Saturday, October 27, 2007

Why Medicine Doesn't Make Sense, #1

How can someone design a drug without knowing how it works?

I keep running across descriptions of drugs that say "mechanism of action unknown". How does this happen? As I get deeper and deeper into the study of medicine, I am more and more amazed by how much what is practiced is a crapshoot.

Maybe medicine is more an art than a science.

Friday, October 19, 2007

On Death and Understanding

A few days ago, I found myself having a very hard time understanding how an infection can actually kill a person.


I asked this question, specifically about pneumonia, as my professor and I walked out of class. Part of the difficulty, I think, is that it's not a simple event. Intuitively, a massive invasion of foreign organisms doesn't seem like it can be a good thing. But to actually outline the steps until death -- pathophysiology, if you'd like to put a name to it -- is much more difficult. Which organs are most affected? What are the proximal causes that actually make these organs fail?

The professor explained that the inflammatory exudate floods the alveoli to such an extent that breathing becomes labored. But, I insisted, can't you just aspirate out the fluid? If we know what's happening to a person's lungs, can't we just fix it?

The answer, of course, is that it's not that easy, antibiotics aside (and antibiotic resistance is a whole other story). Once the inflammation response is at full strength, the influx of cells, cellular debris, and protein into the lungs results in a complete loss of lung architecture such that the normally air-filled lungs actually take on the consistency of the liver.

I still couldn't wrap my head around it. And it will probably be awhile before I do. Because really, it's not just an intellectual difficulty in understanding the process; it's also a psychological difficulty in really comprehending how a body that functions, sustains a living individual, can become one that is lifeless. Humans know what death is from a young age, and have some exposure to it; but really understanding how a person dies is something that comes much later, and much harder. This, I guess, is where the man is who loses a loved one and says, "one minute she was with me, and the next, she was gone."

I know I'll need to wrestle with it some more. And I probably won't really understand it until I have firsthand experience witnessing the end of a life. And maybe not even then.

Thursday, October 11, 2007

Thrilling thought of the week: I love Mondays

You know you've found the right graduate program when you look forward to Mondays.

I love Mondays because those are the days when we're presented with a new case to read through and drive our learning (see a previous post for more on PBL). Mid-week, when we're plowing through test results, synthesizing information from biochemistry and physiology and clinical manifestations, and sifting through sources that contradict each other, things aren't as much fun.

But Mondays, the sky's the limit. Everything that seems like it might fit -- a disease read about long ago, something someone's cousin once had, anything that sounds mysterious and interesting -- makes it up on the white board. Our new patient has abdominal cramps? Well maybe it's appendicitis. Maybe an STI. We should take her sexual history. How about abuse? Let's figure out her social situation. An exotic infectious disease? Let's get her travel history. Something related to a chronic condition -- does she have diabetes? Let's examine her, and maybe give her a pregnancy test

It's an exercise in medicine, but in the part of medicine that requires lateral thinking. Really, it's an exercise in stretching your mind to the limits of logic, and sometimes past that, just to make sure nothing's missed. With eight people in the room, ideas fly like ping-pong balls. The excitement rises as we exhaust all the possibilities we can think of and flip the page for more clues on our patient's problem. Eventually, most of our list will be crossed out as we learn more about the problem and its characteristics. But for a few minutes on Monday, anything is possible.

Friday, October 5, 2007

AMSA needs to work on its grammar

I just sent an email to my congresswoman thanking her for voting yes on SCHIP and continuing support for the bill as it goes back to congress after Bush's veto. And of course you should do the same because this bill will expand coverage to children who otherwise would be uninsured, helping more people in this country achieve a higher standard of health. To me, it's that simple; if you feel differently, please do tell.

But for heaven's sake, don't cut-and-paste what AMSA has written as a letter template:
"As a physician-in-training, your support of the SCHIP reauthorization bill was greatly appreciated...."

What? That means that "your support" is a physician-in-training! People, this is basic stuff. Maybe you should lay off the physiology, or even the health advocacy, for a bit and review English grammar. Maybe it doesn't really matter. But it seems to me that if you want your voice heard, you should at least make sure you're speaking correctly.