Very slow but it will kill you

A couple days ago I was on the GI service seeing a patient. The patient was a 62 year old man who presented with a chief complaint of blood in his stool. The patient has been relatively healthy and is on no medications at this time. He does not drink or smoke or use drugs he is married and has grandchildren. Currently he is retired but spent his working years as a successful executive. There is no family history of cancer. His father died of congestive heart failure and his mother died of heart disease. 

I had done a quick physical exam and history prior to preparing him for a colonoscopy which he had been referred to us to receive. He was happy and ready to get his colonoscopy over and he made some small talk and joked about having a camera put up his rear end. The anesthesiologist gave some medications to put the patient into conscious sedation and we began the procedure. About half way in the colon we came upon and enormous mass. Usually you look for lesions on the way back out of the colon, so you stick the camera in and make your way to the end of the colon casually looking for signs of disease and then you start the journey back out of the colon and look more carefully for disease. If you see a polyp you remove it. The mass we saw was much to big to remove so we took several biopsies to send to pathology so they could tell us what it was. We did not really need to send it to pathology as we both new it was cancer and not a good sign. This cancer had been growing for 10 + years most likely.

After the procedure the patient woke up and when he was with it, the doctor and I went in to talk with he and his wife. Prior to entering the room the doctor and I discussed the case. The doctor said "this guy is done, this cancer most likely has metastasized and is a stage 4 caner and the cure rates are dismal." The sad part is that colon cancer is a slow developing cancer and no one should die of it. You get a colonoscopy at 50 and then every 10 years if your 1st colonoscopy was normal. If a polyp is found it is removed before it turns to cancer and you have a repeat colonoscopy every 2 - 3 years and to look for more polyps or the beginnings of cancer and that is it. However if you do not get the colonoscopy and a polyp is there then over the course of several years the polyp turns into cancer and eventually spreads to the liver and by the time you finally go into the doctor because of blood in the stool or a blockage it is too late and you die. Of course before you die you go through a whole bunch of invasive treatments to try and stop the cancer which are usually not too successful.

We entered the room and the doctor said "we found a mass, but we do not know yet what it is, it could be a cancer but there is no need to worry yet as we do not really know for sure what it is. We took a biopsy and will know more once we get the results back." The patient turned to his wife and said "see honey, I told you it was nothing! I will be fine." The doctor and I gave him follow up instructions and left the room.

Ultimately the pathology came back as cancer which was no surprise and in the mean time the patient went in for an MRI of the abdomen and a mass was detected in the liver. Now he is scheduled for a liver biopsy to determine if the mass is in fact cancer. We are fairly certain that it is cancer which would mean this patient has a stage 4 colon cancer and the cure rates are 10 - 15% at 5 years which means most patients are dead within 5 years. I later asked the patient when he first noticed blood in his stool and he told me he noticed it 10 years ago but never told anyone or thought anything about it. 

So here is a patient that is most likely going to die and if he had gotten a biopsy at any time between 50 - 60 years of age it would have been found and removed before it became anything too serious but now at age 62 it has grown and spread and most likely can't be cured. Does the patient realize this? Probably not. He remains hopeful which is probably a good thing, if there is going to be any chance of a cure he is going to need as much hope as he can muster up. 

When you turn 50 get your colonoscopy!

GI Joe

GI = gastrointestinal. I am doing GI on Tuesdays and Fridays for the next 3 weeks. I had my first day of GI yesterday. What is a GI doctor? It is a doctor who did a residency in Internal medicine for 3 - 4 years and then did a fellowship in GI for 3 - 4 years following the internal medicine residency. The training takes 6 - 8 years after medical school. Once they are done with training they see patients referred to them for a variety of GI pathology like; peptic ulcer disease, GERD, colon cancers, liver and pancreas disease, stomach cancer and anything that affects the GI tract from the esophagus to the rectum. 

A large portion of their practice is doing colonoscopies. These are done to screen for cancer or other problems in the colon. They also do upper endoscopies, which is like a colonoscopy but you go down through the mouth and into the stomach. It is cool that they can do procedures. Insurance companies have always paid more for procedures. GI doctors tend to make a good living because of this.

Yesterday I got to help with a whole bunch of procedures. We did colonoscopies and endoscopies. We also had some clinic time where we basically saw patients and set them up for future procedures. It is now recommended that every person over 50 gets a colonoscopy. So far I really like GI because you get to do a bunch of different things which keeps it interesting. 

Ambulatory

I am now on Ambulatory Care. What is ambulatory care? This is basically treatment of ambulating patients = healthy patients. This is clinic setting medicine where the patients are generally healthy and coming in for follow up treatments of chronic disease states like diabetes, hypertension, etc. Also patients come in for physicals, general check ups, etc. 

Today was my first day of ambulatory and I really liked it. The doctor I am working with is an internist and is a great mentor type physician. He has been in solo practice for 20 + years and has a ton of experience. He is also an excellent teacher which makes for a good learning experience. He also sees a wide variety of patients. Today we saw a bunch of different pathology; penile cancer, diverticulitis, stomach tumor, lung cancer, debridement of an infected finger, stitches removal, hypertension follow up, diabetes management, arthritic knee injection are just a few of the cases I saw. None of the patients were in need of hospitalization but some of them may progress in their disease to the point needing hospitalization or even death.

I was able to see and manage many patients completely on my own. I just started seeing patients and working them up and making my recommendation. The doctor was impressed and said that he has never had medical students work independently in this manner. I did not really give him the opportunity to restrict my level of involvement because I arrived before him and just started seeing patients. Then when he arrived I presented the cases I had seen and told him my diagnoses and plan / treatment. He saw that I had made the correct diagnosis and treatment plan so he was confident in my abilities and let me continue on in this fashion the rest of the day. It was an excellent day.

Tomorrow I am scheduled to work with a different doctor in a different city. This doctor is a GI (gastrointestinal) specialist. I imagine most of the patients will suffer from GI disease like GERD, peptic ulcer disease, cancers of the stomach, small intestine, colon, etc. We will also do colonoscopies as well. This should be interesting and good experience. 

For the next 3 weeks I rotate between the internist and then the GI doctor and I should learn quite a bit. It is amazing to see how much I have learned this year. I was thinking back to my first rotations and how unsure I was and comparing it to now I feel fairly comfortable in most clinical scenarios. I still have a ton to learn but I think that will always be the case. I am sure next year at this time I will look back and again appreciate the growth and learning that has occurred. 

You have MS.......NOT

What a devastating diagnosis. A chronic debilitating disease that no one wants to get. Before I knew much about medicine and diseases in general I thought that MS was a straight forward diagnosis like AIDS or Strep throat. The patient goes to their physician with certain symptoms and the doctor does a test and if it comes back positive, well the the patient has MS. This however is completely wrong! 

20 years ago there was a problem with under diagnosing MS. Many physicians would feel that the symptoms were psychologic in nature and they would reassure the patient and send them home without a diagnosis of MS. In those days many MS cases were missed only to be found later when the disease progressed. MRI and a spinal fluid tests have made the diagnosis of MS more definitive in today's world but are not a sure thing like a pregnancy test would be. You are either pregnant or not pregnant and the test will tell you one way or the other. It is not so easy with MS.

Currently the pendulum has swung the other way and MS is being way over diagnosed. Recent studies have shown that about 30 - 40% of patients who have been diagnosed with MS, in fact do not have MS at all. Why is this? Isn't are diagnostic medicine better than this? Here is the problem. In order to diagnose MS the physician looks at several factors. MS is disseminated in both time and space, which means a patient will have more than one episode spaced apart by a given amount of time and the imaging and other studies will become worse at a future point in time. The patient has to have 2 or more attacks or episodes of MS symptoms and 2 or more objective clinical lesions. There is a "MS" pathology that MRI can pick up in the brain and this characteristic MRI is usually required to make the diagnosis, however a patient can have a completely normal MRI and still have MS or a patient can have the characteristic MRI findings for MS and not have MS. There is also a cerebral spinal fluid (CSF) test that can help diagnose MS. A patient with MS will have a characteristic marker found in their CSF upon spinal tap, however like the MRI a patient can have these markers found in their CSF and not have MS or a patient can have MS and not have the CSF markers.

As you can see MS is a difficult diagnosis and some physicians are too quick to make the diagnosis according to recent data. In general for a patient to be diagnosed with MS they need the following; 2 or more attacks separated by time and space. There will be an initial attack and then a relapse. The patient will also have positive MRI findings and positive CSF findings. How are so many cases over diagnosed? The problem is that many different things can cause a MS like MRI and many things can cause a MS like CSF and when physicians rely to heavily on either of these findings they tend to over diagnose. 

A patient comes in with some strange neurologic symptoms like numbness but not specific to MS and the physician orders an MRI. The MRI comes back consistent with MS and the doctor says we have a diagnosis, it is MS and he tells the patient they have MS. The patient is devastated and tells their family and joins a MS support group. In reality this patient does not have MS. What does this patient have? Most of the studies show that in 80% of the cases of misdiagnosed MS where the patient does not actually have MS the underlying pathology is psychologic in nature and the 2nd most common causes are vascular in nature. How would a physician avoid making a premature diagnosis of MS. In the above case the physician would realize that a general complaint of numbness is not specific enough to qualify as a MS attack and there was only 1 episode as described by the patient. There usually needs to be at least 2 episodes. The doctor needs to look for MS specific attacks which have fairly distinct characteristics and relapsing / improving pattern. Then when a MRI and or a CSF have characteristic findings of MS the patient must also match the diagnosis of MS clinically. If you have a patient who does not have the clinical signs and symptoms but does have the CSF and MRI findings of MS then they do not have MS. 

If the doctor believes he or she is catching MS early, in that a 2nd attack has not yet occurred then they should hold off on an official diagnosis of MS until a 2nd attack has occurred which if it is MS the attack usually happens within 2 years and often within months. This over diagnosis of MS is just starting to become apparent. I think until recently physicians did not realize that the "specific" MRI and CSF findings of MS are only specific for MS when the patient also has the matching specific clinical signs of MS. Further more these clinical signs of MS need to be specific and not vague. Clinically the patient will have characteristic complaints of visual problems and electric like zaps they feel shooting through their body at times. They will have a specific attack that they recover from and then later will experience another similar attack. Again these attacks are not vague in nature. If the patient is unsure that they had an attack of some sort this should be a red flag they they most likely did not have an attack.

If you meet 10 people who have been diagnosed with MS as many as 4 will not actually have MS but have been improperly diagnosed with MS. These misdiagnosed patients will not progress / decline like a true MS patient will. Often they may claim they experienced some sort of miraculous healing phenomenon when in reality they never had MS. The lesson here is that doctors need to be cautious and thorough before pulling the trigger on the diagnosis of MS and patients who have been diagnosed with MS need to make sure they actually match all the criteria and not just bits and pieces of the criteria.

Unfortunately medicine is riddled with disease states that are difficult to diagnose and thus have a large percentage of misdiagnosed cases. Just to name a few: ADD / ADHD, Bipolar, Autism, Lupus, and many others. Fortunately a large majority of diseases are more cut and dry like AIDS, TB, many cancers, etc.

The return of the infant

One of the things I have noticed about about life on all of my rotations is that we come into this world as infants and ultimately we leave as infants. The only difference is that our second time as an infant we smell worse and we are not all that cute or adorable. It can be very frightening examining these patients with serious neurological illnesses. You realize that they are not who they once were. Life has been sucked out of them and they remain like a shell that no one recognizes. I think that it is more painful for their loved ones to watch than it is for the actual patient. 

As the brain breaks down in diseases like Alzheimer's, severe strokes, and other forms of dementia loved ones watch as a little more of the patients personality is lost. This continues until the patient is no longer themselves. It is sad to watch and to see. It has to be frustrating to see a person who has been a very loving and gentle individual slowly become the exact opposite and even violent. The family members can't understand why this is happening and it changes the way they feel about the person. It is difficult for people to separate the man from the disease. Imagine if your best friend hit you. You would not stand for it, but imagine if your best friend had a debilitating illness that stripped him of his personality and then in the throes of the illness strikes out at you. These are the lasting memories that the loved ones are stuck with after the patient dies. This can be a long process taking many years to play out. Often the family needs more attention than the patient. It is called caregiver stress.

I have had several patients with these debilitating diseases and it is frightening. You can have a life time of experiences and knowledge sucked away from you in a few short months to years and then be forced to carry on as a shadow of who you used to be.