The Disease of Sweet Urine

Here’s a slightly odd thing about me: I love diabetes.  I do not, of course, mean that I would enjoy experiencing the disease, or that I wouldn’t embrace a cure if an easily administered one appeared tomorrow.  But I have a strange fascination with it – whatever the type, however blameless or self-inflicted.  Both my grandfathers had diabetes.  One, diagnosed with type I at the stunning age of 35 by his eye doctor, used to fascinate me as a child.  The pineapple orange juice he always kept in his huge car, which he once shared when he came to pick us up at the airport; the daily injections, laboriously calculated.  My other grandfather I hardly knew.  Prey to heart disease when I was only 3, I know nothing about him that wasn’t told me by my father or his family.  But in the double genetics I’ve always felt there was something about this disease that was making itself heard.  Ensuring it had my special attention.

Partly there’s a fascinating history to diabetes.  Specifically it should be called Diabetes Mellitus.  Diabetes by itself indicates a condition of increased urination.  Mellitus means sweet.  This is the disease of sweet urine: diagnosable in the days before lab tests when urine observation was a critical skill in the physician’s training.  Diabetes Mellitus has been with us for some time.  It used to be nearly a death sentence, state of the art treatment until 1920 was near starvation.  Survivors were walking skeletons, and the prognosis was still less than a year.  It wasn’t until a few graduate students injected diabetic dogs with insulin that there was any hope.  Under insulin therapy the walking skeletons put on weight.  They came back to life.  It has been called the first miracle drug.   

And yet even as recently as the 1960’s being diagnosed with diabetes was a dramatic reduction in your life expectancy.  Kidney failure, blindness, heart disease, and neuropathy all lurked just around the corner.  Not to mention laborious medical regimens and high rates of infections.  As recently as 1965 we didn’t understand WHY.  Why did this disease destroy some places in the body, but not others, why did some succumb and others live well beyond expectations?   Although I had read some of the history of insulin discovery, and learned a few key points from a close diabetic friend in college, I longed to understand the connection between too much sugar and these horrifying end results. 

I was somewhat disappointed.  While we were taught key findings in diabetic diseases, shown images of kidneys, retinas, and blood vessels; the pathways were never fully drawn out for us.  I remained unable to explain to myself why A leads to E.  So it was I found myself doing the unthinkable – reading an article recommended by a lecturer, which was not required and far too detailed to be covered on the exam.  The article is here, if anyone’s as fascinated as I am, but it gets somewhat technical and biochemical.  It was worth it though, because I think I understand now.  And by understanding, I can remember.  And if my bizarre need to understand one specific disease is worth anything, it will be that maybe one day I can help someone else understand.  Maybe a patient (because I’ll surely have diabetic patients, we all will).  And maybe it will help them manage things a little better, help motivate them just a little more to watch their sugar levels.  I know it would motivate me.  

On the 40th Anniversary of Roe V. Wade

Today marks 40 years since the highest court in the land ruled women who want to end their pregnancies can legally, safely do so.  Where we have come since then is a long, confusing, at times sad path.  Over at http://bostonreprojustice.blogspot.com/ a number of Boston area professionals and professional students have put together a day long reflection in honor of this anniversary.  I encourage everyone to check it out.  I'll be reading it all day today, and my contribution  as well as several of my classmates will show up at some point.

Thanks.

Nazi Eponyms and Medical Training

I came across this article today: Modern Medical Terms Are Still Named After Nazi Doctors

The author's analysis is excellent, but since this is something I've been thinking about for a long time, I wanted to draw out a couple of other points.  Specifically I think the struggle over eponymous terms highlights one of the most confusing things about medical training: how subject it can be to individual variation.

It's important to note that in medical school, all your courses are broken up and taught be experts.  At our institution, there are one or two individuals responsible for ordering and organizing each class, but they do not give all or even necessarily a majority of the lectures themselves.  Most learning content comes from pHD's and MD's (occasionally JD's and MPH's as well) who are specifically expert in the topic of the day.  This may mean I have 12 different lecturers in the course of a 15 lecture week.  We work more closely with younger faculty members, such as fellows, who lead smaller group discussions.

The point is, there is ample room for disunity.  While in one class the course director stood up and apologized for the phrase, used by a visiting lecturer, "breast-feeding Nazis;" in another we were introduced to the Clara cell without pause or caveat.  Until I read the article above I had no idea it connected with Nazi doctors.  It's hard to eradicate terminology when there is no continuity in the training of the next generation.

One disease in particular highlighted the challenges I see: granulomatosis with polyangiitis, formerly (and often currently) known as Wegener's.  The day we were supposed to have a lecture on that particular disease was the day of Hurricane Sandy.  So we were all instructed to stay home and instead watched last year's videos.  In that video the doctor giving the presentation went into some detail about the Nazi link to the name Wegener's and in fact showed us several papers he had co-written advocating the name change.  This year's lecture was scheduled to be given by a different doctor, whose slides showed no sign of discussing the controversy - although he did use the updated name, unlike some of the fellows who taught our discussion section.  Topping this off,  this disease is complex and influences multiple systems meaning we see it referred to again and again and again.  When we see the same disease presented repeatedly with no unity in the name, it's not hard to see why this terminology is still around.

Could this same phenomenon be at work when it comes to vast differences in outcomes across hospitals and regions?  When we may be taught by one person to describe consciousness in specific terminology, then by another to do it completely differently doesn't it impact quality of care?  My classmates and I will go our separate ways after graduation, scattering across the country to work with diverse institutions and instructors. Even as soon as next year we will all be working at different sites with different doctors teaching us their preferred methodology for each task we must do.  Medicine, for a discipline that claims its roots in science, is absurdly subject to its own history and to local cultural fluctuations.  This can make it a delightful and unique journey, or it can make it imprecise and fallible.  We must acknowledge its vagaries to ensure that we are not falling into the latter category.