Category: Medicine

I’m trying to understand “morgellons syndrome”. Based on Morgellons Research Foundation reports, there are a lot of people out there who believe they have this so-called disease. But what is it? I decided to dig deeper on the research end of things. I went to the MRF website, and to MedLine, looking for something, anything, to help me find out more about this problem. I must report that the science doesn’t look good for the morgie boosters.

First, there has been little legitimate research on morgellons as such. The CDC is doing an epidemiologic study to determine what, if anything, may actually exist.

The medical consensus is that so-called morgellons is a variant of delusions of parasitosis. It may be, however no case definition exists, and no central registry exists. Each case is treated on its own (and probably should be).

Since morgellons resembles in every way but name delusions of parasitosis, it is on the morgellons advocates that the burden of proof falls. If they wish to invoke a new diagnosis, they must have a definition, a way of distinguishing morgellons from DOP, and a reasonable hypothesis to investigate. So far, none of these has happened.

The dermatology literature has treated this phenomenon is a very sensible way. It has been recommended that patients’ feelings and sensations be validated, but that they be told the truth—that there is no evidence of infectious or otherwise primary dermatologic disease. It is sometimes recommended that patients be told that they have a problem with the sensory apparatus in their skin and nervous system, and that medications that act on the nervous system be used. This approach is quite rational, and atypical antipsychotic medications have been used successfully.

This is in marked contrast to the bizarre approach taken by the morgies. Their “research foundation” has preconceived notions of what is happening—they have formed a conclusion rather than a hypothesis. This is fatal to science.

Read on….
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Continuing my series from WhiteCoat Underground, here is the latest influenza update.

While still widespread, numbers are finally starting to drop. I’m ready to drop myself. It’s been a terrible season—the worst I’ve ever seen. This is probably due, at least in part, to this year’s flu vaccine missing some unanticipated strains.

For those of you out there who don’t “believe in” flu shots, remember that vaccination isn’t a religion. The anti-vaccination forces are, however, rather cult-like. Here’s some info for you.

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Last updated 09 October 2008

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Is this thing on?

OK. I think it’s working.

Wow. I mean, wow. Someone seems to have accidentally dropped the keys to denialism blog on my desk, so now I’m in ur blogz, messing with ur words and stuff.

That’s really the only logical explanation. I mean, how else could I, a lowly Doctor of Medicine in a dreary Midwestern town, end up writing on Sb?

I guess I owe you an explanation…
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Has anyone noticed how my sciblings are really ornery at the moment?
We’ve got PZ bringing out the angry stick over Wilkins’ criticism of Dawkins. Physioprof is getting ready to pop Greg Laden in the nose over this thread (and I tend to agree it needs a rewrite).

And then Shelley broke my heart by posting
this video mocking anesthesiologists that I posted a couple months ago. And here I thought my sciblings paid attention to me *sob*.

Mommy and Daddy fighting and my sciblings ignoring me are making me feel insecure and frightened and as a result I’m going to lash out at Jake for this libertarian nonsense. At issue is this article in the Lancet which makes the suggestion that the poaching of doctors from poor African countries should be banned by international treaty. They make a compelling argument, and I tend to agree that it’s a grossly immoral practice that results in harm to millions.

But Jake finds it unbelievable. Why?

What I am aghast at is the cavalier attitude that this article expresses towards the rights of the health care workers in question. In indicating that the health care worker “poaching” violates the rights of Africans, in what way are they construing the rights of the health care workers? Have they concluded that the nations in question are entitled to their own health care workers? Are they implying that the health care workers are a nation’s property?

True, they do include the obligatory homage to the health care workers’ rights:
…
However, this admission contradicts what they say about the rights of African citizens demanding care. Let me make this clear. The authors assert that the individuals in Africa have a right to health care. On the other hand, they assert that the health care workers have right to mobility and the right to pursue a career under any circumstances they find most fortuitous. Does the health care workers right to mobility not include the right to converse with and interact with any organization they choose? The authors seem to suggest that the health care workers should exist is some sort of socially beneficent darkness in which they have rights but no knowledge by which they could appropriately exercise them.

One of the critical problems here is the failure to recognize that states invest significantly in healthcare worker education. I can’t speak to the policies in each of these nations, but as a generalization, medical education does not occur without state subsidy. Here in the US, entitlement programs contribute about $100k a year for each resident’s training (they get paid about half, and the hospital takes the rest), and medical student education is heavily subsidized by state and federal governments. Your tuition, as ridiculously high as it is, is only a fraction of what it costs to educate a medical student. I also am secretly hoping that Jake is in the MSTP program. It amuses me endlessly when people are libertarians while receiving education that is 100% subsidized (and stipended) by the federal government.

My point is that yes, the government does have enough invested interest in medical education that they’re naturally going to expect a return for that investment. When rich states actively take doctors from poor states, it’s a truly disgusting and unethical behavior that is effectively stealing money from already strapped states. From the Lancet article:

In comparison, by recruiting Ghanaian doctors, the UK saved about £65 million in training costs between 1998 and 2002, while their contribution to service provision is estimated at around £39 million a year.30 The benefiting countries should make amends through supporting repatriation of professionals who have left the country, training initiatives, the building and staffing of new health schools, and support for the development of retention frameworks, including improved salaries, pensions, recruitment of retired workers, and rural-worker incentives.

We have money to pay for healthcare (ok, maybe not but more than these countries). It’s really screwed up that to save money on our healthcare training we’re letting poorer countries do it, then just snag their trained docs.

Jake however disagrees and brings up some really silly libertarian views on what our rights as Americans entail.
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I’ve just completed my first month of my surgical rotation and still find almost every day fascinating. I just finished a 4-week rotation in the hepatobiliary service (liver, biliary and pancreatic surgeries mostly) and now go on to thoracic for 2 weeks, and then trauma for 2 weeks to complete the core requirement. I’ll also be doing orthopedic trauma and neurosurgical rotations before I’m done in March and I’ll be sure to write about those as well.

Friday night we had the medical student pimp-off AKA surgical jeopardy. For the uninitiated, pimping refers to the practice of quizzing students on the wards to make sure they’ve been studying (or occasionally to show off one’s own knowledge of medical minutia). For surgical Jeopardy/the pimpoff the residents get all the medstudents on the general service rotations together and quiz them Jeopardy-style. It was a lot of fun, one team even had t-shirts made, everybody was getting pretty into it. I even won a book! Although I’m afraid the smack talk may have gotten out of hand. Oh well.

And speaking of books, I’ve just got to write about what it’s like constantly having your nose in one. Above is the ICU Book I won Friday, as well as the Essentials of General Surgery textbook which is more or less required reading for the rotation. Then there is Surgical Recall (my cat is investigating), a book born right here at UVA which consists of several thousands of questions and their answers. It’s kind of a survival guide for the rotation since the questions are the kinds of things you’re likely to be pimped on. Like, what is the gastrinoma triangle?

Books for me have almost become a form of self-medication. When you start medical school, often fresh out of college, you quickly are overwhelmed by the sheer volume of information you must assimilate. These are the basic science years and in a way the first year is the most difficult. It’s a little bit like trying to drink water out of a fire hydrant. The material isn’t even necessarily challenging, but the sheer overload of information becomes overwhelming.

Somewhere in the middle of second year though you wake up and realize you’ve adapted to the information flow and suddenly you can rapidly absorb absolutely huge amounts of knowledge. You’re all proud of yourself. It’s great, and studying doesn’t seem to be as much of a chore.

Now I’m in third year and it’s back to drinking out of the hydrant again. Not only is the sheer amount of material for any given rotation overwhelming, but in addition you’re learning to apply it practically – a very different beast – while trying learn about managing real patients. I think it’s something people seldom appreciate about medicine is just how immense it is, and every field within it you could devote an entire life of study to. For example, wandering around the library looking for the textbooks to prepare for my next rotation I found these two hefty fellas:

These are huge volumes, with very dense material. Each subspecialty is daunting. Say you want to study plastic surgery?

Or, God-forbid, opthalmology?

See what I mean? You really get the feelings as you go along the best you can do is dent the surface, and you really appreciate why specialization has become so extensive. Each of these multivolume books contains hundreds of chapters dealing with specific diseases and descriptions of medical therapy or surgical techniques. Each chapter represents the work of an expert in that field who essentially writes a review of the scientific literature and current practice applied to a single problem or family of disorders. And on top of that, since texts are constantly going out of date, they are just the starting point. You must always keep up with the current literature on any given problem as you are treating your patients.

The amount of information you don’t know becomes overwhelming. Although these days studying is oddly no longer a chore, but one of the few ways I can decrease my anxiety. You see day to day how critical thorough knowledge of medicine is. And when I get nervous about how little I know I compulsively go out buy a book. It’s an expensive habit, but it seems to be the only thing that decreases the stress of having such inadequate knowledge. Hence I’ve become the Amy Winehouse of textbook purchasing.

Then there is the most frightening thing of all – the realization that the feeling you don’t know enough will probably never go away.

Surely no one can be pissed at me for pointing out that surgeons have some of the coolest tools, so I think I’ll describe a few of them that I’ve seen used a great deal in general surgery.

The one most frequently in use is referred to simply as “the Bovie” and it is used for electrocautery. Named for William Bovie it was first used by the famous surgeon Harvey Williams Cushing almost a century ago. The patient in the OR is laying on a large conductive pad that grounds them, and the Bovie device, which resembles a little plastic pencil with a flat, rounded metal tip, generates an electrical current which is transmitted directly to tissues to cut like a scalpel.

I can’t find a nice video of one in action, but it really is an interesting little device. By generating an alternating current at the tip it rapidly generates a great deal of heat in a very tightly-controlled location. Further, because you aren’t grounded, you can use it in close proximity to your fingers, or touch it to metallic surgical instruments to transmit the current to through the instrument to tissues without burning yourself. The effect of the device is dramatic. On one setting, the cut, a continuous waveform is generated that allows you to cut through tissue like a scalpel. The second setting, coagulation, turns the current on and off rapidly for a slower heat which coagulates while it cuts. The advantage of a Bovie over a scalpel is that a cut can be made that is clean and doesn’t bleed excessively thus maintaining hemostasis. One can also grasp a small vessel with a hemostat (or clamp) and touch the Bovie to the hemostat to rapidly coagulate the vessel to prevent bleeding.

More below…

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