Inspired by Pixar

My two favorite companies are Google and Pixar. They have an amazing group of individuals with energy, passion and creativity that allows them to do things that have never been done before! I think it's absolutely incredible... and perhaps in another life, I would have loved to work for them in some fashion or another.

From watching a lot of special features from Ratatouille and Wall-E, I pondered a lot about the cultivation of the "culture" that Pixar has created for itself. Of course, the playful fun and games environment makes them LOVE working and so, they are all dedicated to seeing a project through to its completion. It is the sort of place that I'd like to work at... but really, can that exist in a hospital or a clinic in any form?

I am reminded of what one of my interviewers said to me. He inquired about my hobbies, my loves and I told him about my enthusiasm for the game of Dungeons and Dragons. How this alternate reality has given me a freedom to explore and understand characters... feel young with my imagination. "Don't lose that," he told me. "Hold onto that when you become a doctor." I guess I could have a pediatrics exam room decorated with anatomy of dragons and old posters of alchemical potions or something. :)

In all honesty though, it really gave me pause, trying to think of how my future profession utilizes creativity in an everyday sort of a sense. After all, a lot of what I spend my days doing is learning facts and understanding evidence, with the ultimate intent of practicing the best medicine possible. What room does that grant me? I can't be wild and crazy with my application of antibiotics in the treatment of cellulitis. I can't come up with some genius new technique for stitching up an incision.

Then, it hit me.

The art of medicine... that elusive thing that I realize each and every time I sit down with a patient, I really don't know anything at all. The art comes from a few things.

Elicitation - Asking the right questions to create a differential and swiftly narrow it down to a convincing diagnosis.
Elucidation - Clarifying the complaints and concerns of the patient.
Inspiration - Recognizing moments of connection and acknowledging them, chasing down a clue that a patient may have only hinted at by a small gesture, snapping on an excellent diagnosis and proper management
Exclamation - Conveying a diagnosis and educating the patient on his/her role in its management

and that's just the doctor-patient relationship. there's the nurse-doctor relationship, the insurance-doctor relationship, the wife-of-doctor relationship things that must be managed with as much care as the dr-pt.

This "art of medicine" may not have the same sort of creative energy that an "art of animated movie" has... but I'd argue that it's much more important, because its so fundamental.

'Bio-Beer' Designed to Extend Life

Nov. 10, 2008 -- Here's a reason to raise a pint; scientists at Rice
University have created beer that could extend your life.

BioBeer, as it's called, has three genes spliced into special brewer's
yeast that produce resveratrol, the chemical in red wine
that is thought to protect against diabetes, cancer, Alzheimer's and other age-related conditions.

The eight graduate and
undergraduate students created BioBeer as part of the upcoming International
Genetically Engineered Machine (iGEM) competition. The iGEM Jamboree, as the
annual meeting is called, took place at the Massachusetts Institute of
Technology November 8th and 9th.

Hehe, proof positive that GE foods CAN kill you! ;)

Head to Head: Hospitalists and PCPs

Dino seems to think that Hospitalists are equivalent to Subprime Mortgage lending... not sustainable and the bubble will pop eventually.

His reasoning?

My point is that if [Happy Hospitalist] cannot produce enough income to cover his salary, benefits, etc. and the hospital cannot find other monies with which to pay him, then eventually the same situation will occur at every hospital. It may take a very long time for this basic fact of economics to percolate through to the critical point -- perhaps longer than Happy's professional career, at which point he'll just retire and laugh at the rest of us struggling to take care of patients, who will always be there. But the situation is not financially stable. Eventually it will break down. It has to. It's just basic economics.

Look at the housing market. It took decades, but because of the fundamentals of subprime lending, it had to happen. You cannot go on indefinitely spending more money than you make.

http://dinosaurmusings.blogspot.com/2008/11/what-happy-hospitalist-and-subprime.html

Happy Hospitalist responds with his opinion.

Simply put, because the market says so. Hospitals are willing to pay for the services hospitalists bring to the table. I blog continuously about how hospitalist medicine has left the fixed pot of the failed economics of RVU/SGR engrained in the Medicare Part B. If hospitals did not value our service, they would not be subsidizing it, and they would not be paying an average subsidy of $100,000 per hospitalist.
...
DRG. Known as diagnosis related group, this is how most hospitals get paid by Medicare. If you get discharged with a diagnosis of chronic obstructive pulmonary disease (COPD), the hospital gets paid a fixed dollar amount for that diagnosis.
...
You see Dino, my value on the front end, doesn't even come close to the value I bring on the back end. Not even close. The millions upon millions of dollars in DIRECT money being paid to hospitals in terms of increased admissions/DRG's more than makes up for the several hundred thousand they pay out for the right to have me at their hospital.

What if the hospital isn't always at capacity? The decreased length of stay could potentially decrease their staffing/labor needs without any decrease in reimbursement.

So the DRG argument is a huge one. It brings in more money for the same labor. It allows much higher paying procedural admissions to have a bed and not get diverted to another hospital. It discharges the often money LOSING internal medicine admissions sooner and decreasing labor resource consumption on your money losing granny with COPD.

He goes on to cite Physician Satisfaction, Happy Staff, Happy Patients, Efficiency, Documentation, Unassigned/Uninsured, CPR response, Out of State Referrals as other reasons. I'm less inclined to talk about them because ... well, a good PCP has these same traits also.
http://thehappyhospitalist.blogspot.com/2008/11/hospitalist-medicine.html

Then, DB chimes in as well.

The Dinosaur, like many generalists, seems to write this rant with some anger. The rapid growth of hospital medicine has actually had a negative impact on family medicine and outpatient internal medicine. I understand Dino’s anger, but I really do believe that hospitalists are here to stay. Hospitalists are here for the same reason that ER physicians are here - because they are filling a role that no one else wants. Many generalists have ceded inpatient care to hospitalists. Many surgeons cede inpatient care of surgical patients to hospitalists. Many subspecialists would rather have the hospitalists provide the daily care and then they can just provide consultation.

http://www.medrants.com/index.php/archives/3908

I am just a mere bystander to this new up and coming Hospitalist field. I'm also at the cusp of deciding which path in medicine I will take, so their arguments mean a lot to me. My own worries about these fields diverge slightly from their concerns about economic sustainability though. I am witnessing a lot of graduates of my medical school in the IM program going on to become Hospitalists. It certainly is nice to run into them in the hospital, but I wonder what will happen to the outpatient internists and other PCPs.

I respect Hospitalists. They bring a lot to health care by providing care to patients IN the hospital. However, I've never heard anyone say "Ooohh... I love my Hospitalist at Queens. You should go to her!" Hospitalists do not have the same relationship with their patients as a primary care doctor. When they DO have continuity of care, it is almost a failing of sorts -- given their block schedule, a patient they've discharged (yay for DRG cost-savings with earlier Hospitalist discharges!) has likely returned with some sort of complication. Not necessarily by any fault of their own; patients like this are really sick. I was totally bummed out when some of my patients came back to the hospital.

I respect Primary Care Physicians. They have the ability to be the most cost effective doctors by providing early education, screening and intervention for preventable diseases. They have relationships with patients that are sustainable over time and are not based solely on the tragedy of illness. They have the tremendously difficult job of being the sentry on watch for ALL disease, filtering out which cases deserve specialist attention... and they take a brunt of the blame if something shows up inside the city. I've heard a professional bemoan "primary-care-ville" whereupon amidst the sniffly noses, hypertension and diabetes, someone missed the diagnoses of hemochromatosis and pheochromocytoma even though they had very benign presentations.


Hospitalists and PCPs follow different philosophies in their practice. I enjoy the academic side of inpatient hospital care. I enjoy the personal side of outpatient family medicine. Hospitalists take the thick slice of comprehensive care, seeing all sorts of patients in an acute setting. PCPs take a long slice of comprehensive care mainly seeing all sorts of patients in an outpatient, non-acute setting. Can they handle seeing their patients in the hospital as well, given the rise of the hospitalist specialty?

Probably not. I think Hospitalists are here to stay and trends in inpatient care management show it. The big question for me is... what do I want to become?

I'd like to think that it's easy to remain vigilant and spot that one zebra in a neverending horse show. I'd like to think that choosing a specialty is about more than the amount of money I'd make, or the money I'd save the hospital or the healthcare system. I'd like to think that I'll have a decent schedule and I'll get respect for my work no matter what I end up in.

I'm quite certain that these are all merely delusions of a third-year medical student and someday soon I'll be ranting as much as Dino and Happy.

Pondering on: Psychiatry

"Psych is a good break, so schedule it in between two hard rotations like OB/GYN and Surgery."

That's the advice that sage MS-3s will give the wide-eyed MS-2s as they plan out their schedules for third year. I wondered why this was so and whether or not Psych deserved the "bad rap" that they got for being easygoing slackers.

The wonder vanished when I entered Psychiatry. As a disclaimer, I am not saying that Psychiatry residents are trying to avoid hard work or do as little as possible for their patients. After all, they are still doctors and ALL doctors are caring and they all work hard (at least all of the ones I've met so far have upheld this archetype.)

I noticed that there is a certain aura that Psychiatrists try to cultivate. It is a very crafty and carefully created sense of ... relaxation. Low stress. The level of care for our med-student well-being went far beyond what was necessary and it was almost laughable at times. Here's a true story of something that happened to one of my friends:

"You rounded on your patients instead of having lunch?!? WHAT?!? Go eat! Go to the dining hall. We don't really need you here for our afternoon psych rounds anyway."

I would almost feel bad about hanging out with the residents in my attempts to soak up psychiatry when they were sitting around idly. I think the record earliest time I ever got out was by noon. Granted, this was after rounds with three separate attendings/groups and we rounded on a lot of patients, but that is really early. And I wasn't done for the day; I still went to school to read about psychiatry.

In my opinion, the reason why the psych residents were so aggressive about being so relaxed has a lot to do with their patient base. I was on the consult-liaison service at a large hospital in my state. There are a lot of patients who were admitted to the hospital and had psych issues come up tangential to their main diagnoses. We were called in to see them for the psych issues. It wasn't necessarily because the medicine or surgical teams couldn't handle alcohol withdrawal syndrome or depression or schizophrenia. They didn't have time to take care of these problems.

THAT is the crux of the psychiatrist. Their niche comes from having this precious TIME to sit down and talk with patient for as long as it takes to make a connection and help them feel better.

Even if they have a ever-growing list of patients on the service, the no-stress attitude keeps them from glancing at their watch or the clock (and undoing a lot of patient rapport when the patient feels pressured to "wrap things up" or what have you.)

5 Tips for Telling Better Stories

And how to apply it to your case presentations. The majority of these pearls are things I've gleaned from simply writing FIVE History and Physicals on some of my patients in the Inpatient Medicine block... my preceptor is very particular. She was very thorough in with her criticism, but as a result, I really felt the difference in my thinking. I'd like to send these tips along to you.

1. Keep it simple.
* A strong assessment needs to occur in your head FIRST, in order to frame a simple story, simply. I've made a lot of short stories much longer with my med-student induced compulsion for all details regardless of relevance.

2. Openings and closings are very important.
* Like an abstract for a research article, the first sentence should be the last thing you write. This sentence should give away your entire story and make the listeners feel smart for figuring it out so swiftly.
* Similarly, for the listeners that zoned out the whole time, you need to piece the whole thing back together at the end.

3. Be mindful of your story’s spine.
Keep in mind that EVERYTHING you say must come from the Patient-First Perspective. What does that mean? You need to pay attention to everything they say!
* Don’t interrupt the patient! There have been studies that show doctors interrupt the pt after only 18-22 sec (on average) after asking "so tell me what brought you here to the ED/hospital/clinic." However, given the opportunity, patients will only talk for 90 sec (on average) and no more than 2 min uninterrupted... much shorter than it feels I'm sure with the most verbose patients.
* Giving patients the opportunity to frame their OWN story before you stuff them into a boxed diagnosis gives you the chance to uncover something brilliant. I always make a few good observations on my team's behalf whenever I remember this particular rule and give the patient some freedom at the beginning of the interview.

4. Make sure not to alienate your audience.
* Residents, attendings and consultants are very busy people, I've learned. It's best to figure out EVERYTHING that's important before you dive in and present your case. The whole reason why med students are required to ask everything in the history, perform everything in the physical exam and present everything in a systematic order is NOT to bore people to death, though that's a major side effect. It's because we're dumb. We don't know what is important yet.
* Basically, as a med student, you should revisit this fact and remember who you're talking to. Sure, for the purposes of displaying your full understanding and adherence to procedure you can recite a HUGE laundry list in your review of systems... but the attendings will cut you off. Cater your speech to them.

5. Tell the truth.
* In rounds, I've frequently joked and said "oh, just make something up, they won't know the difference" whenever someone asks a solid question that wasn't investigated further as a query to the patient, lab data not collected or study left unperformed. But really, this negates the whole point of the rounding exercise. A patient's wellbeing is at stake.


References
Hat tip to A Storied Career
Gordon, GH. Defining the Skills Underlying Communication Competence. Seminars in Medical Practice. Vol 5, No 3. Sept 2002.

McCain Hates Science and Math. (My Biased Opinion.)

I am OUTRAGED that McCain has cited several items in SCIENCE as "pork-barrel projects. Nothing pisses me off more about his campaign than his blatant ignorance about the importance of science.

"[Obama] voted for nearly a billion dollars in pork barrel earmark projects, including, by the way, $3 million for an overhead projector at a planetarium in Chicago, Illinois. My friends, do we need to spend that kind of money?"

MY friends, we spent $3 million of your money to study the DNA of bears in montana. Now, I don't know if that was a paternity issue or a criminal issue, (LAUGHTER)... but the point is, it was $3 million of your money. It was your money. And, you know, we laugh about it, but we cry - and we should cry because the Congress is supposed to be careful stewards of your tax dollars."

On Science Friday and in the Scientific American, the scientists speak out.

They insist that the [Bear DNA] study is not only worth every penny but that the $3-million price tag cited in the ad is, in a word, wrong.

In fact, Congress over the past five years has forked over a total of $4.8 million to study the genetic material of Montana's grizzly bears, according to Katherine Kendall, a research biologist at the U.S. Geological Survey (USGS).

“This is not pork barrel at all,” says Richard Mace, a research biologist with Montana Fish, Wildlife & Parks (FWP). “We have a federal law called the Endangered Species Act and [under this law] the federal government is supposed to help identify and conserve threatened species.”

The fact that he calls it a "$3 million dollar waste of money" instead of the higher price tag goes to show that he can't even do simple MATH to criticize a program. Not only that, but it's evident that this program IS a paternity issue. It's studying the ancestry of an endangered species! DUH.

On ScienceDebate2008, McCain replied to the top 14 pressing questions candidates should answer. Here's his take on science and education. Funny how his actions diverge from his words. Or maybe its just his words contradicting his other words. Hypocrisy!

• Eliminate wasteful earmarks in order to allocate funds for science and technology investments;
• Grow public understanding and popularity of mathematics and science by reforming mathematics and science education in schools;
• Basic research serves as the foundation for many new discoveries and represents a critical investment for the future of the country and the innovations that drive our economy and protect our people. I have supported significant increases in basic research at the National Science Foundation. I also called for a plan developed by our top scientists on how the funding should be utilized.

UGH. I'm soo annoyed by this... on top of everything else that he's said or done so far this election. I must admit, I liked him a lot more when he wasn't running for presidency and merely keeping up his national image on the Daily Show and other shows.

(edit: And apparently, I hate english. I corrected some of my glaring spelling and grammar errors. It's been a while since I've written anything in proper English! *shakes a mocking fist at 5am Medicine Notes*)


Palin chimes in with her bit.

"Where does a lot of that earmark money end up, anyway? [...] You've heard about, um, these -- some of these pet projects they really don't make a whole lot of sense, and sometimes these dollars they go to projects having little or nothing to do with the public good. Things like fruit fly research in Paris, France. I kid you not!"

Wow. I'm sure that "fruit fly research" is EXACTLY the sort of waste-of-money earmarking that you think it is... and it has no impact on autism research.

Pondering: on Medicine

I'm busy on the Medicine service right now. It's by far, my favorite rotation so far in my third year as a medical student -- and I've done a month of inpatient OB/GYN, Psychiatry, Surgery and Medicine so far!

Medicine contains enough of what I learned as a first and second year that I don't feel totally lost in a new world of procedures (uncomfortable bouts of standing and trying not to infect patients in GYN/Surg) or protracted interviews (with difficult formulations in psychiatry!) Inpatient Medicine adds on a whole new level of intensity in admitting patients from the Emergency Department and caring for patients in the Intensive Care Unit, transitioning them down to the Progressive Care Unit and then out into the world. Surgery does this as well, but the majority of my day was spent in the OR rather than the ER or on the wards. To be quite honest, my favorite days of surgery were on the days when our general surgeons weren't in the OR and I had time to round on my patients and figure out how to manage their problems.

That must make me totally IM in the Medicine vs Surgery battle...

Best of: OB/GYN on HPV

In Grand Rounds for OB/GYN, a lecturer talking about vaccinations for young women said something that I thought was totally hilarious. My vague recollection of the quote goes something like this:

A study showed that 32% (95% CI 22.5-44%)of men in a university setting (n=240) had detectable HPV DNA on their hands. (1) That's not necessarily saying anything about their sexual habits...

He went on to say "It just goes to show that HPV is more prevalent than people think. And it can easily spread through hand-shaking." This does raise the distinct possibility of the hand-genital route as well, suggested in an earlier article. (2)

As funny as I found this initial statement to be, it's a serious and sobering topic. Especially since we have the HPV vaccine that can prevent cervical cancer with about 70% coverage. (Not good enough, by Dino's standards.) According to this week's Morbity and Mortality Weekly Report, "an assessment of HPV4 coverage, which is reported for the first time, showed that "25.1% of adolescent females initiated [Gardasil], the vaccine series (>1 dose) in 2007." Yay!

The Health Science Report shares information about the transmission of HPV in general, which can happen through other routes than sexual contact.

A report in 1/08 from the Journal of Infectious Diseases suggests that young women have an increased risk for HPV infection when their first male partner was sexually experienced with a Hazard ratio of 8.5 (95%CI 3.1-23) for 3+ previous partners, 3.6 (95% CI 1-12) for 2 partners and just 0.4 for 1 previous partner (95% CI 0-3.3) with 1.0 Hazard ratio as the reference for first sexual partner. (3)

References
1. JM Partridge - JOURNAL OF INFECTIOUS DISEASES, 2007. Genital Human Papillomavirus Infection in Men: Incidence and Risk Factors in a Cohort of University Students.
2. C. Sonnex. Detection of human papillomavirus DNA on the fingers of patients with genital warts. Sex Transm Infect. 1999 October; 75(5): 317–319.
3. Winer RL. Risk of female human papillomavirus acquisition associated with first male sex partner. J Infect Dis. 2008 Jan 15;197(2):279-82.

"When should I start teaching my children about sex?"

Dr. Karen Rayne has an excellent answer to this question that touches on the underlying implicit emotional issues that are often ignored in our often explicit and graphic culture. Here is an abbreviated version of her typical answer:

When you “should” start teaching about sex doesn’t really matter - you DO start teaching about sex when your children are infants.
...
You teach them what a gentle touch feels like and what it is to be loved.
...
We teach them the names of their body parts, and the names of everyone else’s body parts too.
...
We teach our young children how to be a good friend, how to share, and how to reconcile arguments and disagreements graciously and with love.

This is a wonderful lesson for everyone to have -- I think there are many ADULTS who still haven't been had proper sex-education in this context.

Read more from Dr. Rayne @ Adolescent Sexuality

DNR does not = Do Nothing

I'm finishing up my write up tonight and my last Problem to be addressed in the Assessment/Plan is a terminal condition. I found this article on the subject from Family Physicans/Residents pondering the subject. I'm wondering if this is something I should bring up with my patient since I've avoided it in all of my previous conversations with her.

Discussions of "code status" on a family practice teaching ward: What barriers do family physicians face?
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=80314

One of the things that bothered me when I was a hospital volunteer in high school was the very STRANGE pronouncement in my opinion, on the doors of some of the patient rooms: "DO NOT RESUSCITATE." Even as someone tangentially related to the healthcare field at the time, I thought it was an overtly insensitive and harsh statement. I think my reaction could be summed up as "Why are you banning people from getting healthcare?!?! Isn't that the REASON they are in the hospital?"

I'd like to emphasize that no decisions are final and “Do Not Resuscitate” does not mean “do nothing”. A term like “Allow Natural Death” is equivocal in meaning, but very different in the eyes of a patient and their family. It adheres to their wishes to have “everything done” so they do not feel like they are giving up, without prolonging their suffering with unnecessary and futile medical care.

Ultimately, “Allow Natural Death” is a permissive activity, asking patients if they feel at peace and are willing to let go.
“Do Not Resuscitate” is a dismissive activity and patients may feel ignored or that they would get worse care this way.

As an aside, this is a great example of connotation versus denotation. I struggled to remember these two vocabulary words for about half an hour now. Whew!

This is not the case! One thing I am learning right now by following my residents into the ICU is that many patients who are "Full Code", meaning they will be resuscitated to the fullest extent regardless of the quality of life and eventual outcomes for the patient receive TERRIBLE care as a result... getting hit with all sorts of hospital acquired illnesses from drug-resistant bacteria, thrashed with drugs that work so hard to provide blood to the heart and brain that they literally amputate limbs from within... my goodness.

What is necessary in the hard times when a patient is on their last limb before they go is an honest and heart-to-heart discussion between a knowledgable individual (the doctor) and the people who will ultimately have to make the decision for someone to die. NOT live or die. Just die. There's no other options for a lot of these folks and THAT is the concept that must be conveyed appropriately to the general public who don't know what tonic-clonic twitches are, the different categories of death ranging from asystole to brain death to cessation of all biological function and a shift to true equilibrium. I know I've made no effort of my own to define these words. That makes me a hypocrite (for now.)

Feel free to discuss this topic in the comments (and I'll chime in with my definitions later.)

Trauma Call

I had trauma call for my Surgery rotation last night. It was traumatic, all right. Not in the gruesome sense of the word, images of human flesh cleaved open by a car, or fecal matter spraying the walls of the OR or anything like that. Let's just get that out of the way.

It was intellectually traumatic.
Trauma situations require fast thinking, reflexive actions. They don't spare any moment for deep, ponderous considerations, my usual sort of cognition. I read through a few thick handbooks the night before, nodding off and on around 10-11pm in a meager attempt to prepare myself for the Trauma call.

We had a Trauma Simulation lab at my medical school in the afternoon, complete with ED physician teachers going through the routine of the Primary Survey: ABCDE -- airway, breathing, circulation, disability, exposure/environment... the stuff we've heard "since grade school." There were some fancy manikins (not mannequins) at the SimTiki lab with different critical conditions resulting from a car crash. Also present: ten medical students with varying degrees of ED experience (ranging from super-star ED ward clerks with trauma experience to ... me.)

One by one, we were pulled out of the lab to get an assessment with the surgery clerkship coordinator on our TEAM (Trauma Evaluation and Management) skills. I was the first one and we were only five minutes into the first training scenario.

... I totally let my simulated patient die in front of me.
It was tragic. There were some technical difficulties as the manikin needed to be restarted three or four times. In the interim, before the monitors were setup, the surgeon told me -- "continue with your primary survey."

It went something like this:

"Uhm... I hear breath sounds, but they sound weird. I don't know how to describe them. Rubbing? Clicking? It's ... not right. Where's my pulse ox and BP data?"
"The manikin is still being launched. What else are you going to do?"
"Uhm... I don't know. I can't figure out what those sounds mean. I'm going to continue with Circulation."
then Disability.
then Exposure.

Doh. I clumsily attempted to do some assessments, but I failed to provide any definitive treatment. When the manikin's eyelids closed, the pulse ox data disappeared off the screen and the BP dropped down to the 20s, the overhead voice said in a sardonic tone: "Blood pressure in the 20s is incompatible with life." My failure to diagnose a massive hemothorax with decreased breath sounds, as well as my complete inability to assess the patient properly, led to his eventual demise.

Luckily for me, it was just a fake patient.
The shame of the experience, especially with the surgery clerkship coordinator telling me that I needed to read and review everything really hit home. It's one thing to recognize the correct answers; it's another thing entirely to recall it under stress by yourself with a patient changing status before your eyes.

-----------

I spent my Trauma call reading through the TEAM handout and dreading the moment when a trauma call came in.

On the plus side (which is the whole point of the training sim) I learned the Primary Survey by heart! I'll spell out the basics just for fun.

A: Airway (head and neck)
-establish airway, put on c-spine
-foreign objects?
-if GCS <8, intubate
B: Breathing and vent (neck and chest)
-100% O2 for everyone, nasal prongs
-bag-valve mask if need be or ventilate
-if lung sounds are reduced, needle thoracostomy!
C: Circulation and control of hemorrhage (chest and abdomen)
-BP and EKG
-hemostasis with direct pressure, inflatable sleeves, etc
-place two large bore IVs, drop in 2L of LRs for hypotension
-type and cross for further blood loss
D: Disability (head and rectum)
-neuro exam: PERRLA, rectal tone, GCS (E+V+M<=15)
E: Exposure/Environment
-Strip clothing
-Logroll patient, examine back
-Warm patient (blankets, bair-hugger, fluids, lights)

SAMPLE history
S/sx
Allergies
Medications
Past history/Pregnancy
Last meal
Events

Labs/Studies
ABG
EKG
CBC, Chem7
Type and Cross
PT/PTT
UA, UDS
FAST/DPL
XR/CT/MRI

Mini-Mental Status Exam: ORArL 2,3, RWD!

The components of the Mini-Mental Status Exam (or Folstein test) can be summarized in the quick and easy mnemonic: ORArL 2,3, RWD! It can be a part of a more comprehensive Mental Status Exam performed by psychiatrists as a screening tool assessing cognitive function.

O: Orientation to Person, Place and Time
R: Recognition (repeat three objects, i.e. balloon, Pong and happiness)
A: Attention (Serial 7s counting backward from 100 or spelling WORLD backwards)
r: recall (ask them to recall the three objects 5 minutes later)
L: Language
2: Identify the names of Two objects (pen and glasses/watch)
3: Follow a Three Step command (take this paper in your right hand, fold it in half and place it on the floor)
R: Reading (Read this statement and do exactly what it says: "Close your eyes")
W: Writing (Write a sentence)
D: Drawing (Copy a figure of two intersecting pentagons)

This is a useful series to memorize as you become proficient with various components of the MSE since it occupies the majority of your cognitive section. Most people will have a questionaire to fill out, but its easy to do it orally. I find it helpful to create mnemonics of all interview questions since a smooth Q&A session with your patients is a great way to imbue them with confidence in your skills (and any observing residents/attendings.)

10 parts of the Mental Status Exam (alt: ABC STAMP LICKER)

The Mental Status Exam is the psychiatric equivalent of a Physical Exam. I struggled to remember all of the components and I found it helpful to break it down into 10 parts for rehearsal. My resident told me about ABC STAMP LICKER after I developed my own method, but I'll share it with you as well.

1. Appearance
2. Behavior
3. Cooperation (note eye contact, degree of friendliness/hostility)
4. Mood/Affect
5. Speech
6. Thought (PCP: Process, Content, Perceptions)
7. Cognition and Fund
8. Abstraction (ask "What is meant by 'a rolling stone gathers no moss'?" or "what makes a table and a chair similar?")
9. Insight
10. Judgment

The alternate version (ABC STAMP LICKER):

• Appearance
• Behavior
• Cooperation
  
• Speech
• Thought (Process, Content)
• Affect
• Mood
• Perception (AH/VH)
  
• Level of consciousness
• Insight
• Cognition
• Knowledge fund/base
• Endings (Suicidal, homicidal)
• Reliability

Here is a sample student write-up from the UIC Dept of Psychiatry.

"Show, Don't Tell" Science Stories

Caltech's 2008 Commencement address by Robert Krulwich shares a compelling narrative (video here, skip ahead to 9:09) about the importance of conveying science stories to non-science people: your grandmothers, your friends, and friends of friends... people who will be politely asking you "so what did you study at Caltech?"

Because talking about science, telling science stories to regular folks like me and your parents, is not a trivial thing. Scientists need to tell stories to non-scientists because science stories have to compete with other stories about how the universe works and how it came to be….and some of those other stories, bible stories, movie stories, myths, can be very beautiful and very compelling. But to protect science and scientists - and this is not a gentle competition — you’ve got to get in there and tell yours.

He ends with a great story about evolution through a feathery dino/Robin and a Tyrannosaurus rex named Bob (after Bob Harmon). (@ 28:00)

This brings into focus the KEY thesis of my blog here... why have I struggled so long to come up with blog entries that I deemed worthwhile to post? I want to share these sorts of stories. Tales that enthrall and clarify the world around us, the world within us. I'd like to publish a paper someday that offers alternative metaphors and tales that explain difficult-to-understand concepts to patients. But first, I must struggle to understand them myself! An important part of that mission is to preserve my own memories of these difficult times. To recall the time of my own naivete and so-called "ignorance" of these myriad illnesses so that I can connect with people no matter what their background in science and medicine may be.

I have a few ideas brewing in my head and hopefully they will crystallize so I can share them in turn with you.

Hat tip to A Storied Career and the Frontal Cortex

PDA Resources

This is a list that one of my professors sent us. I've trimmed it down a bit to the things that I recognize and use (or will use, based on her recommendations.) I'm guessing it's very similar to my other list that I've posted previously.

Medical Applications

www.epocrates.com

http://hopkins-abxguide.org/download_center/main/palm/download_center_details.html?siteId=153 - Johns Hopkins antibiotic guide. It used to be free, but now it costs money.

http://eponyms.net/eponyms.htm - List of 1,500 common and obscure medical eponyms (e.g., Rovsing's sign, Virchow's node) with descriptions. Free! Excellent program.

http://www.isilo.com/index.htm - iSilo document reader...many free medically related documents that you can use via iSilo. Partial reader is free. Full version costs $19.99 (Most platforms supported). I bought this and I use it from time to time... I don't really like the interface, but it is a nice reader for all of the www.meistermed.com files.

http://www.meistermed.com/ - A number of different clinical reference programs. Most are FREE but some have a small fee. You need iSilo for most of these programs. The site also includes depot of many medical iSilo applications. (Pocket PC, Palm OS)
- Procedure series: steps for different surgical procedures (FREE)
- Quick tools: small, focused references summarizing a current practice guideline, journal article, or point-of-care tool. (e.g. antibiotic prophylaxis, topical steroids) (FREE if you are on mailing list)
- STD tools: Treatment guidelines. (Free trial version, $5.95 for full version)
- Dermmeister which includes more than 500 digital photos of 66 common skin disorders (FREE)
- Understanding and interpreting Fetal Heart Rate Monitoring – (FREE)
- Breastfeed – breastfeeding reference (FREE)
- Splinting Manual – (FREE)
- Papmeister – Includes screening recommendations, HPV testing, mgmt of abnormal smears, dx/tx of cervical cancer (FREE)
- Lytemeister - good program for analyzing electrolyte abnormalities. Goes through causes, diagnostic work-up, treatments, etc. (FREE)
- Asthmameister – Complete guide to the diagnosis and management of asthma (FREE)
- Lipids by FPPalm.com – Guide to the management of Hypercholesterolemia (FREE)

http://www.apprisor.com/dlselect.cfm - APPRISOR software and Guidelines by AAFP, AAO, AASLD, ACCP, ACP, AHA, ASE, AUA, ACU, CCGC

http://med-ia.ch/medcalc/ – MedCalc, a free medical formula calculator. (Palm, Pocket PC)

http://www.nhlbi.nih.gov/health/prof/other/index.htm - Multiple different tools for professionals (Free)

http://books.mcgraw-hill.com/medical/diagnosaurus/index.html - Diagnosaurus...a FREE ddx tool with 1000+ diagnoses (Palm, Pocket PC) Fun to use in the first and second year, but it's not as helpful in the third year (unless you're working on a presentation re: ddx considerations.)

http://www.pdacortex.com/MedMath_Download.htm - MedMath, another FREE medical formula calculator (Palm OS only) It came highly recommended by Dr. O so I downloaded it.

www.kidometer.com - Kidometer gives a wide-range of pediatric tools.(Palm OS devices only). Free trial then pay to use. ($17.95) A highly recommended resource. I'll probably download this during my peds block and use up my free trial then. :)

http://www.cebm.utoronto.ca/palm/ebmcalc/ - Centre For Evidence-Based Medicine, FREE EBM tools: NNT, likelihood ratios, etc. (Palm OS)

http://www.medicaltoolbox.com/ - OB/GYN Stat tracker (collect delivery and surgery information) and Preg Calc Pro. (calculate due dates). Register for FREE use.

http://pbrain.hypermart.net/medrules.html – Download Medrules, clinical prediction rules. FREE (Palm OS only)

www.immunizationed.org - Shots 2008, ACIP immunization schedule from STFM with lots of vaccine information – FREE (Pocket PC, Palm) NO BRAINER. Get this and update it every year! :)

www.tarascon.com – Tarascon pharmacopoeia for PDAs. Purchase for $39.95/yr.

www.acponline.org/pda/clinical_references.htm - FREE downloadable clinical references from the ACP. You will need some type of reading program (Palmreader, Tealdoc, etc.) to access them. - Clinical guidelines- Medical Care of the Pregnant Patient- Drug Prescribing in Renal Failure- Domestic Violence Intervention Tool- Commonly used ICD-9 codes- Gynecology Alerts- Calorie Savings Food List- Normal Lab Values from MKSAP12- Vaccine Specific Information- JNC VI Hypertension Management- USPSTF guidelines- Many more…
http://pda.ahrq.gov/index.html - AHRQ PDA downloads – Interactive Preventive Services Selector and Pneumonia Severity Index Module. Free downloads.
http://cim.usuhs.mil/pubmed/PubMedClinQuery_pda.html - Pubmed site where you can add it to your avantgo channel list to do medical literature inquiries at the point of care. (FREE)

Medical Websites
http://www.hawaii.edu/hslib/subjguides/PDAresources.html - JABSOM Health Science Library PDA resource page
http://www.hml.org/WWW/pda.php – Hawaii Medical Library PDA Resource site
www.guidelines.gov/resources/pda.aspx - Will link you to sites that have downloadable PDA guidelines.
www.handheldmed.com - reviews, software downloads, hardware/accessories sales, AvantGo medical abstracts
www.pdamd.com/home - general information, reviews and merchandise
www.pdacortex.com/index.htm - reviews and discussions of medical mobile informatics topics
http://pbrain.hypermart.net/index.html - Ectopic Brain – Excellent resource for clinically oriented PDA programs and also includes an extensive list of links to other helpful sites for PDA applications and programs. Too bad this website shut down last year... :(
www.keepkidshealthy.com/pedipilot.html – Pediatric oriented PDA program links
http://www.dcchildrens.com/pdas/ - Pediatrics on-hand. Suggestions for pediatric PDA programs

Websites with freeware and shareware for download – some are predominantly medical, others are general
www.healthypalmpilot.com - extensive medical software links with user reviews
http://www.freewarepalm.com/ - Extensive database of downloadable FREEWARE for your PDA. It has a medical category with some useful apps.
http://www.palmspot.com/software/Medical/- a range of medical software
http://pda.tucows.com/
http://www.palmgear.com/ - Many medical PDA programs available. Freeware/Shareware/Commercial. Can get another free patient tracker through this site “My Patients”

TED Talk: Jonathan Harris -- The art of collecting stories

Artist, computer-scientist Jonathan Harris talks about some of his cultural projects traveling around the world and collecting stories. He starts off with his own and then talks about some ones online and then in the world.

My favorite one is hearing about the wishes and happiness of the people of Bhutan. I have a Bhutanese prayer flag that I made myself at Art After Dark several months ago and it flutters on the chains of my ceiling fan. My wish: to be content with what I get and happy continuing to do the things I do.

Knols and Medpedia to compete with Wikipedia

In the past two weeks, two new websites are rolling out to compete with the behemoth that is Wikipedia.

Wikipedia got its name from "wiki wiki", which means quick or fast in Hawaiian. It fulfilled its name as it rapidly overtook conventional encyclopedias as the internet reference source of choice with its ingenious Web 2.0 user-generated content, relative ease for public editing and dedicated volunteer/power users who keep an eye out for knowledge-vandals, countering deviously misinformative public edits.

So why has Google released its own version of Wikipedia?
The Official Google Blog has this to say:

The key principle behind Knol is authorship. Every knol will have an author (or group of authors) who put their name behind their content. It's their knol, their voice, their opinion. We expect that there will be multiple knols on the same subject, and we think that is good.

Clinical Cases and Images reiterates this view with its opinion:

Google Knol is a free online collaborative knowledge database or an experts' wiki but not an encyclopedia. Knol is not a direct competitor of Wikipedia, at least not in its current version. Wikipedia is anonymous -- there is no single editor in charge. In contrast, Knol includes the author name in the URL of the article. Google expects multiple knols on one subject rather than the current Wikipedia model of one article on a subject. The term "knol" ("unit of knowledge") refers to both the project and an article in the project.

There is a definite focus on medical topics -- most of the 300 or so starting "knols" are disease-based and authored by doctors. Will Google Knol be the mythical universal textbook of medicine that Wikipedia never became (and was not meant to be)?

In some ways, I think that this can be a good thing. There is a discrepancy among articles and I'm starting to notice a lot of them have tags saying things like "this article needs to be cleaned up/shortened/appropriately referenced/etc." Having authorship or ownership over a Knol will encourage the writer to have more careful maintenance over their content... but I wonder if it will differ significantly from Wikipedia if the SAME writers post content in both Wikipedia AND a Knol.

It will remain to be seen how effective this will be in the future... especially with another incoming competitor on the horizon.

Medpedia is slated to be released in late 2008 as the "WORLD’S LARGEST COLLABORATIVE ONLINE ENCYCLOPEDIA OF MEDICINE AND HEALTH:"

Physicians, medical schools, hospitals, health organizations and public health professionals are now volunteering to collaboratively build the most comprehensive medical clearinghouse in the world for information about health, medicine and the body...

Harvard, Stanford, the UC-Berkeley, the University of Michigan Medical School and dozens of health organizations around the world will be contributing. Many will seed content free of copyright. Harvard Medical School will publish content to uneditable areas that members of their faculty have created as part of a medical school wide effort. Others organizations, such as University of Michigan Medical School will encourage members of their faculty to edit Medpedia as individuals.

Other health and medical organizations like American College of Physicians (ACP), will contribute content and promote participation in Medpedia to their members. Medpedia is also receiving content and cooperation from the National Institutes of Health (NIH), the Centers for Disease Control (CDC), the Federal Drug Administration (FDA) and many other government research groups who are eager to have that public domain information distributed to both the general public and to healthcare professionals.

I don't want these websites to become copycats of each other the way About.com simply cuts and pastes their articles direct from Wikipedia. That's a waste of time. On the other hand, I think a lot of users will be fatigued from the WEALTH of science and health knowledge that will be available. The important thing is communicability (aside from reliability and recency) -- the way these articles/knols/pedia entries can effectively share content with and capture the interest of the average Internet user, the guy with a 5 minute attention span at best and at least three browser windows open.

hat tip to Clinical Cases and Images and Medgadget

RIP Randy Pausch

Randy Pausch passed away from complications of pancreatic cancer on July 25th, 2008. He was 47 years old, but he lived to see everything he wanted for himself come true.

He was diagnosed with pancreatic cancer last year -- the 5 year survival rate is 5% -- and this gave him some time to think. He decided to participate in Carnegie Mellon's "Last Lecture" series with a truly great Last Lecture. He talked about Really Achieving his childhood dreams. It was a silly list, as children are prone to do, but it was inspirational to hear how it shaped his life. And the amazing things he was able to accomplish because he had it all written down.

His wishes continued to come true, even after his Last Lecture (Randy Pausch's homepage) as people heard his story through friends on email, youtube and even on TV shows like Oprah and the Dateline.


-------------

I never had the courage to make a list like that as a child. I was a pragmatic and practical kid -- I didn't want to disappoint my future self by coming up with goals like "finding the cure for cancer" or "making sure the world never forgot me." (Which incidentally, were the sorts of things I thought about growing up.)

In honor of Randy Pausch, I'd like to state my future goals/dreams as a human, a student, a future doctor and a future husband/father (distant future for both) for all to see... and perhaps, I can live to achieve them as he had, in spite of the insurmountable odds. It will be just as fantastic and random as his list, I bet.

"The brick walls are there to show us how much we really want something. They
are obstacles only for the OTHER PEOPLE." -Randy

1. Make a movie/film/short about my personal vision OF the world and FOR the world.
2. Do something significant in the field of Science and/or Medicine -- a legacy for others to follow
3. Public service/public health/community building for the people I love in the place I live
4. Go SCUBA diving at the Great Barrier Reef
5. Make my children and my wife my #1 priority, even though other aspects of my life may take more time and be more pressing (at any particular moment in time) and make sure THEY KNOW IT
6. Learn to tapdance and perform a number from Singing in the Rain
7. Write a fairy-tale about my Dungeons and Dragons characters

Hm... I'll have to put an addendum to this list. I need to go to sleep so I can get "psyched" about my Psych rotation. :)

Rest in peace Randy Pausch... I pray that your family and friends pull through in these hard times. May you continue to touch and inspire people as I have been.

100 "Health Quotes"

via ShanelYang.com

I like to read Shanel's self-help stuff... she's got a great attitude. I don't necessarily agree with her list of "100 quotes about good health", especially since it follows a "20lb weight loss in just 15 days" (which can be hazardous to your health!)... Regardless, I thought I'd post a few of my favorites here.

22. Money is the most envied, but the least enjoyed. Health is the most enjoyed, but the least envied.
- Charles Caleb Cotton

33. The best doctor gives the least medicines.
- Benjamin Franklin

59. To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life.
- William Londen

74. The … patient should be made to understand that he or she must take charge of his own life. Don’t take your body to the doctor as if he were a repair shop.
- Quentin Regestein

94. Be careful in reading health books. You may die of a misprint.
- Mark Twain

Multiple Gestations

Multiple Gestations

view presentation

A short presentation I put together for my OB/GYN L&D (labor and delivery) team's morning report. They really liked it and I worked hard to keep it succinct (printed it out as a handout, 9slides/page = 1 page, back&front).

The best thing about it was that we had two expecting mothers on the floor with twins and I got to participate in one of their deliveries (via C-section, a Twin A vertex and Twin B breech)! So I was ready for any "pimp" questions thrown my way by the attending. :)

Unearthing Useful Reference Sites

100 Unbelievably Useful Reference Sites You’ve Never Heard Of

My girlfriend forwarded me this link. Rather than letting it slide down the list of my growing priorities in gmail browsing, I thought I'd deposit it back on the internet with the hopes of new discovery!

The section I went straight to was the Health care section. There were a few sites that I use a lot (Medline Plus and Online Medical Dictionary, for example) and a LOT that I had never heard of before. It's geared towards the interested learner more than the scouring expert, so that might have something to do with it. Good to know what's out there, though.

Health Care

Instead of Googling your symptoms, use these authoritative reference sites to get drug information, find a hospital and research a disease or condition.

31. Medline Plus: Look up anything to do with health care on this site from, prescription drugs to local resources to symptoms and diseases.
32. RxList: RxList is "the Internet drug index," and you search by prescriptions dispensed, names searched or just by letter.
33. Google Directory - Health and Medicine: Categories and individual web pages are listed on this Google reference site. Browse topics like health news, history of medicine, medical dictionaries or patient education.
34. Patient Care: Columbia University Medical Center lists a number of patient resources, including tools for finding a doctor, dentist and hospital.
35. MediLexicon: At MediLexicon, you can use the medical dictionary search, hospital search, medical abbreviations search or read all the latest medical news.
36. InteliHealth: This reference site has an Ask the Expert section, as well as a database full of information for diseases and conditions, from asthma to digestive issues to weight management to STDs.
37. Healthfinder: This government site features a Drug Interaction Checker, a Health Library and consumer guides.
38. The Merck Manual: Search this online medical library for diseases and conditions and drug products.
39. Bristol Biomedical Image Archive: Browse thousands of biomedical images on this site.
40. Online Medical Dictionary: This simple search tool lets you browse by letter or subject area.

Leiomyoma

Leiomyoma

view presentation

What is a Leiomyoma?

As I described their physical characteristics to some of my non-medical friends, one of them excitedly exclaimed "ooh! they are like little tumor pearls inside your uterus!" Yes, indeedy. I guess they could be like that... or they could become much fatter and larger and gunkier.

Dancing around the world

Where the Hell is Matt? (2008) from Matthew Harding on Vimeo.
Via Astronomy Picture of the Day

Explanation: What are these humans doing? Dancing. Many humans on Earth exhibit periods of happiness, and one method of displaying happiness is dancing. Happiness and dancing transcend political boundaries and occur in practically every human society. Above, Matt Harding traveled through many nations on Earth, started dancing, and filmed the result. The video is perhaps a dramatic example that humans from all over planet Earth feel a common bond as part of a single species. Happiness is frequently contagious -- few people are able to watch the above video without smiling.

For some reason, I got really emotional watching this clip. The spark of common humanity touches me.

Pre-Med content featured in this month's NEJM

Relevance and Rigor in Premedical Education
Jules L. Dienstag, M.D.

In recent decades, scientific knowledge has changed dramatically, once-settled scientific principles have been replaced by more sophisticated concepts and entirely new disciplines, and parallel changes have occurred in medical practice and health care delivery. In the face of these new realities, medical school curricula have had to adapt. Yet despite these sweeping changes, including the permeation of most areas of medicine by molecular and cellular biology and genetics, requirements for admission to medical school have remained virtually unchanged for many decades.
...

This article talks about the ever-expanding knowledge base required to become a physician... and Dienstag questions whether or not the old admission criteria for medical school are appropriate for the always-lifting expectations of our future doctors.
1 year of biology + 2 years of chemistry (1 yr gen chem, 1 yr o-chem) + 1 yr physics isn't enough. I agree.

However, I don't think that raising the bar on the admission criteria will somehow magically improve the crop of incoming medical students. Some of my best friends in medical school are History, English, even Real Estate majors and they are excelling. They have admitted to me from time to time that they struggle with some of the basic science subjects we are forced to learn rapidly on our own (i.e. microbiology, embryology) but really... would requiring people to take these courses as an undergrad really be beneficial? A lot of what I learned as a biology major WASN'T applicable to the study of Human Medicine.

Regardless, Dienstag makes a good point that the best pre-med courses would be INTEGRATIVE... encouraging students to make connections across basic science subject lines. I wonder if medical schools could ever require this, since it would be a pre-med subject that would vary greatly based on the lecturer (as no textbooks exist for such a course.)

From All Walks of Life — Nontraditional Medical Students and the Future of Medicine
Sandeep Jauhar, M.D., Ph.D.

When I was growing up, my parents wanted me to become a doctor, but I had other ideas. I wanted to be a television journalist, or perhaps a trial lawyer or private investigator — something with panache. In college, intoxicated by the mysteries of the universe, I ended up studying condensed-matter physics, in which I eventually earned a Ph.D. But after a close friend contracted an incurable illness, I began to have doubts about my career path. Seeking a profession of tangible purpose — like many older students — I was drawn to medicine.
...

Jauhar talks about the benefit of having "non-traditional" students in a class of students straight from college. While they possess different qualities of maturity and dedication, knowing full well the luxury of a student's lifestyle (as opposed to working paycheck to paycheck with little other reward)... they also have fewer years of output towards society before they end up retiring. They also have more outside life to attend to, with husbands/wives and kids. Can the U.S. medical system afford this in the long run?

I think this is the major sacrifice we have to make to have more well-rounded physicians. More female doctors, more older students, more foreign graduates will help to break down the stereotypes of the medical profession. In the ideal world, I think everyone would be a physician -- basically, the knower of their own body -- in the philosopher-king, artist-scientist Renaissance sort of way where we can all be equally enlightened in our equal access to the information we need (Yay, internet!)

PocketMod on the Wards

The PocketMod is a great way to stay organized while you're running around on the wards. It turns a piece of paper into a mini booklet that you can use to write down patient data. I use it to scribble down the Vital signs and daily information I need when I'm rounding on my patients in the morning. It's also good for writing key notes for the wards.

I have three or four different PocketMod booklets in my white coat right now:
1) Tips for the Wards (with sample admits, checklists)
2) Tips for OB/GYN (with the key parts of the SOAP for post-partum and post-op patients)
3-4) Patient logs (tracking data for the patients I've picked up that day.
* the first page always has the current date in the corner, the room # of my patients, their date of admission and other relevant quick tidbits
* each subsequent page has their patient care summary, Friedman's curve progress, daily vital signs, I/Os, H/H, Rh/Rub/GBS status, etc.

Since I've just finished with OB/GYN inpatient and I'm moving onto Psych, I'm in the process of making a new PocketMod with specific psych info. Since my Psych handbook is online, I'm toying with the idea of doing an e-version and posting it online as a sample.

Gamers ought to do SomethingWorthwhile

So I have a lot of friends who are gamers. They play games in their free time (which they have in abundance, much to my dismay) as a way to... avoid boredom, I suppose. Entertainment is an important "virtue" in today's commercialism-driven society.

Some of them play World of Warcraft. It's a role-playing game where you play a fantasy character like an elf, orc or minotaur and you run around and kill things, take their loot, get powerful gear and new nifty skills. It might sound like I'm disparaging this game, but I really like these sorts of games. I play D&D a lot. It operates on the same principles and I've often converted action sequences in movies directly into game terms.

Take the latest Indiana Jones movie for example. There's an action sequence where Indiana Jones hears a countdown after visiting a surreal little town only realize that he's in the epicenter of an atomic bomb test... and he has less than a minute to find a place to go. Hurriedly, he rushes around the house, jumps inside a lead-lined refridgerator and gets blasted like a piece of shrapnel away from the explosion. The fridge tumbles on the ground and he falls out. Climbing the hill, a huge mushroom cloud blooms up, silouetting him in the desert landscape. I was very excited by this totally impossible scene, because it makes total sense from a gaming perspective. If you throw a character into a deadly scenario, there's always a way out. Since he's a lucky sort of fellow, he made a reflex saving throw and he's got evasion so he took practically NO damage from this explosion!!!!!

Anyway, what I'm trying to say is that RPGs are a way of sharing structured dreams/fantasies/stories with your friends, be it on TV, your computer or in the theater. SecondLife has found some surprising ways of being useful in Real Life:
People can have virtual conferences with each other.
Crippled patients can experience walking and enjoy easy mobility.
People can exercise as they traverse a virtual world.
People with anxiety disorders and social phobias can interact with others in a safe environment.

-------

I know some people who like to play Pokemon. They know a bunch of random information about the statistics of Jigglypuff or Jujubee or whatever cutesy names are in the game. Each monster has a set of abilities that allow it to fight effectively against a certain foe. There are magazines dedicated to the constant updates to the card game that outline the latest strategies! People pay money to memorize random useless facts about imaginary foes battling each other?!?!?

Shoot, if people spent even a fraction of this effort learning something remotely useful during their entertainment, they'd be set! I propose that Microorganisms be introduced to the world of Pokemon. Instead of Pikachu, kids could learn about the Influenza virus and it's ability to have genetic drift and genetic shift-- requiring new flu shots every year and terrifying people with the possibility of a deadly new epidemic. Then they'd be learning about REAL monsters.

----------

People sit around and play Solitaire or Minesweeper on their computers all day at work. Why not do something constructive with your mindless puzzle gaming?

Researchers at the University of Washington came up with the idea of combining protein folding scoring and gaming... and put together a puzzle game called FoldIt!

Medgadget shares a little story about the genesis of FoldIt:

Predicting the shapes that natural proteins will take is one of the preeminent
challenges in biology, and modeling even a small protein requires making
trillions of calculations. Over the last three years, volunteers around the
globe — now numbering about 200,000— have donated their computer down-time to
performing those calculations in a distributed network called Rosetta@home.... With the inherent fun of
competition, Salesin thought a multiplayer online game was the way to go.... One
match between teams from the University of California and the University of
Illinois aroused unexpected fervor and cheering among spectators. “30 or 40
people participated,” says Baker. “The competition was very
intense.”
“Foldit” takes players through a series of practice levels designed
to teach the basics of protein folding, before turning them loose on real
proteins from nature. “Our main goal was to make sure that anyone could do it,
even if they didn't know what biochemistry or protein folding was,” says
Popovic. At the moment, the game only uses proteins whose three-dimensional
structures have been solved by researchers. But, says Popovic, “soon we'll be
introducing puzzles for which we don't know the solution.”

Is there a best pre-med school?

HalfMD responds to a reader's question:
Is there a best pre-med school?

Abstract: No! Your academic dedication (GPA, Letters of Rec), your ability to perform (MCAT), your compassion (volunteering), and your familiarity with the health field (shadowing, personal statement) strengthen your application.

However, you might want to consider one of the "Big Five" if you need someone to hold your hand for the application process (the reader's parent submitted the question....)

1. University of California at Los Angeles
2. University of California at Berkeley
3. University of Texas at Austin
4. University of Michigan at Ann Arbor
5. University of Florida

I mean no offense by that, by the way. I was completely clueless about what it took to apply for medical school and quite honestly, my first application was a complete BOMB even though I had enough of the right stuff. It would have been really nice to have a pre-med advisor. The closest thing we had was the Pre-Med Association... but really... would you expect your fellow classmates (i.e. your "competitors") to give you the best advice and review your application? That's why I'm really thankful that I had the support of a more objective and reliable group: the Medical Student Mentorship Program.

5 Tips for your Big Day

The First Aid team offers 5 tips for your "Judgment Day:"

1. Double-check your paperwork.
2. Leave your gizmos behind.
3. Bundle up.
4. Show up early.
5. Chill out!

It's a great list... especially #1! You'll have so much on your mind that it would be a shame to push your test date back because you forgot a picture ID and your confirmation code.

Test taking strategies

There's a few basic strategies when approaching questions. This works for any sort of multiple choice examination, but your results will vary. I suggest swiftly adopting one that works for you. If you run into a question where it doesn't work (and you will!) then slow down, reread the question and use a different strategy.

I've become fond of a few methods as I studied for the USMLE Step 1. I'd recommend using them in the following order:

1. Stop. Think. Predict.
2. Question-directed searching.
3. Answer-directed searching.

Stop. Think. Predict. Start at the beginning and highlight the important clues/buzzwords. Blot out the negatives. Think about the diagnosis (and some of the evident treatments.) Predict what the question will be and what the answer is. If you anticipate the right answer and it's there, BOOM! You're done. You should still review the other answers just to make sure that there isn't anything better. I love this strategy because it MAKES YOU THINK. It's exactly what you'll be doing for the rest of your life as a doctor... might as well get used to it!

Question-directed searching. This strategy is the preferred method by Drs. Walker (Tips for Taking the USMLE) and Dimov (How to Do Well on Boards). Basically, read the question first and look for clues to help guide you. This spares you the frustration of a "bait and switch" question where you read a long stem only to discover that the question is asking you about a basic science topic that's minimally relevant to the stem. I've never ran into this particular scenario myself, so I prefer to read something the way I read a novel -- skipping to the end cheats you out of the pleasure of figuring things out.

Answer-directed searching. Sometimes, you have no idea what the question is asking. Sometimes you have no idea how to guess what the answer is. I've learned a little lesson from Sesame Street. It's called "One of these things is not like the others." :) This proves that ignorance is bliss. Sometimes you can get the right answer even if you totally ignore the question and just look at the answers, isolating the one answer that's different from the others! It might be a drug from a different class than the others or a diagnosis that accounts for that one weird physical finding noted in the stem.

If you've got any other ideas, let me know. I can't think of any other ways to read a question and answers other than top-> bottom, bottom->top->bottom or just bottom...

Cognition for the USMLE Step 1

I scribbled down a few notes when first thought of this blog entry. The thinking process for the USMLE Step 1 is interesting... and the more I realized what I was thinking about (meta-cognition), the more I learned from the process of learning. It was very strange. It's been about two months since I took the exam itself. My sharp dedication to this topic is rapidly fading since I started my third year orientation today. However, I also feel a sense of urgency to at least address this topic before I ponder my clinical years on this oft-ignored-blog-of-mine (but I'd like to do better!)

In regards to the USMLE Thinking Process, consider the 4 R's:

1. Recognition/Resonance
2. Recall
3. Reword/Restate
4. Reconnect

Recognition/Resonance refers to the first part of the question stem. When you're reading, a feeling will come up. Obvious clues related to risk factors (female, fat, forties, fertile for acute cholecystitis, for example) will act as triggers. However, you should watch out -- in real clinical practice, the heuristic of stereotyping may be misleading! Stereotyping in the USMLE is surprisingly effective... and amusing.

Once you've read through the stem, you ought to Recall some basic facts about the problem at hand. This is a great exercise during your tutorial sessions as you go through questions in USMLE World... it will eat up too much of your time if you systematically quiz yourself during a timed exam. Here are some example questions: What are some causes of acute cholecystitis? (Blocked duct by a stone, either pigment or cholesterol.) Why are pregnant women more likely to develop cholesterol stones? (Answer: estrogen increases the cholesterol in the gallbladder-->hypersaturation and progesterone decreases GI motility-->stasis in gallbladder)

Next, read the question. Sometimes, it won't make sense. Restate the question, in the context of the clues given in the stem. A lot of times, certain words will be disguised and you'll have to take the extra mental effort of rephrasing them so you'll readily recognize them. Example: During the physical examination, tenderness is elicited in the upper right hand quadrant of the abdomen. Convert this long sentence to the eponym "Murphy's sign" and voila! You've created a mental shortcut.

Restating the question and the stem in your own words often helps you Reconnect with the question-writer's intent, if you didn't recognize it right away. Sometimes questions will give you a "Bait-and-Switch" and ask you about something slightly different. Sometimes it will be so painfully obvious what the answer really is that you'll wonder 'is it really this easy?!?' I felt that way on the NBME and the USMLE enough times that I felt comfortable responding with a 'Yep!' Rarely, the USMLE will disguise the question and the answer choices to such an extent that you have to rephrase everything. However, USMLE World does an excellent job disguising questions that they are all imbued with high-yield topics. They are worthwhile branches to consider even if the answer is obvious.

Take the time to figure out why every other answer is WRONG! That's more important than knowing the right answer as you study. That's not my second opinion!

Top Ten Tips for Step 1

I've been busy having a lot of fun this summer break (i.e. going scuba diving, getting a girlfriend and suffering the repercussions) so I'm sorry to all my readers out there. In lieu of a more original post, here's the list of tips I sent out to my friends when I was asked for advice about Step 1.... most of it I've said before.

1) Use USMLE World and mark the challenging questions.
2) Go through other question banks Kaplan, USMLE Rx, etc.
3) Revisit the questions you got wrong in World in random blocks and keep at it! Themes for your weaknesses start to emerge, so rehearse this material in the way that suits you best -- for me, it was silly drawings and mnemonics that I scribbled into First Aid.
4) Make First Aid your bedtime reading material. Imagine the question stems related to each subject and some of the tricky answers that typically throw you off.
5) Three weeks before, go to Prometric and take the practice. These questions are representative of Step 1 (albeit 150 questions shorter than the real thing.)
6) Two weeks before, take another self-assessment. I used USMLE World's Self-Assessment ($25, 200Qs) because it gives you the World-class explanations.
7) A week before, take NBME self-assessments to your heart's content. I'd highly recommend doing 350 questions in a day at least once.... I didn't and I found myself wishing I had more "test-stamina" as I had a series of mini absence-seizures by block 6.
8) Keep reviewing your weaker subjects in First Aid!
9) Relax the day before your exam. No matter what you think, you won't learn anything new the day before.
10) I did a quick 25 random Q block before I biked to Prometric on my final day. This warmed up my brain before the grueling 350 question exam.
11) Write down the number of blocks you have (7) on the corner of your blue laminated sheet from Prometric and knock it off as it passes. I lost track and I convinced myself that block 6 was my last one so I missed out on some vital break time.

Sorry, that list turned out longer than I expected.

Some observations I had on the real thing -- there were less calculations and more behavioral sci scenarios than I expected. Common subjects tend to cluster by block (I had literally half a dozen questions on hepatic encephalopathy in block 6 and 7!) The micro was easier than Kaplan's. Review a lot of CTs for your anatomy points. I'd estimate that the questions are 70% like NBME, 30% like USMLE World (in the thinking sense, not the obscurity sense.) Hm... there's a lot more, but the information is draining out of my head as we speak (or more accurately, as I write.)

JABSOM is not Pharm-Free

AMSA PharmFree Scorecard 2008 ranks 150 medical schools on their pharmaceutical rep policies. Only 7 schools received an A while 60 received a failing grade.

JABSOM was the first F.... shame on you, JABSOM! We failed to provide any policy whatsoever on this matter. Comments below:

University of Hawai’i John A Burns School of Medicine has implied that it is not a clinical facility and therefore it is not necessary to create policies in many of the domains on which it was assessed. It should be noted that other schools and colleges of medicine, which are not clinical facilities themselves, have created policies on conflicts of interest that apply to many of the domains assessed.

I've done s presentation about drug reps with my classmates and one of the lecturers in our EBM course expounded on the influence of drug companies in academic medicine. These are just small measures on the part of individuals though and easily tuned out as "just another boring lecture" by students.

AAMC and AMSA are pressuring schools to become more proactive in reducing financial conflicts of interest and lead by example for future doctors. This means banning all gifts and free drug lunches at University events. It means refusing industry support for CME. It means keeping our hands clean and doing our business.

There are some doctors who think that this is impractical. They think that they are immune to influence by pretty women with convincing papers on their latest drug. They think that CME will die without hefty financial support by pharmaceutical companies.

I'm not that naive.

• I know I'm easily impressionable... that's why I do my best to surround myself with good examples.
• In the long run, free samples aren't cheaper if the fancy new designer drug is 10x as expensive and just as effective as a generic drug.
• I don't fret about CME... just checking my blogroll every day is a hefty dose of up-to-date medical education.

"Bodies" exhibition in Hawaii

It's a little strange, but "Bodies... the exhibition" will be at Ala Moana Shopping Center come June 14th. A mall? Really? I guess it's a more accessible venue than a museum. I didn't get the chance to go when it was in Philly a few years ago, so I'm excited!

I'm planning on going. Feel free to come with! Cameras aren't allowed, so no pics. sorry :(

Of note: the Bodies website has a distressing disclaimer.

-This exhibit displays full body cadavers as well as human body parts, organs, fetuses and embryos that come from cadavers of Chinese citizens or residents... Premier relies solely on the representations of its Chinese partners and cannot independently verify that they do not belong to persons executed while incarcerated in Chinese prisons.

Whoa!

Put your cell phone on the dash

Last night, I called my dad to make plans for tomorrow evening. As I chatted with him, some construction workers on the side of the road shouted at me. I didn't realize why until I had finished my call and pulled up behind another vehicle.

Crap. My headlights were off!

Recent studies found that drivers (such as myself) are distracted when they are on the phone while driving. This level of distraction can be equivalent to drunk driving! There's MADD... pretty soon there'll be MACC (Mothers Against Cell Calls.)

Yet, people consider it an "efficient" use of their time when they multitask while driving.

So what can be done to ameliorate this situation?

Devoting 100% of your attention to your road is the best way, of course.

Barring that, NY Times has this tip by Amit Almor, an associate professor of psychology at University of South Carolina:

The volunteers did much better on their visual tasks when they were just
listening, as opposed to preparing to speak or speaking. When they were
listening, if the demands on their brains became too much, they could just tune
out what they were hearing.
...
It may be, the study said, that when people talk to someone
who is not present, the visual-processing parts of their brain create a mental
representation of where the other person might be. This suggests, Dr. Almor
said, that using cellphones may be safer if the sound comes from the front.

A spoonful of Obecalp

At first, it started off as a joke. I mean, it's easy to ask the question. In a clinical trial, if a placebo actually improves a patient's health almost as much as a regular drug, shouldn't we be selling placebo pills? It's certainly a funnier (and more marketable) idea than ditching the drug undergoing clinical trials... especially after the drug company forked over $100 million for research and development up until that point.

Graham at OverMyMedBody! brought the idea of Obecalp to the blogging scene earlier this year.

45% of doctors who responded to a survey said they’ve given placebos to
patients. That number certainly seems high, but sometimes patients don’t
want to hear what you’re saying–namely, that no drug will help them. ...
I’ve certainly wanted to write for “Obecalp 1 tab PO BID” (’placebo’
backwards) but I find it totally unethical and undermining of the doctor-patient trusting relationship. (emphasis mine.)

So now what?

According to the NY Times, Obecalp will now be for sale as a dietary supplement. The example cited? A child with "a nagging case of hypochondria." I'm not sure how I feel about this.

Would you have to deceive Obecalp recipients in order for it to be "effectual?" I mean, I up my Vitamin C content and drink chicken long rice soup (with lots of ginger) whenever I get sick... that's placebo and I know it! Regardless, I feel better knowing that I did something.

Why limit the marketing to harried adults with whiny kids? This drug will fit in perfectly alongside Airborne and herbal remedies. In many ways, I'd prefer something that tells you up front: "I'm completely useless!"

via The Happy Hospitalist: Ma! Ma! I Need Another Fix

image by Djenan (creative commons license)