From our anonymous insider…
Gastrointestinal topics began with four one-hour lectures on the liver. Jane and I did not attend. We took a morning trail run, then watched 65 minutes of liver lectures on Pathoma (“First-Aid of M2”). Jane: “I feel like I have accomplished so much.”
We went to Dr. House’s Tuesday lecture on GI pathogens. “As medical students you will be a valuable member of the team performing digital rectal exams and fecal blood smears. It seems like grunt work, but it is essential to determine the course of diarrhea treatment. The fecal smear for leukocytes is a vastly underutilized, quick and dirty test.” According to Dr. House, the most important step in managing diarrhea is to determine if a patient has invasive or toxigenic diarrhea. Invasive diarrhea is caused by a pathogen invading the mucosa (epithelial lining of the gut tube), which recruits leukocytes [white blood cells] to the infection. These white blood cells end up in the feces. Whereas, toxigenic diarrhea will not have any white blood cells in the stool sample. “Most diarrhea causes are treated with supportive care – hydration.”
Vibrio cholerae causes profuse, toxigenic rice-water diarrhea. “Does Haiti have cholera?” asked Dr. House. “Not before 2012. The earthquake hit in 2010. UN troops from Nepal, where Vibrio is endemic, brought in cholera. One in ten individuals exposed to cholera are asymptomatic carriers shedding it in stool. Without adequate filtration systems in earthquake-ravaged Haiti, cholera spread all over.” How do you treat cholera? Hydration. “Cholera is a self-contained disease if you can survive the extreme dehydration from loss of water. Volume-in must equal volume-out. On the wards you will hear, ‘hang the IV at 125 mL per hour.’ 125 mL per hour is 3 liters over 24 hours or the amount of insensible water loss [sweat, metabolism, etc.]. So hydration would need to be greater than 125 mL/hr in a cholera patient.”
“When I trained Clostridium difficile was segregated to antiquated case reports in journals that no one read.” Dr. House continues, “C. diff is now a hospital’s bane of existence. Studies show that 13 percent of individuals have C. diff spores in the gut. They just lie dormant until a stress such as an antibiotic knocks out the normal gut flora. A severe C. diff patient can have 30 bowel movements per day with a high fever. Talk about dehydration. The best treatment is fecal transplant, ideally from a housemate, otherwise the new poop pill [OpenBiome’s FMT G3 capsule].”
Dr. House cautioned to not jump to antibiotics for every patient with diarrhea. “Some toxigenic diarrhea cases are made worse by an antibiotic. For example, a patient with hemolytic uremic syndrome, a serious complication of shigella and E coli O157:H7, can be killed by toxins released from dead bacteria. I see this all the time: a patient with pneumonia or meningitis is given penicillin. The patient then crashes because of the sudden antigen [molecule to which immune system responds] release.”
We ended a few minutes early so he asked some causal questions: “Has anyone heard of Saccharomyces cerevisiae?” A quite Asian volunteered: “It’s used in brewing beer.” “Yes! Cerveza is beer in Spanish. This fungus is also implicated in exacerbating Crohn disease. Why? We do not know. But that’s the mystery of Infectious Disease medicine!”
Dr. House noticed Type-A Anita’s MacBook Air decorated with five stickers: “I’m with Her”, “Nevertheless, she persisted”, “Nasty woman”, “Change”, etc. “Anita, how are you going to fit more stickers on the laptop next election?” Anita: “I don’t know, I never thought of that.”
At 10:00 am, Dr. House left and we began learning about genetic diseases of the GI system. Our early-40s pediatrician-turned-geneticist explained that she is consulted whenever a genetic disorder is suspected, or “when physicians have no idea what is going on.” She manages several families whose members share a rare genetic defect and also coordinates care for patients with complicated diseases such as Down syndrome, Prader-Willi syndrome, and Angelman syndrome.
She introduced two genetic GI diseases that we’ll see on the Boards: Lynch syndrome and Familial Adenomatous Polyposis (FAP).
Lynch syndrome (also known as HNPCC for “hereditary nonpolyposis colorectal cancer”) is an inherited defect in a DNA repair protein. Lynch syndrome is characterized by a high risk of cancer including colorectal, endometrial, gastric, and sebaceous carcinoma.
FAP results from a defect in the APC gene that is necessary for the transformation of normal colon tissue into a colonic polyp (adenoma-carcinoma sequelae). FAP is characterized by the formation of thousands of polyps in the GI tract. Patients have such a high risk of colorectal cancer that they undergo prophylactic colectomy in early adulthood.
She described some of her daily dilemmas. “Ten percent of patients do not have a paternal relationship to their believed father, don’t rely on paternal medical history. We refrain from testing children for likely genetic disorders that won’t result in symptoms until adulthood. If waiting will not compromise care, we want to maintain the patient’s autonomy. I am also extremely careful with documentation for a potentially afflicted child. For example, what if a child eventually wants to join the military? If I document a 50-percent risk of having Lynch syndrome due to an afflicted father, lights out.”
Our patient case: Jerry, a 50-year-old former truck driver on disability for liver cirrhosis due to chronic hepatitis C infection, presents to the ED for rectal bleeding and anemia. Twenty-five years earlier, te was in a motor vehicle accident (“MVA”) requiring transfusions. A more recent MVA led to the diagnosis of hepatitis C, likely due to the transfusion in the 80s prior to hepatitis C screening for blood donations (1992). [Hepatitis C is transmitted via blood and sex.]
Physical exam shows a distended abdomen with ascites (fluid in abdomen), scleral icterus (yellowing of the eye), and several bruises over his arms and legs. His liver is enlarged, and the tip of the spleen is palpable. CBC and CMP reveal anemia, thrombocytopenia (low platelet count) and hypoalbuminemia (low serum albumin, a protein that creates osmotic gradient to keep fluid in the blood vessels). PCR testing shows an active Hep C viral load. Jerry tests positive for Hep C antibodies. Serum alpha-fetoprotein (AFP) levels are high, suggestive of hepatocellular carcinoma (liver cancer). An abdominal CT shows two liver nodules. Biopsy confirms hepatocellular carcinoma.
Jerry undergoes radiation therapy and surgical resection of the operable masses. Jerry died last year from rupture of esophageal varices while waiting for hepatitis C treatment and a liver transplant.
Our South American hepatologist went over Jerry’s case and discussed the rise of hepatitis C infections in the United States driven by heroin use. Particular Patrick asked her opinion about needle exchange programs (popular in his home state of California). “Hep C rates are skyrocketing due to IV sharing. Every needle shared leads to nine Hep C infections. I cannot understand why needle exchange programs are resisted by conservative legislators. Yes, I understand the idea of traditional values and that drugs are bad. But you don’t simply tell your child ‘NEVER have sex, period.’ No, you say, ‘Sex is bad… but if you are going to engage in it use a condom.’ Otherwise, you’ll get a pregnant child… with Hep C.” Students chuckled. Lanky Luke: “I bet she does not want a needle exchange in her backyard.” [“Do needle-exchange programs really work?” (Amy Norton, March 11, 2010, Reuters) summarizes research that casts doubt on a link between needle exchanges and preventing disease transmission.]
Drug treatment for Hep C costs roughly $90,000. “The first thing I ask my patients is if they have insurance,” said our hepatologist. “If they are uninsured, I tell them, ‘No problem. You will just have to pay maybe $30 for the blood tests. You’ll get the pills free.’ If they do have insurance, I tell them there is no guarantee. I say, ‘I will fight for you, but it will take time and there is no guarantee.’”
How does Hep C treatment compare in other countries? “Australia has a great coverage program. Every Australian gets the drug, no questions asked. Canada and most European countries have similarly good coverage.” Does the drug cost as much? “No, America pays for the Hep C treatment of the world. One of my old patients pioneered going to Canada for treatment because it cost so much less there.” She concluded: “I am hopeful coverage will increase as there are more and more competing drugs. It is truly amazing how science has advanced. A decade ago there was no cure, only poor management with short-lived transplants and drugs with severe side effects such as kidney damage. Now we have several options with over 90-percent cure rates for all genotypes [DNA sequence of the virus].”
This week included three afternoon workshops on nutrition and lifestyle medicine led by a fit 35-year-old internist specializing in weight loss, her blond hair tied in a ponytail ready for her next workout. She began by asking the class, “What percentage of the population does not smoke, has a BMI less than 25, eats 5 servings of fruits and vegetables daily, exercises 30 minutes five times per week? What we would consider healthy?” The class was silent. “Three percent,” she answered. “Meanwhile, 35 percent of the US population is obese.”
She was scornful of the government’s nutrition advice. “Why is diary the only food required in a school lunch?… The milk lobby. Why are grains at the bottom of the food pyramid? The grain lobby. The original 1992 pyramid had grains third from the bottom. Imagine how many lives could have been changed if that guidance was not issued!” Lanky Luke: “Maybe times have changed and people have less faith in institutions, but does anyone really shape their diet based on the pyramid and now plate?”
Students were offered to get free DEXA [Dual-energy X-ray absorptiometry] scans in preparation for the next workshop. Over half the class volunteered for the 10-minute procedure after class. DEXA scan shoots two different energy x-ray photons at the entire body. In addition to providing a measurement of bone density, commonly used to diagnose osteoporosis before a fracture, DEXA scans also calculate percent body fat and fat distribution.
Pinterest Penelope: “I think the DEXA scans were wrong. I’ve been going to the gym everyday this year.” Jane, as she squeezes her stomach into a mouth shape: “This is bad for my mental health, 26 percent fat.” A retired Army physician told her that you do not want to be a fat doctor in the Army. Physical performance is evaluated in the military. “If you are fat, you do not get promoted, you do not get your preference on where you are stationed, and you do not get respected by peers.”
“I never use the word ‘Diet’. Diet implies a temporary strategy. Long-term weight loss requires lifestyle changes. However, as a physician your patients will ask you about common diets. There are copious studies that try to evaluate Low fat versus Low Carb versus Mediterranean, etc. The key is to get them thinking about their intake and outtake.” She cited, “The largest diet study found attendance at group sessions was the greatest predictor for weight loss and reduced cardiovascular events.”
Students filled out a lifestyle goal on scratch paper. Most students promised to lose a few pounds, go to the gym, or make fruit/veggie smoothies daily. (Two weeks later Jane and I accompanied most of these people to Taco Bell and then the local ice cream shack.)
Thursday at lunch students discussed Harvey Weinstein and Kevin Spacey. Everyone had seen the headlines, but not everyone knew the details. What did Harvey Weinstein actually do? “He raped women. He attacked young actresses.” Type-A Anita: “It’s more like what hasn’t he done.” Wildflower Willow: “I have become so disgusted by Hollywood. Power corrupts all men.” What did Kevin Spacey do? “He attempted to molest young male actors. Now he cowardly comes out as Gay as if being homosexual makes you some predator.”
Type-A Anita wasn’t that interested in the question of criminal prosecution: “We are in the public-shaming part of punishment.” What about the presumption of guilt based on unverifiable accusations? “So what if the pendulum swings a little bit in the favor of the accused. The rights of the women have been forgotten for so long. I don’t think people care about the wealthy assholes like Harvey Weinstein. Ladies, take it all!”
Jane: “Part of the divide here is that it is difficult for me to imagine what it would be like to be falsely accused of harassment. It is easy for me to imagine what it is like being the victim of harassment. I understand how one could say it is wrong to expel an accused student of rape or fire a physician for harassment of a nurse, but a suspension is not unreasonable while it is being investigated. That’s not going to destroy his life.”
Gigolo Giorgio: “I can see how this can be a slippery slope. Let’s say a transplant surgeon, one of the best in the country, gets accused of sexual harassment to nurses when he was a resident twenty years ago. Let’s just say we have objective proof — a video — of him doing it and evidence he cleaned himself up since then. Married with kids, upstanding citizen and all his coworkers love him. What should his punishment be? Should he be excommunicated and banned from surgery after society invested all those resources into him?” Straight-Shooter Sally: “Maybe he should be suspended for a few weeks. Just so there is some punishment and deterrence. I think he should still be able to practice eventually.” [Editor: Hospitals are going to line up to hire this guy?]
What does $60,000 in tuition include? “An artistic space,” as our visiting ethics professor explains the two-hour Friday afternoon session. We divide into groups of six to create a nine-panel cartoon with crayons. “Depict your experience with cancer,” the professor says. What if we haven’t had cancer? She says that it can be about a relative, a friend, or something we’ve read in a novel: “Enjoy this space, this is one of the only chances in medical school to express your artistic mind.”
“My grandmother at age 78 underwent surgical resection for colon cancer,” said a classmate on another team. “She ended up killing herself by pulling her feeding tubes out because of her terrible quality of life.” One of my teammates: “My best friend was diagnosed with a brain tumor after a seizure. His doctors assured him it was benign, but took a biopsy. I was with him watching the [2016 Presidential] election results. As we were learning about Trump’s victory he got a text that his cancer is invasive.”
Friday evening, Jane and I drive 45-minutes out of the city to our favorite trauma surgeon’s cabin. Twenty-six students (16 female/10 male) interested in surgery, or just intrigued by her stories, roast marshmallows and eat undercooked burgers around a campfire.
Straight-Shooter Sally asked How difficult is residency? Our hostess: “If you think you learn a lot in medical school, wait for residency. You end medical school knowing how to do a few procedures — NG tube placement, IVs, suturing. You end surgical residency knowing how to reconstruct an aorta.”
Gigolo Giorgio asked What is the progression of a resident? Our hostess: “I expect an intern to be able to navigate the hospital. You are primarily managing patients in the perioperative window—before and after surgery. Maybe at the end you are comfortable performing an appendectomy under guidance. A first-year resident should begin to have opinions and a sense of direction. Second- and third-year residents should be teaching interns. A fourth-year resident should be an equal. I ask for their input on cases. I listen to their thoughts. Attendings will go with the fourth-year resident’s judgment, especially when there are several decent options and no clear winner.”
The trauma surgeon emphasized: “When applying to residency programs, ask where their graduates end up. Do they feel comfortable performing surgeries on their own? A lot of prestigious residencies do not train surgeons to become independent. I see a lot of graduates taking fellowship positions not out of interest in the speciality, but because they do not feel ready to become an attending. You want to go to a program that offers both fellowship opportunities and job placement.”
Students were particularly interested in the lifestyle of the surgeon. “Surgery culture is changing. There is no more God complex. Patient care is now a team effort,” explained the trauma surgeon. “For most of my career, you would take your patients home after you left for the evening. If something happened, you would run back to the hospital. Now you have people on call who deal with it. You can always go above and beyond and follow up on a previous patient. Most physicians do that, but it is their prerogative, not the expectation.” She concluded: “This change is a good step for lifestyle and overall well-being of surgeons, but there is less continuity of care.”
What are some pitfalls? “The biggest issue I see with residents and attendings is ignoring home life. It is very easy to drown yourself in patient care as an excuse to ignore dealing with problems at home. They wonder why they end up divorced with broken lives and children they barely know. It’s their own damn fault.” [Editor: Read Real World Divorce to see which states give plaintiffs the largest financial incentives to pursue a divorce lawsuit; the biggest “fault” of these defendants may well be choosing to settle in a plaintiff-friendly jurisdiction.]
Can a medical trainee start a family? “Do not put your life on hold for residency. Residency is part of your life. If you want children, have children. It will be tough, but you will manage it. I’ve heard some residents say residency is a great time to have children because of the excellent health insurance.”
Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: Jane and I joined Lanky Luke, Samantha, and Mischievous Mary for burgers and beers. Samantha works in a free clinic nearby for her final PA rotation. “I saw a 11-year-old child today. How much do you think she weighed?” Guesses: 150, 175, 210, 250. “She clocked in at 363. I mean that should be child abuse. You cannot recover from that.” The mother, also obese, is on Medicaid. [Editor: therefore, by definition, taxpayers purchased most of the food via the USDA SNAP program (“food stamps”).]
As always, an interesting glimpse into the American medical establishment, the positives, the negatives, and the surreal.
“Drug treatment for Hep C costs roughly $90,000. “The first thing I ask my patients is if they have insurance,” said our hepatologist. “If they are uninsured, I tell them, ‘No problem. You will just have to pay maybe $30 for the blood tests. You’ll get the pills free.’ If they do have insurance, I tell them there is no guarantee. I say, ‘I will fight for you, but it will take time and there is no guarantee.’””
Every American with Hep C should claim they have no insurance, since in a technical sense, apparently even many insured people do not.
I’d be pretty interested to see how many cases the other countries that rain free drugs down for Hep C have compared to the United States, too.
“What percentage of the population does not smoke, has a BMI less than 25, eats 5 servings of fruits and vegetables daily, exercises 30 minutes five times per week? What we would consider healthy?”
5 servings of fruits and vegetables daily + exercises 30 minutes five time per week are healthy only if the servings are small and well chosen, while this ammount of exercises should be at ease and make sense. There are very sugary fruit and exercises that overstress tendons and ligaments, while a glass of beer or wine in pleasant company is good for you.