Goethe quote

If you treat an individual as she is, she will stay as she is, but if you treat her as she ought to be and could be, she will become what she ought to be and can be.

Forks Over Knives documentary

The first real exam of my first year of medical school quickly approaches.

Even as the muscles, nerves and arteries of the arm, hand, back and shoulder become part of my vocabulary, a movie I saw recently constantly forces the question of how our diet relates to the health problems of our country.

Forks Over Knives is a documentary based on "The China Study", a book about cancer etiology in China.

Go see this movie if you have a chance. My vegetarian lifestyle was very strongly reinforced as the links between animal based diets and a dozen diseases were laid out clearly with solid evidence.

Allow Natural Death and other Advance Directives

The first block of medical school has passed quickly, and left me in a better place to find and understand scientific literature. Our second block is centered around anatomy and physiology and will include the complete dissection of a dead person. I feel well prepared to undertake this exploration of structure and function in part due to the recent exploration in a small group setting of palliative care and end of life treatment options.

As an EMT, I was already familiar with DNR (Do Not Resuscitate) orders that any person may prepare in case of cardiac or respiratory arrest in order to instruct health care personnel what measures should be taken. I did not realize that a patient's right to refuse extreme resuscitation efforts had only been protected legally since 1991, with the Patient Self-Determination Act. 

Then there are some states that recognize living wills and health care power of attorney (health care proxy). Thus if you are left incapacitated, your power of attorney can make all medical decisions for you. This is much safer because it does not allow the "crazy aunt from California" to fly in and demand that you be put back on the ventilator.

Finally, there are state specific documents that allow thy will be done even when you are unconscious. In NY, this thing is called MOLST (Medical Orders for Life-Sustaining Treatment). This document details your orders to physicians in various situations.

1. No pulse and/or Is Not Breathing

2. Patient has a Pulse and the Patient is Breathing

For situation #1, you can choose CPR or not.

For situation #2, you can choose 

a. comfort measures only

b. limited medical interventions

c. no limitations

For #2, you can also mark your preferences for 

a. intubation

b. hospitalization

c. artificially administered fluids and nutrition

d. antibiotics

e. other instructions

Other end of life decisions include organ donation or getting an advance directive in your medical record by having your physician note it down. It seems that the most effective way to ensure that your end of life wishes are met is to fill out as much legal paperwork as possible, and appoint a health care power of attorney to somebody who you really trust to follow your directions.

And this leads finally to the anatomical gift program and my sincere gratitude to the individual who has gifted his body to be my first patient and individual tutor on the inner structure of man. 

Blink by Malcolm Gladwell

The most intriguing idea in this book is how too much information can cloud effective decision making.

Gladwell uses examples ranging from war to medicine to illustrate the power of subconscious parts of the mind while at the same time remaining very aware of the limitations of "thin slicing" any situation. "Thin slicing" = rapid cognition.

Too much information was clouding ER docs' decisions regarding chest pain, thus algorithms were introduced that dramatically improved diagnosis.

Gladwell even goes on to suggest a constitutional amendment regarding the right of the accused to see and confront her accuser and jury of her peers. However, the data shows clearly that black males are "13 times more likely to be sent to prison on drug charges than a white man" (275). This is when these two men, white and black, are charged and convicted for an identical crime.

Thus Gladwell remains optimistic that errors in rapid cognition will continue to be identified and appropriate fixes put in place. Examples include the introduction of blind auditions to prevent sexism in classical music.

Gladwell proposes that rapid cognition is most effective at a certain level of stimulation, but too much arousal "leaves us mind-blind" (229).

Hopefully I'll get a chance to read some of Gladwell's other books in the future.

Physician Decision Making

Another guest lecture this morning which I will attempt to condense into a more readable account than my last attempt at sharing my notes.

What does it take to be a good doctor?

fundamentals + experience = good doc

1. Information needs to be sorted according to how it is used.

2. Communication may be the most important part of medicine.

3. Art of healing includes empathy and ritual.

4. Judgment is still necessary even with perfect information.

Here's one way to use data.

Generate evidence-->synthesize evidence-->develop clinical protocols-->apply protocols-->re-evaluate

Then have to balance patient's preference, research evidence, clinical circumstances and clinical judgment.

Every decision is founded on goals, objectives, options, people and preferences.

Situational awareness = observe (data/information/task environment), orient (mental model, anticipate potential future states), decide, act.

OODA loop

often includes an awareness of what decision making process is most 

Intuitive vs. Analytical decision making

Most choices are intuitive = heuristic

really fast, but susceptible to characteristic mistakes

Others become more analytical =systematic

takes a lot of time

Specific practice to develop clinical judgment

1. know and be aware of common decision making errors

2. routinely inquire into and discuss the reasons and rational for decisions that are being made.

3. Simulate with hypothetical cases

4. Reflect and consolidate recent experiences (hopefully that's what this blog is helping me do)

Genes, Environment and Epidemiology

This isn't technically something I read, but rather a lecture in which I am sitting currently.
The problem is that I am already focused on the long weekend ahead, and I don't think this stuff is on any upcoming exams. Therefore, sharing some of these ideas with you may help them stick in my mind.

Central Dogma
Gene transcribed into mRNA then translated into protein and stuff.

Human Genome
3 billion base pairs
30,000 genes
46 chromosomes

Genetic Variation
a. Mutations include deletions, insertions, gene rearrangements, chromosome translocations, copy number variants
b. Polymorphisms are when alternate forms are present. Single nucleotide polymorphisms (SNPs)

Penetrance = strength of the association between a mutation/allele and risk of disease.
expressed by the proportion of variant carriers who develop phenotypic manifestations.

Genetic Epidemiology Approaches
Hope to figure out relative contributions of genetic and environmental factors.
Example: Down syndrome associated with leukemia or alzheimer's?

Time trends = compare disease rates over time.
sharp increase over time points to environmental factor because genetics don't change very quickly.
Melanoma is an increasing very quickly, but why?

Age of onset can also give clues about etiology.
Germ-line mutations have earlier onsets.
Somatic mutation/environmental exposure take longer to lead to disease state.

Family studies
look in family trees (pedigrees aka genogrames)
a. segregation analysis -- is observed pattern similar to mendelian theories?
b. linkage analysis --can help to identify and localize where the guilty gene is.

Twin studies
a. monozygotic twins share 100% of genes.
b. dizygotic tins share 50% of genes
compare the concordance rate between the two.

Adoption studies
can show if some disease is genetic or environmental
especially interesting with behavioral things

Migrant studies
Comparison of disease rates between people in their home country and the same people once they migrate to a new place.

Genetic Markers
DNA markers
SNPs
RNA markers
Protein markers

When disease process identified, try to think which of the following area is most likely for some malfunction.
Metabolism genes
DNA repair genes
Immune function genes
Cell-cycle control genes

Genome-wide association studies (GWAS)
Simultaneous scanning of markers (SNPs) across complete sets of genomes.
Case-control study design.
New pathways can be identified.
Unfortunately variations identified are likely not causal.

Phenylketonuria (PKU) is a metabolic disorder resulting in mental retardation in children.
Requires genetic mutation and dietary exposure to phenylalanine

Nature vs. Nurture
Genetic factors explain only a small proportion of disease.
Remainder can be attributed to environmental factors.
But really it's the interplay between the genetic and environmental factors.
Gene-environment interaction (GE interaction)
Again can use 2X2 tables to figure out relative risk.
This is effect modification.

This lecture is going way to fast to really catch anything or have a moment to think.
Presenter is literally speaking at double speed.

Pharmacogenomics
Genetic variation can impact whether or not a drug is beneficial or toxic.
Gene expression profiling.