Gluten

My daughter is a barista. She came home from work recently and said, "One of the customers came in today and wanted to know if our hot tea was 'gluten-free'. Seriously? It was all I could do to keep from asking her if she knew what tea was made of!"

Gluten sensitivity is a hot topic these days as illustrated by a recent article in the New York Times "Gluten Free-whether you need it or not". I have many patients who are curious about gluten-free diets.  Patients are trying them and losing weight, having fewer migraines, reducing PMS symptoms, getting more energy, and/or making allergies going away. After having been in medicine for a sufficient number of years the exuberance of interest in gluten reminds me of any number of healthcare fads. Because we are human we hope to find an easy answer to our lifestyle problems. 

When patients ask me what I think, my answer is usual a very definitive "I have no idea." Then I elaborate since that tends to be disconcerting to them. First I need to know exactly why they are asking. Do they have symptoms of celiac disease: constipation, diarrhea, nausea, weight loss and abdominal pain (which can be caused by any number of entities besides celiac sprue)? Have they read something on the Internet or heard from a friend about gluten sensitivity and believe they have a problem? Are they presently following a gluten-free diet and if so, for how long and how do they feel? Only after I know where my patient is coming from can I decide where I need to go with her in the context of the visit.

For most individuals I want to be reassured that they are eating a nutritionally balanced diet and beyond that, I don't have easy answers. Usually I find questions like this involve a bit of fact, some fad and most definitely the hope that this "latest thing" will solve their problem, whatever that problem may be. In terms of my response, most things in medicine, like life, are best answered sensibly: All things in moderation.

What would you do?

A text lights up my phone late in the evening. It's from someone who is a patient but we've been together for so many years I consider her a friend. She has my phone number from other times she's needed medical advice. She knows me well enough that she can assume I am adept at texting though we've never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn't originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis. 

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can't be in a text because that's not HIPAA compliant. It also can't be email because that's not HIPAA compliant. SKYPE? Maybe but I'm not sure how good the encryption is. 

So I sit on my couch and weigh options--all the while thinking, "How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can't be utilized to help my patient or me?" Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it's larger? Will she know how to reduce the size? Yes, I could do what my 1950's MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I'll see tomorrow, needing all the rest I can get. 

What would you do?

The Expensive Process of Med School Application

Discouraged by her parents, my oldest didn't consider a career in medicine until after  graduating from college with a BFA in Art History. After taking an Americorps position and feeling lost at sea, she took a battery of aptitude tests. Interestingly enough the tests pointed her to a career in medicine, specifically as a physician or other treating provider. Growing up and watching her parents struggle through the difficulties of primary care, she certainly knew what she was getting into but somehow she must have seen the rewards we shared under the frustration.

So back she went to college, obtaining a 3.8 Science GPA. She took the MCAT, the dreaded test all pre-med students must do well on in order to be considered for medical school in the US, and made a decent if not stellar score. Then she began the application process.

Applying to medical school was an expensive and somewhat demoralizing undertaking. First she paid to send all the necessary materials-scores, transcripts, letters of reference, etc.-to each school through an organization called AMCAS. Then medical schools invited her to submit a secondary application.  At first she thought she'd made it through some sort of vetting process. Each school had a different set of requirements usually involving essay questions. Quickly she learned that they were all "interested" in her, well in her money. Amazingly paying $50-$150 per secondary application doesn't guarantee even a polite rejection email. Most students apply to about 20 schools. That's a lot of cash, considering that only about nine percent of all applicants are actually admitted[1].

As a bystander I have to wonder - is there anyone in the medical education community at least a little ashamed that so many of the hopeful individuals that apply to your "august" bodies are not granted even that tiny courtesy?

As a side note, she did get accepted. And despite all the frustrations I've been through and the issues that face her once she gets into practice, I'm proud of and happy for her. 

1. http://www.usnews.com/education/best-graduate-schools/articles/2011/04/05/10-medical-schools-with-lowest-acceptance-rates