Category: Healthcare

Don’t Believe the Hype

The number of myths about anesthesia out there never cease to impress me. Today, I really want to do some myth-busting because every now and then, these myths actually impact patient care and not positively.

1. Regardless of what you may have heard, anesthesia is not always to blame.
A few years ago, a colleague on call was contacted by an irate Obstetrician (OB) . A patient of the OB had developed a headache after delivery and he blamed it on the epidural she had received for labor. He needed her seen stat to fix the situation. My colleague saw her stat. There was a small problem – she never got a labor epidural or a labor anything from the anesthesia department. My colleague ordered a CT-Scan which showed a Sinus Venous thrombosis and that wasn’t caused by anything we did!
Anesthesia is blamed for almost anything that goes awry preoperatively. Think I’m kidding? Ask any OR nurse or surgeon. Even when a surgeon is late, anesthesia gets blamed for not realizing the surgeon will be late!
Anesthesia is surely not responsible for all preoperative complications and any surgeon who tells you otherwise needs to be tarred and feathered. In blaming anesthesia for all, patients are sometimes cheated out of knowing important history.
2. My doctor said I can never be put to sleep. He said if I need anesthesia, I should get a spinal.
If you are a doctor or nurse practitioner and you ever tell a patient this, may you lawn be invaded by giant dandelions every summer till 2092! Seriously! The result of this bad advice is that, the poor patient shows up for a craniotomy and insists on a spinal. Or needs a thoracotomy and wants only a spinal. If you ever tell a patient that, please come with him into the OR to do the spinal and manage the anesthetic.
Please leave anesthetic choices to people who actually provide anesthesia. Irrespective of how sick a patient might be, with the right anesthetic and monitoring, he or she might do just fine. Telling them they will only survive if they get a spinal makes our jobs harder as we have to spend valuable time trying to explain to the patient why you were wrong and we are right. Don’t do it!
3. Epidurals and Spinals paralyze people.
A study in the UK in 2009 showed a risk of 1:20000 – 50000 of getting serious neurologic injury from an epidural or spinal. It is rare. Not that it cannot happen but it is really rare. The very act of the needle entering your back has not paralyzed anyone yet. Now if a patient is on an anticoagulant and gets neuraxial anesthesia, the chances go way up since an epidural hematoma can result. For most patients though, in the hands of a good practitioner (like most procedures in medicine), the risk is really low. So stop listening to the your cousin Bubba who heard from Leroy that Dan’s wife got paralyzed from an “epidermal”.
4. It’s just a small case.
Dear Surgeon, it may be a small case but there is no small anesthetic. None. If anyone ever tells you otherwise, call the FBI. There is no small anesthetic. The minute a patient’s consciousness is altered, the airway is not as protected and hemodynamics may change. The same degree of vigilance is needed as in every other anesthetic. So repeat after me: “IT MAY BE A SMALLL CASE BUT THERE IS NO SMALL ANESTHETIC”.
5. I woke up during my colonoscopy so please make sure I don’t wake up during my colon resection.
For a colonoscopy, most patients are sedated whereas for a colon resection, almost all patients are under general anesthesia. Prior to the widespread use of propofol for colonoscopies, most patients were sedated for colonoscopies with versed and fentanyl. That combination got some patients through the procedure but for many, the combination was woefully inadequate and these patients never were totally comfortable. Hence, they remembered patches of the procedure. A general anesthesia on the other hand is a different animal. You are out. Anesthetized and paralyzed, often with a BIS monitor on to monitor for awareness.
So no, if you woke up during a colonoscopy, it does not count as having a history of awareness.

Above are a few of the many myths that dog us anesthesia providers daily. Even if this post helps to bust only one myth, that will be awesome. All anesthesia providers will be really grateful. Then as the quote goes by Raheel Farooq goes: “Misunderstanding is generally simpler than true understanding, and hence has more potential for popularity.”

That Nagging Feeling

“When you reach the end of what you should know, you will be at the beginning of what you should sense.” ― Kahlil Gibran, Sand and Foam

Some years back a colleague asked for my opinion on a patient he was getting ready to anesthetize for coronary artery bypass grafts. Something about the patient bothered him. About a week earlier, said patient developed chest pain while helping his daughter move. A visit to the ER led to diagnosis of Acute Coronary Syndrome and soon he was on the table in the cardiac catheterization lab where he was found to have three-vessel disease and was scheduled for surgery.
Preoperatively, even though he was not having any chest pain, no shortness of breath or EKG changes, something about his affect bothered my colleague. I took a look at the patient and concurred that his affect was weird. There was just something we couldn’t put our fingers on.
The patient was wheeled back into the operating room and before induction, my colleague decided to place defibrillator pads on the patient. There was no rhyme or reason for him to do that but he did it anyway.
Well guess what happened on induction? The patient went into ventricular fibrillation! With the pads in place, he was able to be shocked out of it and resuscitated. He went on to have his surgery and did well, allowing my colleague to look like the hero that he was.

That nagging feeling! Anyone who has been in patient care long enough has had it. Nurses and doctors alike. It is called intuition. A hunch. The definition I favor is “a thing that one knows or considers likely from instinctive feeling rather than conscious reasoning.”
As in the above scenario, instinctive feeling rather than conscious reasoning informed the decision to place defribillator pads. I could give several more actual scenarios.
Even though almost every physician has these episodes, the majority do not talk about them. How could we? Beside sounding like one wears tin-foil hats, insurance companies do not pay for decisions based on intuitions and most hospital boards do not take kindly to care based on hunches. So we keep these hunches to ourselves and may occasionally base a clinical decision on it. It does not mean that one always makes decision based on hunches. NO! These are rare occasions where something tugs at one over a case that cannot be explained by the evidence.

In most situations, clinicians do not pay attention to their intuitions. The inclination to act on a hunch increases as the outcome of a case or the prognosis for a patient worsens. So in cases where death is imminent, clinicians have been known to act on intuition as acts of last resort, sometimes saving the day.
A group of physicians who use intuition quite often are older colleagues and family practitioners. I remember my days practicing with an older family practitioner (Dr. M) in Berlin. We had a diabetic patient whose blood sugar levels were uncontrollable. She seemed to take her meds and swore she followed her diet. We wanted to have her admitted but she wouldn’t hear of it.
One afternoon after lunch, Dr M asked me to take a walk with him. We soon found ourselves before the door of an apartment about 2 miles away. From outside, one caught the smell of freshly baked cake. DR M rang the bell. The diabetic patient opened the door and the smell of cake hit us in the face. The minute she saw us, she got this silly look on her face. We had our diagnosis from the hunch of an older colleague.

So where do these hunches come from? I seems to be a function of age and experience. Dreyfus and Dreyfus in “Mind over machine: The power of human intuition and expertise in the era of the computer. Oxford: Blackwell 1986” write:
“The novice practitioner is characterized by rigid adherence to taught rules or plans, little situational perception; and no discretionary judgement.
The competent practitioner is able to cope with ‘crowdedness’ and pressure, sees actions partly in terms of long-term goals or wider conceptual framework; and follows standardized and routinized procedures.
The expert practitioner no longer relies explicitly on rules, guidelines, and maxims, has an intuitive grasp of situations based on deep, tacit understanding; and uses analytic approaches only in novel situations or when problems occur.” (T. Greenhalgh, British Journal of General Practice, May 2002).
There is also the factor of empathy – being able to understand one’s patients and sense their needs. That is also often a function of time and experience
So what is one to do? I think one should not disregard these hunches. How one handles these hunches will definitely spend on specialty. As anesthesiologists, I’ll recommend finding a colleague who believes in intuition and running your thoughts by him or her. Often, they are able to offer another perspective. If the intuition demands a procedure that is not too invasive or expensive or will not delay or prolong care, one may consider doing it. It is surely another story if it could lead to say, a case for surgery getting cancelled.

It is surely possible to weave evidence-based medicine and clinical intuition to give the best care. If the majority of us aren’t to doing it, maybe we should.

The Epipen Saga and what is wrong with the US Healthcare System

Sometime last year, I was having a conversation with a Mylan sales representative who had come by the hospital to introduce herself and tell us about the anesthetic drugs Mylan was now producing. The conversation soon turned to their dynamic CEO, Heather Bresch. Regardless of how you feel about her, she has grown the company from a small generics company started in West Virginia to an international player, now based in Holland.
Imagine my surprise when I heard the venom being flung at her lately and somewhat deservedly over the Epipen price increases.

In 2007, Mylan bought a portfolio of drugs from the German firm, Merck kGaA. Among them was Epipen, an injector containing about $1 worth of epinephrine (adrenaline). It was developed years earlier as a way of treating anaphylactic reactions which can turn deadly rather quickly in patients with say, peanut or shellfish allergies or the bee stings. The injector was developed by a Sheldon Kaplan for the US Military years ago. At that time, it carried antidotes for nerve agents.
Ms Bresch, who was one of the VPs at Mylan in 2007, came up with a brilliant marketing strategy that has turned Epipen into a billion dollar revenue maker. She got Congress to legislate that all schools carry Epipen. She got Disney to stock Epipen in all it’s parks. She has even targeted cruise and airlines. In 2011, Mylan spent $4.8 million on ads, going up to $35 million in 2014.
The marketing campaign paid dividends. Use of Epipen has grown 67% in 7 years and 47 states mandate Eipen in all schools. In 2011,
In 2007, revenue form Epipen sales was $200 million. Sales in 2014 were $1.1 billion. That one drug is responsible for 40% of Mylan’s operating profit and that is saying something for a company that has about 1400 drugs in it’s portfolio. Margins for Epipen were 9% in 2008. In 2014, a whopping 55%.
Increasing revenues have been helped by increasing Epipen prices – the price for a set of two was about $57 in 2007, then $103. 50 in 2009 and $264.50 in July 2013. It rose by 75 percent to $461 by May 2015. This May, the price spiked again to $608.61.
It is easy to attribute the price increase to corporate greed and aggressive marketing, the cost of which is being transferred to the patient. You can even claim the Mylan has a monopoly and arcane FDA policies are to blame. The issue in producing a competing product is the injector and Mylan’s competitor’s have not been able to come up with a good one.
However, there is an even more disturbing issue at play here and this to me, epitomizes all that is wrong with healthcare in the US. The issue of too many players – too many middlemen.
Ms Bresch in an interview on CNBC earlier today showed a graphic about the Epipen supply chain. It showed all the middlemen and how the price goes from the $274 that Mylan charges to $608 at retail. Find it below:

The middlemen in this supply chain are the Pharmacy Benefit Managers (PBMs), the Insurers, the Wholesalers and finally the retailers.
What is a Pharmacy Benefits Manager (PMB)? An example is Express Scripts. These are companies who seek to negotiate cheaper drugs prices for the insurers.
Lets’ say Company A makes drug X. It wants to sell it for $40. A PMB on behalf of all insurers as well as the large corporations like Walmart or GM negotiates with Company A and gets the price to $25. For it’s work, it must get paid. The insurers add, say $10 to the $25 so they can pay the PMB. The drug is now $35. The insurers then commission Wholesaler C (eg McKesson), to get the drug to the retailers. Wholesaler C has to make a profit. The drug is not used by many people. It adds $15 to the $35. Now the drug is $50. The retailers get the drug. They need to make a profit too. They also slam on $20 and the patient now has to pay $70.
So when Mylan offers a rebate of $100 or even $300, it is attempting the cover the costs of the middlemen, so they will carry the drug! However since only about 6% of consumers ever take advantage of rebates, it does not really spend that much. Beside, the total cost of a the rebate program, even at $300 is only a fraction of the revenue generated by the drug.
And that is how drug costs keep escalating. And that is also a microcosm of the healthcare system in the US. In the health delivery supply chain are too many middlemen, all with their hands out for a dollar. Is it any wonder healthcare costs are so high?
I dare say it’s not only our patients who are suffering from obesity. The whole damn system is morbidly obese and needs to lose weight or really soon, things will come to a standstill.

Am I Asleep

Recently a patient asked me if being under general anesthesia was like being asleep. Well, the answer I gave him was not wholly true and for good reason. Let’s explore that.
There are three states of decreased arousal – a coma, sleep and general anesthesia.
A coma is a period of prolonged unconsciousness due to injury to the brain. A comatose patients typically lies still with eyes closed, unresponsive to physical stimuli. At the start of the comatose state, patients may withdraw from painful stimuli or even grimace but as the coma deepens, even these reactions may vanish. EEG (electroencephalogram) shows low frequency, high amplitude waves.
Sleep is a state of very decreased arousal that is controlled by centers in the hypothalamus, brain stem, and forebrain. It is necessary for a human’s well-being. Humans cycle between two phases of sleep – REM (rapid eye movement) sleep and NREM (non-rapid eye movement sleep).
REM sleep last about 90 -120 min and is characterized by dreaming, erections, inability to move and high frequency, low amplitude waveforms on EEG.
NREM sleep has three phases and has low frequency and high amplitude waves on EEG. Restfulness is achieved in this phase of sleep. There are parts there is muscle activity and parts where muscle activity is rather low.
Lastly is general anesthesia. This is a reversible drug-induced state of unconsciousness, amnesia, analgesia, and being motionless. EEG shows low-frequency high amplitude waves. There are four phases of general anesthesia – light, intermediate, deep and profound phases. Surgery is usually performed between the intermediate and deep phases. A profound phase is achieved for procedures where the brain needs to be protected or to stop intractable seizures. As anesthesia deepens, the waves on EEG go from a decrease in number and amplitude to a flatline in the profound state.
So which state is general anesthesia closer to?
You guessed right – a coma.
General anesthesia is a reversible drug-induced coma. The sites in the brain that seem to be affected in a coma are the sites most anesthetics work to effect unconsciousness. For example, propofol induces unconsciousness by it’s effects in the cortex, mid-brain, thalamus and brain-stem. These same areas have been noticed to be affected in comatose patients.
A patient in a coma does not react to pain, just like a patient under general anesthesia, at least when the depth is adequate. Under general anesthesia a limb can be amputated, the appendix removed or even a hip replaced. Now try that in a patient sleeping at night.
Sleep refreshes. General anesthesia does not. Now, pure propofol anesthesia seems to have that refreshing effect. It has been found that propofol can help recover from sleep deprivation.
Sleep also has cycles, something that general anesthesia and the comatose state do not have.
The changes seen on the EEG during sleep differ from those seen the comatose state and under general anesthesia.
So I guess it was understandable that I did not tell the patient the whole truth. Imagine being told before your anesthetic as a lay person that you were going to be placed in a coma! With the kind of patients we see, I bet more than half of them might flee. I’d rather they believe they are going to have a nice, long nap. Ignorance is at times truly bliss.

In the Simulator

There is something irreversible about acquiring knowledge; and the simulation of the search for it differs in a most profound way from the reality.”
– J. Robert Oppenheimer

A Simulator is defined as:
– a machine with a similar set of controls designed to provide a realistic imitation of the operation of a vehicle, aircraft, or other complex system, used for training purposes.
– a program enabling a computer to execute programs written for a different operating system.
Simulators are used extensively in the military, aviation, medicine and other industries for training purposes. With or without actors, they can be used to create scenarios for training. Each scenario is usually managed by the person or team who created the scenario and can be watched live and/or videotaped to be watched later for evaluation. Events in the scenario can be altered to challenge the participants.
Simulators are now used extensively in medical training. They are also required some specialties for recertification and for continuing education.
Being old-school, I wasn’t a big fan of the whole simulation thing. I believed and still do that, for training purposes, a real live scenario beats a simulated one hands down. However a real live scenario is not always available. That is where a simulated scenario is invaluable for training purposes. It is also great for testing one’s reaction and for revising training. For my recertification a few years ago, I had to spend some time in a simulator and in the process, became a believer. It surely has it’s place.
Recently, I have been thinking of taking another simulation course. As I reviewed the available options, I had a thought. We are in the mother of all political seasons. The presidential elections are around the corner and with that the debates. I thought of how we choose who we think deserves to occupy the highest office in the land.
I am sure people vote along party lines, by race, by looks (I’m not kidding!), by their stand on social issues like abortion and gay marriage and so on. Sometimes their experience may sway us. This year, it’s crooked versus crazy!
Even though what they say and promise should not be that important in our decision making, even though words are cheap, they do play a huge role. Unless it is an incumbent, no one has had the prior experience being a president so we are really dealing with the unknown.
So then I kept thinking – what if we could get our presidential hopefuls into a Simulator and have then manage some “crisis” situations?
So, back to my candidates.
We get a simulator and create scenarios that mimic crisis situations for a US President.
We get actors to play all the different parts – Congress, the Supreme Court, the Tea Party, Teachers’ Union, Putin, ISIS etc.
We get the candidates, one after the other to manage these scenarios and see how they perform.
The candidates will know to put their best food forward since the whole world would be watching. It would be impressed upon them to take the scenarios seriously.
Having been in a simulator myself, I can honestly say that it is rather difficult to mask your real abilities during these scenarios.
If they are well written and planned, they can be so real as to elicit reactions from the participants that reflect who they really are in crisis situations.
Remember Hilary’s “3-am ad” against the then Obama? Well we could simulate that.
We could simulate an economic crisis, wars, attacks, conflicts with Congress, natural disasters and so on.
It might just be a better measure than empty words and promises.

Are We to Blame

I see this in my hospital all the time and I am sure it is seen by anesthesiologists all over the US – how much sicker our patients are.
It is also evident that surgeons are pushing the envelope further and further. Patients are sometimes showing up for surgery whose short-term prognosis (don’t even consider the long term) makes one question the wisdom in a surgical intervention.
Then is the rather formidable (no pun intended) issue of morbidly obese patients who need their day in the OR.
We as anesthesiologist seem to take all these challenges in stride and in most institutions, the daily schedule is hardly affected as these challenging cases are shuffled through.
We complain about the wisdom of surgically intervening in these instances but since the show must go on, we do what we have to.
I dare to blame us though for these circumstances. Bear with me and I’ll make myself clear.
Imagine an institution where the anesthesiologist cannot manage ASA IVE cases or secure the airway in that 550 lb patient or get that patient through an exploratory laparotomy who just had a myocardial event. Just imagine!
What do you think the surgeons are going to do? Three options – take their cases elsewhere, stop taking these patients to the OR or hire an anesthesiologist who can or is prepared to do these cases.
What if this was a national phenomenon with all anesthesiologist? Maybe the sickest patients will not show up for surgery!
However, we have a specialty that prides itself in being progressive, being evidence-based and seeking to constantly improve itself.
We attract the smartest and most innovative minds.
We seek and employ CRNAs who are bright, focussed and unafraid.
The results – the ability to manage whatever the surgeons pitch at us! So they keep throwing and we as trusted batters, always hit the home run.
600 lb? Bring it on!
EF of 15%, cirrhotic and anuric? Bring it on!
Hematocrit of 15? We’ll fix it intro!

I think the realization has hit us so most anesthesiologists have stopped complaining and are just keeping on because maybe, just maybe, we are to blame, but in a good way.
No matter what we allow into an OR though, we always have to bear this in mind:
“I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witness, that I will fulfill according to my ability and judgment this oath and this covenant…I will apply…(treatment) for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”

The Mad Doctor

“For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.”
– Matthew 25:35

I dedicate today’s post to an amazing man and physician that I only recently heard about and for that, shame on me!
Dr David Fuseini Abdulai.

Dr Abdulai, born in the Northern Region of Ghana, was one of 11 children. He is the only one still alive. His siblings and parents died from poverty-related diseases. His dad contracted leprosy (Hanson’s Disease) later in life and his mum had to beg for food for the family.. After he lost his family, he lived on the streets where he often went without food. That experience proved critical in what he was going to devote his life to.
Through the help of the Catholic Church, he managed to go to school and then to Ghana Medical School. After graduation, he practiced at Korle-Bu and 37 Military hospitals till 1989 when he decided to move back to the Northern Region to give back.
And has he given back!
He founded the Shekinah Clinic for the indigent and the destitute. He founded the clinic to serve the Very Important People (VIPs, like he calls them) in his life – lepers, the mentally challenged, the crippled, in short any one who society had cast out. In parts of Ghana, lepers, the mentally challenged and the crippled are often homeless. From his childhood experience, he remembered how hungry these people were so he fed them. He still feeds them, houses them, clothes them and treats them when they fall ill.
They come to him in droves, willingly and he goes out to find them too.
All the care is for free, financed by donations and volunteers. His mantra is “God Will Provide”. He hasn’t ever drawn a salary.
He also operates a “meals-on-wheels” service that feeds the destitute and homeless in a 65-km (40 mile) radius. His target here also are the mentally challenged, who live on the streets and are often hungry plus poor families who do not have enough to eat. He has been doing this since about 1992 and has never missed a day.
Every Christmas, he has a party for every destitute person in Gurungu, where his clinic is, and it’s environs.
He has since opened a second clinic.
Besides his VIP patients, he also takes care of the poor who need medical care – for free.
He is assisted by 27 volunteers and serves about 120 people daily.
What a man!
For his efforts, he was affectionately called “The Mad Doctor”.
Life sometimes calls upon us to serve our fellow men. Few recognize this challenge and even fewer are able rise up to this challenge. To the few who can, it is forever an honor and a blessing. To us who can only look on, it is a constant source of amazement and awe and it forces something out of us. It forces our better selfs to the surface, forcing us to rise and be better people.
Most of us became doctors hoping to one day heal the world. Along the way, life gets in the way and we forget our ideals. Dr Abdulai never forgot his ideals. He is out there healing the world.
Dr Abdulai, thank you!

The wonderful story of Dr Abdulai has however taken a sad turn. In May, he was diagnosed with advanced thyroid cancer and is now reportedly fighting for his life. It sounds like he hasn’t had any form of treatment since his diagnosis and is having complications. He was recently flown down to Accra for radiation therapy. He may need further medical care. Also, his work needs to continue. To these ends, a GoFundMe campaign has been started for the dear doctor and his clinics. If you care to donate, please go to:
https://www.gofundme.com/2xbgkzac
His story came to my attention through FB posts of friends and people I follow.
To Pakwo Shum, Kobby Blay, Nana Awere Damoah, Nana Ama Agyeman Asante, Ama Opoku-Agyemang and Christa Sanders, ayekoo!
To President Mahama and Dr Victor Bampoe for facilitating his transfer, thanks!

What Do You Have to Offer?

It was around 1996 and the specter of the Clinton Health Plan was scaring US doctors and medical students alike. A lot of programs in specialties like Anesthesiology and Internal Medicine, couldn’t find residents to fill the needed slots. So several top US programs got together and headed to Europe to find young doctors.
I had finished medical school in Germany two years earlier and after my internship, couldn’t find a job. No one wanted to hire an African! Returning to Ghana was not yet an option as I wanted to finish residency.

One winter night, as I left the Genetics lab where I was working on a project, I saw a flyer. It offered the chance to doctors to go work in the US if one had passed the USMLEs. There was a meeting scheduled for the next evening in an auditorium in the building where the lab was. I made it to the meeting. I met the head of the agency who was organizing the search by the top US programs for residents in Europe. I registered for the interview.

Sometime in the summer of 1996, I headed to Munich for the interview. It was an overnight trip from Berlin. I changed into my only suit in a restroom stall at the train station when I got to Munich. I headed to the venue.
I entered a large hall with lots of people. Each program had it’s table. I registered again, got my name badge and headed to the first table.
For the last two years, I had traveled over Germany begging and groveling for a job. Somehow, my transcript from medical school was just not enough. Somehow what I had to offer was not good enough.
I stood there at the first table, hopeless and expecting disappointment. The words I heard changed everything.
“Dr Ghansah, what do you have to offer our program? Sell yourself!”, the gentleman behind the table said.
I was dumbstruck!
Me? What did I have to offer? Me? A poor African doctor no one wanted but who had a thousand dreams? I was dumbstruck!
“Dr Ghansah, we are waiting!”
Right then, I knew the US was different. Right there, I got hopeful.

I’ve been thinking of this a lot lately as I listen to two very distinct depictions of this country. One is dark and cynical. The other is bright and hopeful.
This country is different. The US hasn’t always done right by all, but man, is this an amazing experiment!
It is a given that there are many for whom life is a daily struggle. It is a given that there are many who are shut out from reaping the opportunities this country has to offer. It cannot be denied that racial bias is still an impediment to some.
In spite of all that, I’ll go with the vision of hope then no other country offers it in spades like the US does. I’ll go with hope because cynicism and darkness never helped anyone.

As an immigrant, I am always grateful for what this country has given me and I can say that about all the immigrants I know. Like me, they all heard that question:
“What do you have to offer?”
That day in Munich, my answer was: “Hard work”.
That is the answer of all immigrants – Hard work. You see, when you offer hope and opportunity, you get a lot back. Hard work, perseverance, creativity, new businesses, entrepreneurs, artists and on and on.

Maybe Americans born and bred here in the US do not see what I see. Maybe they expect more. Maybe their standards are higher. That is fine. However, if you would indulge me, I would like to ask a few questions:
“What does cynicism and darkness get you?
What do they have to offer?”

Journal Club

Welcome to Journal Club! For discussion today is the following:

Article: Increasing incidence of metastatic prostate cancer in the United States (2004–2013)
Authors: A B Weiner, R S Matulewicz, S E Eggener and E M Schaeffer
Journal: Prostate Cancer and Prostatic Diseases. July 19, 2016

Background
Prostate cancer cells secrete an enzyme called Prostate Specific Antigen (PSA) into the bloodstream. Measuring the PSA level has been a way of screening for prostate cancer. In 2008 and again in 2012, the US Preventive Services Task Force (USPSTF) came out with recommendations to curtail the use of PSA for screening. The argument was that it led to the diagnosis of a lot of low risk prostate cancers that left alone would not grow to endanger life. Also, the test led to procedures that patients did not really need but which could lead to complications eg. impotence. Since 2012, there has been decrease in the use of PSA for screening,
The question among urologists has always been whether this recommendation would lead to ta spike in prostate cancer cases.
A group from Northwestern in Chicago, led by a Dr Edward Schaeffer decided to find out.

Study type
The study was retrospective.
Using the National Cancer Data Base (NCDB), they found all men who had been diagnosed with prostate cancer from 2004 to 2013. From 1089 institutions that reported each year in that time period, they got 767 550 patients.

PSA-Study

The patients were split into risk groups (depending on the extent of the cancer when diagnosed). The groups were low, intermediate, high and metastatic. The incidence of prostate cancer for each risk group was then compared yearly to the incidence in 2004.
Of the 767 550 men, 32% had low, 45% intermediate , 20% high risk and 3% had metastatic disease. They teased out information from the data with appropriate statistical tools.

Results
Of all the groups, the one that saw the most significant increase, relative to 2004 was the metastatic one. In 2004, there were 1685 cases. In 2013, 2890. – a 72% increase. The largest increase was seen in men aged 55 to 69 years. In this group, the increase was actually 92%.
Comparably, the incidence of low-risk prostate cancer actually fell.

Discussion
One can probably argue that the decrease in using PSA for screening may be causing the inability to catch the very aggressive types of prostate cancer. The problem though is that, the increase was seen even before the 2008 recommendation of the USPSTF came out.
Another factor could be an increase in the aggressiveness of prostate cancer. Also the use of MRI imaging has improved diagnosis and that can increase the numbers. Lastly, the population may just be getting older and sicker.
Perhaps the biggest flaw of the study was that the authors didn’t calculate a national annual incidence rate – the number of metastatic cases as a percentage of the US population. They looked at it as a percentage of cases from about a 1000 hospitals. They argue in the paper that with over 700 000 patients,they thought their results reflected national patterns.

Conclusion
Even though this study has it’s flaws, the fact remains that yearly PSAs can help screen for prostate cancer. In patients at high risk – those with a strong family history and blacks – it may be highly recommended. Done yearly, it provides a trend that can be very informative.
The recommendation is to start screening at age 45 in those at high risk and 50 for those at low risk.
For my lay male friends reading this who are black and 45 or older or not black but with a family history, if you haven’t started screening already, please see your primary care physician as soon as possible. By the way, just in case you ask, NO, you cannot do the exam yourself. It is very much unlike a breast self exam that women do!

The Amazing Professor Leutert

A hush had fallen on the group of young men and women assembled in the lecture hall. One could hear a pin drop.

Professor_Gerald_Leutert_ADA_Dimensionsmalerei®_Benita_Martin

The portly and balding gentleman who stood in front of the chalkboard looked over the group like he dared then to take their eyes off him. Then he spun around and grabbed 2 pieces of white chalk from the tray that was attached to the side of the chalk board. Now facing the chalkboard, he set both hands, each with a piece of white chalk in it, on the board. If one looked closely, only the pieces of chalk touched the board. Keeping the chalk pieces on the board, he swung his hands out in an arc. Both hands worked simultaneously as he drew. Like a conductor, his arms moved around. He reminded one of Kurt Masur, conducting a Bach performance at the Gewandhaus a few miles away.
As he worked, exhibiting his ambidexterity, a collective gasp went up from the collection of young students. They had heard about it but seeing it made it all the more mystical.
Soon he was done and like a maestro, he lay the pieces of chalk down and spun around. The students were on their feet, in thunderous ovation. When the ovation finally died down, he said:
“That is the cross-section of the spinal cord.”

Gerald Leutert was the Professor of Gross Anatomy when I was at the University of Leipzig. He was feared, revered and respected. He was a legend in his day. As first-year medical students, we had heard stories from the older students. The most amazing story was how he drew a cross-section of the spinal cord.
Now a cross-section of the spinal cord looks like two half-ellipses put together, one on the left and the other on the right. Well, Professor Leutert, being ambidextrous, drew both half-ellipses simultaneously and also added in the nuclei, laminae, tracts etc simultaneously. If you cannot imagine the skill it takes to do that, look at the image of the cross-section of the spinal cord below.

SpinalCord copy

Over the years, I have wondered what his intentions were when he made that drawing with so much pomp. Initially I thought he was just showing off. However as first year flowed into second year of medical school and the anatomy lab become a home away from home, I couldn’t overcome the feeling that there was another reason.
The Anatomy Lab. Home of broken dreams and high hopes. Of the end of life fueling knowledge. Professor Leutert ruled it like a king with us as his lowly subjects.
On those days that he came back to inspect our dissections and test our knowledge, it felt like judgement day. Come to think of it, was judgement day! Portly and short, it seemed he could rest his hands on his ample belly. Flanked by two assistants, and holding forceps in his hands like a scepter, he moved from table to table, passing judgement swiftly and mercilessly, in an atmosphere enriched with formalin.
“What is that?”, he’ll ask, picking up the delicate tissue.
“The radial nerve.”
With a nod he’ll be off to the next table.
“What are the structures that border this organ?”, pointing at the liver.
A hint of hesitation and one wilted under a barrage of even more questions, like said organ when cirrhotic.

I survived Anatomy and went on to graduate. All these years that day in the lecture hall has stayed with me. The day that I watched Professor Leutert display his ambidexterity. Recently, the essence of it kind of hit me.
The dear professor wasn’t trying to show off. Not at all. In showing us his dexterity so early, he tried to impress upon us what it took to do a good dissection. He made us realize the importance of learning anatomy and made us gain a deep respect for those whose bodies we had the honor to learn from. He also made us realize very early that medicine is practiced with both the mind as well as with the hands. He was telling us that no matter what specialty we ended up in, we needed to exhibit dexterity and practice medicine with all our senses.
With that he gained our respect. We looked up to him and revered him. Moreover we feared him. Not because he could hurt us. (Well, if one flunked Anatomy, that was it). That wasn’t the reason we feared him though. We dreaded disappointing him. He had set the bar quite high and we all strived to reach it. We feared not reaching it.

Professor Gerald Leutert died in 1999 at the age of 69. Apart from a short stint as Rector of the University of Leipzig, he spent the majority of his over 40-year career teaching and doing research in the field of Anatomy.
In his own way, he managed to grab the attention of the young medical students he was entrusted with and hold it. In the process he formed them, trained them and influenced them. I would know – he got and held the attention of my peers and I and in the process formed, trained and influenced us.