I’d like to wish all the medical students beginning their arduous four-year med school journey this month the best of luck.  Reminiscing on my first days of medical school, I recall the thrill of reciting the Hippocratic Oath for the first time as part of a ritualistic White Coat Ceremony.  It felt like the incantation somehow connected me to a long line of great men, from Hippocrates to Benjamin Rush to my childhood family doctor.  It marked a distinct line between the life I had already lived and the medical profession that was to become a considerable part of my identity.  But is the Hippocratic Oath an outdated, out of touch relic in the complex modern world?

The original oath swears to deities that no longer “exist”, makes unreasonable promises of servitude to teachers, mandates free tuition, possibly forbids abortion and seems to prohibit surgery.  Yet almost 100% of medical schools in the Unites States administer some contemporary adaptation of the Hippocratic Oath.  According to the AMA’s Code of Ethics, the Oath of Hippocrates “has remained in Western civilization as an expression of ideal conduct for the physician.”

Has it?  In all fairness, no one really recites verbatim the actual translation of Hippocrates’ Oath any more. Most medical schools use variations that preserve the best qualities of the oath, such as compassion and “first doing no harm,” and omit the tenets that seem bizarre in a modern context.

But let’s consider, line by line, the original Oath and how well it holds up, both literally and figuratively, for today’s medical physician, and then let’s see if we can distill it down to a 140 character tweet. 

The Hippocratic Oath

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses*, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
* While Ancient Greek Polytheism is certainly available as a choice of religions, it is not required that all medical students have a personal connection and faith in Apollo, Asclepius, et al, for the terms of this Oath to be meaningful.  But the very act of swearing to a higher power, whether it be to a god or personal sense of honor, is a fundamental human tie that binds marriages and professions with a sense of duty and principle.

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She says it was a sad day Prohibition ended because Dad gets the drink going around to saloons offering to sweep out the bars and lift barrels for a whiskey or a beer. Sometimes he brings home bits of the free lunch, rye bread, corned beef, pickles. He puts the food on the table and drinks tea himself. He says food is a shock to the system and he doesn’t know where we get our appetites. Mam says, They get their appetites because they’re starving half the time.

Is food a shock to the system? The above quote is from Angela’s Ashes, and describes the author Frank McCourt’s father, a man as thin as a rail, who often swore off food. Although he was certainly no paragon of health, as evidenced by his smoking and heavy drinking, there may be a kernel of truth in his assessment of food as “a shock to the system.”

I thought of this quote while talking with a Muslim friend. He’s fasting from sunrise to sundown as part of the observance of Ramadan, and tells me that he only eats at night before bed. In reflecting upon my own experience I realize that I have rarely fasted, and I have never gone without food for an entire 24 hour period in my whole life. How weak and addicted. I hereby resolve that I will pick a day soon and eat nothing (except for drinking water), just for the exercise in self-control it represents.

But does the sustained restriction of calories or intermittent fasting have health benefits (in addition to perhaps boosting one’s sense of pride)? From Wikipedia:

Research suggests there are major health benefits to caloric restriction. Benefits include a reduced risk of cancer, cardiovascular diseases, diabetes, insulin resistance, immune disorders, and more generally, the slowing of the aging process and the potential to increase maximum life span. According to Dr. Mark P. Mattson, chief of the laboratory of neurosciences at the National Institute on Aging, fasting every other day (intermittent fasting) shows as strong of beneficial effects as caloric-restriction diets in mice, though no studies have been done in humans to date.

According to The National Academy of Sciences other health benefits include stress resistance, increased insulin sensitivity, reduced morbidity, and increased life span. Long term studies in humans have not been conducted. However, short term human trials showed benefits in weight loss.

There was a study published in Science earlier this summer looking at Rhesus monkeys fed 30% less than a usual control group of monkeys. Those eating a restricted calorie diet developed less cancer, diabetes, heart and brain disease. The restricted monkeys seemed to die less of chronic disease and old age, although overall their longevity was not statistically different from the control group.

Fasting and caloric restriction are not new concepts of course. Most religions employ some elements of both in their rituals. Christianity, Hinduism, Islam, Judaism, Jainism, Sikhism, and Buddhism all contain some degree of fasting in their doctrine and practice. In a religious context this is motivated by a sense of spiritual cleansing and control over base instincts, but its near universality would seem to hint at an underlying, intuitive survival benefit.

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It’s been a little more than 9 months since Barack Obama was elected president. The hope, elation, and excitement of those who supported him was at a zenith on the night of November 4th, 2008 – so much so that some predicted a small Obama baby boom might follow in August of 2009. Is it happening? It’s too soon to tell, but many news organizations including MSNBC are already pouncing on the opportunity to be the first to proclaim the boom a bust.

MSNBC and The Chicago Tribune both report that there was no boom in August, citing anecdotal reports and opinions from nurses and obstetricians at a few major hospitals. It would seem that the news outlets’ confidence stems not from any published accounting of births recorded, but rather from the inherent improbability that one single event like a presidential election could sway a nation’s birth rate in any sustained way (as opposed to world wars and economic depressions which can certainly effect population bubbles).

The largest mainstream media outlet to hype the Obama baby bubble was Newsweek in 2008, calling the possibility “Change You Can Conceive In.”   Newsweek also noted that Obama himself, born August 4th, 1961, might have been conceived on the very night JFK was elected to the presidency 9 months prior in 1960.  Bloggers from Fox News to the Huffington Post amplified the buzz, and noted that the collective mood of 52% of the country seemed to be one of sustained hopefulness through at least the Inauguration.

So has the first trickle of Obama Boomers begun to arrive this August? It is hard to find actual data that is reliable and in the public domain this early. The Census Bureau and the Department of Health and Human Services do not publish such real time data that I can find. Birth certificates issued in August might be a good proxy, but once again this information is difficult to obtain. I’ve asked some of the local Ob/Gyn’s whether they’ve had an unusually busy August, and most told me they have noticed a modest uptick in births, but I realize the quality of these opinions, like those obtained by MSNBC and The Chicago Tribune, is minimal.

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Welcome to Grand Rounds, a weekly gathering of medical people interested in sharing their best writing from the past week.  I was there in the beginning, back in 2004, when Grand Rounds first started.  Some might say that makes me old, but I prefer the term old school.

Scattered among excellent posts are flashbacks to the old school world of 2004 in which Grand Rounds was first conceived.  To add some extra relevance I’ve visited some of my favorite medical blogs and mined them for good stuff. Here we go, Old School Grand Rounds, a nod to 2004 when it all began, with some of my homies lending their street credibility:

Orac of Respectful Insolence considers the slurs that compare Obama to Hitler, and Healthcare reform to Nazism, and how congressman Barney Frank expertly responded to a particularly rabid critic.  Orac calls for Democrats, Republicans, and the media in general to speak out more bluntly against such outrageous accusations.

Dr. Schwab, author and surgeon, rebuts the “utterly, idiotically, cosmically ass backwards” interpretation of HR 3200 by Betsy McCaughey, as seen on The Jon Stewart Show this week.  He calls for honesty in the debate over end-of-life decisions.

Kevin, M.D. is a tireless medical blogger and proponent of a strong primary care system. He recently published an article on CNN.com about the dual imperatives of increasing Americans’ access to health care and bolstering our nation’s primary care foundation.

Newly published author (congratulations!) and family physician Dr. Hornstein considers what makes a student choose a career in primary care: “Some decisions should be made with the heart instead of the brain.”

Want to know what an NHS doctor in the U.K. thinks of America’s health care squabbling?  Dr. Crippen’s perspective is quite opinionated and fascinating, and shows that many outside the U.S. react to our uninsured and underinsured masses with as much horror as they did when Katrina exposed the shameful realities of poverty in America.

Tara Parker-Pope runs the New York Times Well Blog, and one of her guest authors, Brian Nelson, courageously writes about his numerous medical adversities, including 3 kidney transplants, a pancreatic transplant, chronic Type I Diabetes, and a recently disfiguring surgery for head and neck cancer.  You can’t read this piece and not be moved.

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Typical appearance after a smallpox inoculation through a wound on the hand.

As the world braces for the coming flu season, with H1N1 flu preparations hurriedly taking place in tandem with “regular” efforts, I find it interesting to take a look backwards.   I’m reading Paul Revere and the World He Lived In by Esther Forbes right now.  If you are interested in what life was like in 1700’s Boston, her Pulitzer Prize-winning book is a must-read.  She weaves tales of Paul Revere, Joseph Warren, Sam Adams, and John Hancock among others into an elegant and well-researched Revolutionary chronicle, revealing not only the history but also the life and times of these legendary characters.  There is a particularly interesting section devoted to the smallpox outbreak in Boston in 1763.   There were no vaccines back then, and smallpox was a disfiguring and often fatal disease.   Humanity was at the mercy of most infectious diseases, and deaths in infancy and childhood were commonplace.

In December of 1763 it was acknowledged that an outbreak of smallpox had begun. The last major outbreak had occurred in 1722, during which time one half the population of Boston had contracted smallpox, and out of those infected, 1 in 6 died. The rest bore their scars for a lifetime, and pitted faces were an everyday observance.

There were no effective treatments for the disease, although a crude type of vaccination called “inoculation” was gaining support.  The origin of the smallpox inoculation technique can be traced back to China, although exact dates are uncertain. It probably became common in the mid 1500’s, and spread to places such as Turkey by the 1700’s. The British Ambassador to the Ottoman Empire and his wife observed physicians in Constantinople practicing the technique, and soon it spread to Europe. The history and spread of this technique, and knowledge in general, is fascinating when compared to modern times:

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As I get older I naturally find it more difficult to establish quick rapport and trust with teenagers in the context of routine physicals, and the advent of texting has acutely worsened this trouble.

I routinely ask teenagers’ parents to leave the room at some point. This is an attempt to create some privileged and private space in which any embarrassing concerns, prohibited behaviors, or frank confessions can be voiced without parental scorn. Occasionally a teenager will bring up worries about sexually transmitted infections, or stresses in family life, or more rarely an issue that might constitute abuse. Mostly they just can’t wait for the visit to be over, and so I don’t drag things out. But even though I’ve tried to create a little buffer of privacy in which some trust and candor can take root, there is still a hovering presence, and omnipresent other in the room at all times that cannot be shown the door. It is the text messaging addiction.

I can barely finish a sentence sometimes. The cell phone vibrates, the iPhone alerts… NEW MESSAGE! There can be no sustained focus to a conversation, as the patient must look down and scroll through the communication, as if it were the most important and timely bit of information in the world. We might be talking about how to prevent teenage pregnancy, or how to stay safe at parties, or about the insidious onset of depression, but some other unseen interlocutor is barging in with – hey dude, wassup? I’m just chillin’

Like a complacent parent I rarely engage the issue. It is endemic to the population. When I have asked teenagers (and adults, really) to put away their cell phones and text messaging devices, it’s almost as if I’ve offended them, and closed that door of trust and openness with a judgmental slam. When I asked one child how many text messages he averages a month, he replied that last month he hit 12,000, easy. My jaw dropped. There were 30 days in that month. That’s 400 text messages per day. That’s a mind-numbing 25 text messages per hour, assuming all 16 productive, non-sleeping hours are devoted to maniacal communication. I get about one text message on my phone per day, and even this small intrusion sometimes feels like a horsefly.

But I suspect there is guerrilla, Amish-style revolution among us. The Resistance seeks to preserve a world order that prizes some modicum of privacy, away from the tweets, facebook feeds, manic texts, the pings, hums, and beeps that constantly fragment our waking moments. The revolution is of varying degrees and durations. Although being more socially connected is beneficial in many ways, what sense of self can we nurture when we are constantly plugged in to the matrix? Have we become like the countless cells that make up our bodies, secreting chemokines, blindly responding to hormonal cues, obeying the electric signals that bind us to our shrinking world? Is there a sense developing that a life experience hasn’t really happened until it has been recorded publicly and broadcast widely?

In the context of the office visit I feel defeated each time a text message comes bounding into the room. It is an intrusion as real as the insurance companies, HMO’s, and malpractice threats that have contaminated the doctor-patient relationship.

We should all be selectively Amish at times and turn off our cell phones, feeds, social networking sites, and blogs. There is peace and comfort in un-electrified solitude, beneath white clouds in summer skies, with glorious dirt beneath our nails, and not an electronic tether in sight.

Here’s a decent primer on the healthcare reform proposals (via The New York Times). Even better, peruse what doctors, nurses, and other clinicians are thinking via this week’s Grand Rounds, hosted by the inimitable Dr. Rich at Covert Rationing Blog.

Also, a primary care doc makes a list of the problems he took care of on one random day (also via NYT). Interesting post, which I’ve thought of doing in the past as way of showing a slice of what family doctors might see on a “typical” day.   I’m in a practice model like most family docs that expects me to be much busier than this doctor, so my list would probably be over 100 unique medical issues per day, not including phone calls.  Some patients have over 25 unique issues alone – I don’t know how they manage, but I think the concept of a medical home and a good primary care foundation in this country would help.  More time would also be wonderful.