Saturday, November 29, 2008

The Internet Is Not A Doctor

One of the cool things about working at Microsoft was that I was able to talk to the people working in Microsoft Research(MSR). MSR is basically a playpen where researchers come up with cool ideas, research them, and hope to make a product out of their findings. Only 1 in 100 ideas even get OUT of MSR and fewer still make it to production, but MSR did give birth to a couple of great ideas like the surface top computer.

Anyhow, MSR recently published a paper about cyberchondria, which is basically "internet hypochondria". The premise is that if you wake up with a head ache and search for "head aches" online, you will often find links that state head aches are a symptom of a brain tumour (which can be true). However, you, not being a doctor, don't realize that "brain tumour" is not the only diagnosis for a patient presenting with a headache. In fact, when you consider your age and medical history...brain tumour may be (and often is) the LEAST likely diagnosis. It could just be...that you have a head ache.

Now, don't get me wrong, being curious about your illness and doing some research regarding your symptoms is a great idea. You should also feel comfortable telling your doctor about your concerns if you're worried your symptoms are indicative of a specific illness. However, there IS a problem with doing online research about your symptoms if you're the type of person to panic because some pretend med student wrote an article that makes you think you have brain cancer because you woke up with a little head ache. Long story short...don't blow your life savings because the internet made you think you're going to die soon.

Thursday, November 27, 2008

OSCE = Standardized Waste Of Time?

OSCE stands for Official Structured Clinical Exam. This is an exam that tests a physicians clinical abilities. Forget that book learning, this is where we prove we can interview patients and perform clinical procedures (like a chest exam).

Although I think testing med students on their clinical abilities is essential, testing med students in the first term of their first year is pointless! They can test us on any clinical procedures because we don't know any (not entirely true, we can measure blood pressures, but they don't test us on that) so the OSCE tests our ability to do a medical interview. I think this OSCE is a waste of time because so far, in class, we've done at least 3 practice interviews in front of a tutor and several classmates. We've also had plenty of experience doing interviews when we went out to work in the clinics throughout the term. We really do know how to do these interviews, if we didn't, the faculty would have heard about it by now!

I had to drive all the way out to VGH to do a simple 8 minute interview where we get to know a standardized (read: actor) patient, ask him about his chief presenting complaint, and see how he feels about it. Seriously...I had to drive out their for 8 minutes of chit chat! Yes...I realize that there are BIGGER problems in the world I could be complaining about, but I'm pretty sure this is a close second to obstetric fistula (maybe not, but I thought I'd raise some awareness while I had the chance).

Now I understand that schools live to examine students, so maybe we HAD to have an OSCE, but at least make the OSCE a challenge! Let us practice our complete history taking skills, I've already shown you that I can FIFE! I complaining about an easy exam?! Ok, I'm sorry...I take it back!

Something that I found funny was how I was a victim of standardized examination. In the OSCE, our tutors have a list of questions we are supposed to ask. These range from asking the patient for his/her name and age to asking about how the patient's complaint is effecting their daily function. My patient was a 28 year old professional soccer player who came in with a knee injury. During the feedback session, my tutor told me I aced the OSCE except for the one question I missed...I didn't ask the patient if he was in a relationship. Ok...on what planet would that have been a relavent piece of information in THIS case?! (Turns out my tutor also didn't ask this question when she did a practice run earlier that day...well, at least I'm in good company!)

Tuesday, November 25, 2008

Listening > Teaching

The other day I volunteered to do blood pressure workshops for some less fortunate people. All of the people who attended the workshop were either homeless or lived in low income housing.

These blood pressure workshops are run regularly and usually get a strong turnout. Unfortunately, this workshop was on the Saturday after Welfare Wednesday. In BC, people on welfare receive their cheques once a month. The government seems to think that giving people who are addicted to alcohol or hard drugs (certainly not true of all people on welfare, but often is for the people who attend these workshops) a fat cheque once a month is a brilliant way to help them out. Oddly enough, it turns out that most of these people take their cheques to the liquor store or the shady looking guy on the corner of the block and blow all of their cash on booze and drugs. They end up drunk or high through the rest of the week and end up missing my blood pressure workshops, which, let's be honest, would probably solve all of the problems in their lives. Anyhow, since I'm only a pretend doctor and not a pretend politician, I'll keep my opinions about how I think we should fix this problem to myself.

Other than the low turnout, the workshops went well. I was told that most people who attend our clinics out there tend to have high blood pressures; however, I didn't have a SINGLE patient with high blood pressure and neither did any of my colleagues. We assumed that most of the people who came out on the Saturday after Welfare Wednesday were the types of people who take pretty good care of themselves, so it made sense they had decent blood pressures. We also had a few people who were clearly high on heroine or some other downer. In their case it was obvious that the drugs were going to lower their blood pressure somewhat.

One intersting thing I realized was how our patients valued talking to us much more than they valued learning from us. I was teaching a patient about his blood pressure reading and he was clearly interested in what I had to say...but I started seeing that he just wanted to talk, he didn't really care about blood pressure. I feel stupid about not picking it up sooner...if I was wearing a shirt layered in 3 day old vomit stains, the last thing I'd want is for some pretend doctor to tell me about hypertension. From then on I decided to just chat with the patients about what was going on in their lives and hold off on the blood pressure talk until they brought it up.

Wednesday, November 19, 2008

Who Shouldn't Be Your Doctor?

Today a woman gave us a lecture that included a story about a marathon she ran. During this marathon, she didn't drink any water because "she doesn't drink water when she exercises." She also took Vioxx, a drug that has since been taken off the market in Canada because it has been found to cause extreme cardiac side effects. Vioxx is a Cox-2 inhibitor, which, long story short, causes vasodilation.

Does this sound like a bad idea? It must be...otherwise I wouldn't have anything to post about...Let's look at the perfect storm of problems she created for herself...

She ran a marathon, which means she lost a lot of fluid, through sweat. She didn't replenish these fluids because water and exercise don't mix for her. This lack of fluid would work to lower her blood pressure. She also took Vioxx, which causes vasodilation, which leads to lower blood pressure also. guessed it...she had REALLY low blood pressure. Low blood pressure means less blood filtration occurred at the kidneys. Less blood filtration means toxins built up...

At the end of the marathon her blood pressure was 90/60 (120/80 is normal) and her serum creatinine was 230 mmol/L (65 mmol/L is normal for her).

Here's the kicker...she's a nephrologist (kidney doctor). She did all this because she wanted to run an experiment...on herself. That's all well and good...but if you want to do that, you probably shouldn't be your OWN doctor. I doubt she would even subject anyone else to these experimental conditions because they are (I'm pretty sure!) relatively dangerous. Seems like it would be a good idea to have another doctor there to tell you when you're going too far...

That being said...she didn't really get sick, her body recovered soon after she rehydrated, but still...

Saturday, November 15, 2008

Dating Patients

Dating patients is considered unethical by the profession of medicine (at least in Canada) because of the power differential in the doctor-patient relationship. The theory is that since patients trust physicians with their health and well being, physicians could manipulate patients and coerce them into a romantic relationship, which is obviously unethical (and pretty gross too!). In Canada, physicians are self regulated by the Royal College of Physicians and Surgeons (RCPS). The RCPS decides if a physician can practice within a given province, and they deal with any ethical complaints that have been raised against a physician. Thus, if a patient complains about a doctor coercing them into a relationship, they would raise that complaint with the RCPS. The RCPS would then investigate the accusation and decide if the physician is guilty. If the physician is found guilty, the RCPS also dictates the terms of their punishment, which can range from rehabilitation or suspension, to revoking the physician's license to practice.

In most cases, the rules against dating patients makes complete sense. However, as with any ethical, political, or moral stance, there are always gray areas. The other day we were taught that the RCPS has a zero tolerance policy with regards to the doctor patient relationship. This implies that if you are the only physician in a small town, you will probably be unable to date ANYone in that town, as they're most likely all your patients! That means it's a TERRIBLE idea to go to an isolated rural community and be the only physician there, unless you enjoy celibacy.

Another interesting fact is that the RCPS believes in "once a patient, always a patient". This means if you are on call and you see a patient who comes into emergency, you can NEVER have a relationship with them. If you see them again in a social situation, 4 years later, and hit it can't act on it because one night, 4 long years ago, they were your patient.

Now, in practice, I'm not sure if the RCPS is as strict as we were told they are...but if

Wednesday, November 12, 2008

Futile Care

We discussed futile care in our ethics class today. Apparently we, physicians, are ethically obligated to provide futile treatment (e.g. ventilating a brain dead patient) if the patient or their family want to continue treatment. The justification behind continuing treatment is that the treatment provides psychological benefits for the patient's family.

In a world with limitless resources, I can understand this justification. However, in the REAL world, we already have tremendous hospital wait times and not enough beds for our patients. Keeping a patient "alive" (I use quotation marks because we don't know how alive a brain dead patient truly is) means there is one less bed and fewer resources for another patient. Thus, by delaying the inevitable passing of one patient, we are prolonging the suffering of another.

Obviously, the ethical issues in this scenario are not clear cut. The family of the brain dead patient may think that they are getting air access to health care if their physician decides to terminate treatment because it is futile. Also, what if the physician is wrong (it's been known to happen) and the treatment isn't futile? Or what if you can keep the patient alive for another year, and within that time a new technology is developed that can heal the patient?

There are many interesting dilemnas involved in futile care...I wonder how my experiences through my medical training will change my views on the issue...

Saturday, November 8, 2008

Courage or Denial

We were taking a young woman's history the other day. She seemed like the average first year student. She was very cheerful, intelligent, and she had a good sense of humour. She was recently diagnosed with pelvic inflammatory disease, PID, which she informed us was caused by either sexually transmitted infections or vaginal tearing. We were all glad she explained...we're first year med students, we don't know anything! She would be lucky if one of us could SPELL pelvic inflammatory disease, much less know its causes.

Anyhow, she was telling us how she had strep throat a few weeks ago, and then a couple of days ago she was going through abdominal pain and needed to go to the emergency room (this is when she was diagnosed with PID). Then she casually mentions her house was broken into recently...and then casually states that she was sexually assaulted several weeks ago.

We were all stunned. The patient went on to tell us how she is taking some time off school to get herself together. She also told us she had found great support groups in her friends and community. All in all, she seemed to be doing AMAZING, all things considered.

After the interview was over, our class and my tutor had a discussion about her calm, casual demeanour. Was she an amazingly courageous girl who was handling everything life had to throw at her with a smile...or was she in denial and avoiding her feelings?

Thursday, November 6, 2008

Know Your Audience

A friend of mine interviewed a volunteer patient today. We do these practice interviews to sharpen our interview skills. During the interview, questions about this patients sexual health came up. We always ask any patient if they are practicing safe sex; however, this patient happened to be homosexual.

After the patient confirmed that he practiced safe sex, my friend asked..."What kind of contraception do you use?"

We all burst out laughing...even the patient...who replied, "Uh...I think you mean protection."

I don't take viagra!

You have to love a prof who is willing to make fun of himself. This week is pharmacology week. Dr. Limpman was lecturing about drug uptake and had a slide showing a drawing of an octagonal blue pill going into the bloodstream. He immediately informs us that "everyone assumes the blue pill is viagra, then they think Dr. Limpman needs viagra." He then retorts "it doesn't even make sense, viagra is diamond shaped, not octagonal!" Upon realizing that knowing the shape of the viagra pill could be consiered evidence of his use of viagra..."Wait...No, Look! This is what I do! I'm a pharmacologist...I'm SUPPOSED to know the shape of viagra!"

We were all 100% attentive after that line, out of respect...

Tuesday, November 4, 2008

Prescribing Pharmacists

The provincial government in British Columbia (BC) is planning on giving pharmacists the right to modify and refill prescriptions. They made this decision without consulting the British Columbian Medical Association (BCMA), which is the association representing the doctors in BC. The BCMA has since convinced the government that they need to discuss this paradigm shift with doctors in order to ensure patient safety.

Currently, pharmacists can only fill perscriptions. Their primary role is to ensure the prescribed drug will not have any unwanted side effects, like dosage toxicity or drug interactions. Pharmacists also teach their clients how/when to take the prescribed drug.

The new legislation would allow pharmacists to modify precriptions to a different, but similar drug or refill a perscription for upto a year. The former would be done if the initially perscribed drug was not working effectively or had unwanted side effects.

This legislation was proposed to counteract the doctor shortage we face in BC. If doctor's are not spending time refilling or changing perscriptions, then they can see more patients. This leglislation would also be more convenient for patients because they would not have to wait to see their doctor in order to get a quick refill.

The BCMA has a problem with the legislation because they feel that it will damage patient care. Many patients are given a limited prescription because the doctor wants to see them again quickly. For example, a diabetic may be given a 3 month perscription so that doctor will be able to see him again in 3 months and perform another checkup. If patients are getting their perscriptions refilled by their pharmacists, they may not bother to see their doctor for upto a year, which may be unnacceptable depending on their state of disease. From my time in the family clinic, I have seen many patients, usually men, come in for a prescription refill and then they bring up a number of serious health concerns. Do you think these guys would come to their doctor's office if they didn't have the pretense of needing a refill?

Another concern is miscommunication, if a pharmacist modifies the prescription drug or dosage, then the doctor may not be aware of this change when he is seeing his patient. I think this is a lesser concern because I'm sure that doctors and pharmacists would work together to establish a protocol to ensure these miscommuncations would not happen.

The BCMA is advising the government to modify the legislation because they are concerned with will negatively effect patient care. The pharmacists were supposed to gain prescribing power in January...we'll see what happens.

Monday, November 3, 2008

Metabolism VIII: Low Carb Fad Diets

First off, I'm going to push the disclaimer that I do NOT support low carb diets. There is a substantial amount of literature available online that supports low carb diets, and there is an equally substantial amount against low carb diets. I'm a first year med student; I still don't know how to do a chest exam; you should not be consider this post serious, medical dietary advice.

Now that I've got the disclaimer out of the way, let's take a look at the science behind a low carb diet. Low carb diets can be high protein diets (Atkins) or high fat diets or a combination of high fat/high protein. The key is to reduce your carbohydrate intake.

If you have ever seen someone on any variation of the carb diet, you may have heard them tell you that they have seen immediate results, such as losing 5-10 lbs in a week. You should realize that if you ever lose weight this quickly, unless there is an extreme circumstance, you have lost water weight, not fat. Low carb diet results in water shedding because your glycogen stores are burned (see the previous metabolism post) and not replenished. One molecule of glycogen normally carries 3 molecules of water with it; thus, if you have less glycogen in your body, you have less water in your body. This depletion of glycogen is responsible for the immediate weight loss.

The low carb diet can lead to fat loss in the long run. Low carb means low sugar, and low sugar means low insulin. Insuling promotes fat storage and prevents fat cells from releasing fat into the blood. Without sugar, fat is released to the blood and used by most cells to generate energy. Also, protein and fat lead to satiety (feeling full), so having a high fat/high protein diet can cause you in eating fewer calories overall.

Again, I am NOT suggesting that you start a low carb diet. Altering the proportions of your diet to include more fat or protein can lead to alternate health risks in extreme cases. Too much protein in your diet can cause nitrogen related damage. Too much fat in your diet can cause blood fat to increase, which can cause cardiovascular health concerns. So in the end, if you want to lose weight, talk to your family doctor!

Metabolism VII: The Feed/Fast Cycle

The feed/fast cycle refers to the chain of events that occur after you have eaten a meal. It is a look at the big picture with regards to metabolism. Let's look at the feed fast cycle looking at an average timeline after you have eaten a meal.

0 - 4 hrs
After you have just eaten a meal, your body absorbs the sugar into the blood, which causes your blood sugar to spike up. This stimulates your pancreas to release insulin, which causes most cells in your body to take in glucose from the blood.

4 - 24 hrs
Insulin levels have dropped because the glucose from the meal is gone. Most cells are using fat as their main energy source; glucose is being reserved primarily for the brain. Now blood glucose is maintained by the liver, through the breakdown of glycogen stores. These stores are normaly depleted within 24 hrs.

1 - 2 day
After the glycogen stores are gone, the liver maintains blood glucose levels through gluconeogenesis. Thus, the liver makes glucose from either fat or proteins. Making glucose from protein means the body is breaking down muscle tissue and other essential proteins because the body does not store any protein as an intended energy reserve.

2 days - several weeks
As the fat cells release more fat into the blood, the liver starts to release ketone bodies. The brain begins to use ketone bodies for energy and thus, requires less glucose. This fall in glucose depend results in less gluconeogenesis, which means less protein breakdown.

After the fat reserves are depleted (timeline depends on individual body fat), the sole method of blood glucose maintenance is through the breakdown of proteins. The body basically cannabilises itself. People that die from starvation do not die because they run out of protein; they die because they eat away essential proteins like the heart. Note, many people die from complications of starvation before they get to this point.

That sums up the feed/fast cycle. The next metabolism post will talk about the science behind the Atkins diet and other low carb weight loss gimicks

Metabolism VI: Metabolism and Exercise

If you are trying to burn fat, you may have been advised to work out at medium intensity for an extended period of time (e.g. 60 minutes on the stairmaster), as opposed to having a short, intense workout (e.g. 10 minutes of windsprints). This post will discuss the science supporting this advice.

Exercise metabolism focusses on the metabolism of muscle, which is the primary tissue involved in exercise. Muscle requires ATP (energy) to function and stores enough ATP to last 5 to 10 seconds. Next, muscle transforms another chemical, creatine phosphate, into enough ATP to last 10 to 20 seconds. After that, the muscle uses glucose, which is broken down from the muscle's glycogen stores, to generate ATP. The muscle's glycogen stores can last about 5-10 minutes.

After the muscle's glycogen stores are depleted, it creates ATP from either blood glucose or fat. Oxygen is the deciding factor that causes the muscle to either use blood glucose or fat. If the muscle is not receiving enough oxygen, it will take in blood glucose, which probably originated from the liver, and create ATP. Thus, during short, intense exercise, muscle cells are burning glucose/glycogen stores. However, during medium intensity workouts, muscles decide to burn fat because they are receiving oxygen.

Thus, if you want to burn fat, then exercise metabolism seems to support that longer, medium intensity workouts make sense. Remember, you will need to make sure you can sustain the exercise for more than 5-10 minutes straight because you will not be burning any fat until that point.

Remember that your body is very complex and I don't think burning fat is as simple as exercising for more than 5-10 minutes. Diet, genetics, basal metabolism all come into play too. Also, I think you should focus on burning calories, not burning fat, because in the long run it doesn't really matter WHERE you burn the calories from, as long as they are burned. For example, if you burn 100 calories of glycogen, the next time you have a meal, the first hundred calories of sugar you eat will be turned into glycogen and NOT fat. However, if you burn 100 calories of fat, then the next time you have a meal, the first hundred calories of sugar you eat will be turned into fat because your glycogen stores will be full as they have not been burned. So, my advice in the whatever exercise you enjoy enough to do often, oh, and watch what you eat too.

In the next post, I will talk about the feed/fast cycle.