Sunday, December 16, 2007
Tower Apartments
We just bought a new camera and I thought I'd try to get a picture of the tower behind the building, which is lit up for the holidays.
Friday, December 14, 2007
Sicko
After months of intending to see the movie, Diana and I finally rented it at the movie store. Like other Michael Moore films, it is entirely anectodal, too emotional to allow the viewer to actually consider the issues (without extreme amounts of guilt, anyway), and utterly aggravating. Still, you should see it.
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
Sunday, November 25, 2007
Code Blue
Last week I participated in my first code. First a word on codes in the hospital.
Each night my team is on call, we carry code pagers, which as the name suggests, only go off when someone is coding. A code is called when a patient stops breathing, or either doesn't have a pulse or has a life-threatening arryhthmia. When the code pager goes off, there are a series of distinctive beeps, and then the operator says what kind of code it is, and where in the hospital it is happening. When we are on call overnight, our team is responsible for any code on the wards or in the ICU, which means my senior resident (who is a second year resident) is responsible for running the code. Every one on the team is supposed to have a designated role which ideally has been discussed before the pager goes off. Obviously, code pages are urgent, and when the pagers sounds, everyone goes running.
It was about 4:45 when I was awoken from sleep by the code pager. I took one second to make sure I wasn't hallucinating, and then put on my shoes as fast as I could, grabbed my scrub top, and took off out of the call rooms running toward the ICU. Unfortunately, the medical student call rooms are across the hospital from there, and after a rapid trip up the stairs, I found the ICU (running up stairs in Queen Anne definitely paid off).
It wasn't hard to find the code. The patient's room was overflowing with nurses, respiratory therapists, and numerous other people. I caught the eye of my senior resident right away, and he told me to put gloves on and break the nurse who was doing chest compressions. He told me to do them like her, but faster.
Before this, I had only done chest compressions on mannequins in CPR class. You hear that it is hard, but it doesn't really sink in until you have to do it. As I did compressions, I had no idea what was going on with the patient, nor had I ever seen him before. I focused on what I was doing and kept my ears open for further instructions. It was chaos around me. Hovering over everyone was my senior resident and a cardiology resident, managing the chaos, trying to determine why the patient is coding, and what algorithm they should be following to correct it.
Fortunately, the residents did figure it out, the patient was given some medications (this is another story), and he soon had a pulse again. I no longer had to do compressions, which was good because I was exhausted. From start to finish, the code took about 25 minutes (I did compressions for only a couple minutes) and as far as I know, the patient stabilized and recovered.
It was my first code, and though it ended well, it is a traumatic, even brutal, experience for the patient. It's hard to convey the chaos of the code, with the alarming sounds of the monitors, the resident giving orders, the nurses giving meds, the anesthesiologist having a hard time intubating the patient, the surgery resident seemingly stabbing blindly into the patient's groin with a giant needle, and the patient's unconscious body absorbing chest compressions and these other insults. Fortunately for everyone, this code ended well. It's frightening to think that in a couple years, I'll be a resident in the hospital overnight, responsible for running a code like that one. It's exciting but intimidating to realize how much we're expected to learn in a short time.
Each night my team is on call, we carry code pagers, which as the name suggests, only go off when someone is coding. A code is called when a patient stops breathing, or either doesn't have a pulse or has a life-threatening arryhthmia. When the code pager goes off, there are a series of distinctive beeps, and then the operator says what kind of code it is, and where in the hospital it is happening. When we are on call overnight, our team is responsible for any code on the wards or in the ICU, which means my senior resident (who is a second year resident) is responsible for running the code. Every one on the team is supposed to have a designated role which ideally has been discussed before the pager goes off. Obviously, code pages are urgent, and when the pagers sounds, everyone goes running.
It was about 4:45 when I was awoken from sleep by the code pager. I took one second to make sure I wasn't hallucinating, and then put on my shoes as fast as I could, grabbed my scrub top, and took off out of the call rooms running toward the ICU. Unfortunately, the medical student call rooms are across the hospital from there, and after a rapid trip up the stairs, I found the ICU (running up stairs in Queen Anne definitely paid off).
It wasn't hard to find the code. The patient's room was overflowing with nurses, respiratory therapists, and numerous other people. I caught the eye of my senior resident right away, and he told me to put gloves on and break the nurse who was doing chest compressions. He told me to do them like her, but faster.
Before this, I had only done chest compressions on mannequins in CPR class. You hear that it is hard, but it doesn't really sink in until you have to do it. As I did compressions, I had no idea what was going on with the patient, nor had I ever seen him before. I focused on what I was doing and kept my ears open for further instructions. It was chaos around me. Hovering over everyone was my senior resident and a cardiology resident, managing the chaos, trying to determine why the patient is coding, and what algorithm they should be following to correct it.
Fortunately, the residents did figure it out, the patient was given some medications (this is another story), and he soon had a pulse again. I no longer had to do compressions, which was good because I was exhausted. From start to finish, the code took about 25 minutes (I did compressions for only a couple minutes) and as far as I know, the patient stabilized and recovered.
It was my first code, and though it ended well, it is a traumatic, even brutal, experience for the patient. It's hard to convey the chaos of the code, with the alarming sounds of the monitors, the resident giving orders, the nurses giving meds, the anesthesiologist having a hard time intubating the patient, the surgery resident seemingly stabbing blindly into the patient's groin with a giant needle, and the patient's unconscious body absorbing chest compressions and these other insults. Fortunately for everyone, this code ended well. It's frightening to think that in a couple years, I'll be a resident in the hospital overnight, responsible for running a code like that one. It's exciting but intimidating to realize how much we're expected to learn in a short time.
Ski season!
There's been some snow in the mountains and some of the highest mountain passes haven't closed yet for the winter, so my friend David and I thought we'd check out the early season conditions. Shin deep powder and a blue bird day. Tough to beat for November.
I've figure out how to add a slide show of pictures, so you can view them here or click on them to be taken to another website.
I've figure out how to add a slide show of pictures, so you can view them here or click on them to be taken to another website.
Monday, November 12, 2007
Life at the VA
These days I'm at the VA hospital in Seattle, having moved on from Harborview (I'm still on my Internal Medicine rotation). It's a totally different patient population, but the vets are friendly, tend to see you as their doctor even though you're a student, and they usually have chronic diseases like emphysema or heart failure. So far I have only had male patients at the VA and they are generally over 65. My team has not had any patients who are returning from Iraq or Afghanistan, and I think this is because there is a large military hospital south of Seattle by Fort Lewis.
In my experience so far, the patients at the VA tend to be a little sicker than at Harborview, but this is probably because they are usually older and because unlike at Harborview, our team at the VA has patients in the ICU.
This week two of the patients on our team died. I was with one of the interns to pronounce the patient dead. This requires making sure that the person's pupils are not reactive to light, and then listening for heart and lungs sounds. Both of the patient's on our service had severe liver disease, and they and their families had agreed that they receive only "comfort care". In addition to being DNR (meaning that if they stop breathing or their heart stops, we will not perform CPR or go to extreme measures to prolong their life), they are taken off all monitoring and are made comfortable assuming by treating any pain that they may be in. These people are usually extremely sick, with nothing that can be done to cure them or restore some quality of life. Making them "comfort care" allows them to die naturally, without the trauma of a code (emergent resusitation), which usually breaks ribs, can puncture lungs, can be tragic for the family to see. Moreover, codes usually either don't revive the patient, or lead to a proctracted period of respiratory support in the ICU, with the family having to decide what to do.
When I was on call almost two weeks ago, I admitted a patient who had renal failure which was caused by urinary retention due to benign prostatic hypertrophy (BPH - watch the evening news and you'll see ten commercials for BPH drugs). He also had blood in his urine and was severely anemic. He was stable when he was admitted, and basically all we had to do for him was drain the 3L (that is a massive amount, by the way) of urine out of his bladder with a catheter to relieve the pressure on his kidneys and then watch his renal function hoping that the damage hadn't been permanent. One of the great advantages of being a medical student is that I have lots of time to talk to the patients, and I had gotten to know this gentleman very well. Once I got over the fact that he was originally from Canada, I learned that he had been quite an athlete and outdoorsman, and had done extensive mountaineering and hunting in Alaska. He told me he decided at a young age that he would live for love and adventure and had been successful on both accounts. He had recently been working as a gardener (he is 74), but had experienced gradually worsening fatigue in the past six months or so. As you might infer, I took quite a liking to this gentleman.
That night while I was reading up on renal failure and hematuria, his urine became more and bloody until the bag which his collected it looked like it was filled with blood. He continued to feel fine, but when his labs came back in the morning, he had become dangerously anemic (for you medical types, his Hct dropped from 25 to 15) and needed to be transferred to the ICU. It was a little harrying to discuss the new plan with my senior resident, which now focused on immediate planning should he go into shock. This entailed placing two large-bore IVs, one in each arm, calling the blood bank and writing his orders for ICU transfer. This was my first patient whose condition I watched rapidly deteriorate and it affected me more than I would have anticipated. Meanwhile, the patient himself was nonplussed and without new symptoms. I think he realized that I was more alarmed than he, and was even a little amused by this.
We transfused several units of blood into him, and several days later his urine cleared. His kidney function has improved, but not to normal and now he is waiting to be seen by the urologists to determine the cause of his bleeding.
Experiences like this are one reason I would not want to be an ER physician. It's a special experience to take care of patients throughout their time in the hospital, to see them every morning, ask them how their doing, check their labs every day and modify the plan. Sometimes when you meet them, you can't make a diagnosis, but over the course of hours or days, the pieces start to fall into place. Sometimes the patient gets better, sometimes you can only stabilize them, and sometimes they are found to have a chronic disease (like renal failure) or worse, a terminal diagnosis. No matter what, it's a unique and privileged experience to be with a patient as they go through what is often a life-changing experience.
In my experience so far, the patients at the VA tend to be a little sicker than at Harborview, but this is probably because they are usually older and because unlike at Harborview, our team at the VA has patients in the ICU.
This week two of the patients on our team died. I was with one of the interns to pronounce the patient dead. This requires making sure that the person's pupils are not reactive to light, and then listening for heart and lungs sounds. Both of the patient's on our service had severe liver disease, and they and their families had agreed that they receive only "comfort care". In addition to being DNR (meaning that if they stop breathing or their heart stops, we will not perform CPR or go to extreme measures to prolong their life), they are taken off all monitoring and are made comfortable assuming by treating any pain that they may be in. These people are usually extremely sick, with nothing that can be done to cure them or restore some quality of life. Making them "comfort care" allows them to die naturally, without the trauma of a code (emergent resusitation), which usually breaks ribs, can puncture lungs, can be tragic for the family to see. Moreover, codes usually either don't revive the patient, or lead to a proctracted period of respiratory support in the ICU, with the family having to decide what to do.
When I was on call almost two weeks ago, I admitted a patient who had renal failure which was caused by urinary retention due to benign prostatic hypertrophy (BPH - watch the evening news and you'll see ten commercials for BPH drugs). He also had blood in his urine and was severely anemic. He was stable when he was admitted, and basically all we had to do for him was drain the 3L (that is a massive amount, by the way) of urine out of his bladder with a catheter to relieve the pressure on his kidneys and then watch his renal function hoping that the damage hadn't been permanent. One of the great advantages of being a medical student is that I have lots of time to talk to the patients, and I had gotten to know this gentleman very well. Once I got over the fact that he was originally from Canada, I learned that he had been quite an athlete and outdoorsman, and had done extensive mountaineering and hunting in Alaska. He told me he decided at a young age that he would live for love and adventure and had been successful on both accounts. He had recently been working as a gardener (he is 74), but had experienced gradually worsening fatigue in the past six months or so. As you might infer, I took quite a liking to this gentleman.
That night while I was reading up on renal failure and hematuria, his urine became more and bloody until the bag which his collected it looked like it was filled with blood. He continued to feel fine, but when his labs came back in the morning, he had become dangerously anemic (for you medical types, his Hct dropped from 25 to 15) and needed to be transferred to the ICU. It was a little harrying to discuss the new plan with my senior resident, which now focused on immediate planning should he go into shock. This entailed placing two large-bore IVs, one in each arm, calling the blood bank and writing his orders for ICU transfer. This was my first patient whose condition I watched rapidly deteriorate and it affected me more than I would have anticipated. Meanwhile, the patient himself was nonplussed and without new symptoms. I think he realized that I was more alarmed than he, and was even a little amused by this.
We transfused several units of blood into him, and several days later his urine cleared. His kidney function has improved, but not to normal and now he is waiting to be seen by the urologists to determine the cause of his bleeding.
Experiences like this are one reason I would not want to be an ER physician. It's a special experience to take care of patients throughout their time in the hospital, to see them every morning, ask them how their doing, check their labs every day and modify the plan. Sometimes when you meet them, you can't make a diagnosis, but over the course of hours or days, the pieces start to fall into place. Sometimes the patient gets better, sometimes you can only stabilize them, and sometimes they are found to have a chronic disease (like renal failure) or worse, a terminal diagnosis. No matter what, it's a unique and privileged experience to be with a patient as they go through what is often a life-changing experience.
Thriller
This post is a shout-out to Diana and her crazy ways. On October 27th, about 100 people in Seattle, including Diana and her friend Allison, performed a choreographed dance to the Michael Jackson classic, "Thriller". They joined a couple thousand other people around the world who did the dance at the same time in an attempt to break the world record for most people dancing at the same time. Apparently, 200,000 Canadian children danced the hokey-pokey at the same time a couple years ago, so they didn't break the record. They held practices once a week for two months to learn the over-six minute dance and then they performed at a couple locations in Seattle, including the Seattle YMCA and Westlake center. Oh yeah, and if you're not familiar with Thriller, the dancers are supposed to all be zombies.
Here's a link to a video of the dance at Westlake Center.
http://youtube.com/watch?v=NN-o7a93i0M
Here's a link to a video of the dance at Westlake Center.
http://youtube.com/watch?v=NN-o7a93i0M
Saturday, October 27, 2007
My people
(For reference, "Medicine" refers to internal medicine as a specialty; "medicine" to the field in general. Hopefully that will prevent some confusion.)
I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.
For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.
Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.
I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.
The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.
Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.
I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.
For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.
Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.
I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.
The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.
Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.
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