us with better evidence." The ethics professor, overhearing, jumped in: "I'll try to send other articles, but it is well established that the perception of pain and pain treatment by medical professionals is impacted by race. Keep talking!" Pinterest Penelope: "We all are racist. Some more than others. Everyone, at least, has implicit bias." Nervous Nancy: "Pain management happens a lot in the ED and ortho department. I do not think it is as simple as black and white. A lot of thought goes into writing an Oxy prescription. Does the patient have the support system and structure to handle a three-month prescription?" Straight-Shooter Sally: "I blame First-Aid [Cliff Notes for the first two years of medical school]. We are taught to use stereotypes to develop differential diagnoses. When I say sarcoidosis, you say?" "Black middle-aged female," responds the group. Sally continues: "The irony is that the overprescription of opioids to white-people pain has backfired. Whites are now disproportionately impacted by the opioid crisis." Our class is registering for the USMLE Step 1 board exam, a one-day multiple-choice test that will be taken this summer. After collecting our names, medical school, addresses, and credit card numbers ($610!), the first question that we're asked by the registration system is about our race. Lanky Luke: "Should I identify as Black? No Derm for me otherwise." Particular Patrick added, "I wonder if selecting Asian will hurt my Match?" The week wraps up with a workshop on catheters. An EM physician discussed NG (naso-gastric) tube and foley catheter insertion technique. The NG tube is inserted through the nose and advanced until the pharynx. He continued: "Once you are into the posterior pharynx, ask the patient to swallow some water. You should feel a yank [peristalsis of esophagus]. Keep advancing the catheter until you've advanced it to the predetermined length." You have to make sure you do not insert it into the trachea. "I have done maybe 1000 NG tube placements. Maybe 50 end up in the right lower bronchus instead. It is going to happen. If the patient is violently coughing and unable to speak, take it out. The tube is down the wrong pipe." The EM physician asked for a volunteer. "This is the most malignant procedure we can do on students." After 20 seconds of silence, Wildflower Willow, a free-spirited outdoors enthusiast from Oregon who goes on weekend overnight solo hikes, volunteered. As the EM doctor advanced the NG catheter, he announced, "I am through the first turn. Drink some water." Willow was clearly uncomfortable, but signaled to keep going. She coughed once or twice. "Say something to me." Willow initially signaled she couldn't talk. Finally, she exclaimed, "Oh my." He continued to advance the NG tube until placed, and then quickly removed it. The class erupted in thunderous applause. "You freaked me out when it seemed that you could not speak," said the EM physician. "My teaching days would have been over." William explained, "It was subconscious. I knew that the worst thing would be the tube going down the trachea. I just thought, of course this is going to happen to me of all people. You got that on video right?" Her evening Facebook post: Volunteered to have an NG tube placed on myself today!!! That's the like 2 foot tube used to remove stomach contents or feed patients. It was... unpleasant, but such a good experience to know what patients go through :) On Thursday evening we attended a family medicine panel presented by five physicians. Family medicine physicians treat patients of all ages as a primary care physician. Why is family medicine not in a lot of metropolitan areas? The family medicine chair explained: "You have specialist walls pop up. Large health systems make money on specialist referrals. Health systems are buying up practices for the referral population to specialist care. It is not as lucrative to have a family medicine physician manage a COPD or CHF exacerbation. They will get admitted to cardiology or pulmonary service instead of the family medicine service. We've really lost that continuity of care. I think it is slowly coming back from people realizing the value in it. I feel sorry for my patients when the bill comes back after a hospital visit." The media frenzy around Harvey Weinstein apparently inspired part of the weekly email from our director of academic counseling: When supporting a friend who has been a victim of sexual assault, it’s important to know your resources. RAINN (National Sexual Assault Hotline) staff recommend friends supporting victims keep the following in mind: (1) “I believe you. It took a lot of courage to tell me about this.”; (2) “It’s not your fault. You didn’t do anything to deserve this.”; (3) “You are not alone.” It was unclear whether Mr. Weinstein endorsed the spaghetti squash lasagna or Dijon salmon recipes between which the sexual assault advice was sandwiched. Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Halloween weekend! The social committee organized 9:00 pm private party at a downtown club with $5 cocktails and hors d'oeuvres. Faculty were not invited. Mischievous Mary hosted 30 students pre-game and photos. Most of our class dressed in costumes inspired by SketchyMicro pathogen characters, e.g., an Indian classmate shaved his head and dressed as Toxoplasmosis gondii (Gandhi). Year 2, Week 16 Gastrointestinal topics began with four one-hour lectures on the liver. Jane and I did not attend. We took a morning trail run, then watched 65 minutes of liver lectures on Pathoma ("First-Aid of M2"). Jane: "I feel like I have accomplished so much." We went to Dr. House’s Tuesday lecture on GI pathogens. "As medical students you will be a valuable member of the team performing digital rectal exams and fecal blood smears. It seems like grunt work, but it is essential to determine the course of diarrhea treatment. The fecal smear for leukocytes is a vastly underutilized, quick and dirty test." According to Dr. House, the most important step in managing diarrhea is to determine if a patient has invasive or toxigenic diarrhea. Invasive diarrhea is caused by a pathogen invading the mucosa (epithelial lining of the gut tube), which recruits leukocytes [white blood cells] to the infection. These white blood cells end up in the feces. Whereas, toxigenic diarrhea will not have any white blood cells in the stool sample. "Most diarrhea causes are treated with supportive care – hydration." Vibrio cholerae causes profuse, toxigenic rice-water diarrhea. "Does Haiti have cholera?" asked Dr. House. "Not before 2012. The earthquake hit in 2010. UN troops from Nepal, where Vibrio is endemic, brought in cholera. One in ten individuals exposed to cholera are asymptomatic carriers shedding it in stool. Without adequate filtration systems in earthquake-ravaged Haiti, cholera spread all over." How do you treat cholera? Hydration. "Cholera is a self-contained disease if you can survive the extreme dehydration from loss of water. Volume-in must equal volume-out. On the wards you will hear, 'hang the IV at 125 mL per hour.' 125 mL per hour is 3 liters over 24 hours or the amount of insensible water loss [sweat, metabolism, etc.]. So hydration would need to be greater than 125 mL/hr in a cholera patient." "When I trained Clostridium difficile was segregated to antiquated case reports in journals that no one read." Dr. House continues, "C. diff is now a hospital’s bane of existence. Studies show that 13 percent of individuals have C. diff spores in the gut. They just lie dormant until a stress such as an antibiotic knocks out the normal gut flora. A severe C. diff patient can have 30 bowel movements per day with a high fever. Talk about dehydration. The best treatment is fecal transplant, ideally from a housemate, otherwise the new poop pill [OpenBiome's FMT G3 capsule]." Dr. House cautioned to not jump to antibiotics for every patient with diarrhea. "Some toxigenic diarrhea cases are made worse by an antibiotic. For example, a patient with hemolytic uremic syndrome, a serious complication of shigella and E coli O157:H7, can be killed by toxins released from dead bacteria. I see this all the time: a patient with pneumonia or meningitis is given penicillin. The patient then crashes because of the sudden antigen [molecule to which immune system responds] release." We ended a few minutes early so he asked some causal questions: "Has anyone heard of Saccharomyces cerevisiae?" A quite Asian volunteered: "It’s used in brewing beer." "Yes! Cerveza is beer in Spanish. This fungus is also implicated in exacerbating Crohn disease. Why? We do not know. But that’s the mystery of Infectious Disease medicine!" Dr. House noticed Type-A Anita's MacBook Air decorated with five stickers: "I'm with Her", "Nevertheless, she persisted", "Nasty woman", "Change", etc. "Anita, how are you going to fit more stickers on the laptop next election?" Anita: "I don’t know, I never thought of that." At 10:00 am, Dr. House left and we began learning about genetic diseases of the GI system. Our early-40s pediatrician-turned-geneticist explained that she is consulted whenever a genetic disorder is suspected, or "when physicians have no idea what is going on." She manages several families whose members share a rare genetic defect and also coordinates care for patients with complicated diseases such as Down syndrome, Prader-Willi syndrome, and Angelman syndrome. She introduced two genetic GI diseases that we'll see on the Boards: Lynch syndrome and Familial Adenomatous Polyposis (FAP). Lynch syndrome (also known as HNPCC for "hereditary nonpolyposis colorectal cancer") is an inherited defect in a DNA repair protein. Lynch syndrome is characterized by a high risk of cancer including colorectal, endometrial, gastric, and sebaceous carcinoma. FAP results from a defect in the APC gene that is necessary for the transformation of normal colon tissue into a colonic polyp (adenoma-carcinoma sequelae). FAP is characterized by the formation of thousands of polyps in the GI tract. Patients have such a high risk of colorectal cancer that they undergo prophylactic colectomy in early adulthood. She described some of her daily dilemmas. "Ten percent of patients do not have a paternal relationship to their believed father, don't rely on paternal medical history. We refrain from testing children for likely genetic disorders that won't result in symptoms until adulthood. If waiting will not compromise care, we want to maintain the patient's autonomy. I am also extremely careful with documentation for a potentially afflicted child. For example, what if a child eventually wants to join the military? If I document a 50-percent risk of having Lynch syndrome due to an afflicted father, lights out." Our patient case: Jerry, a 50-year-old former truck driver on disability for liver cirrhosis due to chronic hepatitis C infection, presents to the ED for rectal bleeding and anemia. Twenty-five years earlier, te was in a motor vehicle accident ("MVA") requiring transfusions. A more recent MVA led to the diagnosis of hepatitis C, likely due to the transfusion in the 80s prior to hepatitis C screening for blood donations (1992). [Hepatitis C is transmitted via blood and sex.] Physical exam shows a distended abdomen with ascites (fluid in abdomen), scleral icterus (yellowing of the eye), and several bruises over his arms and legs. His liver is enlarged, and the tip of the spleen is palpable. CBC and CMP reveal anemia, thrombocytopenia (low platelet count) and hypoalbuminemia (low serum albumin, a protein that creates osmotic gradient to keep fluid in the blood vessels). PCR testing shows an active Hep C viral load. Jerry tests positive for Hep C antibodies. Serum alpha-fetoprotein (AFP) levels are high, suggestive of hepatocellular carcinoma (liver cancer). An abdominal CT shows two liver nodules. Biopsy confirms hepatocellular carcinoma. Jerry undergoes radiation therapy and surgical resection of the operable masses. Jerry died last year from rupture of esophageal varices while waiting for hepatitis C treatment and a liver transplant. Our South American hepatologist went over Jerry's case and discussed the rise of hepatitis C infections in the United States driven by heroin use. Particular Patrick asked her opinion about needle exchange programs (popular in his home state of California). "Hep C rates are skyrocketing due to IV sharing. Every needle shared leads to nine Hep C infections. I cannot understand why needle exchange programs are resisted by conservative legislators. Yes, I understand the idea of traditional values and that drugs are bad. But you don't simply tell your child ‘NEVER have sex, period.’ No, you say, ‘Sex is bad… but if you are going to engage in it use a condom.’ Otherwise, you’ll get a pregnant child… with Hep C." Students chuckled. Lanky Luke: "I bet she does not want a needle exchange in her backyard." ["Do needle-exchange programs really work?" (Amy Norton, March 11, 2010, Reuters) summarizes research that casts doubt on a link between needle exchanges and preventing disease transmission.] Drug treatment for Hep C costs roughly $90,000. "The first thing I ask my patients is if they have insurance," said our hepatologist. "If they are uninsured, I tell them, 'No problem. You will just have to pay maybe $30 for the blood tests. You'll get the pills free.' If they do have insurance, I tell them there is no guarantee. I say, ‘I will fight for you, but it will take time and there is no guarantee.’" How does Hep C treatment compare in other countries? "Australia has a great coverage program. Every Australian gets the drug, no questions asked. Canada and most European countries have similarly good coverage." Does the drug cost as much? "No, America pays for the Hep C treatment of the world. One of my old patients pioneered going to Canada for treatment because it cost so much less there." She concluded: "I am hopeful coverage will increase as there are more and more competing drugs. It is truly amazing how science has advanced. A decade ago there was no cure, only poor management with short-lived transplants and drugs with severe side effects such as kidney damage. Now we have several options with over 90-percent cure rates for all genotypes [DNA sequence of the virus]." This week included three afternoon workshops on nutrition and lifestyle medicine led by a fit 35-year-old internist specializing in weight loss, her blond hair tied in a ponytail ready for her next workout. She began by asking the class, "What percentage of the population does not smoke, has a BMI less than 25, eats 5 servings of fruits and vegetables daily, exercises 30 minutes five times per week? What we would consider healthy?" The class was silent. "Three percent," she answered. "Meanwhile, 35 percent of the US population is obese." She was scornful of the government's nutrition advice. "Why is diary the only food required in a school lunch?... The milk lobby. Why are grains at the bottom of the food pyramid? The grain lobby. The original 1992 pyramid had grains third from the bottom. Imagine how many lives could have been changed if that guidance was not issued!" Lanky Luke: "Maybe times have changed and people have less faith in institutions, but does anyone really shape their diet based on the pyramid and now plate?" Students were offered to get free DEXA [Dual-energy X-ray absorptiometry] scans in preparation for the next workshop. Over half the class volunteered for the 10-minute procedure after class. DEXA scan shoots two different energy x-ray photons at the entire body. In addition to providing a measurement of bone density, commonly used to diagnose osteoporosis before a fracture, DEXA scans also calculate percent body fat and fat distribution. Pinterest Penelope: "I think the DEXA scans were wrong. I’ve been going to the gym everyday this year." Jane, as she squeezes her stomach into a mouth shape: "This is bad for my mental health, 26 percent fat." A retired Army physician told her that you do not want to be a fat doctor in the Army. Physical performance is evaluated in the military. "If you are fat, you do not get promoted, you do not get your preference on where you are stationed, and you do not get respected by peers." "I never use the word ‘Diet’. Diet implies a temporary strategy. Long-term weight loss requires lifestyle changes. However, as a physician your patients will ask you about common diets. There are copious studies that try to evaluate Low fat versus Low Carb versus Mediterranean, etc. The key is to get them thinking about their intake and outtake." She cited, "The largest diet study found attendance at group sessions was the greatest predictor for weight loss and reduced cardiovascular events." Students filled out a lifestyle goal on scratch paper. Most students promised to lose a few pounds, go to the gym, or make fruit/veggie smoothies daily. (Two weeks later Jane and I accompanied most of these people to Taco Bell and then the local ice cream shack.) Thursday at lunch students discussed Harvey Weinstein and Kevin Spacey. Everyone had seen the headlines, but not everyone knew the details. What did Harvey Weinstein actually do? "He raped women. He attacked young actresses." Type-A Anita: "It's more like what hasn’t he done." Wildflower Willow: "I have become so disgusted by Hollywood. Power corrupts all men." What did Kevin Spacey do? "He attempted to molest young male actors. Now he cowardly comes out as Gay as if being homosexual makes you some predator." Type-A Anita wasn't that interested in the question of criminal prosecution: "We are in the public-shaming part of punishment." What about the presumption of guilt based on unverifiable accusations? "So what if the pendulum swings a little bit in the favor of the accused. The rights of the women have been forgotten for so long. I don’t think people care about the wealthy assholes like Harvey Weinstein. Ladies, take it all!" Jane: "Part of the divide here is that it is difficult for me to imagine what it would be like to be falsely accused of harassment. It is easy for me to imagine what it is like being the victim of harassment. I understand how one could say it is wrong to expel an accused student of rape or fire a physician for harassment of a nurse, but a suspension is not unreasonable while it is being investigated. That's not going to destroy his life." Gigolo Giorgio: "I can see how this can be a slippery slope. Let's say a transplant surgeon, one of the best in the country, gets accused of sexual harassment to nurses when he was a resident twenty years ago. Let's just say we have objective proof -- a video -- of him doing it and evidence he cleaned himself up since then. Married with kids, upstanding citizen and all his coworkers love him. What should his punishment be? Should he be excommunicated and banned from surgery after society invested all those resources into him?" Straight-Shooter Sally: "Maybe he should be suspended for a few weeks. Just so there is some punishment and deterrence. I think he should still be able to practice eventually." [Editor: Hospitals are going to line up to hire this guy?] What does $60,000 in tuition include? "An artistic space," as our visiting ethics professor explains the two-hour Friday afternoon session. We divide into groups of six to create a nine-panel cartoon with crayons. "Depict your experience with cancer," the professor says. What if we haven't had cancer? She says that it can be about a relative, a friend, or something we've read in a novel: "Enjoy this space, this is one of the only chances in medical school to express your artistic mind." "My grandmother at age 78 underwent surgical resection for colon cancer," said a classmate on another team. "She ended up killing herself by pulling her feeding tubes out because of her terrible quality of life." One of my teammates: "My best friend was diagnosed with a brain tumor after a seizure. His doctors assured him it was benign, but took a biopsy. I was with him watching the [2016 Presidential] election results. As we were learning about Trump's victory he got a text that his cancer is invasive." Friday evening, Jane and I drive 45-minutes out of the city to our favorite trauma surgeon's cabin. Twenty-six students (16 female/10 male) interested in surgery, or just intrigued by her stories, roast marshmallows and eat undercooked burgers around a campfire. Straight-Shooter Sally asked How difficult is residency? Our hostess: "If you think you learn a lot in medical school, wait for residency. You end medical school knowing how to do a few procedures -- NG tube placement, IVs, suturing. You end surgical residency knowing how to reconstruct an aorta." Gigolo Giorgio asked What is the progression of a resident? Our hostess: "I expect an intern to be able to navigate the hospital. You are primarily managing patients in the perioperative window—before and after surgery. Maybe at the end you are comfortable performing an appendectomy under guidance. A first-year resident should begin to have opinions and a sense of direction. Second- and third-year residents should be teaching interns. A fourth-year resident should be an equal. I ask for their input on cases. I listen to their thoughts. Attendings will go with the fourth-year resident's judgment, especially when there are several decent options and no clear winner." The trauma surgeon emphasized: "When applying to residency programs, ask where their graduates end up. Do they feel comfortable performing surgeries on their own? A lot of prestigious residencies do not train surgeons to become independent. I see a lot of graduates taking fellowship positions not out of interest in the speciality, but because they do not feel ready to become an attending. You want to go to a program that offers both fellowship opportunities and job placement." Students were particularly interested in the lifestyle of the surgeon. "Surgery culture is changing. There is no more God complex. Patient care is now a team effort," explained the trauma surgeon. "For most of my career, you would take your patients home after you left for the evening. If something happened, you would run back to the hospital. Now you have people on call who deal with it. You can always go above and beyond and follow up on a previous patient. Most physicians do that, but it is their prerogative, not the expectation." She concluded: "This change is a good step for lifestyle and overall well-being of surgeons, but there is less continuity of care." What are some pitfalls? "The biggest issue I see with residents and attendings is ignoring home life. It is very easy to drown yourself in patient care as an excuse to ignore dealing with problems at home. They wonder why they end up divorced with broken lives and children they barely know. It's their own damn fault." [Editor: Read Real World Divorce to see which states give plaintiffs the largest financial incentives to pursue a divorce lawsuit; the biggest "fault" of these defendants may well be choosing to settle in a plaintiff-friendly jurisdiction.] Can a medical trainee start a family? "Do not put your life on hold for residency. Residency is part of your life. If you want children, have children. It will be tough, but you will manage it. I’ve heard some residents say residency is a great time to have children because of the excellent health insurance." Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: Jane and I joined Lanky Luke, Samantha, and Mischievous Mary for burgers and beers. Samantha works in a free clinic nearby for her final PA rotation. "I saw a 11-year-old child today. How much do you think she weighed?" Guesses: 150, 175, 210, 250. "She clocked in at 363. I mean that should be child abuse. You cannot recover from that." The mother, also obese, is on Medicaid. [Editor: therefore, by definition, taxpayers purchased most of the food via the USDA SNAP program ("food stamps").] Year 2, Week 17 Monday morning begins with an introduction to gynecology from an energetic 36-year-old Ob/Gyn. She began at the end: menopause. "Menopause occurs between 45 and 55, with the average age at 51." She explains that hormone replacement therapy (HRT) is one of the most effective mechanisms to treat vasospasm (hot flashes) in postmenopausal women. "Estrogen is the fertilizer, progesterone is the lawn mower. Remember that. If the patient has a uterus, you must give combination [estrogen/progesterone] to thin the endometrium. If the patient underwent hysterectomy, she can just take estrogen. Nothing to grow!" "Menopause symptoms typically last no more two years, but can last up to 13 years. Every three years we reevaluate the HRT and medications. Usually we take them off for a month and restart if needed. Some patients just feel better on HRT so they request to continue." Birth control pills contain the identical hormones. Straight-Shooter Sally, commenting on a controversy over requiring private employer-provided health insurance to offer zero co-pay contraception: "I wish people would recognize that birth control pills are used for a lot more than just birth control." Particular Patrick asked why so many older women have hysterectomies [removal of the uterus]: "Hysterectomies have fallen out of favor in the past decade or so. The history of hysterectomies is fascinating, especially the regional variation. Where there were a lot of Ob/Gyns, there were a lot of hysterectomies. Same exact pattern for laminectomies [removal of part of the vertebrae to alleviate back pain]. Where there were a lot of neurosurgeons, there were a lot of laminectomies." In our small groups, we discussed the costs and benefits to HRT in treating menopause symptoms. Laid-back Larry, a San Francisco native with a soothing voice, presented on a Women’s Health Initiative (WHI) study on the side effects of HRT in 160,000 postmenopausal women aged 50-79. In our age of identity politics, before talking about the medical conclusions of the study, Larry delivered an encomium about Dr. Bernadine Healy, the founder of WHI and one of ten women (out of 120 students total) in the Harvard Medical School Class of 1966 and later appointed by Ronald Reagan to be director of NIH. After we finished celebrating women overcoming gender barriers, we returned to the study per se. WHI concluded that the lowest dose of combination HRT should be used to minimize the risk of coronary artery disease and breast cancer. Larry: "For anyone who says that investment in public health is not worth it, and that we need more military spending, look at this economic analysis. The study cost $625 million. That’s five F-35 fighters." Our facilitator asked, "So you do not think we should have the F-35 program?" Larry: "No, I do not think we should have the F-35 program or any military spending until we can get our domestic policies in order." Larry cited "Economic return from the Women's Health Initiative estrogen plus progestin clinical trial: a modeling study" (Annals of Internal Medicine, 2014), describing the results of an add-on $260 million study: The WHI scenario resulted in 4.3 million fewer CHT users, 126,000 fewer breast cancer cases, 76,000 fewer cardiovascular disease cases, 263,000 more fractures [no free lunch, unfortunately], 145,000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100,000 per quality-adjusted life-year. The 95% CI [confidence interval] for the net economic return of the trial was $23.1 to $51.2 billion. [Why did this cost nearly $1 billion? It is expensive to follow patients for years.] Wednesday morning, a pathologist led a two-hour workshop on breast cancer, which 1 in 8 women will develop. Breast cancer prognosis depends on several factors: The easiest breast cancer to treat is estrogen-positive and her2-positive (proto-oncogene receptor). We can inhibit the estrogen signal with endocrine therapy (e.g., aromatase inhibitor or estrogen-modulator tamoxifen) and the her2 growth signal can be inhibited with trastuzumab (Herceptin, antibody against her2). Straight-Shooter Sally: "We’re getting all the low hanging fruit. All the cancer signal is going through this bad apple. I just cannot envision us ever getting ahead of cancer with multiple aberrant cross-talking pathways like in triple-negative breast cancer. Good luck!" (Triple-negative cancer does not express estrogen receptors, progesterone receptors, or her2 receptors.) Our patient case: Kim, a 39-year-old nonsmoker premenopausal college professor, presents for a discrete hard mass in her left breast detected on self-examination. She undergoes ultrasound-guided needle biopsy which reveals a ER+/Her2- ductal carcinoma in situ with a high risk of recurrence. She undergoes radiation followed by a mastectomy and adjuvant chemo with tamoxifen (the estrogen modulator discussed above). Kim, now 45, is in remission after five years of tamoxifen. She came in with her surgeon, a 40-year-old who specializes in breast reconstruction. Type-A Anita asked How has this experience changed your perspective on life? "It has not really changed my perspective. I am not someone who creates a bucket list… The main thing this diagnosis did was prevent me from adopting a child. I knew before the cancer that I would not be able to have children so my husband and I began the adoption process. The agency requires both parents be home for a random drop-in session. My husband traveled a lot for his job so he quit, taking a large pay cut. By the time we were settled, I got this breast cancer diagnosis. I remember talking to a woman at the [government-licensed] adoption agency: ‘You think we would give you a child with this gravestone over your head?’" The surgeon answered: "It's somewhat dark and morbid, but dealing with patients has made me realize that we rarely recognize the hardships of people around us. I am not talking about just cancer, but any serious health complication." Kim added: "There is always light in darkness. Chemotherapy is tough. I would get up at 6:00 am to go to the chemo center and get to work by 8:30 am. After a few weeks, I was just exhausted. My husband was gone many days. I remember getting home every weekday to find a fully prepared dinner in a basket delivered by some unknown mensch. To this day I do not know if it was my church, coworker, neighbor. That helped so much." [Kim was not Jewish, but apparently had picked up the Yiddish term mensch.] Kim passed around her various accessories from her mastectomy. "I would wear a lot of scarves. My students must have thought I was a crazy scarf lady. I would wear scarves in the summertime to hide my mastectomy. One afternoon, my husband and I were doing yardwork and I was not wearing my special bra. The neighbors passing by would stare at me. I wanted to curl up into a ball." Lanky Luke asked Why did Kim go on tamoxifen instead of an aromatase inhibitor? Kim's surgeon: "You are correct that tamoxifen has more significant side effects such as embolic events and risk of uterine cancer. However, AIs [aromatase inhibitor] are generally avoided in the premenopausal patient group because of the risk of ovarian activation [producing estrogen, which could stimulate proliferation of the breast cancer cells]." Pinterest Penelope asked What would determine if you get a lumpectomy or radical mastectomy? "Well, radical mastectomy is a thing of the past," Kim's surgeon replied. "A true radical mastectomy included complete removal of the breast tissue, all axial lymph nodes, and pectoralis major muscle. What you mean is a modified radical [mastectomy] where we remove the entire breast tissue and all axial lymph nodes." She continued, "Only in advanced stage breast cancer would we perform this. We try to preserve as many lymph nodes as possible to prevent peripheral edema in the arm. We do a sentinel lymph node biopsy where we resect a single lymph node at a time to see if there are any cancer cells. If the pathologist does not see any, we can leave the distal lymph chains. I will add that most women these days elect for a mastectomy even when a lumpectomy would give clear margins. It is very difficult to match the lumpectomy breast to the other breast." The surgeon explained that breast reconstruction is a two-part surgery. "The first surgery involves placing an expandable implant. We then go back a few months later to reconstruct the expanded space with a silicone implant or a saline bag. Silicone feels more realistic, but there are more side-effects compared to the saline bag. Autologous fat implants are very difficult due to preservation of the vasculature. This leads to sections of the fat graft to become necrotic, which has all sorts of complications such as infection." [Lawsuits regarding silicone implants in the 1980s and 1990s resulted in nearly $10 billion in awards to women who thought that they had developed diseases such as lupus and rheumatoid arthritis from these devices. Dow Corning, founded in 1943, went bankrupt as a result of these lawsuits. No scientific link was ever established, however, and silicone implants are once again on the market. (See "Panel Confirms No Major Illness Tied to Implants," June 21, 1999, New York Times.)] Our Ob/Gyn lecturer returned Friday for a talk on STDs, an evolving subject: "When I was in medical school, fluoroquinolones were the first line treatment for gonorrhea. When I started residency, fluoroquinolones were no longer acceptable, and we transitioned to ceftriaxone. Now we are seeing ceftriaxone is not adequate so we added azithromycin in combination with ceftriaxone. There are already macrolide-resistant [azithromycin] strains, we just hope they will not get together with ceftriaxone-resistant ones. Long term this is going to be a serious concern, especially with the rise in IUDs [because people aren't using condoms]." She continued: "Right now we can assume someone who is treated is cured. I see that paradigm shifting in 5 or 10 years. We will need to confirm successful treatment. That is a problem when our current tests require 4 weeks to confirm cure after treatment [PCR amplification will detect DNA of dead bacterial cells]. Asking a patient to not have sex for a month is a lot more difficult than asking a patient to not have sex during the one-week treatment window." After learning about every kind of STD, it was time for lunch with Luke, Jane and Persevering Pete. Pete graduated college in three years and runs a small real-estate business "flipping houses" with his family who lives three hours away. He spent the last two weekends building a deck and painting the interior. He is in a long-term relationship with his college girlfriend who is an M3 at our school. Pete asks, "What is your biggest problem?" Jane responds: "Figuring out when I will do all my rotations with the Army's constraints." Luke: "Marriage and money." Pete chuckles: "Marriage for me too. My girlfriend wants to get married. What do you think about marriage at our age?" Luke: "Stay away." Pete: "I just do not think I should even consider marriage until I can envision where I will be in five years and until I am financially stable." Jane: "You’re confusing having children with getting married." A handful of states had elections this week, in which Democrats generally prevailed. Students congratulated Anita on the outcome and she responded, "I feel like I can breath for the first time. Hope triumphed over fear." Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Jane visited her alma mater to celebrate the return of one classmate who has been working as an Au Pair in New Zealand for 9 months. I played soccer with classmates followed by two beers with Lanky Luke and Mischievous Mary. Year 2, Week 18 A suave 35-year-old male urologist introduces diseases of the external genitalia, testicles, and prostate. A urologist completes a four-year residency with a one-year internship year, typically in general surgery. "In medical school you are not going to get much exposure to urology because we are a surgical subspecialty. If you are at all interested, come shadow us for a day. You can shadow an academic urologist or a community urologist." Gigolo Giorgio: "That's quite exciting. You become a specialized surgeon in five years." (In a surgical field other than urology, six or seven years is more typical, plus, of course, four years of medical school.) Cryptorchidism is failure of the testicle to descend from its embryological origin in the abdomen. If the testicle is not descended, it will involute (curls up) because the warmer temperature is too high for spermatogenesis (production of sperm). "We wait until age two before we surgically descend the testicle. Most undescended testicles will descend on their own in the first year. If it doesn't, the child still won't remember anything if he gets surgery at two. The mother bears the brunt." Even if the testicle undergoes orchiopexy (peg it to the scrotum), there is still an increased risk of testicular cancer. "If you see cryptorchidism, immediately think testicular cancer on board questions." After skin malignancies, testicular cancer is the most common malignancy in 15-35 year old males. "Testicular cancer is four times more prevalent in white than in African Americans. I have never seen a black male with testicular cancer." The mortality of testicular cancer has decreased substantially over the past two decades. "Testicular cancer is completely curable with less than a five-percent mortality rate. We hit it strong and fast, some of the highest levels of chemo, but we get it." (Younger patients can handle higher doses of chemo.) He emphasized how every testicular mass should be considered malignant as opposed to ovarian masses that are commonly benign. We learned a common board stumper: a 20-year-old male presents for a left testicular mass. After an ultrasound confirms a mass, what is the next step? Answer: orchiectomy (removal of the testicle). "Never biopsy a testicular mass," said our urologist. The testicles drain into a different lymph system than the scrotum. "If you shoot a needle through the scrotum, you can potentially seed a whole new lymph basin [with cancer]." We spent the next two days focusing on the "controversial" prostate, a gland that wraps around the urethra and secretes the majority of the ejaculate fluid. Prostatitis is painful inflammation of the prostate, typically from an infection, but also from pressure. "Always ask the guy if he is a biker or motorcyclist." The urologist continued: "Every guy over 50 will have BPH [benign prostate hypertrophy] with varying degrees of urinary symptoms. BPH is one of the most under recognized, easily treatable health issues." Persevering Pete: "What could internists and family medicine Docs do better?" Our lecturer: "I think BPH screening should be part of the standard wellness check. So many 50-60 year olds have hesitancy, difficulty starting and inability to unload. Most men with BPH get accustomed to it as it is a slow decline in function, not abrupt. We have several lines of drug treatment. We used to have to perform surgery, which is now reserved for the severe refractory cases." Our patient case: Robert, a comedic 5'4" 68-year-old recently retired Ob/Gyn, presents to the urology clinic after a routine wellness check discovers an elevated prostate specific antigen (PSA), a commonly used screening blood test for a protein secreted by the prostate. Robert denies dysuria, urgency, hesitancy, dribbling or erectile dysfunction. The internist was unable to palpate any prostate mass on DRE, but Robert is referred to a urologist who palpates a small nodule on the left lobule. Needle biopsy reveals an intermediate-grade prostate carcinoma. Contrast MRI of the abdomen and pelvis does not show any nodal involvement, and a PET-CT does not show any metastatic bone lesions. (First Aid: "Prostate Cancer loves the bone.") Robert underwent radical prostatectomy with clear margins. Robert: "The diagnosis caught us completely off guard. My wife and I were preparing for our long-awaited retirement entertaining all sorts of crazy ideas. The Caribbean, Florida, Wyoming, who knows where we would have ended up." For 15 minutes, we discussed how he determined to get surgery. "I had fantastic doctors. I went into surgery knowing it was the right decision, even with the potential side effects. I had 2-3 years, now I am cured. I will die of my heart, not my prostate. I live a great life. I fish, enjoy walks with my wife, and celebrate being a grandfather." Straight-Shooter Sally: "Are you able to have sex?" The nerves that control blood flow to the penis for an erection travel travel through the prostate into the penis. Invasive prostate adenocarcinoma can invade the nerve sheaths. The radical prostatectomy can damage these nerves as the cancer tissue is removed. Robert replied, "Oh, yes. Finally, someone asked. Last year it was the very first question from the class. My wife and I had sex last night! After surgery. I had urinary incontinence and erectile dysfunction. The erectile dysfunction improved over six to seven months. My urinary incontinence has still not returned to normal, but it is improving. I stopped wearing adult diapers about six months ago." Gigolo Giorgio: "Does sex feel the same?" Robert replied, "Mostly. As you should know, I do not ejaculate. I still orgasm, but nothing comes out." Classmates turned to each other. The urologist, sensing the general ignorance and confusion, explained that radical prostatectomy removes of the prostate and seminal vesicles, and ties the vas deferens. A discussion ensued regarding the new USPTF [US Preventive Services Task Force, government-funded panel of physicians] recommendation against PSA screening? Our urologist: "I still recommend males over 50 get annual screening involving a PSA blood test and DRE [digital rectal exam]. I understand that it is not a specific test, but I see so many patients diagnosed with prostate cancer prior to metastasis. The screening saves their lives. It is the best we have." The urologist continued: "The challenge with prostate cancer is stratifying risk. 1 in 7 males will be diagnosed with prostate cancer… probably 75 percent of males by age 75 have prostate cancer. Most people will never be affected by their prostate cancer, but we do not have an effective screening method. Most patients present with metastatic disease when it is too late to treat. I am asking each and everyone of you to discover a better way to detect high-grade prostatic cancer. There is some hope with the new bound/unbound PSA ratio test. More and more doctor offices are offering this as a second test if an individual has an elevated PSA." In the small group discussions Type-A Anita expressed her displeasure that we spent much of the week on prostate cancer and male reproductive system. "It is not that serious or complicated compared to other GU issues. Typical male-dominated field." A female group-member: "That is just because you hate men, Anita." Anita: "Just the bad ones." After hours, Anita shared a "Showing Up For Racial Justice" Facebook group's post regarding Roy Moore's Alabama senatorial election loss: @ white people: we need to get serious about changing minds and voting patterns. White people overwhelmingly made a disgusting choice in Alabama, and Jones' victory was because of black voters. How long is this party going to demand the absolute fucking most from people of color and not address the real fucking problem: white people. Also @ white women what the actual fuck. Our Dean lead a mandatory 45-minute session to review an LCME-required survey that our class completed back in May. Highlights of the survey: 15 percent fewer students in our class report they enjoy being a medical student compared to the class of 2010. Students are surprised that only 10 percent of the class felt there was unnecessary competition amongst students. The biggest issue continues to be "work/life balance" (but nobody has a job?). Our Dean: "We created an entire department [two years ago] to improve these issues. Stay tuned for more wellness events." Most of the session regarded mistreatment among students and between faculty and students. The Dean just returned from the annual American Association of Medical Colleges [AAMC] meeting in Boston: "Three of the four lectures were on mistreatment in the learning environment." He shared a PowerPoint with the LCME's definition of mistreatment, which starts with "a behavior that shows disrespect for the dignity of others." Examples include language that "can be perceived as" rude, sarcastic, loud or offensive. Our school has a committee composed of two student representatives from each grade, three deans and rotating faculty that meet monthly to respond to anonymous reports of mistreatment. The accuser need never be involved unless more information is needed. Following the committee's investigation, disciplinary action has included removal of a faculty member's appointment. After class, Luke, Mischievous Mary, Persevering Pete, Jane, her trauma nurse sister and I go to our weekly Thursday beers-and-burgers spot. Lanky Luke: "A student could anonymously report a perceived insult from a resident or attending, which would immediately kick off a multi-month investigation. You don't see an issue when people feel entitled to not be offended?" After a 5-second silence, he added, "I am referring to mistreatment outside of sexual conduct. I agree you need a channel to address sexual harassment." Jane's sister: "Almost every unmarried nurse on my floor is romantically engaged with another nurse or resident. Most of my coworkers who have gotten married found their spouse through work. There is nothing wrong with that. It just should not be someone you work directly with like your charge nurse, attending, subordinate, etc.." Mary: "As a woman, I kind of take being flirted with as a norm. It's not good or bad. It's just life. And it serves a purpose. It lets you know who's interested in whom. Pretty quickly you can tell if someone is interested or not. Jane's sister: "I flirt all the time with this Colombian critical care resident who passed through our floor. We went on a few casual dates. If you did not know him, some women would probably think what he is doing is inappropriate. His English is good, but he does not understand colloquial sayings and expressions. We tricked him to say dirty words to the new nurses. It was hilarious. In this day and age he could get fired for that. There needs to be a mechanism to report if something is inappropriate without that accused individual getting terminated. They should be given a warning." Mary: "Sorry, but someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired." Jane's sister: "All I am saying is there are going to be a lot fewer happy couples because of this culture." Pete changed the subject. Pete and girlfriend, an M3 who competes in bodybuilding competitions, co-signed an 18-month lease on an expensive apartment. She was unfaithful to him on an "away rotation" (extended interview at a different hospital system where one is interested in applying for residency). He broke up with her, but she will neither move out nor approve his removal from the lease. "I either have to move out and pay for two apartments, or stay living in misery. What do I do? Also, her brother is a lawyer and is not afraid to sue me." [Editor: Note that, as marriage rates decline, there is a trend to allow plaintiffs to sue in family court after living with someone for at least two years (e.g., in British Columbia and Scotland). Pete can think of the extra rent as alimony.] Later that evening, Jane and I attend an optional heart workshop led by a 55-year-old cardiothoracic (CT) surgeon and his fellow. The surgeon was crude and direct, laying frequent F-bombs. Anita described him as a "Dick". Jane asked him about the lifestyle of a CT surgeon: "My residency is nothing like surgical residency is now. We would be 32 hours on, 8 hours off. while being on call every single evening -- that meant we were at the hospital every single day. I moved into the hospital for three months on one rotation. I did not see my wife for weeks on end. I learned many years later my wife went to therapy. We both did not think we would make it through my residency." She divorced him five years ago. He concluded: "There are many things I regret. I should have tried harder in my marriage. Despite this, I would do it all again." CT surgery plus divorce apparently does not yield financial security: he wasn't able to pay off his student loans until age 50. [Editor: She might not have divorced him if they'd lived in Nevada, Texas, or Germany, where the only reliable way to spend a surgeon's income is to stay married to the surgeon; see Real World Divorce.] He is a vocal critic of the new CT residencies, which don't require starting in general surgery. "First, how do you know you want to be a CT surgeon in medical school? You don't know anything. I did not know I wanted to be a heart surgeon until my fourth-year in residency. Second, I do not trust the new graduates of these programs. We are hiring one now, and all my partners will treat him as a fellow. He will not be ready for the independence of an attending. He did not get a solid foundation in general surgery, or enough surgical hours." Friday morning begins with a 40-year-old internist teaching how to conduct a sexual history. She starts with an explanation of the CDCs "6Ps": Partners, Practices, Protection against STDS, Prior history of STDs, and Protection against Pregnancy. "Patients now expect you to ask about sexual history. 20 years ago, it was a little offensive." She had been to the same recent AAMC conference as our dean and attended a session specifically on the subject of how to teach taking a sexual history. She read aloud from a copied AAMC slide: "Cultural competency, the understanding of and respect for the cultures, traditions and practices of a community, requires cultural humility. To obtain cultural humility we must undergo self reflection and self-critique as lifelong learners and providers." We learned about the difference between sexual behavior and sexual identity. "Sexual behavior does not always match up to sexual identity. You need to use the correct terminology to keep the dialogue going." We also were instructed to use precise terminology when charting: not "patient is gay" [sexual identity], but "patient engages in sex with men" [practice or behavior]. Our lecturer cautions against stereotyping and racism: "There is a high risk of marginalization due to sexual history taking." Patients who feel marginalized by their healthcare workers experience increased risk of mental health issues, substance abuse, and unhealthy lifestyle. She explained that black males and males under 28 are the least likely groups to disclose to a healthcare provider they engage in same-sex sexual activities. Surfer Saul, a laid-back Southern Californian, commented on his experience working in a free Los Angeles clinic. "I find it helpful to use terminology the patients use. For example, pussy for vagina, dick for penis, blowing for oral sex, rimming." The class went silent, while a favorite 45-year-old former Army doctor sitting in front of Saul slammed his head to the table trying to suppress his laughter. The female doctor acknowledged his comment, and said "Yes" but maybe put it in a clinical perspective. After class, Gigolo Giorgio congratulated Saul on the number of profane words used. At lunch, Lanky Luke objects to the standard of asking every patient where he or she falls on the LGBTQIA spectrum. "It seems offensive if the patient is an elderly woman. I would like to use my discretion." Jane joked: "So you are confident enough in your Gadar?" Type-A Anita: "You need to ask every patient, period. You wouldn’t not ask about IV drug use… If only you knew what it was like to be in the minority for a second." [Anita herself is a white, native-born, and suburban-reared.] The conversation is diffused when Wild Willow shares Ackanator, a phone app that asks questions until it can guess a user's chosen fictional character. "I stayed up all night trying to stump it. It's full proof." Students volunteered two characters: Porkins and a Dragon Ball Z character. We were unable to stump it. Jane: "I want to know its top pick at every question. What is its differential?" Another student added, "Stop doing that! You are making it smarter. It'll take our jobs." I attend an optional evening workshop on opioid abuse led by two EM physicians in their mid-thirties. We had been cautioned by the CT surgeon that surgery was not a likely path to driving a sports car on three-day weekends; these two guys are both rumored to drive fancy sports cars. Physician A: "The CDC in 2002 issued guidance to err on the side of the patient. Treat pain. In 2012, the CDC released really a groundbreaking, earth-shattering statement to every physician in the country. It said, 'We messed up.' When does the government ever say that? Now the official doctrine is that every opioid prescription has the potential to be addictive." Physician B: "This has completely changed our practice." (Nobody asked why doctors en masse were listening to the CDC to begin with.) Physician A described how his brother-in-law is struggling with opioid addiction and has been in and out of rehab. "After rehab he was sober for three months. It really seemed he was turning his life around. He was bored one night, and called up an old friend to hang out. Another friend came over and asked if they wanted to shoot up. My brother-in-law was not seeking. You have to realize how difficult staying sober is. You have to give everything up, start fresh. Delete everyone's phone number because it has become so ingrained in the whole community. He ODed that evening, was saved by Narcan [naloxone], and now is back in rehab." What can we do to help an addict in the ED? Both physicians chuckled. Physician B: "It depends how jaded you are. Frankly, not much." Physician A: "I agree. A patient has to hit rock bottom before waking up. That usually is losing a job, losing a family member, almost losing his or her life. Families blame themselves when in reality they are mostly helpless. This is a disease." Physician B: "You still have to try. I've had one patient come back after six months to explain that my talk in the ED behind curtains turned his life around. He went to rehab because of it. The patients that respond are never those you expect." We were trained and supplied with two uses of Narcan. Facebook excerpt of the week: Anita shares TIME magazine's cover page of women who have accused various men of sexual misconduct. She adds "A fabulous way to highlight an awesome movement and the perfect antithesis to the sexual predator-in-chief’s tweet vomits. #MeToo" Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: we celebrate Jane's birthday at Luke and his wife Samantha's house. Luke and I drive to Lowes the previous weekend in his pick-up truck and built a fire pit. Sarcastic Samantha, finishing her Ob/Gyn PA rotation in a rough urban neighborhood, recounted her on-the-ground experience with the importance of conducting a thorough sexual history. Two days ago she saw a couple who came in due to infertility. "After ten minutes, my preceptor [also a PA] and I were concerned they were not having correct sexual intercourse. We had to explain to the couple that you do not get pregnant by swallowing. That's not how you do it." Luke: "I wonder if you should have told them." Jane: "That's eugenics!" Samantha described her disillusionment from the six week experience: "A mother of four from three different fathers came in for prenatal care of her soon to be fifth child. One child was born addicted to heroin. All she cared about was getting her government check in the mail for this additional child. It made me sick to my stomach imagining how these children are going to grow up. How does my preceptor deal with this everyday?" [Editor: If the patients are covered by Medicaid or Obamacare, the preceptor is also getting checks from the government!] Year 2, Week 19 A reproductive endocrinologist begins Monday morning with a one-hour lecture on infertility. She explains that 15 percent of couples experience infertility, defined as more than one year of unprotected intercourse without conception. Fecundability, the probability of achieving pregnancy in a single menstrual cycle, should be about 25 percent. Infertility is on the rise in America: "More and more of my practice is managing PCOS [Polycystic Ovarian Syndrome, driven by obesity]." An obstetrician finishes the day with three hours of lectures (four hours total for the day, so we were done at noon). "Spontaneous abortions occur in 20 percent of all pregnancies," she notes. "Most people do not even realize fertilization has occurred because the abortion occurs in the first trimester. At eight weeks of age with heart sounds, there is less than 5 percent risk of spontaneous abortion." The risk of miscarriage doubles every 5 years after the age of 35. (My female classmates, especially those who didn't come straight from college, have been talking about this since M1. They may be residents well into their 30s so when do they have children?) The OB lecture covers the placenta, the organ that exchanges oxygen, nutrients and waste between the maternal and fetal circulation. "The placenta regulates all the blood flow to the baby. If you lined 100 placentas up, I could tell you exactly which mother was smoking or using cocaine. Preeclampsia, eclampsia and HELPP [Hemolysis, elevated liver enzymes, low platelet count syndrome] syndrome all involve issues with the placenta." We discussed placenta previa, where the placenta partially overlies the cervix. Cesarean section is performed at 39 weeks because of the increased risk of hemorrhage prior to delivery. "If a third trimester pregnant woman presents for painless vaginal bleeding, DO NOT perform a vaginal exam. During my residency, I saw another resident stick his finger right through the placenta causing hemorrhage." [Editor: maybe don't go to a teaching hospital?] The rest of the week is devoted to three hours of daily lectures on nephrology. A 34-year-old soft-spoken nephrologist begins with a one-hour review of last year's kidney physiology. The block director, a PhD in molecular biology, is charged with ensuring we get our LCME-mandated 10-minute break after 50 minutes of class. During the break female classmates discuss how good-looking the lecturer is, emphasizing his fitness and broad shoulders. Pinterest Penelope (recently broken up from her M3 boyfriend): "I love younger physicians. They understand what we are going through. Our fondness of First-Aid, our cluelessness about residency, our anxiety about Step I. Older physicians live in a different world." Lecture continues with two hours on acute kidney injury (AKI). Every minute, 100 mL bleeds out of our capillaries through the glomerulus, a biological filter, into the kidney tubule system and finally the bladder. Over 99 percent of the filtered volume is reabsorbed through active transport of solutes creating an osmotic gradient for fluid reabsorption to maintain the body's electrolyte and fluid balance. Kidney aging, drugs (e.g., antibiotics, and NSAIDs), and autoimmune diseases decrease the summed rate of filtration, glomerular filtration rate (GFR), and the proportion of electrolyte reabsorption. The nephrologist explains: "You lose about ten milliliters GFR every ten years after the age of 30. As long as you do not have a comorbidity, you will never lose enough to confer disease. The problem is most Americans will develop a comorbidity." Kidney injury is divided into several categories: Our patient case: 4-year old Baby Nora and her family hosted a family reunion cookout filled with beer, burgers and brats. Three days later, Nora develops a fever, abdominal pain, vomiting, and diarrhea. She is taken to the ED that evening, given IV fluids for dehydration and discharged home. The following day, Nora is brought back to the ED after her family notices bloody diarrhea. On physical exam, Nora appears lethargic. She has tachycardia (high heart rate), tachypnea (fast breathing), a 101 degree fever, and hypotension (low blood pressure, 80/60). Given the bloody diarrhea and lack of symptom improvement, a "rainbow" is drawn. The tube for each test has a different color and when EM physicians are stumped, each tube is filled with blood. CMP (Complete Metabolic Panel) shows hyponatremia (decreased blood sodium) and uremia (elevated blood urea). ABG (arterial blood gas) reveals a primary anion-gap metabolic acidosis with respiratory compensation. CBC (complete blood count) shows leukocytosis (elevated white blood cells), thrombocytopenia (low platelets) and anemia (low red blood cells). Peripheral blood smear reveals the presence of schizoschites, suggestive of a vasculopathy. Urinalysis shows the abnormal presence of protein and red blood cells. Her doctors are concerned about hemolytic uremic syndrome (HUS), the most common cause of acute kidney injury in children. The disease is caused by ingestion of Shiga toxin from E. coli O157H7, which typically accumulates in colonized food rather than being produced by bacteria that have colonized the gut. Also, if there is an infection, killing the bacteria all at once can release a flood of Shiga toxin. Thus antibiotics are not started and doctors will rely on the patient's immune system to kill any remaining bacteria. Shiga toxin damages small blood vessels and causes formation of small blood clots (microthrombi). These blood clots shear red blood cells creating the characteristic schiztoschites seen on a peripheral blood smear. Nora's urine output continues to decline, and hemodialysis is started and continued for five days until her creatinine levels improve. Creatinine is a muscle protein product excreted by the kidneys at a constant rate used to measure kidney function. She requires one unit (300 mL) of packed red blood cells to maintain her hemoglobin above 7.5. Nora gradually recovered during a 10-day hospital stay and, now age 9, does not remember the incident. Her parents reflected how scary the experience was. "I was furious at the doctor who sent us home when we brought her the first time. After the emotions simmered down, I have forgiven her. There wasn't any sign that it was more serious than just a typical food poisoning." Nora's kidney function, as measured by GFR, is back to normal, placing her among the lucky 70 percent who recovery fully. Our two hour ethics workshop focuses on disability. We read Enforcing Normalcy: Disability, Deafness, and the Body by Lennard Davis, "a nationally and internationally known American specialist in disability studies [an academic discipline]" and English professor at University of Illinois at Chicago (Wikipedia). Our ethics professor: "He uses the Marxist perspective. The disabled population is oppressed, and thus must be be given justice. Davis argues as long as society uses an ableist mentality, we will be unable to correct the injustice. He exaggerates slightly, but within the pieces are an immense amount of insight into the human experience." From the 1995 book: When I talk about culturally engaged topics like the novel or the body I can count on a full house of spectators, but if I include the term disability in the title of my talk or a session the numbers drop radically. … our goal should be to help "normal" people to see the quotation marks around their assumed state. The fact is that disability as a topic is under-theorized -- a remarkable fact for this day when smoking, eating a peach, or using a bodily orifice are hyper-theorized. Because of this under-theorization, which is largely a consequence of the heavy control of the subject by medical and psychosocial experts, the general population does not understand the connection between disability and the status quo in the way many people now understand the connection between race and/or gender and contemporary structures of power. … The category itself is an extraordinarily unstable one. There is a way in which its existence is a product of the very forces that people with disabilities may wish to undo. As coded terms to signify skin color -- black, African-American, Negro, colorized -- are largely produced by a society that fails to characterize 'white" as a hue rather than an ideal, so too the categories "disabled", "handicapped" "impaired" are products of a society invested in denying the variability of the body. In the process of disabling people with disabilities, ableist society creates the absolute category of disability. 'Normal' people tend to think of 'the disabled' as the deaf, the blind, the orthopedically impaired, the mentally retarded. But the fact is that disability includes, according to the Rehabilitation Act of 1973, those who are regarded as having a limitation or interference with daily life activities such as hearing, speaking, seeing, walking, moving, thinking, breathing, and learning. Under this definition, one now has to include people with invisible impairments such as arthritis, diabetes, epilepsy, muscular dystrophy, cystic fibrosis, multiple sclerosis, heart and respiratory problems, cancer, developmental disabilities, dyslexia, AIDS, and so on. … In 'talking' with Deaf colleges on e-mail particularly those whom I have never 'seen', I often 'forget' that my interlocular is deaf. Recently, in planning to attend a session at the Modern Language Association on disability, I received and sent a welter of messages on email to a number of people involved. I had no way of knowing which of these people was disabled, or in which way. When speaking on the telephone with a person who uses a wheelchair, I have no way of knowing if that person is unable to walk. When the ethics professor was busy with another small group, Geezer Greg said, "I could have learned more by watching Curb Your Enthusiasm. Larry David calls a mechanic to bring his car in. When he brings his car in and meets the mechanic in person, Larry is surprised to find that the mechanic is black: 'You did not sound like it on the phone.'." Persevering Pete: "I am not sure what Davis is arguing. On one hand he does not want people to consider disabled individuals as a separate group, but he wants more financial assistance for the disabled." Luke: "Where does Davis draw the line on collecting disability checks? Am I on the spectrum?" Greg: "That's a Curb Your Enthusiasm episode also! The girlfriend claims her son is on the Asperger's spectrum, but Larry David thinks he is just a spoiled brat." (The wife sues for divorce during Season 8, taking the house and putting Larry back on the dating market.) The ethics professor did not mention the financial aspects of being classified as disabled, nor that medical doctors are now the gatekeepers for whether or not an American can get aspect to disability payments (see "How Americans Game the $200 Billion-a-Year 'Disability-Industrial Complex'" (Forbes)), nor that some doctors earn 100 percent of their income as disability gatekeepers. This is something that Hippocrates probably could not have imagined. Our week concludes with the Genital Teaching Assistants (GTA) teaching us how to perform the scrotal, penis, digital rectal exam, pelvic, and breast exams. The family medicine physician coordinating the workshop introduced this opportunity: "These are professionals that travel the country teaching these exam skills. Ask them any questions you have, this is their job. And let me tell you, they are good and they are very expensive -- largest item in our budget, I am talking thousands of dollars -- so we are partnering with internal medicine residents to bring them." Gigolo Giorgio learned that the female GTAs make $90 per student ($70 for vaginal exams, $20 for breast exam) or over $1,000 (3 groups of 4) in the afternoon workshop. The national standard seems to be that male GTAs are paid less, but so far there have been no demands for equal pay. Luke: "How much would you have to get paid to do that?" A few of the guys responded: "No questions asked, sign me up." No female classmates answered. We are divided into teams of four and rotate through a male GTA for 1.5 hours and a female GTA for 2 hours. My group happens to be all male. The 35-year-old male GTA is a married family medicine resident with two sons who has been doing the GTA program as a side job for 3 years. Patricular Patrick leads the way beginning with the scrotal exam. We individually practice each step of the exam. The GTA is extremely helpful, drawing on his medical experience to emphasize certain pathologies to look out for at each step of the scrotal and penile exam. The digital rectal exam is last. As Particular Patrick is searching for the prostate, the GTA adds, "My right prostate lobe is slightly larger than the left." There is a 15-minute break before the female GTA session. Pinterest Penelope was enthusiastic about having felt a direct hernia in a "65-year-old geezer," but noted the "shriveled balls." Our female session is with a 25-year-old GTA with two years of experience. She uses a mirror to help guide each of us through the exam as we struggle to handle the speculum to locate the cervix and to palpate the ovaries using the bimanual technique. She emphasizes, in an Eastern European accent, never to close the speculum until partially retracted to prevent closure on the sensitive cervix. We took longer than expected, so only one of us is allowed to perform the uterorectal exam. Ambitious Al quickly volunteers with no shame. Gigolo Giorgio was disappointed he could not practice it. This snafu apparently happened in other groups as well, and a few students (not Giorgio to my knowledge) complained how this asymmetric experience was unfair to those who did not get to perform the rectouterine exam. The family medicine physician apologized. Jane: "This experience hit a lot of us. It seemed like everyone respects what happened, it's a kind of a milestone." (Jane might not have heard a few wags joking about the scrotal, bimanual, and uterorectal "shocker" exam.) The Family Medicine instructor comments, "I am glad no one fainted. One gentleman last year fainted while examining the male GTA." Two (male) students became light-headed during both the rectal (male) and bimanual (female) exam, although no one fainted. Jane and I ate dinner with her mother, learning that she loaned Jane's sister just under $10,000 to pay off a Lowe's loan for repairs on the ex-boyfriend's house (see Week 14). Solvent thanks to this and Jane's loan of $5,000 to pay off her credit card debt, the sister has recently gotten back together with the ex-boyfriend. "Well, I feel like an idiot!" said Jane's mom, not a fan of this boyfriend. "I keep thinking if she still had the 10k 'L' [for Loser] hanging over his head, they would never have gotten back together." It is a week before Thanksgiving and Type-A Anita is hosting the class potluck Friendsgiving on Saturday afternoon. Anita's board game collection includes The Cat Game and Trump: The Game, a gift during the election night party. "Still too soon to play it," said Anita. My favorite dishes: Straight-Shooter Sally's sweet potato casserole, Gigolo Giorgio's jalapeno guacamole, and Persevering Pete's homemade rolls. Most of us elected to bring wine or beer rather than expose our weak skills in the kitchen, resulting in 10 bottles of wine and 6 six-packs arranged on the serving table. At 9:00 pm on the dot, 20 classmates whip out their phones to play HQ, a streaming, single-elimination trivia app with a live host. None of us get to share in the $5,000 that is divided among contestants who correctly answer all 12 questions. Classmate Butch Brock and his girlfriend Annabelle the Beauty made it to questions 6 and 7. Annabelle recently moved in with Brock, studied communications at a state university, works as a hostess at a local restaurant, and has decided to apply to PA school. Lanky Luke: "Isn't there anything else people want to do besides medicine?" Jane and I left around 10:30 pm. This Week in Facebook Activity: Type-A Anita shared Huffington Post's "Trump Official Blocked Immigrant Teen Rape Victim’s Abortion Because He Personally Opposed It" and added "Tw: rape [Trigger Warning] Hot Take: if you're a leaky pile of garbage concealed in human skin, you forfeit the ability to tell others what to do with their very real Human Bodies. no one can decide whether or not someone's reason for an abortion is "good enough". Anita shifted gears from attacking our weak commitment to advancing non-white causes to attack a non-white political candidate: "Anyone who invokes God as an unquestionable authority in a secular debate on REAL WORLD phenomena has no place in government. This woman, Angie Reed Phukan, is running for Comptroller of Maryland, and decided to let us all know what actual garbage she is ahead of time. (Anita has never lived in Maryland.) Later that evening, she shared an article on Viagra's patent expiration: "by all means let's help old dudes keep an erection but keep reducing people's access to contraceptives #godwantsyoutohavelimpdick" Pinterest Penelope shared that one on Facebook and messaged the class GroupMe: "The hashtag!!" Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane and I join her college girlfriend who works as an au pair and bartender in Dunedin, New Zealand. In order to stay in New Zealand, she is signing up for a master's degree in international politics at a university there, using $17,000 in U.S. Federal student loans. (Editor: the U.S. welfare program for university bureaucrats now embraces the entire planet! Separately, if so many young people study international relations, why are there still wars?) The Saturday Friendsgiving has thinned the ranks of Monday and Tuesday lecture attendees. At least five of us, including me, are down with an upper respiratory infection. Instead of watching the recorded lectures, I watch Pathoma and read Robbins & Cotran. Chronic kidney disease (CKD) is an irreversible loss of kidney function defined by a GFR of less than 60 milliliters per minute for more than three months. Pathoma explains the process of hyperfiltration, where loss of one group of nephron units, from e.g., infection, inflammation, hypoperfusion (low blood flow), causes the remaining functioning nephron units to increase GFR. I return Wednesday for two hours of CKD treatment strategies by the nephrologist from last week: "What I love about nephrology is there are only four diseases that I have to know: diabetes, hypertension, pyelonephritis (kidney infection), and hereditary kidney disease. 95 percent of all CKD is caused by one of these and they are all covered in First Aid." He discussed some exceptions to this rule, starting with an unsolved mystery in Central America "Certain agricultural communities have up to 20 percent incidence of CKD. We do not know why." (see "Chronic Kidney Disease Epidemic in Central America: Urgent Public Health Action Is Needed amid Causal Uncertainty", Ordunez, et al., PLOS, 2014). He also described an outbreak of "Chinese herbal nephropathy" from a weight loss supplement that used aristolochia instead of stephania. This is the same compound that caused the 1965 Balkan Endemic Nephropathy in the Soviet Bloc. Aristolochia grows in wheat fields along Danube river Valley. This contaminated flour. "When I was in medical school, this was huge news. Now the region has 65 times the risk of getting uroepithelial cancer." We learned about the various types of dialysis for end-stage renal disease. "We tell our patients it is fine to travel. One of the beauties of effective government regulation is that all dialysis machines are standardized. We use the same settings for each machine. Our patients travel all over the country, and we are able to handle dialysis for visitors from anywhere in the world." The nephrologist concluded: "You will each briefly do a nephrology rotation. One of the things I wish you could see is the patients that are doing well. If patients do not take care of themselves there are serious consequences. You see these patients in the hospital. But if they do take care of themselves they can be healthy and productive members of society. You don't see the patients who have jobs, families, and a good quality of life. I wish we could show you what it is like on the outpatient side. Come join us for a day!" Our patient case: Jenny, a recently married 24-year-old manager at a fashion designer store. She was fresh out of college, had moved with her husband for new jobs, and purchased a house, all within one year. Jenny presents for one month of joint pain and an expanding rash over her face and torso. She was worked up for Lyme Disease. "I got a call a few days later by the nurse who referred me to a rheumatologist." The earliest appointment was in two months. "The next week I could not get out of bed because the pain was so bad. I had to lie like a coffin. I thought I was dying. We had to cancel our honeymoon! That's when my husband realized that the problem was more than natural laziness." She chuckled, and continued: "I called my family friend who is a doctor. He gave me a list of tests to get. I called to get another appointment with my PCP, but I could only see a PA. I think she was insulted when I presented my long list of labs and tests." Her labs showed abnormal urinalysis including albuminuria and red blood cells in the urine. "They now wanted me to see a nephrologist instead of the rheumatologist! I saw the nephrologist the same day." Her short, sarcastic 40-year-old nephrologist said that she had immediately suspected systemic lupus erythematosus (SLE or "lupus") given Jenny's age, sex, kidney function, and the expanding characteristic butterfly rash now covering her face. She started Jenny on several drugs, including an immunosuppressant, high dose NSAID, and steroids to bring her lupus into remission. Jenny has been in remission for almost three years since the initial flare up at age 24. Jenny said, "My husband is a saint. Once I got the diagnosis, I immediately went to the Internet. WebMD is a dark hole of death. I thought every little ache or sniffle spelled death. After a week, My husband forbade me from looking up any information about lupus. If I was concerned about something, I told him, and he would search it." After roughly six months, Jenny began tapering down the powerful immunosuppressants. Her lupus is controlled now only with high dose NSAIDs. "The drugs I was on had terrible side effects, but I was just as scared about relapse. Weaning off the drugs takes months. My husband was the only reason I was able to follow the strategy. He reminded me every day, and kept track of the dosing schedules." (Roughly half of individuals with chronic illnesses do not take their medications correctly.) When would a nephrologist rather than a rheumatologist manage a patient with lupus? "It depends on what condition is the most urgent. If lupus is impacting the kidney, a nephrologist will manage the case until the kidneys are safe. The rheumatologist manages the day-to-day stuff, we get involved only to evaluate the kidney." Straight-Shooter Sally asked Jenny to summarize her care. "To be honest, I was not impressed with my PCPs. I felt like they failed me. But, I love my specialists. They know so much. Any question or concern, they have seen before and know exactly what to do." Surfer Saul asked Jenny if she is able to have children. Jenny's rheumatologist does not want her to get pregnant due to the risk of a flare up from the hormone surge. Her nephrologist: "I think it is okay. I've had a few SLE patients get pregnant." Mischievous Mary asked if pregnancy would stress Jenny's kidneys because of the sudden increase in blood volume and hyperfiltration? "Oh no, pregnancy is good for your body, good for the kidney. Pregnancy is a protective risk factor for lots of cancers. I tell Jenny she can get pregnant." Gigolo Giorgio asked if Jenny, in light of her current knowledge of lupus, could remember pre-diagnosis flare-ups. "Yes, I got really sick in college once. Terrible. It had to be a flare up. I also remember being allergic to all these random things like yellow dye." A student asked the nephrologist what her patients can you eat on a renal-restricted diet? "Wonder bread and lettuce. There are no good options. Every food has things the kidney struggles to excrete. I have patients come in to me complaining of having Wonder Bread stuck to the top of their mouth." Our class discussed the proposed Republican tax plan at lunch. Students did not understand the changes to the mortgage interest deduction. One student believed that the new tax plan would increase the mortgage deduction limits "to benefit the wealthy in their McMansions." Luke attempted to correct the group by stating the new tax bill would restrict and cap the mortgage interest deduction at $10,000. (This was also incorrect; it was state and local taxes that were limited to $10,000 while mortgage interest would remain deductible on loans of up to $750,000.) Socialist Sam, a 23-year-old self-described "Democratic Socialist," responded: "Well, then, the deduction would distort the housing market. It would make it more expensive for people to move up in housing market, exacerbating racial housing discrimination." (Decades of government subsidies to homeowners via the mortgage interest deductions apparently did not constitute a "distortion" to the housing market!) Curiously for someone whose future paychecks will be coming from insurance companies, Gigolo Giorgio supported getting rid of the Obamacare "individual mandate" requiring citizens to purchase health insurance. "A bunch of my college friends took the $2,000 hit instead of purchasing health insurance." The argument continued on Facebook. Type-A Anita shared a Bustle article, "The GOP Senate Tax Bill Will Make It Much Harder To Be A Woman In America" underneath "hi warning friends only read this if ur ready to get good and depressed because IDK WHAT I EXPECTED FROM THE TITLE but wowie wow wow." The main point of the article is that people who don't currently pay taxes will be denied the opportunity to claim tax credits: Millennial moms would also be impacted because the bill excludes 10 million low-income children from claiming tax credits. Because women still mainly shoulder the responsibility for child care, families in the lowest income bracket won't receive tax benefits for their children when they're the ones who need it the most. [Editor: Let's see if single moms are so discouraged by this new tax law that they turn over custody, and the child support cash that comes with custody, to the respective fathers!] Some of our female classmates thank her for educating them (8 angry faces; 14 likes). Sample comments: My brain cannot even comprehend the sheer cruelty of this bill I just...don't understand. I DON'T UNDERSTAND HOW ANYONE CAN DO THIS AND SLEEP AT NIGHT Facebook also brought news from my college classmate who decided to leave the United States for enlightened Brussels due to Trump's election (see Year 2, Week 3). His coworker in Belgium has been "jokingly" calling him by a variety of anti-gay slurs: I refuse. I will not be defined by your words and I will not be forced to accept them as “business as usual”. His friends commented that Trump could be blamed for this outbreak of homophobia in Brussels. Statistics for the week… Study: 25 hours. Sleep: 6 hours/night; Fun: none. We leave Wednesday after class for Thanksgiving break. Students complain that the administration scheduled exams for the week after Thanksgiving. We return from Thanksgiving break for exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam. Lanky Luke, Straight-Shooter Sally, and I were most concerned about failing the clinical exams. My first "patient" is a 38-year-old female presenting for diffuse abdominal pain and a two-week history of bloody diarrhea ("tar colored") with no recent travel or sick contacts. She takes Aleve (naproxen) four to six times per week due to headaches and joint stiffness. After the 25-minute encounter, I left the room with no idea what the correct diagnosis should be. Peptic ulcer disease from NSAID use? Inflammatory bowel disease? Irritable bowel syndrome from low fiber diet. I forgot to ask so many basic questions. Several students commented how they similarly stared blankly at the computer screen writing up the H&P (history and physical note). My second "patient" is a 26-year-old female presenting for a two-day history of a burning sensation on urination. She denies abnormal discharge or change in menstruation. I complete a full "5 P's" sexual history: partners, practices, protection against STDs, prior history of STDs, protection against pregnancy. She is in a two-year relationship with a female partner. One week ago, she had a few to many eggnogs at her store's christmas party. She had unprotected anal and vaginal intercourse with a male partner. She is now concerned that her partner will contract whatever she has, and she does not want to tell her. I diagnose her with cervicitis (inflamed cervix) due to chlamydia or gonorrhea. I recommend dual treatment of ceftriaxone/azithromycin with Hep B/C vaccine and HIV screening for risky behaviors [Editor: One of my Manhattan friends, whenever a Ph.D. introduces himself as "Dr. …" at a party, takes the new acquaintance aside and says "Doctor: I have this burning sensation whenever I go to the bathroom. What do you think it could be?"] The challenging clinical 60-question multiple choice exam covered nasogastric (NG) tubes, Foley catheters, nutrition, and sexual history. Questions included: Pinterest Penelope was frustrated at the clinical coordinator for including two questions on immunizations and screening tests based on sexual history, relationships that were not explicitly covered in lecture. The clinical coordinator responded, "Do not blame the messenger. We always tell you that information from prelecture readings and recordings can be tested." Pinterest Penelope after the NBME exam: "I knew everything, but a lot of the questions were poorly worded." Gigolo Giorgio: "What did you put for the question asking about a vaginal ulcer. HSV [genital herpes] or syphilis [chancre]? It did not say if it was painful or not." Penelope: "See poorly worded, there is a reason they are retired board question." Students continue to complain about the black-and-white histology slides. One classmate who is color-blind apparently asked if there are any accommodations for the colorblind because the real NBME exam includes color pictures [Editor: "Pictures of Color"?]. "The answer is no." One question asked about how to diagnose a penile ulcer due to syphilis. Straight-Shooter Sally: "I have no idea what is darkfield microscopy, but I think we've heard it before?" Jane: "Same! I just put it cause why not." I also chose this answer, which is fortunate because darkfield microscopy is actually used to identify the culprit bacteria,Treponema pallidum. Wednesday evening, with one exam remaining, Jane lost her studying motivation and indulged in a three-hour Buzzfeed binge. I was under strict instructions not to disturb her while she laughed hard enough to cry at cat videos and tweet compilations. The case-based exam covered five patients: breast cancer, alcoholic liver cirrhosis, testicular cancer, acute kidney failure, and Crohn disease. Each case had eight short-answer questions. Example questions: Describe the treatment considerations in breast cancer. Answer: premenopausal women with ER positive breast cancer should begin tamoxifen; postmenopausal women with ER positive breast cancer should be aromatase inhibitor. What are the histological characteristics of Crohn disease versus Ulcerative Colitis? Answer: Crohn disease is characterized by inflammation of the entire gut wall potentially causing strictures and fistulas (connection between two parts of the gut tube, e.g., small intestine and large intestine); ulcerative colitis is characterized by pseudopolyps, loss of haustra (gut lumen foldings) and enlarged crypts with neutrophilic infiltrate. What kind of acute kidney injury is this given the CMP with BUN:Creatinine ratio and urinalysis. Answer: BUN:Cr > 20 suggests prerenal causes, e.g., dehydration or hemorrhage; BUN:Cr < 15 with high urinary sodium excretion suggests acute tubular necrosis. A patient with G6P deficiency gets a URI and develops colicky abdominal pain. What is happening? Answer: Red blood hemolysis is causing pigment (bilirubin) gallstone (cholelithiasis) formation. An overweight, 40 year old female on birth control develops colicky abdominal pain. What is happening? Answer: Cholesterol cholelithiasis (gallstones) A 30 year old male develops hypertension, hematuria and flank pain. Ultrasound reveals several dilated cysts on both kidneys. What other tests should be ordered? Answer: a patient with adult onset polycystic kidney disease (PCKD) should get regular MRIs and echocardiograms to evaluate berry aneurysms in the circle of Willis (cerebral vasculature) and mitral valve prolapse, respectively. What is the probability his child will have the same disease? Answer: Adult onset PCKD is an autosomal dominant trait, therefore 50 percent. (On the liver case:) Explain eight etiologies of the disease shown in the above histology slides." Answer: Hep B, Hep C, Hep B/D coinfection, idiopathic/genetic, alcohol, obesity, biliary obstruction. After exams, 15 students trickled into our favorite burgers-and-beers spot. Conversation shifted to the Republican tax proposal when Pinterest Penelope showed a BuzzFeed-produced video lobbying against the elimination of the student loan interest deduction. The video featured a Tufts University drama and communications graduate working as a "freelance production assistant" and receptionist struggling to pay over $118,000 in student loans ($118,000 is roughly 7 times the cost of in-state tuition and fees at Texas A&M medical school). Lanky Luke: "Wouldn't the increased standard deduction cover the entire taxable income of a struggling, underemployed drama graduate? I feel like so much of the 'millennial' frustration is directed at the wrong people. How much were her drama professors making while she was paying sky-high tuition?" Straight-Shooter Sally: "What has changed to propel tuition so high? That is what I cannot understand. There were drama professors 10-20 years ago." The topic turned to ongoing sexual harassment/assault charges and the #MeToo movement. Pinterest Penelope: "Can we just talk about sexual assault and how everyone is a terrible human being." Mischievous Mary: "Someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired." Straight-Shooter Sally: "As a Democrat, I want Al Franken to resign. I know some of my friends who want him to stay to resist Trump, but that sets a terrible precedent." Lanky Luke: "Mike Pence is looking pretty smug with his no dining alone with other women outside his wife." Pinterest Penelope responded by referencing a Vox article, "Vice President Pence’s “never dine alone with a woman” rule isn’t honorable. It’s probably illegal" (sent in GroupMe chat). Luke: "So what are men supposed to do?" Three women all responded in unison: "Not sexually harass women." Type-A Anita: "When a male assaults a female, the male does not need to add that he is attracted to women. No, Kevin Spacey did not need to add that he is gay. Thank you for setting gay rights back a decade. You are trash." Friday evening, four female classmates independently shared Elizabeth Warren's Facebook post. Pinterest Penelope added "Marry Me" on top of the link: [Editor: This is definitely an unfair comparison. Pocahontas died at 20 years of age, an attractive young woman whose cross-cultural marriage prevented a war. Elizabeth Warren is a divorced 68-year-old.] After Type-A Anita and Pinterest Penelope, Lanky Luke played a Tucker Carlson segment on the TV in the small group room for Persevering Pete, the class Orthopod, Jane and myself. The segment interviewed a transgender activist who argues race and sex can be chosen. Lanky Luke: "This is fantastic. I am going to apply to residency as part Native American, part Black. Derm residency, here I come." My small group went to our retired orthopedic surgeon facilitator's house on Friday for a dinner party. After a few glasses of wine, we discussed the opioid epidemic. Surfer Saul: "When it was minorities addicted to drugs, the state began the war on drugs. The war on drugs was a method to suppress and incarcerate minorities, primarily African Americans and Hispanics. Look at how we judge crack-cocaine versus opioids. The moment it is white youth struggling, the drug abuse becomes a public health emergency." [Editor: Actually if it is white youth who want heroin, the government will buy it for them! See "Who funded America’s opiate epidemic? You did."] Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: Saturday night dinner with Jane's sister (26 year old), newly back together with her boyfriend, a U.S. Navy special forces retiree. The apparently healthy 37-year-old, who teaches CrossFit classes, is applying for long-term disability, which will enable him to shift all of his daughter's college expenses onto the taxpayer. He is concerned he will not be approved before school starts this August.Year 2, Week 14
Year 2, Week 15
Year 2, Week 20
Year 2, Week 21
You might have heard that Donald Trump likes to call me “Pocahontas.” … today, he stooped to a disgusting low. This afternoon, in the Oval Office, Donald Trump was supposed to be honoring Navajo code talkers – American heroes who helped save the world from fascism and hate during World War II. Instead, Trump stood right next to those Native American war heroes and came after me with another racist slur.
