Madness! Or, marginally-Michigan-and-medically-mediocre musings, from an M1

It is important to have hobbies outside of medical school or you might go mad. Fortunately, the work/life (or, well, study/life) balance is something that Ann Arbor seems to foster. Even the smartest and most serious students have activities that do not involve the library or the hospital. Sure, there are a few that seem to have caught the “med student disease” and always appear rather stressed and harried, but at Michigan sightings of that susceptible breed are few and far between. Watch out, though, since there will always be someone who studies longer than you, someone who publishes more papers than you, someone who knows more professors than you, someone who got more grants than you, and someone who got their Nobel Prize before you.

I don’t care that this whole work/life balance is something that is incessantly talked about and blogged about. It really never gets old because it never gets solved. Yes, fine, you can make some general progress. You can go after certain things; you can relax certain standards. No matter what, though, the life of a student (or anyone, for that matter) is not one that can be governed by black-and-white rules. You don’t have to always go to Happy Hour or never go to Happy Hour. You don’t have to always study on Saturday or never study on Saturday. You don’t have to always take notes or never take notes. It sounds silly, but applying this principle to more complicated issues can get tricky. How much time “should” I spend with friends? When am I going to practice music or language? How much effort do I put into correspondence with family? Why should I actually sleep eight hours some nights? How many days can I fit in a run? Do I get to keep reading so many random novels? What does it mean to achieve a “balanced” life? 

Obviously no one has a perfect answer to any of these questions. These are the kinds of things you have to ask yourself every single day. Sometimes even when you take the time to do something, you are not exactly sure of your motivation. A recent bicycle tune-up experience comes to mind. Did I really need a trip to the bike garage? Maybe not. Was it still enjoyable and marginally productive? Absolutely.

Bike guy: We’ve had a lot of students this month, but the semester hasn’t started.

Me: Maybe they were also medical students, since we don’t follow university semesters.

Bike guy: Oh, are you a medical student? So you will be the Class of 2015?

Me: Well, med school is four years.

Bike guy: So Class of 2016?

Me: Ummmm, the thing is, actually…nevermind. Anyways, advice on where to ride? I know there is a bike trail that goes through Gallup Park, but I haven’t figure out how to get near there by road on a bike.

Bike guy: How do you know Gallup?

Me: Well, when I run through the Arb, I cut across the train tracks where it says “No Trespassing” and I always end up on the bike trail.

Bike guy: And you don’t want a kickstand?

Me: [look of repulsion and lack of interest at dorky accessory like kickstand]

Bike guy: [trying to decide if I am snobby or impractical or both]

Me: [awkward shifting of eyes and feet]

Bike guy: Do you swim too?

Me: Sort of. I used to. Kind of.

Bike guy: So you need a bike that would work for your future triathlons.

Me: Oh?

Mental toughness

Good news! Obama’s Affordable Care Act (ACA) brings hope for Americans with mental illness. I figured I’d better weigh in on this before everyone points out that I am always years behind on the news (fine, fine, it’s usually true). People with mental illness will now have close to universal health insurance for psychiatric disorders, which is major progress compared to the previously higher deductibles and lifetime caps. Under the ACA, there is no longer exclusion of people with pre-existing conditions, meaning that the Americans who have experienced psychiatric illness can’t be denied coverage.

This is a BIG DEAL given that about half of Americans experience a major psychiatric or substance disorder during their life. Sadly, the stigma surrounding mental illness and the poor access to care has prevented millions from receiving the care they needed and deserved. This is no small problem, and I am not just talking about the individuals’ suffering. People with a mood disorder cost society with their lost productivity; in fact, the World Health Organization ranks depression as the world’s leading cause of disability.

Psychiatric illness is chronic, characterized by remission and relapse even for people who respond to treatment. I spent the last year doing research on disorders including schizophrenia and bipolar depression, and I spent a fair bit of time at the psychiatric hospital. Plus, on a more personal level, multiple members of my family have dealt with mental disorders at one point or another. Anyone who has spent time with these patients and their families can tell you that relapse is common even with the best treatment. It’s completely irrational to tell someone with this condition that his lifetime mental health benefits max out after a certain number of inpatient hospital days. Psychiatric illness is treatable but rarely curable, which is why the current limits on treatment are absurd.

There are obvious public health advantages to the fact that people can remain on their parents’ insurance until they turn 26. I think this is a major step in the right direction for a whole host of reasons, but psychiatric illness provides a wonderful case in point. It turns out that 75% of serious psychiatric illness presents itself by the age of 25. Early treatment is critical in conditions such as major depression and substance abuse, so keeping young people insured through this period is clearly a good idea.

For the elderly and the poor, there are a few additional considerations. Elderly people with mental illness benefit because the law will fill the gap in Medicare drug coverage. In essence, ACA immediately requires drug companies to give a 50% discount on brand-name drugs and then subsidies will be increasingly provided until the gap closes in 2020. Unfortunately, poor people should still be worried. The new law would have expanded Medicaid, but the Court ruled that states could decline the expansion without losing the Medicaid funds. Thus, in states that opt out of the Medicaid expansion, poor people with mental illness might earn too much to qualify for Medicaid but not enough to get the federal subsidy to pay for insurance.

Back to the main point: there is recognition that psychiatric illness is on par with all other medical disorders and these problems have a real, biochemical basis. It is time that people were more open about this reality, as then people might be more willing to seek early treatment. Don’t argue and don’t stigmatize. How will you deal with this reality?

What is a calorie, anyways?

Team Maize did not stop to ask questions today; we simply took over MedChef, the most intense competition that medical students go through during the first week of “class.” The winning team used local lake fish, creative chilled couscous, and a brilliant balsamic reduction. It’s embarrassing how excited I am about the oven mitts that we won.

In honor of today’s competition, here we go with the first of many posts about food. (Full disclosure: I am not always proud to be an American.) I find it amusingly ironic that a country with such an obvious obesity problem also has such a disastrous dieting problem. Yes, I do mean a dieting problem. Eating disorders aside, there is an unnatural obsession with finding easy, clear solutions. “Don’t eat this. Walk this many minutes. Drink this tea. Eat that weird berry.” Sadly, these proposals strike me as the typical American response to a problem. Changing our entire lifestyle, of course, is out of the question. We want a plan and we want control.

Of perennial interest in the dieting and obesity research community is the question of whether a calorie is just a calorie (i.e. does 200 calories of soda affect your waistline in the same way as does 200 calories of apple?).

It’s an interesting question and before we even look at the most recent studies I’ll point out a few obvious caveats, using our soda versus apple example.

People who drink soda are probably not about to go exercise, since bubbly stomach is not so fun during a run.

People who drink soda might be people who also snack on salty, fatty food.

Soda drinking is associated with fast food consumption, which negatively correlates with having a family dinner time, so fast food also negatively correlates with having a regular sleeping/eating/exercising schedule.

Apples are fibrous and therefore might prevent further snacking (though are purely carbohydrates and thus cause a spike in blood sugar that comes with a subsequent crash and further cravings…hmmmm, best be paired with almond butter, I suppose).

People who eat apples might live on a farm and do a lot of manual labor (okay, okay, I digress).

Researchers interested in weight loss and weight gain have long been curious about the importance of where the calories come from. There have been bizarre low-carb fads (news flash: your brain runs almost exclusively on glucose, plus raspberries and oatmeal are delicious) and low-fat trends (N.B.: without enough fat in your diet, your hair and skin will be dry and ugly). A recent study published in The Journal of the American Medical Association tried to show that people on a high-fat, high-protein diet (as Atkins once suggested) burned more calories than those on a high carbohydrate diet. Essentially, the study authors Ebbeling et al. suggested the after losing weight people should be reluctant to add too many carbs back into their daily routine. 

Numerous scientists have come out to publicly disagree with the suggestions this study puts forth. The esteemed Dr. Jules Hirsch of Rockefeller University, who has been researching obesity for almost six decades, looks like he knows what he’s talking about.

I am inclined to listen to Hirsch’s simple explanation for why the study came up with misleading results. The experiment went something like this: Ebbeling took a sample of 21 people, forced them to lose 10-20% of their body weight, and then put them on one of three maintenance diets — low-carb/high-fat, high-carb/low-fat or moderate. The study’s outcome measure was total energy expenditure and resting energy expenditure, expressed as calories burned. However, low-carb diets can cause mild to severe dehydration. Water loss confounds attempts to measure energy output because the measurement is usually expressed as calories per unit of lean body mass. Less water means less lean body mass and therefore more calories per unit lean body mass (or so it appears). What has actually happened is that dieters have lost water, not fat.

Besides, who are we kidding? All that matters in terms of weight loss is calories in versus calories out. People who want to lose weight need to take in fewer calories or expend more, or both.

(There are, as always, a few additional complications, such as the fact that muscle weighs so much more than fat, but we will ignore that for the moment. If you are on your way to becoming a body builder, we should talk more about this.)

Additionally, there have been other studies that explicitly studied how people respond to diets of different compositions. Dr. Rudolph Leibel conducted a fascinating study with people of normal weight who were recruited to live in a carefully controlled hospital setting. While keeping each person’s caloric intake – and weight – constant, he changed the proportions of fats and carbohydrates. There were no differences in response found between the high-fat and low-fat diets. His now-classic study did find, though, that people reduced their energy expenditure when their weight was lower than normal and burned calories faster when their weight was higher than normal. In humans, this is one of the ways in which body weight is regulated.

The moral of the story is that there is NOT a magical diet. As some wise people have been saying for years (or millennia), it’s about moderation. Take a look at France, Switzerland, and Italy, for instance. I can assure you that they enjoy their fair share of cheese, chocolate, and wine, and yet a European’s chances of becoming obese are slim (pun intended).

The other moral of the story is that if you live somewhere humid and you like to be active, be sure to have sufficient sugar and salt in your diet to retain some water. It’s not the end of the world; it’s being well-hydrated.

And, to get back to the question posed in this post’s title, a calorie is technically defined as the amount of heat-energy required to raise one gram of water by one degree Celsius. The “calories” you see on food labels are actually kilocalories. In carbohydrates and proteins, you get 4 kilocalories of energy per gram of food, while in fat you get nine. For instance 8 grams of brown sugar gives you 8*4 = 32 calories and 8 grams of olive oil gives you 8*9 = 72 calories. It gets more complicated, obviously, with something like chocolate where you have fat and sugar and protein. I’d say 8 grams chocolate = not enough = minimal satisfaction = lack of satiation.

HIPAA sounds like “hippo”

“Medical students of those decades had other hard things to learn about…duties required experience to be done well…needed a mixture of intense curiosity about people in general and an inborn capacity for affection, hard to come by but indispensable for a good doctor.”

Lewis Thomas got a lot of things right. I am currently reading my grandfather’s copy of Thomas’s book The Youngest Science and I am struck – chapter after chapter – by his insight. Whatever role Thomas most closely identified with (according to the perfectly-accurate Wikipedia, he was a physician, poet, etymologist, essayist, administrator, educator, policy advisor, and researcher), he was a brilliant man. Plus, in his time, you were expected to simply figure certain things out on your own — things like, say, respecting a patient and genuinely caring for them. I don’t officially start school until next week, but I have heard rumors that there will be a fair bit of memorization. Fair enough, given how much medical science has already been discovered by people other than me…but still. I like what Thomas had to say:

“What I remember now, from this distance, is the influence of my classmates. We taught each other; we may have even set careers for each other without realizing at the time that so fundamental an educational process was even going on. I am not so troubled as I used to be by the need to reform the medical school curriculum. What worries me these days is that the curriculum, whatever its sequential arrangement, has become so crowded with lectures and seminars, with such masses of data to be learned, that the students may not be having enough time to instruct each other in what may lie ahead.”

This is loosely related to my thoughts on the recent online HIPAA training that entering medical students had to complete. (I still often spell HIPAA with two p’s instead of two a’s, since the only word like it is “hippo.” Anyhow, few people even know that it stands for Health Insurance Portability and Accountability Act.) In 1996, when it was first passed, the idea was to protect a patient’s access to insurance even if they lost their job or had a pre-existing condition. Today, HIPAA is an elephantine (or, you know, hippopotamutine?) set of laws governing documents such as electronic medical records and other confusing new things.

What I really want to talk about, though, is whether some of this law-making and law-memorizing is actually a selfish desire of doctors to protect themselves from malpractice suits. Do policies sometimes get in the way of efficiency and good care? I start to wonder if we have lost faith in people’s abilities to make good judgment calls. These are things I learned in HIPAA training:

“A doctor cannot give a diaper company the names of pregnant patients without an authorization.”

“A patient can see another patient’s name on a sign-in sheet if no medical information is on the sheet or may hear a patient’s name as it is called in the waiting room.”

“Speak in soft tones when discussing protected health information.”

“Use (but do not share) computer passwords.”

Really? REALLY?!?!? People who got into medical school couldn’t have figured those things out on their own? This worries me.

Of course, I recognize that some good things have come out of privacy protection laws. Perhaps doctors think twice before leaving a voicemail with test results (it could be a landline with a message machine the whole family listens to!). Perhaps they reconsider which assistants have access to what data. Perhaps they specifically ask patients who they want in the room when they talk about prognosis. Perhaps they double check fax numbers before sending records (or perhaps no one uses fax machines anymore?).

Then again, this should have been common sense, right? I have mixed feelings about all of this, and could easily point to more examples that highlight either the pros or cons of the heightened awareness. Mostly, though, I want us to think more about it. You all (the whopping three of you who read this blog) have good imaginations and analytical skills. Go at it.