Basic science and clinical medicine

So things are a bit different now that I am no longer full-time doing clinical work. I definitely miss it, but doing basic nuts and bolts biology research is so fulfilling and such a creative endeavor.

On the outside the most salient change is my attire. Gone is the tie and button down shirt. For me in the lab it's jeans (you may not believe me but I almost wrote genes--Freudian slip) every day.

On the inside though there has been a big change in how I think about things. The functional unit of time in inpatient medicine, the majority of our training as fellows, is a day, but sometimes can be an hour or even a minute. What do I mean by functional unit? I mean you wouldn't measure the grand canyon with a ruler.

The functional unit in basic science research, I am finding out, is the month. I try to set weekly and monthly goals. One needs incredible discipline to stay focused and on track when the timescale is a month...

It's been a while

So it's been a while since I've posted...I got burnt out from blogging (very short career!) and it took 2 years to recover. I realized that I felt like I had to blog. But now I realize I don't! Things have changed a little bit -- I am now spending most of my time in the lab, which is a whole lot of fun. If anyone can tell me how to get rid of the annoying spam comments before I saw the light and set up verification, I'd appreciate it.

Carts passing in the night

I got called in last night to do an emergency echocardiogram. On the way down to the ER with echo machine, i got on the elevator with a gentleman from the food services department with a cart of late night snacks for patients -- as in one AM late night.

i struck up a conversation.

"We're both pushing carts at this hour...I didn't realize turkey sandwiches were in such demand this late at night."

"Yeah man, you wouldn't believe what people order at this hour... cottage cheese and pears... Trouble is, the nurses put in the order late, and half the time, the patient's asleep by the time they get their food," came the reply.

"Sounds like you and I are in the same line of work, this late at night," I said.

"No man, you guys are miracle workers man... The stuff you do is amazing."

"That's not quite true. People think we're always one step ahead, but actually, we're usually two steps behind... Just like you and that cottage cheese."

That resonated, and he chuckled knowingly. As the elevator door opened and I started pushing at the echo machine, he said, "treating but not curing, huh doc?"

The doors closed and I was left with that thought. We can cure some stuff, but in cardiology, we mostly treat and patients are left on medications for life. Wouldn't it be nice if we could get a jump on things like coronary artery disease and keep it from happening in the first place?

What Doctors Do

My wife and I just came back from visiting my brother- and sister-in-law (both physicians) and their children. It was time to leave, and we explained to their daughter (not yet four), that we had to go because we had to work tomorrow.

My sister-in-law asked her, "What do Kannan and Priscilla do? They do the same thing as Mommy and Daddy... remember we visited Daddy at work the other day? What does he do?" she prompted helpfully.

Without missing a beat, my niece said, "Sits on the computer!"

My three year-old niece already has a more realistic grasp of what a doctor's day is like then I had until my third year of medical school. Really. When I was a medical student, I was sure that most of the time doctors spent in hospitals was face-to-face with patients. I was very surprised to find this not to be true: most of the time a doctor spends in the hospital is spent with other doctors, nurses, charts, or indeed computers! In modern medicine, talk is literally cheap-- docs don't get paid much to do it. Rather docs get paid to do stuff to people. But wait, to get paid, you have to prove you did something. And to do that, you have to document. Documentation is also a good idea from a legal perspective. And it goes without saying that good documentation is good medicine -- patients benefit from having their story and their doctors ideas about their story clearly laid out in the record. But all of this means a lot of computer time.

I came across some interesting thoughts on the burden of documenting in a book entitled "The Young Doctor Thinks Out Loud." In it, the author Julian Price laments:

"...Right here we have one of the great nightmares of the intern's work--so-called 'paper-work.' I think that it is a conservative estimate to say that from ten to twenty-five per cent of the average inter's time on duty is spent in writing, depending upon the hospital and upon the conscientiousness of the young doctor. There is no more monotonous task that the writing of "histories and physicals." How often one feels that he is really not a physician, but just a stenographer..."

This was published in 1931. That's 75 years ago!

I guess things really haven't changed that much; we've just traded writer's cramp for carpal tunnel syndrome.

The mysterious land of OSH

Those of you who have looked at medical records, especially before the era of electronic "cut and paste" may be befuddled by the alphabet soup of acronyms that doctors use to communicate with one another -- that is, if you are not absolutely stupefied by the illegible handwriting first. A typical admission to a cardiology team might look like:

63 yo M c PMHx of DM, HTN, HL, +tob p/w CP x 20 mins c exertion, relieved c NTG.

In English, that's: A 63 year-old man with a past medical history of diabetes, high blood pressure, high cholesterol, and a smoking history presents with chest pain for twenty minutes with exertion, relieved by nitroglycerin tablets.

My favorite of these acronyms is OSH. This stands for "OutSide Hospital." No, not as in referring to something that happened oustide of the hospital, as one might logically infer, but as in another hospital that is outside the one you (the listener or reader) is currently in. Isn't that odd? A patient might have a cardiologist at OSH, as if the most important thing about the cardiologist is that he is not from "our hospital." A patient might have mitral regurgitation, but, we are quick to add, that is from an echo from an OSH.

This is not peculiar to Northwestern, I know. All my doctor friends at OSH use OSH too. What if you worked at Ohio State Hospital? OSH would get confusing for sure. I can just imagine rounds: "so wait, the echo was at our OSH or their OSH? gosh..."

What if in the news, we were to read "OS prime minister assassinated?" or "OS baseball team wins the World Series!!!" What if fourth graders' geography lessons in Chicago consisted of a map that had a dot labeled Chicago, surrounded by a big, fuzzy label that said OUTSIDE? (Well, with the way gradeschoolers test on things these days, maybe this is how it's actually done...)

If we didn't enrich our lives with actually knowing something about somewhere else beside where we are, wouldn't we be poorer for it?

You might think the OSH phenomenon means doctors are snobs, and devalue the work of other doctors. I don't think that's exactly right. What I think it reflects is what experienced doctors know, and what I am beginning to learn: in medical tests and diagnoses, to paraphrase Churchill, there are nuances on top of subtleties inside variations. A written report from OSH, though OSH be the Mayo Clinic, can ony carry so much weight with it. The report can't tell you the worried look on the face of the radiologist when he writes "must consider volvulus." The report can't tell you the severity of mitral regurgitation the way looking at it with your own eyes will. The report can't convey any of our colleagues' intuitions that we rely on to navigate our patients through illness to health.

So when we say OSH, I think we mean to say OSMCZ: outside my comfort zone. I think we are really saying that a piece of data is out of the context we are used to, and therefore we aren't really as sure what to do with it. But since OSMCZ is all but impossible to pronounce, outside (there it is again!) perhaps Eastern Europe, I will CPM & cont c OSH (continue present management, and continue with 'outside hospital').

My blog persona and patient confidentiality

Well, it's been about two weeks since I started blogging. I'm still blogging. I guess that means I have the bug, and I am hopefully infected for the long term, rather than transiently.

Thank you to everyone so far who has been reading my blog and leaving comments! I am humbled by the notion that some people actually find what I have to say worth reading. It's not great literature--but hey, one of the reasons why I started to blog is that I figured it would improve my writing.

One issue I am struggling with is that I want to share stories about things that happen in the hospital, but I want to respect patient confidentiality even more. Because I am completely open about who I am in the real world,meeting both of these goals seems near impossible.

I can't really write about specific patient encounters as they happen, because that would make patients readily identifiable. For example, how many patients really come through the Northwestern emergency room with, say, a long QT-interval resulting in Torsade de Pointes (a specific, whimsically named type of arrhythmia)? I can tell you not many. (By the way, if you have, I assure you it is complete coincidence!)

If such a patient did come through the ER, and I blogged about it that day, he or she would be readily identifiable. Maybe if I changed things around enough, the only person who would know would be the patient himself. But I still think that person would feel that their confidentiality was breached-- if not by the letter of the law, then certainly by the spirit. If a patient of mine ever figured out that I was blogging specifically about him or her, I would feel terrible. I strongly feel that a patient's medical story is their business alone, and it is up to them to choose whom to share it with.

But at the same time, I think specific encounters with real people breathe life into stories. These are stories that involve some of the most fundamental experiences a person can have, experiences that transcend culture, experiences that transcend time itself. A family deciding to let a loved one go is something that can be appreciated here or in China. It can be appreciated now, a thousand years ago, or a thousand years from now. I really think these stories with patients are worth writing.

Trouble is, I haven't figured out how. Any suggestions?

Opting out of the AMA database

I found this post by California Medicine Man to be fascinating. It is regarding how the American Medical Association makes physicians' prescribing information available to pharaceutical representatives, and how physicians can opt-out of this, er... sort of.

Clopidogrel (Plavix) generic in the future?

I just came across this article
in the New York Times, but I guess it is from a few days ago. It is regarding a generic version of clopidogrel, or Plavix. I had no idea there was a patent dispute involving the drug, but I guess there is. Sounds like an alternative manufacturer shipped in a whole bunch of the drug, but isn't allowed to ship in any more, and now there is an extra 3 months' supply on the U.S. market!

All I know is that Plavix = Big Business. Actually, BIG BUSINESS. Anyone who leaves the hospital with a stent these days is put on Plavix. For a month if it is a "bare metal stent," and for at least three to six months if it is a "drug-coated" stent. And, there is some thought that maybe it's better to have people on Plavix for a year after they get a drug-coated stent.

New Rotation

It's the first of the month...and that means all across the country, fellows and residents like me are going through the ritual known as "change of service." If you have been at a hospital during change of service, you know what a chaotic time it can be.

I just finished up a great month in the electrophysiology lab at Evanston Hospital. That's where Dr. Wes got me started on blogging. Hopefully I keep the bug, and keep the blog going!

Anyway, change of service is exciting, because you wrap up things you have been doing, and go on to a new experience. The new thing for me is being the fellow in the CCU at Northwestern Memorial Hospital. This is a rigorous job, and demanding of time and mental faculties, but to me it is the best rotation we go through as fellows because we see the sickest patients-- and therefore can make the most difference and learn the most. Change of service can be disorienting to patients, their families, and the doctors. It can even be frustrating. But in the end I think everyone benefits because everyone gets a fresh perspective.

On call

This is a short post because it has been a long day in the cardiac intensive care unit at Northwestern. I am on call tonight -- this isn't the on call of TV where the doctor is in the hospital, running around, saving lives. Been there, done that (except for the saving lives bit -- believe it or not, I feel that happens rarely).

Nope. Now I take call from home, the middleman between the resident and intern who stay, as we say, "in house" all night, and the attending, who stays at home except in the direst of circumstances. I am the one who goes in if I am needed.

I used to be scared of this brand of call, especially because I have to be the one who decides if a person who is having a heart attack has to get an angioplasty in the middle of the night or not. But now I'm not (as much) because I've figured out that 90% of the fear was uncertainty, and 90% of the uncertainty can be removed by "eyeballing" the patient. There is no room for inertia in medicine, I've learned. The old clinical aphorism "if you think you should do something, you probably should" definitely holds true. In medicine as well as life.

They told me that the biggest thing to learn in med school is to learn how to eyeball a patient -- that is at one glance be able to distinguish between those who are very sick and demand immediate attention and those who are less urgently ill. I definitely think this is sound advice. In quest of a person's eyeball sense, or "gestalt", one will often hear docs say, "is this person sick or not sick?"

So if you hear that, please don't think that the doc is silly for asking if a patient in the hospital is sick.

This simple act of eyeballing can change everything. If a picture is worth a thousand words, then a good "eyeball" is worth a million.

So this is for all the docs who are on call (real call, in house) tonight-- keep your eyes peeled, do what you think you have to do, and may you be rewarded with coffee, bagels, and a fast-rounding attending in the morning!

A little internet history

Where did the internet come from?

On the NewMediaMedicine blog, there is a really interesting 30 minute video on the development of the ARPAnet, the precursor to our modern internet. These guys who put the thing together talk about really what can be described as the philosophy of the internet, and speculate about the future of computers. Almost everything they said in 1972 has turned out to be right on the money, and sounds surprisingly like how people in computers speak today!

Also entertaining are the 70s clothes and graphics.

Angioplasty rates ballooning?

This post starts out with some old news (from a blog perspective) -- news that is a week old.

At an AM conference at Evanston Hospital, the hospital at which I am currently rotating (by the way, thanks so much Dr. Wes for linking to my website and getting me started on a blogging addiction!), a New York Times article regarding off-the-charts rates of angioplasty in Elyira, OH was brought to my attention.

The numbers speak for themselves.


The rate of angioplasty in Elyria is almost double the next closest rate (I can see the people in Lafayette, LA getting nervous...) .

This sounds off the charts. But by another measure, it is half-way to Mars.

The distribution of angioplasty rates above follows the classic bell-shaped curve (in this case the bell is depicted as lying on it's side). Bell-shaped curves are found all over nature, and describe how randomly distributed variables tend to cluster around a mean (or average). Another important property of bell curves is the standard deviation, or a how "wide" the bell is.

A low standard deviation means most of the numbers fall close to the mean number, a high standard deviation means more of a spread. In fact, for an ideal bell-shaped curve, about 68% of the values fall within one standard deviation of the mean. About 95% fall within two. 99.7% fall within three. 999,999 out of a million fall within five. All but one in 384 billion fall within seven.

I just had to get in touch with my inner geek and crunch some numbers in Excel. All I had to work with was the above graph. I found that the mean rate of angioplasties in the country for Medicare enrollees is about 11/1000. I found that the standard deviation is about 3.9 angioplasties /1000 Medicare enrollees. This means that the catheterization rate in Elyria, Ohio is about (42-11)/3.9, or about 7.9 standard deviations above the mean!

This is really off the charts, and cannot be explained by chance.

Now it's interesting that in Elyria there is one dominant cardiology group. One explanation offered in the article is that angioplasty rates are so high because many patients that might get bypass surgery at other hospitals get angioplasties in Elyria. If that's true, then the bypass rate should be rock bottom, right? Right?

Someone also tipped me off to the Dartmouth Health Atlas, a free online database of loads of healthcare information. I queried the database for a graph of the different bypass rates of all the 306 hospital regions in the country in 2003. I got:

The red dot is Elyria, pretty much smack dab in the middle. There goes that argument.

Who knows what the inevitable Medicare investigation will show, but I think it will show fraud. What motivates this? Is it greed on the part of the doctors? Is it the fact that the doctors and the patients don't see the cost of their actions?

Is this something that is widespread? Or is it just a few bad apples that fall very very fall from the main trunk of the bell-shaped tree?

What got me to post on this was an email I got forwarded from a friend of a friend who has just finished Cardiology fellowship, and is about a month into his new job as a general cardiologist in private practice. I know this person to be an excellent physician and an all-around good person. The email addresses the "rules" he has learned so far in private practice. I will post a part of it:

"...Cath EVERYONE. 3 of my first 4 caths were normals on patients who had a negative MPI [editor's note: a type of stress test that is pretty good] within the previous week. My group appreciates this. Funny thing, so do the patients' primary care docs, and so do the patients! Insurance companies can be dealt with ..."

Now, in editorial fairness, at the end of the email, this person also says "...OK, so I'm exaggerating, but the rules are clearly different..."

But I am left with the distinct impression that over-testing may be a widespread thing in Cardiology, which disheartens me a bit. I'd be interested to hear other's thoughts.

On Destruction of Molecules and Men.

I had the privelege of attending Dr. Aaron Ciechanover's lecture yesterday at Northwestern University on his decades-long voyage of discovery regarding the ubiquitin system. For these endeavors, he won the Nobel Prize in Chemistry in 2004. His biography is a fascinating read.

What is the ubiquitin system? It is not one thing really. Rather, it is a family of proteins that Dr. Ciechanover estimates to comprise between 7-10% of the entire human genome. This makes it by far the largest family of proteins in the entire genome. These proteins work to specifically degrade other intracellular proteins, in order to end molecular signals within the cell, as well as to remove excess protein products. This, I discovered, is an incredibly important system of proteins that comprise an important set of targets for drug design.

This -- the removal of the old to make way for the new -- is good destruction.

What is bad destruction? Well, Dr. Ciechanover grew up in Haifa, Israel and has spent the majority of his professional career in that city at the Rappaport Family Institute for Research in the Medical Sciences at Technion - Israel Institute of Technology. For those of you who have been following the news over the past month in the Middle East, Haifa was the target of deadly rocket attacks from Hezbollah, in Lebanon. For that matter, Beirut, the capital of Lebanon, also suffered deadly civilian casualties as a result of Israeli Defense Force bombardment.

I don't care what your view is on the conflict between Israel and Hezbollah-- no matter where you fall, you definitely must lament the death of innocents on both sides.

This --the irrevocable rending of the fabric of human life -- is bad destruction.

The juxtaposition in Haifa of the discovery of the ubiquitin system (the good destruction by molecules of fellow molecules) and the rain of terrorist bombs (the bad destruction of men by fellow men) really brought home to me Sir Winston Churchill's quote:

"To build may have to be the slow and laborious task of years. To destroy can be the thoughtless act of a single day."

I think that this day of choice is dawning for humanity. Will we today thoughtlessly destroy the world? Or will we take up the slow laborious task of years? Are we poised today on the brink of a golden age of discovery? Or instead are we unleashing a dark period of decay?

There are those who want to make the world better. And there are those who literally want to unmake the world. I hope that the thoughtful prevail.

But right now, the score in Haifa is 1-1.

Internal Medicine Board Exams

I just took my Internal Medicine board exams, and now am sitting in the lobby of the silly testing center in Matteson, Illinois, waiting for my friend Raj to finish so we can sit in inbound rush hour traffic on 57 and the Dan Ryan (did I mention that it's under construction?) before downing a few well-deserved beers at Jake Melnick's.

The test I thought was fair. After a year of cardiology, I realized a lot of my Internal Medicine knowledge has atrophied. I'm pretty sure I knew enough to pass. The scores come put in November.

Out of all the standardized exams I've ever taken in my life (PSAT, SAT, MCAT, USMLE I, II, III, and now this) this is definitely the one I've studied the least compulsively for. I'm pretty sure it's a combination of 1. There's no reason to do anything more than pass 2. Mild test-taking burnout 3. Hubris 4. No one who did internal medicine at Northwestern has failed in the past few years.

Also, I figure, what possible bearing does memorization of the workup of glomerulonephritis have on my future career as an academic Cardiologist? Without any exaggeration, knowing how many licks it takes to get to the Tootsie center of a Tootsie pop is more germaine (in that it may allow for the more accurate estimation of the carbohydrate intake of my patients.)

So now with this test out of the way (hopefully), I can move on to other things, like Cardiology boards (2 years away), echo boards (if I decide to take them, also two years away), and the Internal medicine recertification exam (if all goes well, 3650 days away)!

Cardiovascular disease in the developing world

A fascinating article in the Lancet's most recent issue (many will not be able to access the full-text of the article unless they have access to medical journals). I first became aware of it through theheart.org It addresses treating cardiovascular disease in developing nations. Many of us are aware of the impact that HIV is having on developing nations. In some countries, it is literally wiping out an entire generation. Most of us, I think, are less aware of the impact cardiovascular disease (like heart attacks, heart failure, and strokes) has on developing nations. I certainly wasn't aware, and I'm a cardiology fellow!

Turns out that most of the global cardiovascular disease burden is in developing nations. This is not just a function of the fact that most people live in developing nations: apparently the number one killer in the developing world (with the exception of sub-Saharan Africa) is cardiovascular disease.

The idea behind this article is that there are cheap drugs that we know help prevent heart trouble. Aspirin. Statins (a class of cholesterol-lowering drugs that includes lovastatin, pravastatin, simvastatin, atorvastatin, rosuvastatin, and others). Ace-inhibitors (these definitely help people who have already had a heart attack--what is less clear is whether these help stave off heart attacks.) Beta-blockers (help people who have had heart attacks).

What is also known is that lowering blood pressure cuts down your risk of a heart attack.

So these investigators took a bunch of people in the developing world at risk of having a heart attack as predicted by the Framingham risk score (developed from a population of people in the 1950s and 1960s from Framingham, MA), gave them cheap generic medications, and compared them to a group of people who did not get medications. Then they waited and counted who had heart problems, and who didn't.

The results are very interesting. You can predict that the people who got treatment did better. What is fascinating, though, is how little money it cost to save lives. For just a dollar a day...

No, seriously.

For just a dollar a day (about $350 a year), treating people who have had a heart attack already will end up saving a year of life. This figure compares very favorably to the cost of treating HIV in the developing world.

And it beats the pants off the cost-effectiveness of therapies delivered in the West. By way of comparison, mammography costs something like $10,000-$20,000 for every year of life saved.

Woo Hoo!

the internet is a wonderful thing! I can't believe I got the email thing to work on my first try.

email test

This is a test of whether or not I have successfully configured posting from my treo. Not very interesting, I'm afraid.

My picture

This post is just so I can get my picture up on the profile. The picture was taken in Keystone, Colorado, during the American Heart Association basic science conference this year. How dorky, but actually it was a very cool experience!

Palm Medical Stuff

I have had a palm-based PDA ever since March of 1997 when my dad gave me a PalmPilot Pro (or something like that) that he did bought but did not use because it was too hard to pick up Grafitti. Then I got a Palm Vx for graduation from college. That was a really good device. I still see plenty of people using them around the hospital, actually. Then one day in the middle of my third year of medical school, my Palm stopped working. I then got a Sony Clie. That was pretty worthless because the screen was so sucky, but the good thing to it was that it was one of the first 320x320 resolution displays available.

Now I am on my Treo 650, and have had it since December, 2004. I love it. BUT, I still am working on upgrading it with stuff to make it more useful to me.

Recently, I have become enamored with the amount of free wisdom available on Project Gutenberg. There are currently 18,000 free titles available there. The problem is that no one really wants to sit in front of a computer screen and read Milton. Well, maybe the problem is that one doesn't want to read Milton in any form whatsoever, but that's not what I'm getting at.

I think it would be nice if there was a way for me to be able to read these things on my Treo. That way when I am on call or moonlighting, and have nothing to do, I can read. Reading philosophy or literature in the hospital is a challenging thing to do, because such endeavors require an amount of concentration that buzzing ICU alarms preclude, but it can be done.

So I am in the middle of setting up iSilo on my Palm, with the idea that I can convert Project Gutenberg plain text files into iSilo documents. We'll see how it goes...