Tales of a MD/PhD student

A change in focus

2005-07-07T16:14:00.000-05:00

I never wanted to be one of those people who just abandoned their blogs for longs periods of time, but alas that is just what I did. I thank the people who have visited over the past month and found nothing new, but my summer obligations of working, hanging out with friends, having fun, and reading non school-related books as well as a general change in priorities have taken my mind off of blogging. I wish that I could promise in this post that I'll be writing regularly again, but I'll be going on vacation for awhile, for some much needed beach and family time.

I'm still reading my favorite blogs on a semi-regular basis, so hopefully, I'll see you there!

Economics and Psychology

2005-05-25T15:18:00.000-05:00

Via World of Psychology, I stumbled across this article:
Economics-psychology's neglected branch

Economics - to the great dismay of economists - is merely a branch of psychology. It deals with individual behaviour and with mass behaviour. Many of its practitioners sought to disguise its nature as a social science by applying complex mathematics where common sense and direct experimentation would have yielded far better results.

The outcome has been an embarrassing divorce between economic theory and its subjects.

The article outlines many of the difficulties in economics research, and why economics should not necessarily be considered a science.

Scientific theories must also pass the crucial hurdles of testability, verifiability, refutability, falsifiability, and repeatability. Yet, many economists go as far as to argue that no experiments can be designed to test the statements of economic theories.

It is difficult - perhaps impossible - to test hypotheses in economics for four reasons.

Ethical - Experiments would have to involve human subjects, ignorant of the reasons for the experiments and their aims. Sometimes even the very existence of an experiment will have to remain a secret (as with double blind experiments). Some experiments may involve unpleasant experiences. This is ethically unacceptable.

Design Problems - The design of experiments in economics is awkward and difficult. Mistakes are often inevitable, however careful and meticulous the designer of the experiment is.

The Psychological Uncertainty Principle - The current mental state of a human subject can be (theoretically) fully known. But the passage of time and, sometimes, the experiment itself, influence the subject and alter his or her mental state - a problem known in economic literature as "time inconsistencies". The very processes of measurement and observation influence the subject and change it.

Uniqueness - Experiments in economics, therefore, tend to be unique. They cannot be repeated even when the SAME subjects are involved, simply because no human subject remains the same for long. Repeating the experiments with other subjects casts in doubt the scientific value of the results.

The undergeneration of testable hypotheses - Economic theories do not generate a sufficient number of hypotheses, which can be subjected to scientific testing. This has to do with the fabulous (i.e., storytelling) nature of the discipline.
In a way, economics has an affinity with some private languages. It is a form of art and, as such, it is self-sufficient and self-contained. If certain structural, internal constraints and requirements are met - a statement in economics is deemed to be true even if it does not satisfy external (scientific) requirements. Thus, the standard theory of utility is considered valid in economics despite overwhelming empirical evidence to the contrary - simply because it is aesthetic and mathematically convenient.

Hmm...definitely some interesting considerations that are worth further thought and study...

Neuroeconomics

2005-05-18T12:27:00.000-05:00

Given my interest in all things relating to neuroimaging, and the positive reception I got from What's the deal with Neuromarketing? I thought I'd bring up a related field of study: Neuroeconomics.

A recent article in Technology Review entitled The Economics of Brains underscores the implications of fMRI research as it relates to economic theory. The hope is that by understanding how the brain works in things like decision making and reward processing, economists will be able to better modify their theories to account for "irrational" behavior. Of course, the question is, considering the level of neuroeconomic research occurring today, should economists really care?

Perhaps understanding how the brain works is more trouble than it’s worth. After all, some recent findings are not at first glance very economically enlightening. Anyone who has regretted an impulse purchase, for instance, would be unsurprised to learn that evaluations of immediate and delayed rewards use different parts of the brain. For now, neuroeconomics is subject to the criticisms that plague psychology: that its experiments show what is already intuitively obvious, and its models are descriptive, not quantitative. But Stanford psychologist Brian Knutson and psychiatrist Richard Peterson are trying to answer that criticism. Their paper in a forthcoming issue of Games and Economic Behavior reports that subjects seem to use different parts of their brains when they consider financial gains and when they consider financial losses; more recently, they have found that subjects use different parts again to evaluate the magnitude and probability of those gains and losses. Knutson and Peterson’s work is part of an increasing effort to figure out how economic utility may be coded quantitatively in various regions of the brain. If economists could track the different components of utility in a statistical way, they could understand why some people take risks and some don’t—and possibly predict their future behavior.

Obviously, like most neuroimaging research, the subfield of neuroeconomics is still quite young, and only time will tell how effective this type of research will be in shaping economic theory. One interesting aspect of this field is that by putting the results in an economic framework (as opposed to a marketing framework), researchers have been able to isolate themselves from criticisms such as those directed at neuromarketing researchers (see What's the deal with Neuromarketing?). On the surface, both fields study very similar concepts, but neuroeconomic research seems to encompass a wider variety of issues.

For those of you more interested in the topic, I refer you to the following sites:

What is Neuroeconomics? and What is Behavioral Economics? from Decision Science News

Kevin McCabe, 2003, "Neuroeconomics," Encyclopedia of Cognitive Science, Lynn Nadel (ed-in chief), Nature Publishing Group, Macmillan Publishing, New York, pp. 294-298

And, a Neuroeconomics blog which has made its way to my blogroll.

Grand Rounds 34

2005-05-17T06:23:00.000-05:00

Wow. We're already on the 34th edition of Grand Rounds, hosted this week at Galen's Log

To be a part of next week's Grand Rounds (hosted at Iatremia), send submissions to news AT chaplin DOT nu by Monday May 23rd at 6 pm (EST).

Skeptic's Unite!

2005-05-12T14:15:00.000-05:00

The eighth edition of the Skeptic's Circle is up at Pharyngula.

And, while we are on the subject of blog carnivals, next week's Grand Rounds will be held at Galen's Log on May 17 (submissions can be sent to bengland8 AT hotmail DOT com by Monday at 6 pm).

On May 18th, Madhouse Madman will be hosting the next edition of the Tangled Bank (send submissions to madhousemadman AT gmail DOT com)

The Ethical Brain

2005-05-12T09:03:00.000-05:00

The New York Times recently published an interview with Dr Gazzaniga, a prominent neuroscientist, who has just published a new book entitled The Ethical Brain.

I found the following comments particularly interesting:

In "The Ethical Brain," Dr. Gazzaniga discusses his views on stem cell research, along with a range of other important issues. He describes his worry that the techniques of neuroscience may be misused.

For example, he thinks it is wrong to use neuroimaging as a lie detector or as a tool to determine whether criminals are responsible for their crimes. "It shouldn't be dragged into the courtroom," he said. "I think it's totally misused if you're trying to find the errant pixel in the brain that's responsible for why someone killed someone."

Neuroscience's biggest contribution to ethics, Dr. Gazzaniga predicted, is only just emerging: a biological explanation of morality. "In the next 20 years, we're probably going to define why our species seems to have a certain sort of moral compass," he said.

Current research suggests that this moral compass appears to be the product of the human brain's intricate circuitry for understanding other people's thoughts and feelings. Just looking at pictures of people stubbing their toes in doors, for example, activates the same regions of the brain that switch on when people stub their own toes. "When I have an empathetically moment, I literally feel your pain," Dr. Gazzaniga said.

Dr. Gazzaniga argues that when we experience these feelings, the brain's interpreter produces rational explanations for them. The particular explanation it produces depends on a person's particular upbringing. "Each culture may build up a theory, and that may be passed down as traditions and religious moral systems."

But, he said, "the basic reason you don't kill is because your brain tells you it's not a good idea to kill."

Will we ever be able to "define our moral compass" using techniques such as neuroimaging? I'm not sure. Afterall, it stands to reason that other species have a similar "moral compass," but though imaging animals occurs all the time, it would be much harder to study. Perhaps neuroimaging will provide some scientific support for philosophical theories regarding innate morality and ethics, but I'm not sure that the theories can ever be proven. Afterall, if morality can be defined in the brain by a single voxel, what does that really tell us in the broader sense? That knowing that it is wrong to kill comes down to a single group of neurons? Is that group of neurons enough to "prove" that we have a deeper sense of morality than a dolphin (afterall, putting dolphins in a scanner may prove rather difficult)?

One thing's for sure though....Dr. Gazzaniga's book is on my reading list this summer. Science may never be able to prove these philisophical theories, but it is fun to think about!

Will fMRI ever really breach our privacy?

2005-05-08T08:45:00.000-05:00

The New York Times has an article discussing privacy issues that could arise from a development in the technique (although the bulk of the article highlights some interesting work done with more traditional research methods.)

"In the current issue of Nature Neuroscience, however, Frank Tong, a cognitive neuroscientist at Vanderbilt University, and Yukiyasu Kamitani, a researcher in Japan, announced that they had discovered a way of tweaking the brain-scanning technique to get a richer picture of the brain's activity. Now it is possible to infer what tiny groups of neurons are up to, not just larger areas of the brain. The implications are a little astonishing. Using the scanner, Tong could tell which of two visual patterns his subjects were focusing on -- in effect, reading their minds. In an experiment carried out by another research team, the scanner detected visual information in the brains of subjects even though, owing to a trick of the experiment, they themselves were not aware of what they had seen."

Is being able to tell what picture someone is looking at really "reading their minds?" Although some fear that fMRI will be the next pre-employment screening (like drug screening is today), with its ability to uncover racism and other potentially undesirable personality traits, will it ever really pan out in the future? Why aren't we drawing everyone's blood to test for high blood pressure, high cholesterol, diabetes, etc. to see if they will be a burden on company insurance plans? I have heard the argument that fMRI will soon be used to replace pen and paper tests of personality used in certain employment areas. Afterall, you can't "lie" in the scanner. But fMRI is expensive, complicated to interpret, and isn't ready for individual level analysis in most cases. So, is fMRI really a potential invasion of our privacy? Well, if you're concerned that someone can tell what picture that you are looking at (without looking at your eyes), maybe. But if your concern is at a broader level, sit back, because we wont be anywhere near that point for awhile.

Online Neuroethics Resources

2005-05-06T21:16:00.000-05:00

Since the ethics of neuroscience research has come up here before, I thought I'd share a few resources on Neuroethics for some fun weekend reading.

Upenn Neuroethics site This site has articles on brain imaging, pharmacologic enhancements and consciousness, as well as links to other sites (some of which are replicated below.)

The Stanford Neuroethics Imaging Group includes a open forum for the discussion of neuroethical issues (though it hasn't quite gotten off the ground).

Neuroethics from the fabulous Neuroscience for Kids site.

Theme issue on Ethical Issues in Neurology from the Ethics Journal of the American Medical Association.

And finally, The Center for Cognitive Liberty which raises some interesting questions, such as the possible issues related to successful memory enhancement. "What if emergency room personnel automatically begin giving memory-diminishing drugs to trauma victims? What if you are the victim of a violent crime and want to forget what happened to you, but need those memories in order to testify or identify the perpetrator? What if you are the only eye-witness to a crime, could the government compel you to take a memory-boosting drug at least until you testify in court?" While I believe many of these potential issues are just as far fetched as those brought up on the Commercial Alert neuromarketing site, it is some food for thought...

Why wont you put your helmet on?

2005-05-06T21:02:00.000-05:00

This afternoon, one of my new neighbors was teaching her daughter to ride her bike. Her other daughter was on a bike as well. None of the three were wearing helmets.

According to research conducted by the National SAFE KIDS Campaign, nearly half of severe injuries from bike accidents are traumatic brain injuries. And though young adults generally have a better outcome from TBI than older adults, younger children (such as my kindergarten-aged neighbor) are particularly vulnerable to brain injury (especially frontal injury) because many higher level cognitive functions haven't fully developed.

I wanted to tell the kids to put on a helmet. If their Mom wasn't riding with them (sans helmet), I may have suggested that they go and get them when I was out getting my mail. But I didn't, partially because I don't know them, and I feel weird about telling other people's kids what they should do. I understand that it can be difficult to make older children wear helmets, but when you are teaching your child to ride a bike, how hard can it be? Around here, helmets can be purchased at local fire stations for $10 each, and are given away free at local hospitals.

Perhaps my outrage is colored by the fact that I've always worn a helmet, and all of my cousins are good about wearing theirs. I actually even had a cousin tell me the other day, "I can't ride bikes today because I left my helmet at home." Of course, such easy compliance didn't come without a price; a close family friend died tragically two years ago from a backwards fall when rollerblading with her son. The greatest tragedy of all was that just before pulling out of the driveway to go to the park, her husband called out to make sure she had remembered her helmet. After the funeral, he found it their garage. And when my older cousins and I were growing up, there was always my fictitious Uncle John, who hurt his head falling off his bike and was never quite the same (or maybe that was from falling over the railing, or tripping because his shoes weren't tied, or from getting sick because he didn't wash his hands before dinner....)

Moral of the story? Wear a helmet! Next time I go to the Children's Hospital, I'm going to pick up flyers for the helmet drives and put them in my neighbors' mailboxes. I'm sure that these kids, with their shiny new bikes, probably already have them, but hopefully a little information on the benefits of wearing a helmet will give them (and their parents) a push in the right direction.

Submissions for Grand Rounds 33

2005-05-04T07:56:00.000-05:00

Azygos, the host for next week's Grand Rounds, has put out a call for submissions.

He writes, "I would like to suggest that next week submissions focus on some personal interaction, intervention or extra steps you took in the course of making a difference in a patients or patient’s families life. To often we here about the bad doctor, insensitive nurse, or the uncaring treatment one has received from a healthcare worker. We never hear about the extra hours put in by doctors, nurses, PA’s, and nurse practitioners to make sure the patient is appropriately cared for. We don’t hear about the classes all of us attend in the course of our practice just to try and stay on top of current therapy and treatment. Patients don’t hear about the five hours of phone calls the provider had to make to arrange a lifesaving treatment. Maybe some would disagree but I think pulling the veil back to reveal some of the intricacies of patient care might give pause to some before complaining about the care they received."

It's a great suggestion; I'd love to hear these kinds of stories as well!

E-mail submissions to Azygos451 AT yahoo DOT com

Grand Rounds XXXII: A Day In The Life of a Medical Student

2005-05-02T18:39:00.000-05:00

12:35 AM

Finish studying and do a final check of Medlogs. Stumble upon a post by The Anonymous Clerk asking Does NPO Include Holy Food? Decide to head to bed. Because tomorrow will be filled with interesting clinical correlation lectures instead of biochemistry, I'm actually planning on going to class in the morning....

6:45 AM

Radio alarm goes off. Hit snooze

6:52 AM

Hit Snooze again. Why are lectures always so early?

6:59 AM

Drag myself out of bed. On the radio, Red State Moron reports the latest on surrogacy and quintuplets. I wonder why medical stories are the only thing that can drag me out of bed in the morning. Hit the Shower.

7:15 AM

Grab breakfast while checking the traffic on Good Morning America. Diane Sawyer introduces Denni from The Break Down Manual who has an important message about postnatal depression. Though it may make me late, I decide to watch the whole segment.

7:30 AM

Drive to School. Dr. Charles explains the symbol of the Green Man on the morning radio show.

7:45 AM

Since I was blessed with no traffic, I run to starbucks, where I catch up with Jen who has just finished up her last nursing exam for the year.

8:00 AM

Clinical Correlations Lecture:
Dr. Rack, the Sleep Doctor finishes up his lectures on narcolepsy Looking out at my fellow students, I'm amused that a sleep lecture was scheduled so early in the morning. While Dr. Rack is anything but boring, our collective sleep deficit seems to have overcome certain students' interest in the topic at hand.

9:00 AM

Careers in Medicine Lecture:
Dr. Tony describes life in the emergency room in a typical night patient in the EC (part 1) and Part 2. For another perspective on life in the emergency room, Mad House Madman reminds us of why we should always have our white coats on hand. To round out the hour, The Cheerful Oncologist muses on an oncologist's track record in leading the code team during a cardiac arrest in Goodbye to All That CPR.

10:30 AM

Clinical Correlations Lecture:
Dr. Parker from Cut-to-Cure teaches radiologic interpretation using the example of a GSW patient.

11:00 AM

Clinical Foundations of Medicine Lecture:
Kevin MD warns us that Math + Medicine = Confusion.

11:37 AM

Medical Instrument Fair:
MedGadget shows off an amazing video of Vein Viewer.

12:11 PM

Lunch Talk: The Effects of Pharmaceutical Marketing
After patiently waiting for all of us to grab free pizza and pop, Galen discusses the effects of pharm marketing on prescribing habits in Who Benefits? In Ask Your Doctor, DB from DB's Medical Rants explains some effects of Direct to Consumer Advertising. Corpus Callosum follows up with Direct to Consumer Advertisements of Antidepressents. To close the session, Aaron at Two Terms Later gives a student perspective on the issue in To Take or Not To Take? Its great to know that I'm not alone in my confusion over how to approach the issue of pharmaceutical gifts.

1:03 PM

Full from pizza, I head over to the clinical skills lab to learn about the Role of Ultrasound in Dengue Fever from Sumer.

2:10 PM

Break. Finally! I can catch up on reading the latest journals. Dr. Emer at Parallel Universes suggests ACAT2 and Dr. Lawrence Rudel:
Inhibition of ACAT2 in the liver shows great promise in preventing CHD from developing. Since it was mentioned in lecture yesterday, I decide to look up Legionnaires' Disease at New York Presbyterian over at Kidney Notes. Since I still have a few minutes to spare, I pull out the trusty laptop and read Four Shades of Gray at Ad Libitum.

3:00 PM

The Patient Perspective:
In Pain Scales and Daily Living, Peggikaye at Pearls and Dreams explains to her health care providers that what they see is not necessarily what they get. It's an important point that we are glad to hearAcid Test describes a medical episode that taught her more about getting treatment than she ever wanted to know. Amy from Diabetes Mine explains why Stem Cell Research Matters. These patient accounts are worth every word.

3:55 PM

Run to the coffee machine for an afternoon pick-me-up. Medical school is exhausting.

4:00 PM

Medical Ethics:
Orac at Respectful Insolence explores some of the issues in the Taran Francis case in Sad End to a Sad Tale. Dr. Berstein from Bioethics Discussion discusses the priorities regarding the humanitarian issues in life: the born vs the unborn. He examines the case of the 13 year old pregnant Florida girl in Meddling Again? and The Troubled Living Don't Matter as Much as the Yet-to-be-Born.

4:57 PM

Though classes for today are done, the learning is not, and I run over to the Business club meeting where Tim Gee, a connectologist at Medical Connectivity dissects a press release from a wireless networking company that’s getting lots of attention and traction in U.S. hospitals. He emphasizes that, while the technology is way cool, the press release is not. Not to be outdone, David from Health Business Blog points to a hospital that added patient blogs to its website. Our next speaker, Tony from Hospital Impact summarizes the recent blogosphere debate on the uninsured & healthcare reform.

6:15 PM

As I head over to the research building, I run into Aggravated DocSurg who muses on the tragic consequences of a missed diagnosis, and how it hits close to home. I empathize; in high school, my mother attempted (but thankfully, did not complete) suicide three times, and everytime it happened, we were sure that she was finally out of danger.

6:30 PM

Journal Club:
Orac describes the biomedical meeting creatures he encountered at the poster session during his last conference. I can relate to his experiences as it wasn't so long ago that I went to my first major conference and presented a poster in the very first session. Nervous, because I had never even been to a conference before, I stayed up half the night looking up obscure facts that someone might ask me about. It turns out that most of my poster audience simply wanted to be "walked through the poster." I wish I had been warned.... Once everyone has arrived, Dr. Andy presents a recent article about the possible risks (or lack thereof) of biotech foods.

8:07 PM

Dinner Time! I meet up with a few friends and Street Doc, a local paramedic, who regails us with tales of a hydrocodone and alcohol interaction and a particurally good trauma. I think that the people at the table behind us are giving us strange looks. Changing the topic of conversation to something a little more normal, Mad House Madman pulls out a photo of future intern smiling. Joining us for drinks, Saint Nate describes a visit to the Philadelphia Museum and says, "Don't Say 'No' to the Incredible Medicine Show." We quickly decide to visit the exhibit next weekend.

10:24 PM

Heading home. I guess I wont get too much studying done tonight.

10:47 PM

Start reading about Home-Based Rehabilitation for Patients With Cognitive Disorders. Definitely something to keep in mind when I finally get out of school. I hope that this material will be on tomorrow's test, since what I find interesting is usually not what is actually tested.

11:49 PM

Time for bed. Dream of turning over the reigns for next week's Grand Rounds to Azygos.

Good Night!

Grand Rounds Call for Submissions

2005-04-29T15:07:00.000-05:00

Just a friendly reminder that all submissions for next week's Grand Rounds should be sent to mdphdstudent AT gmail DOT com by Monday May 2 at 6 pm Eastern Time. (I have an 8:30 am test...)

I've got a few great posts already, but of course I could always use more (and yes, patient perspectives are more than welcome!)

Attention all Time Travelers!

2005-04-27T15:39:00.000-05:00

The date and location for the one and only Time Traveler Convention has been announced!

May 7, 2005, 10:00pm EDT (08 May 2005 02:00:00 UTC)

East Campus Courtyard, MIT

42:21:36.025°N, 71:05:16.332°W

(42.360007,-071.087870 in decimal degrees)

Most important for the success of this convention will be spreading the word so that future time travelers know about the convention. Write a few words in a local newspaper, carve into a clay tablet, or bury a time capsule in your backyard!

If you happen to be in Boston...

2005-04-26T13:51:00.000-05:00

There is a potentially interesting panel discussion at MIT tomorrow night.

The Impending Healthcare Crisis: Can it be Averted?

Grand Rounds XXXI and call for submissions

2005-04-26T05:08:00.000-05:00

Grand Rounds XXXi is up! I've nothing witty to say quite this early (why anyone would schedule early morning classes is beyond me), but take a look, and tell me what you think!

Also, I will be the host for next week's Grand Rounds. Did you miss Dr. Tony's early deadline? Submissions can be sent to mdphdstudent AT gmail DOT com by Monday May 2 at 6 pm. Yes, I have an early deadline too, as I have a test at 8 am the next morning.... I will try to confirm all submissions by email, if you don't hear from me within 36 hours of your submission, feel free to send me another one.

I need to learn Spanish or Cantonese or...

2005-04-21T17:36:00.000-05:00

The Nytimes has an article on the effects of language barriers in the ER. While the city I live in is not exactly as multicultural as New York, I know that language barriers are a problem here as well.

If only there were time in the medical curriculum to at least learn some basic spanish. Yes, I'm sure that there are spanish interpreters in most local hospitals, but I know that having at least a basic understanding of other languages will greatly help me. I wonder if it might be worth it to require a college-level foreign language class for medical admission, although yet again, it is difficult to continue to add prerequisites for admissions, and requirements during medical school itself.

Home-based rehabilitation for patients with cognitive disorders

2005-04-18T09:37:00.000-05:00

As part of my cognitive disorders course, we have to create an "on call notebook" which contains rehabilitation activities that can be used for a variety of patient encounters. These activities are often subjective, as therapies that address "real world" activities such as going to the grocery store aren't often studied for efficacy in a systematic manner. In addition, rehabilitation is often most effective when the therapy activities can be continued at home (in small, focused sessions spread out throughout the day.) But, caregivers don't necessarily have access to advanced therapy materials that work on specific cognitive skills such as attention or memory.

The University of Alabama at Birmigham has developed a great set of exercises that can be done both in a rehabilitation setting, and at home with primary caregivers. The Home-Based Cognitive Stimulation Program contains a list of 48 exercises that address many every day skills such as working with money and improving motor control. Each exercise has variations for different skill levels, and involves single or multiple cognitive domains. Everything can be done at home, with minimal or no rehabilitation training, and everyday materials. It's a great starting point for involving caregivers in treatment, and empowering both the patient and their caregivers (a very important consideration in rehabilitation.) For patients not in a structured rehabilitation program, this home-based program can be recommended by the treating physician.

In this era of reduced inpatient and outpatient coverage and services, home-based rehabilitation programs will be a valuable resource for patients with stroke, TBI or other neurological impairments. While the most significant gains in cognitive function occur in the "spontaneous recovery period," which is generally within 6 months post insult, improvements can occur any time. I hope that more of these home-based programs are created (and studied for efficacy), because home-based rehabilitation may be the only type of rehabilitation available to some patients.

A Case for Model Checking

2005-04-14T21:18:00.000-05:00

Abstract

Many statisticians would agree that, had it not been for cacheable
communication, the exploration of erasure coding might never have
occurred. After years of unproven research into symmetric encryption,
we disconfirm the synthesis of Smalltalk. we describe new classical
communication, which we call Tab.

Introduction

Recent advances in introspective communication and relational
communication synchronize in order to accomplish local-area networks.
Without a doubt, we emphasize that we allow Boolean logic to prevent
optimal modalities without the investigation of symmetric encryption.
After years of extensive research into the Internet, we demonstrate the
emulation of link-level acknowledgements . On the other hand, the lookaside buffer alone can fulfill the
need for the Ethernet.

Our focus in our research is not on whether wide-area networks and the
location-identity split can collaborate to address this
problem, but rather on describing a methodology for the refinement of
multi-processors (Tab). Existing atomic and wireless systems use
RAID to locate decentralized models. The disadvantage of this type of
method, however, is that the partition table and
Smalltalk can collude to fulfill this intent. On a similar note, the
basic tenet of this approach is the deployment of evolutionary
programming. Therefore, our algorithm studies the lookaside buffer.

Our contributions are as follows. We discover how local-area networks
can be applied to the analysis of A* search. Along these same lines, we
use read-write technology to disconfirm that replication and expert
systems are often incompatible. We propose a novel
methodology for the refinement of Internet QoS (Tab), disconfirming
that the producer-consumer problem and reinforcement learning are
mostly incompatible.

The rest of the paper proceeds as follows. Primarily, we motivate the
need for journaling file systems. Further, to accomplish this
objective, we motivate an analysis of the Ethernet (Tab), proving
that Internet QoS and spreadsheets are entirely incompatible. We
place our work in context with the existing work in this area. Finally,
we conclude....

Generate your own CS paper
The CNN article

A tip for working with stroke patients.

2005-04-13T08:30:00.000-05:00

Another tip from my cognitive disorders class (for speech language pathologists and occupational therapists):

Try to approach a new patient on their "good" side. Many patients will be unable to express that they cannot see you or are having trouble understanding you (especially in the case of left hemisphere stroke), while those with right hemisphere stroke may be completely unaware of your presence, or may be unconcerned by the fact that they can't really see you.

Also, be aware of the patient's premorbid interests. Someone who hated reading the paper before the insult probably won't be excited about practicing reading, so that they can "read the paper again."

Grand Rounds

2005-04-12T10:09:00.000-05:00

This week's Grand Rounds is up at Gruntdoc There are a lot of great posts this week, but I must recommend that when you sit down to read them, you avoid cutting sancho peppers beforehand (or at least, wash your hands better than I did!)

Stigmas in Medicine

2005-04-11T08:16:00.000-05:00

I had a very insightful talk with a physician on friday. Among other things, we discussed how best to approach the fact that someone has an illness when applying to residencies and even when trying to get a license. As someone who is on the admissions committee for one of the residency programs here, he advocated honesty about any chronic illness, no matter how small. (This is actually in contrast to what many of my peers said, which was "just lie.")

His rational is that while disclosing an illness could put you at a slight disadvantage when applying to residency, the process is so subjective and full of prejudice that almost everyone will have some sort of "mark" against them, being personality or illness. However, disclosing an illness actually protects the resident. Think of the diabetic surgical resident. If his blood sugar drops during a long surgery, he needs to be able to take care of himself, and if his residency program is aware of his illness, he will probably already have mechanisms in place for such situations.

Although he was quick to point out that the analogy was not exact, he likened having an illness to being a foreign medical graduate. When reviewing residency applications, inevitably a new member of the committee will tsk tsk an applicant (no matter how qualified) for being a FMG. Of course, the doctor whom I was talking to was an FMG, and I must admit that I never would have known that, unless he had told me himself (he speaks better English than I do!). Even though all of his training other than medical school was done in the US (and he also got a PhD here in the states), the fact that he went to school in India still follows him around his career, though he's reached a point where his accomplishments should more than speak for themselves, and his colleagues are not questioned about their choices of medical school.

Unfortunately, biases still exist; someone with a mental illness will be more likely to be stigmatized than my diabetic surgeon. This is unfortunate given the high rate of mental illness and substance abuse in physicians, as one would think that reducing the stigma of having a mental illness as a physician would encourage more to seek treatment, which can only help the field of medicine.

My first suggestion for reducing this stigma? Reduce the potential career consequences for disclosing the fact that you experienced depression at some point in your life. When physicians in training feel comfortable disclosing the fact that they had a rough time in their first year in medical school, and don't worry that this disclosure will adversely affect their ability to get into a residency program, we will have made a major step.

You'll be back to normal in no time!

2005-04-07T19:58:00.000-05:00

I'm taking a class outside regular medical school on cognitive interventions (focusing on improving outcomes for stroke and TBI for students in the speech pathology and occupational therapy programs here.) One reason I wanted to take this class is to get a perspective on how other health professionals are involved in the types of patients I might encounter as a doctor. This week, we had a moderate TBI survivor come in and talk a little about her experiences.

She highlighted one of the effects of improved emergency medical care that I hadn't really thought much of. Because people are surviving injuries and illnesses that once would have been fatal, there are more people walking around with brain injuries. The firefighters who pulled her from her car never thought she would make it out of the hospital. But, three years later, she was talking to a classroom full of students, with no apparent physical problems about how she learned to function in day to day life again. She likened herself to "that crazy old aunt everyone has, who is just a little bit off." She had developed such effective coping mechanisms that if she hadn't been talking about her brain injury, I may not have even noticed that anything was wrong.

A few things struck me. After her accident, she was told by her doctors that she'd be "back to her normal self" after 6 months or so of a rehab program. But of course, most TBI patients never really return to the same person they were before the accident. She had a hard time believing her therapists that she may not be able to go back to everything she did before the accident (including being a nurse who also taught in the college of nursing.) Three years after the accident, she still attends occupational therapy sessions, still attends the support group, and still has to adjusts her coping mechanisms to fit in with society. She was lucky in that her family has the resources to pay for extended rehab, and that she was very quickly identified as a brain injury patient in the hospital. But because a doctor told her once that she'd be "back to her old self" it took her a long time to accept that it was ok to try a new activity rather than spending all her energy trying to develop her skills to a level where she could go back to the type of volunteer work she did before the accident.

After she left, we had a great discussion on what the goals of speech and occupational therapy should be. Obviously, one goal is to get the patient to a point where they are relatively independent and functional in their environment. But even for those with more mild injuries, trying to get the patient back to the level of functioning that they had before the insult is a double edged sword. Every patient and family will have different goals for themselves that we need to work with when assessing function and developing a rehab program. As doctors, we need to be careful about our wording when dealing with brain injuries. While being able to walk, dress and feed oneself again is a great accomplishment for many patients, simply being able to do these things does not make them "normal" again.

Tangled Bank and Grand Rounds

2005-04-06T07:30:00.000-05:00

This week's edition of the Tangled Bank is up at Orac Knows Click for the best science blogging on the web, and maybe a few tips on how to submit your next article for publication!

And, because I missed it yesterday, Grand Rounds is up at Polite Dissent.

Drive

2005-04-01T12:56:00.000-05:00

A friend from high school stopped by to chat and see the new house. He had just come back from a month in Honduras, and had a totally new outlook on his future. In his words, "It's hard to see that much poverty, and not be affected."

And I have to say, I'm proud of him. He had a few years where he couldn't quite find his place in the world, but now he has a mission. He's registered for a few science classes, to get the prereqs he needs to matriculate into a local nursing program. Eventually, he wants to finish up his four year degree, and become a nurse practitioner, and even wants go to medical school. A masters in public health would not be out of the question. Eventually, he wants to open a clinic in a rural area, and maybe even work in a clinic in latin america.

He just gets it. He has a drive, a passion, to really make a difference. I hope that he can sustain that drive. Though I know that in whatever he ends up doing, whether it is becoming a nurse, a doctor, or whatever else, he will change the world around him. I hope that if he does go to medical school, that this drive isn't beaten out of him. I know that many of my classmates have great expectations of how they will contribute to the world, but these expectations tend to get lost in the biochemical pathways that we beat into our brains. And I know that I can only hope that when I get out of school, all my pre-school idealism will return, but it is hard when looking forward means looking towards the next block of exams, rather than looking to the years after school and residency. Then, there are questions of debt, of politics, and of lifestyle. After years of working and studying for 100 hours a week, how attractive does being an overworked family doctor in Appalachia, look compared to becoming a dermatologist?

But I must say, my friend has inspired me. I needed a boost of idealism and hope. I needed to talk to someone who wasn't already involved and frustrated with the world of medical education and the uncertainty of the future. He has a plan. And I know, even if he never makes it to medical school, he will find a niche where he is happy. He doesn't have the resources or background to achieve his dreams right away, but I wouldn't be surprised if he enters medical school at 40, ready to take on the world. And I will continue to be inspired by him, and proud.

Wearing Two Hats (Part 2)

2005-03-22T09:43:00.000-05:00

Orac has written a follow up to his fantastic post Wearing two hats. Wearing Two Hats, Part 2 explains some of the challenges that clinician scientists might face which are different than those faced by most basic scientists....

Grand Rounds XXVI

2005-03-22T09:37:00.000-05:00

I took a break from packing up my stuff this morning to check out Grand Rounds 26 at The Well Timed Period, and I suggest you take a break from whatever you've got planned today to do the same!

The biologization of psychiatry

2005-03-22T09:29:00.000-05:00

Universal Acid has a great post on the use of biologic markers to diagnose psychiatric illness. On one hand, using a gene expression profile to diagnose mental illness is a great leap forward, especially when the diagnosis is not clear cut (Is my child bipolar or adhd?) But, what if you "present with all the classic signs of major depression but then get your blood test and...[are] told that you're not "really" depressed?"

Fourth Edition of the Skeptic's Circle

2005-03-17T10:09:00.000-05:00

The Fourth Edition of the Skeptic's Circleis up! Previous editions can be found at Circular Reasoning

On that note, there really will be lighter blogging for the next week or so. Blogging is just a great form of procrastination for packing, but I must really get down to business!

National Problem Gambling Awareness Week

2005-03-16T10:49:00.000-05:00

Happy Problem Gambling Awareness Week

The National Council of Problem Gambling has a number of resources to address problem gambling. The Ohio Lottery is running a PSA about problem gambling this week, which is how I learned it was problem gambling awareness week. However, I must say that the spot really made me want to go gambling....

Grand Rounds XXV

2005-03-15T08:32:00.000-05:00

Grand Rounds XXV is up at Respectful Insolence It is perhaps the most creative set up yet! I threw out this month's TV guide in anticipation of the move, so I'm sure I'll be checking back to find out what's on!

And while I'm promoting carnivals, don't forget the fourth edition of the skeptic's circle thursday at The Two Percent Company

As a final note, congrats to everyone who matched yesterday! I hope that thursday brings everyone one of their top choice matches!

On Isolation and Mudfuds on the Web

2005-03-14T02:41:00.000-05:00

Blogborygmi has compiled a list of fellow mudphuds (mudfuds) on the web. You might notice the discrepancy in spelling. At my school, MD/PhD students are generally referred to as MuDPhuDs. However, I was unable to get mudphud.blogspot.com, so I went with the alternative, MudFud.

Nick suggests that one reason MD/PhD students seem to be overrepresented in the medical blogosphere is that md/phd students don't seem to "fit in" with the rest of their md or phd students. I'd have to say that, though I'm not sure this sense of isolation is why I blog, there is definitely a sense of isolation that comes from being an md/phd student. Part of it is that while the first year md/phd class is relatively close, we all got a chance to meet each other well before orientation ever began. Consequently, when those first initial friendships were forming within the rest of the medical school class, we tended to stick together, and probably didn't meet as many people. On a similar note, while having an office is a big plus, it means that we are less likely to be found hanging out in the cafeteria or R&R. Because we are exempt from certain graduate school requirements, there is less opportunity to meet fellow PhD students during orientation or intro classes. And, when an MD/PhD student enters the traditional third year of medical school, they are entering a class of students that have already grown and developed together for 2 years. And, although I'm probably overgeneralizing, I find that most mudfuds are more of a "big picture" or "global thinking" type, rather than of the average "neurotic premed" type. There is always a desire to know more, to reach for a better understanding, and to try and find a better way (this desire seems to be lacking in some of my md "gunner" classmates.)

Obviously, we do have a lot of support within the MD/PhD program both from students and administrators, but being a different program manifests difficulties in all number of ways.

When it was time to get our student ID's, only about half of ours worked properly. When I needed to order a key for the office, it took me a month to "prove" that I was actually a student. Because we are listed seperately in the medical school directory, the first year md/phd students weren't included on the students listserve for over three months (until one of us realized we were missing something) so we missed out on study guides that were sent out, notices for certain events, and even a couple jokes. There is always some uncertainty as to what requirements we have to take care of (generally, in terms of paperwork and such.)

Perhaps I blog and read other's blogs to get a sense of what I should/could be doing with my education, and of course to stay abreast of current topics. I think that Nick got it right when he said,"But why all these new MD/PhD students? I'd like to say that the same qualities that lead one to seek a physician-scientist training program also drive one to blog -- a good mix of analysis and articulation, and a familiarity with explaining things to disparate groups." I blog because I want a forum to analyze things, if only to get my views straight in my own head. I read other blogs because I want to know what others are thinking, and what I can do to make myself a better physician scientist, and even a better person. I blog because I like my study breaks to be stimulating in some way or another (if I totally veg out, I'm done with studying!) I see myself working in academia some day, and so I believe that if I've taught one reader something, or helped them to look at a topic in a different light, I've accomplished something as an educator, and I know that practice make's perfect (or at least better.) I also blog because I tend towards insomnia, and well, there isn't much good television on at 2 am. On that note, I'm going to attempt to get some much needed zz's....

Brain Awareness Week

2005-03-14T02:25:00.000-05:00

It's Brain Awareness Week! I had meant to write a post commemorating this event, but alas, I forgot, and in this late night blogging session, I'll direct you to Saint Nate instead. So, check out Saint Nates fabulous list of brain facts, and a description of brain awareness week activities here and here And, if you haven't gotten your hands on a copy of Brain Facts I highly suggest you get one sent your way. I've found it a very handy resource when trying to explain brain related facts to friends, especially when my previous knowledge wasn't quite enough to explain in layman's terms.

Lighter Blogging

2005-03-11T17:31:00.000-05:00

Just want to warn my few readers out there that blogging will be lighter over the next two weeks as I finish up a few things at school and move into the new house!

What's the Deal with Neuromarketing?

2005-03-09T11:05:00.000-05:00

Neuromarketing, a marketing research technique that uses brain imaging to assess marketing messages was born at Harvard in the late 1990's when Gerry Zaltman (a marketing professor) began scanning people's brains for corporations. From the corporation's standpoint, neuromarketing allows for more concrete data to be collected that is free from problems that plague other types of marketing research, such as self-reporting biases.

As neuromarketing has grown in popularity (and publicity), certain corporations have become decidedly more secretive about their use of the technique. Some institutions who have participated in neuromarketing research have removed any mention of those studies from their websites. There are definitely several ethical issues involved, as well as methodological issues (which I'm sure will decrease if the technique is more widely used.)

First, is it even ethical? While fMRI research is generally considered to be very safe, there are definitely more potential risks than, say, participating in a traditional focus group. Does the end-product of neuromarketing research contribute enough to society to balance out the risks? Is using a medical technology appropriate for something that could lead to increased air pollution after we all buy SUV's? And, in the case of neuromarketing research being done at academic institutions, is it ethical to use research funds and resources to pay for this type of research instead doing a study on schizophrenia?

Commericial Alert is concerned, that if neuromarketing actually works, it will lead to an "increased incidence of marketing-related diseases" such as diabetes and obesity. While you could have the same concern with traditional marketing research, some consider an effective neuromarketing approach to be akin to brainwashing.

One major problem in the field right now is that the early work is being done by people who are not experienced in both marketing and neuroscience. A neuroscientist may not be able to select the best subject pool for collecting marketing data. Also, a neuroscientist will be more likely to design an experiment that minimizes known confounds in fMRI research, but may not minimize marketing confounds appropriately. Similarly, a marketing person may not design the experiment such that any good conclusions can be made from the neuroimaging data.

When reviewing the studies that have been published in scientific journals and mentioned in the news media, I was struck by how the results seemed to be presented in a trivialized manner. For example, in There's a Sucker Born in Every Medial Prefrontal Cortex, Clint Kilts (the director of the BrightHouse Institute) explained "the magic spot -- the medial prefrontal cortex. If that area is firing, a consumer isn't deliberating, he said: he's itching to buy. 'At that point, it's intuitive. You say: 'I'm going to do it. I want it.' " Now, the medial prefrontal cortex is associated with reward processing, goal based behavior, certain types of memory, and sometimes, the sense of "self." I haven't seen anything in the literature that suggests that activation in the medial prefrontal cortex means that someone is going to buy a product, or even that they want to buy it. You could argue that, because the medial prefrontal cortex is a "goal area" that the subject has made the "goal" of buying the product he is responding to. But in traditional reward processing and goal-oriented research, there is a built-in expectation of getting a reward or achieving a goal. In neuromarketing, there is no such built-in expectation. Are the researchers going to give everyone a Porsche because their brain lit up in a certain area when they saw a picture of one?

And in this note, will neuromarketing ever turn out to be a viable marketing tool?

Other questions on the efficacy of neuromarketing abound; this news article also questions whether neuromarketing will even work. An article in The Lancet Neurology highlights privacy concerns inherent in neuromarketing research.

Obviously, there are more issues than presented here. I highly suggest that you check out the articles on the Commercial Alert site, which, though definitely biased against neuromarketing and lacking in scientific analysis, provides some great food for thought.

Grand Rounds 24

2005-03-08T08:07:00.000-05:00

Grand Rounds 24 is up at Hospice Blog! I'm a regular reader of the hospice blog--I know that hospice is something I know little about, and it is something that everyone, doctor or not, should know about!

Long Hours in Residency

2005-03-07T21:13:00.000-05:00

Dr Tony has a great post commenting on public perception of long hours in residency. I highly recommend reading all of the comments on the posts written by Megan McArdle. Definitely some food for thought, and some insight on the opinions of those not already wrapped up in the medical world.

I do have to say that I hope they figure out how to maximize learning and care while protecting residents by the time I get to a residency program. Although I should also add that pulling 36 hour days is not uncommon for 3rd and 4th year medical students as well. At 23, I can feel the difference in how I function after 24 hours sleep compared to when I was 18. I can only imagine that it will be much, much worse at 30. And, I'm not a great driver when I'm even a little tired, so I do worry about being able to drive home on no sleep. Those apartments right across the street from the hospital are looking so much more inviting!

What exactly is a MD/PhD program?

2005-03-07T11:59:00.000-05:00

Because I've gotten the question more than once, I thought I'd write a quick post on what exactly a md/phd program, mstp (medical scientist training program), or pstp (physician scientist training program) entails. (I should note that those three names usually refer to the same thing.)

Generally, a md/phd program will take 7-8 years. The first two years are made up of the preclinical years of medical school (this is where I am now.) Summers during these first two years are often used for research rotations in order to learn new skills, and decide upon the lab that you are going to work in. The next three to four years (and sometimes more) are spent in a graduate program in pursuit of a PhD. At my program, we pretty much have the option of entering any graduate program offered here, (though they may not be too pleased if we choose to study English) and we don't have to choose the exact program until we are ready to start working on the PhD. After successful completion of a PhD, the student then goes back to medical school to complete the clinical rotations.

In order to get this all done, most schools have a few things in place to make things a bit easier on the student. Generally, the medical school coursework will "count" for most of the required graduate coursework, though students sometimes have to take a couple classes to cover things not addressed in medical school, such as statistics. Many schools will allow MD/PhD students to have one less paper published than a regular PhD student. For the clinical years, electives are often not required (mostly to allow for a flexible start time into the third year of medical school). My school requires us to do a "senior project" in the final year (fourth year of medical school) to keep in touch with research. The senior project is often more clinically based than the graduate work, or can be used to explore a different area of research. Coming out of school, there are many different options in residencies/fellowships that allow for protected research time, and some tracks are even shortened from what "normal" residencies might be (this is often done under the assumption that most md/phd's will spend, on average, less time doing clinical work during their careers.)

Programs vary in size from one or two students per medical school class to up to 25 students at Washington University in St. Louis. As a medical student in an MD/PhD program, we have several perks, such as an office, a weekly journal club, career retreats (our spring retreat will be held at an amusement park), extra social activities, and the fact that we are considered "special." (Though sometimes this is a disadvantage when everyone looks to you as the "smart one!") Being in a program within a program gives a built-in support network, and often the opportunity to get free/cheap books.

Funding for MD/PhD programs vary by institution. There are currently 39 schools that receive funding from the NIH. Some schools use purely institutional support. Many programs fully fund all years in the program, which means that a student will not pay any tuition, and will receive a modest stipend throughout the 7-8 years. Some programs only fund the graduate portion, and still others don't fund students at all. (Some institutions do a combination of all three, depending on the student.)

Obviously, due to the small nature of most programs, and the availability of funding, admission to one of these programs is highly competitive. I've heard that 33 is the magic number on the MCAT, along with excellent undergraduate grades and substantial research experience to be a competitive candidate (although this is a big generalization; it is possible to get into a program with much less, or be rejected with much more.) One thing that is really important when preparing an application to a MD/PhD program is finding a balance between clinical work and research. Otherwise, why wouldn't you pursue a straight MD or PhD?

Obviously, doing a formal program like this is not the only way to get both your MD and PhD; many people have done them years apart. Also, having both degrees isn't always necessary to pursue clinical research, but in my experience, having both degrees opens a lot of doors in terms of professional opportunities, grant competitiveness, and more.

For your information, you can see a list of all of the U.S. MD/PhD programs here.

And in closing, for an idea of how md/phd's can spend their time, see Speaking two languages and Wearing two hats at Orac Knows (Do you know of any other good explainatory md/phd posts in the blogosphere? Please send me a link!)

Third Skeptic's Circle

2005-03-03T13:48:00.000-05:00

The third edition of the skeptic's circle is up at Redagast.

And with this publicity blurb, I make a promise to Saint Nate, I'll have a great post ready for round four!

Searching for the Why of the Buy

2005-03-03T12:42:00.000-05:00

Thanks to Saint Nate for passing along this great article, "Searching for the Why of the Buy"

I actually had the opportunity to read the Baylor Pepsi Challenge paper (mentioned at the end of the article) for a journal club in the fall, and the conclusions were questionable to say the least. There were so many problems with the methodology that the results that they claimed about brand recognition could never be applied to a larger population. The sad thing is, that done properly, the study could have been a really novel way of looking at reward circuits in the brain, rather than assessing marketing techniques, which is something that the authors may not have understood to begin with.

I haven't read the other papers mentioned in the LA Times article, but I can only imagine that most of them are riddled with methodological problems as well. Not to say that all the other neuroimaging papers out there are perfect, but you have to wonder why people and corporations would invest money in expensive marketing research that doesn't really tell you anything about how effective a particular brand's marketing really is.

Grand Rounds 23

2005-03-01T08:31:00.000-05:00

Hungry? Check out the delectable menu served up at Grand Rounds XXIII

Suggestions for medical education from retired doc

2005-02-28T10:57:00.000-05:00

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

2005-02-22T15:05:00.000-05:00

Women in math, engineering and science: Drawing on our country's entire talent pool

A 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

2005-02-22T14:15:00.000-05:00

This week's Grand Rounds is up at Catallarchy!

Neuroimaging in Psychiatry

2005-02-21T19:38:00.000-05:00

The Nytimes has a fascinating article in the Magazine section this week on The Therapeutic Mind Scan

Neuroimaging 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

2005-02-20T13:09:00.000-05:00

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!

2005-02-17T09:27:00.000-05:00

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

2005-02-16T20:50:00.000-05:00

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

2005-02-15T00:48:00.000-05:00

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

2005-02-14T22:25:00.000-05:00

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

2005-02-14T13:05:00.000-05:00

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

2005-02-12T23:46:00.000-05:00

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

2005-02-08T17:24:00.000-05:00

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

2005-02-07T15:58:00.000-05:00

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

2005-02-05T16:28:00.000-05:00

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

2005-02-05T16:14:00.000-05:00

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

2005-02-03T16:13:00.000-05:00

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

2005-02-03T08:44:00.000-05:00

Check out the first edition of the Skeptic's Circle over at St Nate

Microscopes for first year histology?

2005-02-02T09:01:00.000-05:00

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.

Dr. Ecstasy

2005-01-31T16:43:00.000-05:00

Dr. Ecstasy (NYtimes, reg required)

This article describes the man who uncovered Ecstasy, who believes in "the pursuit and celebration of chemically-induced alternate realms of consciousness" and has had at least 4,000 psychedelic experiences. He has created over 200 such compounds, and tested many of them on himself. It's interesting to read about such different mindsets about the use of psychedelic drugs, especially in the light of the new Ecstasy studies. I truly believe that such compounds do have theraputic potential, and that studies should be done, though I'm not sure I'd be willing to go through all the red tape to design such a study.

I love Gross Anatomy

2005-01-31T13:02:00.000-05:00

Many of my fellow students hate it, some of them tolerate it, but I must say that I love my gross anatomy course. I was lucky enough to be paired up with a good group of students with very similar learning goals and expectations. But having a good group does not fully explain my love for the course (though having a bad group can explain why some people hate it). We didn't get to choose our groups, which I think worked out for the best for me, as I've gotten to really know a couple of people I wouldn't have elsewise.

I just find it fascinating. I almost get a little thrill anytime we find an anatomical variation, or when a nerve or vessel suddenly pops into view and I can positively identify what it is. I enjoy exploring the body and discovering how we're all put together. I don't mind the time spent in lab at all (in fact, I'd like to have even more time in the lab); I think I actually get much more out of a 3 hour dissection than studying the notes for 3 hours. In fact, I do have to admit that I rarely study the notes (or go to lecture for that matter), and gross is my best class. (Shh...don't tell my professors that) Perhaps I'm lucky that I never really have to study for the practicals because identification is easy for me, but I the studying doesn't bother me either since I'm so into the material.

Part of my love for gross stems from the fact that I'm a very visual learner. Seeing how things are constructed and connected makes it much easier for me to understand how something works, and what happens when things go wrong. I wish all my classes were like gross anatomy.

What would you do if you won the lottery?

2005-01-30T15:56:00.000-05:00

Last night, Dave and I were talking about various large purchases that we will make in the relatively near future (house, car, etc.) and of course, we concluded that in order to actually get what we want, we'd have to win the lottery. He asked me what I would do with my life if I never had to work, and could do anything I wanted.

My answer would be to do exactly what I'm doing now. I couldn't imagine doing anything else with my life. A future without medicine, without research, is not at all appealing to me. Having money would of course make things easier (I could get a housekeeper so that doing normal chores doesn't put me a day behind in studying, a personal trainer to force me to work out, and a chef to make sure I eat decent food). I think that, despite my struggles with school right now, and the fact that I don't exactly love the first year of school, I would definitely continue. I know that even though I will be in school until I'm 30, the end result will certainly justify all of the work I put into it. And I can't see myself happy doing anything else with my life. I'm glad I feel this way, because I couldn't imagine devoting so much of my life to something that I could just give up if a lot of good fortune rolled my way.

One thing I know for sure though, is that if we win the lottery, I will certainly take much better vacations. The nonstop pace of school has been incredibly draining. I miss the MIT philosophy of having at least one day off a month for holidays and such, and devoting the month of january to independent study. It made it so much easier to stay focused, and to get everything done without neglecting things like laundry and real food.

Speaking of laundry, its time to switch loads!

Why MD/PhD?

2005-01-26T15:00:00.000-05:00

Besides the fact that this question came up on every application I filled out, many people have asked why I decided to do a Physician Scientist Training Program (PSTP) instead of just going to a medical school or graduate program. The quick answer is that I really love school, and I'm not ready for a "real job." And hey, who doesn't love looking forward to eight more years of school?

The first time I ever remember being asked what I wanted to be when I grew up, I was in first grade. My answer was "A house painter." Now, I didn't want to be someone who just painted siding, or the interior of a house. I wanted to be someone who painted art all over people's houses. Nevermind that I have absolutely no artistic talent. I then went through typically elementary school dreams--teacher, ballet dancer, veterinarian, etc. In high school, I started out planning to work in theater, and then discovered that I loved science more than anything. Somewhere in there I uncovered a love of all things relating to the brain, and decided to pursue medicine. I got a job in a pharmacy, and taught myself how various drugs worked. I applied to MIT because I knew I wanted to study the brain, knew I didn't want a traditional psychology degree, and knew that the Brain and Cognitive Sciences degree was interdisciplinary and very flexible.

I entered MIT thinking that in the end, I would still apply to medical school. But then the time came for me to get a job, and because MIT has a wonderful undergraduate research program, I was able to completely fund my MIT education by working in various labs. The summer after my freshman year, I worked at the NIH, where I had the opportunity to work along side many physician scientists. I loved working in an environment where clinical medicine and research were mixed, where researchers worked with interesting patient populations and were actually able to see the difference they made in these patients' day-to-day lives. And so I decided that I wanted to focus on research as well as medicine. I continued working in research (a topic perhaps for a future post), and applied, and was accepted to a PSTP program.

So here I am, in my first year of medical school, trying to remember that once I get past these pesky first few years I can start pursuing what I really love. Of course, I do find what i'm learning now to be interesting, and it's unfortunate that my life sort of got in the way of my dreams for awhile. But I will continue on the best I can, knowing that in eight or nine years I'll be out of school and ready to start a new chapter in my life.

MD/PhD Category

2005-01-01T10:40:00.000-05:00

Obligatory Intro Post

Why MD/PhD?

Speaking Two Languages

Journal Club Fun

What Exactly is a MD/PhD program

On Isolation and Mudfuds on the Web

Transitions

Decline of Physician Scientists

Wearing Two Hats (part 2)

General Category

2005-01-01T08:37:00.001-05:00

Ageism

How Good is Your Health Insurance?

Dr. Ecstacy

Ufology and Sleep Paralysis

Women in Science

A Perfect Spot

Brain Awareness Week

Journal Club Fun

Research Tools

Student Health Care

National Problem Gambling Awareness Week"'

A confession: I use drug samples

I need to learn Spanish or Cantonese...

Drive

Why wont you put your helmet on?

Personal Category

2005-01-01T08:37:00.000-05:00

Obligatory Intro Post

What Would You Do If You Won the Lottery?

Why MD/PhD?

Speaking Two Languages

On a Personal Note

Internal Dialogue

A Perfect Spot

A Seat at the Table

Perils of Being a First Year Med Student

The Hurdles We Overcome

Ufology and Sleep Paralysis

Would you like to hire a medical student?

Conditioning

Drive
Spring

Neuroimaging Category

2005-01-01T08:36:00.002-05:00

Neuroimaging in psychiatry

Searching for the Why of the Buy

Whats the deal with Neuromarketing?

Research Tools

Ethics of Neuroimaging

Neuroimaging in Psychiatry

The Ethical Brain

Will fMRI ever really breach our privacy?

Online Neuroethics Resources

Medical Education Category

2005-01-01T08:36:00.001-05:00

A Seat at the Table

Professionalism in Medical Education

Microscopes for First Year Histology

The Early Years of Medical School

Long Hours in Residency

Suggestions for Medical Education from Retired Doc

The Hurdles We Overcome

Medical School Exercise

I need to Learn Spanish or Cantonese or...

Drive

Medical Category

2005-01-01T08:35:00.000-05:00

Student Health Care

Dr. Ecstacy

How Good is Your Health Insurance?

Home-based rehabilitation for patients with cognitive disorders

A tip for working with stroke patients

Stigmas in Medicine

Shopping in Scrubs

The Biologization of Psychiatry

You'll be back to normal in no time!

I need to learn Spanish or Cantonese or...