La Raza, or, Am I Racist?

I just came back from Step 2, and, no, official oversight committee, this is not a blog entry about any details of the exam; I understand that such postings are forbidden.
At the end of our 4th year all of us now have to take an exam that is practical, called step 2 CS; we line up in our white coats, with our non-augmented stethoscopes, without or accessory brains (PDAs), and go in to see 12 standardized patients. In 15 minutes, we have to take a history, do a physical exam, and present our impression to the patient. Then we have 10 minutes to write a note with what tests we want to order. The whole thing costs over $1,000, which I think is a racket, personally. Who's idea was it to charge 4th year students, those whose loans have most likely run out, over a grand for a required test? At least they supplied lunch--cold cuts and pasta salad. That extra scone was about $450.

It's not a bad test, actually. But what I wanted to talk about today is a bit more interesting than details of cases. For whatever reason, there were four of the twelve standardized patients I had that were African-American. I think, having thought about it, that I treated them differently.

I didn't mean to, certainly. However, in the exam situation, it was with young, African-American standardized patients that I forgot, more than others, to tell them about tests I would consider routine in their situation. Perhaps I'm imagining things; or, perhaps there's something to the finding that minorities get poor health care even when you control for income. What was going on? Did I think them less likely to need the test? Did I consciously want them to have a missed illness? I'm sure not. Rather, it was likely my brain did what it did, distracted by the pressure of the test.

I've spoken about Malcolm Gladwell's books on the blog before, and his idea that there is a whole slew of assessments and judgments that occur the split second after you see or talk to someone is relevant. He calls it 'thin-slicing', and at best, thin-slicing in an experienced physician can allow for quick recognition of major illness versus stability. At its worst, however, it can be distracting.

So, because these folks were black, did I somehow make a snap judgment that caused me to order fewer tests? I think so. I think so because when I left to write the note, it was obvious the work up I wanted to do, and I put down those tests I hadn't described to the patient. For whatever reason, though, there was a gap between whatever initial judgments I made without thinking about it and what amounted to good, thorough care. Of course, now there are a maze of confounders--did I know I wanted the tests, but not explain them well because I was less comfortable on some level? Were they less forthcoming with me and therefore I didn't feel like they were acting as sick? Did differences in question style, language, and non-verbal communication make a difference? Not sure; I do know they had two-way mirrors for 'research', so maybe there's a way to find out.

Obama's candidacy for president has made clear that race is an issue in the US. I give us credit as a country for talking about it; there are lots of racists in the world and they often deny that they are much more than we do, as when a Korean student I met denied that there were any Korean homosexuals (I know that's not race but it's similar). The test makes me wonder just how much I'll have to watch myself for hidden bias. Better, I suppose, to see it for what it is and correct it--which is precisely what everyone has to do when their 'thin-slice' is inaccurate.

I remember a class in Mexico where we discussed race, and the class wanted to know why Americans were racist, why they locked the car door when Hispanic youths walked by, why they were so anti-immigration. I found myself on the block for everyone. It was disconcerting, but also enlightening; we have a constant choice to either ignore our own blind spots, or look into them. Hopefully, by doing so, I become a better doctor for everyone, not just the Scandinavian farmers I know how to relate to.

Respect the Momma Bear

The NY Times has brought up vaccines again in this article, discussing a measles outbreak that involved nine unvaccinated kids and some others that were vaccinated. The Times is spot-on in its critique of the decision, discussing both sides and rightly pointing out the public health risk.

However, the angle that is always missing is still missing: the angle of benefit for the individual vaccinated. Rarely do people frame it that way, and when they do, they are often successful, in my experience. This is good for YOUR kid. Not the other ones. Not the public. Not the schools, or the government. YOU and YOUR kid. Why? Because, even if you buy the risk of autism (which I personally don't) the chances of having some bacteria or virus eat holes in your kid's brain large enough to park a Tonka truck in are greater than harm from the vaccines.

Vaccines do harm kids; according to VAERS data, the self-reported network, they do cause fevers and irritability, and can also lead to allergic reactions. But these reactions are much less common and much less devastating than the consequences of the admittedly rare sequelae of our major immunizable diseases. When I was on the pediatric wards, one of four kids I took care of was a CP patient that had an MRI that made me cringe, and the damage was from infection.

The whole problem is that we haven't respected the mother instinct. I'm a guy so I'm a bit bigger and probably physically stronger than my wife, but if there were someone or something threatening our kids, she would be the one to rip its trachea out and stomp on it. This instinct is so strong that it defies the laws of Newtonian and quantum physics. Even when I did a google search on 'momma bear' to get a picture for this post, I happened on a good blog where a mom avowed that she would 'rip the heart out' of anyone who attempted to accost her child. We joke about this in our society, but its very real. Just try it sometime. I dare you. Go up to a mom feeding her baby with mashed up bananas and take the food away. See what happens.

So what? So, doctors like to tell people what to do. It's our job; we go to school for a long time so we can do it. Guess what? Moms don't care. They go through labor to get their kid and who the hell are we to tell them what to do? I think they win, even though school is long. As a medical community, we will never be able to change a mom's mind by telling her what to do, and that is evolutionarily appropriate. Thank God for moms. Even though I'm done with mom doing her mom stuff now, I'm sure it saved my life a couple times when I was seven and stupid.

What Momma bears can teach us is that if we are to change the mind of a parent we will not do it by saying, 'you must succumb to our order to stick your kid in the leg with a needle that may or may not have mercury in it'. Instead we might try, 'I understand you are worried. In my opinion, the risk of getting this vaccine is much lower than the risk of getting a terrible disease if you don't get the vaccine. Both risks are small, but the risk of disease is much bigger than the risk of a serious reaction to the vaccine'.

Mommas don't care about other kids when it comes down to danger to their own cubs. They just don't. So we may plan as a profession with public health in mind, but that is no argument to a momma bear.

Why are vaccines so vital? Chicken pox isn't that bad, right? Well, it's not the normal outbreak that the vaccine is aiming to prevent. It's the rare outbreak that eats the child's brain, the rare measles infection that makes them dance like Satan's marionette, the rare meningitis case that kills them before they have a chance to wake up, or the rare HPV infection that progresses to fungating cancer eating into the wall of their vagina. Once you've seen those cases, vaccines aren't so scary. We just have to respect the interests of patients and their parents and let them know the real consequences they face; and, like it or not, I still believe we have to let them make their own choice.

Match Day

On match day, 4th year students walk to the front of a huge auditorium filled with peers and family and open an envelope that contains their residency appointment. I cheated; I looked at mine before hand, and then had them put it back in the box to read it during the ceremony. People may be mad, but for me, having begun pre-requisite classes for the MCAT seven years ago, I had waited long enough. Someone said, 'can't you wait another hour', and I thought, 'actually, no'. So I'm off to one of the best programs in the midwest, I think. Cincinnati was first, I believe, followed by LA, Pennsylvania, Chicago and Louisville. Many of the other programs in the midwest have also been around for upwards of twenty-five years, and it has a high concentration of well-established programs. There were fewer open spots left in the midwest after intial matching than any other region except the far west, which has the fewest spots and the most extra-curricular attraction.

Although it was probably the toughest program I looked at, that's ultimately what I want. As I said to my wife, 'when someone ultimately dies even though I try and save them, I want it to be because that was what was destined to happen, not because I wasn't prepared'. Whew. Glad that's over. Or, I suppose, just beginning.

Congratulations to all those who matched, good luck to those few that had to postpone, and thanks to those who helped--although I'd like to think I'll thank them a little more personally than this.

The Inadvertent Comment

The other day a surgeon I actually really like was putting in a G-tube on a patient, which is required when they cannot feed themselves by mouth. The approach involves an incision and dissection down through the upper abdomen to the stomach. As he operated, he said, 'you know, it's really nice to finally have a patient who's thin'. We're in the midwest; most of our patients are over 200 pounds, and it is not uncommon to have someone north of 400 pounds, which makes operating quite difficult, and much more dangerous.

The woman had stage 4 squamous cell cancer which was preventing her from eating by mouth. No wonder she was thin.

Insensitive? These types of comments are the ones that get people all mad. But really, I had ample evidence that this surgeon was, though maybe not warm and fuzzy, compassionate. We're just human. His mind was preoccupied with the task, not the big picture, and when he has a long, curved needle in his hand, that's absolutely for the best.

Without thinking I've asked people with ET tubes down their throat how they are doing, or other questions that require an answer rather than a nod. I've accidentally dropped names in the cafeteria, although I'm getting better at that. I've made jokes or light of injuries that may border on insensitive out of a desire to lighten the atmosphere in a room, even though there is evidence that jokes do not help patients feel better about their conditions.

People are right to point out insensitive comments to health care professionals; we often come to wear callous veils to protect ourselves from the stream of injured humanity we see, especially in the critical care or surgical professions. I don't think that there is a way to consistently re-assemble people without detaching a bit. Some situations become so absurd that we end up laughing because we don't know what else to do, and because if we didn't, we'd instead go slightly bonkers. It doesn't excuse us or decrease the need to remain sensitive to the patient; but if you happen to overhear something to which you object, the context might be helpful. Maybe the doctor who seems callous, is; but it may also be that they are distracted or have a point of view that differs from your own.

"You're going to find that many of the truths we cling to depend greatly on our point of view". --Obi-Wan Kenobi.

Beer Belly

There actually is a prosthesis--like a CamelBack only not quite--to carry beer outside your gut instead of in, as seen here. A patient I saw this last week had been working for twenty-five years in order to avoid this problem by just drinking until he had a beautiful beer gut to call his own. Or so we thought.

He came in with just some fractured ribs. Three days later he had gone into kidney failure and had a potassium of 6.9 at the highest, normal being 4.8. He had EKG changes and depressed mental status, shortness of breath. He got dialysis and an endotracheal tube. He felt better.

In the midst of all that running around and worrying that this large man on a small bed was going to crash and die, I never thought twice about his body habitus; facial and central obesity is nothing new in Wisconsin.

It was only when his parents arrived a few days later and said, 'we're still trying to figure out why he gained 90 pounds last year'. Last year? He grew that much in a year?

Ah, the medicine differential. So long, so complicated, so fundamentally useless. I did a longer interview, and eventually came up with a variant of Cushing's disease, or pseudocushing's disease; atypical rheumatoid arthritis, atypical sarcoidosis, perhaps histoplasmosis, even intestinal angioedema from his ACEI--all this in the setting of a CT scan of his abdomen with no free fluid and a normal cardiac echo, as the most common reasons for weight gain are fluid related (ascites, heart failure). I even talked the team into a serum cortisol and some enzymes. Nothing found.

He had a history of boxing, was actually 49-4; perhaps a late lesion of the medial hypothalamus? He had been suffering from night sweats for thirty years--autoimmune disease? Cancer?

On a surgery service, he was treated for his ribs and went home.

Reality 1, Ockham's Razor, 0.

The Abercrombie & Fitch ED

Apparently Abercrombie & Fitch has donated enough money to a hospital in Ohio to get their name on a new ED and trauma center, and people are upset about it--saying that A & C sexualizes teens and it is the wrong message to send to people. The American Family Children's Hospital is apparently more palateable, as is the Nationwide Children's hospital. Hasbro and Mattel have branches.

Everyone's mad about A & C, similar to the ads that Benetton ran a few years ago, saying they are inappropriate. Interesting to juxtapose A & C with a new report that some 25% of teenage girls age 14 to 19 has one of 4 common STDs: HPV, Chlamydia, HSV, or Trichomonas. Any connection there? I leave it up to the reader.

The more troubling point is the number of EDs and Hospitals in the article that have turned to corporate funding. These aren't sports stadiums we're talking about; these are public resources. What does it say about us that the only way to fund a new ED is to turn to a clothing company? Especially given that patients are mandated initial stabilization by EMTALA, generated by the US Congress (yay!) Aren't we more worried that we depend on nekkid teenage models to pay for care?

Has anyone figured out how A & C sells actual clothes?

The Dark Side of Those Souvenier Mugs

You know those mugs people buy from tourist locations with etched scenes of the St. Louis arch, or the Statue of Liberty? Those are etched with hydrofluoric acid, which is my new favorite type of burn. It's perfect for an ER doc--bad and treatable, so it combines toxicology with trauma.

The below is a picture of an HFA burn, which doesn't present as pictured initially. Just like pain out of proportion with exam is a marker for mesenteric ischemia, pain out of proportion with burn is a marker for HFA burns. Why? The fluoride ions diffuse through the skin easily and proceed to precipitate out with calcium and magnesium ions, destroying deep tissue; the consumption is so marked that patients can present with hypocalcemia and hypomagnesemia.

Treatment is to give the acid what it wants; calcium gluconate to the skin, which attracts the fluoride ions and causes a precipitate. That's the white crust seen above--vigorous application of calcium gluconate jelly every hour created a calcium salt on the skin. It also was replaced intravenously and intraarterially in the above case.

Medicine is 'fun' (since I can't use fun without quotes when talking about someone getting their hand burned off) when you have recognizable symptom complex with a clear antidote.

Of course, I haven't actually seen such a patient. My only hope is to file the knowledge away and hope it is still recall-able when I do see it.

Statins Updated

A poster posited a link between Parkinson's Disease (PD) and Statin use, which led me to an article in Movement Disorders, 2006 (PubMed ID 17177184) that points out, in a retrospective study, a strong link between low LDL and Parkinson's incidence. The lower the LDL, the more people had PD: up to 3 times as often with an LDL below 93.

However, that same article seemed to find a 'neuroprotective' effect for statins. The poster obviously knew more biochemistry than me, so I'm not incredulous, that's just what I found in an admittedly quick search. Updated articles are welcome. It certainly did confirm a link between low LDL and Parkinson's, from which I can infer that LDL is perhaps not entirely deserving of the pejorative 'bad' cholesterol label.

A Google search on statins, however, on the broader issue of Number Needed to Treat analysis, showed very high NNTs, like 33 here, based on a 2003 Lancet article. I'm not sure how reliable that is. However, with an NNT of 33 in people with diabetes, I suppose there is good reason to question statin use given the lack of mortality benefit, and given the serious side-effects; I'm not sure about PD, but pancreatitis and rhabdomyolysis are no picnic.

Just don't ask what the NNT is for epinephrine in out-of-hospital resuscitation. The evidence for a lot of our critical situation algorithms seems a bit thin from podcasts I listen to. Just a tad bit hard to study.

The Cholesterol Controversy, or Are We Getting Fleeced by Statins?

5 billion a year, according to this wellness site that I found with a Google search, is how much the big drug companies are fleecing the public for. A lot of this flap came from the 'failed' Vytorin study, which is unpublished but findable in the Medical Letter here, and in a statement from the American College of Cardiology here.

The study was a randomized trial of people with Familial Hypercholesterolemia and showed no difference--actually, Vytorin was less effective than simvastatin--in slowing the growth of plaque. Forbes said their stock tanked. The wellness site above points to it as evidence that lowering cholesterol is a farce (and, of course, we should buy his book).

The Health Beat blog, which I like but which appears to have a bias against pharma, takes on the topic here. For a bit, I felt betrayed. Here I had been talking to people about lowering their LDL and treating cholesterol for weeks, and the dogma is that statins as a class are being used more and more, not less.

We've been looking at pictures like those at right for years of medical school, learning how to treat it with drugs. Don't they work? Well, actually, yes. Let's talk about endpoints. There is a big study in the Lancet in 2008 (PubMed ID 18191683 at pubmed.gov) that was a meta-analysis of 18,686 diabetics which supported a reduction of 1/3 in major vascular events.

A 2006 study in the Archives of Internal Medicine (PubMed ID 17130382) showed a reduction in major vascular events with NO reduction in all-cause mortality. There was, of note, a 14% reduction in the incidence of stroke.

Critics, including Health Beat, argue that lowering LDL numbers do not affect all-cause mortality and therefore are not useful as there is no quantifiable evidence that quality of life goes up, and there are side effects to statins. True. Also, the Lancet article in particular is a meta-analysis of industry-funded studies, which it admits.

Still, large meta-analyses are about as trustworthy as evidence-based medicine gets, and many drug studies are industry funded.

Are statins a fraud? Just money? A plot by Big Pharma to fleece us of billions?

Of course Big Pharma wants to make money, and tons of it. It is the fundamental mission of private companies to make lots of money and they should. No one should have any illusions about that. This perhaps goes towards why we should have a public health care system. But I digress. The question is if people were fleeced, should ask for their money back, were betrayed, and so on. The wellness sites and others point out that lowering cholesterol naturally with diet and exercise is a better way to do it and statins are a rip-off.

Guess what? We tell our patients that. We say, you should lose weight, eat right, and exercise. A lot. Now. And how many do? In six weeks of primary care, I saw TWO people who had done that. They were healthy, happy, had great numbers and a very high quality of life. We encouraged them, held them up as examples. TWO of them.

So should we avoid treating with statins? If I have a person who, for whatever reason (perhaps because they're a tad lazy) can't lose weight, watch their saturated fat intake, or exercise, should I tell them to just go away? Umm...no. Should I avoid giving an elderly, male, smoking, diabetic a drug that might reduce his chances of having a stroke because he SHOULD quit, eat greens, and run a marathon? No. I'll tell him that every visit. But guess what? He just might not listen.

We should accurately represent what statins do: they make a noticeable difference in the risk of a cardiovascular event, but it is mild. It's not a miracle cure. You should stop if you get muscle aches and so on.

But call them a con and a fleece? Western medicine has said all along that patients should eat right, exercise a lot, not smoke, lower their stress level, and so on. It's easy to jump on the statin 'push' and say doctors and the medical establishment are just in it for the cash, because it absolves all those sedentary junk-food eating patients of any responsibility for their terrible disease burden. As an added side bonus, it often helps sell diet books and alternative medicine, which as far as I know, doesn't come with a money-back guarantee, either. Far from it.

OF COURSE Big Pharma wants to make money. Most doctors (I admit, not all) want to help patients. And we figure that even those people who choose not to modify their lifestyle deserve some recourse to try and prevent badness. Crazy us.

To close the circle, let's go back to the Vytorin study. The drug failed to beat simvastatin with regards to thickness of plaque in people with FH, a rare genetic disorder. So, the endpoint doesn't matter (mortality, heart attacks, and strokes matter) and the population is not applicable to every patient. Is it disappointing? Sure. Does it mean statins don't do anything? No. Patients and doctors shouldn't rely on them to get them out of the work of modifying behavior.

There is no quick fix.

Yay! Accepted!

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