Gratitude

It's so easy to forget what's really important in life. All too often we get caught up in what we're doing at the moment and lose sight of the bigger picture.

There was a huge storm outside yesterday. While watching a movie with loved ones, we could still hear the howling of the winds and branches scraping the roof. What of the homeless who have nowhere to turn? What of those that cannot keep warm, or do not have enough to eat? How can I help them??

I am grateful for the roof over my head, for the food on the table, for the people in my life. I am grateful for a job that I love and for the chance to make a difference in someone else's life. I am indebted to those that have given me a chance and those who have shaped who I am today. Being given so much brings a sense of responsibility for my community, the world, and I hope to never forget that the goal is to make this life worthwhile. May I always work to relieve suffering and to bring others happiness.

Police Force Field

Ever notice that when a police car comes into view, the cars around the police car suddenly all slow down into a below-the-speed-limit trot? And everyone obeys any and all traffic signs? This phenomena is predictable enough that if you're driving on the freeway and all of a sudden the pack of cars ahead of you (and only those) seem awfully slow, you slow down and start scanning for the cop car... I wonder what it must be like for policemen - everywhere they go, people must seem like pristine, traffic law-abiding citizens. Maybe that's why they hide out in those favorite ticketing places - to catch a glimpse of reality without the presence of a black and white car.

And always wondered who gives a cop a ticket for speeding? It's not a rare occurrence to see them speeding somewhere. Sure, it could be official business, but the question of the day is who enforces the law for the law?

Timing Is Everything - Or Is It?

Amazing what researchers are interested in. How do people get funding for these things?!

C. Neil Macrae, a professor of psychological and brain sciences at Dartmouth College, and his colleagues theorized that women have heightened awareness of male features during certain phases of their menstrual cycle.

Previous research, Macrae says, shows that women also have an increased preference for "facial configurations that convey dominance" and other stereotypical male attributes. His research found that women prefer more masculine faces during ovulation and more feminine faces at other points of the menstrual cycle. Men's notions of attractiveness (such as ideal hip-to-waist ratio), on the other hand, remain relatively constant over time.

Macrae CN et al, Psychological Science, November 2002.

War of the Worlds

Just watched War of the Worlds yesterday. The movie was pretty bad. What stood out though, was the absolute devastation that war brings to the people. Aliens aside, if you think about human conflict, it is less often that people have issues with people of another country and more that temporary leaders of the two sides have their own issues and feel the need to duke it out... or maybe that is just the case with GW Bush. And people just get dragged into the fight.

Wars are wars, but the worst ones are ones fought on your own land. The U.S. is fortunate that most of her "wars" have been fought in other nations. Wars on your own soil must be horrific - masses of people (who probably did not want to get into a war in the first place) turned into refugees with no food, no shelter, no end in sight. There is a scene in War of the Worlds when Tom Cruise drives one of the few working cars into a crazed mob, and the members of that crowd, war-crazed desperate people, are willing to take the car by any means necessary. There is no place for law, for rights, for concern for others. Might = power, and power = more likely survival. Complete disintegration of the fabric of society as we know it. Amazing to think that many of the elderly of today, from Europe, Asia, Central/South America, Africa have lived through such ordeals and that the ones who survived have come out relatively unscathed. Even more amazing to think that wars still go on today and there is nothing we can do to stop it.

Why must people be so stupid?

Meditation and Neuroplasticity

Functional magnetic resonance imaging (MRI) has really revolutionalized the face of brain research. The ability to instantaneously map out changes in the brain allow scientists to ask questions that could not be adequately studied before.

Here's a great example:

Richard Davidson's* lab is one of the world's most advanced for looking inside a living brain. He's was awarded an $15-million grant to study what happens inside a meditating mind. (*Richard Davidson, Ph.D. , Director of University of Washington's Laboratory for Affective Neuroscience and the W.M. Keck Laboratory for Functional Brain Imaging and Behavior)

His prize subjects – and collaborators – are the Dalai Lama's lamas, the monks. "The monks, we believe, are the Olympic athletes of certain kinds of mental training. These are individuals who have spent years in practice."

"Rather than thinking about qualities like happiness as a trait," Davidson says, "we should think about them as a skill, not unlike a motor skill, like bicycle riding or skiing. These are skills that can be trained. I think it is just unambiguously the case that happiness is not a luxury for our culture but it is a necessity."

There's some evidence that our temperament is more or less set from birth. So and so is always a "downer" while someone else is always "happy." Even when wonderful or terrible things happen, most of us, eventually, return to that emotional set-point. But, Davidson believes, that set point can be moved. "Our work has been fundamentally focused on what the brain mechanisms are that underlie these emotional qualities and how these brain mechanisms might change as a consequence of certain kinds of training," Davidson says.

Happiness and enthusiasm, and joy – they show up as increased activity on the left side near the front of the cortex. Anxiety, sadness – on the right. Davidson has found this pattern in infants as young as 10 months, in toddlers, teens and adults. Davidson tested more than 150 ordinary people to see what parts of their brains were most active. Some were a little more active on the left. Some were a little more active on the right. A few were quite far to the right. They would probably be called depressed. Others were quite far to the left, the sort of people who feel "life is great." So there was a range. Then Davidson tested a monk. He was so far to the left he was right off the curve. That was one happy monk. "This was evidence that there was something really different about his brain compared with the brains of these other 150 people... evidence that these meditation practices may indeed be promoting beneficial changes in the brain."

Researchers at the University of Wisconsin working with Tibetan monks have been able to translate the mental experiences of meditation into the scientific language of high-frequency gamma waves and brain synchrony, or coordination. And they have pinpointed the left prefrontal cortex, an area just behind the left forehead, as the place where brain activity associated with meditation is especially intense. These results take the concept of neuroplasticity a step further by showing that mental training through meditation (and presumably other disciplines) can itself change the inner workings and circuitry of the brain.

"What we found is that the longtime practitioners showed brain activation on a scale we have never seen before," said Richard Davidson. "Their mental practice has an effect on the brain in the same way golf or tennis practice enhances performance." It demonstrates, he said, that the brain is capable of being trained and physically modified in ways few people can imagine.

Does this work in "regular" people?

In an eight-week UW study of non-Buddhists given meditation training, magnetic resonance imaging and other testing revealed changes, some lasting four months: 50 percent more electrical activity in the left frontal regions of the brain, associated with positive emotions and anxiety reduction, and an increase in antibodies of as much as 25 percent.

Fascinating...

References:
1) Lutz, A., Greischar, L. L., Rawlings, N. B., Ricard, M., & Davidson, R. J. (2004). Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. Proceedings of the National Academy of Sciences, 101, 16369-16373.
2) http://psych.wisc.edu/faculty/bio/davidson.html
3) http://brainimaging.waisman.wisc.edu/

Defining Codes

Thanks to Teni, here's an explanation of codes:

"Code" may refer to many different things. Most of these are used in the hospital setting and make sense to the hospital personnel. Most of the time "code" refers to Code Blue, as in
"A patient coded last night."

Code Red = Fire in the hospital!

Code Brown = a favorite among medical residents. Means that someone has gotten a whiff of a patient's poop and is signaling the team to move farther away from that location.

Code Pink = Baby disappeared (used in newborn nurseries, when baby snatchers make off with a newborn, most often, NOT their own)

Code Blue = Patient found unresponsive, often not breathing or with no heart beat and needs resuscitation with CPR, electric shock in an attempt to jump start the heart, medicines to try to make the heart pump regularly, or intubation (tube down throat) to let a machine help them breath. The rates of success of code blues are usually dismal. Occasionally, in the young or healthy, there may be a quickly reversible cause of the unresponsiveness. More often, especially in the hospital setting with older, sicker patients, patients are not able to be brought back to life, and even if their heart is restarted again, depending on how long the patient was unresponsive, there may be damaged neurologic function. The interventions to try to bring someone back are not benign. CPR can lead to cracked rib bones. Often needles are stuck in the patient in an attempt to try to get intravenous access to administer medicines. Electric shocks are not pleasant. When patients are admitted to the hospital, the admitting physician should ask the patient what their wishes are for resuscitation. Sometimes this can be phrased strangely by the physician (in a poor attempt to try to explain in common language). A bad example I've often heard "If your heart stops do you want us to do everything we can to try to restart it?" If I were the patient OF COURSE I want the doctor to try to save me. But I don't know that patients truly understand what "everything" includes. If people were to be present at a code blue, I don't know that they would chose to have that done to them. For those who want everything (CPR, electric shocks, etc), they are given the label "FULL CODE." Those who do not wish for these extreme resuscitation methods are either "modified code" if they want some things but not others, or "no code." I think it is important for people to understand that "no code" does not mean that doctors write you off and won't try to save you. If you are sick and need antibiotics, or have a dangerously low blood pressure, we will give you intravenous fluids to get you better. "No code" just means that in the event that you were found unconscious, we would do everything we could, but would not use the extreme measures of CPR and electric shock.

Jargon

I still remember my first experiences in the hospital setting. I was entering the medical field, but as a novice trainee, I still had the eyes and mind of a non-medical person. Back then, the "cultural" gap between doctors and patients was very clear. Maybe the best example of this was morning hospital rounds. The team would bustle into a patient's room where the intern or the senior resident would update the patient on their medical condition. Even though the M.D. attempted to simplify the description of what was going on, he was often too steeped into the medical culture and medical jargon to make much sense to the patient.

"Sir, your white count is coming down. The IV fluids are helping your kidneys, and we're going to give you another bolus today. "

I could just imagine the questions running through Mr. S's mind. What is white count? What does coming down mean? Down an elevator? What do intravenous fluids have to do with my kidneys? What in the world is a bolus? Patients may have questions, but few ever ask. Most nod and smile, and the medical team whisks off to another room, proud that they were efficient and effective. It's only the medical student that finds out, because he had the time to go back and chat, that while the morning interaction was conducted in English, it might as well have been done in another language - the patient never understood what the resident said.

I remember reminding myself that I would try not to forget these experiences. That the same words used in the medical framework does not mean the same thing in common English. Or that there is no "English" equivalent for certain medical jargon.

It's hard to remember, because you get immersed in a culture that is so different. As it starts to make sense, your language and thought processes are changed to become a part of it. And one day you catch yourself making the same mistake. It's embarrasing. Here's to all the patients out there - if you don't understand, just ask. We'd be happy to explain, if we knew we weren't making sense.

Lunar Lunacy?

The ICU nurses are a smart bunch. Observant too. Which is why when they talk about certain superstitions, it makes one think twice.

Like the one about full moon = havoc in the hospital.

Some of the nurses have been around many years and they have years of experience to back this claim. Even my relatively limited experience on overnight calls bring to mind nights of madness on what was retrospectively verified to be full/new moon periods. Folk wisdom dating back thousands of years also describes strange behavior with the phases of the moon.

Apparently people have tried to study this over the years --

Here are some interesting studies:
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BMJ. 2000 Dec 23-30;321(7276):1559-61.

1,621 patients over 3 year period in England who were bitten by either a cat, rat, horse or dog: the incidence of animal bites was significantly higher around the full moon.

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Compr Psychiatry. 1977 Jul-Aug;18(4):369-74.

The admission records of 18,495 patients to a psychiatric hospital in an 11-year period: admissions for psychosis were highest during the new moon and lowest during the full moon.

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J Clin Psychiatry. 1978 May;39(5):385-92.

11,613 cases of aggravated assault in a 5-year period: assaults occurred more often around the full moon.

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J. Psychology, vol. 93:81-83, 1976.

34,318 crimes in a 1-year period: crimes occurred more frequently during the full moon

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University of Miami, psychologist Arnold Lieber et al.
Data on homicide in Dade County (Miami) over a period of 15 years: correlated incidence of homicide with the phases of the moon - the two rose and fell together for the entire 15 years

Repeated the experiment using murder data from Cuyahoga County in Ohio (Cleveland) with similar findings.

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American Institute of Medical Climatology to the Philadelphia Police Department entitled The Effect of the Full Moon on Human Behavior found similar results.

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Although I've only listed some supportive studies, the data is mixed. Some suggest there is a relationship and others have not found a relationship. Due to the heterogeneity of the studies, and the presence of confounding variables, it's hard to say how good the data is. People who disagree raise interesting criticisms, and I don't think there's adequate data to determine a causal link between the two. But although medical training teaches us to be critical and objective and accept nothing less than randomized controlled trial results, there's something to be said for intuition and observations made over the years. After all, it's gotten people worked up enough to spend time researching the topic! :)

Codes

It's astonishing what we do to dead people. If only members of the lay community knew what "full code" means, we would have less of senseless pounding on chests, IV drug pushes, transcutaneous shocking, bagging of a patient already waxy yellow with the look of death. Competent patients should be educated on what a code (http://wanderingvisitor.blogspot.com/2006/02/defining-codes.html) means and the reality of meaningful success rates after a code. Everyone should have to review this yearly and it should be well documented. No more codes where someone brings up that the patient might actually not be full code. It would be horrible to code someone against their wishes... And demented patients should not have their families make code status decisions, especially family who don't know what the end looks like.

There should be a standardized time that codes are carried out for. Adjustable to situations, but a code that hasn't brought someone back in 5 minutes is not likely to do so in 30... It's almost morbid to keep on pumping the sternum, all the while hoping that the patient/? spirit/ ?conscience goes in peace. Hard to imagine how it could with a room packed full of people, none of whom, sometimes by profession, but often due to patient/family wishes can let the patient pass naturally.

Also astonishing how desensitized we become at these events. We don't usually realize it, except today there was a person in the resuscitation team that was maybe new to code blues - at least that's was the working conclusion after the person burst into tears outside the room halfway through the code. "Is this her first time?" people whispered to each other, more shocked at her reaction than with the situation at hand.

I don't know what the solution is. People need to be educated about death and hospitals and what full code means.

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Why Medicine?

Yesterday I had a patient ask me "Why is it that you do what you do?"

He had a granddaughter who was successful but was thinking about switching to medicine, and his thoughts were that it was an extremely tough career.

"Is it worth it," he asked? "What keeps you going?"

Woah. It's been a while since I've heard that question.

As he was talking, I caught myself about to switch into interview mode. After all, most of us have answered this question a million times - to get into medical school, to curious friends/family members along the way, to get into residency, etc... and many of us have a handy reply that sounds good and moves us right along to the next question.

But this was a different situation.

He wasn't sitting across a table, judging me by my answers. I was already his doctor, he already trusted me and my judgement, and he just wanted to know the simple truth.

So I told him.

I absolutely think that medicine is worth it. (On a silly note, what other field lets me run into the "bedrooms" of people who wear a piece of cloth that only covers their front? :P ) But seriously, medicine has been worth it for the people that I meet and for what they teach me. I don't mean what I learn from them about their medical conditions. That's interesting but not all that fulfilling. More what I learn from them about how they deal with life and their pearls of wisdom. Like the fact that this man was still happily married to his wife of 50+ years. "Never go to bed angry if you want to stay married." Words of wisdom. Granted, these encounters don't come every day, but that just makes them more special.

They never fail to remind me how lucky I am do be doing what I'm doing...

Lost Souls

This is one of the reasons I started this blog. I've had several ideas for things I need to write about related to... medical training. Some of them are related to patient care, but some, like this one, is about the training system itself. I think the system is very good at what it does - it takes an average college graduate, crams a bunch of medical information into their head, and at the end of the road, you have a doctor who can take a cookie cutter history and physical, can formulate differentials as the patient speaks, and can describe a patient in two sentences that's filled with more medical acronyms than words.

Where it fails is best put by Rufsvold and Remen:"Year after year, students enter medical schools across the country inspired to become doctors... Numerous studies reveal that four years later, this excitement has given way to numbness, cynicism, and depression..."

Why does this happen? I think the simple answer is that training isolates us. Medscape recently had an article on whether medical training "strips our souls" - and I think to some extent we are dramatically changed. I am a very happy physician and love what I do, but I was also fortunate to be able to make the choice to train in a more benign specialty. As I watch my surgical* friends and even some internal medicine* classmates, it's frightening how quickly and easily one loses the perspective of life beyond medicine. It's easy to lose perspective, seeing as how, on a q3 rotation all you can do is show up at work, work like a dog, miss meals because the day got too crazy, go home and have to choose between eating or sleeping, and schlepp to bed knowing that you'll just have to do the same in a few hours. The transformation begins in the third year of medical school and slowly worsens so that a surgical resident wakes up and doesn't bat an eye about doing 100 hours (oh, I mean "80") a week in the hospital. Imagine if you took the average college pre-med and showed them a 30 hour call with no chance of sleep. And then showed them that that would be their lives for 3 years. Or 7. Would they still be pre-med? Maybe not. But it's often too late when you realize what kind of path you're on, and you've come too far to look back and change your mind. You've already given up a lot and you go on thinking, "it'll get better someday." Someday never comes until one day you're a tired mid-thirties man who has finally finished a fellowship, has a saddle full of debt, have to look for your first "real" job, and you go home to the empty apartment that you still rent. Your college friends are married, some have children, most own homes, and many have already been promoted several times in their careers. If you took that pre-med and showed them that moment, would they still be pre-med? Maybe not. Training has the potential to become a slow, progressive isolation from the rest of the world. The people and things that keep most people grounded are no longer there. You become who you are at work, a surgeon who saves lives on the operating table, an internist who uses pills to chase after lab values and spends way too much time with paperwork and dealing with insurance companies, because what else do you have? What else are you? That well-rounded profile that helped you get into medical school has long fallen by the wayside, just another victim of the brutality of medical training. How else do you think that the monsters that throw scalpels in the OR come into being?

* Note: Surgery and internal medicine are used here purely as illustrative examples. They are wonderful fields that are extremely rewarding and we all need good people going into these fields. They are mentioned here because of their large size and because they are the first big branching point in a medical student's career. This "isolation" has the potential to occur in any medical field, and as with anything, there is a combination of environment and genetics - each person's likelihood of this happening to them is different. Also the likelihood of this happening depends very much on the type of training program (community versus academic) one chooses. Some are more benign than others.

The Beginning

It's taken me some time to start a blog. Partly because I'm not sure of the purpose of blogs - is it to hear yourself think? To share crazy thoughts with random strangers you don't know? But here I am, starting my very own blog... several factors brought this into being: 1) Have been reading my friends' blogs - some are hilarious and allow us to keep in touch in a pretty effective way. 2) Just had a series of interesting events that I need to put somewhere. Am STILL not convinced that online is the best place. Afterall, who are these people that read stranger's blogs?? Well, here goes... All names and places will be changed to protect identities... after all, you probably wouldn't want your name on here now, would you? ;)