The Hidden Costs of Medical Student Debt

He was a senior surgeon many of us in training wanted to emulate — smart, busy and beloved by patients and staff. But we loved him most because he could have been any one of us. He had slogged through the same training program some 15 years earlier, and he had survived.

I caught up with him one afternoon during my internship, hoping to glean some wisdom, but all he could talk about was how he was going to be seeing patients less and focusing on his dream of improving hospital quality and efficiency. “Don’t get me wrong,” he said. “I love caring for patients.” But the stress of keeping a practice afloat was wearing him down.

“Plus the monkey is finally off my back now,” he said with an enormous grin. “I paid off my last student loan.”

My heart dropped. That the specter of student loan payments would loom over my life for at least another decade and a half was utterly disheartening.

But absolutely true. It wasn’t until my early 40s that I paid off my last loan.

For almost three generations, debt has been a nearly inescapable part of becoming a doctor. Over 80 percent of each medical student class will graduate in debt; and while that percentage has remained unchanged for 25 years, the increase in the total amount owed has leapfrogged over all other economic reality checks, like inflation and the consumer price index. According to the Association of American Medical Colleges, which has been trying to address the problem for nearly a decade, young doctors who graduated from medical school last year had an average debt of $158,000, or $2.3 billion for the group as a whole. Almost a third of students owed more than $200,000, a number that will only increase with the addition of interest over payback periods of 25 to 30 years.

The skyrocketing costs are primarily due to the expansion and increasing complexity of universities and academic medical centers, and to the trend among university administrators to use tuition to support institutional projects that may be only indirectly linked to medical student education.

But while upgraded clinical facilities and spectacular research programs are obvious reasons, another key factor has gone largely unnoticed. It is our society’s assumption that individual indebtedness is required to obtain big-ticket items, whether they are cars, houses or higher education.

“It’s become normal now to take out loans to get anything of value,” said Dr. S. Ryan Greysen, an assistant professor of medicine at the University of California, San Francisco, and lead author of a fascinating study published this month on the historical and social factors that have contributed to rising medical student indebtedness. “Getting a medical education has become similar to getting a mortgage on your house.”

The acceptance of student indebtedness as the “norm” of medical school has provided a kind of carte blanche for robust tuition increases. Median yearly tuition at public medical schools is $29,000, and at private institutions it is $47,000 — increases from two decades earlier of over 312 percent and 165 percent, respectively. While some may counter that future doctors can well afford such increases and loans, the rising debt load has had and will have repercussions on patients, particularly those in greatest need.

Paying so much up front has transformed an education that was once a path to public service into a significant financial investment that needs to yield returns. “Because of all the debt, people stop thinking of medicine as an incredible opportunity to do good,” Dr. Greysen said. For some young people, looming debts mean eschewing a calling to serve a particularly needy, less lucrative patient population or practice, and instead pursuing a well-compensated subspecialty that caters to the comfortably insured.

For others, such large debts mean forgoing a medical career altogether. Cost remains a key deterrent for pre-medical students and is an important reason there aren’t more African-American, Hispanic and Native American doctors. Despite the well-documented benefits of a diverse physician work force, these economic pressures are transforming the socioeconomic makeup of medical school classes; medical students are increasingly from affluent backgrounds. In 1971, almost 30 percent of medical students came from households with incomes in the lowest 40th percentile, but only 10 percent of all medical students now do, and more than half come from families in the top quintile.

The acceptance of debt as a prerequisite of medical education has obscured even the most basic fact: It’s unclear just how many dollars it takes to educate a medical student. Because we accept debt, few university administrators have ever been held accountable for the tuition charged. And costs vary wildly among medical schools even within the same state, with one institution charging as much as three times what another charges for tuition and fees.

But medical students and the general public are not the only ones who are in the dark. Medical student dollars have become so enmeshed in supporting the diverse endeavors of a university or academic medical center that it’s become difficult even for those who set the prices to know what exactly they are charging for.

Over the last few years, some medical schools and educators have tried to address the problem. A few have tried to elicit alumni donations to support medical students, freeze costs or even do away with tuition altogether. Others have suggested highly innovative solutions that would strategically leverage the debt so that those medical students who went into high-need, less remunerative specialties would have less (or nothing) to pay.

But few of those changes will have any significant or long-lasting effect until we disengage ourselves from the notion that debt is a necessary part of medical education. As long as indebtedness is viewed as a normal part of becoming a doctor, tuition will continue to surge unchecked, and the implications for patients will only multiply. And we will be no closer to an answer for the most important question of all: Just how much should students, and society, pay for the next generation of doctors?

Some Nose-Job Patients May Have Mental Illness

Many people who complain about the size or shape of their noses show signs of mental illness, a new study suggests.

About one in three people seeking rhinoplasty — commonly called a nose job — have signs of body dysmorphic disorder, a mental health condition in which a person has an unnatural preoccupation with slight or imagined defects in appearance.

The findings are based on a study of 266 patients evaluated by plastic surgeons in Belgium over a 16-month period. The patients made appointments to discuss a rhinoplasty procedure and were given a questionnaire to assess their symptoms of body dysmorphic disorder. Among those seeking the procedure for medical reasons — to correct a breathing problem, for example — only 2 percent of patients exhibited symptoms of the disorder. But among patients seeking to change their noses for cosmetic reasons, 43 percent showed signs of the disorder, expressing an unreasonable preoccupation and distress about their bodies despite having noses that were relatively normal. Over all, 33 percent of patients in the study showed symptoms of the disorder.

The study, published in the August issue of Plastic and Reconstructive Surgery, shows a surprisingly high rate of body dysmorphic disorder among nose-job patients. Previous studies have shown that about 10 percent of patients seeking plastic surgery suffer from the condition.

Doctors say it is important to note that a person who is highly distressed about his or her appearance because of a very prominent or misshapen nose isn’t necessarily showing signs of body dysmorphic disorder.

“We know body image dissatisfaction falls on a continuum, and there has to be some degree of dissatisfaction that leads us to see a plastic surgeon in the first place,” said David B. Sarwer, associate professor of psychology at the Center for Human Appearance at the Perelman School of Medicine at the University of Pennsylvania. “It’s when it begins to interfere with daily functioning. Patients with more severe B.D.D. struggle to maintain social relationships and have difficulty getting to work or staying employed.”

Dr. Sarwer, who wrote a discussion article accompanying the study, said that while it is normal to be dissatisfied with one’s appearance, most people don’t let minor facial or body flaws disrupt their lives.

“Almost all of us will get up in the morning and look in the mirror and see something in our appearance we may not like or wish looked different,’’ said Dr. Sarwer. “But for patients with B.D.D., that thought never leaves their mind. They are chronically thinking about their nose, checking in the mirror or a reflective surface, or they avoid situations where people can see their profile. You can see that is a distraction and can make it hard to focus on jobs or studies or family.’’

In the recent study, the researchers found no relationship between the level of body dysmorphic disorder and the level of abnormality in the nose. In many cases, patients showing signs of the disorder often were complaining about noses that most people would consider to be normal.

Doctors said more study was needed to follow up on the Belgian study to determine whether people seeking nose jobs have higher rates of body dysmorphic disorder than those seeking breast enhancement, face-lifts or other forms of cosmetic enhancement.

Dr. Phillip Haeck, a Seattle plastic surgeon and president of the American Society of Plastic Surgeons, said the organization advises doctors not to proceed with surgery for patients who exhibit signs of the disorder.

“The biggest mistake is to offer to operate on them, because the chances that they will be satisfied afterward, no matter how good the shape of the nose may be, are very low,” said Dr. Haeck.

Dr. Haeck said he has encountered patients in his practice who clearly exhibit signs of body dysmorphic disorder, but it is often difficult to convince them to seek therapy.

“Often patients who have this can’t stop looking at themselves,’’ said Dr. Haeck. “When I’ve encountered cases like this, I’ve found it difficult to make eye contact. They tend to stand in the mirror in the examination room and look at themselves throughout the exam.”

A Running Debate: Dirt Trails or Pavement?

In today’s Personal Best column, Gina Kolata tells the story of Hirofumi Tanaka, an exercise physiologist at the University of Texas at Austin, who began running on a dirt path after recovering from an injury. He ended up twisting his ankle. She writes:

In the aftermath of his accident, Dr. Tanaka said he could not find any scientific evidence that a softer surface is beneficial to runners, nor could other experts he asked. In fact, it makes just as much sense to reason that runners are more likely to get injured on soft surfaces, which often are irregular, than on smooth, hard ones, he said.

His experience makes me wonder. Is there a good reason why many runners think a soft surface is gentler on their feet and limbs? Or is this another example of a frequent error we all make, trusting what seems like common sense and never asking if the conventional wisdom is correct?

Read the full column, “For Runners, Soft Ground Can Be Hard on the Body,” then please join the discussion below. Where do you land on the dirt versus pavement debate?

Swimming With Sharks, at 61

At the age of 61, Diana Nyad is taking on an athletic challenge that she could not complete in her 20s. She plans to swim about 60 hours in the churning sea, 103 miles across the Straits of Florida from Cuba to Key West.

Every hour and a half, she will stop to tread water for a few minutes as she swallows a liquid mixture of predigested protein and eats an occasional bit of banana or dollop of peanut butter. She will most likely hallucinate and endure the stings of countless jellyfish. Along the way, sea salt will swell her tongue to cartoonish proportions and rub her skin raw….

Ms. Nyad attempted this swim once before, unsuccessfully, in 1978 at the age of 28. She swam inside a shark cage for 41 hours 49 minutes until the raucous weather and powerful current pushed her far off course and she was forced to give up. She had traveled only 50 miles. (One year later, she swam 102 miles from Bimini, in the Bahamas, to Jupiter, Fla., without a shark cage. She still holds the record for the world’s longest ocean swim.)

This time, armed with better technology and a battered but tough body, she is certain she will make it. “Physically, I am much stronger than I was before, although I was faster in my 20s,” said Ms. Nyad, who looks sturdy enough to defy a linebacker. “I feel strong, powerful, and endurance-wise, I’m fit.”

To learn more about Ms. Nyad and her remarkable swim, read the full story. “Ready to Swim 103 Miles with the Sharks,” and then join the discussion below.

Giving Chronic Pain a Medical Platform of Its Own

Most doctors view pain as a symptom of an underlying problem — treat the disease or the injury, and the pain goes away.

But for large numbers of patients, the pain never goes away. In a sweeping review issued last month, the Institute of Medicine — the medical branch of the National Academy of Sciences — estimated that chronic pain afflicts 116 million Americans, far more than previously believed.

The toll documented in the report is staggering. Childbirth, for example, is a common source of chronic pain: The institute found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.

Ten percent to 50 percent of surgical patients who have pain after surgery go on to develop chronic pain, depending on the procedure, and for as many as 10 percent of those patients, the chronic postoperative pain is severe. (About 1 in 4 Americans suffer from frequent lower back pain.)

The risk of suicide is high among chronic pain patients. Two studies found that about 5 percent of those with musculoskeletal pain had tried to kill themselves; among patients with chronic abdominal pain, the number was 14 percent.

“Before, we didn’t have good data on what is the burden of pain in our society,” said Dr. Sean Mackey, chief of pain management at the Stanford School of Medicine and a member of the committee that produced the report. “The number of people is more than diabetes, heart disease and cancer combined.”

For patients, acknowledgment of the problem from the prestigious Institute of Medicine is a seminal event. Chronic pain often goes untreated because most doctors haven’t been trained to understand it. And it is isolating: Family members and friends may lose patience with the constant complaints of pain sufferers. Doctors tend to throw up their hands, referring patients for psychotherapy or dismissing them as drug seekers trying to get opioids.

“Most people with chronic pain are still being treated as if pain is a symptom of an underlying problem,” said Melanie Thernstrom, a chronic pain sufferer from Vancouver, Wash., who wrote “The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering” (Farrar, Straus & Giroux, 2010) and was a patient representative on the committee.

“If the doctor can’t figure out what the underlying problem is,” she went on, “then the pain is not treated, it’s dismissed and the patient falls down the rabbit hole.”

Among the important findings in the Institute of Medicine report is that chronic pain often outlasts the original illness or injury, causing changes in the nervous system that worsen over time. Doctors often cannot find an underlying cause because there isn’t one. Chronic pain becomes its own disease.

“When pain becomes chronic, when it becomes persistent even after the tissue and injury have healed, then people are suffering from chronic pain,” Dr. Mackey said. “We’re finding that there are significant changes in the central nervous system and spinal cord that cause pain to become amplified and persistent even after the injury has gone away.”

The institute emphasized the importance of prevention and early treatment, a novel concept for many doctors who try to diagnose the source of pain before treating it or advise patients to wait it out in the hope it will go away on its own.

“Having pain that is not treated is like having diabetes that’s not treated,” said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. “It gets worse over time.”

Ms. Thernstrom compared the effect of chronic pain on the body to the rushing waters of a river carving out a new tributary. Pain, she says, also changes the body’s landscape.

“My pain is at the level where it’s manageable,” she said. “I do wish I had gotten aggressive treatment in the first year. There is a window of time to intervene, because pain changes your nervous system and pain pathways develop.”

The report also acknowledged the “conundrum of opioids,” noting that doctors are conflicted about how to treat pain because of worries about drug addiction. But the group noted that proper use of the drugs early in a pain cycle can resolve pain problems sooner, and stated that opioids are also particularly useful for pain management near the end of life.

The pain report is only a first step for the community of medical professionals who treat pain. It will be up to medical schools to begin better education of doctors in the treatment of pain, and the National Institutes of Health to decide whether to promote research into chronic pain. Patients, too, need to be educated about the importance of early treatment of pain rather than gutting it out or waiting until it has become severe and chronic.

“Some people were expecting a cure within the report,” Dr. Mackey said. “There’s no immediate cure. But I’ve seen a lot of patients who have said, ‘Finally they are putting out a report that helps others understand what I’m going through.’ ”

The Nagging Effect: Better Health for Married Men

Relationship researchers have long known that marriage is associated with better health, particularly for men. One reason is that wives often take on the role of caregiver, setting up doctor appointments and reminding, even nagging, their husbands to go.

The notion that a nagging effect leads to better health for men is bolstered by new research showing that among heart attack victims, married men arrive at the hospital soonest.

On average, married heart attack victims arrived at the hospital half an hour sooner than those who were not married. But when the researchers analyzed the data separately for men and women, they found that while married men were more than 60 percent less likely to arrive late than their single peers, there was no statistically significant difference between married and single women.

Even when a man is not experiencing troubling symptoms like chest pains, it is not uncommon for a wife to begin pushing her husband to visit the doctor long before a man thinks he needs to go.

Wives are in a unique position to persuade their husbands to seek medical care. Women are far more likely to have a personal physician than men. And even when prenatal visits and trips to the pediatrician are excluded, women are still twice as likely as men to visit the doctor. As a result, they have more regular access to physicians and often use their visits to throw in a few extra questions about husbands and family members or seek a referral for a family member.

And because erectile function is an important barometer of a man’s health, a wife often is the first to notice changes that could signal a health problem like heart disease or diabetes.

A few years ago, I interviewed Phil and Rachael Starke, a couple in San Jose, Calif. Phil was putting off a doctor’s visit, but Rachael insisted, enlisting the help of their child’s pediatrician and scheduling appointments. Finally, Phil did see a doctor and learned he had diabetes. Later, he conceded that he owed his health to his wife.

“There’s an old Jimmy Buffett song where he tells his girlfriend, ‘You treat your body like a temple. I treat my body like a tent.’ It gets back to the value of marriage. If I had been a single man without someone deeply involved in my life, I’m not sure what would have happened. For lack of a better word, I was nagged into doing something.”

Read the full report on married men and heart attacks, “Faster Treatment for the Married Man.” And for more research on the link between marriage and health, read my article from The New York Times Magazine, “Is Marriage Good for Your Health?” Then please join the discussion below.

Gardasil for Daughters and Sons?

Parents of girls have struggled with whether to obtain the vaccine to protect their daughters from human papillomavirus. Now, parents of sons have to make a similar decision.

Until recently, Gardasil was a girls-only proposition. Approved for young women ages 9 to 26, the vaccine promised a great benefit: protection against four strains of sexually transmitted human papillomavirus (HPV), including two that can lead to cancer of the cervix, vagina and vulva….

Now, in the wake of new research suggesting that the vaccine protects against other cancers, Gardasil is increasingly marketed as an important vaccine for boys, too. The Food and Drug Administration has approved it for young men ages 9 to 26, expanding the list of indications just last December.

All of which is sure to leave many parents asking: What’s in it for our sons?

To learn more, read “A Vaccine May Shield Boys Too,” and then join the discussion below.

Athletic Performance and the Monthly Cycle

What makes a female athlete different from a male athlete? Watching Abby Wambach leap above defenders in a World Cup soccer game to head the ball decisively into the net, or seeing her teammate Megan Rapinoe streak a pass down the pitch, the answer might seem to be: not much. As a group, female athletes, like their male counterparts, display coordination, strength, grace, speed, stamina and a bracing competitiveness.

But there is a signal difference between adult men and women, on the field and off. Women menstruate. And menstruation, with its accompanying fluctuating levels of the female sex hormone estrogen, can have a considerable effect on how a woman’s body responds to the demands of exercise and competition, as a range of provocative new science makes clear.

Consider the results of a series of experiments published last month involving female rowers in Europe. Some of the women were competitive athletes, others hobbyists. Some were using oral contraceptives, which lower production of the body’s own estrogen while maintaining consistent levels of a synthetic variety; others were not. All of the women came into the lab multiple times throughout the month, including on days when their estrogen levels were at their peak and ebb, to complete a fitness test on a computerized rowing machine. Each time, their heart rates, oxygen consumption, power output, blood lactate levels and other measures of endurance, strength and general fitness were measured.

Those measurements, as it turned out, never varied, no matter where a woman was in her menstrual cycle. She could row just as long and powerfully whether her estrogen levels were high, low or in between; whether she used contraceptives; and whether she was an experienced, competitive athlete or a rowing duffer.

These findings are important, because many people, including coaches and athletes, have long contended that women’s endurance and overall performance may flag at certain times during the month — although there is disagreement about when those times are. And many female athletes have been told, or have chosen, to start or discontinue using birth control pills to manipulate their hormone levels.

But “endurance performance was not influenced by the phase of the normal menstrual cycle” or “the synthetic menstrual cycle” of those on oral contraceptives, the authors of these new studies write. Consequently, women “should not be concerned about the timing of the menstrual cycle with regard to optimized, sport-specific endurance performance.”

There may, however, still be reasons a woman to consider her period when planning training. A study published this year by scientists at the University of Melbourne in Australia, for instance, found that when women’s estrogen levels were at their highest, around the time of ovulation, they landed subtly differently while hopping than at other times of the month. Their feet splayed, the arch collapsing just a little bit more than it did when their estrogen levels were lower. The women also seemed, to a small degree, wobblier. “We contend that the changes in foot biomechanics may be due to the effects of estrogen on soft tissue and/or the brain,” said Adam Leigh Bryant, a senior lecturer at the University of Melbourne and lead author of the study.

But whether such small bodily changes actually affect injury risk is not clear. Other researchers have examined injury patterns in female athletes and found little consistent evidence that injuries, including the dreaded A.C.L. tear in the knee, are more common at any particular point during the menstrual cycle.

Still, said Dr. Bryant, active women probably “should be careful during the ovulatory phase of their menstrual cycles,” particularly if they play sports that involve hopping, landing and cutting, like soccer, basketball and, for those of us who are regrettably clumsy at striding off of curbs, jogging.

None of which, though, should suggest that female athletes are in some indefinable way more fragile than their male counterparts. Quite the reverse may in fact be true, according to some reverberant new research into athleticism and the menstrual cycle. In a series of experiments at the University of Denmark, scientists found that during exercise training, women’s tendons and ligaments didn’t grow as thick and powerful as men’s did, which had been expected. But after they reduced or stopped their workouts, women did not, in subsequent studies, lose their training benefits as quickly as men did.

Estrogen, the researchers concluded, had maintained the women’s hard-won strength and fitness gains better than men’s bodies had held on to theirs, for a simple evolutionary reason. It was protecting the women “against fast muscle and collagen loss when she is inactive,” as during pregnancy, the study’s lead author, Mette Hansen, a researcher at the Institute of Sports Medicine in Copenhagen, told me in an e-mail. Estrogen makes women stronger in adverse conditions, Dr. Hansen concluded, a lesson that the fine, battle-hardened United States women’s soccer team can take solace in going forward.

Could You Run the Country With a Migraine?

News that the presidential candidate Michelle Bachmann suffers from severe migraines has suddenly cast the headache disorder in a new light.

Every migraine sufferer knows the pain, nausea and other symptoms that cause such misery. Symptoms can be debilitating, and many sufferers take refuge in darkened rooms or make trips to the emergency room for treatments to relieve the nausea and pain.

In a video that went viral, the television reporter Serene Branson babbled gibberish during a live report from the Grammy awards. Her doctor later concluded a complex migraine had rendered her unable to form words.

While the suffering caused by migraine is well documented, now the question is whether migraines represent a handicap.

Robert Dalton, executive director of the National Headache Foundation in Chicago, said that while migraine can be debilitating, the larger problem is that many people who suffer from it aren’t getting proper medical care.

“What we want to make sure people understand is that it’s a debilitating disease when it’s not managed properly,’’ said Mr. Dalton. “From that standpoint, our position would be that a well-managed migraine circumstance would not prevent anybody from taking on any challenge that they wanted to.”

Tell us what you think. If you have experienced migraines, have they affected your job performance? Would a president with migraines be able to do his or her job effectively? Join the discussion below.

Why Would Anyone Choose to Become a Doctor?

You hear it all the time from doctors — they would never choose medicine if they had it to do all over again. It’s practically a mantra, with the subtle implication that the current generation of doctors consists of mere technicians.

When I first started in practice, I found such comments both perplexing and annoying. I loved medicine and was excited to come to work every day. I considered those naysayers jaded has-beens, fusty old-timers pining away for the nonexistent “days of the giants.”

However, as the years have passed, the warts of medicine have grown more conspicuous to me. During some of the more stressful days — crushed by impossible time constraints and ever more onerous bureaucratic demands — I can’t deny that the thought of giving up clinical practice has crossed my mind. Life would be so much easier….

Yet, each year, a new wave of enthusiastic medical students floods our clinics and our wards. Part of me always wonders: Why do these students still choose to become doctors?

It certainly can’t be the money — Wall Street is the faster and more reliable route to wealth, as evidenced by the skyrocketing of applications to M.B.A. programs.

Applications to medical schools, surprisingly, have held steady over all, despite an exodus of top students to finance and banking. According to the American Association of Medical Colleges, about 40,000 students apply to medical school each year, with some 17,000 matriculating. (For comparison, there are about 45,000 students starting law school each year, and 100,000 starting business school.)

Incoming medical students, while steady in their numbers, have had a major shift in their demography. In 1970, medical students were nearly entirely white men. Now half are women, and a third are Asian, black or Hispanic.

I recently worked with a third-year student who’d just interviewed a patient with chest pain. The chest pain turned out to be nothing serious, just some acid reflux — a fairly ho-hum case in a medical clinic. But the student’s eyes were ablaze with fervor. “This was such an exciting case,” she said. “I had the chance to figure out whether or not the chest pain was life-threatening. And the patient was so happy when I reassured him that it wasn’t.”

The awe of discovering the human body. The honor of being trusted to give advice. The gratitude for helping someone through a difficult illness. These things never grow old.

But the frustrations of daily clinical life continue to mount. Administrative requirements increase exponentially, while the time allotted for the patient visit remains 15 to 20 minutes. The additional paperwork, electronic documentation, phone calls, insurance forms and quality assurance measures are all expected to be subsumed into the same workday.

I once tried to calculate how many thoughts a primary care doctor has to juggle on a given day. (My tabulations came to 550; you can read about it in an article I wrote for The Lancet.) We keep pushing so many more balls into the air that there’s no doubt a few will fall. It’s this feeling of not being able to do as good a job as I’d like that makes me consider walking away from clinical medicine. I can’t countenance mediocrity, and I cringe whenever I feel that I can’t get it all done.

But then I cringe when I think about what it would mean for patients if doctors walked away from medicine because of the frustrations.

On top of that, I have to wonder about the alternatives if I gave up clinical medicine — pushing papers, sitting in endless PowerPoint meetings, crunching numbers — and realize that I am lucky and immensely privileged to be able to work directly with patients.

When I close the door to the exam room and it’s just the patient and me, with all the bureaucracy safely barricaded outside, the power of human connection becomes palpable. I can’t always make my patients feel better, but the opportunity to try cannot be underestimated.

If I’m having a really rotten day in clinic, all I need is one of these new medical students to pop in, even if they make a long day even longer. The fact that medicine is still compelling enough for 17,000 people each year to commit a decade or more of their life to training is inspirational.

And when my students and I have our inevitable “career talk,” I tell them that there is nothing else I’d rather do in my life than medicine. If I had it to do all over again, I’d end up right here in this office — telling them that there’s nothing else I’d rather be doing.

Chilled Soups for Hot Summers

If you’re looking for a way to cool off and treat your taste buds at the same time, consider one of these new chilled soup recipes from Martha Rose Shulman.

Some of these blended soups were elegant enough to serve not only as meals but also as dinner party aperitifs. I poured them into shot glasses and espresso cups and passed them on a tray.

I also made more robust yogurt-based soups, combining greens, legumes, grains, herbs and spices. These made hearty meals with lots of texture, packed with nutritious ingredients like spinach, watercress and tomatoes. And though a few of this week’s soups require some cooking, I’ve kept it to a minimum.

Watermelon Gazpacho: Celery brings together the elements of this surprising soup.

Chilled Yogurt Soup With Spinach and Chickpeas: Counterintuitive though it may seem, this cold soup is actually comforting.

Yogurt Soup With Spelt, Cucumbers and Watercress: This chilled summer soup has an unusual crunchy texture.

Tomato-Cucumber Soup With Basil: Not exactly a gazpacho, this summer soup can be kept in the refrigerator for a few days after it’s made.

Chilled Pea, Lettuce and Herb Soup: This elegant soup is sweet and heavenly. The texture is silky and the consistency thick — but only because there are lots of peas in it.

Really? The Claim: Air-Conditioning Can Cause Colds

THE FACTS

In the midst of a nasty heat wave, air-conditioning can make life so much easier to bear. But some people believe that sudden drops in temperature can play havoc with the immune system. Others say air-conditioners act as germ-spewing machines, cultivating bacteria and viruses like petri dishes and then blasting and recirculating them in enclosed spaces.

As with colds and other respiratory ailments contracted in the wintertime, cold air itself is not the culprit — viruses are, said Dr. Ujwala Kaza, an allergist and immunologist at New York University Langone Medical Center.

Still, researchers at Cardiff University in Wales say it’s possible air-conditioners may contribute in some small way to respiratory infection. They extract moisture from the air, which can dry out the protective mucus that lines the nostrils, allowing viruses a better chance to become established in the nose.

One study in 2004 compared 920 adult women and found that those who worked in offices with central air-conditioning had higher rates of absence due to sickness and more visits to ear, nose and throat doctors than those without it. A similar study of almost 800 office workers in 1998 also found more symptoms of sickness in workers in air-conditioned offices, compared with workers in offices with natural ventilation.

THE BOTTOM LINE

There is evidence that air-conditioned environments may contribute to colds, but it’s not definitive.

Putting Men on the Pill

For years, contraception has been mostly a woman’s responsibility. But now scientists are studying new treatments that may help men control fertility.

While male contraception has been studied before, no method met the stringent safety and effectiveness criteria that female methods do. It was also unclear whether men would use them.

Now, scientific advances are producing approaches that could pass muster. Prompted by women’s organizations, global health groups and surveys indicating that men are receptive, federal agencies are financing research. Some methods will be presented at an October conference sponsored by the Bill and Melinda Gates Foundation.

To learn more, read the full article, “Scientific Advances on Contraceptive for Men,” and then please join the discussion below.

How Men Experience Grief

The loss of a loved one is a profoundly heartbreaking experience, but it is not the same for everyone, as reported in Tuesday’s Science Times.

Research increasingly suggests that men and women experience grief in different ways, and the realization has bolstered a nascent movement of bereavement groups geared to men throughout the country.

Concern about reaching men in grief has gained new urgency with shifting demographics. The number of men ages 65 and older increased by 21 percent from 2000 to 2010, nearly double the 11.2 percent growth rate for women in that age group, according to census figures. As the gender gap in life span narrows, experts suggest that many more men will be facing the loss of loved ones, particularly spouses. Many will be not be prepared for the experience.

While women who lose their husbands often speak of feeling abandoned or deserted, widowers tend to experience the loss “as one of dismemberment, as if they had lost something that kept them organized and whole,” said Michael Caserta, chair of the Center for Healthy Aging at the University of Utah.

Read the full article, “Men in Grief Seek Others Who Mourn as They Do,” and then please share your thoughts in the comments section. And don’t miss “Men Who Grieve Together,” an interactive presentation in which men talk about their experiences with bereavement.

Migraine Miseries Push Patients to Ways of Coping

The news that the presidential candidate Michele Bachmann suffers from severe migraines has touched off a national discussion about a surprisingly common disorder that is little understood and often undertreated.

Migraine patients are coming forward with their stories. And while each one is different, they have two common threads: suffering and trying to cope.

For some, a migraine represents throbbing head pain and nausea so severe they retreat to a darkened room for a day or more. For others, it’s about a scary moment, driving on the highway when a migraine-induced aura or vision change forces them to pull over.

“Imagine someone having driven a nail straight through your head,” said Craig Partridge, 50, chief scientist for a high-tech research company in East Lansing, Mich., who began having migraines in his late teens. “And then they periodically tap on it to remind you it’s there. It’s that painful.”

More than 10 percent of adults and children suffer from migraine — which is three times as common in women and girls as in men and boys — and the Migraine Research Foundation reports that nearly a quarter of households are affected. The World Health Organization ranks migraine among the top 20 most debilitating health conditions; more than 90 percent of sufferers are unable to work or function normally during an attack, which can last for hours or even days.

Some migraine sufferers say the attacks are so debilitating they couldn’t imagine taking on a job with significant responsibility. But others note that years of experience and new drug treatments have helped them find ways to cope. Some say the condition forced them to take better care of themselves and adopt healthful behaviors, like getting enough sleep and learning to manage stress.

Mr. Partridge has learned to avoid caffeine and bright lights, and is vigilant about wearing sunglasses in strong sunlight. Years of taking ibuprofen to treat headaches led to an ulcer. Eventually, he learned that a magnesium supplement reduced the frequency of his headaches, and now he gets only about three a year.

“As far as I can tell, everyone is a little different,” he said. “Some people have auras, but I never had auras. I get tunnel vision. My tongue starts to get heavy and I have trouble talking.”

Kat Smith, a 47-year-old mother of three in Bryn Mawr, Pa., remembers her teenage brother suffering terribly from migraines, but she never experienced them until a bike accident in her 20s. Then, after the birth of her son, she had migraines “regularly and fiercely” about 12 times a month. She discovered that small amounts of alcohol and vigorous physical activity acted as a trigger.

“I was a fairly carefree person, but I became rigid, very disciplined with myself,” she said. “It seemed I had to eliminate things that other people associated with joy. I had to reconstruct my life as a person of migraine after accepting that these weren’t going to go away.”

She adapted, giving up ice hockey and aerobics and switching to yoga. But sometimes she pushes her limits. This weekend she took part in a vigorous dance class and was punished with a migraine.

“I’ll do something incredibly vigorous and physical, and it will feel so good,” she said. “That night I will get a massive migraine.”

For many patients, including Ms. Smith, a class of migraine drugs called triptans have been a godsend, helping to cut short the pain. Triptans work by causing blood vessels in the brain to constrict and change blood flow, and can often stop a migraine completely or reduce its severity if taken in the early minutes of an attack.

Other patients take daily treatments to prevent migraine from setting in. Barbara Thompson, a 59-year-old communications specialist in Manhattan, uses Topamax, a seizure drug that has been shown to prevent migraine. An attack sometimes “breaks through” despite the daily dose, and on those days she uses a triptan drug.

“Often I get them when I’m at work,” she said. “I find that I get more quiet, and I have to focus more intently on what I’m doing. It’s a more internal day — I don’t have a better way of putting it.”

In a video that went viral, the television reporter Serene Branson babbled gibberish last winter during a live report from the Grammy Awards. At first, it seemed as if she were having a stroke on live television, but her doctor later concluded that a complex migraine had rendered her unable to form words.

Some migraine sufferers, including Ms. Bachmann, experience pain so severe they go the emergency room. But a recent review of emergency room doctors in Ontario found that patients were rarely treated with the proper drugs for migraine, according to a report last month in the journal Pain Research & Management.

The data suggests that more education is needed.

“If it’s not well controlled with the right combination of preventative or acute therapy, it can be very disabling,” said Dr. Satnam Nijjar, the study’s lead author and an assistant professor of neurology at the Johns Hopkins Headache Center. “It’s probably the most common cause for time missed from work in the U.S.”

Robert Dalton, executive director of the National Headache Foundation in Chicago, says that while migraines can be impairing, the larger problem is that many sufferers aren’t getting proper medical care.

“What we want to make sure people understand,” he said, “is that it’s a debilitating disease when it’s not managed properly.”

How Exercise Can Keep the Brain Fit

For those of us hoping to keep our brains fit and healthy well into middle age and beyond, the latest science offers some reassurance. Activity appears to be critical, though scientists have yet to prove that exercise can ward off serious problems like Alzheimer’s disease. But what about the more mundane, creeping memory loss that begins about the time our 30s recede, when car keys and people’s names evaporate? It’s not Alzheimer’s, but it’s worrying. Can activity ameliorate its slow advance — and maintain vocabulary retrieval skills, so that the word “ameliorate” leaps to mind when needed?

Obligingly, a number of important new studies have just been published that address those very questions. In perhaps the most encouraging of these, Canadian researchers measured the energy expenditure and cognitive functioning of a large group of elderly adults over the course of two to five years. Most of the volunteers did not exercise, per se, and almost none worked out vigorously. Their activities generally consisted of “walking around the block, cooking, gardening, cleaning and that sort of thing,” said Laura Middleton, an associate professor at the University of Waterloo in Ontario and lead author of the study, which was published last week in Archives of Internal Medicine.

But even so, the effects of this modest activity on the brain were remarkable, Dr. Middleton said. While the wholly sedentary volunteers, and there were many of these, scored significantly worse over the years on tests of cognitive function, the most active group showed little decline. About 90 percent of those with the greatest daily energy expenditure could think and remember just about as well, year after year.

“Our results indicate that vigorous exercise isn’t necessary” to protect your mind, Dr. Middleton said. “I think that’s exciting. It might inspire people who would be intimidated about the idea of quote-unquote exercising to just get up and move.”

The same message emerged from another study published last week in the same journal. In it, women, most in their 70s, with vascular disease or multiple risk factors for developing that condition completed cognitive tests and surveys of their activities over a period of five years. Again, they were not spry. There were no marathon runners among them. The most active walked. But there was “a decreasing rate of cognitive decline” among the active group, the authors wrote. Their ability to remember and think did still diminish, but not as rapidly as among the sedentary.

“If an inactive 70-year-old is heading toward dementia at 50 miles per hour, by the time she’s 75 or 76, she’s speeding there at 75 miles per hour,” said Jae H. Kang, an assistant professor of medicine at Brigham and Women’s Hospital at Harvard Medical School and senior author of the study. “But the active 76-year-olds in our study moved toward dementia at more like 50 miles per hour.” Walking and other light activity had bought them, essentially, five years of better brainpower.

“If we can push out the onset of dementia by 5, 10 or more years, that changes the dynamics of aging,” said Dr. Eric Larson, the vice president of research at Group Health Research Institute in Seattle and author of an editorial accompanying the two studies.

“None of us wants to lose our minds,” he said. So the growing body of science linking activity and improved mental functioning “is a wake-up call. We have to find ways to get everybody moving.”

Which makes one additional new study about exercise and the brain, published this month in Neurobiology of Aging, particularly appealing. For those among us, and they are many, who can’t get excited about going for walks or brisk gardening, scientists from the Aging, Mobility and Cognitive Neuroscience Laboratory at the University of British Columbia and other institutions have shown, for the first time, that light-duty weight training changes how well older women think and how blood flows within their brains. After 12 months of lifting weights twice a week, the women performed significantly better on tests of mental processing ability than a control group of women who completed a balance and toning program, while functional M.R.I. scans showed that portions of the brain that control such thinking were considerably more active in the weight trainers.

“We’re not trying to show that lifting weights is better than aerobic-style activity” for staving off cognitive decline, said Teresa Liu-Ambrose, an assistant professor at the university and study leader. “But it does appear to be a viable option, and if people enjoy it, as our participants did, and stick with it,” then more of us might be able, potentially, to ameliorate mental decline well into late life.