Back to the Future

    Recently, I reconnected with an old friend. We were childhood friends through college and then slowly drifted apart. Around 2001 he got married to his wife while I got engaged to medical school. Several years later, he contacted me and it's been great reminiscing about our past lives. He has a younger brother who's currently in medical school and remarked how he sees the same passion in his brother as he saw in me when we were younger. I chuckled thinking about what a stubborn and immature person I was in my early doctor wannabe years. Despite my ability to memorize textbook facts ( perhaps the most overrated skill for the modern doctor) my friend has a much better memory of those years. He backs his assertion that I've always had passion for my career by recalling a website I built in college.
    I believe I was a junior in college (circa 1998) and my efforts towards medical school were in full effect. MCATs, biochemistry and molecular biology courses, volunteer work, work-study research job and a gradually receding hairline were all happening simultaneously. In between all of this activity I became enamored with the Internet. My free college email address changed my views of human communication and connectivity. Web browsers like Webcrawler, Alta Vista and Netscape opened doors to the entire universe. With WebMD in its infancy, I began exploring health related information on the web. It was scattered and disorganized.  I saw an opportunity to build my own healthcare website that would combine my love for the internet, my desire to serve people while augmenting my medical school credentials.  I wanted a site that would provide quality information on a health topic that also appealed to the young adult crowd. So naturally, I chose sexually transmitted diseases!
   I called it "Scary Things to Discuss." In retrospect,  it sounds cheesy but back then I thought incorporating the letters STD into the title was clever. I gathered information from both old school (library) and new school ways (online) on some common diseases such as HIV, gonorrhea and chlamydia. I also included pictures, which wasn't easy without services like Google Images. I copied some from other websites and scanned some from textbooks to create an easy to follow and colorful page. I wasn't a computer programming major but I did learn some basic HTML code on my own. But thanks to Netscape Navigator, they packaged website building tools in their browser for non-computer folks like me. It was a labor of love that took me several months. Once it launched, it was one of my proudest moments. I continued to swell with pride as the website gradually gained momentum with a steady stream of positive comments from all corners of the globe. I actively maintained the site for about 18 months during which time it had logged over one hundred thousand hits.
     Sadly, the website met a quiet demise. After college and working full-time I didn't have the energy to maintain it. I regret not archiving it for posterity. I don't even remember what company hosted the site but I do remember they went from being a free hosting service to a paid one; a deal breaker for me at that time. The website's success was always a great conversation starter for me personally, but I actually never got to talk about it with the most important people at that time ; US medical schools. I didn't receive any interview offers.
   Since then I still became a physician but the world has changed. I've become a digital health enthusiast and advocate. I see the Web 2.0 (as opposed to 1.0 back in 1998) as a critical component of modern healthcare. And I'm no longer an outlier, shouting random things about syphilis and HIV into the internet void. Rather, I'm proud to be part of an incredible movement that hopes to improve and change medicine by bringing it back to the future.

The Ironic Illness of Izzy

     When I first met Izzy (name changed) he was a portly elderly gentlemen with an effervescent and jolly personality that lit up the clinic every time he visited. His most recognizable feature was his voice. His lifelong hobby was singing opera, as a tenor. The first time I discovered this, he belted out a few lines that echoed through our entire clinic. It was marvelous and since that moment, I always made sure my medical students and residents not just saw him, but heard him as well. He was a spectacular patient and person.
    A few years from our initial encounter, I found myself wandering the halls of the hospital with 2 medical students. They were 2nd year students looking for patients to practice taking histories and doing physical exams. Earlier that day, I received word that Izzy was admitted. Though this was unfortunate for Izzy, it was fortuitous for my fledgling doctors that such a great patient was available to talk to. And not surprisingly, despite feeling unwell, Izzy with his wife by his side, welcomed my students openly.
     I stood off to the side of the room, while my students peppered him with questions for over an hour as they tried to piece together his medical history without much experience and medical expertise to fallback on. They learned about his vocal talents and though he wasn't well enough to sing on that day, Izzy was quick to point out how his voice swept his wife off her feet when they were in college. I thought I knew everything about Izzy from our several appointments together, but these medical students were able to illicit a entirely new story from him that even I was unaware of.
    My intrepid students were taking a travel history when they discovered his wife was originally from  South America. He reminisced about the last time they went to visit her family which was about 4 to 5 years prior. He fondly recalled staying near a seaside town, enjoying the fresh ocean air and wonderful local cuisine. The only thing he didn't enjoy about this trip was going further inland to visit in-laws living in more mountainous areas. He recalled getting sick during that part of the trip, blaming it on some bad food and lack of sleep. His wife reminded him that he almost passed out a few times that week from feeling so unwell.
     After almost 90 minutes of questioning, doing a physical exam and sharing lots of laughs, my students and I left Izzy to go debrief on everything we had talked about. There was just an incredible amount of things to learn from Izzy. We were able to weave together his history, his physical exam, basic pulmonary physiology, and pathology to explain what had happened. I described to the students that Izzy was suffering from pulmonary fibrosis and explained some of general facets of this illness including impaired gas (oxygen) exchange and just the progressive reduction in his lungs' abilities to perform . We reviewed oxygen disassociation curves and the effects of altitude and oxygen saturation. In light of his diagnosis, it became clear why with his reduced lung function and thinner mountain air, Izzy felt so ill on his vacation. This was probably one of the first signs of his illness until later when it became sadly obvious his opera singing days were coming to an end.
     With every patient, there's always something to learn and Izzy's story was no exception. For me, when I look back at his story, I began to appreciate medicine as something more than doctors treating individuals with specific diseases affecting affecting well defined anatomy through different but predictable mechanisms. Medicine, as a science has surprisingly very abstract human qualities. At times, it can be funny, or sad, thrilling, uplifting, unpredictable and often dramatic. When an opera singer that relied on powerful lungs got a relatively uncommon condition affecting those same lungs, medicine got my attention that it also has a knack for irony.


   

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn't qualify for Medicaid and couldn't afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn't have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the "Low T" marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member's reward for obtaining health insurance wasn't good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

Don't hate the Anti-Vaxxer

     It's easy and convenient nowadays to take a few minutes to rally against the "Anti-Vaxxer" movement. With the recent measles outbreaks, there's no shortage of articles, memes, jokes and cartoons to share on blogs, Facebook, Twitter etc. But I'm going to throw a very small teeny tiny microscopic bone to the Anti-Vaxxer camp. I will do so with the disclaimer that as a primary care physician I think vaccines are an extremely important part of good health. Anyone that doesn't see their value, is misguided and perhaps misinformed.

    Having said that, there's no denying that the Anti-Vaxxer  movement  is real and unfortunately seems to be growing. They have quietly become a significant part of the general population. The reason for their growth is multifactorial, but the easiest targets are probably defrauded scientists, celebrities and politicians with dubious opinions. But the target that's probably hardest to identify is the one looking right back at us in the mirror.  When a problem afflicts society, the easiest thing to do is blame others. The introspective route asks us to look within to identify causes and offer solutions.

     How did we let this happen? The Anti-vaxxer movement is just another example of the growing mistrust and lack of faith in our doctors and healthcare system. There are many reasons for this. When it comes to vaccines, why aren't we, the trusted physicians able to educate and change their minds? Perhaps we are not living up to the true latin meaning of the word "Doctor" which is "to teach." Perhaps the modern doctor,  gathered and taught in traditional (antiquated?) methods are struggling with modern informed patients who challenge and question rather than accept paternalistic physician decision making. Perhaps we simply just don't have time to have a decent conversation with our patients about the importance of vaccines.

    Whatever the reasons, we need to figure out better ways to connect with this subset of our patients whose beliefs about vaccines post significant individual and community health risks. What we don't need to do is further alienate this population by kicking the proverbial horse while it's down. The amount of  seemingly joyous vitriol pouring from the medical community against anti-vaxxers is disappointing and at times bordering on classless. Social media is teeming with derogatory descriptions of this population.  I think this only furthers many people's views of rampant intellectual elitism in our doctors. The most disappointing stance on this issue is when doctors proclaim they will refuse to see patients who don't believe in vaccines. Hey genius, if you don't see that patient, then they definitely don't stand a chance of getting a vaccine!

   The anti-vaxxer type of population is something that has always existed in most medical practices. They represent a group of people who don't believe in the gospel you are preaching. I have patients who don't believe in cancer screenings, statins and a whole host of other great evidence based ideas. They can be frustrating and time consuming.  But they are still my patients and I will continue to respect them and care for them with the confidence to know I will eventually change some of their minds.

Endings and Beginnings

It's been a while since my last post. I've been busy and life has been changing.

For one, we had our third baby! She's beautiful and certainly takes up a significant amount of our time (disproportionately at night!)

I'm also moving. After a lifetime of calling myself a New Yorker, we're packing up and moving to Dallas, Texas.
I will always be a New Yorker and the emotions regarding this change are far too complex to discuss on this post.

But with this move ends a tremendous chapter of my medical life. Much of my posts on this blog were based on stories and experiences from these past 5 years.

We go into medicine because of the patients. The patients and their stories will always be the crux of my life in medicine. They will always inspire me to write and keep practicing medicine.

But these past 5 years have been about more than patients. I also took care of a different group of people. I got to be a caretaker of some pretty incredible internal medicine and med-peds residents.

They inspired me, taught me, challenged me, tested  me, made me laugh but most importantly made me proud to be a medical educator.

As doctors we love making patients better. As medical educators we love making patients better and making doctors better. It's an incredibly fun and gratifying career path.

So with that, a sincere thank you and good bye to my trainees past and present. I hope your interactions with me were as meaningful to you as it was for me. I can't wait for our paths to cross again as professional colleagues.

To my new patients, I can' t wait to meet you all and take care of you

To my new trainees, I can't wait to meet you all!. Let's get to work to make healthcare better and change medicine!