Alfie Evans: A Reasonable Economic Decision Disguised as a Horrific Moral Determination

The tragic case of Alfie Evans has roiled Great Britain and the world. Alfie was a 2 year old child in the United Kingdom with an unknown degenerative brain disease who eventually deteriorated to the point that he required life support- his brain had become mostly liquid, and he could not see, speak, or hear. Alder Hey hospital decided his condition was terminal and irreversible, and wanted to stop further treatment. His parents disagreed, and wanted to transfer care to another hospital in Italy which was willing to accept him. Alder Hey went to court, arguing that it was better that the child be allowed to die because keeping him alive was cruel and harmful. They ultimately won, and Alfie Evans passed away. This has sparked a great outcry, particularly among the pro-life movement in the US. And indeed, the idea that the state can literally declare that death is better than life for anyone should be horrifying to everyone.

But the decision to take Alfie off life support was a reasonable and ethical one- if it was justified as being fair to all patients. It is even a reasonable one for individual doctors to conclude that further treating a patient in front of them is harmful and not ethical. But when court decided it had the right to decide that the child should die rather than live, it became an abomination.

Theranos, The Wall Street Journal, and what Everyone is Missing: the Harms of Overtesting

Theranos is a Silicon Valley start-up dedicated to revolutionizing (some would say disrupting) the medical blood testing industry.  The claim to fame of the company was to use a single drop of blood from a finger stick to run hundreds of tests.  This premise led to a $9 Billion valuation and rock-star status for it's founder, Elizabeth Holmes- and was recently threatened by a Wall Street Journal exposé, which claimed the company's tests were not that accurate and that they used traditional blood testing for most of their work.

Marijuana, Neurosurgery, and Physician Impairment

A brief article several days ago posted the name and picture of a neurosurgery resident accused of smoking marijuana on the job.  Dr. Gunjan Goel, MD is a neurosurgery resident at UC San Diego, and the list of her awards and publications alone is almost as long as my entire residency application.  The article is brief, and rather uninformative.  The only facts that are known are this: the Medical Board of California investigator demanded a hair sample, and in response Dr. Goel acknowledged smoking 3-4 occasions over a 6 month period, on her days off.  This incident touches on a lot of complicated issues- intoxication on the job, surgeon quality and competence, and not least of all anti-drug enforcement efforts.

Update:
This piece was picked up by KevinMD, and one of the commentators posted this link to the full court complaint.  The highlights are that no action was taken by the medical board for 8 months after the complaint was received, and that Dr. Goel had a negative urine test and positive hair test- a result consistent with occasional, recreational usage rather than heavy, daily use.

I will not comment further, as this piece is not so much about this individual case, but rather about the more general problem of what regulations and rules should guide the medical profession with regards to marijuana as this country increasingly moves towards legalization.

To my Fellow Medical Students: Beware before Judging your Residents, for you may Easily Become them

A recent paper in the Annals of Internal Medicine has sparked a large news media response.

In it, two incidents are described: in one, a male obstetrician-gynecologist is prepping a patient's vaginal area for surgery, which involves running a brush soaked in betadine or chloraprep solution over the labia, mons pubis, perineum, and inner thighs when the patient is already put to sleep by anesthesia.  He makes an appalling joke, "I bet she is enjoying this".

In the second, another male obstetrician-gynecology resident runs into a room with a patient bleeding to death from her vagina.  He controls the bleeding with manual pressure, putting his hand into the woman's vagina.  And then, when the crisis is over, he starts dancing and singing, while his hand is still in the woman's vagina, keeping the woman from bleeding again.

Many comments, especially from other medicals students, are condemning the behavior of these doctors and likening it to sexual assault.

I make no excuses for this behavior.  But while it is easy for us as medical students to judge, the reality is that residency will put us all at risk of becoming these doctors.  The lesson here should not be "what monsters!", but rather "I must make sure I never become them".

Physician-Assisted-Suicide and Pay-for-Performance: an Unholy Union

Recently, a young woman named Brittney Maynard became a symbol for the Physician-Assisted Suicide (PAS) movement in the United States.  Brittney had been diagnosed with an incurable form of brain cancer- glioblastoma- which had recurred after an initial brain surgery.  She then moved to Oregon, one of three states where Physician-Assisted Suicide is legal by statute, and purchased the drugs which she could use to end her life.  She kept them with her until November 1st, 2014, when she took her own life.  But not before recording testimony to be played posthumously in California legislature where a bill was introduced which would legalize the practice of PAS.  The bill looks increasingly likely to pass, as the California Medical Association which killed previous versions of the bill now looks to stay neutral and sit out the fight due to changing attitudes among its member physicians.

I have serious concerns about the way PAS comes to be implemented, and how it will interact with the statistical measures that are increasingly being adapted throughout the healthcare system to "measure quality".

I support vaccines- but I am somewhat surprised that more parents don't

As a medical student, I strongly support vaccination. It works, it's safe, and it doesn't cause autism. But I also understand why many parents don't believe me and the medical community when we beg them to vaccinate their kids.

Medicine has come a long way from "Do No Harm". Now we talk about risks and benefits: and none of our tests, medicines, or procedures are without risks. Increasingly, pharmaceutical companies have been caught concealing those risks from doctors and the public.

Informed Consent is a Chimera

This post by Paul Levy got me thinking about informed consent, and a case I saw recently got me to take a little time and write about an issue frequently ignored in medical school.

A bit of background for non-medical readers: Informed Consent is a term in medicine for when doctors get the agreement of the patient to do something to said patient.  For example, before a patient is cut open for surgery, the patient has to say "yes I want to be cut open and have _____ happen".  Less extreme examples abound- the patient has to consent to anything from a blood draw for a lab test to a CT scan.  Part of informed consent is that the patient has to be "informed".  It is acceptable for a patient to say "tell me nothing, just do it", but the patient has to be offered information regarding their disease as well as the risks and benefits of the procedure they are consenting to.  For example, "This x-ray will tell us whether or not you have pneumonia or something else, but may slightly increase your risk of cancer in the long run.  I recommend you get it.  Do you agree?"

The Coming Downfall of Medicine: Scientific Corruption

Some recent news about a(nother) scandal in the pharmaceutical industry has led me to post on something that is critical to the future of medicine and science.

Let me start off by saying that I believe strongly in most medicines. I think the data behind their safety is incontrovertible. But for medicines that were invented recently, that same data would still leave me quite suspicious.

Here's why.