Monday, May 28, 2012

Miserere

Gregorio Allegri's Miserere is an amazing piece of choral music composed during the 1630s. It makes use of a popular Renaissance technique called polyphony which is a texture of two or more independent melodic bodies as opposed to a single dominant melody accompanied by chords. Allegri wrote the music to be sung by one choir of five and another choir of four standing on opposite arms of the cross-shaped cathedral. One choir sings a simple version of the Miserere chant and the other sings an embellishment. 
At some point it become forbidden, punishable by excommunication, to transcribe or perform anywhere except the Sistine Chapel during the last week of Lent or the week before Easter. However, in 1771 14 year-old Mozart traveled to Rome where he first heard the piece performed during the Wednesday service and afterward wrote it down entirely from memory. He returned on Friday to make minor corrections. Dr Charles Burney acquired the transcript from him and published it in London. The ban was lifted and instead of excommunicating him, Mozart was summoned to Rome by the Pope to praise his musical genius.



Have mercy upon me, O God, after Thy great goodness
According to the multitude of Thy mercies do away mine offences.
Wash me thoroughly from my wickedness: and cleanse me from my sin.
For I acknowledge my faults: and my sin is ever before me.
Against Thee only have I sinned, and done this evil in thy sight: that Thou mightest be justified in Thy saying, and clear when Thou art judged.
Behold, I was shapen in wickedness: and in sin hath my mother conceived me.
But lo, Thou requirest truth in the inward parts: and shalt make me to understand wisdom secretly.
Thou shalt purge me with hyssop, and I shall be clean: Thou shalt wash me, and I shall be whiter than snow. 
Thou shalt make me hear of joy and gladness: that the bones which Thou hast broken may rejoice.
Turn Thy face from my sins: and put out all my misdeeds.
Make me a clean heart, O God: and renew a right spirit within me.
Cast me not away from Thy presence: and take not Thy Holy Spirit from me.
O give me the comfort of Thy help again: and establish me with Thy free Spirit.
Then shall I teach Thy ways unto the wicked: and sinners shall be converted unto Thee.
Deliver me from blood-guiltiness, O God, Thou that art the God of my health: and my tongue shall sing of Thy righteousness.
Thou shalt open my lips, O Lord: and my mouth shall shew Thy praise.
For Thou desirest no sacrifice, else would I give it Thee: but Thou delightest not in burnt-offerings.
The sacrifice of God is a troubled spirit: a broken and contrite heart, O God, shalt Thou not despise.
O be favourable and gracious unto Sion: build Thou the walls of Jerusalem.
Then shalt Thou be pleased with the righteous sacrifice, with the burnt-offerings and oblations: then shall they offer young calves upon Thine altar.

Sunday, May 20, 2012

Neurosurgeon

I had an interesting experience this week that I have not yet had in my life. I challenged a question that a neurosurgeon wrote on our neuroscience final and the challenge was denied. I've never challenged a question before because I never felt so definitively right about something.

The question asked about the significance of the pinprick test and there were two correct answers:

a.) rectal tone and perianal sensation indicate sacral sparing.
b.) it demonstrates an intact spinothalamic pathway.

The other 3 responses were obviously wrong and I don't remember them. Pinpricks test whether the tract (spinothalamic) that carry pain signals to brain is intact. Since there are more components to sacral sparing than the two listed in response a I chose answer b which was the 'wrong' right answer because he stressed 'a' more during class.


Challenge denied.

Morals of the story are:

The difference between a neurosurgeon and God is that God doesn't think He's a neurosurgeon.
It only takes one neurosurgeon to screw in a lightbulb. He holds it and the world revolves around him.

PS You gotta wonder about the first person to think of testing 'rectal tone' in spinal cord damage cases.

Wednesday, May 16, 2012

Autism and MMR

When you tell people you come in contact with around the community that you are a medical student, they don't want to talk about how hard medical school is. They don't want to hear about the grossest thing you have seen or even how much money you expect to make. The conversation goes something like this:

Me: "Oh, I'm a medical student at the school here."
Them: "Do you know what you want to go into?"
Me: "Not yet, but I'm excited for years three and four when we start getting exposed to various fields."
Them: "Hey, what do you think about (insert controversial medical topic here)?"

More often than not, I have no idea what I think about the controversy they bring up and even if I did, they would not want to know what I think. Usually, people only ask to see if I agree or can validate their own beliefs. Medical ethics and controversies are not stressed very strongly in medical school. Every now and then a quick reference is made to some current movement, but largely medical students draw their own conclusions.

However, when a popular movement has been thoroughly debunked (or is patently untrue) so that there is only one position a doctor can have and maintain credentials, the teachers briefly morph into paladins of the scientific process, eager to dispense knowledge from leading authorities. This doesn't happen often, but it's kind of fun when it does.

Recently, one of those moments happened while we were discussing statistics and lab studies. The topic of autism and the role of the MMR vaccine came up and we took a few minutes to discuss it.

The issue first arose in 1998 when Andrew Wakefield, a British surgeon, published a paper along with 12 other authors claiming to have discovered a new syndrome called autistic enterocolitis which raised the possibility of a link between inflammatory bowel disease, autism, and the MMR vaccine. The paper was immediately controversial and contested in papers from Japan, but public outrage was fueled by a press conference that Wakefield held shortly thereafter.

A few years later, a new controversy emerged when it was revealed that Wakefield had applied for a patent on a single-jab measles vaccine. Certainly no conflict of interest there. Additionally, the UK General Medical Council hearing that investigated Wakefield's conduct concluded that he conducted the study without approval from the hospital ethics committee, dishonestly disclosed how patients were recruited for the study, and purchased for 5 pounds each, blood samples from 7 children attending his son's birthday party. Oh, and the sample size for his sweeping conclusions was a whopping...12.

Wakefield lost his credentials, is barred from practicing medicine in the UK, the journal that published his article fully retracted the publication, 10 of the 12 original authors released a re-interpretation of the original findings, but still Wakefield claims innocence and decries the use of MMR. Immunization rates in Britain dropped from 92% to 73% and there are estimates that as many as 125,000 US children born in the late 90s did not get the MMR vaccine. In 2011 a journal article labeled the "autism-vaccine connection as the most damaging medical hoax of the last 100 years."

Not many people listen to the CDC, USPSTF, or read medical journals. The public came to know of this controversy because a woman named Jenny McCarthy (PhD from the University of Google) championed the cause as her pet project. Jenny McCarthy started her career as a porn model for Playboy. In 2007 she claimed her son had been diagnosed with autism and she became the spokesperson against MMR vaccine and advocate for chelation therapy (the mercury in vaccines causes autism) to cure autism. She has made appearances on Oprah and Larry King.

The effects of this fiasco are manifested in the anti-vaccination movement. This website is particularly insidious because it doesn't state anything-it only implies possibilities. Is it possible, even a little bit, that vaccines could predispose to autism that might otherwise lie genetically dormant? Yes, that is a possibility. It is also just as likely that immunizations keep elephants away.

Tuesday, May 15, 2012

Hypnosis

I love going to bed at night knowing that I woke up that day believing something completely wrong and now stand corrected. It doesn't happen often, because there are some things every adult knows and the closer you are to becoming an adult, the fewer new things you learn.


This week in psychology we discussed hypnosis which I thought was about as legitimate as Tarot cards. I realized that I used to vacillate between two extreme positions. When it served my purpose I thought that hypnosis meant the hypnotist could control the patient. At other times I posited that it was placebo or that demonstrations were staged.

In lecture, the doctor said that in randomized clinical trials, hypnosis has been shown to be 25% effective against smoking, treating surgical pain (in place of anesthetics), and helpful for treating phobias and habit disorders. Hypnosis does not shut the brain down and convert the patient into a mindless, obedient serf, and is not a treatment in and of itself. It does allow the brain to be more open to suggestion. The American Psychiatric Association's position is that it is a "state of aroused, attentive, focal concentration with relative reduction in peripheral awareness that can be utilized to facilitate a variety of psychotherapeutic  interventions...The technique of induction of the trance state usually can be brief. Long induction ceremonies using a sleep paradigm are misleading."

Hypnosis is effective in controlling pain and the process is not well understood, but the changes on fMRI seen below indicate that there is diminished activity in the anterior cingulate cortex which is very active during the perception of pain.




From the Church Handbook of Instructions we find this: 


The use of hypnosis under competent, professional medical supervision for the treatment of diseases or mental disorders is a medical question to be determined by competent medical authorities. Members should not participate in hypnosis for purposes of demonstration or entertainment.

Wednesday, May 9, 2012

HPSP Cost Analysis

The theme of this week was, "You signed up for the HPSP?! I had a (relative) who did and it was a terrible experience, nothing went right, recruiters are all liars, et cetera ad nauseum." The HPSP or Health Professionals Scholarship Program is the name that the armed services gives to the deal they make with interested and qualifying medical and dental students. Each branch of the military has essentially the same deal which is that in exchange for a four year commitment to the branch once you have graduated, they will pay tuition, books, fees, plus a small stipend for the four years of school.

I've heard arguments for and against ever since general chemistry back in undergrad, but honestly haven't talked to anyone who has been through the program. I made the decision to do it shortly after hearing the words, "We'll pay you..." After having been in just short of a year there are still some aspects (such as how the residency match works) that are unclear to me. For now, I'm collecting paychecks and hoping that things will work out. I'm not a finance major and so this is a rough sketch of private versus military doctors (I am ignoring the 7.9% GradPlus loans that finance anything over the $18,000/year Unsubsidized Stafford loans and $4,500/year Subsidized Stafford loans which go away in 2012).

Each school has a maximum amount per year that they will let you take out in loans. They calculate this number by adding together all tuition, fees, books, and personal expenses. The personal expenses include their estimates for food, rent, recreation, travel, etc. which all vary greatly depending on how parsimonious a student is, but they "award" about $19,000 a year.  

Funding from Loans                       One Year      Four Years (with interest)
                                                     $72,000        $317,157


Using my school as an example (on the high end of tuition, I know) here is what the Air Force pays me.

                    Yearly                  Total
Tuition $51,510.00 $206,040.00
Health Insurance $1,500.00 $6,000.00
Books $1,670.00 $6,680.00
Supplies $700.00 $2,800.00
Stipend $21,924.00 $87,696.00
Sign On Bonus $20,000.00 $20,000.00
Laptop Rental $200.00 $800.00
Total $97,504.00 $330,016.00
                                                                 
Remember this is at the end of four years of medical school. During residency which lasts 3-6 years, you make about $50,000/year (very rough estimate depending on the hospital). The total you actually pay back would be quite a bit more than the numbers above because repayments enter a period of forbearance during residency in which you don't have to pay anything, but interest accrues. I'm not a finance major, but for an internal medicine residency lasting three years, interest on $317,157.00 at 6.8% would be an additional $64,700 for a grand total of $381,800.00. For a general surgery residency lasting 5 years, tack $107,833 onto the amount borrowed for a grand total of $424,990 when you begin repayments.

I used the FAFSA repayment calculator for the following based on the amount an internal medicine resident might expect to pay.

                                                                             Monthly          Total Paid
Standard Repayment Plan (10 Years)                  $4393/month   $527,252.00

Extended Fixed Plan (25 Years)                          $2650/month   $794,991.00

Graduated Plan (25 Year Incremental Increases) $2163/month   $861,113.00


So if I were going into internal medicine, the real value of having the military pay for it is the fact that I don't have to pay $530,000. Savings would be bigger for a longer surgery or radiology residency. The question really is, to what extent is the cost of debt to finance medical school offset by the expected salary? Medscape just released the average Physician Compensation Report for 2011 and here are the results.


 Here's how the numbers compute first for an internal medicine residency and then for a surgery residency.



At the bottom line, the military doctor comes out ahead in either field. In order for the civilian route to come out in front, you can either go to a less expensive school, or pick a better paying specialty like radiology or neurosurgery. There are other comparisons, but we'll save those for another time.

Tuesday, May 8, 2012

Al Capone and Patient Power

We finished neuro this week and now we're on to behavioral medicine and psychiatry. After this first week of psychiatry I have to say that the teachers are much more engaging and enthusiastic. The presentations that the psychiatrists prepare are stories about the craziest cases they have seen with a little bit of diagnostic criteria. Since there are no lab studies to diagnose depression, bipolar, schizophrenia, etc psychiatrists rely on patient presentation meeting Diagnostic Manual criteria to attach a diagnosis to a person. 

The most interesting lectures so far have been about drug addiction. I did research with a drug addiction expert during undergrad and it's been rather close to my heart since then. The professor who runs an alcoholics intervention clinic told us that 5% of drinkers consume about 35% of the alcohol and 10% of drinkers consume more than 50%. One in ten people who ever try alcohol will go on to lose their life, spouse, or job. One in six who ever try cocaine will become addicted. I asked him after he told story upon story of terribly addicted alcoholics and the extremes he's gone through to keep people clean what he thought about prohibition, decriminalization, and legalization of drugs. He said prohibition of alcohol would be futile - we'd return to a system in the 1920's where everyone is a criminal and only the Al Capone's would prosper. The data on alcohol price elasticity is: a 1% increase in price leads to a 0.3% decrease in beer consumption, 1% decrease in wine consumption, and 1.5 % decrease in liquor consumption. As far as legalizing drugs, last year 440,000 people died from tobacco-related complications, alcohol accounted for a low estimate of 100,000, and all other illicit drugs combined added up to less than 20,000 deaths last year. He seemed to think the war on drugs was serving its purpose.

What I did not enjoy was the section about domestic abuse. It made me sick to my stomach. Studying the terrible things one person can do to another person is like studying the etymology of curse words - you read and internalize what you'd rather skip.