The "D" Word

I have a vividly clear memory of a conversation with my sister-in-law that happened years ago.  At the time, I don't think she was even my sister-in-law yet; I think she and my brother were dating or maybe engaged.  They must have been in their senior year of college or just graduated, and she was somewhere in the midst of the very long academic-requirement-and-standardized-test-filled process of getting into medical school.  Someone asked her where she thought she might want to go, and she told them she was hoping to get into UAB, in her home state of Alabama.  She was a resident there, she explained, and going to a public school with in-state tuition would be far less costly than other options.  As a happy bonus, it also happens to be quite a good school, but, as she told her inquisitor, keeping her student debt load as low as possible was a priority, because she did not want to feel its pressure someday exert influence on her choice of medical specialty.

At the time, I was still working random jobs to prolong my gallivanting the globe as long as possible.  I had no idea what I wanted to do with my life, but I had zero intentions of going into medicine.  I remember overhearing this conversation, and privately thinking to myself, "Well, now, that is just absurd."  After all, I thought, doctors are not poor.  They may not be investment bankers, but they do just fine.  Even the lowest-paid specialties in medicine earn significantly more than most other jobs.    And plenty of people go into plenty of debt for graduate school, but it works out - in a field like medicine, you will be able to repay your loans eventually.  How short-sighted to limit your options for something like money.  (I must confess that the other thing I thought during this conversation was, "Alabama??  Really???"  And not just because of some inherent prejudice I had against the south, although that was certainly part of it.  I totally adore my sister-in-law and my brother, and I was maybe just a teensy bit pissed off that she would not consider moving to Colorado, or some other, more desirable part of the country, closer to the rest of the family.)

I should stop here to note that I could probably tell dozens, if not hundreds, of personal stories and sprinkle them liberally with giant asterisks that would direct you to postscripts about the overwhelming force that irony seems to have in my life.  Seriously, if I have ever thought that something would definitely not happen to me, that thing will most definitely happen.  If I ever say that I will never do something, I might as well just start planning for the day that I will do it. *  

I am posting an article tonight about student debt that originally appeared about a month ago in the New York Times.  It is a subject that hits painfully close to home, and it's a rather interesting (in addition to distressing) factor for me to ponder as I near the point in medical school where I will need to get serious about one medical specialty and decide to devote my career to it.  Our schedule at Emory being set up as it is, I am approaching the end of the third-year curriculum, and have now rotated through many of the major specialties and spent a very small amount of time on just a few of the minor ones.

I, like my sister-in-law, came to medical school enthusiastically committed to the idea of primary care - its importance to health, the critical need in this country for more physicians in this specialty, my own career heading in this direction - and at this point, my theoretical commitment to it has not wavered.  On a personal level, however, I am not at all sure that this is the specialty I want to pursue.  Multiple factors obviously play into this: my experiences on my third-year rotations, my greater understanding of what different specialties entail, my clearer vision of myself, my talents, my interests and my future goals.  It would be naive of me, though, to assume that debt burden and future potential salary were not at least subconsciously casting their votes as I try to process this decision.  

*Of course, the multiple ironies in this story, starting with my going to medical school, include my moving away from family, to the south, where I am currently very much aware of the burden of student debt and its potential influences on choice of specialty.

Tackling the Problem of Medical Student Debt

By Pauline Chen, M.D.

December 13, 2012

Thursday's announcement from the University of California, Los Angeles, of a $100 million medical student scholarship fund should inspire all of us to question the fact that medical education in the United States is paid for largely by student debt.

The new merit-based scholarships, established by entertainment executive David Geffen, will cover all educational, living and even some travel expenses for a fifth of next year's entering medical school class, some 33 students. Mr. Geffen and school officials hope that eventually the school will be able to pay for all medical students and free them from the obligation to take out student loans.

"The cost of a world-class medical education should not deter our future innovators, doctors and scientists from the path they hope to pursue," Mr. Geffen said in a statement. "I hope in doing this that others will be inspired to do the same."

The cost Mr. Geffen refers to has skyrocketed over the last 25 years. The median annual tuition, or yearly cost for attending classes, is now more than $32,000 at public medical schools, and more than $50,000 at private institutions. And medical students must also pay for textbooks, equipment, room, board and travel expenses, adding $20,000 to $30,000 to each year's expenses and pushing the total four-year cost of attending medical school to more than $200,000 at public institutions and close to $300,000 at private schools.

Some medical students commit to military service or to practice in a medically underserved area to reduce costs. But the vast majority end up borrowing money from federal or private loan programs, or from family if they are fortunate enough. The median debt for medical students upon graduation is more than $160,000, with almost a third of students owing more than $200,000. And those figures do not include interest costs over payback periods of 25 to 30 years.

There are several reasons for the runaway costs. One is that the academic medical centers that house medical schools have become increasingly complex and expensive to run, and administrators have relied on tuition hikes to support research and clinical resources that may have only an indirect impact on medical student education.

An equally important contributor to the problem has been our society's placid acceptance of educational debt as the norm, a prerequisite to becoming a doctor. Obtaining a medical education is like purchasing a house, a car or any other big-ticket item, the thinking goes; going into debt and then paying over time with interest is just the way the world works. And, say many observers, newly minted doctors will earn big salaries, allowing them easily to reimburse their loans.

While it is true that most doctors can pay off their debt over time, those insouciant observers fail to consider how loan burdens can weigh heavily on a young person's idealism and career decisions.

For example, financial considerations have been shown to be a major deterrent for undergraduate students considering a career in medicine, particularly for students from diverse backgrounds. And even the most committed students who do make it to med school may eschew research or specialties like geriatrics, family medicine and pediatrics in favor of a more lucrative career in dermatology or ophthalmology.

These choices have enormous social repercussions. Despite the well-studied benefits of a diverse physician workforce, more than half of all medical students currently come from families with household incomes in the top quintile of the nation. Even more worrisome, student concerns about debt are exacerbating the nation's physician shortage. By the end of this decade, we will be short nearly 50,000 primary care physicians and an additional 50,000 doctors of any kind.

Educators and groups like the Association of American Medical Colleges have been trying to address the problem of medical student debt for more than a decade. Some have suggested simply freezing costs or prorating debt according to the earning potential of a student's chosen area of specialty.

But the most durable solutions thus far seem to be scholarships made possible by philanthropic donations like Mr. Geffen's. The University of Central Florida's new medical school, for example, was able to offer its charter class in 2009, consisting of 40 students, a four-year scholarship that covered tuition and living expenses thanks to several gifts. And the Cleveland Clinic Lerner College of Medicine, established with a $100 million gift from philanthropists Al and Norma Lerner, has been able to educate a small cadre of future physician-scientists while granting all of them scholarships to cover tuition costs.

Mr. Geffen's fund represents the first sustained scholarship to cover all expenses, not just tuition, for a sizable portion of students at a single medical school. Combined with his unrestricted gift of $200 million that led to naming the medical school in his honor a decade ago, Mr. Geffen's contributions represent the University of California system's largest donation ever from a single individual.

But the real importance of Mr. Geffen's donation for the rest of us lies in not its historic largesse, nor its hopeful vision. Rather, it is in the dramatic impact one individual can make when he makes medical education a priority, and the inevitable question such a gesture raises: Why has our society been so slow to do the same?

Day One

The patient was not a young man, but his disabilities and medical problems far outstripped his chronological age.  Chief among them was diabetes.  Disadvantaged circumstances, hard living, some drug use here and there, and good dose of the euphamistically-termed "health illiteracy" were among the many factors that got him to where he was that day.  Admitted to our service from the ED with a chief complaint of chest pain and syncope, he nonetheless had a laundry list of different issues we would need to address, including a seeping wound left behind from the recent amputation of all of his toes on one foot, the unfortunate and unfortunately predictable consequence of an advanced diabetic foot ulcer.  It was actually the least of his worries on this hospital visit.

The resident who had worked him up introduced him to the rest of the team and summarized his lengthy problem list, verifying details with him and clarifying others.  There was a serious discussion of the points that most concerned us regarding the state of his health.  The patient nodded along.  Very little of this was new information for him, but this most recent incident seemed like it had hit home in a rather new way.  He seemed eager to collaborate; he spoke of experiencing a wake-up call and told us that he fully intended to live a long life, as healthy as he could make it.

The attending wrapped up the summary of the plan going forward, checking to make sure all the patient's questions had been answered and that all of us on the team were on the same page.  The patient shook her hand and looked around at everyone else in the room, saying how much he appreciated the help.

There were the usual "okay"s and "very good"s and "we'll be back to check in on you, sir"s as we collectively straightened up and slowly turned to shuffle for the door.  His face still worked, betraying unfinished thoughts.

"Hey, Doc?  Can I tell you somethin' that's really just been on my mind?"  His voice dropped, softer, timid, something maybe a little bashful about it.  His fingers worried the thin sheets in his lap, rolling and twisting the fabric in small movements.  His chin dropped to his chest as his eyes momentarily closed; every muscle in his face moved together to paint weariness and suffering into deep crevices.

"Diabetes just... sucks, man."  Head lurched with voice for greatest possible emphasis.  "I just... caint even tell you how much it sucks.  It just makes everything bad, man..." he heaved a great sigh.  "I just caint even describe to you all the suffering it causes me.  It's just right up there next to marriage!"  And with that, hands slapped thighs, head lurched again, this time with crackly laughter.  His eyes twinkled at us, checking to make sure we got the joke, as he shook his head, shoulders bouncing.  A fine tension dissolved as we broke into smiles along with him, an unexpected bit of levity trailing behind us as we left his room and moved on down the hallway.

Welcome to the medicine rotation.

Smartypants

She was six years old, tow-headed and blue-eyed, whip-smart and just as precocious as she could be. 

She had a raging, fluctuant abscess in her axilla about the size of an egg.  It had been there, erythematous and growing, for six weeks by the time they finally came in to be seen.  It was painful for her - and it looked it.  Luckily, the treatment of an abscess is straightforward: you incise and drain it.  For a pediatric patient, this would be done under anesthesia in the operating room.

She came in to the hospital with her father, and they were shown into one of the day surgery suites, where they would wait until she was taken back to the OR.  The surgical intern went to do her pre-operative history and get consent for the surgery.  When she was asking details about the time course of this rather large lump in the patient's armpit, her father explained that they had noticed it a few weeks back, but that he had not brought her in sooner because he had assumed it was an enlarged lymph node.  She had had a recent cold, and her father chalked it up to that for a while until he realized it wasn't resolving.  

The intern began to explain to him and his daughter that it appeared that the lump, instead of an enlarged lymph node, was actually an abscess. 

"This basically means that it is a collection of pus from an infection somewhere that the body has walled off into this pocket, and that is what we are going to drain today."

The father politely cut off her explanation, "Yes, I know what an abscess is.  I have a PhD in Biology."

The  daughter piped up:

"Yeah, and he thinks he is smarter than aaaallll the doctors!"

Trauma

I don't care what surgery service you're on, even if it's not trauma - it's ALL trauma.

Seriously?  Surgery is trauma for everyone involved.  Even an uncomplicated, routine case involves fairly significant trauma for the patient.  Don't be fooled into thinking otherwise - it is very carefully controlled trauma, but trauma nonetheless.  Minimally invasive?  I mean, sure, you end up with three or four tiny little neatly-closed incisions around the belly, but have you ever seen the whole process?  The way those trocars get maneuvered around in their ports, the shoving things around, tearing things down, cauterizing whole swaths of tissue... man.  I love watching surgeries.  I think it's the coolest thing, and it is super easy to become desensitized to the violence of it.  But yikes.  Surgery is no joke. 

It is also trauma for the residents and the med students.  At least for me it is... the whole time you're standing there during the surgery, the attending can pimp you at will - basically, he or she can just ask you anything they want to ask, related to the surgery or not - and I never feel totally confident about my answers.  It can happen at any time and without warning... you're never free to just relax, you always have to be on guard for random flying tricky questions smacking you in the face and making you look like a total idiot.  It can be trauma for the nursing staff and the scrub techs - some attendings have notorious temper control issues, and all attendings have very different, nuanced personal preferences about how they like things set up, what they like to use, etc, and they are not shy about letting someone know when they don't get it right.

Surgery is trauma physically and emotionally, too.  Being on your feet all day is less than ideal for your back.  The crazy hours lend themselves to terrible self-care.  I have literally not worked out in three weeks now and am starting to feel totally nuts mentally and super crappy physically.  Nutrition has mostly gone to pot - remember the cookie party on Sunday night?  Yeah, it has basically sustained me all week.  Only I have long-since finished the actual cookies and have now started in on the huge batch of gingerbread cookiedough that never made it to the baking stage on Sunday.  That was my dinner tonight.  Not kidding.  Trauma regarding my personal life - today, my attending asked me if I had kids.  When the answer was no, the question was, well, are you married?  No?  Ok, well, what about someone special, then?  I said no, absolutely nothing, nothing at all going on my life.  And his response was wellllll.... at least... at least you can do what you want whenever you want...?

It's even trauma for the floor nurses. Ok, so this incident didn't actually have anything to do with surgery, and I don't even know if it was one of our patients that was involved, but when I got to work a couple of mornings ago, some of the nurses were shaking their heads and muttering in disgust.  When I asked, one nurse told me that everyone was all in a tizzy because one of the patient's parents had been, shall we say, getting amorous in the patient's hospital room.  Not only that, but it was happening while the patient, a young baby, was crying the entire time.  And not only that, but the nurses knew this because they could hear it from out in the hall!  Ugh, really?  Gross.

~ ~ ~

And then there is the actual trauma.  The awful, horrible, heart-pounding, life-flight bloody trauma, that, when you are in a pediatric hospital, can just be too much to bear.  

Last night there was one of those.  

It came in just as I was about to leave at a decent time in the afternoon, and it was absolutely horrific.  There are really no words for when something like that happens to a small child.  But one of the worst,  sickest aspects of the whole experience?  The truth is that a part of me was thrilled to be there for this case.  It feels horrible to admit that.  It was such a hideous tragedy.  I think I was mostly just so happy to finally be helping, to finally be useful, to finally be able to use skills that I actually do have and to feel like I actually did know what to do and how to do it and then actually be able to do it.  I love being in the operating room when I am getting to participate. 

We operated for probably close to seven hours, sewing and sewing, trying to put this little girl back together.  

When we finished around midnight, I went home and slept for roughly about three hours before I got up to go back in this morning.  We rounded, went to grand rounds, had lecture, went to clinic, went back to the school for a lab on advanced vascular access.  

It was sort of a shitty, blah daze of a day.  A reminder that I have not even started to do a fraction of the studying I need to do for the exam that is fast approaching.  No breakfast food left, no coffee made, not even any crappy energy bars left to grab on my way out the door.  A text from my landlord letting me know that hey, fyi, your rent check bounced, again.  Oh yeah, my financial situation is still so far down the shitter that it is actually in the water-treatment facility an hour down the highway.  Half a dozen more automated phone calls from my credit card company telling me that my payment is late, again.  Which was then followed by a voicemail informing me that my precious doggie has finally figured out that she can clear the fence and so now, even though we have finally bullet-proofed the gate that she had continuously, ingeniously found a way to foil until very recently, she is still escaping.  And when she was put back in the yard and tethered to a line set up on her leash, she chewed straight through her leash and severed it completely.  Her dog walker has apparently not been showing up and she has also somehow destroyed the latch on her crate door, so now I have zero good options for her while I am gone for 14-hour days.  

I wore heels today.  My feet were killing me.  When I left the school, it was dark already.  I walked to the parking garage in the dark, drove home in the dark, got home to a completely dark house.  Not a single car in the driveway, not a single person at home.  And I just burst into tears and proceeded to have a small breakdown.  My first cry on surgery.  My first cry in a good long while, actually.  My roommates got home a little while later and walked in and said "hi" to me and I started crying again.  I took a long, hot shower and sobbed.  I am crying right now, sitting in bed and typing.  

I don't really know how to deal with this stuff.  When I started this post a couple of days ago, I meant for it to be sort of a funny "wow, this is super tiring and intense and ridiculous and how about those inappropriate parents?!" post, but then last night happened, and I was mostly really put-together about it until a couple of hours ago.  Now I just feel drained and exhausted beyond belief and I can't think about last night at all without crying.

If you are a pray-er, maybe say some extra-special ones for a little girl in an intensive care unit tonight.  She has a really hard road ahead. 

Surgery Dreams

... dreams that I have while on my surgery rotation, that is.  Let me know if you want to take a stab at deconstructing this one.

~ ~ ~ 

Last night, I dreamt that I was in some sort of indoor/outdoor castle for some sort of interview (unclear what the interview as for - it seemed to be some sort of admissions or job interview, or possibly both - you know how things can do that in dreams) and I was interviewing with a close friend, and the interviewer was a surgeon (again, not entirely clear why, maybe the school/job had to do with surgery, I don't know, but he was a very important and intimidating person.)  And I thought it was all going quite well, until at one point, for some reason, I had to stand up to deliver my responses for that part of the interview, and for some reason, there was what I thought was a hand-sanitizer dispenser on the wall next to me, and for some reason I knew that I had to clean my hands before I would be allowed to speak, and so I  stood up, reached out my hand, dispensed some into my open palm and then proceeded to rub my hands together, immediately realizing that I had made a mistake, and that it was actually regular soap instead of sanitizer, and so now I was in the middle of this very important interview, wearing a suit, with both hands entirely covered in liquid soap.  No sooner had I made this tragic error than the surgeon-interviewer lowered his chin, scowling at me from under furrowed brow, folded his hands on his lap and announced that my interview was over.  And my very good friend, who had been seated behind me while all of this happened, laughed at me and said something to the effect of "too bad for you" before continuing to converse with the interviewer, with whom she suddenly was best friends. 

It was awful.  

And then after that my flying skills came in handy when I joined some sort of outdoor field game involving something like keep-away with a small French horn.  Whatever.

On second thought, if you know anything about dream interpretation, I probably don't want to hear your read on this.

~ ~ ~

PS.  Last night, we hosted a Christmas-cookie-baking party at our house... sooooo you can guess what my dinner was when I arrived home twenty minutes ago.  Also, I am seriously contemplating sleeping in clean scrubs so that I can save the 38 seconds that it takes to put them on in the morning.  Don't judge.  I am also going to bed NOW... it's 8:30 pm and I have to get up in less than 8 hours already. Sweet sleepy Jesus.

Quickie

Heyyy!!  Howzabout squeezing in one more post for the month right at the last second??  Surgery is  just killing this whole blogging thing over here... so it's gonna be all pictures, sorry.  :)  Here is another handful of shots I took last week.  

Enjoy your weekend!!

Back

Back to life in Atlanta, back to surgery, back to hot showers, back to studying, back to my puppy, back to worrying about lots of the same shit.  In other words, plusses and minuses.

Haiti was amazing.

I feel rejuvenated, revitalized, re-energized, re-excited.  Mostly, though, just so incredibly blessed to have had the opportunity to go on this trip, and incredibly fortunate to have a passion that I am lucky enough to follow.

I'll write more about the trip later, and just post a few quick pics right now.  I took way fewer pictures this year, and those that I took were mostly nowhere near as good as the shots I got last year, but a few other people took a bunch, so I will post a lot of good ones when I get the chance.

In the meantime, happy belated Thanksgiving, friends.  So much to be thankful for.

The Score So Far

One and a Half Weeks In: 

I have to preface this by saying that I was really, really nervous about the surgery rotation, for a few reasons.  The main reason is that I am not a morning person, I hate getting up at unreasonable hours (and for me, anything before 8 am is unreasonable), I am always late to everything, I am naturally a diehard night-owl, and I do not function well on little-to-no sleep.  Granted, I do it all the time, but I rarely feel like I am functioning well.  Anyway, needless to say, all those factors taken together made me very afraid that I was a) probably going to be the worst surgery student of all time and b) certainly going to be totally and completely miserable on the rotation.

The uniform.

I was also nervous because I hate feeling inept, and even though I feel that way every single day in medical school, I figured that feeling would be intensified on surgery (and this has actually turned out to be more or less true.)

New fall shoes! :)

Other reasons I was nervous include some of the questions mentioned in my previous post (and, full disclosure: the last question/concern was actually mine).  I was feeling really bummed that my heretofore somewhat-respectably-consistent exercise routine would be over forever, and that my much-healthier eating as of late would be out the window also.  

However, I am very happy to say that so far, none of my fears have been realized.  (Major caveat: I am starting out on my specialty surgery half of the rotation, and I am on the plastics service... they are notorious for having amazing hours - read: only somewhat longer than regular working hours, as opposed to inhuman hours - and they are also just a very laid-back and fun service to be on in general.  In other words, THIS COULD/WILL ALL CHANGE when I go to general surgery next.)  

In terms of getting exercise, I have actually made it FitWit most nights so far, and squeezed in a run one night when I couldn't go!

[winner: me]

Haters gonna hate.

How about eating healthy?  For the most part, I think I have done fairly well.  Eggs for breakfast!  Salads for lunch!  Apples for snacks!  Boo-ya!  Today was actually the first time in over two months that I have not packed my own lunch for work.  Pretty good streak, right??  But it might be over, sadly... I have no more groceries at home.  And today I had not one, but two Cliff Bars.  And a burrito.  And a beer.  And lots of Halloween candy.  Soooo... let's call it a wash.

Social life?  Haha... ok, this one has been sort of legitimately sucky.  Thank God I live with people I like talking to, because I have pretty much only seen them.  And I have only seen them a handful of brief times.

[winner: surgery]

But!  On plastics, you basically have weekends off (shhh, don't tell the other surgery students!), so this past weekend, I was able to drive up to Chattanooga to visit my great uncle John along with my mom, aunt Jane, and brother Martin.  Beautiful chilly fall weather, gorgeous leaves, lots of good food, plus seeing my great-grandparents' old home for the first time in probably 17 years...

[winner: me]

Great Uncle John, Aunt Jane, Mom, Martin, yours truly

And of course, there have been some holiday celebrations... that have consisted mainly of making Izzy wear this awesomely adorable costume (hey, it's my first Halloween with a dog!  I couldn't help myself.)  The roommates and I also carved jack-o-lanterns last night, which I haven't done in years.  It was a lot more work than I remembered!  But so fun.  And we also roasted the seeds... yummmm.  It also took a really long time, and so I didn't study at all and I went to bed really late, which made today sorta rough.

[winner: me, I think]

Izzy the WonderDog!

(She doesn't love wearing costumes.)

Also, on a somewhat surprising note, I have found that I am kind of loving surgery.  Like, a lot.  So all in all?  I'd say, so far... I'm still coming out ahead.  :)

Surgery Has Started....

Today, in orientation...

Clerkship director, MD: "So let me just take a few moments to address some of your fears about this rotation."

[Student concern.]

"You are worried about getting enough sleep.... You'll be fine.  You'll be really tired, that's just the way it is.  But you will be fine."

[Student concern.]

"You don't think you will be able to study enough and learn all there is to know?  Ha.  Yeah, you won't.  Don't even try."

[Student concern.]

"Your knowledge of anatomy is rusty?  Um, yeah, none of you know anatomy.  Don't worry, we expect that."

[Student concern.]

"Getting enough exercise and eating healthy??  Oh, forget it!"  [Laughs hysterically.]  [Recovers a little.]  "Seriously, though, take the stairs."  [More laughter.]

Everything Possible?

During my nursery week on my pediatrics rotation, I saw a patient in the NICU who, even in the land of unbelievably tiny, critically ill infants, was doing exceptionally poorly.  She weighed around three pounds, required assistance to breathe, had severe hydrocephalus and a ventricular assist device to help shunt the excess fluid out of her skull.  She had already spent more than two months in the unit, and she was still two months away from her estimated due date had she made it to term.  She had been born via emergency C-section when her mother went into pre-term labor as a result of an infection at 22 weeks of pregnancy.  She had a twin sister that did not survive.

For reasons that aren’t entirely clear – perhaps unreliable dating of the pregnancy and therefore the infant’s gestational age, perhaps poor communication between the patient, the obstetricians, and the neonatologist – the neonatologist who was present at her birth believed that she was around 27 or 28 weeks’ gestational age.  She had to make a quick decision at the time of birth about whether or not to intubate the infant, and she says that even though her visual assessment of the girl was that she seemed terribly small, even for a 27-week preemie, she went ahead and intubated anyway.  She says now that she doesn't know if it was the right thing to do, that she had simply acted on the information she had at the time, and that she often regrets it when she passes by the isolette of this horribly fragile, tiny baby.

Babies born prematurely suffer more adverse health outcomes than term babies, and the more premature they are, the greater the number and severity of the complications they have, both in the short-term and the long-term.  Normally, the cutoff age for viability is 24 weeks’ gestation, and babies delivered at this age have a grim outlook – less than 50% even survive – but in this case, an infant even younger than that was kept alive when prevailing best medical practices would have dictated not to resuscitate such a premature baby.  The reasons behind these guidelines are numerous and range from the sheer probability that the child will live to the overwhelming health challenges they are guaranteed to have if they do.  Another, not at all insignificant factor, is the incredible amount of resources it takes to care for them after birth.  The daily average NICU stay exceeds $3,500 per infant, the average NICU stay costs $45,000, and it is not unusual for the total cost of an extended stay to exceed $1 million.  That is the kind of extended stay that Baby 22 Weeks is currently having here in an Atlanta hospital.  It is unclear at this point whether or not she will ever be well or strong enough to leave the NICU, and if she does, what quality of life she will be able to have.  Her mother won’t entertain any sort of conversation at all with her baby’s doctors about how to manage her case other than to “do everything possible”.  

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No real deep thoughts here tonight.  It's test week, so I have neither the time nor the energy to do a whole lot of reflecting or writing.  I was just doing a quick little write-up for an upcoming ethics session we have during this last week of the peds rotation.  It is supposed to be about an ethical issue that we have witnessed during the rotation, and this is what I kept coming back to.  I am curious about people's thoughts.  I am not at all saying that this baby does not deserve to live, and I really hate the economic/financial expense argument when talking about the worth of a life.  I am in awe of what doctors are able to do, both before and after birth, to save the lives of infants with conditions that, until only very recently in history, would have had a 100% mortality rate.  I'm not even totally sure there is a real ethics issue here: the obstetricians tried to keep the mother's preterm labor at bay, the neonatologist acted to save the life of an infant she believed to be unquestionably viable, the mother wanted (and continues to want) everything possible to be done for a child that she loves.  Surely mistakes were made and surely this outcome was by no means unavoidable.  Maybe it's just the tragedy of the whole situation that gets to me.  Maybe it's just that, in a medical world with so much potential to do so much good, sometimes a lot of very smart people trying their best still get it wrong.  And maybe it's not the ethics of this case that gets to me.  Maybe it's that sometimes there are just no easy answers to be had.

Bicycle Built for Two

Bicycle bicycle bicycle
I want to ride my bicycle bicycle bicycle

I want to ride my bicycle
I want to ride my bike
I want to ride my bicycle
I want to ride it where I like

-Queen, “Bicycle Race”

It won't be a stylish marriage --

I can't afford a carriage,

But you'd look sweet upon the seat

Of a bicycle built for two.

-Harry Dacre, "Daisy Bell (Bicycle Built for Two)"

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In the world of hipsters and wannabes, wedding blogs and Pinterest, anyone who is between the ages of 20 and 40, or knows anyone between the ages of 20 and 40, will have already been familiar with the adorable image of a tandem bicycle on a wedding invitation (if you haven’t yet, don’t worry – it’s coming.)  However apt the image of a tandem bicycle might be for a new marriage or young love, in the unexpected setting of Parkinson’s disease, it makes an even more fitting, touching and literal symbol of not only love and devotion but even cutting edge medical promise, as well.

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Parkinson’s Disease is a devastating neurological condition in which the afflicted slowly lose control over the movements of their body.  Slowness, tremors, deterioration of speaking ability and balance are some of the major manifestations of this disorder that affects an estimated 1 million Americans, and for which there is no cure.  In addition to problems with movement, people with PD also commonly suffer from depression, dementia, sexual difficulties and sleep disturbances.

PD is a progressive, degenerative nerve disorder that affects the neurons in the brain that control movement. The main neurons affected are located in the substantia nigra of the basal ganglia, which serve as the coordination center for signals coming from the cortex of the brain to the spinal cord in order to move muscles on command.  Their deterioration causes a deficiency of dopamine, a key chemical for proper brain function and the main neurotransmitter that they produce.  This is where the bicycles come in.

In the spring of 2010, Dr. Bastiaan Bloem of the Radboud University Nijmegen Medical Center in the Netherlands was visited by a patient with advanced Parkinson’s.  This man had been afflicted with the condition for ten years, and he had been left nearly unable to walk at all, with a severe balance deficit, feet that repeatedly froze on the floor and a tremor that would cause him to fall after just a few shuffling steps.

This patient told his doctor that he could, however, still ride his bike perfectly – and was determined to prove it.  So doctor and patient went out to the parking lot, and with the help of a nurse to get him on the bike and shoved off, the patient rode off in perfect control, making a U-turn at the end of the parking lot and pedaling smoothly back, all Parkinson’s symptoms vanished.  The moment he brought the bike to a halt and stepped off, he froze immediately, unable to move his legs in a single step.  The episode was filmed and photographed, and the images were published in the April 1^st, 2010 issue of the New England Journal of Medicine.

Dr. Bloem – wheels turning, as it were – then asked 20 of his other patients severely affected by Parkinson’s disease if they could ride a bike.  It turned out that they all could. 

One explanation for the finding, according to Dr. Bloem, could be that bicycling uses a different part of the brain than walking – and that this part might not be so severely affected by Parkinson’s disease.  It could be, perhaps, that bicycling doesn’t require very much input from the part of the brain that’s diseased in Parkinson’s patients, the basal ganglia.  It’s the basal ganglia that processes signals for voluntary movements, and its impairment is the reason Parkinson’s patients freeze – the part of the brain that tells them what to do next isn’t functioning.  It’s certainly possible that one of the reasons the Dutch patient wasn’t showing any sign of Parkinson’s while riding a bike is that riding a bike doesn’t require a lot of signal processing in the basal ganglia.  Nurses helped the patient onto the bike and got him going, but once he was going, he could keep doing the same thing without much thought about motor strategies.  (Gives new significance to the old adage, “like riding a bike.”)

Another theory regarding the reason for this phenomenon is that it could be that the rhythmic pressure of the pedals on patients’ feet cues the nervous system to allow a cycling movement.  He suggests that the rotary motion of the pedals may provide an external pacing cue that keeps the Parkinson’s patients on track.  Given appropriate visual or emotional cues, people with Parkinson’s can dance, walk without freezing and perform complex movements for a few minutes at a time.  For example, there are many stories about patients with PD being caught in a building on fire and finding themselves able to run down stairs and escape safely, only to have symptoms return as soon as they got outside.  But this kinesia paradox, as it is known, does not last long, and is entirely different from being able to ride a bike flawlessly for miles at a time.  Until now, it was not known that patients with Parkinson’s could ride bikes.

In fact, the "bicycle sign" might help clinicians differentiate between the Parkinson’s disease and Parkinsonism of other disorders.  Patients with atypical Parkinsonism lose their ability to cycle during the early phase of the illness, while patients with Parkinson's disease continue to ride well.  This has important treatment implications because atypical Parkinsonism disorders can often look very similar to Parkinson's disease, but respond differently to therapy.  There is a legitimate question of whether or not the bicycle sign is universally applicable, given environmental and cultural differences between patients (Dr. Bloem and his patients reside in the the Netherlands, where absolutely everyone rides a bike.) 

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While there are a number of useful medications that help ease Parkinson’s disease symptoms for a few hours, advancements in significant relief have eluded Parkinson’s researchers.  In a surprising and somewhat whimsical discovery, new evidence suggests that tandem cycling may bring a longer relief from the disease’s symptoms, with improvements lasting for weeks at a time.

The serendipitous discovery was made in 2003 when neuroscientist Jay Alberts, then a Parkinson’s disease researcher at Emory University in Atlanta, rode a tandem bike across the state of Iowa with his friend Cathy Frazier, a Parkinson’s patient.  The two were riding the staewide bicycle tour to raise awareness of the neurodegenerative disease, but they also found, much to both of their surprise, that her tremors disappeared after about an hour of riding.  She told him that she felt great while riding and that it was as if she didn’t have the disease.  They also noticed that her handwriting improved.  Patients with Parkinson’s often develop micrographia, meaning that their handwriting becomes small and illegible.  Alberts’ friend Cathy had noticed the progressive shrinking and illegibility of her handwriting as her PD progressed, but during this bike tour, she wrote on a birthday card with beautiful, large, legible letters.  It made Alberts take note.

Alberts wondered if this mysterious side effect of the tandem bike ride held an intriguing medical possibility: the improved motor control in the arms and hands even though only the legs were exercising seemed to suggest that there was some change taking place in the central nervous system that improved global motor function, perhaps by triggering the release of biochemical messengers.

Now a researcher at the Cleveland Clinic, Jay Alberts has conducted several studies with Parkinson’s patients inspired by these discoveries and his passion for biking.  Many patients are able to lower their medication dosages and regain motion in extremities.  Other patients have regained their sense of smell from bike riding, which is commonly lost in PD and often one of the first symptoms that patients notice before being diagnosed.

Dr. Alberts had volunteers with Parkinson’s ride a solo stationary bicycle at his or her own pace.  Most chose a pedaling cadence of around 60 revolutions per minute, a relatively non-strenuous level of exertion.  He then placed them on the back seat of a tandem bike that had been modified to ensure that the back rider would have to actively pedal; he or she could not just passively let the pedals turn.  On the tandem, the rider in front had been instructed to pedal at a cadence of about 90 RPM and with higher force output or wattage than the patients had produced on their own.  The result was that the riders in back had to pedal harder and faster than was comfortable for them.

Tandem bike riding has turned out to be beneficial therapy for patients, but Alberts determined it was because the exercise was forced.  The challenge of pedaling much faster than normal activates the part of the brain that controls body movements and releases dopamine, which is what improves symptoms in Parkinson's patients.  According to Alberts, the medications often given for symptom improvement in PD activate certain areas of the brain or increase the blood flow there, and an almost identical pattern of activation is seen in the brains of patients who have done forced exercise.

This is an exciting finding because it contrasts with some earlier results involving voluntary exercise and Parkinson’s patients.  In those experiments, the activity was helpful, but often in a limited, localized way.  Weight training, for instance, led to stronger muscles, and slow walking increased walking speed and endurance.  But such regimens typically did not improve Parkinson’s patients’ overall motor control.

The forced pedaling regimen, on the other hand, did lead to better full-body movement control, which prompted Dr. Alberts to conclude that the exercise must be affecting the riders’ brains as well as their muscles.  His theory that was substantiated when he used functional M.R.I. machines to see inside his volunteers’ skulls.  The scans showed that, compared with Parkinson’s patients who hadn’t ridden, the tandem cyclists’ brains were more active.

Dr. Alberts suspects that in Parkinson’s patients, the answer may be simple mathematics. More pedal strokes per minute cause more muscle contractions than fewer pedal strokes, which, in consequence, generate more nervous-system messages to the brain. There, he thinks, biochemical reactions occur in response to the messages, and the more messages, the greater the response.

This raises fascinating questions not only about whether exercise can help to combat the disease but also whether intense, essentially forced workouts affect brains differently than gentler activity does, even in those of us who are healthy.  In lab animals, forced and voluntary exercise can lead to different outcomes.  Mice and rats generally enjoy running, and they will voluntarily hop aboard and run on a wheel placed in their cages.  But if an animal is placed on a treadmill and the speed controlled so that it must keep pace, often with help from a finger prod or electrical shock, the activity becomes forced.

Interestingly, the effects in animals, especially on their brains, are typically more beneficial after forced exercise.  In one study from 2008, rats forced to run wound up with significantly more new brain cells after eight weeks than those who ran when they chose, even though the latter animals ran faster.  And in another experiment, mice that were required to exercise on treadmills subsequently performed better on cognitive tests than those given access to running wheels.

A small eight-week study was launched to gauge the effects of forced exercise in which the patients underwent hour-long sessions of forced riding, pedaling at 80-90 RPM.  And the results were impressive: there was a 35% improvement in motor functioning, significant lessening of tremors and better body control for the patients who did the forced exercise compared with those exercisers who pedaled a stationary bike at their own pace, and the improvement lasted for four weeks after the cycling sessions ended.

Whether forced exercise would similarly affect healthy brains is unknown at this point, he says, as is the question of whether riding on the back of a tandem behind a stronger cyclist is the only qualifying exercise.  It seems likely that intense exercise of any kind should produce comparable brain reactions.  There is even some data showing that people who exercise intensely have a lower risk of developing Parkinson’s and other neurological diseases. 

In addition to motor difficulties, individuals with Parkinson's disease often experience cognitive declines.  And although pharmacologic therapies are helpful in treating motor deficits in PD, they do not appear to be effective for cognitive complications.  While acute bouts of moderate aerobic exercise have been shown to improve cognitive function in healthy adults, individuals with PD often have difficulty with exercise, for obvious reasons.  Another recent study looked the effects of passive leg cycling on executive function in PD, which was assessed with two different tests before and after the cycling.  Volunteers showed significant improvements on the test after exercising, and the difference between times to complete the two exams significantly decreased from pre- and post-cycling times.  It is thought that the improved executive function after passive cycling may be the result of increases in cerebral blood flow, which correlates with theories regarding post-cycling motor function improvement as well, suggesting multiple benefits from forced exercise in patients with PD. 

Regardless, bicycling offers patients an opportunity to be symptom-free while they are riding, to look and feel normal, and to get some real cardiovascular exercise even when their disease is so far advanced that they cannot walk.  The humble tandem bike was one of the Top 10 Medical Innovations for 2010 at Cleveland Clinic.  Remember how awesome that is the next time a bride-to-be tells you how totally adorable she thinks it would be to exit her reception on one.  It could add just the perfect element of kitsch to her perfectly color-coordinated DIY wedding.  But it could also hold the key to someday saving lives.