Tuesday, April 26, 2011

In Defense of Goofi(ness)

I've been wondering why young people seem to have the preponderance of good ideas and energetic enthusiasm. I think it's because they're naive, and some of them are goofy.

There's a first year resident on our medicine team who is constantly throwing out ideas about patient symptoms and findings. He's wrong more often than others on the team, and he's wrong in front of the attending.

He's publicly wrong, repeatedly. And he really doesn't care. He's a little goofy.

As may be expected, I've learned a ton being around him, far more than the tight-lipped who are right the few times they venture a conjecture. As may not be expected, everybody else, patients included, are better off. He stimulates thoughts, forces consideration of new ideas, and all that great stuff that people like to say is so important.

Best of all, his attitude is so non-prepossessing that others relax their wrong fear and likewise pose novel questions and ideas. Being goofy by definition means you're not trying to prove anything. In response, others aren't trying to prove anything back. In the absence of defending appearances, people think about patients.

You don't want your doctor to be a goof, and you don't want him or her to be naive. And for a large part, doctors-to-be are loathe to be perceived as such than pretty much anything else. Is there a way to improve this? Medicine is an understandably conservative field. But I don't think conservative has to come at the expense of stodginess.

My school has recently queried the students to see if the honors, high-pass, pass grading system should be abandoned for the third and fourth years. Absolutely.

Wednesday, April 20, 2011

Emperor of All Maladies: Lesson Three [What is Disease?]

Mukherjee describes oncologists' difficulty "lumping the lumps."

He cites the massive differences between a condition like Hodgkin's lymphoma and pancreatic cancer- both are termed cancer, but they couldn't be much different from each other in presentation, course, and prognosis. Calling them both cancer seems naive. But, lumping them together galvanizes support to attack their common roots. (All cancers share at least one common trait- they derive from a single aberrant cell from among the many trillions that make up our bodies.)

So here we are, stuck on the horns of the dilemma between splitting conditions into separate disease classifications so they can be understood, and lumping them together so that we can summon our collective forces against common roots.

Both approaches have their merits and limitations. I propose a unification.

Tuesday, April 19, 2011

Emperor of All Maladies: Lesson Two [Cure doesn't require understanding]

Sidney Farber (born in Buffalo NY!) comes off as almost God-like in his devoted and capable assault on childhood leukemia in Mukherjee's prose. He has a fantastic quote:

"We cannot wait for full understanding; the 325,000 patients with cancer who are going to die this year cannot wait; nor is it necessary, in order to make great progress in the cure of cancer, for us to have the full solution of all the problems of basic research." 

Clifton Leaf highlights this point in a 2004 article "Why We're Losing the War on Cancer--And How to Win It"

"Indeed, the cancer community has published an extraordinary 150,855 experimental studies on mice, according to a search of the PubMed database. Guess how many of them have led to treatments for cancer? Very, very few. In fact, if you want to understand where the War on Cancer has gone wrong, the mouse is a pretty good place to start."

I contend this points to a disconnect in medical education. Medical students devote much of their spare time, their aspirations, and their tickets to the upper echelons of their chosen field to laboratory research. Or, in a word, to understanding disease. A heavy focus on understanding overshadows the need for tinkering, tweaking, trial and error. Or, in a word, to engineering a disease solution.

A few esteemed authors who advocate engineering are Matt Ridley and Aubrey de Grey. In "The Rational Optimist," Matt Ridley describes how the inventors and refiners of the steam engine knew very little about thermodynamics. In "Ending Aging," Aubrey de Grey describes a novel approach to degenerative disease that focuses on allowing damage to occur. He simply endorses cleaning it up faster than it accumulates. (I deeply, deeply urge you to make 18 minutes to watch de Grey's TedTalk. Please.)

I think the major problem with engineering solutions to diseases in the medical sciences is that it necessarily entails making mistakes and being wrong. In Kathryn Schulz's incredible "Being Wrong," she outlines the virtues of embracing the practice of making mistake after mistake after mistake in order to reach true progress.

Wronghood is verboten in the medical world, causing medical students to cower in fear. Pursuing quiet, removed understanding in the laboratory is vastly preferred. Yet the removed nature of these pursuits hamstrings the connection of this understanding to disease solutions.

Engineering begins at the source of the problem and proceeds in dumb stubbornness, but when it works, it works immediately on the problem without the need to be translated from a published text to a point of care intervention.

Somehow, we need to figure out how to free medical professionals to be wrong in a safe but productive way. Then, as Farber said, we can get solutions to patients without necessitating the added effort of first understanding.

I propose medical students can start by attempting quality improvement initiatives on the floors. Students could query the clinicians about aspects of workflow that are difficult, and then pursue avenues to streamline them. These are essentially engineering challenges, and success directly and immediately translates to patient care.

Emperor of All Maladies: Lesson One [Count Something]

In honor of my hematology/oncology rotation, I've started to read (or, better, listen to on audio format) The Emperor of All Maladies by Siddhartha Mukherjee. (A quick testament to how amazing this writer is- when he opens his chapters with quotes from literary giants, I often can't tell when he's done quoting people and has started the text. He's that eloquent.)

Mukherjee describes the early breakthroughs in cancer treatment achieved by Sidney Farber. Farber started with leukemia because it was the easiest cancer to measure accurately- all he had to do was count the white blood cells in a quantity of blood to track the progress of his latest treatment.

After counting, and some trial and error, progress was inevitable.

More importantly, until Farber started reliably counting something about cancer, zero progress had been made for thousands of years, and it was decided that treatments for cancer were impossible.

I can't help but extrapolate to the modern self tracking movement.

Self tracking is ultimately about counting the previously uncounted: sleep, activity, happiness, literally any parameter that one is interested in. The premise is the same as Farber's- once you have reliably quantified something, only then can you make genuine progress towards improving that condition.

Sunday, April 17, 2011

Healthcare in 20 Years (In 500 Words)

I was asked yesterday to predict the practice of medicine in 20 years. After stating that any such prediction is massively speculative, I indulged because it is massively fun.

I am persuaded by Clayton Christensen’s arguments in “The Innovator’s Prescription” that healthcare will go the way of other massively disrupted industries, wherein healthcare will follow the arc of decentralization.

Using the music industry as an example, Christensen's arc begins with consumers going to centralized experts like those at Carnegie Hall, then to buying players and music in local stores, and eventually to using a mobile device to purchase and listen to music in the back of a taxi. Similarly, much of the publishing and retail industry have traced this arc. It is only a matter of time until healthcare does the same.