Wednesday, July 28, 2010

ADCOM Q&A (learning from your mistakes)

Everyone makes mistakes. Even pre-medical students. And one trend I've noticed in the medical school interview questions I've looked at (this applies to job interview questions as well) is that the interviewers quite often will bluntly ask you about those mistakes or other shortcomings. For example, there is the infamous "What is your greatest strength and weakness?" question, which I have been asked in multiple job interviews. A similar medical school question I found online literally begins with these words: "What has been your biggest failure ... ?"

Clearly, though, if an applicant goes on for 10 minutes about how badly he did in organic chemistry, that's not going to go over well. That's why the question about your "biggest failure" ends with these words: "... and how did you handle it?"

So if an applicant did poorly in organic chemistry, explaining why he didn't do well -- such as that he didn't have good study skills -- and then what he gained from the experience -- such as that he developed better study skills as a result of his failure-- would be a much better answer.

ADCOMS want to hear us pre-meds admit that we're not perfect, and then talk about what we have learned from our mistakes, shortcomings, failures, weaknesses, and other "problem areas." Because failing is part of life (as much as I hate to admit that). It's what you do after you fail that sets you apart from other people.

The reality is, everyone falls down sometime. The question is: Do you get back up?

My answer is: YES. And here's an example from my childhood.

(Let me preface this example by saying that I was homeschooled from preschool through the end of fifth grade. So when I talk about my mom giving me a test ... it's because my mom was my one and only teacher from age 4 to age 10.)

When I was about 7 or 8, my mom gave me an impromptu spelling test. You know the kind -- the ones that are supposed to gauge where you are and where you need improvement. They're called diagnostic exams, I believe. As someone with something of a failure complex, I hated these exams because I never did well on them -- you're not SUPPOSED to do well on them. At the time, this point escaped me.

Anyway. I miserably failed this spelling test. I don't remember the number of right and wrong, and it's probably better that way. I was distraught at first. I had failed! What was I supposed to do? Then my mom sat me down and explained the purpose of this "diagnostic" exam. Her explanation brought some comfort. And in the end, while I was not necessarily happy that I had failed, I understood that the test pointed out some areas where I needed to improve.

And so I made it my absolute mission to become the best speller possible. I learned all the rules. I memorized the exceptions. I practiced spelling words until I was practically murmuring them to myself under my breath in the bathtub.

Then came time to take the exam again. And I aced it. All that work paid off -- I had learned what I didn't know, what I needed to work on, and I made it a point to not make the same mistakes again.

And guess what? When I attended public school a few years later, I went on to win several school spelling bees, and even a district spelling bee.

To this day I am a fantastic speller, and in my previous jobs, earned a reputation as such. All because I failed an elementary school spelling test and made up my mind that wasn't going to happen again.

And while I still don't like failing (although who does?!), I try to remember this example when I do. Because it proves that you can learn from your mistakes. And perhaps, that without making mistakes, we wouldn't learn quite so much.

Wednesday, July 21, 2010

ADCOM Q&A (working under pressure)

Being a doctor is, quite often, about working well under pressure. If someone stops breathing, for example, you better figure out how to get them breathing again, and quick! There is no time for consulting the Internet, a textbook, or (very often) other doctors. You must act. Now. Or someone might die.

That's why ADCOMS often ask pre-medical students a variation on this question (which I found on the Internet on a list of practice questions): How do you work under pressure? Give an example. What, in hindsight, were you most dissatisfied with about your performance? What did you learn from your experience?

"I'm no stranger to working under pressure," I thought when I read that question. And that is the truth. For the year and a half that I worked at the Forest Park Review, a local weekly newspaper in the Chicago suburbs, "pressure" was my constant companion. (And this was my first job out of college, so I learned it early.)

It was especially intense, though, on Tuesday mornings. That was deadline day, when the paper was sent to the printer. I would wake up at 2 or 3 a.m. in order to write a half-dozen or so stories and an editorial by 7 or 7:30 a.m. And then I would go to the office. What for? For another three hours of deadline drama: writing headlines, creating captions, approving page layouts, and so on. It was grueling.

But through it all, I had to be at peak performance. Exhaustion was no excuse. I had to get the facts right, get the dates right, and get people's names right. And do it all in captivating prose. Oh, right -- make that captivating prose in less than 700 words per story.  

But I didn't need any excuses. In fact, I kicked things up a notch on deadline day. I was intense, driven, focused. When I have a goal, and time constraints for completing that goal, I find myself subdividing time into estimated allotments for each portion of the task I have to complete. This helps me stay on track so that I don't spend too much time doing any one thing. On deadline day, that might mean 30 minutes for one story, and one hour for another. (I prioritized as well as subdivided.)

The process was intense, and I was intense during the process. It was hard to turn that intensity off right away. So when I'd leave the newsroom at around 11:30 a.m. or noon, snippets of stories would float through my mind. And I would question myself: Did I do X right? Did I change Y like I told myself I needed to? Maybe I should have opened that one story with another lede ...

Then when I saw the newspaper the next day, I saw the in most cases, yes, I did do X right, I did change Y, and in actuality the lede I opened on that one story with was fantastic.

I gradually learned to trust myself, not to second-guess myself in those high-pressure situations. Because I knew what I was doing, I really did, I just needed to BELIEVE that I knew what I was doing, and go with that. Because it was often the second-guessing that led to the mistakes.

This is an essential skill for a physician to have. There is often no time for second-guessing. Making a second guess might mean your first act is one moment too late. So trusting yourself, your skills, and also your intuition, is something that a physician must do ... is something that hopefully I will one day do.

ADCOM Q&A ... (an introduction)

ADCOM (ăd´kəm) n. An abbreviation that refers to a member of a medical school admissions committee. Can also refer to the medical school admissions committtee as an aggregate. ADCOMS are, essentially, the gatekeepers to medical school. It is their decision--based on a student's application, GPA, MCAT score, and interview--whether the student will be offered a slot at that medical school. Thus pre-medical students refer to ADCOMS with, alternately, fear, derision, and respect.


The above definition (my own) is the way most people think about the ADCOMS: cold and impersonal. And in a sense, they are. They have to make dozens of decisions, based on established criteria, in a limited amount of time. To do that effectively, you have to be a bit calculating and unemotional. (That is not meant as an insult, rather as a compliment.)

On the other hand ... ADCOMS are people. In fact, I know a handful of them personally. They smile, laugh, eat, sleep, do all the things we "normal" humans do. I have even found them to be helpful, if you can believe that. No, they are not the enemy. In fact, it would behoove more pre-med students to make ADCOMS their friends. But that is a topic for another day.

Right ... ADCOMS are people. Which means that, essentially, they respond as people, at least on some level. They possess curiosity and emotions, for example, which no amount of established criteria can completely wipe away. (That's my belief at least, however naive.)

Why do I care about all of this? The reason is simple: in a couple of years, the ADCOMS will hold my fate in their hands. So I need to understand what that means. And what that means is that I need to affect them -- to stand out above my peers -- in some way that says "Look at me! Choose me! I'm different! I'm the ONE!" I need to do this both on my application and during my interview. (Um ... in a slightly more subtle, professional way, of course.) Because there will be, literally, thousands of people just as qualified, on paper, as I am. And not all of them will get in. I want to be one of the ones who gets in.

So how do I do that? Well, there's no sure way, of course. The best way I can figure (other than do well in school, do well on the MCAT, volunteer, and get clinical experience, which are givens) is to get into the right mindset. No, I haven't gone all New Age-y. What I mean is to think about what the ADCOMS will likely want to know beyond my statistics, what types of things they are likely to question me about during my interview, and have my answers ready. And no, I'm not trying to predict the future and conjure up a list of questions that I will be asked.

My plan is two-fold: to prepare for common questions (i.e., "Why do you want to be a doctor?") and for common categories (i.e., medical current events), using sample questions to jump-start -- but not contain -- my thinking. Because the sample questions I have found online (and believe me, there are hundreds) are only a small slice of what could potentially pop up. I then plan to use this blog as a sounding board for some of my potential (but certainly not final) answers.

You might be wondering why I am giving away my strategy, and why I plan to give away some of my answers. After all, couldn't the ADCOMS, then, just ask me different questions than the ones I've prepared for?

To address the first issue: My strategy is not brilliant. It is common sense. So why hide it? In fact, I'd kind of like the ADCOMS to know that I can analytically approach something and realize it has a real-life, common-sense solution (as opposed to a nebulous theoretical one). There are plenty of pre-meds I've met -- very smart people, to be sure -- who have exactly zero common sense. I understand theory; I also understand real-world application. To be a doctor, you need to be able to understand both. So read on, ADCOMS!

To address the second issue: I don't plan to write a blog post about every single question or question type that I prepare for. That would take for frickin' ever. So I am not worried about showing my whole hand. Showing part of it, though, I don't think is such a bad thing. The medical school interviews I will (hopefully) have will be short, and there will be no way for me to communicate to the ADCOMS everything I want them to know about me. If they stumble upon my blog and discover some more pertinent information that puts me in a good light, even if it means they throw in a few more difficult questions during the interview, it is worth it to me.

As I see it, the ADCOMS and the interview are not what keep you OUT of medical school (which is how a lot of people seem to look at it), they're what get you IN. So best to embrace them, early and often.

Managing The Seagulls' Sh** (and other messes)

In my last post, I explained how I think that I might have a decent start when it comes to developing a good bedside manner--i.e., working well with patients. What I didn't take into account in that post, however, is that you don't only work with the patient. You also work with the patient's family. And that can create its own set of problems, dilemmas, and conundrums, as a hospice nurse I know explained to me this week.

Take the case of Mr. Martinez, * a terminal lung cancer patient. Most hospice patients have a DNR--a "do not resuscitate" order, which directs hospital and emergency personnel to NOT use life-saving techniques such as CPR or a ventilator, but to let the patient die naturally. Mr. Martinez, a native of Argentina, does not have a DNR, although he would like to have one. Why? Because his son, who still lives in Argentina, wants the father's life prolonged until he can make it to the United States to say goodbye to his father. The father doesn't have the heart to disagree. While this seems like a natural desire in a way, it really is very selfish, the nurse explained--it would mean keeping the father alive, perhaps in pain, just so the son can meet his own emotional needs. And it's not like the son never sees the father; he visits every couple of months, and has had plenty of opportunity to say a meaningful goodbye. Because what do you really gain from seeing an empty, non-communicative shell that's kept alive by a machine?

The nurse I know said this is a common situation--family members simply can't let go, even when the end is imminent. So it has become her job to try and convince the son--via e-mail, since he is in Argentina--to encourage the father to have a DNR. Not a task I envy, that's for sure. It's one that requires great finesse, compassion, and understanding. And a thick skin, to boot. All done in a one-way conversation, without facial expressions, body language, or vocal inflection--all tools that can be extremely helpful when trying to talk about something so serious and traumatic. 

Mr. Martinez's son, an out-of-town family member, is what one of the nurse's co-workers calls a "seagull"--someone who flies in, sh**s on everyone and then flies out. They want to help, and they (usually) have the best of intentions, but they don't really know the day-to-day situation or the intricacies of their family member's care (or health condition). So they rather muck things up. Often, they step in so aggressively and vehemently because they feel guilty for not being there on a more regular basis, the nurse told me, so they feel they must "fix" what seems "broken" to make up for that absence. When really, the opinionated assistance often does more harm than good. 

But it's not just the "seagulls" who can cause a wrinkle in a patient-care situation. Nearby relatives, even daily caregivers, can create serious problems, the nurse told me. She related the story of one family where two sisters were, in her words, "at each other's throats." Just about literally, it seems. One of the sisters actually called 911 on the other sister because she felt that sister wasn't appropriately administering the patient's medication. 

The kicker? The patient's problem was agitation. I doubt if sirens, police, EMTs, and whoever else showed up helped alleviate the symptoms the sisters *claimed* they were so concerned about. 

This is another situation that, as a health care worker, would be a sticky one to resolve (if a resolution was even possible--a temporary cease fire might be your best bet).

This is not to say that family members are always a source of trouble and ire. As the nurse told me, "Family can also be the greatest resource." When that happens, it makes the health care worker's job infinitely easier and richer. So you hope and pray for this scenario.

But for those times when the family members seem to be working against you rather than with you, I imagine you must tap deep into yourself for strength, composure, patience, and endurance. And still, even though it seems undeserved, compassion. Because while the family members may be making your life hell, you have to realize that their life is hell right now, too.

Come alongside. Understand. Empathize. And then maybe you stand a chance not of changing the family, but of helping them to decide to change themselves. 

* Names and details have been changed to protect patient anonymity.


Sunday, July 18, 2010

Grocery Carts and Call Waiting: Why I'll Make A Good Doctor

The title of my blog is, obviously, "My Bedside Manner." So far, though, I haven't done much talking about my own bedside manner. Mostly because I haven't had much of a chance (aside from the summer I spent working in an ICU back in 1999) to develop one, officially speaking.

That doesn't mean, though, that I haven't thought about it. In fact, I've thought about it a great deal. And I've come to the conclusion that, in all likelihood, my initial bedside manner won't be so bad. It might even be a tad bit good. And hopefully, it will get even better as time goes on.

How did I come to this conclusion? It all started with my grocery cart dilemma. I was at the local Mexican produce market and had just finished loading my trunk with fresh fruit and vegetables for the week. I had parked about as far away as possible (not on purpose, believe me), and it was at least a sun-blazing 90 degrees outside. So when I saw a cluster of about a dozen other shopping carts circling a streetlamp in the parking lot, I was sorely tempted to wheel mine into the bunch rather than back to the storefront. But then I sighed, realizing that I am not the kind of person who leaves the grocery cart in the middle of the parking lot. It just feels wrong to me somehow, unnatural. I would have driven away feeling guilty, and I didn't want that. So I marched off toward the store, cart in tow.

After my sweaty walk back to the store, I returned to my car and switched on the AC. As I sat waiting for the hot blasts of air to cool down, it occurred to me that my reaction to the cart dilemma might say something about me as a person. It might indicate that I can be thoughtful, even when I don't know who will benefit from my thoughtfulness. That I don't like to make extra work for other people if I can help it. That I have a sense of responsibility, and that I take things seriously even when so many people around me (i.e., the other customers) do not.

OK, I will come clean: I am far from perfect. I do not always take the cart back. But I tend to. And so I think what I have just said has some validity.

I got to thinking more about that tendency to take the cart back. Not only what it might mean about me as a person, but also what it might mean for the kind of bedside manner I will have. Thoughtfulness, pitching in where needed, a sense of responsibility? These sound like components of a decent bedside manner to me, as well as a recipe for getting along with my future hospital or clinic co-workers.

"Are there any other clues as to my future bedside manner?" I wondered to myself. Driving home, I thought through some of my other habits (my husband would be more likely to call them "quirks," but then again he's allowed that privilege). Of course everyone has habits, but I was looking for habits linked to my ability to relate to others (especially strangers), and to care for them. Sure as Sherlock, I found my clues.

"Eva." She was my first clue. I don't imagine she gets called "Eva," which is her real name, very often during the 9-to-5 workday. But when I stop by the Student Union at the University of Illinois at Chicago for coffee, I do call my barista by her given name. We exchanged names a few weeks ago, and have had little chats ever since. (I've had to remind her of my name several times, which is fine--she has dozens of customers every day; I have only one barista.) I don't pretend that I've solved all the problems in her life, but I do believe that I've shown her the respect she deserves, but doesn't often get because she's working an "unskilled labor" job (and is surrounded by hoity-toity doctors who are more than happy to point that out).

In a hospital setting, that would translate into exactly the same thing: learning people's names, and using them. Rather than, for example, calling someone "the gall bladder in 241" or "the stroke in 332." Yeah, not much respect for the person there. Learning someone's name shows that you care about them as an individual person, and (in the hospital) not just about their disease or what kind of health insurance they have. That's pretty important for building the patient-doctor relationship.

Using a person's name is one important aspect of communication. Another is saying "thank you" when someone deserves it. Of course, when you're at the grocery store, most people say "thank you" when the bagger hands over the plastic sacks. I'm not talking about those automatic situations. I'm talking about going out of your way to thank someone, where it really makes them feel special and rewards extra effort.

I have found that this really goes over well with people. Although that's not why I do it. I do it, perhaps, because I like being thanked. Or maybe because my mom forced my sisters and I to write thank-you notes for every little gift we ever received as children, so it's ingrained in my head now. Regardless, I do it. Like when I was at the craft store the other day. The cashier rung something up as regular price. I thought it was on sale. Rather than tell me to go find another item with a more accurate tag, or call someone else to check on it, she went over to the shelf herself. Turns out, she was right. Regardless, I thanked her for making the extra effort to verify the price for me. She smiled, and I think she even blushed.

In the doctor-patient relationship, it's the doctor who's helping the patient, and who should be thanked. So my habit doesn't apply. Right? I wholeheartedly disagree. In any relationship, there is give-and-take. One has to help the other, and vice versa. Sure, the patient has come to the doctor looking for help, and it would be nice if the patient thanked the doctor, but that's not why the doctor does his or her job. However, the doctor can make his or her job a bit easier by saying "thank you" to the patient. This may not work in all situations, but it will in many. For example, a patient reveals something very personal that was difficult to say, but necessary to treating a condition. "Thank you," says the doctor. Or the patient comes early as requested to fill out some paperwork. "Thank you," says the doctor. You get the idea. The obvious corollary of this is for the doctor to say "I'm sorry" when he or she has done something wrong, is running late, etc. Both appreciation and apology go a long way toward building a relationship with someone, and maintaining that relationship. This is the philosophy I have developed so far, and the one I intend to implement in the future.

A common thread here so far has clearly been respect. So if I want to have a good bedside manner, I want to avoid disrespect (this is obvious, but bear with me). One of the most disrespectful inventions in the history of man, in my opinion, is telephone call waiting. It has its purpose, I understand. And I use it from time to time--but ONLY if I am expecting a particular telephone call, and one that is extremely urgent. If I am talking to someone, and another person calls, that second person can either leave me a voicemail message or call me back later. End of story. Because I consider it in very poor taste to interrupt my first conversation to (ostensibly) find out whether the second call is more important, and should therefore be given priority. This call waiting fetish says much about the "NOW" need in our culture, but I will not go into that. Suffice to say I ignore my call waiting 95 percent of the time.

OK, I admit, this one won't work in the physician setting. If, as a doctor, I am on the phone with a patient, I may very well get a phone call from someone else (another patient, the hospital, a resident, etc.) that may very well be urgent, but I won't know that until I find out who it is or what it is about. So I will have to make some philosophical adjustments here.

However ... my principal still holds in another respect: respecting a person's time. (Because when you break it down, that's a large component of the problem with call waiting. You're saying one person's time is more valuable than another's.) For example, if a physician is talking to a patient, that physician should, whenever possible, give his or her full attention to that patient. Doctors filling out patient charts while they talk to a different patient about a potentially life-threatening condition, and having to ask that patient to repeat things because the doctor was busy writing something down on the chart? That's not respectful. That's just like saying, "I've got another phone call. Hold on." Again, there will be plenty of urgent, and warranted, interruptions. That goes with medicine. So make those five minutes, if that's all you've got, count. That's my plan, at least.

Along with paying attention, there's another aspect to respecting a person's (and a patient's) time. That is running on time. Also not always possible, clearly, due to those aforementioned interruptions, emergencies, and so on. But I have seen a number of different medical practices at work--some run efficiently, others not so much. There are ways to running closer to being on time. Those ways sometimes cost money (i.e., salary for additional staff to process patients or shelf charts). But if your patients are happy, they are more likely to come back and pay you again. And if you, your patients' doctor, is on time, your patients are more likely to be happy. Because their time is valuable, too. Having sat in more waiting rooms than I'd care to think about, I heartily and readily acknowledge this.

None of this is to say that I am extra special, am grandly talented when it comes to interpersonal affairs, am a superhero, or am the next Dr. Schweitzer. Nothing of the sort. I'm just saying that these habits, which really (so far) have nothing to do with medicine, illustrate that I respect people in various ways and that I am willing to put myself in their shoes to make sure that respect comes across. And that, to me, is at least part of what having a good bedside manner is about.

Wednesday, July 14, 2010

Getting An Accurate Interpretation

Hormigueo (tingling). Escayalo (plaster cast). Expediente (patient's file). Presión arterial (blood pressure).

Two weeks ago, I didn't know any of this Spanish medical terminology. Sure, I'm fluent in Spanish, but these words -- as well as a few dozen (er, a few hundred) others -- simply never came up in regular conversation. I'm hoping that will change soon, as I have applied to be a volunteer Spanish translator at an urban clinic in Chicago. * Which means, of course, that I will need to know quite a bit of Spanish medical terminology to successfully do my job.

I never took this position lightly. But the more I think about it, and the more I learn about interpreting, the more I understand that "professional" interpreters can make the difference between a successful and an unsuccessful clinican-patient encounter, and between helping a patient making an informed versus an uninformed medical decision. I can help make that difference. I want to help make that difference.

When it comes to demand for Spanish interpreting, the need is only going to grow. According to a 2008 report from the U.S. Census Bureau, the Hispanic population is expected to grow from its level of 15 percent in 2008 to 30 percent in 2050. The percent of non-Hispanic whites is expected to fall from 66 percent to 46 percent -- meaning whites are expected to no longer be in the majority, although they will still be the largest minority. And my home state, Illinois, is one of the centers of the Hispanic population. A 2006 U.S. Census Bureau document ranked Illinois as number 5 in the nation in terms of size of Hispanic population (1.89 million). Cook County, IL, my home county, was also ranked number 4 in the nation in terms of Hispanic population size, with 1.2 million Hispanic people.

Along with that increasing number of Hispanic people comes an increasing number of "Limited English Proficient" (LEP) patients in the medical context. These are people whose primary language is not English (Spanish, in this case), and who have difficulty reading, writing, speaking, and understanding English. According to a number of scientific studies, this language barrier can cause many health care problems, as summarized in an article published in Health, Research and Educational Trust in 2006 ("Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency?"):
- less access to routine care
- fewer physician visits
- lower rates of preventive care
- less follow-up for chronic illness
- poorer understanding of Emergency Room visits (i.e., diagnosis and treatment)
- less satisfaction with care
- more medication complications

When it comes to Spanish, the problem is often not the lack of a translator. The problem is more frequently with the quality of the translation. Very often, "ad hoc" interpreters -- people who are untrained, such as family members, receptionists, or other people in the waiting room -- are used, which results in inaccurate and sometimes disastrous consequences. Sometimes, it is that the interpreters who are used are simply poorly trained. Because unlike courtroom reporting, there are no  national standards, or even guidelines, for health care interpreting at this time. The National Council on Interpreting in Health Care, an organization dedicated to promoting professional and culturally conscious interpreting, is working to develop a set of training standards (which are set to be done at the end of 2010). The idea is to eventually have national certification for interpreters.

Right now, though, we are far from that. And it is affecting patient care, sometimes dramatically. One study, published in 2007 in The Society of General Internal Medicine ("Are Good Intentions Enough?: Informed Consent Without Trained Interpreters"), found that Latina patients who were at a prenatal clinic being given the choice of whether to have amniocentesis were unable to truly give their informed consent to the procedure. In some cases, their interpreters did not fully explain what the medical practitioner was saying, either because of a lack of fluency in Spanish or a lack of medical understanding in general. In other cases, the procedure was not presented as being "optional," but as "simply the next step in the clinical process." In addition, it was often not communicated that there were any alternatives to amniocentesis (while a woman could have an ultrasound instead, although this test is not as definitive).

In short, the complicated nature of translating medical terminology, risks, benefits, potential complications, alternatives, etc. is something that requires more than being bilingual or "good" at speaking Spanish. It requires training and a fluency in medical terminology, in addition to privacy practices and other issues related to health care.

At the clinic where I want to volunteer, there is an orientation/training seminar where volunteers are tested on medical terminology to ensure they meet at least a minimum of requirements. In addition, I have spent hours (and I mean HOURS) studying literally hundreds of flashcards with words copied from my new best friend, the Spanish Medical Dictionary. I may not have to pass a set of national standards at this point, but I have my own standards. And I have set the bar high. Because I am serious about this job -- it's an important one, and it's even more important to do it right.

* I'm still waiting to hear back regarding my application; apparently they are currently reviewing my references.

Health In The Headlines: Life Span vs. Health Span

Good news, if you're a roundworm: researchers at Stanford reported last month that blocking the expression of a particular protein can extend a worm's life span up to 30 percent.

That is good news . . . right?

It depends on whom you ask. Clearly, the Stanford researchers, as well as other researchers who have studied caloric restriction (another method purported to promote long life) think so. But there is another camp of scientists dedicated to improving not so much life span, but health span.

So what does "health span" mean? According to the Macmillan Dictionary's online "Buzzword" feature, "health span" is "the period in a person's life during which they are generally healthy and free from serious or chronic illness." So the focus is on living better, as opposed to living forever.

Sounds simple enough, doesn't it? But this concept is really a very complex one which scientists are only beginning to grapple with, understand, and research. Ironing out some of the complexities, and getting more scientists, policy makers, and regular people to think this way, though, is key to making sure that "aging gracefully" is not just a catch-phrase.

One major problem in the world of aging research is a disconnect between the viewpoints of clinicians and "basic" science researchers on this very topic. In an article published in the Journal of Gerontology in 2009, authors Drs. James Kirkland and Charlotte Peterson write that "Geriatricians and others providing health care for the elderly have long recognized that disability, frailty, and age-related disease onset are the critical end points that need to be addressed in older populations." Hence, many clinicians are on the "health span" wagon. However, Kirkland and Peterson also claim that "Most investigators in the basic science of aging use survival curves and maximum life span as key end points for studies of effects of interventions, rather than health span or function." Hence many basic science researchers are on the "life span" wagon. And when researchers and clinicians are on two different wagons, little if any progress will be made in terms of going from the scientific "bench" to the bedside with new treatments.

What needs to happen, writes Marc Tatar, a biologist at Brown University, is first clarification of the health span concept. While Tatar explores a more scientific definition of health span than the one I previous listed, his comments relate to our more simple definition as well. For example, how do you define "healthy"? What is the threshold between healthy and unhealthy, in terms of time and quality of life? And even if you use baseline performance as a judge, that baseline performance declines over time -- how do you factor that in? These issues need to be resolved before any progress can be made, Tatar says.

Once some of that ambiguity is resolved, the next step is to develop a better animal model for studying health span, Tatar says. That will allow researchers to take results and translate them to human models. For example, researchers should look at how best to study osteoporosis -- clearly a factor in human health span -- in mice, flies, or worms (three of the best animals for studying aging issues).

Kirkland and Peterson agree that better animal modeling is needed, although they focus on the concept of frailty: "Frailty usually describes a condition in which a critical number of impairments occur in parallel, becoming evident after a threshold is reached, and if a stress such as an infection or injury is applied." They say that indicators of "frailty syndrome" include weakness, fatigue, weight loss, impaired balance, decreased physical activity, slowed motor performance, social withdrawal, mild cognitive dysfunction, and increased vulnerability to physiological stress.

According to Kirkland and Peterson, screening for frailty in humans is being developed and validated, and could be adapted for use in animals. Testing animals for frailty -- after giving them an anti-aging compound, for example -- could help show whether the added longevity compromised health span, and therefore whether the compound was potentially appropriate for trials in humans.

Living longer, obviously, can be a good thing. But only if that extended life is a healthy one. That's what the study of health span is about. And while the idea is catching on, it has some catching up to do.

Thursday, July 8, 2010

Room To Breathe, Room To Vent

Of the dozens of patients I encountered the summer I worked in an ICU in the Chicago area, the person I remember the best is Mr. Chesterfield. * Rather, I remember Mrs. Chesterfield -- her husband was on a ventilator and was unconscious and unable to talk the whole time I was there. But Mrs. Chesterfield and I had some lovely conversations while I stocked the nurse's cart in Mr. Chersterfield's room, brought in new boxes of gloves, and changed the sharps box. She even sent me a thank-you note, telling of her appreciation for how I had encouraged and comforted her during that difficult time.

At the time, I knew the machine hooked up to Mr. Chesterfield was pumping his lungs full of air, breathing for him. But I had no idea how it worked, or what damage such a life-saving device could potentially cause. Until today's lab meeting.

Clearly, if someone cannot breathe on his or her own, having a machine do it is a good thing. There are several problems with using a ventilator, however. One is that using a ventilator at "high-tidal volume" -- which is sometimes required, when a person's lung capacity is diminished (from what I understand) -- can "hyperinflate," or overstretch, the lungs. This excessive stretching breaks the cell-cell junctions (sticky stuff that keeps the cells together). This necessary (but damaging) overstretching results in a condition called "volutrauma." In this condition, the permeability of the lung cells (specifically, alveolar epithelial cells) increases, which affects gas (i.e., oxygen and carbon dioxide) exchange, the spread of micro-organisms (and infection/inflammation), and the build-up of fluid. When volutrauma is taken to the extreme, according to one person in my lab meeting, you basically drown to death because your lungs fill with fluid. Not good.

Of course, when you breathe normally, you are also stretching your lungs -- perhaps about 8 percent. High-tidal volume ventilation might stretch your lungs about 20 percent instead. With that extra stretch comes increased permeability and the cell-cell gaps that create all the problems.

What one of my fellow researchers has found is that decreased levels of a particular protein seem to be linked with those cell-cell gaps and increased permeability. Increased levels of that protein may be associated with fewer gaps, called a "partial rescue." This means the protein could be a "therapeutic agent" for ventilator-induced lung injury. Which would be a huge deal, especially considering that many ventilator patients are older, and that the ratio of elderly people in the overall population in the United States is about to jump sky high.

Of course, there are plenty of issues to work out with this research. (I won't even start on those.) This is basic science, not even close to a clinical trial. But it's exciting to see how something happening in the lab next door could potentially save lives a few years (or decades) down the road.

And who knows? Maybe by the time I'm an anesthesiologist (a thought that has occurred to me more than once) this is a treatment I'll be using.

* Name has been changed to protect the patient's privacy.

Lessons From The Local ER

When even the gravitational pressure from resting my head on a pillow became unbearable, I decided it was time for a visit to my local ER. Believe me: I did not look forward to this visit. When you tell someone in the ER that you have a migraine, they usually smile and nod, and then put your name at the bottom of the list with a little sticky note next to it that says "NO NARCOTICS." Little did I know that it was medical judgment -- not my medication habits -- that would get me in trouble this particular evening.

This was my first trip to the ER for a migraine, although I've been getting them for years. Since about 2008, my doctor and I have had them mostly under control with Topamax as a prophylactic (daily preventive medication) and Fioircet as a PRN ("as-needed" medcation taken right away to squash the headaches when they start). But this time, nothing worked. And I was honestly not sure how I would make it through the night with such intense, knifing pain. I know this is a cliche, but it really did feel like someone was trying to penetrate the area above my right orbital bone with an ice pick. Or it could have been a chisel ... anyway, you get the idea. It hurt. A lot.

Surprisingly, once I arrived at the ER, I got called into the triage area less than 10 minutes from when I checked in. "OK, I can live with this," I thought. The nurse took my vitals, which were pretty normal for me, and then asked me how bad my pain was, on a scale of 1 to 10. I didn't even hesitate. "10."

The nurse quickly and efficiently ushered my to room "number C" (that confused me a bit, in my addled state -- a number, and a letter, together ... never mind). After a few minutes, a physician's assistant, Stephanie, came in. She promised me pain meds and a CT scan. The former, I expected. I would have gotten down on my hands and knees and kissed Stephanie's feet for a shot of something, ANYTHING. But an emergent CT scan? At 9:30 p.m. on a Wednesday night? Hm. "OK, they pay those guys the big bucks for a reason," I told myself, and decided not to argue. Even though, in the last five years, I've had one CT scan and two MRIs, all completely normal. (Thank you, BlueCross & BlueShield of Illinois.)

Got my shot, went to the CT room. Not too much of a wait at 9:30 p.m. I think the tech was glad to see me, in all honesty. He looked bored, and was quite chatty. Once that was all done, it was back to the ER waiting room to (guess ...) wait for the results.

My husband, Geoff, and I had a bit longer to sit this time. But finally we made it into another curtained-off room. This time it was "Kevin," another PA, who came to greet us. As I expected, the test results were normal. Not that I really cared, because what I'd come for -- headache relief -- had arrived more than an hour earlier.

But Kevin had it in for me. "When you come in here and say your pain is a '10,' that means it could not get any worse," he told me. "That means you could have a gunshot wound and it wouldn't be any worse."

I just sat there, confused. "Well," I thought to myself (though I didn't dare share any of this with Kevin), the nurse asked me how bad my pain was. I rated it based my pain experience, and this was the worse pain I'd ever had, so giving it a 10 seemed a natural resposne." Based on my understanding of the pain scale.

Now Kevin was telling me that I'd mislead the medical personnel, which had caused an unnecessary CT scan, and unnecessary time in the ER for both of us. But that was based on his understanding of the pain scale.

I'm not about to say that I'm right, and Kevin is wrong. He is the PA, after all, and is trained in such matters. I'm just a lowly pre-med student, with aspirations of someday doing a rotation in the ER and handling just such a situation.

What I am saying is that there was a serious breakdown in communication. And a serious mishandling of that breakdown.

First of all, it was the nurse's responsibility to explain to me what she meant by a "1" and a "10" on that pain scale. I Googled it just now, and there is conflicting information on the Web. The National Institutes of Health simply states that pain of 7 to 10 is "severe" and "disabling" and intereferes with "ADLs" (the activities of daily living, such as eating, brushing your teeth, etc.). Another chronic pain Web site I looked at described people experiencing a 10 as "bedridden" and "possibly delirious." The site stated that "few people will ever experience this level of pain." These two sites obviously have different ideas about the intensity of a degree-10 of pain.

So ... who is right? Answer: It doesn't matter. What matters is that people on both ends of the scale understand, and are using, the same rubric for comparison. Otherwise, the results are meaningless. It's like transferring a hockey score to a basketball game, without using any kind of conversion factor. For example, picture this game score: Chicago Bulls -- 92; Chicago Blackhawks -- 5. Ummmm ... Who won? Right. Makes no sense. Because they're on a different scale, and the numbers mean different things.

It's about communication, first of all. And that communication was certainly lacking during my ER visit this week.

Beyond communication, working in any medical environment -- ER or otherwise -- requires some empathy and understanding. And Kevin just didn't have it that night. Maybe it had been a long shift, or a really hard day. I get that. But that's still not a reason to blame a patient for not "getting" something that wasn't properly explained.

When I think about spending time in the hospital, I usually think about spending time there as a volunteer, or a shadower, learning the "how-tos" of taking care of people. Developing a good "bedside manner," if you will. Hence the title of my blog. But sometimes you learn just as much by watching people and observing what you don't want to repeat. That was my experience this time around. And as unfortunate as it was, I learned an important lesson from it.

Confessions Of An Addict

While some of my friends are busy planting and harvesting strawberries, artichokes, or melons to earn coins on FarmVille, I am also likely on the Internet. But not on Facebook. These days, you're more likely to find me on, a Web site run by the National Center for Biotechnology Information, the U.S. National Library of Medicine, and the National Institutes of Health.

And yes, this is more proof that my brain has been taken over by an alien being. Or perhaps an entire colony of them.

Seriously though. PubMed is incredible. It's an online database of more than 20 million citations to scientific/medical articles dating back to 1865. Nearly 3 million of those citations include FREE full text. (The vintage-bargain-hound in me loves this.) It's a fantastic resource if you want to know, say, the role of caveolin 1 in embryonic lung development (something my mentor, Olga, is writing about for a textbook chapter). Just like with Google, you type in your search terms and hualah! Article citations.

Of course, quite often the article I want is NOT free ... so I must be satisfied with a mere abstract, or perhaps a less recent (or somewhat less relevant) article. If it's a matter of life and death (er ... success and failure of an experiment, more likely), I can just buy 24-hour rights to read the article from the publishing journal.

It's that easy. And anyone can do it. You don't have to be a scientist (or a pre-med student) to enjoy the pleasures of PubMed. For people whose brains haven't quite mastered the technical language (I include my alien-infested gray matter in this category), reading "reviews" of articles instead of the actual articles themselves is a much easier way of digesting and understanding the information. Just a little tip I picked up from Olga.

So what are you waiting for?

Wednesday, July 7, 2010

Health In The Headlines: Personalized Medicine

"Wait and see."

How often has your doctor spoken those words to you after handing you a prescription? Too often, it seems to me. And this is not where we should be in the year 2010, says Dr. Bryan Schneider, an oncologist who was interviewed in June on Indiana University's Sound Medicine podcast.

Instead of "wait and see," Schneider thinks doctors should be able to predict a patient's reaction -- both in terms of positive effects of the medication and its negative side effects -- saving both lives and money.

This idea -- called "personalized medicine" -- is not really new. But it's gaining traction and speed, with recent support from the Food and Drug Administration and the National Institutes of Health. And while the government is behind on regulating this new field (which has led to a number of problems, including reports of women unnecessarily having their ovaries removed), there are promises to catch up on that front.

So why isn't all of our medicine personalized? Good question. It would be nice. But we are not there in terms of technology.

Personalized medicine is really about genetics. People react differently to medications because of variations in their DNA. The Mayo Clinic's Web site explains it well: For example, one genetic variation might cause a drug to remain in your system longer than normal, leading to dangerous side effects. Another variation might make your body less sensitive to a medication, meaning it won't work as well, and you might need a higher dose than other people.

If doctors could test for different genetic variations, and how those variations affected your body's response to a medication, they could prescribe more efficiently. Doctors could choose both more effective medications, and more effective dosages, for individual people. This would save not only in terms of a "grief" factor, but it could save lives -- according to the Mayo Clinic, some 100,000 Americans die each year from reactions to medications, and more than 2 million wind up in the hospital. If a doctor knew someone would react poorly, he or she could avoid prescribing a medication entirely. This philosophy would also save money (always a selling point). Many treatments -- especially those for long-term illnesses such as cancer -- cost tens, if not hundreds, of thousands of dollars per year. Prescribing selectively and effectively eliminates guessing, grief, and waste.

The problem is that there could literally be millions of genetic variations (no one's sure how many). And sometimes a response to a medication may not be governed by one gene, but by many genes interacting with each other. We simply do not know enough about the interactions between genetics and medications.

There are, however, a few genetic tests available today that allow doctors to personalize a patient's medical care, most of them related to cancer treatment.

One example a test for HER2, a gene involved in breast cancer. If a woman's cancer is HER2 positive, the results indicate use of Herceptin, a drug that can shrink the tumor, get rid of HER2 cells that have spread beyond the original tumor, and possibly prevent recurrence of the HER2 positive cancer. HER2 negative tumors do not respond to Herceptin, so before Herceptin is used, patients are tested with either an immunohistochemistry test or a gene-amplification test.

Another example involves metastatic colorectal cancer. If the cancer expresses the protein epidermal growth factor receptor (EGFR), then a medication called Erbitux may be used in combination with other treatments. Erbitux inhibits EGFR (which helps the cancer grow), so the medication may slow or stop the spread of the cancer. But Erbitux only works if the cancer expresses EGFR, so a genetic test called an EGFR immunohistochemistry test is required first.

So where do we go from here?

Scientists are making great strides in discovering those genetic "variations" that interplay between disease and medications, according to a recent article in The New England Journal of Medicine (published online on June 15). The problem, according to this article, is that "there is insufficient evidence of a downstream market to entice the private sector to explore most of them [the genetic variations]."

Basically, drug companies don't see the dollar signs. So they don't invest anything.

The purpose of that New England Journal of Medicine article (called "The Path to Personalized Medicine") is to lay out a plan to show how the Food and Drug Administration and the National Institutes of Health plan to "fill that void."

The FDA and NIH plan to do this in several ways. The first step is an "integrated pathway" between academic research and approving treatments for clinical use. The FDA and NIH promise public-private partnerships, as well as a program called Therapeutics for Rare and Neglected Diseases (TRND), aimed at accelerating the development of drugs, developing "targeted" drugs, and rescuing "failed" drugs by finding certain groups of patients who might benefit from them.

A second step is collecting information about genetics and treatment outcomes. For this, the NIH is relying on its various research centers and hospitals.

And last but not least, the FDA has established the "Critical Path Initiative" to regulate this up-and-coming industry and science. It is, in my opinion, about time they did this. As the article authors admit, there have already been instances of regulatory failure: "Increasingly, however, the use of therapeutic innovations for a specific patient is contingent on or guided by the results from a diagnostic test that has not been independently reviewed for accuracy and reliability by the FDA." In other words, doctors may be using tests that the FDA has not approved to guide their treatment decisions. Not good.

For example, the FDA approved the drug Rituxan for certain cancer treatments in 2006. According to the NEJM article, a particular lab company has since then been marketing a test that claims it can tease out the 20 percent of people who will not repsond to the drug from those who will respond to the drug. Says the article: "The FDA has not reviewed the scientific justification for this claim, but health care providers may use the test results to guide therapy."


In addition, the article's authors point to other issues with laboratory tests that lacked FDA oversight, including situations where women were given "false readings that reportedly led to the unnecessary removal of women's ovaries."

Apparently, these glitches will now be taken care of. I sure hope so, because personalized medicine might just be the future of medicine.