Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine, by C. Scott Mahan
The many books comparing alternative medicine to Western medicine tend to be biased in one direction or the other. Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine offers a balanced view. C. Scott Mahan, M.D., an infectious disease specialist, is co-author of the best-selling “Clinical Microbiology Made Ridiculously Simple.” Are You Afraid of Snakes? describes his 5-year medical journey from Africa to Appalachia, as he encounters many alternative approaches to medicine (voodoo, naturopathy, homeopathy, chiropractic, acupuncture, hot yoga, barefoot running, performance enhancing drinks, titanium necklaces, magnets, hypnosis, detoxification diets, and ayurvedic medicine). Dr. Mahan relates his personal and often humorous experiences in the dual worlds of alternative and Western medicine. He offers an unbiased analysis and opinion of the differing approaches to medicine. 257 pgs; $16.95.
Allergy and Asthma Made Ridiculously Simple, by Massoud Mahmoudi
Allergy and Asthma Made Ridiculously Simple is a brief, clear, and practical guide to the diagnosis and treatment of allergies and asthma. Dr. Mahmoudi practices internal medicine, allergy, and immunology in California. He has published or edited numerous scientific papers and 9 books related to allergy and immunology, including the best-selling “Immunology Made Ridiculously Simple.” He was a medical columnist for local newpapers and the San Francisco Chronicle, has spoken locally and nationally on allergy and immunology, and appeared on local television and Fox News. Dr. Mahmoudi is currently president of the American Osteopathic College of Allergy and Immunology and on the faculties of the University of California San Francisco, Rowan University, and Touro University. 72 pgs; $22.95.
Medmaster is pleased to announce the following new editions:
Nelson: Psychiatry Made Ridiculously Simple (Ed. 5). Includes the newer DSM-5 terminology in the diagnosis of psychiatric illnesses.
Each Board review book presents the material in a rapidly read chart format, plus Internet links to 1000+ review questions.
Previous blogs have discussed memory techniques for rapidly learning and remembering information in medical school:
Apart from these memory methods, there is another aspect of learning that requires more time to acquire, the ability to quickly recognize disease patterns; this depends on experience.
Often a patient presents with a number of symptoms and signs that may all point to one particular disease; or they may be the result of more than one disease; or some signs and symptoms may be red herrings. Without experience, there may be a tendency to create a differential diagnosis that is too large or too small, and without proper assignment of correct probabilities to the various potential diagnoses.
For instance, my wife not infrequently experiences headaches in the middle of the night. When I look up the differential diagnosis for this in one of the computerized programs for differential diagnosis, the leading diagnosis comes up as “massive intracranial hemorrhage.” Obviously, this is not true, but the computer program spins this out because the data was collected from hospital admissions, not outpatient visits. Someone admitted to the hospital with headaches arising in the middle of the night likely has something more serious than someone who is not admitted.
The ability to correctly formulate a differential diagnosis depends on the physician’s experience — whether it is outpatient or inpatient, and even which area of the country or world, where certain diseases are more prevalent than in other areas. Gaining experience requires time. That is why the medical student’s differential diagnosis is often so long, and not necessarily listed in order of disease probability. Eventually, though, the physician learns to quickly determine the most likely diagnosis, based on known disease patterns. It is important, though, that the physician does not become sloppy and superficially misinterpret patterns by rushing to a diagnosis in the midst of a busy office (or, to save time, simply adopt a shotgun approach, ordering unnecessary tests that may be invasive or expensive).
Humans are expert in recognizing patterns, but often come to the wrong conclusion when they read too much into a pattern (e.g. a face on a pizza). The ability to efficiently arrive at a medical diagnosis comes with learning on a longer time scale than the memory techniques listed above.
I cannot help but notice the great amount of time spent by students discussing how to pass the medical Boards; students are compelled to spend a great deal of time in rote memorization of esoteria for the exam; otherwise they may not pass. In my view, this emphasis interferes with the need for students to acquire a proper understanding of the topics discussed in the first two years, understanding that is vital in taking care of patients.
Today, it is relatively easy to electronically search for isolated points of information through apps and the Internet; there is less need for rote memorization, which computers do best, and greater need for understanding, which humans do best. Despite the information explosion, surely there is less need to memorize so much and greater need to promote understanding of the clinical material as a whole.
Even the best physicians may have trouble with questions on the Boards. We would like to gear medical education to turning out the best physicians. But what constitutes an excellent physician?:
• Most cases a physician sees are common situations rather than zebras. Good medicine is largely a matter of applying common knowledge and principles to diagnosis and treatment, without getting sloppy, rather than coming up with a roundsmanship coup. The excellent physician does not, to save time, routinely order, in a shotgun fashion, all manner of rare, invasive, and expensive low-yield tests. Nor does the excellent physician hastily rush to decide on a diagnosis based on a too-quick, superficial initial impression. The best physician is not necessarily the one who has the greatest knowledge base, but the one who consistently and meticulously applies common knowledge.
• Patients do not care so much about the physician’s medical school or residency diplomas as they do care about how the physician responds to them as individuals, whether the physician is compassionate, and allots the patient the necessary time. “Patients do not care how much you know, until they know how much you care.” This aspect of medicine is also important, just as is the knowledge base.
• The good physician, unless there is an emergency, schedules reasonable office waiting times, promptly notifies patients of lab results, follows up on the patient’s progress, and adopts more than just a cookbook approach to diagnosis and treatment. Medical education needs to emphasize understanding of important concepts, as well as familiarity with where and how to search for isolated points of information, which have grown too large for anyone to remember. This is not emphasized on the Boards. Emphasizing understanding, something Medmaster has focused on for the past 34 years, may seem to be a minimalistic approach to education, but in fact it is a maximal approach, insuring that the student acquires the greatest degree of understanding. Every patient is different, and a cookbook approach may not work for all patients; understanding what one is doing is critical to good patient care.
So, should Step 1 of the USMLE be eliminated, or modified? Perhaps Step 1 should be an open-book exam; this would more resemble everyday practice, where physicians now have ready access to point-of-care information. What do you think?
Last week Steven Goldberg (no relation), a former student of mine at the University of Miami School of Medicine, passed away of lymphoma at the age of 42. After 25 years of my teaching at the U of M, his name stands out in my mind, not because of similarity of name, but because of his brilliance and character. He was a true mensch.
Steve was born with transposition of the arteries, which required surgical correction. When he advanced in medicine, his goal was to become a pediatric cardiac surgeon and offer to other children what had been provided to him. He did just that, training at the same institution that had operated upon him as a child. He specialized in difficult cardiac procedures in children, including the kind of congenital defect that he had, as well as cardiac transplantation.
You can gain a better glimpse of his character through the YouTube video he prepared for LeBonheur Children’s Hospital last year. Within only a few days of his passing, there were hundreds of facebook postings by people whose lives he had touched.
Steve was also a skilled artist who illustrated significant parts of my books on Clinical Physiology Made Ridiculously Simple and Med’Toons. Here are three of my favorite cartoons that he drew:
Steve will be greatly missed. He was the personification of the ideal physician.
Should the patient and family participate in the decision-making process as to whether or not to pursue an aggressive course of therapy?
Of course, there are those patients who say “Whatever you think would be best doc.” And there are others who are so mentally incapacitated as to not be able to render an intelligent decision.
But what if a patient wants to help decide on the course of therapy? There are two points of view. There are physicians who feel that patients and family should not participate in decision-making in aggressive treatments, such as surgery, radiation, and chemotherapy, as they are too emotionally involved and may not think rationally. I feel otherwise. Apart from the patient having the right to agree or not agree to a particular treatment, there are situations in which the patient may be in a better position than the physician to decide. For instance, say a patient has a tumor of the arm and the statistics indicate that there is a 90% chance of survival if the entire limb is removed, but only a 70% chance of survival if the tumor is removed locally, but leaving the function of the arm intact if successful. What should one do? Leave the decision up to the physician, or seek the patient’s opinion? The physician may opt to remove the arm to improve the chances of survival but the patient may want to take the gamble, in order to keep a functioning limb. The patient’s choice may well be the better one; it suits the patient’s individual needs. The patient and family may be willing to gamble, while the physician may not.
If the patient and family are well-informed of the facts, the therapist should encourage their participating in the decision-making. The patient and family not only have the right to do so, but their input may be helpful, even invaluable, in making the right decision.
Previous posts (A, B, C) discussed the pros and cons of digital versus print books. A survey of students by Bowker Market Research (June 11, 2013) indicates that only 3% of college students in the previous semester used a digital textbook as their main course material. Publishing Business Today (Jan 21, 2015) confirms the student preference of print books over ebooks.
The Bowker survey of 1,540 undergraduate college students found that students overwhelmingly prefer print, at both four-year and two-year institutions of higher education. The reasons include students preferring “the look and feel of print,” the greater ease in highlighting and note-taking, and the fact that they can’t re-sell digital textbooks.
Among those few students who prefer digital textbooks, the reasons include price, ability to search the text, and ease in carrying around.
As of March 2013, laptop computers are by far the most popular device for students reading digital textbooks. The iPad is No. 2:
Laptop computer: 51%
iPad tablet: 21%
Desktop computer: 8%
Android tablet other than Kindle Fire: 6%
Kindle Fire tablet: 5%
The topic continues to evolve. We welcome your continuing thoughts on the use of ebooks in medical student education. In the meantime, Medmaster is working on the best ways to present its books in both print and ebook formats.
In addition to the popular medical apps listed previously, here are a few more to consider:
1. MedPage Today. This app connects you to the top breaking medical news stories that the public is reading. While these news reports are not necessarily written by medical professionals, they do give you an idea of what your patients are reading and may ask you about. For iOS, Android, and web view. Free.
2. Unbound Medline. This excellent app connects you to over 20 million journal articles. You can also instantly email articles of interest to your colleagues. For iOS and Android mobile devices. Free.
3. Wasting time trying to find the right usernames, passwords, and PINs among an ever growing list? One way is to have a single app to access all your passwords and PINs. Some key ones are reviewed here. A very simple (and free) password protection, though, is to simply list your usernames, passwords, and other codes alphabetically in a Word document that has a single password to access the file. Security is easy to set up in Word’s Preferences, under Security.
The huge amount of studying that medical school demands can at times be so frustrating as to make one question medicine as a career. The following illuminating story is reproduced with permission from the interesting blog WaitingForMd.
“It was a beautiful sunny day as everyone filed into the windowed room and took seats around a large, oblong table and scattered seats along the wall. Medical students chit chatted about needing to get back to class and wondered when the main attraction, free Thai food, would finally arrive. Meanwhile quietly in one corner a young woman sat with her hands neatly folded in her lap with a white lab coat. She didn’t make conversation but smiled politely.”
“The meeting began after everyone was done scooping little heaps of pad Thai into their plates and shuffled back to their seats around the table. Some introductions of board members were made and the general idea of the student organization was described. At the close of the meeting they asked for any questions or comments and after some expected questions the young woman in the corner raised her hand and said ‘could I please share a story with the group’.”
“The club president smiled at her and replied ‘of course’.”
“‘I had always wanted to be a doctor; it was just something I never thought was possible for me. I was married very young. I spent most of my life in Africa and when I came to the United States I did not think that even going to medical school was an option for me. I was always one of the brightest girls in my class and I even went to college but it all seemed so far away. By that time I was already a mother of two young children, which made a very busy schedule for me. Somehow I managed to secure admission into a program that allowed me to do some coursework, and upon successful completion they would allow me to go to medical school. I could not believe my eyes or ears and I worked hard, so hard to make sure I could do it. My grades were all very good. But then I started to notice that my youngest son was not speaking as he should be; he was not developing at a proper pace. The doctors said that he had autism. He would need speech therapy and physical therapy. Hours of individual attention were needed but my husband worked. He told me he could not do anything; we needed the money; he had to go to work. I was left with no choice and I had the acceptance letter in my hand and I declined my admission to medical school. After all of that work, someone had to take care of my son. I had to care for my child and I had to give up my dream for it. I wish my husband had supported me more, so I could achieve my dream. Even today when I walk on the sidewalk and I am walking in one direction and one of you, a medical student, is walking the opposite direction and passes by me in a white coat, I stop and I turn around and I look at you walking away. I see my dream that I had walking away from me. I am so happy for each of you and I am so sad for myself that I did not find a way to make my dream.’”
“The entire room sat in silence. Sitting in that room with nothing on my mind besides needing to get back to class at the end of the lunch hour, this woman’s story really touched me. I could feel tears welling up in my eyes. This story just serves as a stark reminder that this is an opportunity that we were lucky to have been given. It sucks sometimes. It’s really hard. It makes you want to punch the wall. But no matter why you did it, there was something that drove you. If you can keep a piece of that with you and remember back to the time when you would have traded anything to be where you are today, everything gets a whole lot easier.”
On a personal note, I was at the bottom half of my class in medical school and there were many frustrating times. I was a slow reader. What I have learned is that under such circumstances, it helps to simply keep going. In the end, it will work out. Small steps each day add up. When it appears that you are hopelessly behind, you are not as far behind as you think. And just like a hiker cuts through the obstacles of a dense forest underbrush, but eventually arrives at a clearing with a brilliant panoramic view, there will be a time when you no longer have the continual pressure to pass exams.
Apart from the information overload of medical school study, modern technology adds to the problem. While technology has made it easier to find information, its distractions can be time-consuming.
We depend on the Internet but sometimes it is down. There is the beloved “Error” message that punctuates computer illnesses of unknown origin. Email, texting, Facebook, Twitter, blogs, Google searches, the same news multiple times per day, and a zillion different apps compete for our attention. It is as if we have taken a step backwards in the way we read, switching from the centuries long efficient and easily grasped format of print books to the variable ways of reading books electronically, with smaller pages on mobile devices. Certain ebooks can only be read on certain tablets, and some tablets only allow certain reading apps, and certain ebooks are listed in only certain ebookstores. This can be upsetting to students who would like their ebook library to be available in ebook format on a single tablet or computer and available from a single source.
Hopefully, the way we read electronic books will become standardized so we can purchase and read ebooks anywhere, and not depend on a particular reading tablet, ereading app, or ebookstore. Personally, I think the optimal way to read ebooks in the future will evolve toward reading on the web. In that way, ebooks can be read anywhere in the world by anyone who has internet access, on any computer or tablet, and will not depend on having a particular brand of reading tablet, a particular reading app, or a particular ebookstore. There would be little concern about the time and expense of shipping print books, and books could be updated continually. At Medmaster, we are looking into the most optimal ways we can offer our books in electronic format. Presently, the field is not yet ready for prime time, due to different format issues with complex books, publisher terms with ebookstores, and the great variety of competing, often mutually exclusive reading apps and tablets. We receive inquiries from students as to when Medmaster will have all of its books in ebook format. While we have done so for a few books, we are exploring the evolving ways of presenting them and hopefully we will shortly be able to offer the remainder of Medmaster titles in ebook format as an alternative to print for those who prefer that way of reading.
Choosing the best way to read ebooks can be confusing. There are many different reading tablets. Some ereading apps work with some tablets and not others. There is also the growing ability to read books directly from the web, whether from a tablet or a computer.
While it may seem obvious that publishing companies should simply list all their books on every eBookstore (e.g. Amazon, Barnes & Noble, etc.), it is not that simple. The particular ebookstore’s terms to a publisher may differ depending on the size of the publisher and the price of the book. Thus, a publisher may opt to place certain titles in only certain ebookstores. Also, some books do not presently lend themselves well to ebook format.
Buying print books is relatively simple: buy them any place; no need to distinguish between reading tablets, apps or booksellers. For ebooks, though,with time-consuming usernames, passwords, and wrestling with computers, mobile devices, and reading apps, it is a wonder that a medical student can get any reading done at all. Time is at a premium for medical students, and we need the most efficient ways to read.
I still prefer print books. But others prefer ebooks for their ease of acquisition, portability, searchability, hyperlinking and multimedia capability, and generally less cost than print books. If you want to read using an ebook, which is the best tablet to purchase, and which ebookstores and reading apps should you use? I have summarized my current understanding of the matter in the chart below, along with some general observations that follow.
1. Of all the tablets, only the iPad supports reader apps from the all the various ebookstores (iBooks, Nook, Kindle, etc.). I suspect that is because Apple, although having its own ebookstore, is mainly interested in selling iPads and wants its readers to know that with a single iPad they can read any ebookstore’s books. On the other hand, Nook (Barnes & Noble) and Kindle (Amazon) are mainly bookstores, and are more resistant to having other eBookstore apps on their tablets. Thus, their tablets do not support the broad range of reading apps as the iPad.
It is interesting that while the iPad has its own iBookstore, you cannot read iBookstore books on a Macintosh computer (!), or for that matter on any other tablet or computer. So if you want to read books from Apple’s iBookstore, you presently need an iPad.
2. Medical students’ needs differ from that of the general public in that medical students, in addition to studying a lot, commonly want to highlight, and to a lesser degree take notes when reading. I found highlighting more awkward on the Nook tablet than on iPad, Kindle, or Android. While the Nook tablet otherwise has excellent reading features, its somewhat awkward highlighting and lack of support for reading apps other than its own is a drawback.
While the Nook app for Windows Vista works well, it appears the Nook for Windows 8 does not presently have a highlighting or notes feature. I found Nook for Macintosh buggy in that sometimes its menu does not appear when the application is opened.
3. In contrast to tablets, it seems easier and quicker to highlight using a computer, whether Mac or Windows, using a mouse or trackpad. The availability of relatively large monitors for Mac or Windows computers makes them easier to study from than the smaller monitors of mobile devices. And the external keyboards of Mac and Windows computers make typing, as for notes and other functions, quicker than on a tablet.
4. There is an increasing ability to read books on the web. Kindle, in addition to its reading app for computers and tablets, also allows reading directly from the web via its Kindle Cloud Reader, which makes it easier for the student to log in anywhere, even without a tablet or a computer that has the Kindle app. Kindle Cloud Reader has good highlighting and note-taking ability. Google Play, Inkling and Vitalsource (VS) also have tablet readers as well as web-reading functionality with good highlighting and note-taking. Nook for web allows direct reading from the web, but at this time it does not appear to support highlighting or note-taking. Of course, the drawback of relying on the web to read is that the web may be down, or you may be out of range of wi-fi.
5. In addition to the specific ebookstores, such as Apple’s iBooks, Barnes & Noble’s Nook, and Amazon’s Kindle, there are also many independent bookstores that have their own reading apps (help!), or whose books readers can access with what I will call “generic” readers. Two of the best generics are Adobe Digital Editions (ADE, especially the latest edition), for Mac and Windows computers, and BlueFire (BF) for tablets, both of which can read ePub and PDF files.
There is now a Windows 8 Surface Pro tablet, which, unlike the Windows Surface RT tablet, has the full range of Windows 8 function, just like a regular Windows 8 computer. It, however, is thicker and heavier than most tablets and does not presently have a large screen. It also does not support the full range of reading apps as the iPad.
The bottom line: I suggest that the student, where possible, use a computer (Mac or Windows) for ereading because of the easier ability to highlight, the larger monitors, and the greater ease in typing on an external computer keyboard. But if you want to use a tablet, the iPad offers the greatest range of ebookstores to choose from, good highlighting and note taking features, and an intuitive interface.
[Update Jan 16, 2014: Apple now has an iBook app for Macintosh computers, which appears to run very well. However, at this time it is not available for Windows or other tablets except iPad. One would have to purchase books from the iBooks bookstore. It seems to me that the wave of the future, for those who prefer eBooks to print books, will involve reading off the Internet. In that way, books will be accessible to everyone who has Internet access, not requiring a specific reader or computer.]
The field of ebooks is changing rapidly and these opinions may change as well. What do you think?
Having taught medical students for 25 years, practiced in several different medical fields, edited all the Medmaster titles in the basic and clinical sciences, and received feedback from many instructors and students through the years, here is how I would revamp the medical curriculum:
1. I would continue learning the basic sciences in the first two years, followed by 2 years of clinical experience, as opposed to the idea of learning the basic sciences and seeing patients right from the start. While one may want to see patients as soon as possible, it is better to first learn the basics, since you can then approach medicine with overall understanding, rather than scattered facts. It is like the juggler, who needs to combine a number of different skills to perform, such as simultaneously juggling 6 balls, twirling 3 hoops around one foot, and balancing a stick on his head. He would do better by first learning each skill separately and then putting them together, rather than trying to learn by practicing all of them together from the start. The basic sciences, though, should not be taught without reference to clinical medicine; they should be taught with a clinical emphasis, showing the clinical relevance of each subject as it is taught.
2. While small group discussions of clinical cases in the first two years can be an excellent source of learning for a given case, they tend to be an inefficient way to learn. They are time-consuming and cannot get into the vast amount of medicine that has to be learned. Also, when scheduled in the basic science years, they are presented too early for an adequate understanding of the topics, since the student has not yet learned the underlying basic science. While case discussions in the basic science years provide a way to introduce clinicians into the discussion (as most basic science courses are taught by PhDs, rather than clinicians), clinical relevance can be introduced more efficiently through well-designed reading, audio, and video presentations.
3. There is an overload of information in the medical curriculum today. We need to focus on general principles and understanding as opposed to numerous esoteric facts. People are much better at understanding than rote memorization, while computers excel at memorizing detail. The game-changer in today’s education is that it is easy to search for facts as needed on electronic media such as the Internet, in contrast to the past, where one had to rely on the latest reference texts and printed journals or go to the library to search through tomes of Index Medicus for relevant articles.
By the end of medical school we forget many of the facts that we learned. And we do not acquire an overall understanding of many topics because of the deluge of information that we are hit with over the four years; we do not see the forest through the trees. It is better to acquire overall understanding and know where to search for further detail. Learning general principles with understanding is in itself a fulltime job.
4. I would, for the most part, eliminate classroom lectures. Lecturers vary in quality, and even when there is an excellent lecturer, it can be difficult keeping up with note taking and grasping what is being said in a fast-talking delivery, especially when tired after staying up late. Why sit through a classroom lecture when one can learn the same thing through a YouTube or other video venue, at one’s own time and pace, and stop and go back to review points for clarification? I think the best use of the future instructor will not be to deliver a lecture in a classroom, but as a facilitator in pointing to the best educational sources for the student and responding to student questions. Where an instructor has something special to relay to the student that cannot be found elsewhere, it often would be better to present it as a personal reference video than as a classroom lecture. The instructor should, however, be available for individual questions from students, whether in person or by electronic communication. This will not only be better educationally for the student, but for the basic science instructor, who in many cases would prefer to spend more time in research activities. Rather than repeating the same lecture many times, the instructor can point to a well-designed video that can be accessed by different classes.
5. There should be a detailed list that the student receives on entering medical school as to what material in the basic sciences to learn, with recommendations as to where to find the information. The student should largely learn independently. There should be periodic tests to insure that studying is not crammed in toward the end, when the tests are given.
The same should apply in the clinical years. The student should have a list of the most important clinical conditions, with suggestions as to the most reliable learning resources to diagnose and treat them, whether they are books, apps, or videos. As is, education in the clinical years is often not organized, with the student left on his/her own to determine what is important to learn. As in the basic sciences, there should be periodic tests of knowledge. Learning through direct patient care is also very important, perhaps the most important way of all to learn. After seeing patients in the hospital each day, the student should seek out information as to differential diagnosis and treatment of the conditions seen that day. The student cannot learn everything, but by focusing mainly on the illnesses of the day, at the end of the four years the student will have studied the most common diseases.
6. Exams, including the Boards, should not present ‘gotcha’ questions, but basic information highly relevant to practice. So what if the questions are so basic that nearly everyone can succeed at the tests. They should be designed to confirm that the student has the necessary practical knowledge base. With the time saved by teaching general principles and promoting understanding in the basic sciences, rather than an overload of esoteria, the student will have more time to review for the Boards and study medical topics of personal interest.
7. While this may seem to be a “minimalist” approach to education, it is not. In the end it would maximize a student’s overall understanding of medicine, while inculcating a lifelong method of seeking out detailed information as needed.
What do you think?