So it begins.

We have come to yet another week of exams. Seems like that's all I do sometimes. Next week I will answer over 300 multiple choice questions on two major subject tests and two cumulative finals. Should I survive, I will finally be done with Physio and Biochem. Then I get an entire 2 day weekend before starting block three!

See y'all in Behavioral and Neuroscience!

WILTIMS #114: Now you CME, now you don't

This evening I attended a showing of Dr. Kildare's Strange Case (1940) put on by my school as part of a continuing medical education (CME) series. CME requirements are credits that doctors are required to amass throughout their careers to maintain their licensure. CMEs can be everything from classes, to research conferences, to (apparently) educational movie nights. After the showing there was a panel-led discussion of the movie and medical issues it presented.

Of particular interest was the use of insulin shock therapy to treat a patient with schizophrenia. This was a positively medieval treatment used from around 1935 to 1960, to little proven effect. In the words of one of the panelists, "the reason insulin shock therapy was perceived as working on schizophrenic patients was that, for the first time, someone was actually trying to kill the patient."

The bizarre idea was to put the patient into a hypoglycemic coma and see if she or he is better when you wake them back up (if you can wake them back up). This only seems humane compared to the alternative treatments of electroshock therapy and lobotomy. Amusingly, electroshock is still in use as a last line intervention, although using much more compassionate methods.

I think my favorite quote from the movie was from the chief nurse: "Nurses are just like husbands. You can abuse them, insult them, work 'em to death, jump all over 'em. They'll take it. But give 'em a bad cup of coffee and you got a revolution on your hands."

TIL: Adenosine deaminase deficiency is the cause of ~15% of severe combined immunodeficiency (SCID), the disease made famous by the "bubble boy."

WILTIMS #113: Let talk about...

Yay sex! Not gonna lie; it was an interesting day. I can't tell if everyone is actually getting more mature or if we've just gotten better at holding back the giggles. Maybe that's all maturity is.

TIL: Sperm are not transported to the site of fertilization by their own means (e.g. their flagellate tail). An inert particle placed at the vaginal opening of the cervix will get to the site of fertilization just as fast as a sperm. The tail is used for smaller distances like getting to the egg once in the general vicinity and for penetrating the egg's membranous defenses.

Calcium intake has to be closely watched during pregnancy. If the mother cannot provide enough calcium from the diet, her body with start breaking down bone to fill the gap.

The placenta is very cancer-like. It grows rapidly, produces hormones in proportion to its own size, and is autologous (unresponsive to all normal feedback loops). It is only stopped by being removed during parturition (the time leading up to and including labor and delivery).

So to recap, pregnancy is like growing a parasite within a bubble of cancer inside your body. Yay!

Physiologists are terrible at drawing breasts. The lactating breast is like a bunch of grapes still connected to the stem. The stems are the lactiferous sinuses and ducts that branch out from the opening of the nipple. The grapes are alveoli that secrete milk and, upon manual stimulation of the areola*, can pump milk into the ducts in preparation for lactation. Suckling by the infant causes the release of the hormone oxytocin which feeds back to the alveoli causing contraction and release of milk. If the baby is not switched between the breasts when feeding, the unused breast can eventually begin leaking milk from over-stimulation by oxytocin.

Babies do not suck milk out of the breast. The ducts have very weak walls that would instantly collapse if placed under negative pressure. Instead a baby pinches the nipple in its mouth and rhythmically squeezes the breast tissue, quite literally milking it. There is probably some sucking going on, but that's not the principle means of excretion.

For some humor on the topic of maturity and breasts, enjoy this song by Tim Minchin (contains some explicit and inappropriate language):
                                                                                                                        

*I had thought that areolus was the singular, but in fact areola is the singular and areolæ is the plural. Learned all sort of things today!

WILTIMS #112: A case of the Mondays

Today was a long day. Who holds a quiz on Monday morning?

After class there was a screening of the documentary Fire in the Blood about the unavailability of affordable antiretroviral drugs for the African countries with the highest rates of HIV infection. As with most documentaries I was shocked, appalled and a tad skeptical about some of the more extreme claims presented. Well worth the watch though, if you find the time.

TIL: The release of luteinizing hormone (LH) and testosterone in pubescent boys occurs exclusively during nightly sleep. Getting a full night's sleep as a teenager is important!

WILTIMS #111: Conflict of disinterest

Last night, or in the wee hours of this morning, there was an interesting debate going on in the private Facebook group for first years at my medical school. A student club had just been posting about their campaign to educate our class about the rampant conflict of interest in the medical field, specifically from physicians who receive compensation from drug companies. Fitting perfectly into their narrative, some overly prepared student looking over the upcoming lectures for today noticed that one of our lecturers not only had a slide announcing a conflict of interest, but seemed to have used an entire presentation put together by a pharmaceutical company.

The 1AM hubub was considerable because we had, up until today, never had any presentation that wasn't, with admittedly varied degrees of success, directly put together by one of our professors. How is it that we were already being brainwashed by Big Pharma when we weren't even through our first year of medical school? Why are we paying tuition for a presentation paid for by industry?

When the lecture finally started, no one actually cared about the topic of presentation because we all just wanted to see if the lecturer was the Pharma stooge we had painted him to be that morning. Turns out the presentation was 90% super dry background slides about the physiological basis for the disease process and then a couple case studies of patients that had successfully been treated with the drug. He did a pretty good job of pointing out that the drug in question isn't always right for every patient, though since this topic was his primary area of research, he was solidly in favor of treatment when indicated.

The presenter did seem arrogant and kinda sleazy, but we all agreed it wasn't because of the presentation - that was just him. And like every other presenter we've had, he thought very highly of his own research. Am I glad he had to disclose his conflict of interest? Of course. But am upset that he used a slideshow put together by a drug company that was paying him? Meh. It just showed that he was too lazy to make one himself. I am proud that my classmates and I are involved enough in our own education to have this discussion.

TIL: Artificial growth hormone replacement works really well, sometimes. World renowned endocrinologists can be unpleasant people. All the money in the world still can't buy an interesting presentation.

WILTIMS #110: A tasty, tasty lie

Sometimes the body is stupid. The α-cells of the islets of Langerhans of the pancreas produce glucagon, the hormonal opposite of insulin. Whereas insulin decreases blood sugar levels, glucagon increases it. Ideally, you'd like the cells that make each of these hormones to be able to sense the amount of sugar in the blood, to see if they are needed. The β-cells, which make insulin, can detect blood sugar through GLUT2 glucose transporters. The α-cells, however, use an insulin sensitive glucose transporter, GLUT4, that requires insulin to function.

So, imagine you have type I diabetes. Sorry. Your β-cells don't produce enough insulin, so your blood sugar is always high. The lack of insulin turns off the GLUT4 transporters, convincing the α-cells that you are hypoglycemic when you are in fact quite the opposite. The α-cells release loads of glucagon to fix the imagined problem, stimulating the liver and other tissues to release even more sugar into the blood, making all of your problems worse. As I have said before, 'intelligent design' my ass.

TIL: One protein that promotes fatty acid transport is called, seemingly unimaginatively, fatty acid transporter. But this is conveniently abbreviated as FAT.

The actual cause of death for starvation is typically respiratory failure. In the body's desperate search for energy, it turns from burning the last stores of sugar and fat to breaking down protein, which is mostly found in skeletal muscle. When the diaphragm, the muscle responsible for the bulk of our breathing, is degraded to the point that it can't sufficiently do its job, the person dies.

WILTIMS #109: T4: Judgement Day

Medical euphemisms are interesting. Today we were discussing hypothyroidism, which when left untreated causes physical and mental symptoms that were once referred to as cretinism. This is where we get the word cretin. Well, that's actually tricky because the term vastly predates our understanding of the illness, so in a way the disease was named for the people described by the word. Like spastic, crippled, moron, and many other terms, cretinism was once perfectly acceptable but has become politically incorrect.

The word retarded is particularly interesting because it has a very literal meaning that is still used extensively in medicine, among other places. Retard simply means to slow, e.g. fire retardant slows the spread of a fire. So to say that a child is mentally retarded literally means that their mental faculties are developing slowly. This has become taboo to say outside of a strict medical setting, so we've had to come up with new euphemisms like developmentally delayed. It still means the same thing but hasn't been used as a derogatory slur... yet.

TIL: Competency is a legal distinction determined by a court. Capacity is a medical distinction determined by medical professionals. The latter can be used as evidence of the former. In every other way these two words are synonymous in regards to medical ethics.

T4 - Note the 4 iodine atoms

Thyroid hormone comes in two active flavors, T3 and T4, which differ only by the number of iodine atoms bound to the molecule. T3 is the more active of the two but T4 is both more prominent in the circulating blood and the preferred hormone given orally for thyroid replacement therapy. This is the case because T4 has a half-life of about a week, compared to T3's paltry 1 day. This increased retention allows thyroid hormone levels to remain more constant.

This related tidbit was something I learned while volunteering at a cancer screening clinic last year. The iodine used in the synthesis of thyroid hormone is actually the reason we make and consume iodized salt. The thyroid is the only organ that uses this trace but essential nutrient. This provides a surprisingly easy target for treating thyroid cancers. By injecting radioactive iodine, you can use the body's own natural pathways to target the radiation directly to the thyroid.

WILTIMS #108: It's a kittycholamine!

Meow?

Catecholamines, a class of molecules that includes dopamine and epinephrine, apparently look a lot like a cat to my biochemistry professor. Her drawing from lecture is on the right. It has hydroxyl ears, an amino tail, and electron eyes and whiskers. I didn't see it at first, but now I won't forget their structure anytime soon.

In other news, I touched a 350 year old book today. It was a medical manuscript by Dr. Thomas Willis, after whom the Circle of Willis in brain circulation is named. I actually touched the page with the first image of the aforementioned circle. This is the same book that coined the term neurology. #geekingout

Willis' Cerebri anatome from 1664

TIL: You can decrease hormonal release from the anterior pituitary by adding the unwanted hormones. The anterior pituitary and hypothalamus are part of a portal circulation system, meaning it has two capillary beds in series. This peculiar arrangement is used to monitor and reabsorb any hormones released by the second bed as they arrive back at the first bed. By adding an unwanted hormone upstream, you trick the brain into thinking that it's secreting too much, so it absorbs what it can of the hormone and down-regulates its production.

Kisspeptin is a protein, specifically a G-protein coupled receptor ligand, named for Hershey's Kisses. The molecule was identified at the Penn State College of Medicine, which was established through a grant from Milton Hershey, the founder of the candy company, and is located in Hershey, PA. 

Growth hormone (GH) only affects the last third of adult stature. Put another way, the first 4 feet of a six foot person's growth are due to influences independent of GH. A lack of GH causes pituitary dwarfism (giving a height of about 4ft or ⅔ of 6ft) while an excess can cause gigantism (causing up to a ⅓ increase to 8ft).

George Washington's face, though rarely portrayed as such in paintings, was noticeably scarred by smallpox which he contracted as a young man. When he became commander of the revolutionary forces, he required that the entire continental army be vaccinated, resulting in the lowest infection casualty rate of any army in the world at the time.

John Snow memorial
at the former site of
the Broad Street Pump 

John Snow is not just an ignorant member of the Night's Watch, but one of history's most famous epidemiologists. He was a physician in England who stopped a cholera epidemic by identifying one specific contaminated water source, the now infamous Broad Street pump. At the time it was completely unknown how cholera was spread. He discovered that sewage was contaminating the pump's water source, the River Thames, just upstream of the pumps intake. When they capped the pump, the outbreak immediately ended.

Snow was also famous for popularizing anesthesia. He used calculated doses of chloroform and ether on Queen Victoria for the births of her youngest children, giving the practice unprecedented visibility.

And lastly, Gray's Anatomy (not to be confused with Grey's Anatomy) was pirated by publishers in the United States from its source material in Britain for nearly 50 years, from 1859 to 1908. By the way, just try typing "pirated gray's anatomy" into Google and getting anything related to medical literature. Not easy to research this one.

WILTIMS #107: Bladder? I barely know her!

TIL: Vincent's curtsey is the actual medical term for the clinical sign of urinary incompetence, especially in kids on the playground. I'd include a picture but I think you know what this looks like - crossed legs, partially bent, probably bouncing up and down. This is normal if you've been in a confined space for eight hours and really need to go, but if a kid is at recess and always seems to stand like this, they likely have a medical condition and should see a urologist.

Spinal cord trauma can cause kidney failure in a round about way. The injury paralyzes the urinary sphincter muscles, which are the only muscles around the bladder over which we have direct conscious control. The muscles that compress the bladder work independently and use secondary signals to determine when to contract. Things are wired this way because the sphincters that block the ureters (inlets to the bladder from the kidneys) are weaker than the sphincter to the urethra (outlet used for micturation (peeing)). If you could compress the bladder without opening the urethral sphincter, urine would go the wrong way.

With the spinal cord injury, this is exactly what happens, albeit without the person's control. The urethral sphincter is tonically closed due to the injury. Urine and pressure build up in the bladder until the sphincters that block the ureters are overcome and urine flows back to the kidneys, raising the pressure there. The kidneys cannot function under this pressure and will fail. The take home message is to always check that a patient with a spinal cord injury is either urinarily competent or with a catheter.

Snow day diatribe

The weather is conspiring against me providing you with interesting factoids! Well while we wait for the snow/sleet/ice/etc to stop, I thought I would vent on a topic that's been on my mind of late. Yesterday there was an alumni association event targeted toward medical students for the purpose of networking. I hate networking. Loathe it, actually. But it took me a while to riddle-out why.

I pride myself in having a wide, diverse network of people that I know, but I don't purposefully meet people just to have connections to exploit. That just seems disingenuous. I understand that it's usually mutual - that when you attend an event explicitly designed around networking, you will only find people there that are hoping to create a similar connection with you. This doesn't make me any more likely to attend, in fact quite the opposite. I also understand that networking is necessary in areas like business and entrepreneurship, but I think it can and should be more organic in medicine.

Reflecting on this a bit more, I think this drives to the heart of my outspoken dislike for premed students. First of all, let me clarify that "premed student" in this context does not simple mean a student who wants to go to medical school. Premeds are Type A, cut-throat, grade grubbing, aggressively qualified students who will go to med school or else. They have perfect grades, perfect test scores, a dozen inconsistently attended volunteer activities, and just enough research experience to get a letter of recommendation. Premeds have a list of everything it takes to get into medical school and will do everything on that list, because it's on the list.

Imagine you are opening a new medical school and you wanted to recruit the very first class of students. What would you look for in an applicant? They'd need to be smart, studious, caring, and committed. You'd want someone who did well in school because they're smart and studious, someone who voluntarily volunteers (not as redundant as you'd think) because they want to give back to their community, someone who has some experience in medicine to see if they really like it, and someone who sticks with their commitments because the 7+ years of added school they are signing up for will test their resolve.

For premeds classes aren't about fulfilling a curiosity, volunteering is a burden on their schedules, and research is another talking point on their applications. Everything is a means to an end. I'm not saying that they are all in it for less-than-noble motives like job security, financial stability and prestige (though those people exist), but that they have such tunnel vision toward that goal of helping people as an orthopaedic surgeon that they lose sight of all the people they could help along the way.

So back to networking. Doctors are great at it. When you treat thousands of people from every walk of life, you naturally build a strong, diverse network of connections. The medical field is also all about collaboration. Everything the body is connected, so when something goes wrong, doctors often have to consult with other specialists to get the best care for their patients. In this way doctors build a professional network quite organically as well. So why do we need to network outside of our normal interactions with the people around us?

I guess my point is that I'm fine with people going to events like the one that set off this tirade, but I refuse to feel guilty for not attending. </rant>

WILTIMS #106: Maximally confusing hormonal responses

TIL: Changing the number of hormone receptors on a membrane does not change the maximum response of the cell to hormonal stimulation, but it does change the sensitivity. If, however you change the affinity of the receptors to the hormone, then sensitivity remains constant as the maximum response changes. This is not the most intuitive concept, so here's an example to help explain it:

Say you have a membrane just filled to the brim with receptors. If you have another membrane with fewer receptors it will take more hormone for the second membrane to induce the same response. For either membrane, if you add infinite amounts of hormone you will still produce a maximal response, the second membrane just takes more hormone before it reaches that level (see graph 1 below). In other words, membrane #2 is less sensitive to the hormone.

If you instead have two membranes with the same number of receptors but one has a slightly defective version of the receptor*, that second membrane will not be able to reach the same maximum response as the first regardless of how much hormone you throw at it (graph #2 above). Membrane #2 is still equally sensitive to the hormone, it just can't do as much with the same signal. The new maximum rate will be reached just as fast and with the same amount of hormone, it will simply be lower. Thus the sensitivity has not changed, as represented by ED₅₀ above. ED₅₀ is shorthand for the effective dose to bind 50% of the membrane hormone receptors.

Still confused? Me too. If I find a better way to explain this, I'll come back to it... but don't hold your breath!

*This scenario also works if, instead of damaging the receptors, the number of receptors is reduced to a level so low that it cannot properly trigger the maximal cellular response.

WILTIMS #105: What the floc?

One more thing from yesterday's history bonanza: part of the reason that both ancient and Renaissance European physicians are so much better known than their middle-eastern counterparts from the Golden Age of Islam (aka. Europe's "Dark Ages") is that the latter had no anatomical art. The Islamic tradition of aniconism, forbidding the depiction of the human form, extended all the way to to medical anatomy. Thus, though Islamic physicians such as Rhazes and Avicenna made huge strides in diagnosis and the clinical exam, they had a harder time passing-on their anatomic discoveries.

TIL: One of my professors casually dropped the word "flocculation" into a discussion today and I half-thought he just made it up. Alas, apparently it was incredibly apt. Flocculation is the process of colloids (suspended microscopic particles (in this case clotting factors on the blood)) precipitate out of solution.

After about 20 hours of fasting or 20 miles into a marathon, you hit "the wall." Physiologically, this is when your body runs out of its glycogen stores. The body has several types of energy to burn, including glucose, glycogen, fatty acids, and proteins. It uses these differently in different tissues and prefers some stores over others.

Free glucose is used first and is burned within a few hours. As glucose is depleted the body turns to glycogen (a high-density polymer of glucose) to take up the task. If all of the glycogen store is used, your body is -and this is a technical phrase- not happy. Now it has to make glucose from fatty acids, which isn't very efficient, or from amino acids, which requires the breakdown of protein. Not happy.

WILTIMS #104: On the shoulders (and hearts) of giants

Today was a history heavy day, even in classes not entitled History of Medicine.

One of the stories we discussed was of William Blalock, Helen Taussig and Vivien Thomas, the trio credited for pioneering one of the first major cardiac surgeries, effectively curing blue baby syndrome. One of the most amazing aspects of this collaboration was the diversity of the three people involved, especially for the year of 1948. Blalock was the esteemed chief of surgery at Johns Hopkins, Taussig was a renowned female physician and master clinician, and Thomas was a high school educated lab technician working under Blalock.

Dr. Taussig approached Dr. Blalock with a theory of the cause of and a potential surgical intervention for the very common blue baby syndrome, a condition where the lungs can't get enough blood flow from the pulmonary artery. Blalock and Thomas devise a way to divert blood from the aorta back to the lungs. Thomas masters the surgery on over 200 dogs and guides Blalock though the first surgery on a child. The story is told very well in the 2004 HBO film Something the Lord Made; watch the trailer below:

TIL: Vitamin K is named for the German word for blood clotting, koagulation. It is used to modify clotting factors in the blood and vitamin K deficiency can cause bleeding disorders.

I actually already knew this one but it's too fun not to share. The term "limey" as a name for a British man originates as a derogatory term for ye olde British sailors. When shipping companies learned that citrus (containing vitamin C) could completely eradicate scurvy (vitamin C deficiency), they supplemented sailors' diets with concentrated lime juice.

Galen was the greatest physician of the Roman empire. He moved from Greece to Italy and was appointed to the prestigious position of physician to the gladiators, a great way to learn anatomy and surgery. His observations reworked beliefs of the ancient Greeks and defined medicine for over 1400 years, even longer than Hippocrates, the father of medicine. The Galenic tradition was a vast improvement over humoral theories but was still a ways from correct. For instance, until the 16th century it was thought that food was digested by the liver which produced blood that was consumed by the heart.

Rhazes, an Islamic physician in the 9th century, was the father of pediatrics.

Avicenna, probably the most influential physician between Galen and the European Renaissance was ridiculously smart. At the age of 10, he had memorized the Koran; at 15 he had intellectually outgrown every tutor that could be found to teach him. He was so skilled that he famously offered the following treatment to a wealthy patron: marry the girl. While taking the man's pulse and talking with him about various subjects, he noticed a quickened pulse when talking of a certain woman. Avicenna was a prolific author and wrote The Canon of Medicine a prolific work that recalled and expanded upon the traditions of both Hippocrates and Galen.

The University of Padua, founded in 1222, was the major university for Venice. It was located inland from Venice which provided both literal and figurative distance from the Church. This fostered free thought which produced great scientists such as Galileo and Copernicus, and the pioneers of modern anatomy, Vesalius and Harvey.

Heart regeneration was proved by doing autopsies on men who had received a heart transplant from a female donor. The genetically XX cells from the donor heart had disappeared and been replaced by XY cells from the recipient.

WILTIMS #103: Stars, wings and licorice

TIL: The prefix "sidero-" is confusing. In Latin it relates to the stars, as in sidereal time (telling time by the stars). But in Ancient Greek it means iron, as in sideromancy (divination by watching the burning of straw dropped on red-hot iron). In biochemistry, sidero- is also used in words describing iron containing molecules such as the precursors to heme, the iron containing part of hemoglobin.

Sticking with the etymological theme, pteroylpentaglutamate contains the prefix ptero- for wing, as in pterodactyl. This is because pteridine, the molecular building block of pteroylpentaglutamate, is also the precursor to the dyes responsible for the striking color of butterfly wings.

Consumption of large amounts of licorice (the plant or black-colored candy, not Red Vines) inhibits 11-beta HSD2, an enzyme in the kidneys that converts cortisol to cortisone. This causes a buildup of cortisol which in high concentrations can stimulate the kidneys' response to aldosterone by mineralocorticoid receptors. This causes the kidneys to increase sodium and water retention and secrete excessive amounts of potassium, resulting in hypertension and hypokalemia, respectively.

Dandy–Walker syndrome is a congenital brain malformation involving the area of the brain around and within the cerebellum. It is named for Walter Dandy and Arthur Earl Walker, two consecutive chiefs of neurosurgery at Johns Hopkins.

WILTIMS #102: Say aa

Today in biochemistry we delved into the ridiculous complexity of amino acid metabolism, summarized very briefly to the right. The body can convert all of these building blocks of proteins into other useful molecules for energy production or other molecular synthesis. All of this is confounded by the ability of many amino acids to be inter-converted and the limited ability of some of them to be transported across the cell's various membranes.

In physiology we zoomed in on the nephron of the kidney and looked at the filtering and resorption of various solutes and disease processes that can impede this. This was pretty much entirely review for those of us that have taken physiology before, but it was nice to have a manageable amount of information presented after the barrage we received from biochem.

I also was a patient again today for one of my perpetual follow-up appointments from my bout with cancer two years ago. All clear once again! These visits always put the troubles of med school back into perspective for me. Life's pretty good, all things considered.

TIL: Though there are only 9 essential amino acids (that cannot be made by humans and thus must be consumed in the diet), most of the remaining dozen are still conditionally essential. This means that although the body can synthesis more of the molecule, certain life events (such as childhood growth or pregnancy) or disease processes (like phenylketonuria) reduce or eliminate the synthesis process, requiring supplement through the person's diet.

Snow day... again

Sorry for the dearth of posts this week; blame the ambiguously phased precipitation that descended upon our area. I should be back tomorrow with all sorts of goodies!

WILTIMS #101: The Catholic consult

The snow day yesterday delayed our return to classes, but things were in full swing today. Biochemistry has become nitro-centric with protein catabolism and the uric acid cycle. Meanwhile physiology has turned its gaze from the heart to the kidneys. Lastly, we started History of Medicine as taught by our well-spoken chancellor.

After classes had ended I attended a guest talk by an ethicist and physician, Dr. Barron Lerner, on the changes in medical ethics from the times of his father, who was also a physician, to his own contemporary views. The takeaway was that medicine used to be far more paternalistic, with doctors making decisions on behalf of patients without ever necessarily consulting the patients themselves.

One dramatic example made my classmates and me question whether our current legal and moral framework is truly the best. An ailing woman who was terminally ill and had expressed a desire to discontinue treatment suddenly coded (cardiac arrest). She had not signed a DNR (do not resuscitate) form so the hospital staff went to call the code team, as they are required to do by policy and law. The speaker's father yelled for them to stop, saying that this was wrong and that the moral thing to do was to let the woman die with dignity. The staff called the code anyway and when the team arrived, the speaker's father literally laid his body across her chest to prevent them from doing CPR, and the woman died. Today, such an action would likely result in a lawsuit and/or sanctioning by the hospital. But was it truly wrong? I don't know.

A less serious anecdote was told of an old woman who needed an invasive surgery but wouldn't consent to being operated upon. The speaker's father explained thoroughly explained the need and brought in several other preeminent physicians to do the same. Finally he asked if another doctor from another institution could come take a look. The woman assented but still adamantly refuse surgery. The other doctor was devoutly Catholic. After he recommended the surgery and the woman refused again, the doctor accepted this and then asked the woman if he could pray for her. She was taken aback but said yes. The doctor proceeded to take out his rosary and make a show of his elaborate desperate prayer. The woman had surgery the
following day.

TIL: Hippocratic medicine was founded on the principles of the four humors, which though not correct, was the first time disease was attributed to natural causes rather than deities and treatment to physical action by physicians as opposed to intervention by said deities. The Hippocratic age was also the origin of the technique of taking a history and physical, as well as keeping a medical record for empirical research about the efficacy of treatments.