Medical School: the cast

MED STUDENT

Generally considered a semi-sentient creature ranking just below newts and precocious fungi on the evolutionary tree, the medical student is able to process crude emotions and to withdraw from painful stimuli, but has rarely been observed performing higher-level cognitive functions.  Masochistic at best, and likely suffering from pathological psychosis, the med student chooses to undergo four years of studying 100+ hours per week while suffering routine ridicule from clinical instructors who treat him or her with approximately the same level of respect as one treats the sock lint that accumulates at the tips of one’s shoes.  Med students are easily recognizable by their shuffling, dejected gait; by the patronizingly short, white coats they wear; and by the ease with which they create awkward situations, such as turning red-faced and stuttering during the clinical breast exam or gleefully offering to manually disimpact a 90-year-old constipated elderly man.  Being unlicensed, the med student cannot provide any substantive assistance to the medical team but does serve as a convenient scapegoat for any failings of the US medical system–whether medication errors, missing documentation, rising healthcare costs, the collapse of Medicare, or unpalatable cafeteria food.  In a process that still baffles leading scientists and that should terrify the general public, the med student on the July 1st following his or her graduation from medical school ceases to be a lowly bottom feeder and metamorphoses into a resident physician who is expected to knowledgeably manage patients.


RESIDENT

The resident.  A med student in heart; a doctor in theory; a peon in reality.  Residents are the curious hybrids of the clinical world.  They have graduated from medical school and, having earned a medical degree, enjoy the esteemed title of “Doctor,” without any of the privileges: they cannot yet practice medicine independently, they don’t have vacation homes in Monaco, and they don’t drive vintage German automobiles.  Instead, they labor at the hospital under the auspices of attending physicians (see below) in a sort of medieval apprenticeship called “residency,” in which they obtain further medical training in a specific specialty such as emergency medicine or dermatology or orthopedics.  The length of this purgatorial residency varies from three years for primary care fields such as pediatrics to seven years for surgical disciplines such as neurosurgery.  The cushy schedule during residency involves a mere 80-100 hours of work per week.  The resident typically arrives at the hospital at the hearty hour of 3 or 4 AM, visits all of the patients on his or her attending’s list, and then writes notes and places orders for each patient–knowing that the well-rested attending will arrive after a morning tennis match around 11 AM and will berate the resident’s medical decisions while issuing directives that exactly match the resident’s original orders.  The resident then remains at the hospital until 8 or 9 PM to complete the day’s activities and to polish the attending’s golf clubs for tomorrow’s early morning tee time.  Residents are easily spotted as the sleep-deprived zombies in wrinkled scrubs and dingy white lab coats running frenetically around the hospital and answering a constant stream of ringing pagers strapped to their waists.  Raking in an average gross salary of ~$50000, they enjoy a competitive hourly wage of just over $10/hr, an ample return on their investment of 8+ years of higher education and only slightly less than they could make stocking shelves at the local department store or selling their nonvital organs on Craigslist.

 


ATTENDING

The word “attending” operates in everyday speech largely as a participle or gerund (e.g., “Attending church was a Sunday morning tradition…”), but in medicine, it serves as a noun for the doctor in charge of the medical team caring for a patient.  It translates roughly as “Boss Man,” “Divine Being,” or “Your Majesty.”  Technically, the word is only the first half of the phrase “attending physician,” but the full title is rarely necessary; the mere utterance of “attending” generates immediate genuflection–if not prostration–on the parts of all sentient beings in the vicinity.  Having usually studied alongside, and perhaps even tutored, lesser healers such as Hippocrates and Jesus, the attending possesses unassailable authority.  He or she dictates the diagnosis and therapy for each patient under the team’s care and makes certain to criticize, refute, and ridicule any and all aspects of the team’s clinical decision-making.  It is customary for God to seek the attending’s permission prior to intervening in the outcome of any given patient.  For mortal humans, receipt of no fewer than twenty-six Nobel prizes is required before one may speak directly to an attending.  Residents and medical students must not meet the attending’s gaze, and students in particular must take caution not to step within the attending’s shadow, lest they risk immediate corporeal combustion for transgressing the sanctified boundaries of Holiness.  Attendings earn prodigious salaries, take solemn oaths to drive only Porsche and Audi vehicles, and live in resplendent luxury while their resident underlings work 12x harder than they do but can scarcely afford the crumbs of the imported French brioche that the attending has for breakfast every morning.  Lastly, attendings do not die; they answer Death’s page, at their own leisure.

 

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Villanelle for Cody

What future lies in eyes of tarnished bronze?
Beneath cruel blows, young boy’s shy gaze burns bright.
Comprising hate or hope, keen glint there dawns.

His father’s fists the sole paternal bonds
Defined in child’s experiential sight.
What future lies in eyes of tarnished bronze?

The monster drinks and strikes and then absconds;
Precocious son bleeds, weeping through the night.
Comprising hate or hope, keen glint there dawns.

Alone, afraid, as precipice dark yawns,
The lad considers life: where to, what’s right,
What future lies in eyes of tarnished bronze?

Perpetuate his father’s sin, mere pawns
To Evil’s might? Or flee and seek Love’s height?
Comprising hate or hope, keen glint there dawns.

Outside the clinic, breeze across the lawns,
As he, my patient, lets his tears alight.
What future lies in eyes of tarnished bronze?
Comprising hate or hope, keen glint there dawns.

Why Do People Die?

The question seems straightforward: why do people die?  Answering it is surprisingly difficult.  One could take the biochemistry perspective and explore the molecular disturbances–such as DNA mutations–that cause individual cells to stop functioning.  Or, from the physiology perspective, one could describe the organ system perturbations–such as shock from blood loss–that cause a human being to cease having independent brain and/or heart activity.  Lastly, from a public health perspective, one could discuss the various causes of death as categorized by mechanism.  Each of these three perspectives offers a unique insight into what it means to be a human and what it means to die.  The public health vantage is the topic for today: what are the top causes of death around the world?  Let’s take a look.

If one considers broadly all ages, both sexes, and all countries around the world, the top five causes of death for the most recent year on record are the following (1):

TopMortality_world_2015

This list is short and simple and easy to understand, but digging into the details can prove illuminating.  Within the general category of “heart disease,” the largest player by far is ischemic heart disease–namely, heart attacks.  Among all cancers, the leading type is lung cancer, followed by liver cancer, colon cancer, and stomach cancer.  Stroke splits into two forms: hemorrhagic strokes, where a person bleeds into their brain, and ischemic strokes, where a clot abruptly cuts off blood flow to a portion of the brain.  Chronic respiratory disease consists primarily of chronic obstructive pulmonary disease, or COPD, a condition caused almost exclusively by smoking.  Unintentional injuries encompass many different mechanisms, but the most prevalent is motor vehicle crashes (1).  Note that none of the major global causes of death is infectious in nature; in public health terms, they are “noncommunicable” diseases, meaning they are not caused by infection with a microbial organism.  If one were to ask, then, in the most general sense possible, “What is the main reason people die around the world?,” the answer would be noncommunicable heart disease.

The data become more interesting when one begins to examine population subcategories.  For instance, comparing the poorest countries in the world versus the richest, the lists of top causes of death show some striking differences (1):

TopMortality_byincome

Among poorer populations, the noncommunicable diseases seen globally play a smaller role–though, notably, they still feature as prominent causes of death.  In the place of these chronic conditions, we see infectious diseases such as pneumonia and diarrhea.  For citizens of the USA or Western Europe, it’s hard to imagine someone dying of diarrhea; but the fact remains, it ranks as the fifth-leading cause of death in the world’s poorest regions.  In contrast, among the world’s wealthiest populations, as in the overall global list, infectious diseases do not appear anywhere in the top five causes of death, and heart disease and cancer remain the two biggest killers.  The category of neurological disease includes chronic degenerative disorders such as Alzheimer dementia and Parkinson disease, neither of which features prominently in poorer settings.  Thus, stratifying the global population by even a single metric, economic status, begins to reveal much wider variation in disease burden than one might have expected based on the overall world data.

Next, we narrow our focus even more, to a single country.  In the United States, the pattern of disease mortality for all ages and both sexes appears similar to that of wealthy countries in general (2, 3):

TopMortality_USA_2015

Note, though, a few differences.  Neurological disorders fall just outside of the top 5 for the US, with Alzheimer dementia ranking in sixth place (2).  Heart disease remains in first position in the US, whereas it has fallen second to cancer among wealthy countries worldwide.  Despite the US having abundant cardiologists, cardiac catheterization labs, and even entire hospitals devoted to nothing but heart problems, heart disease still kills more Americans than does any other cause.  There are many potential explanations for this observation–to be explored in later blog postings!  The US has managed to push stroke to last place in its top 5, while unintentional injuries–mostly car crashes–figure third in the US list, much higher than they do among wealthy countries at large.  These differences between the US and other wealthy countries highlight that even within groups sharing similar demographics there exists variation in the array of diseases faced.

As a former high school teacher, I believe young people represent the most important subgroup within any population.  They literally represent the future of that country, and their health statuses and skill sets will determine the capabilities of the country in twenty years’ time.  Unapologetically, then, I tend to focus my clinical and public health endeavors on youth.  On that note, we turn now to the mortality burden among US young people.  In the US in 2014, the top causes of death for various young age groups were the following (3):

TopMortality_USAyouth_2014

Immediately, one notices that the causes of death for young people differ from the causes of death for the country’s population as a whole.  Other than pediatric cancers and rare birth defects, the mechanisms that kill youth in America are not chronic conditions like heart disease but are largely preventable, often behavior-related, traumatic etiologies.  Car crashes, suicides, homicides.  These are the things killing our kids; and we can adopt measures to prevent or at least to mitigate these traumatic forms of death.  We can engineer safer cars, pass automotive laws that ban texting-and-driving, design smart guns that prevent unauthorized access, improve inner-city cohesion to counteract gang violence, etc.  The young people in a population warrant special public health attention, not only because of their relative value to society but also because of the unique set of life-threats that afflict them.

One final, related note on youth.  We’ve explored the causes of death for young people in the US, but another question one could ask is: what is the actual risk of death?  For children, ages 5-9, the risk of death is almost zero!  Out of every 100000 kids in America aged 5-9 years, only 11.5 die every year–giving a risk of 0.012%.  This is truly incredible when one steps back and appreciates the significance; we as a society have virtually eliminated the risk of death for an entire portion of the population.  Pretty cool.  Unfortunately, the risk of death starts to climb once a child ages into the preteen and adolescent years (3).  As already noted, youth in these age ranges tend to die not from medical illness but from trauma, much of which is likely related to increased risk-taking behaviors.  This observation is tragic, but also encouraging because it means we can potentially affect the statistics.  If as mentioned earlier we apply engineering, policy, and/or socioeconomic interventions to reduce the mortality impacts of adolescents’ risk-taking tendencies, then perhaps we can lower the teen death rate towards that of younger children–thereby saving thousands of lives for future America.

As we’ve seen, the answer to “why do people die” can vary considerably depending on which population one examines.  Further, the preceding discussion has focused only on causes of death; but short of death, diseases can also cause tremendous harm through injury, which is a topic for future discussion.  For now, we’ve established the primary causes of death around the world and at home in the US, and we can now begin to look at those individual etiologies and at ways to combat them.

References

  1. Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva, World Health Organization; 2016.
  2. Xu JQ, et al. Mortality in the United States, 2015. NCHS data brief, no 267. Hyattsville, MD: National Center for Health Statistics. 2016.
  3. Heron M. Deaths: Leading causes for 2014. National Vital Statistics Reports; Vol 65 (5). Hyattsville, MD: National Center for Health Statistics. 2016.

Beginnings

As I begin to build this blog, I wonder what shape it will take, what content it will include, and what messages it will ultimately speak.  Essays on public health topics?  Anecdotes from clinical encounters?  Poetry?  Travelogue?  Daily journal entries?  Maybe all of these things.  I suppose I simply want a space in which to put into words the myriad thoughts swirling in my mind; a chance to make sense of the constant noise of society; a way to weave my own insubstantial thread in this giant yarn ball of our interconnected world.  If sharing in this journey helps you to navigate your own paths, then by all means, please feel free to join in and enjoy some healthy discourse.  Thanks for being here!