August 31, 2006
Last week, I had a simulated patient experience that did not go as well as I would have liked. I was put into a small group with a "teenage patient who had just been drinking and driving in a car accident" (played by a MS-2 student) and we had to use HEADSSS to direct our questions and learn more about her. Unfortunately, the actress was playing the part right from the script -- I felt as though she was firmly sticking to the limited information she was given and didn't want to improvise any real answers with our genuine, conversational questions. The HEADSSS acronym proved useful in insuring that we covered all of the appropriate topics, but it did not generate any information from our patient other than "Yeah," "No," or "I dunno." We were getting frustrated towards the end because nothing we did really brought her out of her hostile bubble. Perhaps that was the whole point of the experience (though others in our class had different ones,) because the MS-2 came back into the room, reviewed what we had talked about and offered this advice: "Well, you could have invited her back for another appointment if there is anything she wants to talk about." As one of my group members put it: "There was no way we could have won that scenario." I think he took it especially hard because he had the counseling portion on responsibility, drinking and life goals.
On Tuesday, I had my first clinical skills experience. A group of us carpooled with Our Selected Preceptor out to a local rural hospital and we went over some of the components of the "chief complaint" and the "history of present illness," two parts of the patient write-up that doctors do. I took a few notes and then we were shuttled off to different hospital rooms to see our first patients!
I was in a group of three and I was assigned the role of History-taker. We chitchatted with Mrs L. for a while to find out why she was in the hospital and I was happy that the OLD CARTS mnemonic came in handy for the chief complaint. She had a fever and severe lower abdominal pain that prompted her to seek medical attention. She talked about her work in a restaurant, the stress involved, her kids and all that good stuff. I wrapped up my section with a good feeling about the experience. She was being transferred out of the Intensive Care Unit because her condition had improved significantly during the week that she was in the hospital. Two of my other classmates performed the vitals and examined her head, eyes, ears, nose, throat, lungs and heart. I was happy that they did it because I didn't really review the components of the physical exam beforehand and I was afraid that I might have missed something.
As it turned out, I missed a lot. Most of the information that a doctor picks up doesn't come from the physical exam; it comes from the patient's unwitting self-exam and history. On the ride back to school, Our Preceptor wanted a mini-report on Mrs. L. I botched the order of presentation, not really realizing the importance of standardizing the report for the listener (as opposed to sharing things in the order that they came up during the interview.) All of my questions were good ones... but I didn't follow up with the right sort of questions.
"So she had a left lower quadrant pain... what is located there?" asked Our Preceptor.
We outlined the various organs located there: her ovaries, her ureters, kidney, large intestine, etc.
"Did you ask about her stool? Was it red or black? Was she constipated? Did she have diarrhea?"
"Ah.... no. Well, I only asked her about the diarrhea, actually."
"What about her urination? Was she having trouble? Did it hurt when she went to the bathroom? Did she have to go often?"
"No, that didn't come up either. She mentioned that her pain worsened when she coughed..."
"She had a recent surgery. Did you ask her about it?"
"Well... I thought that the surgery actually happened after she was admitted to the hospital and we weren't supposed to find out her intervening treatments as a part of this exercise."
The questioning wasn't as brutal as I make it out to be, but I did realize how much of an art it is to properly interview a patient. They aren't going to offer all of the appropriate data freely, sometimes they need prompting, sometimes they might not have even noticed it themselves until you bring it up. It is certainly difficult to try and be an expert when we haven't even covered abdominal problems in our case studies yet... but I'm trying my best.
I'll be reviewing the physical exam sequence and proper medical record documentation so I can be more prepared in the upcoming weeks.
August 27, 2006
This doc was very engaging, very funny and very Chinese. He's a doctors as well as a lawyer, so he's well versed in the legalities and professionalism of medicine. He made a quadrant on the board with an ethical principle in each section:
- Non-maleficence -- Do no harm. ("Primum, non nocere" was nonsensical to him, since it is Latin (and Hippocrates was Greek.)
- Beneficence -- Do good.
- Confidentiality -- To gain the trust of a patient, we must keep it.
- Truth-telling -- To learn the truth from a patient, we must tell it.
- Autonomy -- The Patient has a Right to Decide.
- Distributive Justice -- This was a new one for me. I had never thought of correcting health disparities as a guiding principle, but as we grow in power learning more about ourselves and how we can save lives, it makes sense that we shouldn't reserve it just for the rich and powerful.
- "Rights: Patients have a right to health and health care.
- Balance: Care of the individual patient is central, but the health of populations is also our concern.
- Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health.
- Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.
- Improvement: Improving health care is a serious and continuing responsibility.
- Safety: Do no harm.
- Openness: Being open, honest and trustworthy is vital in health care."
We were posed the question: what would you do if a convicted felon needed a heart transplant? Would you pass him/her over on a transplant list to give it to someone more "deserving?"
We tried to wiggle out of it with qualifying factors: what crime did the prisoner commit? (Someone countered with 'Does it matter?') Is the prisoner a perfect match? Is there someone who is closer to the hospital? What about age?
A girl behind me in class was obviously disgusted with the idea of giving the heart to someone who was obviously heartless. "What if you did the heart transplant and the prisoner escaped the next day and killed your mom? How would you feel?" she asked me.
"That would make me feel bad." I replied. An emotive answer, then a rational one. "But it does not make sense to use that as a reason to deny someone a heart. 'Sorry, but I'm afraid you might escape and kill my mom.' That is a fear reaction. Hopefully it doesn't become a regrettable reality... but it is our job to care."
It is tempting to take a utilitarian POV here and deny the prisoner the valuable organ because he/she is not valuable to society. It is easy to rationalize why they shouldn't get it by looking at an assortment of biological factors. It is nice to hide behind this sort of "objective" rationale...
Which makes me wonder how often these hard decisions are made and who makes them. Do we still have "God Squads" who decide which person lives and which one dies? Do courts injunctions demand one ruling over another?
Just so we aren't left in a sticky situation of ending with difficult rhetorical questions, I'll end with this thought. Ethics are high ideals that we aspire to. Laws are just the baseline of things that can be enforceable. Most of us are stuck somewhere in between.
August 22, 2006
Ask questions in HEADSSS format to perform a psychosocial history on adolescents.
(Originally just HEADSS, now it is HEEADSSS.)
- Home: Who lives with you? What are your relationships like at home? Who are you closest to at home?
- Education: What classes do you like best? Least? Grades? Tell me about your friends at school.
- Activities: What do you and your friends/family do for fun? What sorts of hobbies do you have? How much TV/video games do you do in a week?
- Drinking/Drugs: Do any of your friends smoke? Drink alcohol? Do you? Have you tried other drugs?
- Sex: Are you attracted to boys? Girls? Do you have a boyfriend or girlfriend? How long? Do you get along well? Do you have sex? Does it go OK? Do you know how to say “no”? Do you know how to protect yourself from STDs and pregnancy?
- Suicide/depression: Are you “bored” a lot of the time? Have you lost interest in things you used to enjoy? Have you started hanging out with your friends less and less? Have you ever thought of hurting yourself or suicide?
- Safety: Do you feel unsafe? When? At school? At home? In your neighborhood? Have you ever been hurt by someone?
Start the conversation with light banter to make them feel at ease and possibly open up with something personal after a nice compliment about their clothing or something that reflects their personality.
Accentuate and praise positive behaviors that suggest maturity and resilience.
Use open-ended questions and do not make assumptions during the interview.
Ask questions about friends first -- youngsters are willing to divulge their friends' behavior more readily than their own.
A good way to wrap things up is by asking teens to sum up their life in a word.
Alternately, ask for a " weather report" for the week.
Goldenring, J.M. Contemporary Pediatrics. "Getting into adolescent heads: an essential update" Jan 1, 2004.
August 21, 2006
1) Have you ever felt the need to cut down on your alcohol use?
2) Have you ever been annoyed by criticism of your drinking?
3) Do you ever feel guilty about drinking?
4) Do you need to drink in the morning to wake up (eye-opener)?
Ewing, J.A. Detecting Alcoholism. The CAGE questionnaire. JAMA, Vol. 252 No. 14, October 12, 1984
August 20, 2006
Another reason is related to our visceral belief, our need to feel that we are pure. That we are unflawed at birth. The truth of the matter is... we are not. We are creatures borne of error in the face of chaos, risking everything, day by day. We live to defy our own destruction -- and it scares us. Innate health, the belief that we can heal ourselves... to be truly dependent is a pleasing one. "Why take medication when our bodies makes the same things, the correct things?" I often ask myself. Medicine itself is a dynamic process, changing year by year as we increase our knowledge of the human body. Like the body itself, it comes with inherent limitations. We cannot conquer all boundaries, we must all face the same ending. Inevitability and uncertainty are our enemies. A doctor must be an ally in the process, not an antagonist. They must listen with humanity and empower their patients with confidence and acceptance. Confidence that modern medicine is doing it's best and acceptance that there can be nothing better. Snake-oil is pricy, especially for something that's actually nothing.
"Have you ever seen a Dr. Nx?"
"Do you have a personal blog where you made any negative comments about him?"
"He's accusing you of slander, for painting him as an inconsiderate, tardy doctor."
BWA? Sure. However, this was an event that was a year old and I had gone on a trip for spring break to shadow some doctors with a club. A bunch of doctors had agreed to let the pre-meds follow them around in various parts of the hospital and clinic. I was just commenting on my experiences and I mentioned that "Dr. Nx left me sitting around for half an hour, then when he got to work, he left me sitting around for another half hour so I ended up following another doctor around." It was just a sentence in a long reflection entry. This was on a blog entry that I had made "private", but unbeknownst to me, Google had a cached version of the entry.
The dean believed me and told me that he thought the doctor was on pretty thin ice to get me on academic probation for libel, especially if the incident was well over a year ago and no longer "public." I was given the doc's phone number so I could call him to apologize.
I swallowed my emotions and I called up Dr. Nx. He seemed very upset, but he tried to talk to me in a reasonable manner, telling me how "I screwed him over." He calmly explained how easy it would be for someone to Google his name for a job interview only to see my little careless blurb about his tardiness that stains his reputation as a doctor. Then he proceeded to give me his excuse/explanation for why he was late and why he ignored me when he arrived.
Okay, I can see how unprofessional it would be to be googled and have these negative impressions pop up #7 of maybe 20 sites. I didn't write with the intent to upset anyone; I just wanted to say "oh, I had a fun trip, except for a few rare instances."
Then, he dropped the bomb.
"If I weren't such a nice guy, I could call up your medical school and .... talk with Dr. Sx, your medical school interviewer, right? I could tell them that you slandered me. I could make sure you wash test tubes for the rest of your life."
This certainly implied that he had been reading through my entries since the event.
I thanked him for being a nice guy. I promised to "contact Google to get rid of its Google cache of my personal blog site." They were both lies, but they placated Dr. X... and that was sufficient. My Undergrad School had their "formal record" of the story from both sides and received no further complaints from Dr. Nx.
This was an eye-opening experience for me. This will be the ONE and ONLY time I will make negative comments about anyone on NotMySecondOpinion. I've learned that casual comments on the internet can last forever... luckily for me, there weren't any regrettable consequences from my harrowing experience.
August 17, 2006
"Oh, I'm allergic to alcohol..." you might say. The flushing reaction, the nausea, vomiting and headache sound like good symptoms.
Not quite. You actually have a mitochondrial enzyme deficiency in "ALDH2." What is that? Well, alcohol is absorbed in your stomach and your liver starts grinding away at it with alcohol dehydrogenase (ADH.) The byproduct of this reaction is acetaldehyde. In most people, this acetaldehyde is converted into acetate with the enzyme aldehyde dehydrogenase (ALDH.) However, some asian people lack this enzyme and the aldehyde builds up. The high concentration of aldehyde (along with alcohol) builds up in the blood, leading to those unpleasant feelings that other people might get after having 10x as much alcohol.
The fact that this is a "mitochondrial enzyme" made me wonder if this meant that you could blame your mom for your intolerance to alcohol. After all, you inherit all of your mitochondria from the parent that bore you into the world. I poked through a few scientific journals on PubMed. I learned that it was a dominant allele (meaning that your parents are much more likely to pass on to you and affect you.) ALDH is active in mitochondria AND the rest of the cell (likely by ALDH1 or something like that)... so you actually clear acetaldehyde slowly... and your dad might be to blame.
"Why would evolution punish me so?!?" you might ask, being afflicted with this horrible, party-pooping disability that cripples your now-withering social life. Well, there's a theory that it has to do with cancer. HepB is a sexually-transmitted virus that you can get from your mom at birth if she has it -- and a lot of women in Asia have this virus. HepB greatly increases your chance for liver cancer. Drinking adds to this risk by causing liver damage and cirrhosis, so having ALDH2(2) might be a historic marker helping to prevent cancer! Nowadays, we have a vaccine that prevents Hepatitis B, as I've mentioned before.
If that is not enough for you, be glad that it prevents alcohol toxicity, which can lead to serious problems like blackouts, coma and death. You just get minor aldehyde toxicity instead. Just remember, there's a reason why it is called inTOXICation.
Crabb, DW. Genotypes for aldehyde dehydrogenase deficiency and alcohol sensitivity. The inactive ALDH2(2) allele is dominant. J Clin Invest. 1989 Jan;83(1):314-6. PMID: 2562960
Jenkins, WJ. Subcellular localization of acetaldehyde dehydrogenase in human liver. Cell Biochem Funct. 1983 Apr;1(1):37-40.
Lin, YP. Why can't Chinese Han drink alcohol? Hepatitis B virus infection and the evolution of acetaldehyde dehydrogenase deficiency. Med Hypotheses. 2002 Aug;59(2):204-7. PMID: 12208210
August 13, 2006
This program allows you to freely link concepts together in a simple-to-use, free program with a lot of powerful features like synchronous editing (for maps hosted online,) suggestions (that offer linked-concepts from other maps) and an outline view (with a list of the concepts made, prepositions used and linking phrases.)
How is this useful for a med student? Here's a few maps that I've made last night using this program -- the little icons illustrate the ability to link resources to the map!
It is very useful for visualizing mechanisms and learning where your knowledge is deficient!
Here's a wikipedia link to a list of concept map programs that you can check out.
Some professors will have a recommended reading list -- they might even require some texts. There's only a few that I've been told are really required and those are the only ones you should really buy in your first year.
You might also be hearing about PDA software. You don't need to fork over a lot of money to get the portable info you need. There's a few programs that everyone I've talked to uses and I'll share them with you.
First, some reading lists:
So you'd like to... know what books I bought for medical school Amazon.com
So you'd like to... succeed in medical school Amazon.com
Notice the overlap in books.
A medical dictionary like Taber's or Stedman's comes with software. I bought the Stedman's with PDA software and I really like it. Since I'm pretty clueless at this stage in the game, it has been very helpful.
Robbin's Pathologic Basis of Disease is a must buy. Some people recommended that I read through the 1st ten chapters of this big book by the end of the semester. Sure. That doesn't sound so bad, but it is dense reading. Perhaps "baby" Robbins (Basic Review of Pathology) would be better suited for this purpose.
Lippincott's has a review of Biochemistry, Pharmacology and Microbiology. Biochem is the favored Lippincott's text; the other subjects have different books that suit different people.
Clinical Microbio made ridiculously simple looks ridiculous alright. At first, I didn't really like the pictures, but they are starting to grow on me now. I already took microbio in college, so most of the concepts are not very helpful. There are a lot of fun mnemonics though!
Each school has their own curriculum. My Med School is geared by case-based studies of organ-systems, so the books that I have are mainly looking at differential diagnoses, rather than "basic" science subjects covered in the USMLE Step 1.
PDA software sites
Ectopic Brain is a blog with a lot of up-to-date resources.
Yee's Medical Palm Info is little outdated, but he still has some good info.
Epocrates Rx free is a drug reference program that also has a formulary based on local insurance policies so you can write the right prescriptions.
Medical Mnemonics.com - Use this! It is a lot of fun... and I've already been posting up a few mnemonics from this program that I've found useful.
Johns Hopkins Antibiotics Guide is an "Epocrates Rx" for Abx.
MedCalc - I'm hoping I won't get in trouble by relying on this one too much in the future.
On a different note, I really like using McPhiling to switch quickly between my programs without going to Home first. It also has a cool pseudo "Alt-Tab" feature to flip back and forth between your current and previous program.
Well, I hope that has been helpful!
If you have any other links or books to recommend, please feel free to comment.
August 11, 2006
August 10, 2006
The thing is, ethical issues are HUGE. I feel like I don't give the time they really deserve if I poke in and comment on the few issues that crop up day by day.
Philosophical entries are monstrous as well. I love thinking about these things, but it is difficult to trim down my thoughts into a coherent essay -- a recreational essay at that -- and give it a solid opening and closing.
So, I'm going to change my focus a bit. My other goal of this blog, educating the public (read: you!) about health and social issues, has been much more successful. I think that the addition of the mnemonics section to my themes will give you new entries to check out on a daily basis. Mnemonics and news are just short little clips that I can pop out with next to no effort or thought.
Unfortunately, next-to-no-thought is not what I want this blog to be about. Weekends will give me the time to compose myself and write the better entries that I have been stewing in my mind that I have not had the time to write during the week.
August 09, 2006
The parts of a sarcomere correspond to the following mnemonic:
Additionally, the light and dark bands are isotropic and anisotropic. The second letter of each word corresponds to the band name and its properties.
dArk (A-band, anisotropic)
lIght (I-band, isotropic)
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August 04, 2006
pu·ri·ty Pronunciation (pyr-t) n.What is so great about purity?
1. The quality or condition of being pure.
2. A quantitative assessment of homogeneity or uniformity.
3. Freedom from sin or guilt; innocence; chastity: "Teach your children . . . the belief in purity of body, mind and soul" Emmeline Pankhurst.
4. The absence in speech or writing of slang or other elements deemed inappropriate to good style.
5. The degree to which a color is free from being mixed with other colors.
[Middle English pur, from Old French, from Latin prus; see peu- in Indo-European roots.]from the FreeDictionary.com
Frankly, I'm not such a big fan of the idea. I am not suggesting that the other extreme of corruption is ideal either... but the broad advocation of purity does not sit well with me. I think that balance should be the focus, not purity!
What am I referring to?
Plenty of things. Innocence, for one. Lack of "taint" or "color" for another. Finally, too much of one good thing.
What about innocence?
Innocence is a quality that can only recede or remain constant in people over time. Experience constantly exposes us to new things; some of these things shocking and horrible like the death of a close loved one, or the marriage of another. ;-) Other things can only be experienced with other people (like sexual intercourse) in an intimate setting -- creating a great deal of mystery about what goes on behind those closed doors.
Unless we block out our memories, traumatizing events will remain with us for the rest of our lives. Even if we forget, paper records, people and other things exist and remind us that we are not so innocent after all.
Why is innocence valued?
When we see young children playing, people often comment "oh, to be so young and innocent again..." These children have something that we never will. However, is Ignorance a thing to be treasured? What about Confusion? Children are clueless, chaotic little creatures that need guidance and discipline. They can be brainwashed to learn absolute garbage or they can be groomed to become multi-talented bright young stars. Purity provides adults with a blank slate. Careful though! Kids scribble on slates just as well as parents do.
It is nice that children have a fresh outlook on life. This gives us perspective and in many ways, it balances our own lives.
We might get lost in the day to day "grown-up" activities of making money, paying bills and acting busy that we forget the reasons why we are working hard. Children live life. They want to learn new things, be amazed by the world and experience things! It is this process that enriches the lives of parents who rediscover their child-like wonder.
What were you saying about lack of "taint" or "color"?
How many colors are Red and Yellow and Blue? (Answer: Three.) Now, if you mix these three colors together in as many ways as you can think of, how many do you have now? (Answer: Lots! All the colors we know!) From an aesthetic point of view, which do you prefer?
Purity is boring. In many ways, purity is a cultural force that drives us to become stiff, self-conscious and dull. Purity can leech our lives of things that might be dangerous, exciting or fun. It also drives us to a single, unifying extreme; polarizing the world by drawing constrast between Us and Them.
How can we have too much of a good thing? What is wrong with that?
I'll answer with a story. In ancient Peru, Incan settlements were far apart from each other, from the Amazonian jungles in the east, through the mountainous Andes in the center, to the coastal plains in the West. In order to travel these long distances, Incans often carried bags of small leaves that gave them a boost of energy and suppressed their hunger. These leaves were so important to travel that distances were measured in how bags one ate along the way!
When the Spaniards first heard about this magical leaf with the powers to imbue strength and energy, they dismissed it as ignorant nonsense. However, they soon found out that they were true and they began to use it as a cash crop. It also had properties of pain-relief and it was beginning to worm its way into medicine.
The active ingredient in the leaves was isolated in 1855 and it was the subject of Albert Niemann's dissertation in which he stated that:
"Its solutions have an alkaline reaction, a bitter taste, promote the flow of saliva and leave a peculiar numbness, followed by a sense of cold when applied to the tongue."Cool! It began to be used as a cure for flatulence, teeth whitening, toothache, morphine addiction. It was put into various drinks to enhance their ... experience. Coca-Cola is a famous example.
This magical leaf comes from the coca plant; the active ingredient that was isolated is cocaine. The Victorian era that used cocaine as a harmless anesthetic now looks quaint in comparison to now. We have a strong street drug culture hooked in the powerful cycle of addiction.
This might look like we have been tainted by the influence of cocaine on our society, making it less pure. This is true, to some extent. I prefer to see it as the purification of cocaine from the coca plant as the root of our current problem. Same goes with the poppy seed story. And perhaps,
What is the real evil of cocaine, though?
It is not the knowledge of how to isolate and purify these narcotic compounds. It is not necessarily their use either -- someone on their deathbed might need powerful painkillers as a palliative measure (and if they are going to die, the risk of addiction is irrelevant.)
The real evil is the ABuse of these drugs. The people who are irresponsible and use these powerful chemicals to mess up their bodies big time for a single, very selfish purpose -- entertainment and recreation.
Why should we be wary of purity?
It is important to remember that there is a balance in all things. Too much innocence makes kids vulnerable to bad influences because they don't know any better. Protect them, but at the same time, let them explore. It is important to educate them about consequences and responsibility.
Adults are just old kids. They can be subject to brainwashing too. In order to differentiate between good and bad things, we need the knowledge of good and evil. We make our judgments about what actions to take based on this knowledge -- an uninformed opinion is one in danger of being 50% wrong!
Everyone has their differences. Stamping a few of these differences out because they make other people feel uncomfortable is not a good thing. Diversity, exposure to many novel and interesting things, is what gives us a broader perspective about the world.
The isolation and purification of any particular thing, be it a certain group of people or a chemical, can lead to an overdose if abused! Purity driven by self-righteousness, greed, selfishness or hedonism is a destructive influence.
Purity must always be tempered by the virtues of balance, education, diversity and responsibility in order to be used wisely.
August 03, 2006
PERRRLA or PERRLA or PERLA
R ound, Regular, Reactive to
L ight &
This one is well-used by physicians. The doctor turns off the lights and determine light reflex with a penlight or opthalmoscope.
This one will help you remember the various techniques you can use to assess the patient.
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