Strategic Plan for Medical Education: A New Constructivist Model of Cognition

A New Model of Cognition

My main driver for getting a Masters degree in Medical Education was to have the opportunity to do high-level research in the field of clinical reasoning and medical decision-making.  Even as a fourth-year medical student tutoring first-year students through their Problem-Based Learning seminars, I was very keen on the process of developing a differential diagnosis and becoming an expert diagnostician.  I recently discovered an old email showing that I looked through the literature with a librarian for this exact question:

Hello, I am a fourth year medical student interested in conducting a research project on the cognitive process of generating a differential diagnosis (ddx) geared to second year medical students…  the project I want to do involves teaching second year med students how to be systematic in making a ddx and avoid the pitfalls, with a pre-unit and post-unit survey to measure their progress and confidence in differentials.  Some of the questions I might ask are:·         How many ddxs do you routinely make in PBL sessions on the first page of your [case]?
·         How often do you feel that you have the right, specific diagnosis in your HCPs before the conclusion of the case?
·         How confident are you that you have a broad number of ddxs in your [case]?
·         How would you rank your ability to generate a ddx compared to your peers?
·         Pick the best definition for the following terms: heuristic, bayesian analysis, attribution error, pre-test and post-test probability
I have done some general searches on Pubmed looking for articles on medical education and differential diagnosis, but I have not found any literature that has done any similar projects in the past.  It would be helpful to know if there are any surveys that have similar assessment measures.

I recently discovered a new constructivist theory that explains the cognitive process of clinical reasoning that I am calling “[redacted, pending publication]”.  In a nutshell, the current dominant dual-process model involves weighing judgments as Type I automatic thinking vs Type II deliberate thinking, in which we toggle between the unconscious heuristics/biases brain and our rational, conscious brain.  I think this is incorrect.  I feel that we form ALL ideas as spontaneous, self-assembling “crystals.”  The formation of diagnostic crystals is catalyzed during the brewing process by nucleation on heuristics/rules/prior experience under the right cognitive conditions.   (see Appendix 1 for details)

My vision is that in the next 10 years, I will change the way doctors think about clinical reasoning.  I plan to accomplish this in the next 6 months by doing research to justify my “[thesis]” theory through a demonstrative literature review for my Dundee thesis project.  I plan on showing how my new theory meets the criteria of quality (trustworthiness, transferability, dependability and conformability) as well as authentic criteria of fairness (ontological, educative, catalytic and tactical) as outlined by Guba and Lincoln (1989).  Then, I plan on working as a clinician/researcher and in the next 5 years, I will publish articles on this subject in several major journals (aiming for Academic Medicine, Medical Education and Psychological Review where most of my literature review has derived).   In the next 10 years, I write a book on “[redacted]” as a new theory on the psychology of judgment.

These are “big, hairy audacious goals (BHAGs).”  I will share my vision by telling stakeholders that "We will change the way doctors think about clinical reasoning, using procedural methods to ---[to be revealed]."  According to Collins and Porras,

“A true BHAG is clear and compelling, serves as a unifying focal point of effort, and acts as a catalyst for team spirit... A BHAG engages people—it reaches out and grabs them. It is tangible, energizing, highly focused. People get it right away; it takes little or no explanation.”  (Collins and Porras 1996)

The idea of changing the way all doctors think is compelling.  Even though the theoretical concept will need to be explained, I feel that everyone intuitively“gets” the concept that our brains bubble and brew and sometimes, while we are in the shower or out on a walk – BAM!  An idea comes up seemingly from nowhere.  "[The thesis]" model elucidates this process and invites people to maximize their chances of creating “Eureka!” moments.

My institution has a Department for Clinical Decision-Making (CDM) that is well-known for its leaders in the field of CDM.  (Tufts, n.d.)  We have a course for first-year medical students called “Introduction to Clinical Reasoning” that I will be building on by preparing fourth-year medical students for residency in an elective called “Family Medicine Exploration Elective” in which I plan on exploring the concepts of flow and intuition for expertise development.  In order to gain alignment with the CDM department, I plan on utilizing Kotter’s model (1996) for Change Management, to determine how to best accomplish our shared goals.  I will share a hybrid model that adds in Heath and Heath’s “Switch” concepts (2010) that use a visual analogy that making change is hard, like a human rider trying to force an elephant to walk down a path.  (Appendix 3.)

The first step in the hybrid Kotter-Heath-Heath model is to Motivate the Elephant.  This means that I need to “Find the Feeling and Create a Sense of Urgency.”  I plan on instigating a change with a shift from the analytical Bayesian approach that the Department for CDM is used to and publishing my radical new theory which is an intuitive “adaptive toolbox” approach that Gigerenzer (2002) utilizes.  (Appendix 2.)  Convincing the majority of people that change is needed (Kotter recommends convincing at least 75% of managers that the status quo is more dangerous than the unknown) will hopefully prompt a forthright discussion, leading to the next step.

Next, I will Shape the Path.  This means that I need to “Rally the Herd and Form a Powerful Guiding Coalition.”  My fellowship advisor can facilitate a meeting with various members of the CDM department to discuss the implications of my research.  I need members with enough power to lead a change effort.  Kotter specifically encourages the team to work outside the normal hierarchy:

“This can be awkward, but it is clearly necessary. If the existing hierarchy were working well, there would be no need for a major transformation. But since the current system is not working, reform generally demands activity outside of formal boundaries, expectations, and protocol.” (Kotter 2007)

Together with a group of change agents, we will Direct the Rider.  In other words, “Find a Destination and Create a Vision.”  My preliminary vision statement to share with stakeholders is: "We will change the way doctors think about clinical reasoning and help them [in ways outlined in future works]."  I would like to focus on medical education by changing our curriculum for PBL and clerkships to include these scaffolding concepts.  I already have a hand in creating a new fourth-year FM elective that will integrate these principles for outpatient primary care.

Providing rational explanations is not enough to push the broader community to change.  Next, we will Motivate the Elephant by “Pointing to the Destination and Communicating the Vision.”  If we are going to push all physicians to change how they think about generating a differential, we have to tap into their feelings.  All physicians strive to become expert diagnosticians and are afraid of missing the diagnosis.  Achieving “expertise” is nebulous, but Ericsson (2004) provides us with a clear goal.  Deliberate practice and the acquisition and maintenance of expert performance require 10,000 hours over 10 years of practice.  It is my belief that we can get the attention of various parties within the institution with the following message:

•  Medical students: “You CAN dedicate 160 hours of 10,000 hours towards becoming an expert in Primary Care reasoning in a month-long elective.”
• Family Medicine Residents:  “You CAN accumulate around 2,000-3,000 of the 10,000 requisite hours towards becoming an expert in clinical reasoning”
• Family Medicine Faculty: “You will only be supervising residents for ~300 hours of primary care clinical reasoning in a year.”  How do you plan on making the best use of this time?

With enough medical students, residents and faculty sufficiently motivated, we need to Shape the Path and “Tweak the Environment and Remove Obstacles.”  This involves revamping the first-year medical student “Introduction to Clinical Reasoning” curriculum so it is developmentally appropriate.  I would propose moving material like illness scripts, better suited for the onset of clinical exposure in the third-year.  Additionally, memorizing numerical likelihood ratios for determining post-test probabilities is not practical for real clinical practice.  Research by Czerlinksi, Gigerenzer and Goldstein (1999) has shown that utilizing the Tallying heuristic (Appendix 2) can achieve a higher predictive accuracy than multiple linear regression analyses when applied intelligently.  After the concepts of numeracy are established, we can change these burdensome LR to more teachable concepts like the Tallying method.  A smartphone “app” can be created to make the cognitive checklists we will design freely available for everyone to use (and hopefully if someone else does this grunt work for me... they will also make it free to the public!).  Many of these ideas are nontraditional and risky, which is encouraged (Kotter 2007.)

Finally, we will establish a set of Milestones for the Rider and the Elephant to achieve.  Typically, this is done by “Following the Bright Spots and Scripting Critical Moves” for the Rider to perform, as well as “Shrinking the Change and Recognizing/Rewarding Contributors” so the Elephant isn’t frightened and feels motivated to contribute.  However, my ideas are completely novel (my initial literature search in 2009 and updated search in 2014 provided no leads), so I will have to forge a path ahead.  I hope we will be able to set up curriculum for all years of medical school and my family medicine residency to include relevant clinical reasoning topics.  Personally, I have already achieved some milestones for myself in terms of spreading this information: designing medical student elective curriculum, presenting a Grand rounds on this subject in 2012, and give a regional conference on this topic in 2014.  My future milestones will include presenting a national conference on my thesis material in the next 3-5 years as well as publishing in major journals in medical education and psychology.    I hope to give a TED Talk on the subject of [redacted] as an analogy for judgment in general and spice it up with some memorable clinical examples.  Eventually, I will strive to write a book.

Kotter has a few more steps on “Systematizing Wins” and “Institutionalizing New Approaches” that will not matter to me specifically, unless I become a department chair or some other leader in medical education.  The vision statement and milestones I’ve set up for myself are ambitious and I would be happy even if I can make a local change within my residency.

In summary, one of my goals in life is to become a master clinician and systematize an approach for clinical expertise.  I feel that my theory on [redacted] is novel and opens up a lot of avenues for future research, medical education and continuing professional development.  The hybrid Kotter-Heath-Heath model I outlined above will help me align my personal goals with my institution.  It also helped me develop a key strategic plan that I can enact to become a leader in the field of Clinical Decision-Making and change the way doctors think.

Appendix 1.  [redacted theory.]

Appendix 2: Gigerenzer’s Adaptive Toolbox.

Combined Model for Change Management  (Heath 2010 and Kotter 2007)

	1.       Motivate the Elephant: Find the Feeling and Establish a Sense of Urgency a.       Knowing something isn’t enough to cause change. b.      Make people feel something.
	2.       Shape the Path: Rally the Herd and Form a Powerful Guiding Coalition a.       Behavior is contagious.  Help it spread. b.      Assemble a group with shared commitment and enough power to lead the change effort c.       Encourage them to work as a team outside the normal hierarchy
	3.       Direct the Rider: Find a Destination and Create a Vision a.       Change is easier when you know why its’ worth it. b.      Create a vision to direct the change effort c.       Develop strategies for realizing that vision
	4.       Direct the Rider: Point to the Destination and Communicate the Vision a.       Change is easier when you know where you’re going. b.      Use every vehicle possible to communicate the new vision and strategies for achieving it c.       Teach new behaviors by the example of the guiding coalition.
	5.       Shape the Path: Tweak the Environment and Remove Obstacles a.       Remove or alter systems or structures undermining the vision b.      Encourage risk taking and nontraditional ideas, activities, and actions
	6.       Milestones: a)      Direct the Rider: Follow the Bright Spots & Identify Potential Wins b)      Direct the Rider: Script the Critical Moves & Engineer Wins c)       Motivate the Elephant: Shrink the Change & Recognize/Reward Contributors
	7.       Systemize the Wins a)      Motivate the Elephant: Develop/promote/hire visionary employees b)      Motivate the Elephant: Tweak the Changes a.       Reinvigorate the change process with new projects & change agents c)       Shape the Path: Tweak the Environment and Build Habits a.       Use increased credibility from early wins to change systems, structures, and policies undermining the vision
	8.       Institutionalize new approaches a)      Direct the Rider: a.       Articulate connections between new behaviors & corporate success b)      Shape the Path: a.       Create leadership development & succession plans consistent with the new approach

Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  Broadway Books: New York.

Kotter, J. (2007) Leading Change: Why Transformation Efforts Fail. Harvard Business Review. Jan 2007.  Reprint R0701J.

References

Croskerry, P. (2003)  The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them.  Academic Medicine. 78(80) pp775-780.

Collins and Porras (1996) Building Your Company’s Vision. Harvard Business Review. Sept 1996. Available from: https://hbr.org/1996/09/building-your-companys-vision

Czerlinksi, Gigerenzer and Goldstein (1999)  How Good are Simple Heuristics?  In G. Gigerenzer, P.M. Todd, & the ABC Reseach Group, Simple heuristics that make us smart (pp. 97-118). New York, NY: Oxford University Press.

Kruglanski and Gigerenzer. (2011) Intuitive and Deliberate Judgments are Based on Common Principles.  Psychol Rev. 118(1) pp97-109.

Gigerenzer, G. and Selten, R. (2002) Bounded Rationality: The Adaptive Toolbox. Cambridge, MA: MIT Press.

Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  New York, NY: Broadway Books.

Kotter, J.  (1996) Leading Change.  Cambridge, MA: Harvard Business School Press.

Kotter, J. (2007) Leading Change - Why Transformation Efforts Fail. Harvard Business Review. Jan 2007. Reprint R0701J. Available from: https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail/ar/1

Tufts Medical Center: Department of Clinical Decision Making.  Available from: https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Clinical-Decision-Making/Overview.aspx

Number Needed to Treat in Severe Sepsis and Septic Shock to Save a Life = 4.

Teaching Pearl: In severe sepsis and septic shock, only 7 out of 10 survive.  the NNT for antibiotics (in general is 4.)  There is good evidence to consider broadening coverage if: there are risk factors of surgery or prior antibiotic use.

The prevalence-adjusted pathogen-specific number needed to treat (PNNT) with appropriate antimicrobial therapy to prevent one patient death was lowest for MDR bacteria (multidrug-resistant bacteria) (PNNT = 20) followed by Candida species (PNNT = 34), methicillin-resistant Staphylococcus aureus (PNNT = 38), Pseudomonas aeruginosa (PNNT = 38), Escherichia coli (PNNT = 40), and methicillin-susceptible S. aureus (PNNT = 47).

Conclusions: Our results support the importance of appropriate antimicrobial treatment as a determinant of outcome in patients with severe sepsis and septic shock. Our analyses suggest that improved targeting of empiric antimicrobials for multidrug-resistant bacteria, Candida species, methicillin-resistant S. aureus, and P. aeruginosa would have the greatest impact in reducing mortality from inappropriate antimicrobial treatment in patients with severe sepsis and septic shock.

http://journals.lww.com/ccmjournal/Abstract/2014/11000/Using_the_Number_Needed_to_Treat_to_Assess.4.aspx

They note a few other risk factors identifies by multivariate logistic regression analysis as: resistance to cefepime, resistance to meropenem, and presence of multidrug resistance, but these are less useful clinically since they can only be determined post-hoc.

The Setting Sun

His steady hands were folded in his lap and his posture was erect, as if he were called to a silent attention when I walked into his room. As I gathered a medical history from him, I was reminded of someone, but I could not quite place it. He was a stoic, strong Army veteran. He fought in the land of the rising sun. In spite of all that he had seen, he tried to keep a positive attitude about everything. Recently, he told me, he had been taking miscellaneous classes at a community college for fun -- computer science, psychology, ceramics, whatever struck his fancy.

He was an old man. He had been smoking ever since he enlisted, as a way of passing the time. In spite of all the PT he had done to stay healthy, his lungs failed him. He grew acutely short of breath a few months ago, barely able to walk across a street on the once strong legs that used to carry large crates of ammunition. His hair was thin and short, a reminder of times past. It was not because of an enforced crew-cut this time. A cycle of chemotherapy took its toll on his elderly body. In spite of all that he had been through, he tried to keep a positive attitude about everything.

He smiled at me, a steady and determined smile when I leaned forward and touched him on the elbow.

“So, how do you feel?”
“I feel okay, doc. I just want to know… when is it going to happen?”

I paused, not quite sure how to answer this question.

My brain was still reviewing the list of symptoms of chemotherapy: nausea, vomiting, diarrhea, alopecia, oral ulcers, skin rashes, pain, numbness/tingling/weakness, kidney failure, heart failure… I consciously shoved aside the ticker list scrolling across my mind and focused on the man in front of me.

“The condition you have… the type of lung cancer that it is… is incurable. The chemotherapy only staved off the worst of it that was wrapped around your throat and the blood vessels around your heart. People typically live anywhere from a year to … weeks.”

I looked at him and suddenly caught a glance of my Ojii-san, a man who won a purple heart in the Korean War for valor. He was featured on the cover of Time magazine, according to my mother. All I could remember of my scary grandpa was his raspy breath, stained teeth and the smell of tobacco smoke. He seemed to never move from his recliner and refused to see a doctor when he developed breathing problems of his own. He passed away when I was very young.

“I wish I could give you more specifics, but it is hard to say.”

These men grew up in a different time and likely never thought they would survive the war.
In spite of everything, they had lived past their prime.

I looked out the window where the setting sun flared across the grey clouds on the horizon.
“Well, I’ll come and see you tomorrow,” I said, hefting my backpack over my shoulder.
“I’ll do my best to see you too,” he said with a wink.


____________
Picture by conceptjunkie, c/o flickr

Double Vision

I saw a patient today who incidentally complained of double vision.

"Look straight at me...


To the left...


And now, to the right!"


The misalignment was most evident when I first awoke this patient, but you can still see that the left eye does not track well, especially when looking to the right. (Hint: look at the slight difference in the reflection between the eyes, subtle but present in all photos.)

I was able to diagnose this patient's underlying condition, which is practically pathognomonic for...


Med students: do you know what it is?








----------

Left-sided internuclear ophthalmoplegia, caused by an injury to the medial longitudinal fasciculus...

And the most common source of this lesion is multiple sclerosis. This patient has chronic relapsing, remitting multiple sclerosis (curiously, the patient didn't have any visual problems until a week ago.) We prescribed an eye-patch. I was graciously given permission to photograph the eyes for educational purposes and spread the word.


Sometimes double vision can be "monocular," signifying astigmatism in the affected eye. When it is "binocular," requiring BOTH eyes to be open to create double vision, then you worry about cranial nerve and ocular muscle defects.

Interesting Optho Cases

Here's some of the cases that I had on my Optho service.  Really, that should be "Ophthal" cases, but no one seems to pronounce the "ph" anyhow.  I'm not sure if this is of interest to anyone else, but reviewing this list helps me remember what I've seen. 

 

Most interesting/unexpected

• Ruptured globe -> repair -> enucleation to prevent sympathetic ophthalmia
• Herpes zoster opthalmicus
• Narrow angle glaucoma s/p laser peripheral iridotomy (visible via retroillumination!)
• Congenital cataracts, amblyopia
• Anterior uveitis, HLA B27(+), tx w/ MTX
• Anterior uveitis, secondary to psoriatic arthritis (striking case of dactylitis!)
• Exposure keratopathy secondary to CN VII palsy s/p parotid tumor resection
• Pterygium vs pinguecula
• Grave's ophthalmopathy
• CN IV palsy secondary to meningioma
• Metallic foreign body removal (rust from car) w/ 18 gauge needle, wet Q-tip and Algr brush

Routine but important!

• Corneal abrasions vs ulcers
• Floaters and flashes: vitreous detachment vs retinal detachment vs ocular migraine
• Conjunctival stye vs chalazion
• Background vs proliferative diabetic retinopathy
• Open angle glaucoma
• Age-related Macular Degeneration
• YAG laser
• Cataract surgery
  

Glad that Ophthalmologists Know What the Heck they are Looking at

• Pseudophakic bullous keratopathy
• Choroidal melanoma s/p proton beam radiation
• Pigmented basal cell carcinoma
• Irvine-Gass cystoid macular edema secondary to atopy and cataract surgery

Shoulder Exam

Last week I did a presentation at the HOME project on the shoulder exam with a few clinical cases I saw in clinic. It was a smashing success -- everyone seemed to appreciate an introduction/review of some of the maneuvers!

One of the toughest parts of the physical exam is remembering all of the routine shoulder maneuvers.

Here's a few mnemonics I shared that I use to help myself remember things:

Arm Movements

• Flexion of the arm = Forward to the Face
• Internal Rotation of the arm = In handcuffs
• (alternatively, External Rotation = Execution of Ex-Convict)
• ADduction of the arm = ADDing to the midline
• Scarf sign = toss a scarf around opposite shoulder

Forearm Movements

• Supination = Holding a Bowl of "Soup"
• Pronation = Putting away Palm

Special Maneuvers

• Range of Motion (and Impingement Signs)
• Neer = arm "Near" to the ear
• Hawkins = flap like a "Hawk"
• Apley scratch test = Applying Suntan lotion to back
• Rotator Cuff Tears
• Supraspinatus
• Jobe's Empty Can (duh!)
• Hornblower's (ditto!)
• Biceps
• Speed's = speedin' down the highway
• Labral Tear
• O'Brian = *Irish accent*
  What, so O'Brien gets the thumbs down, but Leno gets a thumbs awp?  I'm cryin' heah!!
• Subscapularis
• Gerber's lift off = wiping baby food off the back (okay, its a stretch, but you can't win 'em all!)

 

That's not my second opinion! :)

Pre-op "clearance"

Physicians often receive requests from surgeons for a pre-op physical to "clear the patient for surgery."

What this "clearance" entails is not entirely clear.

Surgeons are worried that an unknown medical problem will rear its ugly head during the surgery and bite them in the butt... or the anesthesiologist will call off the surgery because of blood pressure concerns.

 

Consults are often made to a cardiologist with the intent of doing a pre-op EKG/Echo + stress test to determine if the patient is fit for surgery at the surgeon's behest.  What is important to understand is that another physician is often the one responsible for keeping the patient alive during the surgery and it is this person, who is most interested in the pre-operative assessment.

Unfortunately, the anesthesiologist often just turns out to be the doctor who happens to be in the OR on that particular day and has not established any sort of relationship with the patient beyond their initial bedside assessment in the waiting room.

In the Cleveland Clinic Journal of Medicine, two anasthesiologists tackle this issue and give some general advice for pre-op consults.

Consults that provide pertinent quantitative data about the patient are helpful—eg, the heart rate at which ischemia was exhibited during stress testing and the degree of ischemia.

Anesthesiologists do not need assistance with managing intravenous drugs (with the exception of unusual agents), but they can use specific guidance on managing oral medications pre- and postoperatively to best achieve optimization and steady-state concentrations.

Pertinent recent information (< 5 years old) from the nonanesthesiology literature should be provided.

Medical consultants should arrange for follow-up care for patients with active conditions not addressed by the surgery.

Absolute recommendations should be avoided in a consult: the surgical team may have good reason not to follow them, and legal repercussions could ensue. The words “consider” or “strongly consider” usually suffice, except where there is an absolute standard of care.

Specific questions to answer include such things like assessment of cardiac function (hx of angina, last echo results, exercise tolerance,) successful blood pressure and diabetic regimens, etc.

 

References

Giving Anaesthesiologists What They Want: How to Write a Useful Preoperative Consult.  CCJM 11/2009

Rheum Case 1

A 55 year old Caucasian male presented to a neighbor island ED with lower extremity skin rash, swelling and severe arthritis following a sore throat.

History of Present Illness:  Pt had an itchy and sore throat for which he was treated with azithromycin.  He sought out new antibiotics after 5 days without relief.  Approximately ten days after the onset of the sore throat, he went to bed complaining of a "sore wrist."  Upon awakening the following morning, he felt severe pain in both wrists with progressive immobility of the left wrist.  His skin broke out with a rash later on in the day on his hands, wrists and ankles.  His legs started swelling and he had difficulty walking.

Denied red eyes or pain with urination.

Past medical history: significant for migratory arthritis, Crohn's disease, HLA-B27(+).  Patient has a long history of severe anaphylactic/eczemal allergic reactions as well.

 

Pertinent physical exam:

Skin exam revealed multiple, progressive, round tender "palpable purpuric" lesions on the hands and ankles.

4+ pitting edema was present in the lower extremities.

 

Diagnosis: enteropathic arthritis and erythema nodosum most likely secondary to a streptococcal infection of the throat with subsequent reaction *HLA-B27(+)

Differential:
Reiter's/Reactive arthritis triad: conjunctivitis, arthritis, urethritis (Can't see, can't pee, can't climb a tree)

Course: Dermatology, ID, and rheumatology consultations were made.  Pt was reluctant to start a course of steroids in the ED, given a past history of steroid-associated insomnia and psychosis.  After 5 days of worsening edema and tender arthritis, he agreed to a steroid burst of 40mg daily and tapering regimen with rheumatology to follow.

 

References

eMedicine: Erythema Nodosum

eMedicine: Enteropathy arthritides

Learning Radiology: An Approach to Arthritis

What does PPD/BCG/TB mean?

Clinical scenario:
In the Hawaii HOME project, we had a series of patients who were being screened for TB with PPDs.  Three of them had a history of (+)PPDs.  Two of them claimed to have a history of (+) chest x-ray without follow-up of medications.  One of them came in with fever and cough.

Definitions:

• TB: Tuberculosis
  • Caused by Mycobacterium tuberculosis
  • Tubercles are warty, cheesy lesions
  • Respiratory infection characterized by:
    • Cough
    • Hemoptysis (bloody sputum)
    • Fever/Chills/Night sweats
    • Weight loss
  • DIFFICULT: to catch, to culture, to get rid of
• BCG: Bacillus Calmette-Guerin
  • Calmette (French bacteriologist) and Guerin (assistant) cultured a cow-version of the TB bacteria and created a TB vaccine
  • Similar theory to the smallpox vaccine
    • Jenner made a vaccine from cowpox
  • Causes a false-positive PPD skin test
• PPD: purified protein derivative aka Mantoux test
  • Sterilized tuberculin glycerol extract from the tubercle bacillus
  • Injected subcutaneously (right under skin)
  • Read 2-3 days later (delayed type IV hypersensitivity reaction)
    • (+) if induration (hardness) forms >5/10/15mm depending on situation
    • (-) if no reaction is present
• Chest x-ray
  • Test of choice in non-active TB for determining clinical status
  • (+) indicates that lesions suspicious for TB are observable
  • (-) indicates that the patient is at risk for secondary TB activation in the future, but currently does not have active TB assuming the patient is asymptomatic

Why is this important?
Swaziland has the highest prevalence of TB in Africa (1,198:100,000), shortly followed by South Africa (948:100,000). In the Pacific Islands, Cambodia, Kiribati and the Philippines have high rates as well (495, 365 and 290:100,000 respectively.) In Southeast Asia, DPR Korea, Timor-Leste and Bhutan have high rates; also places of conflict.
Many immigrants pass through Hawaii to the mainland US and the immigrant homeless population has a significantly higher risk of exposure to TB and subsequent infection.

Treatment
Active TB Standard recommended regimen:
2 months of RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol
4 months of RI: rifampicin, isoniazid
Latent TB infection:
6 months of isoniazid, or 3 months of RI
-Advise patients about side effects of isoniazid:
GI upset (loss of appetite, nausea, vomiting, stomach pains)
Weakness, peripheral neuropathy (prevented by vitamin B6 intake)
Liver damage
-Do Cr and LFTs monthly for monitoring

Resolution of clinical scenario:
The two patients with (+)PPDs and (+)chest x-rays were questioned further.
The one with fever and cough was confused and through a translator, thought that the word "positive" meant "good."  In the context of the tests, both were negative.
The other patient had a card with a record locator number.  The main office for TB screening was contacted for confirmation: the chest x-ray was reportedly normal.  This patient had unintentional weight loss of 35 lb over the past year (since becoming homeless.)
The patient was warned about the possibility of "reactivation TB" and was advised to start isoniazid.  The patient agreed to prophylactic treatment and routine testing.

Take home lesson:
Always question your patients about what they mean!  Positive in terms of disease is may not mean the same thing to a patient as it does to a clinician.

References:
WHO estimates of TB incidence by country, 2007
NICE 2006 guidelines: Clinical diagnosis and management of TB and measures for its prevention and control by the UK's National Institute for Health and Clinical Excellence

Traumatic rhabdomyolysis

In recent news, a survivor of the 7.0 earthquake in Haiti have been found after 10 days -- including a 22 year old, Jean-Pierre.  In the rubble of the collapsed hotel he fed on cola, beer and cookies to stave off dehydration and malnutrition until his timely rescue.

He was lucky enough to dive underneath a desk as the earthquake hit, avoiding major trauma.  What if his legs were pinned under tons of rock and timber?  What if he were held immobile for the better part of a week?

Jean-Pierre was spared the fate of acute renal failure/acute tubular necrosis by traumatic rhabdomyolysis.  It would start as dark red urine, that eventually lessens until there is no urine being produced at all.

 

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

Myoglobin is a heme-binding molecule present in skeletal and cardiac muscle. It makes our muscles red, especially the slow-twitch (Type I) muscles. It is similar to hemoglobin but greedier -- it's affinity for oxygen is much stronger.  Underwater mammals like seals and whales are able to hold their breath much longer than us due to their higher concentration of myoglobin in muscle.

For reasons that are not entirely clear to us, when muscle tissue breaks down from trauma and immobility, myoglobin is released into the bloodstream and subsequently filtered by the kidneys where it can cause major damage -- nephrotoxicity by iron-dependent and -independent mechanisms.
1) Ferrous oxide (Fe2+) is oxidized into Ferric oxide (Fe3+) and leads to free radical damage in the kidneys.
2) Tubule obstruction and direct toxic effects are thought to occur as well.

Aggressive saline infusions with possible addition of sodium bicarbonate to alkalinize the urine (and prevent conversion of myoglobin into its more toxic metabolites) are the sole treatment of this kidney condition.  This makes sense, since you're clogging up the filtration system with this muscular gunk, you vigorously flush the whole system out!

We're talking about boluses of 20cc/kg (or ~1.5 L of NS for the typical person) initially, with maintenance IVF of 200-300cc/hr thereafter!

This is expected to go on until the urine output hits 2-3cc/kg/hr (or 150-200cc/hr for the typical person) and the urine clears up.

 

Hopefully you find this topical and interesting as well.

 

References

Photo by simminch via flickr

BurnDoc ICU Rounds:
-Traumatic rhabdomyolysis/Crush Syndrome
-Acute Renal Failure

Myoglobinuria - Medscape

"Nonreassuring" Vocabulary

The word "nonreassuring" is a curious phenomenon of OB/GYN.  Nowhere else is this particular word used in a professional context... which is embarrassing that the word is cited in literature when it doesn't exist.

 

Reassuring is defined thusly:

tr.v. re·as·sured, re·as·sur·ing, re·as·sures

1. To restore confidence to.

2. To assure again.

3. To reinsure.

The implication is that "nonreassuring" means the opposite -- worrisome, vexing.  Of course, to a pregnant mother about to deliver, that's some of the scariest news to hear about her unborn child!

 

In an effort to further obscure the assessment in Fetal Heart Tone monitoring, in April of 2008 the "National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring" issued a new statement to categorize it in a "Three-Tier Fetal Heart Rate System:

Category I
Category I fetal heart rate (FHR) tracings include all of the following:
• Baseline rate: 110–160 beats per minute (bpm)
• Baseline FHR variability: moderate
• Late or variable decelerations: absent
• Early decelerations: present or absent
• Accelerations: present or absent

Category II
Category II FHR tracings include all FHR tracings not categorized as Category I or Category III. Category II
tracings may represent an appreciable fraction of those encountered in clinical care. Examples of Category II
FHR tracings include any of the following:
Baseline rate
• Bradycardia not accompanied by absent baseline variability
• Tachycardia
Baseline FHR variability
• Minimal baseline variability
• Absent baseline variability not accompanied by recurrent decelerations
• Marked baseline variability
Accelerations
• Absence of induced accelerations after fetal stimulation
Periodic or episodic decelerations
• Recurrent variable decelerations accompanied by minimal or moderate baseline variability
• Prolonged deceleration 2 minutes but 10 minutes
• Recurrent late decelerations with moderate baseline variability
• Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,”
or “shoulders”

Category III
Category III FHR tracings include either:
• Absent baseline FHR variability and any of the following:
- Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia
• Sinusoidal pattern

Basically, Category I is "reassuring", Category III is "Nonreassuring" (ugh) and Category II is somewhere in between.

 

Personally, I don't like it when the assessment of a patient needs to be translated for the patient's benefit -- why is there a deliberate effort to make something difficult to understand even harder to explain to patients?!?  We don't need to tell someone what they already know, but in a completely different language.

 

It's doubtful, but in the future it could be categorized as "good," "hmm" and "uh oh."

 

DR C BRaVADO: mnemonic for Fetal Heart Monitoring

Define Risk (low/high)
Contractions (freq)
Baseline Rate (110-160)
Variability (10-15bpm)
Accelerations (2, >20 over 20s)
Decelerations (early/variable/late)
Overall assessment (reassuring vs "nonreassuring" ugh!)

 

References:

Advanced Life Support in Obstetrics (ALSO)

AAFP website

AAFP Mnemonics brochure

National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring

The Match.

I submitted my Rank-Order List for Family Medicine programs on Friday. I updated it again today to double-check that my top program numbers were inputted appropriately. Whew!

There's a lot of factors that go into the decision-making process for residency program selection -- geography, work-hours, resident/faculty support, curriculum, monetary factors, etc.

When I looked at Family Medicine programs on the Mainland, I must say, I had NO idea what to look for -- being a medical student from Hawaii, almost all of the faculty in our Family Medicine department trained in the Family Med program here as well! So, I took a shortcut of investigating the P4 programs because I figured that they were excellent programs already, looking for fresh new ideas to integrate into their curriculum. My other choices were based on good things I heard from people, as well as my discussions with them at the Kansas City AAFP National Conference (if you're looking for the perfect family medicine program for YOU, I'd highly recommend visiting in your first month as a fourth year!)

Despite the "4", in the name, not all P4 programs are four year programs, although I found some of the ones that were to be of particular interest. Innovations are a great topic to discuss, but I want to share something else on my mind.


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

Now that the rank-order list is out of my hands, I have nothing to do but wait and see what the final outcome will be, come March 18th. The National Resident Matching Program "matches" me with my #1 choice, putting me in the queue of their program according to their ranking for me -- if I happen to be in their top 10 (or so,) then I get matched there. If someone higher on their list ranks the program highly as well, then I would get bumped down (and possibly off) their list and when all the slots are filled, I would move on to my #2 choice or my #3, until I get placed.

Naturally, I feel a sense of relief.
I've gone through the grueling process of medical school (for the most part.) The countless hours of mind-numbing study in the first two years, culminating in the Step 1 exam. The thrill and terror of third year, suddenly exposed to the organic, living, breathing patient that we've heard so much about. The uncertainty and anxiety of the interviews and the ever-expanding hole of debt traveling across the country far and wide for the perfect place to spend the next three+ years of my life. Now it is time to relax and breathe. It is out of my hands.

I also feel a sense of dread and underlying anxiety.
Questions of self-doubt and second-guessing arise.
Should I have applied to X program?
What if the people at Y didn't like me?
Would I really be happy at Z program?
Can I handle the responsibilities to come?
Will medical school be enough preparation for the next harrowing experience known as INTERN YEAR?

This lack of control is both comforting and anxiety-provoking.
I have no choice but to have faith that my interviews went as well as I felt they did and just keep my brain active in the mean-time. I am tutoring a small group of incredibly fun second year med students and I'm touching on all sorts of issues that I know will be important in the future. More to come on this. :)

*Picture by 96dpi, courtesy of flickr.

Adventures in Brain Tumors (Prolactinoma!)

notmy2ndopinion: Adventures in Brain Tumors, (by @mathowie) http://bit.ly/37DMa4 (via @JoshuaSchwimmer)

My favorite part comes in the conclusion and it is very revealing about how AWFUL the patient experience can be. All too often, health care professionals feel pressured by their own time schedule and do not take the time to move at the pace more comfortable for the patient. Even small, simple things can make a big impact, like pulling up a chair to sit while talking, tuck the blanket in after pulling it down to examine their abdomen, etc...

The days in the hospital didn't go by so much as a blur as they did a smear. I was either asleep, passed out and seizing, lethargic, and very briefly completely awake each day as an army of medical professionals grilled me with a couple dozen identical questions and eventually life altering decisions were presented to me when I had been awake for all of 30 seconds.

I came away from this experience feeling the OHSU hospital in Portland continues to impress me with its amazing staff, but that the process of dealing with patients could be done in a more efficient manner. I know they all sort of kept an internal log of my story but to constantly be asked the same things by different groups of people and then not know who is your main decision maker was a challenge. Given my state of sickness and exhaustion, I felt like what an elderly man might feel like in the medical system. I had trouble understanding what people were saying as they woke me from sleep, I was constantly poked and prodded without descriptions of what results entailed, I literally wanted to "phone a friend" when those surgeons asked me in the early morning hours what I wanted to do.

"Time Lost is Brain Lost"

I woke up at 0430 and I couldn't get out of bed. Oh, that's weird, I thought. My right arm was completely numb from the shoulder all the way down to the fingertips. After about two minutes I jumped out of bed but I fell straight down onto the floor with a crash. My legs were weak -- it was like the right side of my body didn't exist!

My wife awoke in the commotion and asked me what was wrong.

I opened my mouth to talk to her, but nothing came out! I could understand her but my words weren't there.

After about three minutes, I got up and I said "oh, I'm okay now." I took a shower (there was still some numbness in the arm) and went to work. I figured something was probably going wrong so I called the doctor and he told me to go to the ER.

Lucky thing too... it sounds like you had a mini-stroke or what we call a"transient ischemic attack," (TIA) -- a temporary event. The residual numbness suggests more long term damage though. Since you're right-handed, you are most likely left-brained -- and your language is controlled by that side of your brain too. When you had the brain ATTACK (as threatening as a heart attack!), you wiped out your left brain, paralyzing your right body and knocking out your ability to talk.

We call this right-sided Hemiparesis (weakness) or hemiplegia (no movement), right hemineglect (inability to register things on the right side of the world) and Broca's aphasia (inability to verbalize thoughts; staccato, halting speech.)

I went over the ABCD2 scale with him and calculated a moderate risk for stroke:

2-Day Stroke Risk: 4.1%.
7-Day Stroke Risk: 5.9%.
90-Day Stroke Risk: 9.8%.

We started him on clopidogrel (Plavix) and he is undergoing a cardiac workup to rule out an embolic cause for his TIA/stroke.

In stroke patients, further assessment is done with the NIH Stroke Scale.

An pdf of the NIH Stroke Scale is available at http://www.ninds.nih.gov/doctors/stroke_scale_training.htm

An online course for provider education is available on
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

ddx

I have a project that I am putting together about differential diagnosis.

it is by no means a topic that I have "mastered" by any means... but there are a few things that i try to keep in mind.

one of them is the quote:

if you hear hoofbeats, think horses, not zebras.

this quote is supposed to remind people that common things are common.

But db reminds me that premature closure is also a problem.
So I would revise the old saying thusly:

If you hear hoofbeats, think horses, not zebras. unless you're in a savannah and you see stripes.

Differential Diagnosis Generation

View more presentations from Clinton Pong.

something that I want to be a part of

Eye am so confused!

I remember when I had my one and only ophthalmology lecture in medical school (in a Problem-Based Learning curriculum, few formal lectures exist if at all.) We spent just 30 minutes on this topic and I still stumble on it, so I thought I'd clarify it and review it using a simple image (see slide three.) The rest of the presentation is just gravy, but that's notmysecondopinion.

Eye Am Confused

View more presentations from Clinton Pong.

Pong's Postulates (II)

Pong's Postulates
1) Health is something we have until we notice we do not.
* Preventive services help people notice their health.
2) There are two types of disease: those we live with and those we do not.
3) "Docere" in latin means "to teach." Doctors primarily help people know their illnesses.
* It does not matter what doctors say; what matters is what patients hear.
4) Comprehensive Generalists see the big picture.
* Interventions happen all they way along the natural history of health to disease to complications.
5) I want to be a part of my patients' long lives through sickness AND health acting as their advocate and guide.
Therefore, I want to be a Primary Care Family Physician.

Elucidating Pong's Postulates

Health and illness:

One of my early experiences with disease is unusual. It was nothing more than a nuisance at worst but it affected me greatly. I have a condition called hyperhidrosis, characterized by excessive sweating. As a child, my palms would literally drip with sweat, sometimes for hours. I went to a dermatologist and after failed trials of topical antiperspirant and uncomfortable iontophoresis, I considered Botox or surgery. So in the midst of applying for medical school, I had a bilateral thoracic sympathectomy performed. Now I can take notes, read books and put on gloves without a struggle. I reflect upon it every time I greet a patient, now that I can shake their hands without hesitation. I am thankful for the help of my dermatologist and the skills of my cardiothoracic surgeon who have boosted my confidence as a physician.

Disease and dealing with it:

In the summer following my first year of medical school, I shadowed a few doctors at a clinic for the underserved. One patient in particular stands out in my mind. She was an obese Micronesian woman who came in with her teenage daughter complaining of fatigue, thirst and frequent urination. The resident made the diagnosis of diabetes. The plan seemed simple enough: diet, exercise and metformin. I was impressed with the way that the resident delivered the information but I noticed that she stopped listening. She broke down and started to cry. Her sobbing grew even louder as the resident started to raise his voice -- as if it would help her hear what he had to say!

"I'm sorry," I said as I handed her a tissue. "I know this is all coming as a shock to you..." I struggled with what to say next. "Are you afraid you'll be like your father and need an amputation?" Suddenly being diagnosed with the same disease that almost killed her diabetic father was too much for her. The resident apologized; "I'm sorry. Sometimes I forget that this is not as routine for you as it is for me." I have never forgotten those words -- it does not matter what doctors say; what matters is what patients hear. What can be a straightforward routine for physicians is often a life-altering alien experience for patients.

We comforted her. Diabetes was something that she could learn to live with instead of dying from it. "You need to lose weight. I do not want to say 'go on a diet.'" I said at the end of the visit. "That is temporary. We really ought to work on lifestyle changes for you AND your family... you do not want your daughter to follow in your footsteps, do you?" Both of their eyes welled with tears at that and they silently shook their heads. I was gratified to see that her daughter's half-full soda was swiftly discarded as they left the exam room.

The Big Picture and Interventions:

In my first elective as a fourth year clerk, I rounded with a cardiologist covering his partners' patients in the hospital. One of the patients we met was an elderly Hawaiian man with forty grandchildren who clotted off his stent. Three weeks ago, he was told very emphatically to gather up his family and say goodbye. Three weeks later, we found ourselves face to face with a restless grandfather. "I don't want to die here in the hospital." It was a sentiment I could understand except he had a surprising recovery. The cardiologist tried to negotiate with him to stay to make sure he was stable on the correct medications. "You may die if you leave the hospital. Do you understand?" The patient frowned and replied "Do you have grandchildren? Do YOU understand?" "No. But I understand. Do YOU?" It went back and forth until the cardiologist left abruptly.

I could see them slicing past each other trying to press their points. No doctor had given him the simple courtesy of three minutes of time in the past three weeks. He was frustrated and confused. At first, he was told that he was going to die in the hospital, then he could go home for hospice and now he was supposed to stay. I do not have any grandchildren, so I could not understand how he felt. This man cared more about his family than his own health. Perhaps it was a pervasive trend; there were many interventions that could have guided him down a different path. Yet here we were with only one thing to do: I just listened to him.

I want to be a Primary Care Family Physician:

I often wonder how the story ends for these patients. I wish I could be a guide for the mother and her daughter through health and an advocate to fight for the grandfather. I know that this is precisely what I will get to do as a family physician.

My doctors helped me prepare my HANDS for medicine. My teachers in medical school helped me prepare my HEAD as well, but it is my patients that have prepared my HEART for a lifelong commitment to medicine.

DeGowin Quotable.

DeGowin's Diagnostic Examination seemed like a silly book to have, but I inherited it from one of my previous upper medical student benefactors. I had already read through Bates... what more could it offer?!?

Boy, was I wrong.

I bought the book for my Kindle and I have enjoyed reading it from time to time. It goes beyond talking about history taking and physical exam maneuvers to philosophy.

Here's my favorite quote:

DeGowin's Diagnostic Exam (Richard F. LeBlond, Donald D. Brown and Richard L. DeGowin)
- Highlight Loc. 898-901 | Added on Saturday, July 25, 2009, 11:17 PM

Disease is a four-dimensional story, which follows the biologic imperatives of its particular pathophysiology in specific anatomic sites as influenced by the unique characteristics of this patient. Your task is not verbal, but cinematic; construct a pathophysiologic and anatomic movie of the onset and progression of the illness: the words are generated from the images, not the images from the words. After all, a picture is worth a thousand words.

Indeed, I remember my patient's problems better and I learn better when I visualize things instead of simply trying to MEMORIZE. It is tough to stay on task with it, but it is very effective during presentations -- when I've got things straight, the story comes out the right way.

Patient Centered Medical Home... say what?

One of the key components driving our healthcare debate centers on something called the "Patient Centered Medical Home." In a simplified, beautiful poetic statement it is:

"A continuous relationship with a personal physician coordinating care for both wellness and illness."

At the recent AAFP FM NC (American Academy of Family Physician's National Conference) for Residents and Students that I attended... the speaker Dr. McGeeney said:

People get the concept. People like the idea. It's the NAME that they hate.

I will freely admit, it sounded like just another silly buzzword that's thrown around to me. I do readily subscribe to the concept of a medical home -- and I do want to put my patients first in all respects. These are things that I got excited about planning for my future practice without even realizing what a PCMH is!

One of the commenters at the end of Dr. McGeeney's talk summed up my own sentiments quite nicely. He raised his hand and said "it sounds great and all, but you REALLY have to change the name. No one knows what that means. I get that it's an old concept from 1967, but it needs to change. It sounds like a nursing home to me."

So, I found myself thinking about the CONCEPT.

What does it mean to have a PCMH?
To me, it means having a doctor for life. Someone you can trust. Someone who has known you through thick and thin.
It means having a group of people who work with you. Dietician, exercise trainer, medication manager, physical therapy, diabetes educator, etc... "ancillary services" that deserve a central role in care.

Why don't people get it?
I think Home is a solid object in a lot of people's minds. When you tell them "we are going to give you a medical home" they think of a location, rather than a group of awesome people who are trying to keep them healthy! A funny story is that one of the family medicine residency programs got a phone call from a reporter, asking to see their new medical home. "So, this home. Is it a house? A clinic? What sort of structure is it?" After some forehead slapping in trying to explain that it was just a concept, the director ended up just telling him their address. UGH. PCMH really doesn't lend itself well to a clear definition.

So what's your brilliant solution?!?
I am very biased on this point. I'll say it up front because it is a shameless plug for my specialty of choice.
I propose that we call it Patient-Centered Medical Family.

Think about it.