Category: Essays

“That is not a drug, it’s a leaf.”
– Arnold Schwarzenegger

In the next few years, two of the many areas that could be interesting areas of medical research and therapy may be the the fields of cancer immunotherapy and the medical use of cannabinoids. Yes, cannabinoids – those extracts from cannabis aka marijuana aka weed!

No other plant is as controversial as Cannabis. In spite of an almost 5000 year-old history of use around the world, it has been a banned substance in most countries in the last 100 years or so.

It’s ill-repute stems from it’s psychoactive effects which can be significant.
Some of the chemicals inherent in the most common species of this plant, Cannabis sativa, have been isolated and they are called cannabinoids. There are about 85 of them. The two most researched are:

– Delta-9 Tetrahydrocannabinol (THC) and
– Cannabinol (CBD)

Whereas THC is responsible for most of the psychoactive effects (the high), CBD has none of the high effect. Both cannabinoids have some very significant therapeutic effects.

THC – analgesic, anti-spasmodic, anti-tremor, anti-inflammatory, appetite stimulant and anti-emetic
CBD – anti-inflammatory, anti-convulsant, anti-psychotic, anti-oxidant, neuroprotective and immunomodulatory effects

Even more interesting is that the human body has cannabinoid receptors. This has been an area of research for the last 20 years or so. Two types of cannabinoid receptors have been found so far – CB1 and CB2. CB1 receptors are present in the brain and spinal cord and in certain peripheral tissues. CB2 receptors are expressed primarily in immune tissues.
Now if the body has cannabinoid receptors, then humans must produce natural cannabinoids. At least 3 have been isolated so far – arachidonoyl-ethanolamide (anandamide), 2-arachidonoyl glycerol (2-AG) and arachidonyl glyceryl ether (noladin ether).

These endocannabinoids are involved in areas of the brain responsible for:
– movement and postural control, pain and sensory perception, memory, cognition, emotion,
control and reward centers in the brain (limbic system and hypothalamus)
– cytokine release from immune cells and immune cell migration

So when one uses marijuana, do the cannabinoids from the weed react with the natural receptors? That is the thought and that is how they exert their action.

The push is then for strains of Cannabis high in CBD to capture the medicinal sans psychoactive effects. This is achieved by altering the genome of the cannabis plant to get strains that contain mostly CBD. An example of a strain with high levels of CBD is Charlotte’s Web.

In the forefront for drugs made out of CBD is GW Pharma, a company out of the London, UK. They have a drug out named Epidiolex for Dravet Syndrom. This a condition marked by intractable seizures in kids. These kids can have over 20 seizure a month. It reduced the incidence of seizures in a study of 120 children by close to 40%. FDA approval is pending.

CBD-based drugs are also being studied for Multiple Sclerosis. It reduces the incidence and severity of muscle and bladder spasms as well as the intensity of neuropathic pain.
CBD has been shown to reduce the incidence of psychosis in Schizophrenics and may modulate symptoms of fear in patients with PTSD.
CBD has been shown to be very effective in the treatment of chronic pain with a much safer safety profile than opioids.
There are a few studies out showing the cytotoxic effects of CBD on breast cancer cells.

All these examples are but a few of the therapeutic possibilities being researched actively.

CBD however still remains a Schedule I substance and thus viewed as illicit when used without a prescription or in a state where the use of marijuana is not legal.

Maybe Bob Marley was right after all:
“Herb is the healing of a nation, alcohol is the destruction.”

“Half of us are blind, few of us feel, and we are all deaf.”
– Sir William Osler

This incident occured in my third or fourth year of medical School in Leipzig (outside the US, most medical schools are 6-year programs). We were on a medical-surgical (med-surg) floor one afternoon with one of our instructors for a session on the Physical Exam. Before we went off to terrorize our patients, he warned us to pay attention and observe. He asked us not to be too distracted by what the patients said – to listen but also to watch. To use all five senses.
I marched off to my patient – a 60-something year old woman who was in the hospital with an unknown-to-me cardiac condition. My job was to talk to her, examine her and figure out her condition and the cause. The patients are usually asked by the instructors beforehand not to divulge their diagnoses.
Well, my patient was as garrulous as they come. She thought I was the cutest thing she ever saw and I allowed her to pinch me cheek and pull my hair (I had a ‘fro then!). Soon she told me what her ailment was – Atrial Fibrillation (a condition where the heart beats iregularly) – and all the medicines she was on. Well, who was I to complain? I had my diagnosis and treatment. I stepped out, feeling like the second coming of Hippocrates. I had totally forgotten why I was in the room in the first place.
Well, I presented my patient to my instructor who promptly asked me what the cause of her Atrial Fibrillation (A-fib) was. Having neglected to examine her, I promptly responded that it was idiopathic, a fancy term for ‘I don’t know’. He asked me to list the causes of A-fib, which I did. He asked me if the lady could have Hyperthyroidism (an overactive thyroid gland and a cause of A-fib). I said no.
At this point, most of the other students were back. He introduced my case to the group and asked me to lead the group to my patient’s room. The instructor was a tall man and he was right behind me when I opened the door to the patient’s room. From the door, one saw the patient resting in bed and she turned her head to look at us as we entered. From about 12 feet away, one could see the goiter (a large swollen thyroid gland) bobbing in her neck. I wanted to vanish!

It’s a lesson I’ve never forgotten – to observe, to watch, to feel, to smell and listen. Do I do it well or all the time? Of course not but I try.
The power of observation is as important to the practice of medicine as the power of taste is to a chef. A doctor needs to be able to notice that jaundiced skin, that throbbing mass in the abdomen, those engorged veins in the neck, those blue lips, the child who is alwsys squatting instead of playing, those trembling fingers, that deviated tongue, that strange gait.
We need to listen to the patients’ answers but above all know what to ask. We need to examine patients and really listen to those breath sounds and make out those murmurs. We need to be able to smell those almonds on a patient’s breath.

The practice of observing the patient has been dealt a serious blow by the use of technology in medicine. In this age of CT-Scans and MRIs, why even bother? What not let technology do all the work? An echo will soon tell you if the patient has valvular disease so why does one need to know what aortic stenosis sounds like?
First, it makes one a better doctor then it forces a one to be interested in that human in front of him or her. You have to be truly interested in another person to observe them closely.
It also does save time and money. It cuts down the amount of useless tests. Sure, we do a lot of tests to cover our butts (Defensive Medicine), but there are also cases where a good physical exam does make a huge difference.
Further, it gives one a better picture of the patient. One may pick up other ailments that the patient may not even know about.
Our colleagues who practice in developing countries will tell you most times, all you have are your five senses.
(At this point, a shout out to all the doctors in Ghana and to two esteemed colleagues – one who spends half his time working in Haiti and the other who volunteers with Doctors Without Borders).
Recently, the practice of observation has been dealt another blow. Since electronic medical record-keeping became mandatory in most medical practices and hospitals, I often take time to observe other colleagues and nurses working. It is a sad sight. One sees extremely well-trained and dedicated professionals observing not the patient, but a screen. A culture that already suffered from the lack of observing the patient has been worsened by the need to chart electronically.
Then is the notion that the practice of medicine is nothing but a series on protocols and best practices and that the best results are obtained when everyone sticks to these protocols and best practices. Well, the jury is still out on the wisdom and effectiveness of that. As most practitioners will tell you, no two patients or two cases are ever the same.
Lastly, just the volume of patients one has to deal with plus production pressure make it sometimes really challenging to really observe well.

I look on in despair and wonder what William Osler would say if he was alive today. He aptly once wrote:
“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”
We have all become experts but are we in the process forgetting how to see, hear, feel and smell? If we do forget, what kind of experts do we become then? I wonder, I really do…

Like life, the practice of medicine is filled with the highs and lows, the moments of heartbreak and euphoria of success, times of hair-pulling (if one has any) frustration and uplifting encouragement.
Loosing a patient unexpectedly is very traumatic. It happens to every doctor and it is a pipe dream to think it would never happen to you. It is a fact that some specialties are less prone to experience it than others. However, when it does happen, most physicians have no one to talk to.
Fellow physicians are the worst group of people to seek solace from. The majority have their own professional and personal issues. Then is the judgmental bit – “If you had done A instead of B, maybe…” Which leaves our significant others, the majority of whom have already been overburdened with medical talk to the point where they are insensitive and frankly do not care anymore. And then is the small issue of “..anything you say can be used against you when the family sues you!’
Would it not be great it there was a ‘listening ear’ for physicians in those times? I am thinking a 1-800 number one could call and be able to unload the disappointment and pain. Say 1-800-i-LISTEN.
A physician could call and talk anonymously to a listening ear about the death one had in the operating room (or emergency room or cardiac cath lab or floor).
About the fact that the team did all it could? About the fact that the patient had undiagnosed SAM or carcinoid or an unknown tight left main? About the fact that you were in the operating room for 15 hours? About the fact that you bonded with the patient and his wife gave you a hug and his kids shook your hand? About the fact that the malignancy was inoperable? About all those things we are supposed to keep inside because we are supermen but really aren’t?
What if you could just open up without fear of judgement or medico-legal action?
What if…?

“The Scream” by Edvard Munch, 1910

Then are those times where one out of pure frustration wishes to yell or scream or throw something. My surgical colleagues, can I get an Amen? Yet you cannot yell or swear or throw anything. It is unprofessional and creates a hostile work environment. It is absolutely disrespectful to the team busting their chops to make it happen. You may have done it in the good old days but we are in 2016 and that kind of behavior will get you in trouble quickly. However, every doctor has had a day where frustration rolled down like waters and impediments like a mighty stream. Where that surgeon didn’t understand that blocks sometimes don’t work, where that anesthesiologist cancelled that case even though the best cardiologist in town “cleared the patient”, where that cardiologist wants you to do that CABG today and not on Monday, where you are stuck in the OR because the PACU is full, where you find out that some administrator decided to pull your favorite suture or antibiotic because it’s too expensive, wherw you have to work with the scrub tech you cannot stand….. the list goes on.

You want to scream and yell and call someone names that would make Tony Montana wince, don’t you? You want to do that because long before you became a doctor, you were a human with emotions and long after you cannot practice anymore, you will still be that human!… And humans get frustrated and sometimes, just sometimes, want to yell and scream and hop up and down on one leg and then the other.
So won’t it be great if there was a Scream Room?
“Scream Room?”, you wonder. “What is a Scream Room?”
The Scream Room would be a soundproof room somewhere in the hospital where one could go and scream and throw things of one’s choice for as long as one wanted to let out pent-up frustration. One could use as many four-letter words as one wanted and jump up and down like Rumpelstiltskin if one wished to.
The room would also have a 100-lb punching bag hanging from the ceiling. There would be boxing gloves available. One only has to pin a picture of the cause of one’s ire on the bag, don appropriate size boxing gloves and punch away.
What if there was such a room?
What if…?
Like I wrote earlier, before we become doctors, we were humans. Humans are strong but can also be weak. They can be wise but sometimes folly reigns supreme. They can be patient and understanding but occasionally brash and irritable. It’s only in accepting our strengths and weaknesses that we become whole. Whole humans. Whole doctors.