Soapbox

Mark Bittman is one of my favorite cooks and NYTimes columnists.  His cookbooks are also fantastic.  His opinion article about Congressional budgetary priorities in today's Times made me an even bigger fan.  I think this is such an important issue, and we should all be telling Congress that their budget is morally unacceptable.

MARCH 29, 2011

Why We’re Fasting

By MARK BITTMAN

I stopped eating on Monday and joined around 4,000 other people in a fast to call attention to Congressional budget proposals that would make huge cuts in programs for the poor and hungry.

By doing so, I surprised myself; after all, I eat for a living. But the decision was easy after I spoke last week with David Beckmann, a reverend who is this year’s World Food Prize laureate. Our conversation turned, as so many about food do these days, to the poor.

Who are — once again — under attack, this time in the House budget bill, H.R. 1. The budget proposes cuts in the WIC program (which supports women, infants and children), in international food and health aid (18 million people would be immediately cut off from a much-needed food stream, and 4 million would lose access to malaria medicine) and in programs that aid farmers in underdeveloped countries. Food stamps are also being attacked, in the twisted “Welfare Reform 2011” bill. (There are other egregious maneuvers in H.R. 1, but I’m sticking to those related to food.)

These supposedly deficit-reducing cuts — they’d barely make a dent — will quite literally cause more people to starve to death, go to bed hungry or live more miserably than are doing so now. And: The bill would increase defense spending.

Beckmann, who is president of Bread for the World, made me want to join in just by talking about his commitment. For me, the fast is a way to demonstrate my interest in this fight, as well as a way to remind myself and others that there are bigger things in life than dinner. (Shocking, I know.) I expect I’ll learn something about patience and fortitude while I’m at it. Thirty-six hours into the fast, my senses are heightened and everything feels a bit strange. Odors from the cafeteria a floor away drift down to my desk. In the elevator, I can smell a muffin; on the street, I can smell everything — good and bad. But as hungry as I may get, we know I’ll eat well soon. (Please check my blog for a progress report.)

Many poor people don’t have that option, and Beckmann and his co-organizers are calling for God to create a “circle of protection” around them. Some are fasting for a day, many for longer. (I’m fasting until Friday, and Beckmann until Monday. And, no, it’s not too late to join us.)

When I reminded Beckmann that poor people’s hunger was hardly a new phenomenon, and that God hasn’t made a confirmed appearance recently — at least that I know of — he suggested I read Isaiah 58, in which God says that if we were more generous while we fasted he’d treat us better. Maybe. But a billion people are just as hungry, human, and as deserving now as the Israelites were when they were fleeing Egypt, and I don’t see any manna.

This isn’t about skepticism, however; it’s about ironies and outrages. In 2010, corporate profits grew at their fastest rate since 1950, and we set records in the number of Americans on food stamps. The richest 400 Americans have more wealth than half of all American households combined, the effective tax rate on the nation’s richest people has fallen by about half in the last 20 years, and General Electric paid zero dollars in U.S. taxes on profits of more than $14 billion. Meanwhile, roughly 45 million Americans spend a third of their posttax income on food — and still run out monthly — and one in four kids goes to bed hungry at least some of the time.

It’s those people whom Beckmann and his allies (more than 30 organizations are on board) are trying to protect. The coalition may be a bit too quick to support deficit reduction, essentially saying, “We understand the need for fiscal responsibility, but we don’t want to sacrifice the powerless, nearly voiceless poor in its name. As Beckmann knows, however, deficit reduction isn’t as important as keeping people from starving: “We shouldn’t be reducing our meager efforts for poor people in order to reduce the deficit,” he told me by phone. “They didn’t get us into this, and starving them isn’t going to get us out of it.”

This is a moral issue; the budget is a moral document. We can take care of the deficit and rebuild our infrastructure and strengthen our safety net by reducing military spending and eliminating corporate subsidies and tax loopholes for the rich. Or we can sink further into debt and amoral individualism by demonizing and starving the poor. Which side are you on?

If faith increases your motivation, that’s great, but I doubt God will intervene here. Instead, we need to gather and insist that our collective resources be used for our collective welfare, not for the wealthiest thousand or even million Americans but for a vast majority of us in the United States and, indeed, for citizens of the world who have difficulty making ends meet. Or feeding their kids.

Though Beckmann is too kind to say it, he and many other religious leaders believe that true worship can’t take place without joining this struggle: “You can’t have real religion,” he told me, “unless you work for justice for hungry and poor people.”

I don’t think you can have much humanity, either.

A Good Weekend

Some quick pictures for you this evening.  

Last weekend was the perfect collision of St. Patrick's Day, Match Day for 4th year med students, Jake's visit from Austin, my dad's visit from Colorado, Martin and Marielle's visit from Alabama, a wedding here in Atlanta, and absolutely glorious spring weather (pretending that I didn't have to study didn't hurt, either... at least not until Monday.)

My roommate Ajanta celebrates matching at her #1 residency choice.

Enjoying the perfect sunny afternoon on a patio.

Good times with Martin and Marielle.

Universal Joint --> awesome place.

Marielle tries to talk an old lady out of her St. Patty's Day hat.

The Rev kicks back.

Group shot!

On a mission to win spring break.

Gets the hat, wins unlimited points.

awww...  :)

Colorado goodness.

Wedding-ready with Dad and Marielle.

The groom's special-edition brew for his own reception. 

The happy couple.

Groomsman lets down.

And then GETS down.

Complete with costumes and props.

Life of the party!

Post-reception beers with friends.

Fancy (and amazing) night out to dinner before he heads back to Austin...

It was super hard to come back to reality after such a fun time, and it has been a little bit of a rough week.  I am still in the thick of cardiology... less than two weeks until our module exam, and just a little over two weeks until I leave for Haiti!!  Counting down the days for multiple (and very different) reasons.  Will write a better update soon... for now, if you are a praying person, please remember me in the upcoming days and weeks!

A Subject That Takes Up a Lot of Room in My Brain

The Changing Face of Medical Care

By DOREEN CARVAJAL

March 7, 2011

The plastic surgery unit at Chelsea and Westminster Hospital welcomes patients in a spare waiting room with padded blue chairs and a bright yellow lane of stripes running along the floor like a street intersection.

It is the crossroads for Dr. Shweta Aggarwal, a plastic surgeon in training, who summons her patients for consultations ranging from burns and breast reconstruction to tummy tucks and implants.

Across the Western world, it is her generation of young women that is transforming the once-male bastion of medicine, swelling medical schools and flocking to the front lines of primary care.

They wear the stethoscopes and wield the scalpels in increasing numbers: women make up 54 percent of physicians below the age of 35 in Britain, 58 percent in France and almost 64 percent in Spain, according to the latest figures from the Organization for Economic Cooperation and Development, which tracks the trend in more than 30 countries.

“It’s like social work — to be able to do something with meaning, to be able to help someone while you are doing a job,” said Dr. Aggarwal, 36, the mother of a year-old child and a holder of dual Indian and British citizenship. She graduated from an Indian medical school but said she chose to study plastic surgery in London because of better training opportunities and the flexible scheduling that it offered.

As the world marks a century of International Women’s Day on Tuesday, women in the medical field can pride themselves in having made huge strides.

Over the past three decades, the proportion of women in medical schools has risen in Europe, the United States, Canada, Australia and South Africa. Most medical schools in England have more female students than male, with almost 56 percent, or 5,170, in the entering classes last year. At the current rate, the Royal College of Physicians expects women to make up the majority of all doctors in Britain by 2017.

But the steady advance of women, generally lauded in the West and increasingly seen everywhere, has also left the medical establishment in Britain and other countries fretting about the future, provoking studies and sharp debates about the trend.

Will the feminization of medicine lead to losses in income and status? Will countries need to train and pay for more doctors to make up for maternity leaves, part-time schedules and job sharing, which are often sought by female doctors trying to balance work with their personal lives?

Some experts are intrigued by another question: Are female doctors offering lessons in more effective care-giving?

The National Clinical Assessment Service, which tracks and evaluates patient complaints in the United Kingdom, is urging further study of the differences. It issued a report last month that reviewed suspensions over the past nine years of general practitioners, a field that women will dominate by 2013. The figures, adjusted to reflect the composition of the total work force, showed that men were five times more likely to be suspended than women for patient complaints. They were also more likely to be the subject of complaints by patients.

“The $64,000 question is, Why?” said Dr. Alastair Scotland, the medical director of the assessment service. “We have some untested theories that women consult in different ways. They are less likely to take risks than men. Someone who is cautious and risk-averse is more likely to seek help and to talk through issues with their colleagues, interacting as a team.”

Some German researchers also detected signs of a female factor in treatment. A 2008 study in the Journal of Internal Medicine found that patients with Type 2 diabetes responded better under the care of women, showing more improvement in blood pressure and cholesterol counts and taking their medicine doses. The researchers said that female doctors were more likely to communicate well and involve patients in their own care.

The Medical Women’s Federation, the largest organization of female doctors in Britain, is reluctant to draw differences between the care-giving techniques of female and male physicians and resisted proposals at its own conferences to declare there are too many women in the field. In the view of the leadership, women are not taking over, but catching up.

“All doctors have changed the old patriarchal style of ‘I am the all knowledgeable doctor, and I tell you what to do,”’ said Dr. Fiona Cornish, a general practitioner who worked part-time while raising four children and is the president-elect of the M.W.F. “If one had to make a generalization, women are more cautious. Women spend longer talking to the patient and listening. If you listen well, you’ll get the right story.”

Some patients still have qualms despite the good bedside manners. “Men find many G.P. practices very female environments, for example, a waiting room full of women’s magazines and posters about women’s health issues,” said Colin Penning, a spokesman for Men’s Health Forum, a charity based in London that raises awareness about male health issues. He added that female doctors often practice fewer hours, making it difficult for men to break away from work to see them.

The first surge of female medical students in Britain started in the 1980s, and by 2007 young women accounted for 57 percent of entering medical students. By 2010, the numbers started leveling at about 56 percent. More men were pursuing careers in information technology, engineering and mathematics — fields where the ratio of women has barely changed, hovering at less than 20 percent, a Royal College of Physicians report about women and medicine says.

Experts suspect that men are drawn to higher-paying fields, like computer engineering, which requires less training.

Money and the gender shift trouble Dr. Bernard Ribeiro, the former president of the Royal College of Surgeons of England and a new British lord. At a conference of the Medical Women’s Federation in 2009, he raised the issue of whether there were too many female doctors.

Dr. Ribeiro said in an interview that he still believed that work needed to be done to save “the lost tribe of medicine,” which he described as men who are attracted to more lucrative ventures like the financial services industry.

“Medicine has moved from being a vocation, which is sad,” Dr. Ribeiro said. “Smart kids coming out of school are looking at medicine as any other job — what are the prospects and the terms of remuneration.” Dr. Ribeiro said research was needed to explore why boys are outpaced by girls at earlier levels of school.

Among female doctors who have finished their training in Britain, 44 percent are pediatricians, 49 percent are in public health and only 8 percent are surgeons, according to the Royal College of Physicians report. Within surgical specialties, women are drawn to delicate work such as plastic surgery as opposed to orthopedic surgery, which requires heavy lifting.

“Women choose specialties that deal more with outpatients and less emergencies because the jobs are more plannable, while men choose specialties that are techie and exciting,” said Dr. Jane Dacre, a physician and vice dean of University College Hospital Medical School, who also notes that young male and female doctors share the same desire to reduce hours.

Typically, female doctors find it harder to rise to leadership positions in hospitals and medical schools. They are also more likely to make less than their male colleagues. The British Medical Association detected a salary gap of £15,000, or $24,000, in 2009 between male and female doctors in the National Health Service.

With many women seeking part-time work, new organizational challenges are emerging, including the possibility that some countries will need more doctors. France and Germany, for instance, have warned about future shortages, as older male doctors retire and are replaced by women working part-time. The German Medical Association has called it an urgent threat, particularly in rural areas. In France, some doctors are trying to set up a pilot project for a “maison médicale,” or House of Medicine, where part-time doctors can parachute in to offer different disciplines.

“It’s difficult to get the work-life balance completely right. It’s part of the challenge,” said Dr. Beryl De Souza, a plastic surgeon at Chelsea and Westminster Hospital and a mother of three who works with Dr. Aggarwal and two other female surgeons, Dr. Effie Katsarma and Dr. Sherine Ravendran.

Dr. Aggarwal, the plastic surgeon, relied on her parents who came from India to help care for her baby. Dr. De Souza, whose husband is also a surgeon, also turned to her parents. Other women patch together strategies, sharing jobs and working less than three days a week. Some hospitals offer child care centers — not a solution for doctors on call late at night.

Late last year, the junior doctors conference of the British Medical Association called on the national Department of Health to start preparing for a demographic transformation by creating a regional system of job pooling.

Dr. Eleanor Draeger, deputy chair of the conference, who is training in genitourinary medicine in London and a mother of two, recalls that when she had her first child in 2007, four of the 11 trainees in her rotation left on maternity leave. In a rotation of doctors in a pediatric unit she knows, nine of the 10 women working there became pregnant last year and announced plans to go part-time after giving birth.

Most studies issued in England show that women ultimately return to work, increasing hours as their children grow up. As her four grew older, Dr. Cornish, the president-elect of the Medical Women’s Federation, did just that.

“I think most places are more family friendly now. When I started, I would be terribly nervous to say that I need to leave to go to a Nativity play. Now what really amuses me is that the men are announcing with great pride that they are going to a Nativity play,” she said.

But as female doctors pursue careers — and care for children and parents — some researchers in Spain and in France have found that female physicians are more vulnerable to the combined pressures of career and home life.

Last year, a study by the European Union of more than 3,000 French doctors found that women in particular had a higher burnout rate than men in emergency care. A lack of teamwork among medical staff members contributed to the meltdowns, according to the report.

“When you rush from one patient to another, you feel guilty for your family life. When you don’t feel that work is properly done, you feel guilty,” said Dr. Madeleine Estryn-Béhar, one author of the report and a physician with the Hôpital Hôtel-Dieu in Paris. “Social support protects from burnout. People who work well together have less problems.”

In Honor of Starting the Cardiology Module

18 Stethoscopes, 1 Heart Murmur and Many Missed Connections

By MADELINE DREXLER

One by one, the medical students bent down to listen to my heart.

There were six of them, led by a bright-eyed physician with a charming Irish accent — so charming I almost didn’t care that he never called me by name. All told, 18 second-year Harvard medical students would listen to me on this darkening winter afternoon, each group of six overseen by a different cardiologist.

“Place the diaphragm of your stethoscope here,” the Irish doctor was saying. “Start at the base of the heart and move down to the apex.”

He listened quietly. “Ma’am, take a breath in, and breathe out and hold it.”

I felt like an oddly invisible prop: part artist’s model, part one-night stand, heard but not seen. At first nobody made eye contact or spoke to me, a situation that evoked the universal vulnerability of patients: exposed, invisible, dehumanized.

Amplified through a stethoscope, the human heartbeat sounds like the muffled cadences of a marching band. Thuh-rhumm. Thuh-rhumm: A low washboard rumble, signifying a poorly functioning ventricle. Thhrrum-BUM. Thhrrum-BUM: A diastolic murmur, with its bass-drum finale. PAH-da-da-PAH. PAH-da-da-PAH: The crisp roll of aortic stenosis. Flutters, skips, thunks, whooshes, crescendos, decrescendos, telltale pitches and tempos — each conveys a diagnostic meaning.

Indeed, it was my “click” that had brought me to this class in the first place. The click is a prime feature of mitral valve prolapse, a generally benign condition in which the valve separating the upper and lower chambers of the left side of the heart doesn’t close properly.

During my annual physical, my doctor at Massachusetts General Hospital had remarked how loud and distinct my click was. Would I consider volunteering as a “patient,” so fledgling medical students could listen and learn?

I was intrigued by the chance to gain perspective on the doctor-patient interaction. Make that “Patient-Doctor II,” the intentionally reversed name of this second-year course that focuses on learning the physical examination.

Now, as I sat in an open-stringed green-and-blue-print cloth gown, I began to wonder if the students realized they were examining a live human being, as opposed to a particularly sophisticated anatomical model.

The fourth student who strode to my chair was a guy I remembered from a cardiology lecture I’d attended at the outset, taught by Dr. Katharine Treadway. He’d sat up front and answered her toughest questions, brimming with enthusiasm and brains. I had found myself rooting for his medical career. Now he listened, smiled at me and said, “Awesome!”

That broke the ice. At last I was a person, not a prop.

The next student opened with “Hi, how are you?” When she finished, she said, “Thank you very much!”

In this class “listening” had more than one meaning, as Dr. Treadway had illustrated with a cautionary tale. About 10 years earlier a woman agreed to let students hear her heartbeat. She had an advanced condition called severe mitral regurgitation and needed a valve replacement.

One student examined her, removed the stethoscope and blurted to the instructor, “How can she live if her heart is this bad?”

“This was a student who is not uncaring or unkind,” Dr. Treadway told the class. “But in that moment she did something all of us do all the time: she was so engaged with the problem that she forgot about the person who had the problem.”

As students master the intricacies of the physical exam, “the experience of that patient’s illness will be completely invisible to you, unless you consciously look for it,” she warned, adding: “At the end of every interview, say to the patient, ‘How has it been for you, being in the hospital?’ I want to bring you back to the patient.”

Now the Irish physician’s group departed, and the second group trundled in. This doctor introduced me right away. He had an easy and personable way about him, and I admired his arty cuff links.

Again, some of the students spoke to me, while others did not. One let his hand linger too long on my shoulder as he thanked me and turned to walk away: creepy.

Another remained stony-faced as he fumblingly examined me, never saying a word: really creepy. So inept was he that I decided not to lean forward, thus making my heart more difficult for him to hear. (Doctors who don’t earn the trust of their patients, by the way, are more likely to be sued in a malpractice claim.)

I didn’t become a full-fledged person until the 10th exam, this one at the hands of a student with short combed-forward hair and rectangular wire-rims.

“Hi, my name is Ben,” he said with a warm, professional smile as he looked me in the eye and shook my hand. I was instantly at ease.

Ben moved with natural confidence, as if he had been practicing cardiology for decades. While listening he closed his eyes, the better to hear the subtly separate click between the two heartbeats.

He made such a vivid impression in person — kind, compassionate, smart, capable, intuitive — that when I later played back our exchange on my digital recorder, I was surprised that his soft voice had barely registered. At the end of the session I asked him why he wanted to be a doctor.

“I had an experience in the hospital with my mom, who passed away,” he told me. “That’s when I realized what I wanted to do.”

The third group seemed to have picked up a few pointers. The doctor in charge not only called me by name, but rubbed her hands and the stethoscope to warm them up, which the students mimicked. They greeted me at the start and thanked me at the end.

Before beginning, they explained where they would be placing the stethoscope and why. And they listened to my heart intently, for longer stretches — one fellow for 5 minutes 25 seconds: a lot of listening.

Feeling like an acknowledged human being, I was more apt to adjust my posture for them and inquire whether they had heard what they were listening for. I wanted to meet them halfway; I felt I owed them a good click.

Still, it was not until the 18th student — the last — that someone bothered to ask my first name. She told me hers and shook my hand. How wonderful it felt to finally say my name, to be heard and seen.

At the end, I asked if I, too, could listen to my heart. The doctor handed me her stethoscope and placed the diaphragm on my chest. I donned the headset. “Other way,” the students said in unison. I turned it so the earpieces pointed in the right direction.

Like them, I had to listen silently and for a long stretch. At first I couldn’t discern the click. I leaned forward, breathed in and out, and held my breath.

Then I heard it. To my ears it didn’t sound like a click so much as a rolling wave with an accent in the middle. But I heard it — my billowing valve, my flapping leaflet — and I was transfixed.

A few minutes later my Mass General doctor, Diane Fingold, walked in. Dr. Fingold is helping to rewrite the Harvard Medical School curriculum.

At Harvard, she explained, students don’t touch patients until the second year; some schools even delay that fundamental skill until the third. Now a move is afoot to make this happen right away, in the first year, so the connection quickly becomes natural and ingrained. Blending the mechanics of the physical exam with meaningful conversation is what Dr. Fingold calls “the unwritten curriculum.”

I asked what she had learned about listening in her 20-some years as a physician.

“When I was not able to help someone or not able to cure a disease,” she replied, “my personal temperament and way of coping was to talk a lot.

“What I’ve learned is to shut up and listen and be comfortable with silence. Because that allows people who are not talkers to have a place and a space to speak. As the doctor who’s in a position of power, there’s this feeling that taking a medical history is something active — but you need to be an active listener.”

I told her I had seen stark differences among the students. Some, like Ben, seemed to be born doctors. Others appeared to have no grasp of human connection.

“We used to assume,” she said, “that people who went to medical school were all compassionate, were all good listeners — that we just needed to give them the knowledge and they would be good doctors. We now know that’s not the case.

“But we don’t give up on the ones who don’t have it from the beginning. We can give feedback that helps. It won’t make a stiff lab-rat type into a palliative-care oncologist. But it can make a difference.”

Dr. Treadway quietly leaned in the doorway, listening to our conversation. After a few minutes, she said: “There are some doctors who do not view you as a patient. They view you as someone with a heart murmur who they’re going to listen to.”

Then she told a story about a physician who had lectured her second-year medical school class in the 1970s. He described being in intensive care for three weeks with a frightening, potentially fatal condition.

“He told us that one of the things that had surprised him most about being a patient was that every single person he interacted with — be they nurse, resident, senior physician, respiratory tech, physical therapist — it was as though they had a neon sign on their forehead that said either ‘I care’ or ‘I don’t care.’ ”

But what illuminates those neon signs? What are the clues that were so starkly apparent to me, even in second-year medical students?

Perhaps the answer lies in the medical lexicon. Auscultation — listening to heart sounds with a stethoscope — is a required skill. But actually feeling the vibration of a murmur through the chest wall is a rarer proficiency.

The students had just learned the technical term for a heart murmur that a physician can feel: a “thrill.” As any patient knows, the touchstone of a good doctor is the ability to feel one’s heart.

iHealthcare

Treat the Patient, Not the CT Scan

By ABRAHAM VERGHESE
NY Times, Feb. 26, 2011

THE other day as I walked through a wing of my hospital, it occurred to me that Watson, I.B.M.’s supercomputer, would be more at home here than he was on “Jeopardy!” Perhaps it’s good, I thought, that his next challenge, with the aid of the Columbia University Medical Center and the University of Maryland School of Medicine, will be to learn to diagnose illnesses and treat patients.

On our rounds of the wards, Watson would see lots of other computers with humans glued to them like piglets at a sow’s teats. We might visit a patient with a complex illness — one whose second liver transplant has failed, who has a fungal meningitis and now also has kidney failure and bleeding and is on a score of medications.

Watson might help me digest the sheer volume of data that is in the electronic medical record and might see trends in the data that speak of an impending disaster. And since Watson is constantly trolling the Web, he would perhaps bring to my attention a case report published the previous night in a Swedish journal describing a new interaction between two of the drugs my patient is taking.

Better still, if Watson could harness data from all the patients in our hospital and in every other hospital in America, we might be alerted to mini-epidemics taking shape. For example, Watson might recognize that the kidney failure in our patient is linked to kidney failure in a patient in Buffalo and another in San Antonio; all three patients, he might inform me, were taking a “natural” weight loss supplement that contained a Chinese herb, aristolochia, that has been associated with more than 100 cases of kidney failure.

In short, Watson would be a potent and clever companion as we made our rounds.

But the complaints I hear from patients, family and friends are never about the dearth of technology but about its excesses. My own experience as a patient in an emergency room in another city helped me see this. My nurse would come in periodically to visit the computer work station in my cubicle, her back to me while she clicked and scrolled away. Over her shoulder she said, “On a scale of one to five how is your ...?”

The electronic record of my three-hour stay would have looked perfect, showing close monitoring, even though to me as a patient it lacked a human dimension. I don’t fault the nurse, because in my hospital, despite my best intentions, I too am spending too much time in front of the computer: the story of my patient’s many past admissions, the details of surgeries undergone, every consultant’s opinion, every drug given over every encounter, thousands of blood tests and so many CT scans, M.R.I.’s and ultrasound images reside in there.

This computer record creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.

Imaging the body has become so easy (and profitable, too, if you own the machine). When I was an intern some 30 years ago, about three million CT scans were performed annually in the United States; now the number is more like 80 million. Imaging tests are now responsible for half of the overall radiation Americans are exposed to, compared with about 15 percent in 1980.

With that radiation exposure comes increasing risk for cancer, but what worries me even more is that this ease of ordering a scan has caused doctors’ most basic skills in examining the body to atrophy. This loss is palpable when American medical trainees go to hospitals and clinics abroad with few resources: it can be quite humbling to see doctors in Africa and South America detect fluid around patients’ lungs not with X-rays but by percussing the chest with their fingers and listening with their stethoscopes.

Of course, we still teach medical students how to properly examine the body. In dedicated physical diagnosis courses in their first and second years, students learn on trained actors, who give them appropriate stories and responses, how to do a complete exam of the body’s systems (circulatory, respiratory, musculoskeletal and the rest). Faculty members stand by to assess that the required maneuvers are performed correctly.

But all that training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be “throughput” — getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge. And the engine for all of that, indeed the place where the dialogue between doctors and nurses takes place, is the computer.

The consequence of losing both faith and skill in examining the body is that we miss simple things, and we order more tests and subject people to the dangers of radiation unnecessarily. Just a few weeks ago, I heard of a patient who arrived in an E.R. in extremis with seizures and breathing difficulties. After being stabilized and put on a breathing machine, she was taken for a CT scan of the chest, to rule out blood clots to the lung; but when the radiologist looked at the results, she turned out to have tumors in both breasts, along with the secondary spread of cancer all over the body.

In retrospect, though, her cancer should have been discovered long before the radiologist found it; before the emergency, the patient had been seen several times and at different places, for symptoms that were probably related to the cancer. I got to see the CT scan: the tumor masses in each breast were likely visible to the naked eye — and certainly to the hand. Yet they had never been noted.

Too frequently, I hear of (and in a study we are conducting, I am collecting) stories like that from all across the country. They represent a type of error that stems from not making use of basic bedside skills, not asking the patient to fully disrobe. It is a more subtle kind of error than operating on the wrong limb; indeed, this sort of mistake is not always recognized, and yet the consequences can be grave.

IN my experience, being skilled at examining the body has a salutary effect beyond finding important clues that lead to an early diagnosis. It is a ritual that remains important to the patient. Recently my ward team admitted an elderly woman who had been transferred from her nursing home in the night because of a change in her mental status. A CT of the head and all other tests were determined to be normal; the problem had been dehydration, and she was better, ready to go back. But as our team was about to enter the room, my intern warned me that the patient’s lawyer daughter was unhappy with the plan to return her mother to the nursing home, and was waiting impatiently to see me and contest the transfer.

After introducing myself to the patient and to her daughter, I did a thorough but quick neurologic exam. I put the patient through her paces: mental status, cranial nerves, motor and sensory function, used my reflex hammer and pointed out interesting things along the way to my interns and students. I then said to the daughter that her mother seemed back to normal. To our surprise, the daughter seemed comforted, and now had no objection to her mother’s return to the nursing home.

Later, our team discussed what had just happened. We all felt that the daughter witnessing the examination of the patient, that ritual, was the key to earning both their trusts.

I find that patients from almost any culture have deep expectations of a ritual when a doctor sees them, and they are quick to perceive when he or she gives those procedures short shrift by, say, placing the stethoscope on top of the gown instead of the skin, doing a cursory prod of the belly and wrapping up in 30 seconds. Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: “I will see you through this illness. I will be with you through thick and thin.” It is paramount that doctors not forget the importance of this ritual.

An answer that might have been posed on “Jeopardy!” is, “An emergency treatment that is administered by ear.” I wonder if Watson would have known the question (though he will now, cybertroller that he is), which is, “What are words of comfort?”

Haiti

As many of you know (because if you are even reading this blog, you probably got the mass email that I sent out in December), I am traveling to Haiti twice this year.  

During my first trip this April, I will be going as part of a women’s health team from Emory to provide medical care and humanitarian support to the underserved Central Plateau.  Our team is part of an established non-profit 501(c)3 organization, Project Medishare, and we will be running clinics near Haiti's border with the Dominican Republic. The team will include physicians, residents and medical students, and we expect to see close to 900 patients in our five days running clinic.

In terms of fundraising for the trip, we have 2 major costs that we are trying to cover: the trip costs for ourselves and for the physicians and interpreters that generously volunteer their time, and supplies for the trip, including much-needed medications, medical supplies, nutrition supplements, bed nets, water filters, diagnostic testing, and other public health interventions.

Because of the nature of our project, we are able to get medicines and supplies at very reasonable rates -- that is to say that even a small donation can make a huge difference and go a REALLY long way. Just to give you an idea, here are some estimates...

$0.55 covers 1 liter of oral rehydration solution to treat diarrheal illness, which we'll see in hundreds of kids

$5 covers a bednet to protect one patient from malaria for the next year

$10 covers antibiotics to treat malaria in one patient

$20 covers a water filter to protect one family from future parasites and diarrhea

Your donation will be put towards buying these supplies, which we will then deliver to patients during what will be, for many of them, their only visit to a doctor all year long. 

Right now, I am about a third of the way to my fundraising goal.  It would mean so much to me to have your support.  Please consider making a donation... even $5 would make a big difference!

The easiest way to donate is through my personal (secure) fundraising webpage:

Click here to make a donation.

Or, alternatively, you can send checks made out to "Project Medishare for Haiti" with “Cathy McDermott” in the memo line.  My address is 1445 Monroe Drive NE, Apt. C31, Atlanta, GA 30324.

If you know anyone else who might be interested in supporting this project, please feel free to pass this along.

 Many of you know how long I have looked forward to being able to make a difference for those in need around the world… I would love for you to be a part of my first experience as a medical student doing global health work.