From our anonymous insider…
Classmates are enjoying the flipped classroom format, especially because class begins at 9:00 am instead of 8:00 am. Type-A Anita: “I do not even watch the online lectures. I prepare for lecture by watching the corresponding Pathoma videos. It solidifies the material when we go over cases in the workshops.”
A tall Russian-immigrant pulmonologist in his late 50s introduces diseases of the pleura. Pleura is a thin membrane that runs along the inside border of the chest wall and outside border of the lung forming an air-sealed fluid sac called the pleural space. (Embryologically, the lung bud from the esophagus actually grows into this pleural sac like a fist going into a balloon). The pleural space links chest wall expansion to lung expansion. Chest wall expansion produces a negative pleural pressure that expands the lungs.
A pneumothorax occurs when air gets into the pleural space, thus destroying the negative pressure gradient that holds the lung expanded (-5 cmH20). This can occur spontaneously, typically in “long and thin” men, when a small section of lung parenchyma ruptures the visceral pleura, creating a connection between small airways and the pleural sac. It can also happen from trauma when the parietal pleural membrane is punctured. Tension pneumothorax, a life-threatening complication of a pneumothorax, occurs during trauma when the punctured pleura forms a one-way valve allowing air in on inspiration but not on expiration. The pleural pressure can get so high that it displaces the heart in the thorax.
A pleural effusion is a buildup of fluid in the pleural space. This causes increased intrapleural pressure and displacement of the lungs and potentially heart in the thorax. The fluid can be composed of plasma ultrafiltrate (transudate) suggested of inflammation or exudate (“a pus filled mess”). Pneumonia (infection of lung parenchyma) frequently leads to a harmless transudative pleural effusion, but the bacteria can migrate into the pleural space causing an exudative empyema. “Never let the sun set on an empyema. This is a medical emergency.”
Mesothelioma, a rare complication of asbestos exposure, is cancer of the pleura. “Most of my asbestos-exposure patients were in the Navy, stationed either in shipyards or on ships. I ask them if they were exposed to asbestos. They respond, ‘Oh yeah. I would go to the engine room and particles would be falling down.'”
“All of the data on the risks of asbestos exposure is from studying construction workers during the 1960s skyscraper boom in New York City.” Asbestos exposure in the absence of smoking history is associated with a 6-fold increase in lung cancer. According to UpToDate, “asbestos exposure acts synergistically with cigarette smoking to increase the risk of developing lung cancer (not mesothelioma) 60 times over that of a similarly matched non-smoking, non-asbestos-exposed cohort.” The pulmonologist: “The Board loves to test that mesothelioma is far less common than lung cancer or pulmonary fibrosis from asbestos exposure.”
If lung cancer is a more common consequence of asbestos exposure, why so many commercials from plaintiffs’ lawyers looking for mesothelioma patients? “Lawyers salivate over a mesothelioma case because it is no work. There is a one-one causal relationship between mesothelioma and asbestos exposure. Smoking is not a risk factor for developing mesothelioma. The defense cannot say it was lifestyle choices or smoking that led to the disease.”
An invasive pulmonologist in her 50s discussed lung cancer for two hours. An invasive pulmonologist gets one to two years of training after a pulmonary fellowship and three-year internal medicine residency (i.e., there is no pulmonary residency, only the post-residency fellowship). With this additional training, an invasive pulmonologist can perform procedures such as a biopsy and bronchial thermoplasty (burning airway smooth muscle for non-responsive asthma). Symptoms of lung cancer are nonspecific. These include dyspnea, cough, cachexia (wasting, sudden weight loss), hemoptysis (coughing blood), and pleural effusion (from metastasis to pleura or to lymph nodes draining the pleura). “The most important aspect is to recognize the chronicity of the symptoms versus a more acute episode of pneumonia.”
Smoking is the most important risk factor for lung cancer. She defines a non-smoker as “someone who has had fewer than 100 cigarettes in his or her lifetime.” Smoking also causes the more aggressive forms of cancer: squamous cell carcinoma and small cell carcinoma (SCC). “SCC has a proclivity to metastasize to the brain. We treat SCC with prophylaxis brain radiation because by the time we can detect it in the brain it is too late.”
She then went over the staging system for lung cancers. “Staging is important to be able to give the patient an estimate of his or her life expectancy. I would expect my fellows to be able to give an accurate stage. I just expect you to know the different components that go into staging.” Staging incorporates the tumor size, nodal involvement, and presence of metastasis. “Lower stages are typically dealt with through surgical resection of a lung lobe and resection of any lymph nodes. Higher stages require chemotherapy.”
Gigolo Giorgio asked the pulmonologist her thoughts on e-cigarettes. “E-cigs are such a new product. Each tobacco company uses a different formula. A new FDA regulation requires tobacco companies to release the full set of ingredients used in the vapor. I will withhold judgement until this information is analyzed.” She did mention that she has noticed a rise in fungal pneumonia cases among e-cig smokers.
Gigolo Giorgio, true to his Los Angeles roots: What about pot? “That’s also a tough question. There are no studies that show an increased risk of lung cancer that I know. When my patients tell me they smoke pot, I cannot tell them to stop for fear of getting lung cancer. Cancer patients? I say go for it.”
She described how the second cause of lung cancer is radon exposure. Radon exposure increases the risk for adenocarcinoma, a less aggressive form of lung cancer compared to smoking-associated small cell and squamous cell carcinoma. “If you live in a high radon state, make sure you get a radon inspection. My house was off the charts. I had a radon mitigation system installed.”
Our patient case: Beth, a 45-year-old spunky sarcastic mother of three, presents to her physician for worsening shortness of breath and joint pain. A chest x-ray reveals hilar infiltrates (enlarged lymph nodes of the lung). She was referred to a tertiary hospital for follow-up.
“I was diagnosed for three years with asthma. When I finally was referred to the university hospital for biopsy I was almost relieved.” She drove three hours for her lung biopsy appointment. “When I was called back from the waiting room, the nurse grabbed my hand and started praying. I was like, ‘Damn, Woman, what are you doing?’ I did not realize I was in the OR. I did not sign up for this!” Her lung biopsy revealed non-caseating (no necrosis) granulomas diagnostic for sarcoidosis.
Sarcoidosis is a systemic inflammatory disorder that causes granulomas, a collection of immune cells formed in an attempt to wall off a substance. The soft-spoken Indian pulmonologist explained, “We have made incredible progress in understanding sarcoidosis. This mostly shows how little we knew ten years ago and how far we have to go. We still do not know what causes this immune response. It likely is an unknown substance that certain individual’s macrophages cannot deal with.” These granulomas can form anywhere in the body, but sarcoidosis almost always involves the lungs. “Patients are diagnosed due to shortness of breath from the pulmonary fibrosis or on incidental findings.”
Beth has a lot to say about her physicians. “I cannot stand when the doctor comes in and says, ‘So what brings you in today?’ Look at my damn chart. Spend two seconds getting to know me. I once told a physician, ‘Well I was learning to twerk on the kitchen table and fell. That’s what causing my joint pain, not my sarcoidosis on my chart.’.”
Beth is managed with glucocorticoids and methotrexate (folate synthesis inhibitor) to reduce her immune system response. These have greatly improved her joint pain and lung function, but have lead to significant weight gain. “Laugh all you want. Call me Fatso.” She explained how frustrating it is that people around her, both strangers and close family members, attribute her weight gain to laziness. “It does not matter how much I eat or exercise. I will just keep putting on weight. It makes me depressed. I cope with it with humor, by poking fun at myself. I would not wish this even on my worst enemy… my ex-husband. And I hate him.”
Beth has not had to increase her dosage for two years. Most patients will regress and require more intensive pharmacologic agents. “I am hopeful I can continue this lifestyle. I view my disease as that devil on your shoulder. He’s always there, and I hope I can keep him silent for a little longer.”
This week’s ethics session: “Distributive Justice”. Before the lecture and small group meeting, we read several papers and completed a quiz:
True or False: The Affordable Care Act can be viewed as an effort to mandate distributive justice in the United States? Lanky Luke had a field day: “I was going to put false. Then I remembered a liberal probably wrote it.” [Editor: sometimes justice is not fully distributed; more than 30 million Americans were without health insurance in mid-2017, seven years after Obamacare was enacted.]
True or False: Distributive justice refers to the fair and equitable distribution of goods and services.
Which of the following strategies for eliminating healthcare disparities is the most difficult to implement? Answer: Collection of standardized data on patient and provider race and ethnicity.
One required paper was “Ushering In The New Era Of Health Equity” by Joseph R. Betancourt: (Health Affairs Blog, October 31, 2016):
several promising opportunities are on the horizon … activities focused on diversity and inclusion, and especially new conversations about racism, implicit bias, and stereotyping as root causes for disparities, are bubbling up now more than ever before. This is likely a direct consequence of the coverage of police violence against Black citizens, the Black Lives Matter movement, and the current and toxic political climate around race relations.
Luke: “My problem is not that they are making us read these articles. It is important to keep an open mind to new information. My problem is that they state their opinions as fact. Their job is not to indoctrinate us, but to provide the tools and resources for us to make our own opinions.”
[Editor: Dr. Betancourt thought that the political climate was “toxic” in October 2016; imagine how he felt after Donald Trump was elected in November!]
Another article contained an interview with the physician president of a free clinic. He explained how they had planned to close down the clinic after the passage of the ACA. “Little did we know we would have more business than ever before from people with high-deductible plans not able to pay for small checkups and medications. Of the 4 million dollars in services we provide now, about 3 million go to the pharmacy.”
An endowed university professor of ethics and member of the ethics committee at the hospital introduced the topic with a 1.5-hour lecture. He proposed that people agree on two principles:: (1) a decent minimum access for all, and (2) better or faster care for those who can afford it. [Editor’s note: this is what most countries around the world, from Mexico to the U.K. to Russia, actually do provide. The public hospitals are free and can be reasonably good; private hospitals and doctors are available for the rich. They manage to do this while spending only a fraction of what U.S. society spends.]
He gave a personal story about Canada’s attempt to provide gold-plated service for all: “I used to teach in Canada. My daughter went to an ophthalmologist where she was told she may have brain cancer and needed an MRI to rule this out. She was given an urgent 3:00 am appointment… in 6 months. Instead of waiting, we went across the border to get a $500 MRI that was emailed to her Canadian doctor. It was quite the spectacle. There are these lots near the border where MRI and CT machines are set up in trailers. The whole parking lot was filled with cars with Canadian license plates.”
After the lecture we broke into six-person groups with a facilitator. Our group’s facilitator was a 35-year-old female professor of ethics from our affiliated university. She had completed a Science, Technology, and Society (STS) PhD dissertation on “kind of the intersection of technology and how knowledge is generated — ethics is my passion.” She disclaimed having better answers to ethical issues than others, but felt that her training enabled her “to ask the right questions about an ethical dilemma.” Gigolo Giorgio scoffed. She began the discussion with “I do not want this discussion to be political. However, being engaged in politics is important, now more than ever with the ongoing ‘medical apartheid’ [instituted by Donald Trump]. I am not saying how you should feel about it. But be engaged, and always reframe to the cultural context.”
We started by watching a clip from Dallas Buyers Club, a movie about getting ddC and peptide T at a time when neither drug was FDA-approved. [Today, drugs related to ddC are used in standard of care combination treatment and used while peptide T is not part of any recognized treatment.] One student whose internist father has practiced in India and England added, “My father told me how grateful he is to have the FDA. There are some whacky treatments and patient requests in medical systems without the FDA framework.” Capturing the spirit of current discussions regarding inequality and race, the ethicist framed the FDA’s 1980s approval process for AIDS drugs: “Although the AIDS epidemic was primarily impacting African Americans, it was wealthy white men with AIDS who had sufficient influence to expand treatment options for AIDS patients. This was fortunate, but it serves as an example of the challenges different groups face.” She was confident in her race- and class-based analysis, but did not explain why the government would ignore wealthy white men with AIDS in the early years of the epidemic and then begin to listen to them in the late 1980s. Nor did she explain what the government could have done in the early years of the AIDS epidemic when there was no scientific basis for treatment.
We discussed Boston REACH, a community program to address modifiable risk factors, particularly obesity and smoking, among African Americans living in the Boston metro area. Straight-Shooter Sally said, “This program is great. There are whole communities that are alienated from the healthcare system. My concern is a growing culture that blocks candid conversations. Healthcare workers have to say you are beautiful no matter what. It’s difficult to convey to an obese individual that, yes, you are beautiful but you are fat and you need to lose weight. I mean you are literally a walking poster child for risk factors.”
Can future generations of doctors be reformed via ethics discussion? Lanky Luke: “I kept my mouth shut the whole time… Time to go shoot a gun!”
Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 nights. Example fun: Jane and I joined Luke, Samantha, and Mary for drinks at our favorite burgers and beer joint. Samantha will be finished with PA school in a few months. She is almost as excited as Luke. “I married you for the money,” exclaims Luke. “In a few months I get the money.” Samantha recounted her two-month psychiatry rotation: “We worked with foster youth. I never was exposed to this. Several kids were sexually abused by their parents and now sexually assault their new foster siblings. The older children are so mentally screwed up they are forever dependent on social services. The government pays for housing, food, and all the medical care.”