Nobody wants to catch the flu. Millions of people get vaccinated against the latest flu strains every year because they don't want to suffer through the misery the flu brings. One very common symptom that most patients with the flu complain about is deep body aches and pains.
If you think about the life cycle of a flu infection, it is actually surprising that the influenza virus (the virus that causes the flu), which primarily lives in your respiratory tract, can cause pain throughout your entire body. In reality, the influenza virus itself is not directly responsible for this pain. The pain occurs because your immune system releases inflammatory chemicals (cytokines) while fighting the influenza infection. Some of these cytokines cause your own body's cells to produce an enzyme called cox-2, which creates chemicals called prostaglandins. Prostaglandins have many functions, but one is to sensitize your nerves to pain...causing that aching sensation that comes with the flu.
At first glance, you might ask why would our own immune system hurt us. That's a good question and no one really knows the answer. I suspect that these aches and pains may have evolved to force us to rest when we are sick, so maybe our immune system is hurting us so that it can help us by fighting off the infection faster?
Tuesday, March 9, 2010
How to give a good lecture: state your objectives
Lecturing is a skill that is in short supply. Unfortunately, university policies don't prioritize lecturing when hiring professors. Most professors are offered positions at universities because of their talent as researchers; however, good research does not imply competent teaching. This may not be true in all faculties, but it is certainly the case in science, engineering, and medicine.
University policy often dictates that professors must spend a certain number of hours lecturing students. I do certainly see the validity in the policy; it would be ridiculous if you had a world renown professor working at a university and none of the students were given a chance to learn from him/her. However, forcing professors to lecture when they are astonishingly bad at it is a recipe for disaster.
In medicine, we have had many lecturers, some good, some bad, some terrible. There are often many common flaws that are ruinous to any lecture and one of them is not starting off the presentation with a slide stating the lecture's objectives.
We need to know what we are supposed to learn from the talk before you start lecturing. If we don't, we can't filter the vital information from the extraneous or esoteric. If we can't filter out the unnecessary, we are overwhelmed with the overload of information and it all becomes white noise. Remember, in medicine, we have a lot of information that we need to absorb...if you don't help us prioritize, we will resent you for it and not learn properly.
It really isn't hard, just give us bullet points on the information in your lecture that you think is absolutely essential for us to retain. Then, even if you are disorganized and jumping around from topic to topic (which you shouldn't be doing!), we know when we can relax and when we absolutely have to take the time to note specific details you may have forgot to put in our note package.
University policy often dictates that professors must spend a certain number of hours lecturing students. I do certainly see the validity in the policy; it would be ridiculous if you had a world renown professor working at a university and none of the students were given a chance to learn from him/her. However, forcing professors to lecture when they are astonishingly bad at it is a recipe for disaster.
In medicine, we have had many lecturers, some good, some bad, some terrible. There are often many common flaws that are ruinous to any lecture and one of them is not starting off the presentation with a slide stating the lecture's objectives.
We need to know what we are supposed to learn from the talk before you start lecturing. If we don't, we can't filter the vital information from the extraneous or esoteric. If we can't filter out the unnecessary, we are overwhelmed with the overload of information and it all becomes white noise. Remember, in medicine, we have a lot of information that we need to absorb...if you don't help us prioritize, we will resent you for it and not learn properly.
It really isn't hard, just give us bullet points on the information in your lecture that you think is absolutely essential for us to retain. Then, even if you are disorganized and jumping around from topic to topic (which you shouldn't be doing!), we know when we can relax and when we absolutely have to take the time to note specific details you may have forgot to put in our note package.
Thursday, March 4, 2010
Mental Illness and the Resume Gap
Mental illness is probably one of the challenging diseases to live with. Yes, it is a disease; if you have mental illness, you are sick, no different than being sick because you have leukemia or hepatitis. However, if you had leukemia or hepatitis, people would acknowledge that you were unwell and probably rally around you for support. Unfortunately, society's stigmatization of mental illness results in many mentally ill people being shunned by their closes friends and family.
Mental illness is also very challenging to treat, partially because we do not fully understand the physiology behind the disease and it is difficult to fix something when you do not know how it is broken, but also because mentally ill patients do not often realize that they are sick. Mental illness can distort the way your brain interprets reality; thus, mentally ill patients may hallucinate without realizing that their hallucinations are not real. Many of these patients are unwilling to take anti-psychotic medication because they do not believe that they are sick and they do not want medication to alter their brain chemistry, which they think is healthy/normal.
Patients who have had mental illness in the past can also face many problems once they have recovered from the disease. Recently, a patient made a presentation to our class about her battle with mental illness and mentioned how difficult it was for her to find employment after her illness was finally being adequately treated.
She became mentally ill and refused to take medication for several years because she believed that her hallucinations were based in reality and thought that medication would needlessly cloud her brain. She basically believed that she was healthy and the medication she was being asked to take to treat her mental illness would, in fact, make her mentally ill. During the time she was mentally ill, her hallucinations prevented her from being able to keep a job. After years of being untreated, her husband finally convinced her to take medication. Shortly after that, her hallucinations stopped occurring and she was able to function normally again.
This woman was ready to get her life back and, for her, a major part of getting her life back included returning to the work force. Fortunately, in Canada, we have laws that prevent employers from asking prospective employees if they are mentally ill (actually the law prevents them from asking any health related questions). Unfortunately, there was a huge, unexplained gap of unemployment in this patient's resume which spanned several years. Thus, she would be forced to either lie or tell the interviewer that she was ill for an extended period of time. How many employers are going to hire a person who was chronically ill for several years? Now, if she was completely honest and told them about her mental illness, how many would hire her then?
This resume gap is a huge problem for patients who were once mentally ill and are now healthy and trying to live a normal life. Finding work with an unexplained period of unemployment is incredibly challenging. This results in many of these patients being forced to work in the mental health sector where the stigma around mental health is obviously significantly lower. In larger cities, this may be a reasonable means of reintroducing mentally ill patients into the work force. However, in smaller cities, there may not be a mental health team, or the teams may be very small and not looking for new members. How are mentally ill patients in these cities or towns supposed to return to the work force?
This is a major problem because meaningful employment is an important aspect of many people's lives in terms of determining their self-worth. People who are returning from mental illness often need to feel productive. If they do not, it is incredibly easy for them to slip into depression, for which they already have an increased susceptibility.
Until the stigma around mental illness subsides, this resume gap is a small issue that will be causing huge problems...
Mental illness is also very challenging to treat, partially because we do not fully understand the physiology behind the disease and it is difficult to fix something when you do not know how it is broken, but also because mentally ill patients do not often realize that they are sick. Mental illness can distort the way your brain interprets reality; thus, mentally ill patients may hallucinate without realizing that their hallucinations are not real. Many of these patients are unwilling to take anti-psychotic medication because they do not believe that they are sick and they do not want medication to alter their brain chemistry, which they think is healthy/normal.
Patients who have had mental illness in the past can also face many problems once they have recovered from the disease. Recently, a patient made a presentation to our class about her battle with mental illness and mentioned how difficult it was for her to find employment after her illness was finally being adequately treated.
She became mentally ill and refused to take medication for several years because she believed that her hallucinations were based in reality and thought that medication would needlessly cloud her brain. She basically believed that she was healthy and the medication she was being asked to take to treat her mental illness would, in fact, make her mentally ill. During the time she was mentally ill, her hallucinations prevented her from being able to keep a job. After years of being untreated, her husband finally convinced her to take medication. Shortly after that, her hallucinations stopped occurring and she was able to function normally again.
This woman was ready to get her life back and, for her, a major part of getting her life back included returning to the work force. Fortunately, in Canada, we have laws that prevent employers from asking prospective employees if they are mentally ill (actually the law prevents them from asking any health related questions). Unfortunately, there was a huge, unexplained gap of unemployment in this patient's resume which spanned several years. Thus, she would be forced to either lie or tell the interviewer that she was ill for an extended period of time. How many employers are going to hire a person who was chronically ill for several years? Now, if she was completely honest and told them about her mental illness, how many would hire her then?
This resume gap is a huge problem for patients who were once mentally ill and are now healthy and trying to live a normal life. Finding work with an unexplained period of unemployment is incredibly challenging. This results in many of these patients being forced to work in the mental health sector where the stigma around mental health is obviously significantly lower. In larger cities, this may be a reasonable means of reintroducing mentally ill patients into the work force. However, in smaller cities, there may not be a mental health team, or the teams may be very small and not looking for new members. How are mentally ill patients in these cities or towns supposed to return to the work force?
This is a major problem because meaningful employment is an important aspect of many people's lives in terms of determining their self-worth. People who are returning from mental illness often need to feel productive. If they do not, it is incredibly easy for them to slip into depression, for which they already have an increased susceptibility.
Until the stigma around mental illness subsides, this resume gap is a small issue that will be causing huge problems...
Saturday, February 20, 2010
Prevention vs. Treatment
The global recession was a horrific experience for many people across the planet. The realization that spending beyond your means is a dangerous game with dire consequences was a harsh return to reality for many people throughout the developed world.
Now, more than ever, if I suggested that your current spending was putting you deeper and deeper into a debt that you would have to spend the rest of your life repaying, you would probably rush to your financial planner and reorganize your budget.
So why are obesity rates across the developed world increasing? Why are we so comfortable with the idea of eating ourselves to death?
If most would agree that it is better to stay out of debt than to spend a lifetime repaying debt, why do we not see that overeating is analagous to going into debt and that that chronic illness like diabetes and ischemic heart disease from atherosclerosis is analagous to spending a lifetime repaying that debt?
It is because when it comes to their health, most people lack foresight. Many feel that they can just take medication when they are sick. They don't care to exercise and eat healthy so that they won't need the medication in the first place.
In many ways I understand this thought process. I might even support this behaviour if we actually had pills that would cure disease with no costly or chronic side effects. Unfortunately, that is not the scenario that is available to us. Metformin and glyburide do treat diabetes, but they are not a cure. Diabetics are still chronically ill and face a decreased quality of life despite the availability of diabetic medication, which they will have to take for the rest of their lives. As for atherosclerosis, once your arteries are clogged with fat, your heart will not function to its full potential...ever, regardless of how much nitro you take.
Ignoring prevention in favour of therapy is not solely the fault of patients (it is still mostly their fault; after all, you should take responsibility for your own body and health!). Physicians tend to focus on treatment; they spend significantly more time with the already sick patient than they do with the healthy patient who will be sick in the future if nothing is done now.
I attribute this phyician focus on treatment partially to physician training and mostly to the health care system. Medical school focuses on teaching us how to heal the sick much more than it focusses on how to prevent the healthy from becoming sick. This may be unavoidable because you absolutely need to ensure that your doctors know how to heal the sick and there are so many diseases out there it already takes at least 6 years of training to become competent enough to practice medicine. Does that mean we need another set of health care professionals working on prevention? Or maybe we should have a new specialty physician who focusses on prevention?
The health care system has a role to play in physician interaction with patients because MSP, the government organization that pays physicians for their services, does not provide much financial compensation for preventative treatment. I don't want to get into an argument about how much doctors should/should not care about finances when they are the ones entrusted to care for the sick, but realize that human nature will motivate anyone to act in a manner that maximizes their profit to effort ratio. If we want to see doctors spending more time on prevention with patients, maybe the health care system should value prevention more.
In the end though, as I have already said, you can't blame your doctor or your health care system for making you fat if you are the one eating poorly when you know better... and in this country, most people do know better.
Now, more than ever, if I suggested that your current spending was putting you deeper and deeper into a debt that you would have to spend the rest of your life repaying, you would probably rush to your financial planner and reorganize your budget.
So why are obesity rates across the developed world increasing? Why are we so comfortable with the idea of eating ourselves to death?
If most would agree that it is better to stay out of debt than to spend a lifetime repaying debt, why do we not see that overeating is analagous to going into debt and that that chronic illness like diabetes and ischemic heart disease from atherosclerosis is analagous to spending a lifetime repaying that debt?
It is because when it comes to their health, most people lack foresight. Many feel that they can just take medication when they are sick. They don't care to exercise and eat healthy so that they won't need the medication in the first place.
In many ways I understand this thought process. I might even support this behaviour if we actually had pills that would cure disease with no costly or chronic side effects. Unfortunately, that is not the scenario that is available to us. Metformin and glyburide do treat diabetes, but they are not a cure. Diabetics are still chronically ill and face a decreased quality of life despite the availability of diabetic medication, which they will have to take for the rest of their lives. As for atherosclerosis, once your arteries are clogged with fat, your heart will not function to its full potential...ever, regardless of how much nitro you take.
Ignoring prevention in favour of therapy is not solely the fault of patients (it is still mostly their fault; after all, you should take responsibility for your own body and health!). Physicians tend to focus on treatment; they spend significantly more time with the already sick patient than they do with the healthy patient who will be sick in the future if nothing is done now.
I attribute this phyician focus on treatment partially to physician training and mostly to the health care system. Medical school focuses on teaching us how to heal the sick much more than it focusses on how to prevent the healthy from becoming sick. This may be unavoidable because you absolutely need to ensure that your doctors know how to heal the sick and there are so many diseases out there it already takes at least 6 years of training to become competent enough to practice medicine. Does that mean we need another set of health care professionals working on prevention? Or maybe we should have a new specialty physician who focusses on prevention?
The health care system has a role to play in physician interaction with patients because MSP, the government organization that pays physicians for their services, does not provide much financial compensation for preventative treatment. I don't want to get into an argument about how much doctors should/should not care about finances when they are the ones entrusted to care for the sick, but realize that human nature will motivate anyone to act in a manner that maximizes their profit to effort ratio. If we want to see doctors spending more time on prevention with patients, maybe the health care system should value prevention more.
In the end though, as I have already said, you can't blame your doctor or your health care system for making you fat if you are the one eating poorly when you know better... and in this country, most people do know better.
Thursday, February 11, 2010
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.
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.
Tuesday, February 9, 2010
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.
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.
Thursday, February 4, 2010
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?
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?
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