Three guys.

Okay, this is a bit overdue but sometimes school and other things (ask me about renovating houses sometime) take over.  But, in honor of my 7am ethics breakfast/discussion/mandatory session this morning, my favorite story from The Immortal Cells of Henrietta Lacks by Rebecca Skloot (summarized in my own words, I wrote more about the book as a whole last week).

Today, if you want to perform an experiment involving people in any way at all, you have to get it past the IRB: your institution's Institutional Review Board.  You have to explain exactly how you'll be getting your participants consent: what exactly you'll be telling them (about any risks and benefits, especially) and how you'll be taking care of any problems that might arise.  You can still mislead participants if that's important to the study (e.g. Psychological studies in which you claim to be testing on thing, but are really checking another, or placebo controlled drug studies in which some participants get the study drug and some get a placebo) but you have to justify exactly why its important to do so, and that the patients won't come to any harm (or in the case of placebo studies, that the new drug has an unknown effect such that the placebo patients aren't missing out on any proven benefits).  This was not always standard.

In the early 60's one researcher was interested in using the HeLa cells to see what would happen if patients - both cancer patients, healthy individuals, and those with other diseases - were injected with the cancer cells.  He ran a number of these experiments on prisoners and patients in various hospitals, never telling the injectees exactly what he was putting in their arms.  Until he decided to work with a Jewish hospital in Brooklyn.  The researcher formed an agreement with the hospital director, who instructed his doctors to inject their patients without telling them that the injections contained cancer cells.  This would only unnecessarily upset them, the researcher and the director believed.  Three young Jewish doctors thought differently.  They refused to give the injections, arguing that performing experiments without full giving the participants all the information was unethical.  The director ignored them and had residents do the injections anyway (and can we talk about that particular delegation? but not today).  So the doctors resigned, wrote a letter explaining exactly why and mailed copies not just to the hospital, but to the press.  This got people's attention, and, at least according to Ms. Skloot, initiated a spiral of lawsuits that ultimately lead to the rules regarding patient consent in research we have today.

But here's the part I think is crazy:  it was just three guys.  Three guys in a backroom of a hospital somewhere deciding that this wasn't right.  Three guys who played their cards smartly, and got the right people to pay attention.  But still - without those three guys who knows when the NIH would have gotten around to creating laws.  I'd never much thought about the participant consent rules; they just seem like the right thing to do.  I guess if pressed I might have assumed it was a movement, like animal rights.  Or maybe in response to something like the famous Tuskeegee Syphillis study.  Ironically, what probably pushed these three doctors to action was the same horrific thing that altered the face of much of American science: the holocaust.  That hospital - Jewish, remember?  Those three doctors - also Jewish.  In 1963 one of the only ethical guides for doctors performing experiments was the Nuremburg Code, established by the Nuremburg tribunal in response to the horrors of Nazi human experimentation.  But it was just guidelines, and most doctors didn't know about it or thought of it as only for those who needed it - like Nazis and dictators.  But those three Jewish doctors knew about it, knew why it existed, and decided that this experiment wasn't okay and needed to be stopped.  By them.  So yeah, if you ever get too bogged down in the bowels of a system doing things in a way you don't like, remember:  just three guys.

Books!

So I have nothing inspired to say about med school this week - possibly because I've been on break for two weeks now.  Anyway, instead I bring you a couple of books that I've read in the past year that may or may not be tangentially related to medicine:

Why We Make Mistakes by Joseph T. Hallinan
Not specifically focused on medicine, but important nonetheless for a profession in which mistakes are made and carry nasty consequences.  An interesting exploration of human psychology and how it naturally leads us to screw up sometimes.  The author pulls from a lot of good research to cover this, and provides a couple of really valuable examples of how to avoid some of the common fallacies by building in safe guards like airline pilots do now, for example.

The Immortal Cells of Henrietta Lacks by Rebecca Skloot
So I actually had to read this for an ethics breakfast coming up, but it was really interesting.  For those not biomedically inclined, HeLa is a line of human cells that has been growing indefinitely since the 1950's and has been used in nearly every form of biomedical research, particularly cancer research, since that time.  It's extremely unusual for human cells to grow indefinitely - most die after a set number of cell divisions, but these are cancer cells.  Of course, when they were first grown it was without the knowledge or consent of their owner who was dying of cervical cancer.  And she happened to be a poor black woman.  This is her story, and the story of her family as well as of those cells.  It's a really interesting readable book - shocking to me in a lot of ways.  I have a hard time sometimes remembering how young Medicine in its current scientific incarnation really is, and just how much bioethics have changed in even the last few decades.  I personally would have liked  to know more about the bioethics side of the story, while Ms. Skloot focuses more on the human interest - her relationship with the Lacks family.  But from what she writes of that family's history, they deserve to have that story told.  I hope to focus more on one of my favorite bioethics tidbits from this book later, so come back and check that out.

How Doctors Think by Jerome Groopman, MD
So true confessions: I haven't actually finished reading this yet.  But it was one of the first books recommended to me by my medical school adviser, and the half of it I have read is a really interesting cautionary tale in misdiagnosis.  Somewhat similarly to the first book above, this focuses on how doctors are trained (or not really trained, but pick up by osmosis from their elders) to diagnose patients, and how that system can leave people falling through the cracks.  I was inordinately pleased with myself to guess right on the first patient story in the book - but then I have an unusually high awareness of dietary intolerance and allergens as problems (you all know who you are, and my future patients thank you, or not when they have to give up diary and gluten to see if that's the problem).  In any case its a very readable account of problems specifically in medical thinking that I promise I'll finish as soon as I can find my copy . . .

Stiff: The Curious Lives of Human Cadavers by Mary Roach
Of course the author begins by discussing the sordid history of anatomy.  Early anatomists' usage of human remains was a far cry from what we have today, in which donors at least choose to leave their bodies to science.  But there's a lot more in here than that.  Did you know, for example, that before we can make crash test dummies someone has to do experiments on cadavers to discover exactly what force damages human tissue?  Otherwise we won't know how to interpret our crash test dummy results.  Also, one of the big problems with automotive safety for children is that no such data exist for children - because who donates their child's body to science?  Also included are fun tidbits like the history of cremation and human transplants and the up and coming industry of composting human remains (yes, I would totally do that.  But I'm not sure those who survive me would feel comfortable working in the garden afterwards).  Not recommended for the weak of stomach, but if you like dark humor and weird facts this is a great book.

The body electric

***Short one for the holidays!  Also full of oversimplified neurophysiology, not designed to be used as an actual source for teaching or research or anything.  I'm just a med student, not a teacher***

So, like most med students, I hated physics.  Sorry physics professors, that’s just the way it is: we all take your classes because we have to, forget it all, cram some of it back in for the MCAT, forget it all again.  No wonder we get really cranky when Neuroscience time comes.  For the not medically or biologically inclined out there: your nervous system is all about electricity.  Everything you know about the world around you, all your memories, feelings, sight, sound, touch, and taste – it all at some point in your body gets boiled down to an electrical current running through you.  I don’t say this to denigrate the breadth and depth of the human experience – I say it because it amazes me.  It’s a miracle – a full scale major marvel of the world that we are able to experience everything the way we do.  

It’s the holiday season and one of my favorite things to do is to listen to Christmas music – full rich brass quartets and eight part church choirs rendering the classis (with descents and harmony, of course).  To hear this music the sound waves have to travel from the speakers through the air, through my ear, eardrum, bones of the ear to a tiny snail shell organ – the cochlea.  Inside this is a membrane so perfectly tuned that when the vibrations hit this fluid-filled canal it causes vibration in a small area – an area that differs depending on the pitch.  So the soprano descent causes vibration in a different place than the tuba.  That vibration disturbs some cells, actually pulls open channels in their cell membranes to allow ions to flow in, converting music to a tiny electric current.  And no matter which cells, no matter how loud the sounds, the size of the current (amplitude for the nerds out there) never changes.  All the richness of sound, the variations of timber, pitch, temp, and volume are coded by which little cells light up and how often they light up.  Their little electrical signals travel to the brain stem, to be organized, categorized, sorted and perceived.  Incredibly, they pass through multiple nerves carefully placed just so for any point in space two cells will light up at the same time (one from each ear) and your brain knows what it means when they do – this is how you can find that band playing in the shopping mall.  Even more incredibly, when we hear even the simplest of musical sounds – a lone pianist for example – there’re are actually a whole group of tones.  When I play a note on a piano it sounds different from the same not played on a harp.   Again, we have to deal with physics, but this is because each instrument actually produces a specific set of extra pitches with each tone played – the harmonics.  This is how we learn to recognize different types of sound.   But somehow we know which pitches are the central ones and which are just harmonics.  Somehow the nerves all line up and we know where the sounds is coming from, somehow the pitches trigger the right piece of the membrane and connect to the right cells which our brain knows to perceive as music.  The fact that this works all day, every day is incredible to me. 

What to say in the anatomy lab

So yesterday we had a return visit from one of my most and least favorite of instructors.  Yes, he really is both.  On the one hand, he is plainspoken in a classroom that is often full of new and baffling terminology.  He is extremely interactive in his teaching, and after hours on end of PowerPoint lectures I really to appreciate that.  He always seems to understand exactly what we know and don’t know (this is an obnoxiously big problem in my classes so far, more on that another day).  However.  He tends to air his biases loud and clear, and often words things in ways that mange to be simultaneously offensive, human, and funny.    

This gets to the heart of one of the most difficult issues I’ve had with medical school so far: how do we maintain appropriate respect, teach professional behavior, and nurture compassion without stifling the human beings that we already are in a haze of serious tones and somber thoughtfulness?   An excellent example of this is the dissection lab.  It is extremely important to be respectful of our donors (the people whose bodies we are dissecting), and I never at any point in this post want there to be any confusion about that.  But the process of lab itself is very stressful for a hundred different reasons: being bluntly faced with a dead body, surviving your first few months in medical school, breathing all the preservative fumes.  And dissecting is not easy.  Sooner or later you look up at the clock and realize that for the past two hours your entire world has been narrowed to a few square inches of tissue in which you’re trying to sort out what’s important and what’s not and what you have in your hands mostly just looks like a mess.  My thumb was slightly numb and tingly for a week after I spent four hours doing the same motion with the same dissection tool.  In this situation you need some humor, some lighter conversation.  Whether it’s gossiping about your team-mates love lives or trash talking each other’s home teams, we can’t spend every second of our time in the lab being consciously respectful and survive. 

That doesn’t mean that anything goes, there are always lines.  But where exactly should we put them? What’s offensive and what’s not varies: person to person, place to place, day to day and throughout time.  I’m sure that if we polled enough people, we could find someone who thinks sports trash talk is too much, much less talking about sex lives over a dissecting table.  But more important is that these issues aren’t limited to gross human dissection.  In the lecture hall there are no patients, no bodies to remind us of the consequences of our speech.  Combine this with an odd tendency medical school instructors have to try and treat students as future colleagues (and sometimes, I think, a desperation to get a response from the sleepy hall) and we get these gems (paraphrased, of course):

“In pediatrics we have funny looking kids, he’s [a hypothetical patient in a photograph] a funny looking adult”

“This [part of the physical shoulder exam] is really fun, because they jump – because it feels really weird, you’re dislocating their shoulder.”

Both of these were very awkward moments for me.  On the one hand I definitely thought both of those things.  And I believe it’s important to take time to acknowledge such reactions, to recognize that we’re its natural to think and feel certain responses – appropriate or not.  This can help us sift through all the crazy things we do think and feel and help us separate what’s okay and what’s not.  On the other hand when there are instructors involved we should be more careful.  Can an instructor talking about irreverent and inappropriate responses help to facilitate important conversations about mental health, emotional responses and professional behavior? Yes.  Should an instructor be modeling potentially inappropriate responses without taking the time to reflect on and explore them? I don’t think so.  Because the bigger point is that these are just things I personally noticed.   What did someone else, someone with a different perspective, notice and think about that I didn’t, that no one pointed out to me or brought to my attention?  What did I accidentally learn?

Transporting Skulls

Context is everything.  While I’ve done some strange things in medical school, I usually do them in the land of the utterly bizarre: the gross anatomy lab.  No matter how taken aback you might be for an instant, in that room you have only to look around as you dig through the layers of the human body to remember that everyone there understands. 

Not so with transporting skulls.  I recently had the opportunity to take a human skull home from school to study for our anatomy exam.  Have you ever had the chance to look - I mean really look - at a human skull?  They’re infinitely more complex than I had hitherto imagined.  I recall a lot of talk in undergraduate anthropology classes about the foramen magnum (Latin for big hole) and its position leaving us telltale clues about the development of bipedalism.  Little did I know that this is “the big hole” because there are approximately a zillion small ones.  Yes, a zillion.  Most of them have specific names, too, so in an effort to help us learn all the ins and outs of these sneaky passageways each pair of students was assigned our very own skull. 

So it is that I found myself one day last week boarding a city bus line with a very peculiar box.  The box is gray plastic with egg-carton foam lining the inside to protect the bones.  It’s kept closed tightly with a giant rubber band – like the kind for newspapers or broccoli, but bigger.  On either side it sports a white label marked: “Human.”  This is, I assume, so that the skulls of all types can be kept in an orderly fashion when not being used.  The box does not fit in my tote bag, where I was planning to keep it hidden from the other passengers.  It goes in, but the top doesn’t close.  This leaves the label, “Human,” clear for all to read.  I would prefer that wasn’t the case.  Even though I’m doing nothing wrong I have a guilty sensation.  I expect to be pulled into questioning by the transit police for transporting human remains.  I try to think of how I will prove I’m a medical student when this happens.  My student ID doesn’t specify my program and it’s not like I carry proof of registration with me.  I have an anatomy syllabus and a copy of Grant’s Dissector - a manual on how to dissect a human cadaver - in my bag.  Maybe those will be enough?   I tuck my scarf over the box, hiding the box from view. 

As I stagger to the back of the bus, I set the bag down reverently, gently.  I recall thinking that anyone observing must think there was a computer inside – because really what else would the modern commuter be carrying that’s so fragile and valuable?  I, of course, know the truth.  I’m carrying so much more than a computer.  I keep my hand on top of the bag trying to protect it from falling sideways as the bus turns and stops.  I still envision someone watching me.  Deciding to search my bag that so clearly contains something of value, something possibly dangerous.  In the end of course, nothing happens.  Just as no one ever cares what I have in my bag, no one cares today.  No one pulls aside my scarf to find the “Human” label on the side.

In the end this is just one of the moments of medical education when you stop and think: how strange were the things I did today?  Not only did I have the opportunity to cradle in my hands the place that once held this person’s brain - the seat of all that they were - but I put it in a gray plastic box and hid it in a tote bag to ride the bus.