Finding fulfilment in an unexpected place: smoking cessation

In residency, they say the days are long and the years are short. Buried beneath the hours and work, it can be hard to find joy in the work we do. The work of a resident isn’t always filled with life-saving moments and wind-blown hair. In fact, moments where we personify our Grey’s Anatomy or House counterparts are scarce or implausible. Babies are not delivered pristinely clean and patients rarely walk out of a hospital after having had CPR. For internal medicine residents, our work of taking patient histories, performing physical exams, analyzing data and pinpointing the right treatment is less glorious and more repetitive. Given what we actually do, it is not surprising that 76% of internal medicine residents have experienced burnout at some point.

However, what we do is still important. We treat chronic heart disease, obesity, diabetes, high blood pressure, low blood pressure, and many other things in between that Hollywood never shows because the effects are more subtle, especially in the clinic setting. It was in one of these moments that I unexpectedly fell upon the sense of fulfillment. I had been in clinic, typing a visit note – my attention fixed on the computer in front of me – when my patient had started to talk about his smoking. My patient had smoked for decades and would be nearly breathless every time he arrived in my clinic room after calling his name in the waiting room. Smoking was part of his biker, jean-clad persona. I never had the time to lay out a few minutes to discuss all of the aspects of his smoking given all of his other medical problems but in previous visits I at least had covered the first two “A” of the five “A’s” of smoking cessation counseling: asking about smoking and advising to stop if they do smoke. In fact, nearly 80% of smokers don’t receive any further counseling during the average office visit.2,3 A woefully high number that has been attributed to simply the lack of time doctors have.4 In one study, the minimum amount of time for smoking cessation was determined to be three minutes – less than the amount of time to microwave a bag of popcorn. But when you add up the time needed for all the other things doctors have to do in a clinic visit – 190 other tasks (yes, people did count this and published it) – it adds up! 5 One study looked at the amount of time it would take to just cover prevention – all the things you should be doing to prevent a disease or its complications down the road, like getting enough, wearing a seat belt, being checked for sexually transmitted diseases, having a mammogram, et cetera. For one physician’s clinic patients, that physician would have to spend no less than 4.4 hours of each and every day just on the sole task of health care prevention! 5 Clearly, physician time is constrained and we are forced to make decisions on which area of a patient’s health care we should focus on. It is not an ideal situation, but this is one of several hard realities in health system with limited resources.

At the least, I try to see my patients more often to cover all those other things. Every time I did see this particular patient, I felt compelled to tell him to stop smoking. In studies, barely any intervention has been shown to be better than nothing at all. 6 If you don’t have time to spend the minimum three minutes, at least telling your patients that it is one of the worst things they could do for their health and they should stop is better than waiving the white flag and letting them walk out. In my limited attempts to have my patient stop smoking, I somehow managed to pull this off and it felt great.

“Doc, I have to tell you something,” he said.

“What is that?” I replied, barely listening while my face was buried in the computer screen looking up notes of his cardiac history.

“I took your advice and quit smoking.”

My response was nothing short of a contained tonic-clonic seizure. It was surreal. “Really?” I stammered from my mouth while my mind thought differently, “You listened to me? I was solely responsible for you giving up your twenty year habit of smoking that probably has given you heart disease, COPD, erectile dysfunction, and who knows what else? I struggle with basic life tasks like avoiding ketchup on my shirt and I somehow convinced a real live person to give up smoking!” I looked around the room half-expecting to find it was a prank, half-hoping to find somebody recording this life-changing moment – life-changing for him and for me – but found none. It was a quiet victory that deserved a loud celebration. For this person’s health, I single handedly had altered the course of his future health by getting him to quit smoking. In a parallel universe, I had avoided my patient perhaps going down the road of having heat attacks, being hospitalized for breathlessness, or succumbing to an early death. For example, quitting smoking can add a whole decade to one’s life expectancy. By not inhaling cigarette smoke, patients avoid exposure to the 70+ known carcinogens and thus reduce their risk of cancer. After several years, risks of cancer and heart disease can approach those of non-smokers. After his casual announcement, I stopped my note browsing and gave him the congratulations he deserved. On the inside, I felt like I had received my own reward: fulfillment as a doctor.

Finding fulfillment in smoking cessation is not easy because quitting smoking is not easy. On average, it takes a patient 8 to 11 attempts before they successfully quit smoking. 7 The longer a person goes without a cigarette, the greater the chance of successful cessation.8 Although smoking is not as common as it used to be, nearly 1 in 5 Americans smoke and nearly 1 in 5 deaths are attributed to it. 9 Kicking the habit is worth it for the patient. As a result, physicians should participate in some form of counselling with every patient at every visit. 10 In time, patients will quit. Resounding victories are rare in medicine, but when they do happen, they are a reminder of our purpose as physicians. And despite not being shown on TV, moments like this certainly are a bright spot in my day.

References:

  1. Shanafelt, Tait D., et al. “Burnout and self-reported patient care in an internal medicine residency program.” Annals of internal medicine5 (2002): 358-367.
  2. Ferketich, Amy K., Yosef Khan, and Mary Ellen Wewers. “Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS).” Preventive medicine6 (2006): 472-476.
  3. Thorndike, Anne N., Susan Regan, and Nancy A. Rigotti. “The treatment of smoking by US physicians during ambulatory visits: 1994-2003.” American journal of public health10 (2007): 1878.
  4. Yarnall, Kimberly SH, et al. “Primary care: is there enough time for prevention?.” American journal of public health4 (2003): 635-641.
  5. Wetterneck, Tosha B., et al. “Development of a primary care physician task list to evaluate clinic visit workflow.” BMJ quality & safety1 (2012): 47-53.
  6. Stead, Lindsay F., Gillian Bergson, and Tim Lancaster. “Physician advice for smoking cessation.” The Cochrane Library (2008).
  7. Women and smoking: A report of the Surgeon General. [US Public Health Services], Department of Health and Human Services, 2001.
  8. Hughes, John R., Josue Keely, and Shelly Naud. “Shape of the relapse curve and long‐term abstinence among untreated smokers.” Addiction1 (2004): 29-38.
  9. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
  10. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
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Remembering Seamus Kennedy and my first, major medical mistake.

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Photo credit: https://www.flickr.com/photos/gracekifer/5042922854

I remember the first time I met Seamus Kennedy*. I was rushed, he was not, which is ironic, considering that he was a man facing death, and my only curse was to admit a patient five minutes before I was supposed to leave. Being on the inpatient hematology and oncology service at the private hospital, it wasn’t unusual for patients to come after working a half day or even a whole day, which, unfortunately, meant I often had many admits strolling in the final minutes of my own shift, necessitating me to stay additional fraction or multiples of an hour to complete their admission, depending on how fast or slow I worked.

Like I had done with all others admissions, I reviewed his chart and learned of Seamus’s advanced cancer. I learned how his CNS lymphoma had failed to respond to first-line chemotherapy, radiation, and second-line therapy. I walked briskly into his room, past an empty bed and the dividing curtain, to find Seamus being basked by the bright white of the overhead hospital lights as if to remind those around him of the inevitable. As I approached, Seamus’s bald head reflected the lights, his face hinted at a smile, even though his eyes were closed. I said hello, stated my name, and told him that I would be his doctor. I was automated, proceeding from one step to the next. But before I could, I was enveloped by the presence and personality of the person that was Seamus Kennedy. Seamus was a large person, but his personality was larger. For somebody who had months to live based on the last outpatient note – “will now refer to palliative care since we have no other options” – Seamus seemed to be as relaxed as somebody you would find in the lobby of the Ritz Carlton on South Beach, and just as happy. For every question I asked Seamus, he doubled back, and I patiently answered all of his queries. It became clear that Seamus didn’t come to just get palliative chemo, he was hell bent on living every moment of his life, just as he had done until the moment he was diagnosed with brain lymphoma. I lost track of time and even strayed far away from the usual script of asking about nausea, vomiting, and the other usual cancer questions. I asked him about his Irish heritage, whether he bore any relation to the Kennedy family, even a distant one, even a really distant one, and where his favorite parts in Ireland had been on his many return trips to the Emerald Isle. His responses were never short and not without his own set of questions for me; Seamus’ grandparents had immigrated to America in the late 19th century, he bore no relation to the Kennedys of American politics (not even a really distant one), and his favorite place had been Galway, a part of Ireland I did not have a time to visit during trip there only a few months before I started my internship.

Even though I had changed my tempo during our initial encounter, I regret that I had initially started the interaction so mechanistically. I had not expected to find a friend in that setting or that hour, but I did. I am glad that I was able to appreciate the beauty of the person that was Seamus, something that is rare as so many patients lose their personality to the disease process and we, as physicians, make little effort to uncover the person underneath. William Osler, one of the founding physicians of Johns Hopkins Hospital and perhaps of modern medicine itself, once said, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The reference to Osler is ironic as Osler established the 24/7 residency program, where interns were interred in the hospital and residents had no other residence. More than a century later, interns and residents are fortunately allowed to have homes and visit them, like myself.

Over the ensuing days, Seamus and I became fast friends. I would spend moments in my day with Seamus, visiting him to fill the void while his wife was at work at the corporate office for a company that made cable boxes for America. During my encounters, I came to learn how real his lymphoma was. In showing me pictures of himself, I saw how much weight he had gained after starting chronic corticosteroid therapy, on which he was now dependent. The corticosteroid – oral dexamethasone every 8 hours – was the difference between him telling me stories of Ireland’s Aran Islands and him drooling on himself, mumbling incoherently, half-asleep. The lymphoma created a lot of brain swelling and the dexamethasone slowed this process down. One morning, I saw the lymphoma beginning to efface the Seamus that I had come to know; I had come to find Seamus slurring his words and drooling. I didn’t know what was happening, but Seamus had mumbled that the nurses didn’t give him the dexamethasone the night before. I chased down the night nurse who thought she had given him the medication but in actuality didn’t because she had gotten confused with another patient. A medical mistake that paled in comparison to the gaffe to be committed later. Shortly after getting the medication, Seamus started to return to his usual self.

After a few days of chemotherapy, Seamus was done and it was time for him to go home. On the day of his discharge, our team rounded on him in the morning and said their goodbyes. His presence and now departure was palpable among the team. We had walked out of the room, and well out of earshot, our attending had begun talking about Seamus’ care and prognosis going forward. It was dismal. Months. At best. I took the moment to write down his discharge medications on the prescription pad that I kept in my pocket. As the attending stopped rounds to teach about therapies for CNS lymphoma, I wrote down all of his medications on small prescription pages the size of index cards, including his dexamethasone and an antimicrobial – Bactrim – to prevent a type of pneumonia that can occur in patients taking dexamethasone for long periods of time, as Seamus had been doing. After rounds, I put the prescriptions in the patient’s chart, just as I had been instructed, for the nurse to photocopy, document, and ultimately give to the patient.

A couple weeks after Seamus had been discharged, I was nearing the end of my rotation in the hematology and oncology service at the cancer hospital when I found out that Seamus was returning with same type of pneumonia that I had hoped he would never get. If he had been taking the antimicrobial I had prescribed for him, how did he get the pneumonia? There was no question that Seamus had the type of pneumonia I had dreaded: Pneumocystis jiroveci pneumonia. Seamus was short of breath, the oxygen saturation in his blood was low, his x-ray showed random patches and the CT was even worse. This type of pneumonia occurs typically in people with advanced immunosuppression, like patients with HIV or taking medications that can lower the immune system’s ability to fight infections, like dexamethasone. In an attempt to thwart the fungus from ever gaining a foothold in patients who may be susceptible, physicians give Bactrim (also known as TMP-SMX or trimethoprim-sulfamethoxazole). Seamus, struggling to breathe, told me he had never taken the Bactrim. In fact, he never saw the prescription that I had written. Being responsible for his prescriptions and his care, I felt that I had erred gravely. I felt like all of my training and my efforts were worthless.

Worse, Seamus had been feeling short of breath for more than a week and had been trying to get our attention. He and his wife had called the hematologist’s office several times to state their concern for Seamus’ worsening shortness of breath. The first time they could not get through and left a voicemail and nobody called back. The second time Seamus’ wife called and got through to a nurse who informed her that the doctor had been out and she couldn’t take a message for liability reasons and to try calling again later. The third time she called she was repeatedly put on hold and could never talk to a physician. The fourth time she called she was told that Seamus had a follow up appointment the following week with his hematologist and not to worry. When Seamus finally arrived in the hematologist’s office, Seamus could barely stand up before feeling like he was going to pass out. While walking, his oxygen saturation plummeted to the 70th percentiles, by comparison anyone less than 88% percent should be on continuous oxygen. Seamus was skirting the line of needing to be intubated and a breathing machine for life support. As if Seamus’s medical care had not experienced enough problems, Seamus came in minutes before shift change. My resident shot one look at the clock and, without giving it a second thought, told me to “handle it” and walked out.

As a new intern, handling a respiratory emergency was like tasking a monkey to land the space shuttle. She didn’t even come to see Seamus. When I first saw Seamus, he looked like a goldfish that had been plopped out of the fishbowl. My plan had been to give oxygen and he was already on it. I needed help. I knew that if I went straight to the day attending, I might be ridiculed for my lack of knowledge, be viewed as the intern that throws his resident under the bus, or experience retribution from my resident. I skirted the issue entirely, I paged the night attending, who happened to be a specialist in critical care. I told him the whole story in painful detail. Without judgement or complaint, he walked me through Seamus’ management like a dad holding his hands around a child learning how to ride a bike. Seamus did well overnight and slowly recovered over the ensuing days.

What didn’t improve was how I felt about the whole situation. Seamus recovered, but I shaved two, maybe three, weeks off his remaining few months left, precious weeks that could have been spent living his life at home. Adding the time he spent in the hospital, the time he felt sick before arriving, and the time he spent recuperating at home afterwards, the total amount of time likely could have been three weeks. And, I had no way to give him those three weeks back.

Nowadays, mistakes like this are entirely averted by the use of electronic medical records and electronic prescribing, where physicians can electronically send prescriptions to a patients pharmacy as easy as an email. In my attempt to understand why Seamus got all of his other medication prescriptions and not the fateful Bactrim, I reanalyzed all the surrounding events. I even went to medical records to look for the photocopies of the prescription. I even doubted that I had ever written the Bactrim in the first place, or if I had written it, it never made it into the chart. In the bewildering repository that is medical records, I was never able to find the photocopy of any of his prescriptions. Even now, I wonder if I actually wrote the prescription or thought I wrote the prescription. I had no proof to show that I wrote it and no way of obtaining it.

Worse, I didn’t know who was responsible and who was going to apologize. Being the closest member of the medical team to Seamus during his first admission, I felt responsible for the mistake and for the requisite apology. But for what was I apologizing? For not handing the prescription to him directly? For it being lost? For him being unable to get through to us when he was trying ask about his shortness of breath? My attending did not apologize, nor did the hospital, my resident, the nurses, or anybody else. In studies, only one third of physicians explicitly apologized in a way that acknowledged the error, most just detachedly express regret, as everyone else had done with Seamus1; “oh, you didn’t get the medication. That’s too bad.”

Despite medicine’s increasing commercialization, we are still the face of the care we provide. Beneath our white coats, beneath our degrees, we are still humans. We have made mistakes and will continue to make mistakes, but we also have the capacity to acknowledge the mistake and apologize. The apology is so important; 98% of patients surveyed “desired or expected the physician’s active acknowledgement of an error”2.

The words did not come easily. In the days after his re-admission, my heart grew so heavy that I felt like I could not enter his room. I was ashamed to see him, wearing the oxygen mask, gasping between words. The encounters were distinctly less often and less enjoyable. Being genuinely good people, Seamus and his wife never complained about the serial mishaps or noticed my withering spirit. The fact that they did not notice made it at all the more difficult to break the ice, to form an eloquent apology and explanation, and to actually voice the words with my own voice. It felt like I was bringing out an issue that had conveniently been swept under the rug. With each passing day, I felt the pressure to apologize.

My last day arrived on the rotation. It was a Sunday, and Seamus was still requiring oxygen to breathe, albeit much less than before. Even during the day, I delayed the inevitable. Finally, late in the afternoon, I walked into his room, much different than the very first time I walked into his room. I wasn’t walking in like a robot; I was walking in as a human, a very small human. Feeling the pressure that we as humans – humans who are entrusted with the care of other humans – owed an apology to Seamus, I apologized. For all of the mistakes, mistakes that were mine, could have been mine, and definitely were not mine. Fearing anger, yelling, disparagement, and tears – mine or theirs – I voiced everything and took responsibility. The Kennedy’s accepted my apology and understood my explanation. I gave them my personal cell phone number for emergencies. They thanked me for the apology and for providing Seamus with the care that I had given. There was no yelling. There was no blaming. There were almost no tears. Despite being delayed, the apology could not have been better. I hugged them both, and I left.

I never saw Seamus again. I knew that his time was limited. I had promised to follow up with them but I never did. The speed of intern year – new patients, new medications, new diagnoses – distracted me from the incident. Periodically, I would google the local newspaper obituaries for Seamus Kennedy’s name. Finally, one day, I found it. I was heartbroken. A part of me wanted to believe that Seamus would never die, that I would never find his obituary, but I did. Since that experience, I remember three cardinal rules that were once bestowed upon me by a surgical oncology fellow when I was a medical student, but had not realized their value until this incident. The rules are written to minimize the number of medical mistakes, even though it maximizes our own paranoia. The rules:

  1. Trust no one.
  2. Expect sabotage.
  3. Do it yourself

The rules are overly cynical but are necessary if we are to be proactive about medical mistakes. When I have medical students and interns of my own, I now impart these rules to them. Now that most prescriptions are now electronic, I rarely find myself telling people to hand prescriptions in person. I hope that others can learn from this mistake, even if the mistake was mine or not, and also learn the importance of the apology. And, of course, we can remember Seamus Kennedy for his personality, and not his lymphoma.

*Patient’s name has been changed to preserve anonymity and is completely unrelated to Seamus Kennedy, the musician. Other pieces of this story may have also been changed to preserve anonymity.

References:

  1. http://www.ncbi.nlm.nih.gov/pubmed/16908791
  2. http://www.ncbi.nlm.nih.gov/pubmed/8951299

How our idiosyncratic, and sometimes anally retentive, approach to mild hyperkalemia affects patient care. Or does not.

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(Kionex = Kayexalate = Sodium Polysterene Sulfonate)

Photo Courtesy of JYR

Once, when I was a night intern presenting to the day team an admission, I was questioned, then berated, regarding my management regarding hyperkalemia. Mild hyperkalemia. The specifics of the case I don’t remember. However, I remember running through the presentation:

Lung sounds were clear blah blah blah Patient was alert an oriented blah blah blah.

Labs: Sodium normal Potassium 5.5 mEq/L, for which we gave 15 grams of kayexalate…

 The patient didn’t have any reason for the hyperkalemia. None of the classic effects of a potassium sparing diuretic, renal failure, or the surreptitious – or not so surreptitious – use of an angiotensin converting enzyme inhibitor. The patient had plain, ol’ hyperkalemia. The red blood cells in the sample had not hemolyzed, or ruptured releasing all of their intracellular potassium stores and falsely elevating extracellular concentrations of potassium – more on this later. And, the patient’s heart had not ceased beating from a cataclysmic change in cardiac myocyte action potentials.

As I attempted to continue my presentation. I was stopped by the attending – the king of my medical audience, “What else did you do for the potassium?” I was puzzled.

I errr gave kayexalate…(Damn, I just said that.. There must be something I am missing. Did he want me to load this patient up with other medications… The potassium was only 5.5, only 0.5 mEq/L above the upper limit of normal. Only a 10% change from being normal!)

 Most people would say that clinically relevant, or moderate hyperkalemia, doesn’t start until 6.0 mEq/L or higher. Normal potassium being between 3.5 and 5.0 mEq/L plus minus a few. Life in the Fast Lane, a popular website for those within the emergency medicine circle and close-by, does not classify hyperkalemia until it is greater than 5.5 mEq/L – an upper limit that would have allowed me to pedal my way through my admission presentation without questioning and sooner to sleeping.1 Alas, my attending probably had neither visited the website nor cared to, I assume.

Management techniques vary from administering beta-2 agonists, like albuterol, to the combined administration of insulin with dextrose – all of which abscond potassium into the cells of the body and away from the all-important cell membrane of the heart, but only for a short period of time. After a couple hours, the potassium re-emerges from the body’s intracellular storehouses as the effects of albuterol and dextrose abate. The only way to truly remove potassium from the blood is to remove it from the body, either by peeing it out or pooping it out. Bodily excretion is facilitated renally by the water pill furosemide and gastrointestinally by the potassium binding resin kayexalate. In some emergent cases, potassium can be removed by dialysis.

The danger with moderate or severe (> 7.0 mEq/L) hyperkalemia is the genesis of fatal, cardiac arrhythmias, whose non-fatal progenitors can be seen on electrocardiograms by the creation and absence of peaks in places where there shouldn’t be any. As I learned in the ensuing seconds of my presentation, my transgression was in my failure to obtain an EKG. I never obtained the electrocardiographic tracing because of the reported lack of seeing anything with such mild elevations. Most medical students learn that the earliest changes can be seen with serum concentrations starting at 6.0 mEq/L, assuming the other electrolytes are in order. Regardless of the appropriateness, I had forever been molded to get an EKG for a serum potassium level 5.5 mEq/L.

Months later, I found myself dealing with mission creep when a different patient’s serum potassium level was 5.4 mEq/L. Do I get an EKG now? Reminiscing of Catch-22’s Captain Yossarian, I found myself wondering if 0.1 mEq/L made all the difference between when I would get an EKG on a patient or not. If 5.4 mEq/L was high enough, then what about 5.3 mEq/L? 5.2 mE/L? As the resident on the team this time, I had an intern that I could defer to management and override as I saw appropriate, as the attending had done to me earlier.

“I gave him 15 grams of kayexlate,” my intern said. 15 grams of kayexalate, or sodium polystyrene, was enough to lower his potassium to a theoretical level of 4.4-4.6 mEq/L based on nearly five decades of experience since its first use and in accordance with American Heart Association guidelines.2,3 For some fateful reason, I found myself looking at the actual lab report of the patient’s electrolytes and found the archetypal asterisk next to the potassium measurement. It had marked the sample as hemolyzed – the potassium level measured was higher than the patient’s true serum potassium level. The patient’s potassium level could have been normal, or even low, and giving a medication to lower serum potassium levels further could have been just as unfortunate as having too high a potassium. I felt knowledgeable educating my naïve intern about the subtle asterisks trailing lab reports. More importantly, I was relieved that I didn’t have to deal with the vexing question of whether to get an EKG for mild hyperkalemia.
Mid-way through residency, however, I could not escape the question. I found myself with another intern treating the same serum potassium level of 5.4 mEq/L on an entirely different patient. This time the patient’s measurement had not been hemolyzed. Feeling anally-retentive, I ordered an EKG and gave kayexalate. Probably both of which were unnecessary, but I had been pre-programmed by my previous experience to obtain EKGs in mild hyperkalemia. And, I could not make the same mistake twice.

As my intern was presenting our management, he met a cavalcade of criticisms for now over-testing and over-treating mild hyperkalemia. I jumped in, blurting

I just wanted to be sure that we didn’t…

My attending cut me off with the same fervor the previous attending months ago had for doing the exact opposite management for nearly the same situation. I felt like I was in the twilight zone. Or the hospital of Catch-22. I was the Captain Yossarian of medicine. The situation left me wondering if 5.4 mEq/L was all that different from 5.5 mEq/L? Or not? Our attending this time was content to have mild hyperkalemia and would have preferred us not to have given the kayexalate or ordered an EKG. True, kayexalate has the rare and unpleasant side effect of intestinal necrosis requiring emergent surgery, and an EKG can lead to more testing and intervention than otherwise would have been necessary.4 We as a medical team also had more pressing issues, like the persistence of a fever in the other patient across the hall. But probably the biggest reason to not intervene would be because mild hyperkalemia is called mild for a reason. The best course of action would be to repeat labs the next morning, or perhaps earlier if one was absolutely concerned that the serum potassium level was rising.

The differences in management within healthcare can be considered to be the so called “art of medicine.” However, to borrow another adage, beauty is in the eye of the beholder. To some, the varied and polar managements in the same setting might be called the “craziness of medicine.” This is repeated over and over in many other situations, like the physician’s preference for PSA testing in older men. For more permanent and serious issues, it is worthwhile to include the patient in the discussion and have them pick their management. In the age of ever-increasing patient awareness and involvement, some would argue that I should have presented the various treatment strategies with all of their associated risks, benefits, and alternatives and allowed the patient to make an informed decision for mild hyperkalemia. In effect, I would be consenting the patient for a minor electrolyte abnormality, but patient-centered decision making will always trump physician-centered decision as we, as a medical community, have made a conscientious effort to value patient autonomy. However, if we started doing this for mild hyperkalemia, where would it stop? Would we consent patients for the blood draw to check the electrolytes in the first place? A blood draw, or venipuncture, gone wrong can cause a hematoma, an abscess, thrombophlebitis, a blood infection, and worse when one patient’s blood is mislabeled as another and physicians then treat the wrong patient. The possibilities of the risks are endless. To consent for everything individually would bring healthcare to a halt. Hospitals have circumvented this by consenting patients for most “non-major” things with a general consent. Patients are consented for treatment upon admission with some variant of a “General Consent for Treatment” form that most of us usually don’t pay attention because it doesn’t explain the details of something like the treatment of mild hyperkalemia.

In the end, attending physicians will have their own personal preferences towards medical management. Their preference is a product of their learning and experience, which may have been as confusing and contradictory as their residents’. When following suit, we should understand their choices as best we can, even if they are at odds with what we have learned in the months or days prior. Someday, we will be attendings of our own and be making our own decisions. Some of us will even have our own interns and residents to guide. In the future, I will only observe a potassium of 5.4 mEq/L but likely intervene for a potassium of 5.5 mEq/L.

Citations:

  1. http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/
  2. http://onlinelibrary.wiley.com/doi/10.1002/jhm.834/abstract
  3. http://circ.ahajournals.org/content/112/24_suppl/IV-121.full
  4. http://www.ncbi.nlm.nih.gov/pubmed/21463839

How much physical activity do I need?

The question of how much physical activity is enough is one that will persist as long as there are physicians. The recommendations that I have heard from the professional organizations and pundits stewarding our health vary as much as the patients asking them. 30 minutes three times a week. 45 minutes daily. Exercise as often as you can. The permutations go on…

Perhaps it is of use to think of the purpose of exercise. Yes, exercise is a way to be healthier – however effluvious and variable the concept is for you. But the purpose of exercise is to recreate what humans – and our ancestors – have been doing millenia: moving! Since the advent of bipedal locomotion 4.4 million years ago1,2, our prehistoric brethren have been walking and, later, running. Some have argued that the development of our wanderlust is rooted in the necessity for being able to travel far and fast to capture prey while hunting3. Since the development of bipedalism precedes our ancestors ability to become effective hunters (at least 40,000 years ago, if not more), it is likely bipedalism evolved to expand the foraging range of early homonins. As our primate-like ancestors became more human, ambulation served other purposes, likes evading dangerous animals and perhaps intra-species foes. It is difficult to truly know the distance our ancestors were traveling since their remnants are fossilized bones and not pedometers. However, we can look at extant hunter-gatherer groups to draw inference.

The best studied hunter-gatherer group of the twentieth century may be the Ju/’hoansi (formerly the Dobe !Kung) of the Dobe area of the Kalahari desert. In the 1960s, the then young Richard Lee, now Professor Emeritus of the University of Toronto, undertook a series of field studies learning about the livelihoods of the Dobe Ju/’hoansi. He found that these people were walking a variable distance daily. The distance they traveled was based on the availability of food sources. After establishing a camp site, they would progressively exhaust their food in a circumferential pattern, initially traveling 5-9 miles4 and later reaching 10-15 miles in search of food – a distance that does not take into account other activities5. Some days they traveled less. Some more, especially when in the pursuit of prey6. Others have found described similar values7.

Into how much time does this translate? Well, that depends on your ability to traverse 5-9 miles daily. Time may not be as important as distance, which may be more representative of our absolute fitness. A recent study has shown that the average American takes 5117 steps, or the distance to cover 2.5 miles assuming there are 2000 steps in a mile – half the value of the minimum 5 miles the Dobe Ju/’hoansi were traversing on an easier day8. On harder days, the Dobe Ju/’hoansi were traveling 15 miles or more. Who is traveling 15 miles or more these days in America today? Using your Subaru or the subway does not count.

The World Health Organization (WHO) recommendation for adults between the ages of 18 and 64 is to get either 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week9. According to the WHO’s lengthy report on physical exercise, moderate intensity is 5-6 on a ten point scale of physical exertion that is solely determined by the one exercising. Vigorous ranks a 7 or 8 on our own personal scale. For the sake of simplicity, assume running an 8 minute mile was a moderate- or vigorous-intensity aerobic activity. All of my readers save for those that are ultra-marathoners, would agree with this. If an 8 minute mile is a vigorous activity for you, then you should be running 1.3 miles a day. If it is a moderate activity for you, then you should be running double. Yet, how does this compare to the Dobe Ju/’hoansi? Well, it may not. The original studies describe the Dobe Ju/’hoansi as walking and, at times, running when in the pursuit of prey or for other reasons. The studies do not describe what their individual ranking of their intensity level or the times spent at varying intensity levels. What the WHO and Dobe Ju/’hoansi do suggest is that if you aren’t walking ten miles regularly, then it would be of benefit to you exert yourself further via moderate- or vigorous-intensity aerobic exercise according to the WHO guidelines.

As living beings, we are self-interested in conserving energy. The advent of combustible engines, electricity, and other labor savor technologies allow us to exert ourselves less and expend less energy. As such, it is vital we continue to find time AND ways to move. We should be moving more. We may not have enough time or knee cartilage to traverse 15 miles every day, but we certainly are more static that our hunter-gatherer comparison, and likely our ancestors.

References:

1 Haile-Selassie, Yohannes. “Late Miocene hominids from the middle Awash, Ethiopia.” Nature 412.6843 (2001): 178-181.

2 Galik, Karol, et al. “External and internal morphology of the BAR 1002’00 Orrorin tugenensis femur.” Science 305.5689 (2004): 1450-1453.

3 Bramble, Dennis M., and Daniel E. Lieberman. “Endurance running and the evolution of Homo.” Nature 432.7015 (2004): 345-352.

4 Lee, Richard. The Dobe Ju/’hoansi. Cengage Learning, 2012.

5 Lee, Richard Barry, and Irven DeVore, eds. Man the hunter. Transaction Publishers, 1973.

6 DeVore, Irven, and Richard Borshay Lee, eds. Kalahari Hunter-gatherers: Studies of the! Kung San and Their Neighbors. Harvard University Press, 1976.

7 Eaton, S. Boyd, SB 3rd Eaton, and M. J. Konner. “Paleolithic nutrition revisited: a twelve-year retrospective on its nature and implications.” European journal of clinical nutrition 51.4 (1997): 207-216.

8 Bassett Jr, David R., et al. “Pedometer-measured physical activity and health behaviors in United States adults.” Medicine and science in sports and exercise 42.10 (2010): 1819.

9 http://www.who.int/dietphysicalactivity/factsheet_adults/en/

A New Year, A New Blog

Photo courtesy photos-public-domain.com

Photo courtesy photos-public-domain.com

With the New Year only a few days away, people all over America are putting pen to paper and partaking in the tradition to begin something a new – to make a New Year’s Resolution. For the patients in my continuity clinic, I hope they use the calendarial homage for change as an opportunity to really seize their health! Carpe sanitas! In my utopian vision at the Veteran’s Affairs outpatient clinic, I see my patients slimming to their ideal weight, living lives without boxes of rolled tobacco in their pockets, foregoing their gastronomic affair with the unhealthy, attending to their medication regimen, and becoming exercise enthusiasts! What an ideal! Yet, I know that if history is any indication of the future, people everywhere, including my patients, are cursed to return to their old habits and to depend on me to keep them from spiraling out of control. However, I have hope: the hope that most of my patients will be better off in 2015 than they were in 2014.

In parallel, I, like so many of my patients, have set my own New Year’s Resolution. Apart from the universal, pre-written resolutions of eating healthier and exercising more, I had one unique and important resolution: to start a blog – a seemingly trivial resolution. In today’s world, a blog could not be easier, but my personal restraints to this blog’s success are not trivial. Time, the enemia major of many resolutions, afflicted me and delayed the creation of the blog for six months. I, like my patients, must overcome these barriers. For all resolutions, their purpose is in something better. For this blog, it is to provide a haven for all things unsaid during daily rounds. It is an opportunity to remember the dying in their last moment, a forum for improvements in health care, a respite from the hum-drum of daily medicine, and likely many other topics of discussion.

I realize that many of my patients who embark on their flavor of a New Year’s resolution diet will have failed within the ensuing weeks. However, some will succeed, and I hope I do too. In thinking of my journey of this blog, from fleeting thought to contemplation to now reality, I think of the quote from the 13th century Francis of Assisi:

Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.