Can a Man Handle Childbirth?

This is so great! A little long, so skip around. 3:15 is funny... 7 min too. Funny to see him sweating a writhing in pain.

http://www.youtube.com/watch?v=6AdFdmE9A84&feature=player_embedded#

Comparative Anatomy

Courtesy of my embryology professor...

and as he notes "women's thought frequency of sex diminishes to zero after marriage"

My favorite? The listening particle.

That Feeling of Powerlessness....

If you asked my a year ago, I probably would of never guessed that I would ever feel this affected by the reality of powerlessness that physicians face. I probably would have brushed it off, and thought that it was just physician's egos getting in the way of reality... physicians trying to play god and not accepting the limitations of science and humanity.

But I had my first dose of powerlessness yesterday. The feeling that I have no good advice, no plan, no alternatives, and that I couldn't help a patient get better. No matter HOW much they were willing to help themselves.

Yesterday my group participated in the simulated case review of a patient. Only this time we had a "real" patient (standardized patient actor) in the room with us. 10 students, 1 SP, and our professor. The case (based off a real case from 10 years ago), was a 20 year old female, presenting to the surgery clinic with blood in her stool for the past 6 months and increasing fatigue. No other signs or symptoms, no associated pain, no blood in vomitus, no history of fever, alcoholism, etc. So we did all the normal stuff, CBC, stool analysis, urinalysis, the eventually a Chest Xray, EKG, and onto a sigmoidoscopy and colonoscopy. Turns out she has familial adenomatous polyposis... a genetic condition in which part of the intestines (in this case the large intestine) gets covered with hundreds of little sac-like polyps. These polyps are essentially just tissue growths, and while many or most may be benign, some of the polyps will most certainly become cancerous over time. Treatment options are pretty much nil (no drugs, no removal of the polyps)... so we had to tell her that she could either... 1) opt to do nothing and hope she doesn't die... not exactly appealing. Or 2) opt for surgical removal of her entire colon, thus requiring that she use an ileostomy bag for the rest of her life (a "poop" bag that hangs outside the body, that you must empty instead of passing feces through the rectum). Clearly... neither of the options were good.

As a group we had to break the news to her through one person we selected as a moderator. Frankly, I wouldn't have wanted to be him. I don't know his background, but I'm guessing this was his first time breaking horrible news to a patient... and he had to do it in front of all of us and our professor. Truthfully, he did a damn good job. Or maybe it just seemed that way since I was so relieved that I didn't have to do it. But you could hear every one of our hearts thumping through our short white coats.

It was really surreal... imagining a 20 year old coming in because she was concerned about blood in her stool and a little fatigue. And now her life is different forever. My pulse raced as I thought about how I would feel if it were me.... and all the things that I would eventually have to deal with and think about. Would it be painful? A poop bag? Would it smell? Would it leak? Could I swim? Would I be stuck wearing bulky clothes to cover it up? I guess my future wouldn't include any spontaneous sexual encounters with some hot guy I barely know. Would I even want to have sex? Would anyone ever want to have sex with ME? With an ileostomy bag? And what about changing my diet? And going to the doctor regularly forever.

Everything changed for her in just one doctors visit. Which certainly begs the question.... what if she simply ignored the signs and never went to the doctor? Is there a chance that she wouldn't have developed any more complications? That she would have lived a long life blissfully ignorant of her condition? Perhaps. Most likely the cancerous cells would have invaded some other important organ and she would have died at an early age.... perhaps suddenly, perhaps painfully.

The ABC's of Cancer

I wrote this for a patient of mine a few years back when we were discussing cancer developing from cirrhosis of the liver. Certainly he didn't understand 95% of what was going on with him medically... he just put all his faith in the docs. He had really low levels of education.. and I wanted him to have something he could understand. Feel free to use it (or parts of it) if you like...

Note: Often in these things I use words that aren't technically correct.... like using the word "chemical" generically instead of molecule, protein, enzyme, etc. Or "bug" instead of virus. Some patients can't sort out molecule from protein, but if you say "chemical" they get a mental picture of what you're talking about. Trust me on this.

Here goes..

The trick with cancer is that it's well, tricky. Just because you have a tumor doesn't mean you have something bad. A tumor is just an overgrowth of regular tissue.... some cells in your body have gone nuts and can't turn themselves off from growing and dividing. Lets just say a normal cell in your body makes a new cell every 2 days. A tumor cell might make a new cell every 2 hours... so it grows way faster than everything else.

So if you have an overgrowth or tumor of skin (like a wart)... that may not cause you any problems if it's just chilling on you finger. Tumors cause problems with they spread and start interfering with the rest of the body's ability to do it's job. So a wart or a mole might be no problem forever, or it could start growing out of control...eventually affecting the ability of your skin to protect your body... or in worse cases it might start growing deeper, affecting whatever is UNDER your skin. That's when a tumor becomes cancer.

The other tricky thing about cancer is what we call metastasis. That means that some of those crazy tumor cells got into your circulatory system... in your blood and lymph... and are traveling around the body to set up camp in other places.... possibly your liver, lungs, stomach, who knows? And of course having a tumor in those places is a whole lot more dangerous than having a tumor on your finger. Tumors on important organs can really start messing things up.... and there is no one way that tumors can cause problems. Just think about it. A growing tumor, depending on where it is, can do a lot of damage. It can grow against something...thus "pinching" something that's not supposed to be pinched... like nerves, arteries, or any "pipes" in your body like your esophagus. Tumors can also have a bully affect on other organs... basically stealing the blood and important molecules they need for it's own survival.... then your own organs start starving to death. Tumors can also pretend that they are part of your own body. For example, you have lots of organs in your body which make chemicals for your body to work... like your kidney makes a chemical that keeps your blood pressure normal, and your pancreas makes chemicals that keep your blood sugar normal. If one of these organs gets tumor cells attached to it, it can start going crazy, too.... maybe making too much or too little of a chemical. All of these tumors are considered "cancerous" or are said to have "metastasized".

There are three basic reasons why you can get cancer in the first place.... and unless it's really obvious to the doctor, it can be really hard to figure out why you got cancer.

The first reason is because of genetics. Basically, for whatever reason, people in your family have "genes" (a code in your DNA) which makes it more likely that you'll get cancer. It's just in your blood. Since most people don't know what genes they have, the best thing you can do to avoid genetic cancer is to be as healthy as possible... and to do all the check-ups your doctor advises (like colonoscopies, mammograms for women, etc.).

The second reason is that some behavior a person does is making your normal cells go crazy and turn cancerous. Things that are known to increase your chances of cancer are smoking, drug and alcohol abuse, obesity, exposing yourself to harsh chemicals (like pesticides, coal, smoke) for years, tanning in the sun too much, or having unsafe sex (basically having many sex partners without a condom). Of course, every person can control how much they do all of these activities... so reason #2 is controlled by you.

The third reason for getting cancer is basically no reason at all. Sometimes it can just happen. Nothing you've done has caused it, and it doesn't seem to run in your family. Sometimes the healthiest, most careful people in the world get cancer... and no one knows why.

If you do get cancer, there are some things we can do. Most everyone has heard about treatments called "chemotherapy" and "radiation". And these are just some of the things we can do. For treatment, we need to be able to 1) get the cancer out of the body altogether if we can, and 2) stop the cancer from spreading around everywhere.

The first part might involve just cutting out the tumor... basically you go in for surgery and they cut out the bad stuff, sew you up, and see what happens. Most of the time you'll have to take medicine to keep the cancer from coming back afterwards. Sometimes you end up good as new, sometimes the cancer comes back and we have to try a new treatment.

Stopping the spread might involve "chemotherapy" or "hormone therapy"... which is basically just medicine which we use to try to poison the tumor. Remember, we can try to stop the tumor from getting bigger... but we really can't dissolve tumors and get rid of them.... for that we need surgery.

The medicine can be pills that you take, fluids that you get through an IV, or medicine injected directly into the tumor with a needle. The hard thing about chemotherapy is that there are usually lots of side-effects... everybody reacts different, but you can bet at the least you'll feel sick like a dog. And this makes sense. We need a drug strong enough to shut down the cancer cells... but not strong enough to shut down YOU and all your normal cells. Tumors usually "like" the medicine more than the rest of your body does... so our hope is that most of the medicine will head to the tumor and poison it first. Unfortunately, some of the medicine we gives you goes elsewhere in your body... and shuts off some of your normal cells, which makes you sick. Bummer. Thousands of researchers in the world are trying to find better drugs that just jump on the highway to tumor and don't take any back-roads around your body to make you sick... but that's tough work.

Radiation is another treatment for cancer. Basically, doctors use a beam of light (similar to an XRAY) to kill the tumor cells. Just the same way the sun can burn your skin if you stay out too long... different types of light can kill different kinds of cells. Depending on what type of cancer you have, you might need to get radiation all over your body or just in the spot where the tumor is.

Treatments aren't always successful. Some types of cancer are almost always curable, and some types less than 5% get cured. And your body can change. Sometimes a medicine works the first time, then it stops working. Whatever treatment you choose, you have to remember that cancer is tricky. Cancer can't be 100% cured like pneumonia or a broken bone. Once you have cancer, it will ALWAYS be lurking around in the hidden corners of your body. Your treatment might work great, and you might be healthy, but you will have to get regular check-ups forever to make sure the cancer hasn't started poking around again.

Do you see things other people can't see?

A patient was in the ER the other day who had been previously labeled bipolar... and the physicians were trying to decide if he should get to go home or get PEC'd (Physicians Emergency Certificate)... basically "committed". He'd been drinking in the FQ, passed out, and was brought in by the po-po. The physicians were convinced he needed to be committed (and ultimately they were right)... but in the initial hours I wasn't convinced. At all. I mean, the guy was wacky for sure... but he made sense. To me anyway. Here's a smidge of the psychiatric interview:

(Imagine a 70 year old patient speaking really fast... and occasionally switching to gringo spanish)

Q:Sir, do you see things other people can't see?

A: Well, I think so! I see corruption, I see idiots, I see morons running our government! Nobody else seems to see it!

Q: Ok, sir do you have any special powers?

A: Yes, I have a bullshit radar! And frankly this is bullshit!

Q: Do you think you're depressed?

A: Hell yes, I'm depressed. Isn't everyone?

Q: Do you think anyone is out to harm you?

A: I'm considering your intentions right now as potentially predatory, but other than that just my brother. He only gives me $20 a week!

Q: Sir if I let you leave the hospital right now, where will you go?

A: Home! I already spent my $20 last night in the French Quarter!

Q: And how would you get home?

A: Walk!

Q: Walk where?

A: Ok, Hitler... do you want me to draw you a damn MAP? I walk down Canal, hop on the ferry, and head to Algiers.

Now maybe it's me, but the guy sounds totally fine to me. Wacky, yes. An alcoholic, yes. I don't know what committing him accomplishes... but I guess that's why I'm not a physician yet. Good thing, cause I definitely would have sent him home. Oops!

Sniff Test

So you know that SMELL on the anatomy floor in a med school? And in the stairwell, and the hallway, and the bathrooms, and pretty much everywhere that first year med students go?

I have a theory that most of that is because there are students who have never washed their scrubs. Ever. How do I know this? Well besides the fact that some med students openly cop to never washing their scrubs, and the fact that we didn't stink the first day when our scrubs were new and pretty,... try this little experiment. Walk close to your dirty scrubs (which have only been worn to 1 or 2 lab sessions) and see how close you can get before they actually start stinking. Sure, they reek when you get close... but they don't permeate the entire house. Now have you noticed how just 1 stinky anatomy student can be over 10 feet away from you even BEFORE lab, and still make you gag? Yuck. That didn't happen overnight. That's pure anatomy funk.

So I'm proposing that if you conduct the "sniff test" and you can smell cadaveric nastiness wafting from your scrubs from further than 3 feet, it might be time for a little Tide action. For the health of your fellow classmates.

Top 40 of the Last 10 Years

I decided to make a list of the things I would have missed out on if I'd started medical school at 21. Wow, the last 10 years have been busy!

1. Was a paid-on-call firefighter

2. Graduated from college with my BA in Political Science

3. Was an RA, Vice President of my university, and a sorority girl

4. Studied Italian in Italy for several months, traveled all of Italy

5. Was an ecology research assistant

6. Had 4 long term relationships... and a bunch of not-so-long-term ones

7. Moved to Boston, lived in a beautiful brownstone, attended Harvard for PBPM

8. Became a high school chemistry, biology, and sex education teacher

9. Traveled around Brazil, camped on the Amazon River, discovered Rio de Janeiro

10. Helped 21 of my illegal-immigrant students get into college with full scholarships

11. Got my EMT certification

12. Conducted clinical research study at Beth Israel Hospital in Boston

13. Lived in Phoenix (downtown), Miami (MiMo), New Orleans, Boston (South End), Washington DC and San Diego

14. Won a scholarship for infectious epidemiology from the CDC to train in Charlotte

15. Bought my first house, gutted it, and am rebuilding it from my own design.

16. Conducted clinical research for the Department of GI and Cardiology

17. Invited by a prestigious research group in Colombia to work on p. vivax vaccine candidate (I went by myself.... with little ability to speak Spanish!)... and I traveled around Colombia

18. Got my Masters degree in tropical medicine

19. Got to be an extra in a movie with Brad Pitt

20. Was an ID Epidemiologist for the state

21. Watched every episode of Sex and the City like 10 times

22. Adopted the best dog in the world

23. Got into med school!

24. Met my wonderful boyfriend

25. Taught General Chemistry I, II to undergrads

26. Was an HIV/STD safe sex educator for elementary & college students, residential bootcamps, drug rehab, etc.

27. Worked in behavioral neuropsychology researching the effect of the estrous cycle on neuron morphology

28. Learned to speak conversational Spanish

29. Taught over 150 children and 2 adults to swim

30. Evacuated 2 Hurricanes... and actually escaped 1

31. Road trip across the United States 4 times

32. Taught English in Tijuana migrant worker camps

33. Designed my own study to assess tumor cell response to combination treatments for pancreatic cancer

34. Was present (team right leg!) for the birth of one of my favorite student's first baby

35. Advised the 12th grade physics class "solar tech" club... we built a full size (2+ people!) solar powered boat to race in the "Solar Spectacular" competition

36. Was featured in an article in the San Diego Union Tribune for "interior design" advice from amateur, alternative, designers.

37. Built a great circle of friends and advisors who I love.

38. Completed an internship in Washington DC on politics and the media

39. Went skydiving (Ok, this may have been 11 years ago)

40. Canoed up the Colorado River to Black Canyon Hot Springs.

Ok... that's all I can think of right now. But you should make your own list. It makes you feel better!

True Dat...

My neighbor also happens to be the Chief of the ICU at the hospital affiliated with my medical school. He spoke to the med students today about something very important. His talk was a little esoteric, in that I'm not certain that all of the medical students really GOT it. I knew the importance and the truth of the things he said, perhaps because I am a little older and have had enough experiences to know he's dead on... but truthfully, 10 years ago I would have been bored bored bored by what he said and would have grabbed the free lunch and snuck out the back door. Which many people did.

He made his point in a round-about way, discussing various philosophers, readings he found thought provoking, pearls of wisdom, and discussing the merits of minimalism. I knew what he was getting at, but the dots weren't real close together for the younger folk. The point isn't something you can only "get" if your older, but rather it's about the experiences you've had... which often come only with time.

Here's the gist of what he meant (or how I interpreted it at least):

It's essential to surround your life with things which are truly meaningful to you, not with things that are disguised as meaningful. Medicine can truly be meaningful and by keeping it in balance with other valuable practices you can lead a wonderful life in which you are happy and feel that you hold value in society.

The thing about medicine is that it is really easily to get consumed by it. In order to be the best of the best, you must invest so much of your identity in what you are doing that you can lose sight of other things that are important in your life. Namely, family, spirituality, health, art, your home, etc. And because medicine often affords you wealth, many physicians fill their lives with meaningless material items, mistakingly thinking they are valuable (homes, cars, boats, vacations, etc.).

So I think his point was not simply to bash all those ferrari wielding docs, but rather to prompt future physicians to really define what they consider success... rather than getting sucked along in the current of power, money, prestige, etc. that naturally seems to follow many physicians. If you define success in terms of material possessions and wealth, etc. that's fine... but know your definition of success before you set out to attain things you never really wanted in the first place.... thus missing out on those things that really create meaning and value for YOU.

Worth a ponder for sure.

This will make you feel better about getting a late start...

If you're worried about starting med school "late", this should make you feel better. Leila Denmark is 112 years old, and she practiced medicine until she was 103. She was a pediatrician from Georgia. So if you're starting at 44, you'll have at least 50 years to get good and tired of being a doctor. On a more realistic note... (for those of you who aren't sure you'll make it to 112)... I personally know several doctors who are practicing clinicians and are well into their 80's. In academic medicine, private, practice, and hospitalists. That's the good thing about medicine. As long as you keep learning, you actually get better the older you get. Not so true for other professionals (it's all downhill for models after age 17).

A $2.3 Billion Dollar Boo-Boo

Here's my hypothesis about Pharmaceutical Companies...

Clearly, there is a major discrepancy in their level of "ethical behavior" before they get FDA approval vs. after. Pfizer just had to pay out $2.3 Billion dollars for "mis-marketing" the painkiller Bextra... which seems pretty steep to me (although admittedly I don't know crap about pharmaceutical annual profits). This is a result of some scam they cooked up to market an approved drug in an unapproved way. Of course they knew they'd get fined... but I'm assuming they figured that their fines would be off-set by the amount of revenue they could generate from the mis-marketing before they got wrapped up in litigation... if that ever occurred. I guess Obama got 'em good this time.

Now I've spent the last 3 years working VERY closely with tons of pharmaceutical companies, including Hoffman La-Roche, Eisai, Solvay, AstraZeneca, Sucampo, Cardiokine, Osiris, Debiopharm, Sanofi-Adventis, Johnson & Johnson, Takeda, and others. These are all considered "top" pharm companies. In my experience on the research side, I have honestly and truthfully NEVER seen anything that I considered unethical or questionable behavior. In fact, I have seen numerous examples of "over-cautiousness" by the project team managers, medical directors, etc... to the point of annoyance. Meaning that they have made me obtain waivers, submit protocol violations, and drop patients off the study medication at the first sign of ANY side effect. Do you know that if your patient is enrolled in a pharmaceutical study for a GERD medication and they slice their finger accidentally while chopping tomatoes at home, that MUST be reported as an "adverse event". EVERY adverse event has to be submitted to the pharmaceutical company and the institution's IRB for review and approval. I've had to have "meetings" with top dogs in the pharm company because I had patients who forgot to fill out their medication diaries correctly, or because after page 17 the informed consent was signed in blue ink instead of black (the pen ran out of ink??), or because my patients threw their empty med bottles away instead of returning them for count verification.

Anyway, my point is that in the research phase pharmaceutical companies are hyper-diligent... but when it comes to the marketing phase they've somehow managed to throw their ethical behavior out the window. Which leads me to believe that they clearly know what they're doing from day one.... and that all their pretenses about "ethics" are just to get the damn FDA approval. Duh.

That being said... Pharmaceutical companies are, in fact, a business. And although unethical, drug-rep promotion of a drug is just that. DRUG-REP promotion. It is the PHYSICIAN'S job to look at a drug and say "hey this is approved by the FDA for condition X only. Maybe I should look into this a little more before I prescribe it for condition Y just because the drug-rep "unofficially" said it was ok". Everybody's looking for someone to blame.