Back to Basics

I should warn you that tonight's blog might seem a bit fundamentalist in timbre, but I've been thinking it over for some time, and I feel that it needs to be said. I'll start with a little background information. The first year of medical school is traditionally focused on learning what's normal about the human body. Anatomy, physiology, biochemistry, all the things that provide the backbone for a medical education, and allow one to begin to view the body as a working unit, not just a randomly connected network of organ systems. Beginning second year, the fun starts and students learn what goes wrong when the body becomes diseased. In addition, students are taught how to apply the fundamentals they learned first year to return the body to an un-diseased state through pharmacologic, surgical, osteopathic or psychiatric methods. Third and fourth years allow fine tuning in the clinical sciences, and provide necessary exposure outside of the classroom to allow the student to "get their hands wet," and really see medicine in action. By the time most students reach the end of their fourth year, the fundamentals they learned way back in first year have all been but forgotten, as the glamour of working with patients has replaced the ardors of the anatomy lab. Herein, I believe, lies one of the main problems in the medical profession today.

As one progresses through their medical education, the amount of information required to pass to the next level is immense. Once one enters practice, the amount of knowledge required is even more, as people's lives depend on what a physician does or does not do in a given clinical situation. When I started doing disability physicals, I was shocked to see that quite a number of claimants were applying for benefits due to conditions that were not being properly treated by their physician, and therefore had been allowed to run rampant.  I'm aware that some of the claimants are being treated by physicians who have been in practice since before I was born, and that my whole clinical experience amounts to a medical school, an internship and what I've learned so far this year, but come on - if a patient continually has blood pressures above 180/90 (normal is around 120/80), and has evidence of end-organ damage (visual changes, decreased urination, etc), maybe you should consider doing something besides upping the dosage on their HCTZ (a very mild diuretic, mainly used in mild cases of high blood pressure). It's like the physicians treating these people stopped caring about their health once they began writing scripts for Lortab. Another disease that is commonly mistreated is diabetes, something that with the increase in obesity across our nation is becoming more prevalent yearly. I understand that by its nature, diabetes is a very difficulty disease to control, especially since the patient has to do so much on their own. But, if you have a patient that continually brings in blood sugar logs that read over 200 most of the time, maybe you should add something to that Metformin (useful as an insulin sensitizer), and take them off of their corticosteroids (steroid throw blood sugars all out of whack) for their mild eczema. It's getting back to basics, people. It's about understanding the body's physiology, the pathophysiology of the disease, and the mechanisms by which the pharmacologic intervention seeks to mend the problem. My favorite example of this breakdown occurred three weeks ago, when a woman presented to my office stating she needed disability because she could hardly breathe.

This woman was in her 30's, had never smoked a day in her life, but had struggled with lung disease in the form of asthma and hereditary emphysema since she was a child. Due to poor roll of the genetic dice, she had had a heart attack a year prior, and thanks to the cardiac damage from that event, had gone into heart failure. She currently was using an inhaler and an anti-histamine for her lungs, and was on a slew of medications for her heart - aspirin, an ACE inhibitor, and two beta-blockers, which helped reduce cardiac oxygen levels, and allowed her heart to pump better. Recently, however, the woman had begun to get incredibly short of breath if she moved from one room of her house to the other, and had been fired from her job because she took too many breaks to catch her breath. She was concerned about this symptom, and had asked her doctor what could be causing it. He stated that her heart failure was probably worsening, and upped the strength on her beta-blocker. The symptoms became worse. As she told me her story, I couldn't help but think about the relationship between beta-blockers and lung function. Both the lungs and the heart have beta receptors. In the heart, they control rate and contractile ability, while in the lungs they control dilation and constriction of the airway. If you use a medication that blocks beta receptors in the lungs and heart (a non-selective beta-blocker), you cause the heart to slow down, and basically take it easy. In the lungs, however, you cause constriction of the airways, which, as you might imagine, doesn't really help with breathing. So, looking at this patient's med list, I discovered that both of her beta-blockers were non-selective, and her physician, who I'm sure meant well, had just increased the strength of one. It's no wonder that she had difficulty breathing - the medication that was helping her heart was also causing her lungs to constrict, thereby explaining her symptoms.

Medicine as a whole is ever progressive. We love to talk about new cancer drugs and robotic surgery, but tend to laugh when someone mentions physical diagnostic skills or basic pharmacology. Why do we need to listen to our hands when a CT shows us what lies beneath? Why do we need to remember how drugs work when certain online tools tell us everything from geriatric renal dosing to the price of certain medications in Chile? Don't get me wrong, I love technology too, but we have to remember that people were correctly diagnosing and treating diseases with nothing more than their God-given senses, herbs and plants and a little intuition. We as a profession cannot forget that people don't always fit into little evidence-based medicine boxes - just because Harvard says "give beta-blockers to a patient with heart failure" doesn't mean that you can forget your basic knowledge of the human body. "Harvard made me do it," is a poor defense for a malpractice trial.

And now for the disability quote(s) of the day:

"When I take those meds, I get zombie feelings."

Patient's written response to the question "Has your disability kept you from doing any activities? If so, please explain."
"My pain keeps me from loving on my cat."

Get back to basics,

-DD