Friday, August 29, 2008

Art and Medicine: “The Gross Clinic” by Thomas Eakins

The Gross Clinic
Thomas Eakins

Why is there so little famous / popular art about medicine? This is especially surprising to me when one considers how much other attention other human endeavors such as war get. Here is one relatively well-known piece "The Gross Clinic" by Thomas Eakins. Per the UCHSC site, the piece can be described as:
Thomas Eakins, a Philadelphia artist of severity and sobriety, approached the renowned Dr. Samuel Gross in 1875 with the idea of painting a portrait in the operating theater at Jefferson Medical College.

Dr. Gross, an innovative surgeon of the day, pioneered the surgical technique depicted in the painting: saving a gangrenous leg by removing pus.

“The painting was submitted in an art exhibition, but it was a little too bloody for their tastes,” Dr. Claman said. The intense realism and drama of the work shocked the art world and offended the public.
But it also communicated a lot about how surgery was practiced in the late 19th century.

“What you notice is that there were no gloves – those weren’t introduced until the 1890s,” Dr. Claman said. “There were no gowns or masks. And our dear Dr. Gross was not a devotee of Dr. (Joseph) Lister, who discovered the use of carbolic acid, launching the principle of antisepsis. He was kind of behind the times.

“The light is natural, you will notice, coming from a hole in the ceiling.”

The painting shows the medical school students looking on from the shadows, and a friend of the patient – perhaps his mother – recoiling in fear in the corner.

The picture also has a unique Denver connection.

In the 1880s, there were two medical schools in Denver. A third one was begun in 1887 by a student of Dr. Gross, and it was named Gross Medical College. In time, the school merged with the Denver College of Medicine, which eventually merged with the CU School of Medicine.
Perhaps this is where we got the term "gross" anatomy from. Anyone know for sure?

Updated 2015-12-13

Thursday, August 28, 2008

On the Razor's Edge

As I go through my medicine sub internship, I am struck by how little of what I do during the day actually relates to medicine. I’d say I spend approximately 60% of my day doing paperwork, 30% doing social work, and perhaps 10% actually practicing medicine. If you ignore the paperwork, the relative ratio implies that I spend three times as much time dealing with social issues relative to medical issues. Perhaps this issue is unique to this particular rotation in this particular hospital, but I often feel that it is endemic throughout my rotations, especially in primary care specialties.

For me and many of my peers, I think much of the frustration within medicine stems from this skewed ratio. We have not spent all these years training to deal with people's social concerns. Don't get me wrong, I am not belittling the importance of these problems in our patients' lives. My point rather is that, just as social workers are not trained to titrate blood pressure control medications, physicians are not trained to deal with the myriad of social issues our patients face. That is not our role in the system. Of course, in a case of need, physicians should do everything possible to help their patients, but using physicians as social workers is an inefficient use of their time. Furthermore, because they cannot dedicate their time fully to social issues, physicians let such items lapse, which in the end does not serve the patients' interests.

For me, medicine is interesting when I feel that I can take the knowledge I have learned and apply it to a patient in an uncertain situation. As cliche as it seems, I want to know that my actions made a difference, and I imagine most of my peers feel the same way. For the patient who enters our care on the razor's edge, teetering between calamity and convalescence, I want to know that my actions helped pull the patient through the darkest of times and that my training was not in vain. Is it selfish to feel this way? Perhaps, but I would rather be a selfish but satisfied physician than one who begrudges my patients' concerns and in the end does not serve the patient at all.

Wednesday, August 27, 2008

Bert O'Malley Awarded National Medal of Science

As you may recall, Dr. Bert O'Malley surfaced in the news a few months ago, linked to the Roger Clemens steroids probe. I voiced my opinion on the matter, but I figure I should give credit where credit is due. Dr. O'Malley was awarded the 2007 National Medal of Science, to be awarded by President Bush at the White House in a ceremony this month. The official award for O'Malley states, "For his pioneering work on the molecular mechanisms of steroid hormone action and hormone receptors and coactivators which has had a profound impact on our knowledge of steroid hormones in normal development and in diseases, including cancer." Regardless of my earlier views, clearly, a well-deserved honor.

Tuesday, August 26, 2008

Is Boredom Good for You?

Everyone gets bored sometime. However, could boredom be good for you?

Scientists know plenty about boredom, too, though more as a result of poring through thickets of meaningless data than from studying the mental state itself. Much of the research on the topic has focused on the bad company it tends to keep, from depression and overeating to smoking and drug use.

Yet boredom is more than a mere flagging of interest or a precursor to mischief. Some experts say that people tune things out for good reasons, and that over time boredom becomes a tool for sorting information — an increasingly sensitive spam filter. In various fields including neuroscience and education, research suggests that falling into a numbed trance allows the brain to recast the outside world in ways that can be productive and creative at least as often as they are disruptive.

In a recent paper in The Cambridge Journal of Education, Teresa Belton and Esther Priyadharshini of East Anglia University in England reviewed decades of research and theory on boredom, and concluded that it’s time that boredom “be recognized as a legitimate human emotion that can be central to learning and creativity.”

Interesting. Boredom as an emotion. Well, call me very emotional during most of my med school lectures then.

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Monday, August 25, 2008

Stephanie Tubbs Jones, 1949 - 2008

Stephanie Tubbs Jones died last week of a brain hemorrhage after a cerebral aneurysm ruptured. Per reports, she was found unconscious in her car and rushed to an Ohio hospital with limited brain function. She died the next day. Her story sparked some controversy as she was initially reported to have died while she was in fact still alive but in critical condition. On a tangentially related note, recently named Vice Presidential candidate Joseph Biden has also suffered from cerebral aneurysms. He was absent from the senate for roughly 7 months in 1988 to correct 2 aneurysms.

Why mention this sad news here? Well, I don't know much about aneurysms but I wonder if we will ever able to develop a cost-effective, benign way to screen for them. Right now, I believe the options are basically a CT head with contrast or a cerebral angiogram, but the former exposes the patient to radiation while the latter not only has the radiation exposure but is also invasive. Still, given the catastrophic outcomes of a ruptured aneurysm, I wonder what the cost-benefit analysis of screening would be. Anyone out there have any idea? Just curious.

Friday, August 08, 2008

What's the difference between the INS and U.S. Hospitals?

Answer: Only INS has the legal right to deport illegal immigrants.

Yet, some U.S. hospitals have taken it upon themselves to deport patients who are illegal when they overstay their welcome. In this NYTimes piece, writer Deborah Sontag chronicles the journey of an illegal immigrant from Guatemala Luis Alberto Jiménez and his misadventures with Martin Memorial hospital in Florida. After work one day, Mr. Jimenez was in a car driving home when the car he was in was struck by a drunk driver. He was taken Martin Memorial where he was initially given a poor prognosis due to his traumatic brain injury (TBI) and other trauma. He was in a comatose state for nearly a year. But then:
Eight years ago, Mr. Jiménez, 35, an illegal immigrant working as a gardener in Stuart, Fla., suffered devastating injuries in a car crash with a drunken Floridian. A community hospital saved his life, twice, and, after failing to find a rehabilitation center willing to accept an uninsured patient, kept him as a ward for years at a cost of $1.5 million.
What happened next set the stage for a continuing legal battle with nationwide repercussions: Mr. Jiménez was deported — not by the federal government but by the hospital, Martin Memorial. After winning a state court order that would later be declared invalid, Martin Memorial leased an air ambulance for $30,000 and “forcibly returned him to his home country,” as one hospital administrator described it.
While I understand the hospital's dilemma, the article notes that other options were available:
Jack Scarola, representing Mr. Jiménez’s guardian, said that he empathized with the hospital’s “significant economic burden” but said that it was the “quid pro quo” of accepting Medicare and Medicaid funds to help finance the hospital’s services. (About 45 percent of Martin Memorial’s net operating revenues came from Medicare and Medicaid last year, based on state data.)
“Also,” he continued, “they chose the wrong way to deal with it. The right way would have been through the Legislature. There is no program in place to appropriately distribute care to undocumented persons who are catastrophically injured, and there should be. But you don’t stick a brain-injured immigrant on a private plane and spirit him out of the country in the predawn hours.”
Keep reading to see what kind of conditions the hospital left Mr. Jimenez in. In public hospitals, as many medical students know, the issue of 'disposition' often becomes a patient's most significant one, far outshadowing their medical concerns. Still, no matter how dire the disposition issue may be, hospitals and communities must find better solutions than dumping their patients overseas.

Thursday, August 07, 2008

Randy Pausch's Last Words

Many of you have seen Randy Pausch's The Last Lecture on Youtube and elsewhere. If not, check it out (1 hr, 16min):

Although his talk does not directly relate to medicine, it is generally applicable to people in many walks of life. For us in medicine, I think the parts about brick walls within "The Last Lecture" are especially useful. A recent post noted what were quite possibly his final words:
Mr. Seabolt only shared a few moments with viewers, noting that even near death, Dr. Pausch’s sense of humor remained. He said Dr. Pausch talked about how glad he was that he was home and his family and friend were close, and laughed, saying, “I just feel so bad about the dying part.”
Mr. Seabolt also relayed a conversation he had with Dr. Pausch’s 6-year-old son, Dylan. They were talking about cancer and he told the boy that “some problems can’t be solved, or they can’t be solved yet.'’
Dylan responded, “My daddy has taught me that every problem can be solved, and that I should believe that every problem can be solved, and that I’m strong enough and smart enough that I should never let a problem get in my way.”
At the end, as Dr. Pausch’s body was clearly failing, Mr. Seabolt said he told his friend, “It’s important for you to feel like you can let go. It’s okay.”
Dr. Pausch’s reply: “I’ll get back to you on that.'’
And those, according to Mr. Seabolt, were the final words of Randy Pausch.
Hopefully some good has come of his tragically early loss to pancreatic cancer.

Updated 2015-12-13

Wednesday, August 06, 2008

Three's Company, Four's A Treatment Plan?

Having discussed second opinions before, it was interesting to read about how Sen. Ted Kennedy, who was recently diagnosed with a brain tumor, sought the advice of experts:

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

If only the rest of us could summon dozens of experts to our bedside to discuss our ailments. However, the article does go on to note that many experts do look at the records of regular patients with unique cases. Still, the piece does say that:

Just sending images and records is far less preferable than meeting with a patient before rendering an opinion. “I do not operate on films,” Dr. Flamm said. “I operate on people.”

Meeting with patients “is an important factor in terms of their expectations and concerns,” he continued, adding: “I can see a white ball on a scan and say yes, that is a tumor, I agree. Beyond that it is rather difficult to come up with a treatment plan based on that, other than saying, yes I would operate or I won’t.”

Hm, it seems that privilege indeed still does have its benefits in America.

Tuesday, August 05, 2008

Show Us The Money!

Trying To Save By Increasing Doctors' Fees explores the not-so-novel idea paying doctors more to, get this, actually spend time with their patients:
Cutting health costs by paying doctors more?

That is the premise of experiments under way by federal and state government agencies and many insurers around the country. The idea is that by paying family physicians, internists and pediatricians to devote more time and attention to their patients, insurers and patients can save thousands of dollars downstream on unnecessary tests, visits to expensive specialists and avoidable trips to the hospital.

Nationally, Medicare and commercial insurers pay an average of only about $60 a visit to the office of a primary-care doctor and rarely if ever pay for telephone or e-mail consultations. Many health policy experts say the payments are not enough to let the doctors spend more than a few minutes with each patient.
Gee, ya think? I don't know why people in the healthcare industry are so slow to realize that physicians act on incentives just like anyone else in any other profession. If you are still unsure, just look at the numbers:
Advocates of the approach hope it will attract more doctors to primary care. Last year only 7 percent of medical school graduates chose family practice, a field with a median income of $150,000, according to the American Academy of Family Physicians. That compares with $406,000 for gastroenterologists and $433,00 for cardiac surgeons, as measured by the Medical Group Management Association.
The American Medical Association said that in its latest count, in 2006, there were slightly more than 251,000 practicing family physicians, general, practitioners, and internists in this country, compared with nearly 472,000 specialists.
The shortage of primary care physicians is not news. Finally, it seems the powers that be are starting to take notice. Heh, still though, it ain't enough to convince me not to go into radiology... better luck with the med students 10 years down the road.

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Monday, August 04, 2008

Medical Marvel: Biracial Twins

One twin, black; the other, white. Unpossible, you say? Well, probably, but the difference is striking enough to make the news:

It's kind of like that subplot in "Me, Myself, and Irene," but... not really.


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