TikTok, NyQuil, vaccines, the frontal cortex, and making wise decisions: something we all need to do better

“FDA warns against cooking chicken in NyQuil”, the title of an article from Family Practice News, and reprinted by MDEdge, may seem a little “Hey, what? Why would the FDA have to issue a warning about this?” It certainly caught my attention. I don’t claim to be a gourmet, or conversant with all the ways recipe books have to cook chicken, but I certainly never heard of using NyQuil. But, then again, I don’t spend a lot of time on TikTok. I read a bit more and caught the key phrases that largely explain why this is an issue, “adolescent” and “TikTok challenges”. Aha. It is not a celebrity chef who has been suggesting that we cook our poultry in a liquid designed to treat the symptoms of colds, and that includes a variety of drugs to treat pain (acetaminophen), suppress cough (dextromethorphan) and decrease sniffles (doxylamine, an antihistamine), which all are concentrated and made more toxic by cooking them down. It is, rather, morons on social media. Or how about the “One chip challenge”, which has led to hospitalizations of children eating a chip made with peppers with 400 times the capsacin (thus hotness) of jalapenos?

Or maybe they’re not morons; maybe they’re smart folks with an agenda, although the agenda is likely to simply be getting more views and becoming more of an “influencer” than intentionally trying to poison our young people. Although the impact can be the same. One question is “why do people (especially young people) get so ‘influenced’ that they do crazy, stupid things?” Actually, it’s easier to answer for young people. They have a biological, developmental excuse. Contrary to what we learned decades ago (or in the last millennium!) about brain development, that no new neurons grew after birth, the development of the brain is not complete until the mid 20s. And the last part of the brain to completely develop is the frontal cortex, which is associated with both executive function and judgement. Judgement is very different from intelligence or knowledge; it is the ability to integrate knowledge and come up with a wise plan of action. It is why a young adult or late teen, otherwise both very smart and even very knowledgeable, can often do something that seems, well, stupid. “Why did you drive into that crowded intersection? What were you thinking?” “Thinking?”…

Addressing this issue (helping learners to know how to integrate knowledge into a wise plan of action) is one of the key goals of education; and in my experience, in medical education. It is important, in making a diagnosis or deciding upon a treatment, to think critically, and this is not necessarily a skill that comes naturally. Before electronic medical records (EMRs) came into being, I would encourage learners to write the important laboratory and x-ray results in their chart notes, on the theory that in going from their eyes to their hands it would go through their brains and significant results that needed further investigation or action would trigger those brains to follow up. Now with EMRs, it is possible to block and paste all those results and insert them into the physician’s note, which does not have the same effect. It does make the notes a lot longer, but that in itself serves no purpose since the results could be seen elsewhere in the chart.  The goal was not to have them in the note (easy with cut-and-paste) but to have awareness of them in the physician’s brain. The traditional “SOAP” note includes “Subjective” (what the patient relates), “Objective” (what is found by physical, lab, imaging examination), “Assessment” (how the physician integrates that information into a decision on what is the most likely diagnosis or diagnoses, and what are the alternatives), and “Plan” (what are we going to do now to clarify the diagnosis and/or treat?). Assessment is by far the most important part; it is the part that requires that the data, relatively easily available, interact with the physician’s knowledge and experience. It is also, unsurprisingly, the one most often lacking in quality and thoroughness. It is, indeed, the one that require the most out of the frontal cortex.

The bigger question is not about adolescents and young adults, whether training in medicine or not, and why they cannot distinguish between a “challenge” that is a gimmicky fundraiser for a good cause (e.g., pouring ice water on your head so people will contribute money for ALS research) and one that is idiocy (e.g., cooking chicken in cold medicine). After all, we train children to irrationally believe things (Santa Claus, the Easter Bunny, parents are omniscient, good guys always win) so it is understandable that aspects of this may persist for a while. The bigger question is about adults. Why do they find it so easy to believe what should be obvious nonsense, and act on it, and have it determine not only what they do in a mildly risky manner (chicken and NyQuil, incredibly hot chips) but in their work, their relationships with others, their beliefs in the world around them, how they vote, and how that affects our world.  

Vaccines, for example, work to prevent disease both in the individuals who receive them and the communities of which they are a part. They are good. They are one of the few things (along with surgery) that healthcare workers can actually do to/for people that enhances their health, as opposed to making recommendations, whether for diet/exercise or giving small pieces of paper, which have to be taken somewhere and, with money, redeemed for medicines that have to actually be taken. But there  is still a lot of vaccine skepticism. Some of it is political; being skeptical of COVID vaccines has become de rigeur for many Republicans and conservatives and this has bled into distrust of other vaccines. But it also a belief of many who think of themselves as liberal, and are economically well off. It is just as wrong and dangerous. We read now that vaccine reluctance is now moving into people’s views about vaccinating their pets; we may soon face not only outbreaks of measles in children but rabies in dogs!

I understand and have written about the fact that all doctors are not always correct, that they sometimes are motivated by interests other than those of their patients’ health (their own financial interest or that of the corporation they work for), and that asking questions is good. But the dangerous irony is the same people who are suspicious of “mainstream medicine” are often far too willing to accept unproven and unlikely alternatives. Because something is recommended by those who are not mainstream physicians does not make it correct; in fact it is often quackery.

People often adopt behaviors, or either eat or eschew certain foods, or take supplements, that they believe will make them healthier. Maybe they do help. No one thing is going to make you healthy; there are too many factors affecting health. People usually choose those consistent with what they already believe and are things that they feel that they can do (thus the popularity of supplements; you don’t have to do anything hard like change your lifestyle). Unfortunately, people often think that doing the things they like or believe in or find easy cancels out other things – “if I take supplement X (or eat a lot of Y but no Z), I don’t have to do A or stop doing B!”

Near the end of Herman Hesse’s novel “Siddhartha”, the protagonist meets his childhood friend Govinda when they are both old men. Siddhartha shocks Govinda, a devotee of the Buddha, by saying that wisdom cannot be taught. Knowledge can be taught, he says, but wisdom must be acquired by the person themselves. I do not think we need less knowledge, but we do need more wisdom.

I’ll share some knowledge: Don’t cook your chicken in NyQuil. And get vaccinated, get your children vaccinated, get your pets vaccinated.

I’ll also try to share some wisdom: Because you want something to be true does not make it true. And if something seems too good to be true, it probably is.

Culture and Medical Culture: Understanding to increase benefit and reduce harm

Culture is often understood, at least by that culture that is in a majority in a given place, as a characteristic of others. That is, we are “regular”, they have a culture. The greater the disproportion between the dominant group and others in terms of numbers, the less diverse a community is, the more this – incorrect – assumption prevails. In the 19^th century, before the work of Bronislaw Malinowski and Margaret Mead, who actually spent time in the places and cultures they were studying,  cultural analysis of the world by anthropologists was often done “offline” by what have become known as “armchair anthropologists”. All European, they ranked cultures from least to most civilized, and guess what: European, and especially Western European, cultures were always at the top!

It should be needless to say that this was wrong. In addition to all the examples that can be given of other non-European cultures were far more advanced (think the Arab world for mathematics and science, China for all kinds of things), all cultures are different. They do not just have “strengths” and “weaknesses”, or areas in which one is “better”, but differences which have developed to serve the needs that existed where they lived. Weather, for a start, makes a difference in the types of crops grown or how housing is designed. In addition, of course, different cultures share many similarities. This allows for, for example, religious ecumenism, in which folks of different religions can come together based upon the values that they share. In the US today, we have seen great advances in understanding not only that differences between cultures do not mean one is better than another, but also that similarities between people usually exceed differences. Recently, we are seeing great strides against racism, sexism, jingoism, and all the other “isms” that promote hatred instead of understanding. Unfortunately, however, we also see a backlash from people who feel threatened by the idea that other people, whom they have disparaged and discounted, are indeed their equals. This has gone beyond attitudes; it has led not only to violence, but to legislation enshrining prejudice, hatred, and discrimination. I hope this will get better, but it might get worse first.

One way that we have on tried to address this issue in medical education has been discussions between small groups of students about how they see common phenomena in the world, in their communities, in families, and relationships. The more diverse a class is, the richer these discussions become and the more the students learn that what they think of as “regular” is in fact just as much a cultural belief as that of other people. Of course, this also can reveal assumptions that they may make about what is “normal” that are not normal for others, particularly regarding financial and socioeconomic issues. Or, for instance, whether the police are seen as your protectors or your persecutors.

This becomes an important entry point for examining medical culture, which certainly exists and carries its own beliefs and prejudices, as do most professions. These beliefs are no more, or less, “true” than sociocultural beliefs. Because medicine involves not only extensive interaction with other people who are not immersed in the culture but, even more, extensive power over the lives and health of those people, coming to grips with what you (and your teachers) believe because, well, we all believe it, rather than what is based in evidence, is important. This is more difficult because a big part of the socialization to a profession such as medicine is for a novice who is from outside that culture to learn the jargon, way of thinking, and indeed prejudices that characterize it, and this can have negative as well as positive results.

For example, our medical students usually enter perfectly capable of speaking English (and perhaps other languages) and conversing with others and communicating ideas and information. As part of becoming doctors, they learn new language, new terms, new acronyms, new meanings, and eagerly repeat them as evidence of their acculturation. Unfortunately, this can become an obstacle to communication with their patients, who do not speak this language. One example: a couple of sentences ago, I used “positive” and “negative” in their usual English senses of “good” and “bad”. However, when doing medical tests (lab, imaging, biopsies) a positive result is usually bad, and a negative result is good. But when a doctor, or student, informs a patient that their results are negative, it is common for the patient to react with fear, since this sounds like a bad thing. We urge them to say “normal”. Whew, that’s a relief!

Some other issues of medical culture are address in an Op-Ed by Robert Pearl in the Los Angeles Times of May 16, 2021, “How doctor culture sinks US health care”. A big part of Dr. Pearl’s critique in the distinct bias, not only in physician attitudes but in medical journal articles, towards intervention and procedures rather than prevention. This, he notes correctly, is very much tied to money, since physicians and hospitals and health systems (which are increasingly the physicians’ employers) stand to make much more money from them. Medical journals are more likely to print articles with positive (there is that word again!) results, demonstrating that a procedure had benefit, than negative results, demonstrating that, actually, compared to something – or nothing – else, something (or nothing) that was easier, cheaper, less interventive, and less dangerous, it had no better outcomes. Of course, anyone can see that knowing this information, that doing something is not worthwhile, is at least as important as knowing that something works well.

However, the inclination (or perhaps prejudice) among most physicians is to do something, to intervene; aside from making money, it makes them feel that they have skills, are justified, are important. Unfortunately, this is also an attitude quite prevalent among their patients, who want something done to help their problem – to cure their disease, or increase their lifespan, or improve the quality of that life, and in particular to ease their pain. But doing something does not always improve things, and can definitely increase the risk of harm. We need to know what works (and what doesn’t), and in what circumstances, and what the dangers are, and what the alternatives are, and their potential benefits and risks, and then have discussions together about what, in the specific circumstance a specific person is in, what would be the best choice for them.

This effort is likely to overlap with more traditional sociocultural and religious beliefs, which can have an influence on what a person thinks would be best for them. Communication around this requires care, and a real effort on the part of the medical professional to understand and to make their own thoughts clear and clearly expressed. This is even more complicated when, as is the case, physicians are from a pretty narrow slice of the American population, racially, culturally, and economically (and, again, a good argument for increasing its diversity). As in all situations where there is a power differential (and in medical care, the greater power lies with the physicians and health systems) it is incumbent on those with greater power to make the effort to understand those with less. And, at least as important, to not make decisions for and about people based on only your understanding – or worse, assumptions – about what they want, or are because of race, religion, gender, national origin, etc. Doctors, even when they are well-meaning (and all of them are not always) too often allow themselves to fall victim to the ecological fallacy, and confuse “condition X is more common in population Y” with “the patient is a member of group Y so probably has condition X”.

It is, of course, also very important to recognize that all interventions and procedures are not a bad idea; indeed, they are often the best treatment. And, also, that not everything sold as “preventive” is really so; plenty of tests and treatments called preventive are not proven to prevent anything. It is not easy to overcome prejudices and beliefs.

But understanding that we all have culture, and trying to not be bound by it and doing our best to understand that of others, is a good start.

The high cost of medical education: Who should be trained to become doctors?

Medical school is expensive. College, for that matter, is expensive, but medical school is more expensive. According to a consultant website, based on data from the Association of American Medical Colleges,

On average, medical school tuition, fees, and health insurance during the 2019-2020 academic year ranges from $37,556 (public, in-state) to $62,194 (public, out-of-state). Average private school figures come in just below public schools for in-state and out-of-state students, at $60,665 and $62,111, respectively.

That is a lot of money. Per year. Multiply by 4 years. Add books, living expenses (you know, food, rent, like that), and miscellaneous other costs, and it is not surprising that the average medical student graduates a quarter-million dollars in debt.

Of course, if your family is very wealthy, it is not a problem. But given that the mean household income in 2019 was about $63,000, just about a year’s tuition in many of these schools, it would be a stretch for those families to pay such expenses. Indeed, at the 75^th%ile ($113,000) it would be more than half of gross income, and I doubt that even those at the 90^th%ile ($184,000) would find it easy to support a medical student. As medical schools (hopefully) strive for increasing diversity, by income of family of origin, race and ethnicity, and geography (rural vs. urban), this cost becomes a bigger and bigger issue, much more than when only children of the elite (including physicians) attended medical school.

Of course, these students are going to be doctors, on average the highest-paid profession in America. According to most sources, including this one based on a survey on the doctor site “Medscape”, even the lowest-income medical specialties would be easily in the top 10% of income, and several way into the 1% ($475K). (Indeed, the income for those highest-paid specialties seems to be lower than those I have known, who not uncommonly make over $1M.) But even using those numbers, there is a several-fold difference in being in, say, Pediatrics ($212K) or Family Medicine ($219K), and Orthopedics or Plastic Surgery ($500K). It is certainly understandable that, at such high debt loads, the greater income of a high-paid specialty seems more attractive, and may further decrease student choice of primary care (lower paid) specialties. (At a difference of almost $300K a year, a plastic surgeon could expect, over a 30 year career, to earn almost $9M more than a pediatrician! That is real money!)

In addition to their own cost of living, often having to help support, rather than be supported by, a family, is another reality for those who are in medical school and later in residency training. This is a major focus of an important NY Times article on the topic published November 26, 2019, “I have a PhD in not having money”, about the challenges that low-income medical students have, and by extension the challenges for medical schools that really might wish to have a diverse class. The challenge is not only for minority students, who on average come from families with significantly less wealth and income, but across-the-board for students from families with incomes that are not in the higher ranges. It includes most students from rural areas.

In fact, there is an enormously close correlation between students from areas and population groups which are most needed in medicine and those most poorly represented in medical school. In some ways this is a tautology; since doctors are likely to practice in communities like those in which they grew up, poor, minority, and rural communities which are dramatically underrepresented in medical school are the least served. Also, the higher income earned by subspecialists (and, let us not forget, the explicit and implicit encouragement by faculty for students to enter these fields) means that they can practice only in “major medical centers”, places with populations big enough to support a need for that specialty and with hospitals that can provide them a place to practice. Thus, fewer medical students train to be family doctors, who can practice in and are much needed in rural areas, exacerbating the existing reticence of students brought up in cities and suburbs to relocate there.

The Times article is good, but it focuses almost entirely on the issue of paying for medical school. Clearly this is incredibly important. The students featured in it say things like “You have to decide, do you use your loans for a study aid or for a rainy-day fund in case someone at home gets sick?...I haven’t had dental insurance in two years. When tuna is on sale for 80 cents a can, I go buy 30 at CVS,” and “There’s this idea that because we’ll all be doctors one day, the loans don’t matter and it’ll all even out. But that doesn’t account for day-to-day expenses now, like if my mom texts me asking for help.” This begins to get at the larger issues, that it is not only the question of how to pay for medical school, but a variety of related things that characterize students from lower-income backgrounds.

Students from poor families tend to live in poor neighborhoods. Because of the US’ regressive system of financing public education, which depends a great deal on local funds, the quality of the education is likely to not be as good. I refer not to the skill or dedication of the teachers, but the resources to provide additional instruction, instructional support, and special classes such as Advanced Placement. Similar conditions apply in rural areas. Where the student from an upper-middle-class suburb may have many advanced placement classes, especially in sciences, by the time they graduate from high school, and have learned disciplined study habits and been given lots of role models, students from less-well-off school districts are much less likely to have. In a rural area, there may be one science teacher who is shared by more than one district. This gives the more privileged students a leg up before they even start college. Before they start high school. Before they start school altogether.

Then, disadvantaged students have to compete on academic criteria with those from wealthier backgrounds on Medical College Admissions Tests (MCATs), a type of test for which those others have been prepping for years. Medical school faculty on admissions committees often can’t – or don’t care to -- distinguish between the ability to perform well academically and the potential for becoming a good doctor if given the right support. A child of a well-to-do family who has had not only excellent schools but tutors and other support when needed, and who looks like the children of the MD and PhD faculty, might be “hitting on all cylinders” to do as well as they are, while the child of a farm worker or motel cleaner in a rural area may have unlimited untapped potential.

And, yet, it is still more. Producing more doctors from the top income levels means that the communities like those they come from, which already have enough or more than enough physicians, will become more overserved; that the specialties that exist in abundance in those locations will have more members. And lower income communities, rural communities, minority communities, communities that need primary care doctors, will remain underserved. And the health of the US population will be further jeopardized.

Some schools, like Mount Sinai in New York, have eliminated tuition. That is a good thing for the students who are admitted, especially for those who are from low-income families, but it does not explicitly choose students from low-income families. That is a major flaw; it mostly serves to further advantage the most-highly-advantaged students who comprise the bulk of the class. To care for the American people, medical schools need to admit and train physicians who “look like America”, for real, not a few token students in a class mostly comprised of scions of the top 25% or even 10%. This means that the first pass for admission should be demographic – students who come from low-income, from rural, from minority communities, students who don’t look like most current students, students who don’t look like the children of medical school faculty and their neighbors. If there are to be some slots reserved for those who are from privileged backgrounds and overserved communities, they should be for those who are most likely to practice in areas and specialties unlike those in which they were raised, those who have a demonstrated history (not an essay expressing intent) of real service. Were they in the Peace Corps, or AmeriCorps, or Teach for America, or something that actually required extended work and sacrifice?

Those students who are admitted will need maximal financial help, scholarships as much as loans, and even more educational support, so that they can reach their full potential and be able to become the doctors who can help their communities if they choose to return (not all will but they are much more likely to than others). That is what medical school funds should be spent for.

And we need it to start soon. It will be 30 years before currently accepted medical students replace the existing doctors, and we shouldn’t have half-measures.