Suggestions for medical education from retired doc
Retired Doc has made his first
suggestion for improving medical education Teach medical students basic economics. I will readily admit that I know very little about economics and economic theory. Hell, I don't know much about basic finance (luckily, I know someone who does who patiently answers all my questions.) As the practice of medicine becomes more and more influenced by politics and economic policy, we should all be striving to be educated in these things.
But of course, there is one pesky problem. Where do you fit it in? So many important topics are already left for self study or even ignored completely in our formal training. The motivated (and interested) student will find time to teach herself economic theory instead of watching tv or doing something else, but everyone else will leave economics up to someone else.
Women in Science
Women in math, engineering and science: Drawing on our country's entire talent poolA fabulous response to the controversy over Harvard President Lawrence Summers' recent
comments on women in science and engineering. In case you missed it, you can read about it
here.
Grand Rounds XXII
This week's
Grand Rounds is up at
Catallarchy!
Neuroimaging in Psychiatry
The Nytimes has a fascinating article in the Magazine section this week on
The Therapeutic Mind ScanNeuroimaging will soon become commonplace in psychiatric medicine. But should getting a brain scan before getting diagnosed with ADHD or bipolar disorder be a common practice now? I'm of the opinion that we are really not ready for using neuroimaging to diagnose most psychiatric disorders. But, as described in the article, Dr. Daniel G. Amen, (a child and adult psychiatrist based in California) thinks otherwise. His patients get two scans (for $3000 that probably wont be covered by insurance) before he designs a treatment program which may include biofeedback in addition to medication and talk therapy.
I'm all for innovative uses of technology in medicine, and know that in order for new diagnostic tools to be developed, someone has to test them. But I don't think the technology is quite ready for mainstream use. Techniques such as fMRI still need to compare groups of patients--hardly useful for an individual diagnosis. Dr. Amen uses brain scans as a diagnostic tool which is a dangerous practice as there is no "standard" diagnostic criteria for what he does. He makes assumptions that someone is bipolar based on a diagnostic scan, but where is the data that says such a scan is actually indicative of being bipolar?
Admittedly, imaging studies using psychiatric patients is immensely complicated. There are issues of how medication will affect results, and it isn't exactly ethical to keep patients unmedicated for the purpose of scanning them. Until more research is done into the effects of common psychiatric medicine on brain structure and function, it may be hard to conclude that the brain of a bipolar patient who has been on depakote for 10 years will look like the brain of a newly diagnosed patient. And what happens when someone meets the D.S.M. criteria for ADHD but has the brain scan of a schizophrenic? Do you treat the schizophrenia in order to prevent any future problems? Do you wait and see what happens? What about a patient with no psychiatric symptoms with a brain scan indicative of someone with borderline personality disorder? Is it an efficient use of resources to do a scan on someone diagnosed with postpartum depression (especially if they are responding well to treatment)?
I have no doubts that neuroimaging will be commonly used as a diagnostic tool for psychiatric disorders during my medical career. I can only hope that when it does become commonplace, enough studies have been done to make sure it isn't a giant waste of resources, or that it doesn't cause more problems than it solves!
Transitions
One great thing about being in a smaller program within a larger medical school class is how incredibly supportive and helpful the students are. Yesterday, we had a little question and answer session for PSTP students about the transition to the third year of medical school. Obviously, there are sessions about this with the entire medical school, but it's nice to get the inside scoop and uncensored opinions while eating food in someone's livingroom. Though I know I've got quite a long way to go before 3rd year, it was incredibly helpful in terms of knowing what to expect, how to fit in PSTP requirements with the different pathways, etc. As PSTP students, we are exempted from certain requirements (in order to allow for a flexible start time in the 3rd year), and are required to do a senior research project in the 4th year.
Having these little get togethers to talk about experiences in the different stages of our education is rather common in my program. In the fall, we have a careers retreat, where students, residents, fellows, and faculty talk about their experiences with md/phd training, and how we can prepare for things down the line.
I must admit that it is a little intimidating how much work and time the 3rd and 4th year of medical school entails. Is it really more work than being a 1st year, or a grad student trying to finish in 3 years? It may not, depending on the person. As someone who needs a good 8.5 hours of sleep, and some downtime, I know it will be a challenge for me. But despite the complaints about the hours, the subjective nature of rotations, and terrible residents, it was clear that they loved every minute.
One thing is clear though. I need to work on my ability to be proactive and ask for things. I've never been one to ask for favors or specific treatment, but I really had no idea how important it is to be a bit outspoken in your rotations in order to get the most out of the experience.
Skeptic's Unite!
The second edition of the skeptic's circle is available
here! Orac has rounded up the best posts on creationism, intelligent design, pseudoscience and more!
But I'm only interested in medicine, you say! Check out how
Orac has collected a number of posts debunking myths and the findings of new studies in both conventional and alternative medicine. Pull up a chair and start reading, you wont be disappointed!
Research Tools
It has always amazed me when researchers don't understand the very tools they use conduct their work. I'll always remember a particular summer research experience where I had to explain how I did some very simple statistics to a postdoc working in the lab. I can understand not being familiar with various statistical packages, but all scientific researchers should know what a t-test is, at least in concept if not in practice. I'm sure there is a similar problem with doctors not truly understanding their diagnostic tools, but this is a topic for another day.
Not understanding one's own research tools is a particular concern with research that involves fMRI. Despite the fact that I have worked on many fMRI projects, I do not feel comfortable with my knowledge of how the machine actually works, and what exactly the software packages are doing when analyzing the data. Now, I'm not arguing that all cognitive neuroscientists should become experts at MR physics, but having at least a basic understanding would be ideal. I am in a unique position at the moment because I am joining a lab which is just beginning work in neuroimaging. Because of this, I'm giving myself the time and opportunity to learn more about the technique, and what exactly the software is doing. I don't think I'll ever be satisfied in my knowledge of the techniques used in neuroimaging, but at least I know this means I will always strive to understand more, rather than being satisfied with my current knowledge.
If you'd like to learn more about fMRI, I suggest you check out
The Basics of fMRI and
fMRI for Dummies
A seat at the table
Once, as a lowly undergraduate shadowing an attending neurologist, I sat at a table. Not just any table, but the table in the conference room where that morning's patients were going to be discussed before rounds. I did not know that such pre-rounding was going to happen; I just walked into the room with the neurologist, and sat when he sat down.
Not a moment later, a resident walked into the room. The attending was bent over some charts as I watched a parade of long white coats enter the room, then sit around the table. I was given a passing glance, but no one said anything to me.
And in came the medical students in short white coats. They dutifully took seats along the edge of the room, away from the table. A handful of nurses came in. One sat at the last seat in the table, the other two sat with the medical students.
I then realized I had made a grievous error. The table was a place of honor, reserved for the attending, residents and the nurse who was presenting a patient that day. I contemplated moving to the edge of the room, but decided it was probably too late.
The discussion commenced, and I was introduced. The stories of that morning's patients were dissected, treatments were discussed, and several patients were transferred off the floor. Halfway through the second patient, another long white coat came through the door. Turns out it was the chief resident. Oops! He looked at me, and went to the chair in the back.
We proceeded to go on rounds, and I received quite an education on the types of patients that make up an urban neurology service. No one really took me under their wing as had happened in previous shadowing experiences. That didn't quite matter to me, but I always wondered whether the colder reception was because I took a seat at the table.
Grand Rounds XXI
This week's
Grand Rounds is up at
Sumer's Radiology Site!
A fabulous collection of posts, complete with illustrations. Grab a cup of tea and relax for awhile, you wont be disappointed!
Ageism
A recent
article from the washington post discussed ageism in the workplace, using an example from medicine.
They discuss the steps many take to hide their age in order to get a job, and how many seniors internalize the prejudices they experience for being older. In light of my mother's own difficulties in finding a job, I thought I'd research the topic a bit more.
In a
statement before the Senate Special Committee on Aging, Daniel Perry argues for better geriatrics training in medical school. Geriatric patients risk facing "inappropriately invasive procedures" or being denied life-saving measures due to their age. He argues that geriatric patients are not adequately screened for disease (though I would argue that this holds for any number of patient groups.)
Of particular interest to me, is that the
Alliance for Aging Research found that "older people are systematically excluded or discouraged from participating in the clinical trials that determine the safety and efficacy of new therapeutic drugs, even though older people predominate as the end users of pharmaceutical therapies." I must admit that I know little of the factors that go into the selection of subject demographics for clinical trials, but it seems that along with increasing the numbers of women and minorities in such trials, an effort should be made to also include geriatric patients. However, Mr. Perry does not acknowledge that such patients often have medical conditions or are on medications that would preclude their participation in most trials.
My medical school has taken some steps to increase our awareness of geriatrics in general. During our orientation, we went to an assisted living community to interview the residents about their healthcare experiences, and their thoughts on how medicine is practiced today. The topic of elderly relationships was a significant point of discussion in our sexual health class. First year students were encouraged to apply for a special geriatrics program, which allowed ~10 students to get a better idea of how geriatric medicine is practiced.
Is that enough? Maybe not given the increasing elderly population, though I can only assume that more attention will be paid to the issue as the years go by. Until then, I'm going to call my mom and suggest a few ways she can "hide" her age as she goes about her search for a new job...
Professionalism in Medical Education
Professionalism is a favorite topic at my medical school. We are warned that not filling out certain forms will result in a letter about professionalism in our files. Our clinical foundations of medicine course has ill-defined "professionalism" points for things such as attendance.
Professionalism in my medical school is defined by a number of factors including proper dress in clinical (or mock clinical) encounters, attendance at required sessions, timely completion of assignments, ethical learning behavior, and good behavior in general. Our clinical foundations course includes modules on ethics, death, dying and grieving, and cultural competency which could be construed as a way of teaching professionalism in different situations. During orientation, we were lectured on the importance of acting "professionally" outside of the classroom.
But what really defines an education in professionalism? Is it as simple as discouraging bad behavior at a formal and loosely encouraging professional behavior, or should it be more explicitly taught?
AMSA suggests that the teaching of professionalism should include elements of the PharmFree campaign and how to resolve professional conflicts. Many schools introduce the concept of professionalism with a
white coat ceremony and continue teaching the concepts of professionalism by integrating them within other courses to varying degrees.
The issue of professional behavior is a critical one. A relatively recent
study showed that unprofessional behavior in medical school is correlated with later disciplinary action by a state medical board. Fortunately, a number of studies have been done to investigate different educational approaches to teach the concepts professionalism (just check out
academic medicine.)
The question that must be addressed is how an education in professionalism will be reflected in how we eventually practice medicine.
The ABIM Foundation stresses the need for such an education in a world of "managed care and for-profit medicine...." Is my medical school properly preparing me for such a world? I'm not sure. Granted, I'm only in my first year, but I can't see how stressing that we do what I consider to be common sense (doing things on time, proper attire when appropriate, not cheating, etc.) in the name of professionalism is really preparing me for a life in professional medicine. On the other hand, our clinical foundations of medicine course, while not explicitly stressing acting in the name of "professionalism," has probably taught me more about how to be a medical professional by discussing ethical issues and exploring our own personal feelings regarding death, cultural stereotypes, sex, and the more.
I am of the personal opinion that professionalism is best developed through experience, and is poorly served by using the term as a catch phrase and catch-all for acts that might be better covered by using a conventional honor code. (Or is "professionalism" simply a euphemism for honor code in the preclinical years of medical education?) But with numerous
studies showing that medical students become increasingly cynical as the years go by, it seems logical that an education in professionalism should start early, before we have many concrete experiences in professional behavior. I believe that preclinical discussions of professionalism should focus more on issues such as the influence of pharmaceutical companies, the atmosphere of managed care, common ethical dilemmas, etc.
Obviously, there is only so much you can squeeze into the preclinical years. I can only hope that as more investigation into the efficacy of different methods teaching professionalism is done, medical schools will do a better job at preparing us for the future medical environment. Until then, I plan on finding myself the best role models I can, and learning about professionalism from them.
Wow, I dont think I've ever used the word "professionalism" so often! I must admit that replacing the word madlib-style in this post is quite entertaining!
A quick post for some great links
The role of medical school admissions committees in the decline of physician-scientists and the
replies
Ah, if only I had time to respond, but for now, I leave you one final link for your enjoyment.
The 2005 American Physician Scientist Association Conference Not sure if I will be going, but its location is mighty convenient for me (I know people in chicago, and it is only about a 5 hour drive), and I'd like to go.
Speaking Two languages
In response to the post at
Orac Knows I thought I'd add my two cents to the conversation. Though I'd first like to thank Orac for the post, I always love hearing from fellow MD/PhD's who are a lot farther along in the process than me!
For me, being a physician scientist is not really about wearing two hats, but is instead about about speaking two languages. For those who think that MD/PhD's are spreading themselves too thin, or giving one discipline the short end of the stick, I ask, would you ask a translator to pick a language? Putting two translators together who speak different languages is not exactly conducive to having a conversation. And while having partnerships between doctors and basic scientists is important, there is something to be said for being able to approach a problem with multiple perspectives, using insight gained from medicine to steer your research, being able to assimilate the results of basic research in to theories of how to better treat your patients....
Perhaps I'm a bit lucky in that my preferred area of research (functional neuroimaging) is a bit more conducive to being a physician scientist in that the disciplines are not incredibly far apart (one way or another, I'd be working with people and not mice or cells.) But I recognize the importance of having physician scientists who focus on basic science--it is a very different language than most of us are familiar with, and requires years of study. While doctors with no PhD training can certainly be great scientists, we M.D./Ph.D.'s are afforded such luxuries as protected research time, shortened fellowships with a research focus, a competitive edge when applying for grants, and more!
Journal Club Fun
On thursday, I had the honor of presenting a paper on
hypospadias for our pstp journal club. As you might expect, presenting a paper on male genitalia leads to all sorts of exciting side conversations, including tales of voluntary
cremasteric reflexes, detailed discussions of mouse urogenital anatomy, contemplations of reproduction between saint bernards and daschunds, and much much more. We should definitely make it a point to present such provocative topics in the future!
the research questions that matter
Weekends provide a little time to get a few things done around the house, take care of my parrot, and time to think about the kinds of research I might want to do for the rest of my life.
Yesterday, we had a very interesting lunch talk about translational research, specifically the relationship between mutations in the Nkx2-5 gene and pediatric heart disease. It's an interesting research problem that mutations in this particular gene cause a wide variety of cardiac problems, from AV block, to atrial septal defect, and even teratology of fallot (and that knowing a patient has a particular mutation is not exactly predictive of the type of defect that the patient will develop.) To address the problem, mouse models have been developed with varying success. I'd imagine that this research will eventually lead to new treatments for the acquired defects, but what about the congenital defects? We know that mutations in Nkx2-5 generally follow an autosomal dominant form of inheritance, so there is genetic counseling. Surgical techniques can obviously repair many of cardiac defects, but can the current research approach answer any questions on how to prevent them from occurring in the first place? And is that even a worthwhile research question?
Along a similar vein,
this article on progeria (nytimes) made me think about another aspect of genetics based research. The families were obviously overjoyed when the defect in Laminin A was discovered, but in the short term discovery of this defect will probably do more to elucidate questions on cell structure than provide an effective treatment for kids with progeria. As a scientist, I know that we should be happy when research gives a clue towards any problem--not just the one we are trying to study. And I'm sure the progeria families are glad that all the efforts they've made towards raising awareness and research funds will be able to help someone, if not their children. But if you were the scientist studying progeria, how would you tell a family that by studying their child, you were able to develop something that could help someone who was 60 years old?
As someone who ultimately wants to do neuroimaging research with people, I will be more likely to be in contact with people who have the very disease I am studying. I'll also probably be seeing that type of patient in my clinics. Knowing that I will potentially have to explain my research motivations to my subjects, I know I will want to be very careful in selecting my questions. I'd like to say that all the research I will do will directly help the people I am studying, but I know that is not exactly realistic. All I can hope is that the work that I do will be worthwhile, and will make a difference in someone's life, even if it is long after I leave medicine and science.
Ethics of neuroimaging
I have long been fascinated with the ethical delemmas posed by developments in neuroimaging. So fascinating in fact, that I had planned to research and write a nice post about it. But, it seems like the folks at
slate beat me to it, so I will let their words and time spent researching the issue stand in my place as I study for my quiz tomorrow.
Skeptics' Circle
Check out the first edition of the Skeptic's Circle over at
St Nate
Microscopes for first year histology?
Apparently, there is quite a raging debate in our curriculum committee about whether to stop requiring students to have microscopes for our first year histology class. We already use a lot of computer based slides in addition to the traditional slides. There is also a great Histology program on the library computers, any number of internet sites and of course books like Wheaters.
So far, opinion on this matter seems to be split. I do have to admit that I rarely use my microscope, partly because I do most of my studying at home, and because I don't get a lot out of going to the lab times (I need to study alone to get anything done.) Would I like to save the $250 or so that I spent to rent the microscope? Sure. For that money, I could buy review books for every course to help out with my exams, and then step 1. But, I also realize that I need to know how to use the microscope. There wont be time to learn during my clinical rotations where its required. Though I had used a microscope before coming to med school, I admit that I really didn't know how to use them, and it certainly took some time before my eyes were trained enough to use it well.
My solution would be to share microscopes between our tables of 4. We already share laptops, and slides as well. There is a liability issue here. The school does not have money appropriated to buy enough microscopes, so for next year, we would probably still need to rent them. Who pays the bills if one of them gets broken?
The curriculum committee is simply voting on microscopes or no microscopes for next year. I'd imagine that they will decide to keep the microscopes in the curriculum for now. There will be grumbling from the students--renting microscopes is an expensive hassle. I think the hassle is worth the intellectual reward.
