How Reliable Is Your Medical Information?
Perhaps oxygen wasn't such a good idea!
When working in the hospital and medical office during the clinical years, it is common to receive pearls of wisdom from interns, residents, and attendings. How reliable is this information? And how reliable is the information we receive from lectures, journal articles, books, and drug reps?
A lot of information is passed around, and since some of it is wrong, it is important to rely on the best sources available. In the 1980’s, some of the best minds in medicine made a disastrous mistake. It was known that significant cardiac arrhythmias were correlated with death. A search was undertaken for drugs that would reduce such deaths. But rather than using reduction of deaths as an end point in the drug studies, it was easier to adopt a “surrogate” endpoint, namely whether the drug reduced arrhythmias. If a drug reduced arrhythmias, it presumably would also reduce deaths. It was not adequately considered that the drugs might have unexpected harmful side effects that would in fact worsen the problem and contribute to death. Antiarrhythmics became widely prescribed, even for non-life threatening arrhythmias, leading to many unnecessary deaths (which initially were felt to be due to the heart disease, rather than the drugs), until studies were properly done to assess whether the drugs actually saved lives. They didn’t; they killed thousands of people.
There is so little time to read and evaluate the medical literature, particularly the Materials and Methods sections of research articles, and there is an unfortunate tendency to rely on the word of physicians above us in the hierarchy, or on drug reps, or on research reports (particularly those funded by drug manufacturers) that may have biased and erroneous conclusions. It is necessary to know how to read and evaluate a research article. This requires some knowledge of biostatistics. For further information, see Ann Weaver’s brief and intuitive book, Clinical Biostatistics Made Ridiculously Simple, which focuses on the pitfalls of clinical research reports and how to evaluate them.
It is also important to use reliable medical search engines on the Internet, since the Internet contains lots of unreliable information. Such search engines are described on the MedMaster search engine page.
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Do you prefer eBooks or print books? And why? Feel free to comment.
How To Study Pharmacology
The Seven Dwarves' Medicine Chest
When I was in medical school, Pharmacology was taught by Alfred Gilman, a coauthor of Goodman and Gilman’s Manual of Pharmacology and Therapeutics, a superb reference text, both then and now.
However, I had great difficulty in grasping an overall picture of the subject through this reference text. It was too big; after reading one drug after another, the drugs soon started blending into one another, becoming difficult to sort out and remember.
What is the best way to learn Pharmacology? This goes to the question of what facts are important to memorize and which are not so important to memorize but can be looked up in a reference text or computer program.
In Clinical Pharmacology Made Ridiculously Simple, the author, James Olson, has sorted out the general characteristics of each drug group at the top of the page, for understanding and memory. Other details, particularly those contrasting the individual drugs in a given group with one another, are placed in a table for cross reference at the bottom of the page. Such information can be looked up rather than memorized, except for certain features that are highly characteristic of one drug in comparison with the others.
It is helpful to have a good reference text in addition to the small book that quickly enables the reader to grasp general principles.
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What is your opinion about the usefulness of eBooks versus print books? Which do you prefer?
How To Study Biochemistry
In 25 years of teaching medical students, I found that Biochemistry is the course that students have most difficulty relating to for clinical relevance. While Biochemistry has much clinically relevant information, the material students are taught often does not reflect this.
I think this is because there is a big difference in what is important to PhD students and what is important to medical students. For instance, ALT and AST are liver enzymes that are vitally important to the function of cells. Their detailed biochemical reactions are important to the PhD student, but not to the medical student. It is more important clinically to know that these enzymes leak out of damaged liver cells and are useful as markers for liver damage.
As another example, creatinine is a waste product of muscle biochemistry. It is not so important to the PhD student, but very important to the medical student as a marker of muscle and kidney damage.
It would help to have more clinicians teaching the basic sciences and providing a more clinical focus.
Of course, if your instructor emphasizes topics of greater interest to PhD students, you need to learn that, as well as facts that are asked on the USMLE. But teaching would be improved by emphasizing clinically important areas.
There is a problem with just rote-memorizing isolated facts. Somewhere along the line it would help to understand Biochemistry as an overall whole, particularly in a clinical context, for future practical use. For instance, there is much discussion about the value and side effects of HMG CoA reductase inhibitors (“statins”) in suppressing cholesterol synthesis. It helps to see this enzyme in the context of a broader Biochemistry map to understand the pathways involved in cholesterol synthesis and what may be affected by suppressing it.
In Clinical Biochemistry Made Ridiculously Simple, I have tried to do just that, present the clinically relevant points in Biochemistry (particularly the metabolic pathways and the diseases that affect it) on a single map that can be grasped as a whole. It is not a reference text, which disappoints some readers. I suggest that readers also acquire a good reference text, bearing in mind that it can be very difficult to see the overall picture in a reference book. The best way to study Biochemistry is to first grasp the overall picture in a small book, but also have a reference text and your class notes to fill in on other details.
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What do you think about using eBooks versus print books?
The Best Medical Apps
Treatment that works for one patient does not necessarily work for another.
The term “app” (application) generally refers to a small, specialized program that is downloaded onto a hand-held (mobile) device such as an iPhone or tablet, although the term is also used for laptop and desktop computers.
There are over 5,000 medical apps, which are continually evolving. There can be “app overload,” where many apps are downloaded, but few are used. What sort of apps should you look for?
Ideally, a medical app for a mobile device should provide rapid, useful information at the bedside or office visit (“point-of-care”) in such areas as:
Drugs (dosages, side effects, drug interactions)
Differential diagnosis
Current workup and treatment
Lab values
Calculation formulas and algorithms
Specialty items such as heart sounds, EKGs, dermatologic diagnosis, radiologic images, and vision testing, depending on your needs.
The top 5 applications that are favored by students at Harvard Medical School (http://mobihealthnews.com/10745/top-five-medical-apps-at-harvard-medical-school/) are:
- Epocrates:provides drug dosages, drug side effects and interactions, pill ID, lab values, calculation formulas, and algorithms.
- VisualDx Mobile: contains dermatologic images and diagnosis algorithms.
- Dynamed: provides up-to-date approaches to diagnosis and treatment.
- Unbound Medicine uCentral: has many apps that can be combined and customized for your particular needs and interests.
- iRadiology: shows a compendium of radiologic images.
I add a few more:
WebMD provides a rapid guide to symptoms, conditions, drugs and treatments, including first aid information.
Medscape provides information about drugs, including over-the-counter and herbal medications, diseases and conditions, procedures and protocols, and drug interactions.
MurmurPro offers a set of heart murmurs.
Vision Test provides vision tests.
Mediquations: While Epocrates offers calculation formulas, Mediquations provides more formulas and actually does the calculations.
In addition to the above apps, there are also Internet medical search engines that can look for reliable and specialized information, as opposed to the sometimes unreliable information that is found through general search engines, such as Google. A list of these search engines can be found at the MedMaster website, which also offers a downloadable app, called MedSearcher (free), which allows quick access to the major medical search engines. MedSearcher presently is only available for computer use on Mac and Windows.
All the above apps offer isolated point of information. Apart from individual facts, it is also important to have a general understanding of the subject and field. This requires a fair amount of reading, which for many students would be tedious on a small hand-held mobile device like an iPhone. It would require a print book or an eBook reading tablet. MedMaster specializes in books that promote understanding.
Do you have a favorite app that you would like to share? Please feel free to comment.
How To Study Neuroanatomy
The director of medical student cardiology training at the University of Miami once told me that cardiology was really not that difficult to learn, since it was based on a few general principles, but that neuroanatomy was difficult, since there were so many isolated facts that are difficult to digest.
I found this conversation interesting, since I had experienced just the opposite. Cardiology to me was always nebulous; there were just too many facts to learn, especially drugs and their effects, and I always had difficulty with cardiology. Neuroanatomy, though, seemed far simpler, since, to me, a few general principles conveyed the essence of the subject. It occurred to me that the learning of a subject has a lot to do with the grasping of general principles.
For instance, there are some 100 billion neurons in the brain and in the range of a quadrillion synaptic connections (connection points between nerve cells). This would surely be an overwhelming amount to learn. However, it is interesting from a clinical standpoint that of all these synapses, there is only one that is of clinical significance to know about in evaluating a patient. That is the synapse that separates an upper motor neuron from a lower motor neuron. Where the synapse is located makes a big difference in the kind of paralysis that a patient experiences, whether of the upper motor neuron kind or the lower motor neuron kind (I won’t go into the details here). Other than that synapse, it is the pathway along which information flows, rather than the number of synapses in that path that is important. Whether or not the pathway has one synapse or many within it is unimportant in making a diagnosis as to where the problem lies. This simplifies the study of the subject.
As an example, the right side of the brain connects with the left environment of the body. Thus, an injury to the right brain will result in sensory loss or weakness on the left side of the body. It is not necessary to know where all the synapses lie along these pathways to know this. Who would concern the physician more, a patient who complains of a right-sided headache and weakness and lack of sensation on the right side of the body, or a patient who complains of a right-sided headache and weakness and lack of sensation on the left side of the body? It is the latter, because a problem with the right brain should not affect the right side of the body. The location of the synapses is not so important in making this determination.
In learning neuroanatomy, then, it is more important, at least at first, to learn the general principles of pathway layout, rather than the location of synapses. If you want to learn all about synapses too, it would be better to first understand the general principles of direction of flow of the pathways, then move on to greater detail. This is the approach I have taken in Clinical Neuroanatomy Made Ridiculously Simple.
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Which do you prefer, eBooks or print books? And why? Your opinion counts!
How To Study Anatomy
In learning Anatomy, I think it is better to first learn through conceptual diagrams, rather than through photos of actual anatomy. Photos of dissections contain fascia (connective tissue) and other features that obscure the conceptual picture of what connects with what. In our medical school anatomy program, we had available a series of stereoscopic slides of actual dissections. Few students used them. During my ophthalmology residency, I also found relatively useless a book of photos of orbital dissections. It is better to learn the anatomy conceptually, as through line drawings, and then fine tune this knowledge when learning surgery, having first learned the anatomy conceptually.
Anatomy is a very visual subject. Here, a good way to learn the anatomy is to distort it into pictures that are common knowledge. A typical vertebra, for instance, looks like a snowman, whose arms, legs, shoulders, and head resemble the actual vertebral anatomy (see below). While learning other people’s mnemonics can be very helpful, they are often longer-lasting if they are your own.
From Clinical Anatomy Made Ridiculously Simple, by S. Goldberg, MedMaster
Ditties (e.g. “C3,4,5 keep the diaphragm alive”), acronymns (e.g. “SCALP” for layers of the scalp: Skin, Connective tissue, Aponeurotic layer, Loose connective tissue, Pericranium), and ridiculous associations (e.g. for cranial nerves 7 and 3, which open or close the eyes — see below) are also useful for learning anatomy. A collection of such mnemonics may be found at medicalmnemonics.com.
CN7: A hook - closes eyes. CN3: 3 pillars - opens eyes. From Clinical Neuroanatomy Made Ridiculously Simple, by S. Goldberg, MedMaster.
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Which do you prefer, eBooks or print books? Why? Your opinion counts.
Benji’s Shot
Romance on the surgical service
Sometimes, an otherwise complicated diagnosis can be made with a simple observation, without requiring many procedures or expensive tests. Witness the case of Benji:
One day, a neighbor frantically knocked on my door and told me that she could not arouse her 6 year-old son, Benji. I raced over to the house to find Benji lying on the couch, and indeed it did not seem possible to awaken him. A preliminary neurologic exam revealed nothing wrong. I then raised Benji’s arm above his face and let go. Now, when a person is really unconscious the arm will hit his face. However, if he is faking, the arm misses, since the patient does not want to hurt himself. Benji’s hand missed.
I then announced to Benji, that since I could not wake him up, I would have to give him a big shot in the behind with a needle that he would not feel since he was not awake, and that I was going out of the room to prepare the shot. I left the room with Benji’s parents and came back about a minute later. Benji was gone. He was hiding behind the couch.
So arriving at a complex diagnosis is not always difficult when there is a pearl that shows the way.
Should Lectures Be Eliminated in Medical School?
Lectures have always been a staple way of educating in medical school, particularly in the first two years. But are they the most efficient way to learn?
PROS:
• There are excellent lecturers, who can provide insights and important points not presented in other sources.
• The lecturer, as a facilitator, is available to the student for clarification of ideas that are not clear.
• Lectures provide a different avenue of learning that can add to the learning experience.
CONS:
• You can’t just stop in the middle of a lecture to mull over the ideas, or go back, as you can with a book or an electronic presentation. Key points may be missed, especially if you can’t write fast enough.
• Students learn at different paces, and books and computer programs allow students to learn at their own speeds. The quality of computer teaching programs is continually improving.
• In cases where a lecturer speaks poorly, or does not teach with clinical relevance, would it not be better to use computers or clinically relevant texts to learn?
• Some lecturers in the basic sciences may be excellent researchers who would make better use of their time in the research lab, where their talents and interests lie. The department could also save money by hiring fewer lecturers.
• Clinicians can be good sources of clinically relevant information, but are often too busy to put in a consistent teaching schedule.
Some students do not show up at lectures, and others do so because it is more likely that what a lecturer says will show up on an exam. Others rely on note takers.
Should the emphasis on lectures be reduced? Should more teaching shift to self-learning? Would it be better to provide students with a list of clinically important concepts and points to learn in the basic sciences and then allow the student to learn them at their own pace?
What do you think?
Medical Curriculum In The First Two Years Of Med School
Say you have a juggler who wants to be the best ever, to juggle 7 balls at the same time as balancing a stick on his head and twirling 3 hoops around his leg. How would he go about learning this amazing stunt, which combines three skills? You might say to start off practicing all of these skills together, since this is the final result the juggler wants to achieve. However, the juggler is more likely to succeed by practicing one skill at a time, and then, after learning each of them, practicing them together.
It is similar in working with patients. In evaluating patients, it is important to incorporate the considerable information you have acquired in the basic sciences. For that reason, medical school education in the past consisted of spending the first two years learning the individual basic sciences and then putting this information together when seeing patients.
More recently, however, the trend in some schools is to start right from the beginning seeing patients, before there is a background in knowledge. Is this the best way to learn medicine? I suspect that a leading reason for the change to seeing patients right away is the impatience at having to wait so long before entering the clinical world. In particular, since the basic sciences are typically taught by non-clinicians, and much emphasis is on information that the student does not find relevant clinically, the student wants greater clinical exposure right from the start.
It seems to me that the better way to approach medical education in the first two years is the old way of learning the basic sciences first, but with a strong clinical emphasis, minimizing information that does not have clinical relevance. By cutting down on the more esoteric, clinically non-relevant information, there would be more time in the second year to study for the USMLE Step 1 (an exam taken at the end of the second year), put the information together, and better prepare for seeing patients.
You, as a student, may have little control over how your school arranges the curriculum, but should not feel as if something is wrong with you if you feel somewhat lost in evaluating patients before you are prepared. Some schools may offer the student a choice of following the more traditional curriculum or following one that emphasizes early clinical exposure. Personally, I would opt for the former, but use a text that emphasizes clinical relevance.
What do you think?
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Which do you prefer, eBooks or print Books?
Learning Speeds In Medical School
Heroic measures in cardiac arrest
In the classic fable of the Tortoise and the Hare, the tortoise wins the race against the hare by slow and steady persistence. There are some students who quickly grasp concepts and facts, and have a steep rising learning curve. Others are slower, but with persistence, can not only achieve the goal, but achieve a greater degree of knowledge and understanding than quicker learners. Their learning curve may rise slower, but end up higher.
I was a relatively slow reader in medical school. It sometimes felt like I was miles behind and would never catch up. However, I eventually learned that understanding key concepts, as opposed to simple rote memorization of isolated facts, can quickly reduce the gap. Once one has understanding, the facts are more easily organized and remembered.
If you are having difficulty keeping up, you may not be as far behind as you think. Sometimes, understanding a few key points quickly closes the gap. I suggest trying to understand, rather than simply rote memorize, and bear in mind that slow and steady adds up down the line.
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Which do you prefer, eBooks or print books?
The Importance Of Patient Followup
The spontaneous cure has kept many a healer in practice.
In the busy pace of medical practice, whether in-hospital or outpatient, it is common to lose track of what happens to the patient after discharge. There are two good reasons to try to follow up, when possible, on how the patient fared after leaving the hospital or outpatient office:
1. Calling a patient is important psychologically to the patient. Your call lets the patient know that you care by taking the time to follow up.
2. It is important to your own education. Once the patient leaves the hospital or office, if you don’t hear back is it because the patient improved and doesn’t feel the need to return? Or perhaps the patient’s condition has not improved and the patient may have sought care elsewhere or otherwise feels hesitant to return. This is an important source of learning that can help you in treating future patients. You wouldn’t want to continue a treatment that doesn’t work, but you would want to emphasize one that does.
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Which do you prefer – eBooks or print books?
The Healing Power Of Just Sitting Down
We enter medical school full of humanitarian goals. Somehow, though, something seems to happen all too frequently in the clinical 3rd and 4th years and beyond. There is less focus on the patient as an individual and more emphasis on lab tests and presenting on rounds.
Perhaps it is the busy schedule, where so much time has to be spent with performing, ordering and reviewing lab tests, making rounds, writing notes, and preparing for presentation to interns, residents and attendings. Perhaps it would be too draining to become emotionally involved with the patient’s illness, as would be the case for a family member. But the opposite extreme, of overlooking the patient’s emotions, is not good either; there needs to be a happy medium.
When I was a student, I noticed that the internal medicine interns and residents who were considered the best knew their medicine and were up on their lab tests. But there was little evidence that they really knew who their patients were as people. The chief resident, who had the most status, had even gotten an article published in the prestigious New England Journal of Medicine. He was very much involved in the lab tests, but I doubt if he knew anything about who his patients were as individuals.
With such a busy schedule, there is a simple change on rounds that can make a difference. That is sitting down with the patient, rather than standing and quickly passing through.
Sitting down briefly doesn’t take much time. But it gives the patient the feeling that s/he is not just a statistic, and the physician truly cares; it relieves some of the patient’s mental stress, which is part of any illness. It also gives the physician a little insight into the patient as an individual. We call this bedside manner. It is practiced much better by certain practitioners of questionable areas of “alternative” medicine. There is no reason why it can not be done in all areas of medicine.
