Thursday, September 25, 2008

Anxiety Tremors

I went out on my first family practice visit this week. This is part of a course wherein we work with a preceptor at his family practice and get some hands on experience doing patient interviews and taking vital sign readings.

During this visit, I learned that patients can develop tremors that come on due to anxiety. When I saw the tremors, I immediately thought Parkinson's (mostly because it was the only cause of tremors I had known about at the time); however, these tremors were physically different than Parkinson's tremors. Instead of the trademark wrist grind of Parkinson's, anxiety tremors are a constant shaking. Also, anxiety tremors do not go away when the afflicted individual attempts to do something this his hands, whereas in Parkinson's the tremors often go away when the individual uses their hand (e.g. reaching for a glass).

Anyhow, these anxiety tremors, often caused by depression, are brought on solely by anxiety. The emotional stress induced by constant anxiety causes the brain to lose control over the body's nervous system and causes neurons in the arms to fire, causing them to shake.

I'm not sure WHY anxiety causes this to happen...I'm also not sure if I don't know because I'm an ignorant 1st year medical student, or if I don't know because the mechanism behind anxiety tremors hasn't been discovered yet. Anyhow, I just thought I'd mention the phenomenon.

Monday, September 22, 2008

Referred Pain

Referred pain is an interesting phenomenon where your body is injured or damaged in one location and you feel pain in a completely different location. For example, often when a patient has a damaged diaphragm (muscle located just above your abs) they go to their doctor complaining about shoulder pain.

To understand why this happens you need to look at the anatomy of the nervous system. The nervous system can be divided into somatic and autonomic systems. The somatic nervous system involves the nerves that react to external sensations, like the touch receptors all along our skin. The autonomic nervous system involves nerves that we cannot consciously control, like the nerves that tell our heart to beat.

The diaphragm is a muscle that helps us breathe, and though we CAN consciously control it, it also runs automatically so we don't have to consciously think about taking a breath all the time (good news for all those people who can't multitask...imagine talking on the phone, while surfing the web and watching the t.v. if you had to remember to breath every 5 seconds). The diaphragm is innervated by the phrenic nerve (an autonomic nerve), which comes out of the spine at the same level as the the somatic nerves that innervate the shoulder (nerves C3, C4, and C5 for those who care).

If the diaphragm is injured, the autonomic nerves that warn the brain about this problem start firing. However, on the way to the brain, they get to the spine and mix with the somatic nerves that innervate the shoulder. NORMALLY, somatic nerves warn the brain about pain because somatic nerves are the pain recepters in our skin...where pain will most often happen. Since the brain isn't used to having the autonomic nerves complain about pain, it just assumes that the pain is coming from the somatic nerves. Those somatic nerves are connected to the shoulder, so the brain thinks the shoulder hurts.

Of course...if you just dislocated your shoulder, don't assume your diaphragm is the reason you want to cry.

Saturday, September 20, 2008

Buying a Stethescope

One piece of equipment every doctor medical student needs is a stethoscope. Fortunately, our school organizes a medical equipment night every year. This is a mutually beneficial relationship between the students and the medical equipment manufacturers because they can present to all 300 of us at once and we can cash in on high purchase volume discounts. Unfortunately, this equipment night is held before any of us have a clue how to even use the equipment, so we are just a flock of blind geese and the salespeople are basically hawks out to get us. At our medical equipment night, we had Company A, Company B, and Company C. Most students who attended the night were only looking for stethoscopes; however, diagnostic sets and blood pressure cuffs were also being offered.

Company A was a German, family run business. Their marketing strategy was to have a 30-something year old, very attractive, blond woman tell us about their products. This same marketing tactic has done wonders for Budweiser, Bacardi, Axe, etc. However, considering most of our class is comprised of women and not the male, 18-24 demographic that the aforementioned companies have been successful in targeting, Company A really needs to rethink their sales pitch. Another fatal mistake by Company A was that they spent most of their allotted time pushing their diagnostic sets, which range in the $700 region, and they barely talked about their stethoscopes (the only product most of us were planning on buying that night). How the brilliant minds at Company A don't realize that new medical students, who are paying medical tuition and buying medical text books for the first time, probably can't part with $700, is beyond me.

Company B was next, they were the Canadian branch of a worldwide, originally American, conglomerate. Their marketing strategy was to have a man, dressed as a used car salesman, pitch their only products, stethoscopes, in the most monotonous tone ever. Either he is completely dispassionate about his job and wants to quit 2 years ago, or he has some kind of illness which leads to extreme fatigue. I realized that I'd be unable to help him in either case because I'm not a career counsellor and neither of the two diseases I can diagnose at this point present with fatigue (I probably can't even diagnose THOSE diseases correctly, but that's not the point), so I decided to take a nap through his presentation.

Company C, an American owned family company (I don't know why A and C kept stating they were family owned, it really doesn't make me any more or less likely to buy their product) was next. Their marketing strategy was the paradigm of American capitalism. Their salespeople were all dressed in Company C golf shirts. Their presenter was loud, concise, and kept pushing their products. They had sales pitches left, right, and center. For example, they offered an opthalmoscope for $25 if we bought a diagnostic set (not a big deal considering a diagnostic set is $700). They also offered a free penlight if we bought a diagnostic set and a blood pressure cuff (even less of a big deal since we were already given free penlights...and let's be honest, a free penlight is hardly a good motivator to part with $700). They also had a random prize giveaway where they gave 20 lucky students a free stethoscope with a $50 coupon for another stethoscope, which they could give to a friend.

After these three presentations, I was ready to buy a Company C stethoscope. Their tight sales pitch made me feel like they had their act together; I also thought that a company like Company C really cared about their reputation, so they would be sure to help me if I ever had any problems with their product in the future.

Next came the product demonstrations. The three companies took up space in our atrium and we were allowed to try out their equipment. Company A didn't even have any demo stethoscopes, so I didn't bother going to their booth (if you can figure out who Company A is, and you work for them, seriously...get a new sales staff). Company B had their stethoscopes on display and they even had a CD of heart sounds with a device we could use to try to listen for wheezing, heart murmurs, etc. (a brilliant idea in general, wasted on us since we know next to nothing about listening for heart sounds). Company C had the sales army on overdrive. They were talking us into trying out their diagnostic equipment, which again was useless since we didn't know what to look for even after they showed us how to use an opthalmoscope. Another pro for Company C's stethoscopes was that they had adjustable ear pieces, so we could change the size of the stethoscope to fit our heads without worrying about doing any damage to the equipment.

The problem with the Company C sucked. The sound quality it provided was terrible. They had me sold with their marketing campaign, but their product was sub optimal. I'm sorry, but what is the point in dropping all those dollars into sales if the customer is disappointed the second he tries your product?

I guess the lesson in all this is to skip the sales pitches and try the product. I ended up getting a Littman Cardiology III. I really didn't want to get one initially because this is what EVERY med student gets, but clearly the reason for that is the sound quality it provides.

Note, HalfMD disagrees with me.

Sunday, September 14, 2008

More Medical Students = Worse Doctors?

It is a well documented fact that both Canada and the USA are dealing with a shortage of physicians. This is best noticed in the primary care field because fewer and fewer people actually have a family doctor. Most people rely on walk-in clinics for their medical needs and thus do not build a long term relationship with a physician, which results in poor continuity of care. The physician shortage is also seen in other specialties where patients have to wait months before they can meet with a neurologist, nephrologist, etc.

One solution to this problem is to open up more seats in medical school and pump out more doctors. This seems like a brilliant idea because it means we can ensure that these new doctors are trained in an accredited school (i.e. exactly how we (the Canadian Medical Association) want them to be trained).

The potential problem that this can cause is that opening up more seats does not NECESSARILY mean that you will have more qualified applicants that graduate to become excellent doctors.

One key attribute I want in my doctor is intelligence. Now, becoming a physician requires a lot more than just intelligence, a doctor also has to be good with people, organized, caring, etc. However, intelligence IS still a key attribute that I would want ALL of my doctors to possess. My fear is that creating more seats may result in a lower bar to get into medical school, which in turn leads to the production of less capable doctors. I am fairly confident that I will be able to accurately judge the quality of any doctor my friends or family are going to see within four years, after I complete med school. However, I sincerely doubt that the average patient will be able to accurately judge a physician's competence without having an extensive medical background themselves. Thus, I wonder how much creating more medical students will help our nations medical problems.

Obviously, the problem I am discussing here disappears if every single med school seat is filled with a brilliant, qualified applicant, or if the unqualified applicants who do get in do not make it through the arduous journey of medical school (though it is very difficult to fail out of med school, which I will discuss later). Also, remember that this is just an issue I am thinking out loud about at this point. After only three weeks of medical school, I am hardly qualified to judge the state of the Canadian medical education program :)

Another issue that I think may reduce the quality of our next generation of medical doctors is the medical school admissions committee's focus on diversity. However, due to the controversy surrounding that topic, I am going to hold off on that post for a while!