Looking for a kidney? Check the pelvis

I was working with a family doctor who asked me to go in and do a cardiac and abdomenal physical exam on a patient who had "interesting findings". He told me to make sure I palpated the kidneys. I was also told that the history had already been taken so I didn't have to bother with that.

I began with a cardiac exam. The only significant finding was a grade 2/6 (very quiet) systolic murmur. I figured the doctor asked me to do a cardiac exam on this patient because he wanted me to find that murmur, so I was happy to find it so quickly. I then continued with the rest of the exam.

I began the abdomenal exam thinking this patient must have a kidney tumour or some kind of kidney inflammation because the doctor made a point of asking me to palpate the kidneys. Normally you cannot feel a kidney on an abdomenal exam because they are surrounded by fat and muscle. The only time you can feel a kidney is when it is pathologically enlarged, or so I thought...

I was trying to palpate the kidneys for five minutes but I couldn't feel anything. Not being able to palpate enlarged kidneys may be expected in a fatter patient, but this patient was relatively thin. Finally, the patient, clearly seeing that I was struggling, began laughing at me. He decided to put me out of my misery and pulled his shorts down past his groin revealing an abnormal bump in his pelvic region...his kidney.

Turns out this patient had bilateral pyelonephritis that ended up destroying his kidneys, so he had to have a transplant. Often with kidney transplants the old kidneys are not removed; instead, their ureters (tubes connecting them to the bladder) are cut and ligated to the new, transplanted kidney, which is placed in an empty space in the pelvis.

Open Sourcing Research Software

An article in the Guardian calls for researchers to open source (release to the public) the computer code they use in their research.

As a former programmer, I think that this is a great idea. It is surprisingly easy for even the most talented programmer to make simple mistakes in their code that cause their program to provide erroneous, misleading results. Asking for the computer code to be released to the public will allow skeptics and peer reviewers the chance to criticize how data was analyzed. This criticism can catch mistakes and lead to more powerful experiments, but will researchers have too much ego to release their code?

In industry, programming errors are caught by demanding that programmers test their own code and then having a team of testers test the code. Unfortunately, the luxury of a robust testing team is not afforded to many researchers. Also, it is hard to expect, for example, a biology researcher, who is a self taught programmer, to create a detailed and powerful test harness for his software.

I would actually be surprised to see the open sourcing of research code become a common practice because I think many inexperienced programmers who program for research will be too embarrassed to release their code in a domain where professional software developers are able to criticize their work. I blame this on the programming profession rather than the researchers. Programmers are notorious for being outspoken and rude when commenting on amateur code. Another barrier to this practice is that code that is being released to the public domain needs to be readable/understandable, instead of being readable to only the programmer who wrote the code. This preparation will add time to the already busy schedules of most researchers.

Unfortunately, I suspect this will be one of those great ideas that many support, but few practice.

Lithium perscriptions are not supplements

No, I cannot give you a prescription for lithium.

Why?

Because lithium is used to treat bipolar disorder and you do not have bipolar disorder. I understand that your naturopath tested your hair for trace elements and his tests show that you have low levels of lithium; however, you just said you didn't have any health complaints.

You want to try 5 mg of lithium per day, but the smallest tablets I can find are 100 mg. Are you really going to cut this tablet into 20 pieces? Even if you did, if anything happens to you, like thyrotoxicosis leading to hypothyroidism (a side effect of lithium)... how am I going to explain that I gave a perfectly healthy patient, who was not bipolar, a prescription for lithium?

Disabling proquota.exe in XP Home Edition

Windows is not a normal topic of discussion here, but I struggled to find any information to help me with this problem, so I thought I'd post my solution.

After running combofix to clean up some viruses, proquota.exe was found to be missing from my system32 folder and combofix kindly reinstalled it. Unfortunatly, proquota.exe limits the profile size of user accounts, meaning that you can only store so much (10 MB in my case) on your profile (which includes your Desktop, MyDocuments folders, etc.). As a med student, I have a LOT of documents that I like to store in MyDocuments, so this was unacceptable.

If you have XP Pro or Server2003 you can easily find instructions to disable proquota; however, if you have XP Home, you're more or less hooped.

To disable proquota I had to make the following change to my registry (remember, hacking your registry is ALWAYS risky if you don't know what you are doing):

First, go to Start->run and type in "regedit".

Then in the Registry Editor, go to HKEY_CURRENT_USER->Software->Microsoft->Windows->CurrentVersion->Policies->System

Finally, double-click on EnableProfileQuota and set it to 0.

Restart your computer, and proquota will not bother you again.

Engineering vs. Medicine

When I was accepted into medical school, many people congratulated me with a "dude, you're leaving a good job to go back to school, med school's tough, why would you bother?!"

Friends who had graduated from engineering like I did responded a little differently, "dude, you're leaving a good job to go back to school, oh well, med school can't be that much tougher than engineering."

Having been through 1.5 years of medicine, I can certainly say that the engineers were very wrong. Conceptually, I don't think any single topic covered thus far in my medical education is any more difficult than the topics covered in electrical engineering. In fact, I would argue that courses on quantum mechanics and nanotechnology were probably more difficult to understand than anything I've been taught in med school. However, the major difference is volume of information. A single week in med school seems like at least half of an undergrad course. We have to read, understand, and memorize a ridiculous amount of information.

Which brings me to another difference between engineering and medicine. Engineering required very little memorization. For the most part, in engineering, you only have to memorize first principles and then you can usually derive any other equation you need. There is no way to derive the cranial nerves and their functions, nor is there any way to derive the different pathologies responsible for papulosquamous eruptions...there's no way around it, you have to memorize in medicine!

The workload in engineering is above and beyond that seen in most other university programs; however, the workload is much, much greater in medicine than even engineering. The only consolation med students have is that most schools grade on a Pass/Fail system, as opposed to a letter grade system. So for the most part,in med school, getting a 60% is as good as getting a 90% on an exam (not from the patient's point of view obviously), you don't have to worry about getting A's anymore.

The last difference that became very apparent to me last month is the difference in exams. My engineering exams were almost entirely math based; I don't remember ever seeing multiple choice on any of my exams. Med exams are entirely multiple choice, and there are a LOT more questions asked, which makes sense considering the significantly greater volume of information taught. After completing an engineering exam, most students have a good idea about how they did in that exam. After completing a med exam, most students have no clue how they did in that exam! A number of my classmates have seriously believed that they failed an exam, only to later find out that they aced it.

Why Nerds Wear Glasses

Society and pop culture paint a picture of the smartest, most intelligent people (nerds) wearing thick glasses and rocking pocket protectors. Admittedly, I would normally advise against buying into stereotypes, but there may actually be some validity to this particular generalization.

Studies looking at myopia (nearsightedness) have found that the more educated a person is, the more likely they are to have myopia [1, 2]. Another study showed a correlation between myopia and time spent reading in children. This correlation may indicate that "close work", including reading or any other activity that requires the eyes to focus on some nearby object, results in myopia. Of course, correlation does not necessarily indicate causation, but the theory reconciles the two aforementioned findings nicely. If increased reading causes myopia, it is not surprising that a higher degree of education is associated with an increased likelihood of myopia as more educated people probably tend to read more.

Now, why do nerds wear pocket protectors?

What they don't tell you before med school: Choosing where you work

Each year medical schools in Canada are flooded with more and more hopeful applications from students who are praying for the chance to wear a white coat and introduce themselves as "Doctor". These students have put forward superhuman efforts to achieve: they have great grades and solid MCAT scores; they have resumes polished with extracurricular activities showing their leadership, determination, and compassion; and they have spent hours on end crafting essays describing exactly why they want to enter the field of medicine. The competition is so steep in Canada that thousands of students are rejected time and time again, causing many to go off to international schools in the Caribbean, Australia, and Ireland.

Unfortunately there are many negatives to being a doctor that you just don't hear about when you are applying to medical school. One major drawback is the limitations placed on where you can live when you finally graduate. Medicine is touted as a very stable profession in Canada, one that is "recession proof". This stability is due in part to the major physician shortage we have in Canada. However, this shortage is not ubiquitous in location or profession.

If you want to be a family doctor, you're set, you can basically work in any city and you will be able to find patients and establish a practice. However, if you are a heart surgeon, you may complete your residency without a job available. Imagine that, finishing 4 years of med school and 6 years of residency without a job to show for your efforts. The lack of employment is simply because there are only so many facilities that can offer cardiac surgery and there are more graduates than there are retiring surgeons whose spots need to be filled.

Even if you are interested in a specialty that does provide employment opportunities for its graduates, you may still have little say in where you are employed. For instance, I was talking to an ENT surgical resident who was complaining that he will definitely not find work in Vancouver when he graduates because everyone wants to work here; thus, only the most experienced and capable surgeons are hired (good news if you have an ENT problem in Vancouver).

Some may argue that this problem is not unique to medicine because many occupations force people to relocate to where work is available. However, this is especially unfortunate in medicine because many people go into med school without being aware of this reality. Going tens of thousands of dollars into debt, slaving through med school and then residency, to realize that you have to move far away from your family and friends to find work can be a rough fact to deal with...so try to deal with it before you apply to med school. Either that or be comfortable entering a specialty with more flexible options...