"I should've brought you a sedative." -- Medicine in the Sherlock Holmes: A Game of Shadows

Holmes and Moriarty meet in person for the first time.
A good scene.

[SPOILER ALERTS]

My holiday break just started and naturally the first holiday movie I saw this season was Sherlock Holmes: A Game of Shadows.  This is the sequel to the 2009 film Sherlock Holmes with Robert Downey, Jr. and Jude Law, certainly one of my top pair of actors to play Holmes and Watson.  The story is based partially on Doyle's The Final Problem which ends with Holmes and Moriarty falling over Reichenbach Falls.  This was a highly enjoyable movie and a great way to start my break.

That being said, medical fact, as usual, takes a backseat in Hollywood.  Nothing major in this film.  Only that Holmes drinks formaldehyde, a pretty significant poison.  According to the Agency for Toxic Substances & Disease Registry, as little as 1 oz. of a 37% solution of formaldehyde is lethal.  The chemically affluent Holmes would have known that.

Holmes also has a cardiac arrest in the movie, although I am not sure why.  He was injured and ran through a German forest while under a lot of heavy fire but he didn't bleed out that much.  Nevertheless, it was fortunate that Watson had Holmes' wedding present, a shot of adrenal gland extract.

Overall, neither of these events in the movie were that significant.  As before, the film paid a lot of respect to Doyle's stories while bringing a fresh take that is lead in large by Downey's interpretation of the character.  Also, Stephen Fry as Mycroft Holmes was a definite plus.        

The Physician's Library: 2011 in Review

2011 has been a very medical year for me.  For the first time in a long time I have seen myself grown a lot as I transistioned from my first year to second year of medical school.  Here's a bit of the year in review in some of the best medically-related things that I encountered this year:

Medcine in fiction: The Citadel by A.J. Cronin. 
This year, I gained a new literary hero in A.J. Cronin who I imagine will be largely unknown to American audiences.  I have written about Cronin before and cannot encourage my colleagues enough to read this book.  Cronin is not only writes with great artistry but touches on issues that I am sure he observed in medicine as a doctor, himself.  Many of those issues still exist today, almost 90 years since the novel was written.

Medicine in non-fiction: Every Patient Tells a Story by Dr. Lisa Sanders

Again, this is another book I have written about previously and another highly recommended book for medical students.  There are plenty of reasons medicine can be enjoyable but Sanders' top reason is very much my own: the detective work of medicine that leads to diagnosis.  In a series of real life cases of difficult diagnoses, Sanders illustrates how important history taking, technology, and the physical exam all generate key data that lead to a final conclusion. 









Medicine in TV: The first of half of Season 7 of House, MD

Honestly, it's been difficult for me to get through the second half of Season 7 (post-break-up with Cuddy) because House has regressed a lot, negating the personal progress that was nice to see in Season 6.  The medicine in some of the first episodes of Season 7 was decent, too. 













Medical Teacher: Dr. Edward F. Goljan

People will tell you different things when it comes to USMLE Step 1 Prep but there are two constants: First Aid for the USMLE Step 1 by Dr. Tao Le, et al. and, my personal favorite, Rapid Review: Pathology by Dr. Edward Goljan.  Not only is Dr. Goljan's book great but so are his audio lectures.  Dr. Goljan is every medical student's dream professor not because he is an easy tester (probably far from it) but because he tries to get his students to think like doctors and integrate multiple facets of medicine into pathological concepts. 



Person in Medicine: Dr. Atul Gawande

I have had the great opportunity to listen to Dr. Gawande lecuture twice this year.  If you follow my blog you will know that I have posted a lot on his work, which I have enjoyed a lot since discovering it a few years ago.  Dr. Gawande is the de facto voice of reason in medicine today.  He has no political agenda or advocates for any position other than "this is what evidence is showing might work - let's try it." 

Doyle Syndrome

Today, I had the fortune of meeting a patient with Marfan's syndrome.  The disease is officially named after the French physician Antoine Marfan but almost a decade earlier Sir Arthur Conan Doyle had created a villain who was very likely to have the condition in his very first Sherlock Holmes story, A Study in Scarlet.  Doyle, through the voice of Watson, described the character of Jefferson Hope as a tall man in his late thirties who an aortic aneurysm.   These are common features seen in Marfan's syndrome which is now known to be a connective tissue disorder.  As Doyle was a physician, himself, he frequently had very clinical descriptions of characters (probably the most accurate in all of fiction) and it is likely he had made an association between very tall, slender individuals and aortic aneurysms.    

"Ventricular Tachycardia. Digitalis"

I am currently in the middle of my cardiology module at school and digitalis shows up a lot.  I wrote previously about digitalis in a post about an episode of The X-files.  I just remembered that digitalis poisoning showed up much more accuratley portrayed in Casino Royale.  Bond manages to induce some vomitting but at that point some of the drug has started affecting his heart.  He ends up with ventricular tachycardia and is defibrillated in time with the help of Vesper Lynd.  This was a change from the novel where Bond was under threat of getting shot with a cane gun.   

Gawande Part II

If you missed my previous post, I recently had another chance to hear Dr. Atul Gawande speak, this time at the University of Akron.  Last time, I posted my initial impressions surrounding Dr. Gawande's promotion of the idea of coordinated, team-based medical care as the solution to what he has called the "appallingly patched-together ship" of American healtchare.
Today, I want to discuss Dr. Gawande's ideas for getting the "cowboys" of medicine to form "pit-crews".  I recently found out that this was not the first time that Dr. Gawande has shared this idea; he gave a similar speech at Havard's commencement which was posted online at The New Yorker.  In summary, Dr. Gawande identifies three skills necessary for a "pit crew" to function successfully as a system:
1) the ability to recognize successes and failures,
2) the ability to devise solutions
3) the ability to implement solutions on a wide scale. 

He also enumerates three values that members of the team need to share:
1) humility to understand that you can fail,
2) discipline to stick to standards to minimize failures
3) teamwork to allow others to save you from failure.

The difficulty in implementing solutions to the problems in healthcare today is that not every physician is on board with these values and it will be no easy task to convince everyone that this is what needs to be done, even with solid supporting evidence.  What Dr. Gawande is calling for is a cultural change in the profession of medicine and, to me, that is one of the most difficult changes to incite.  With cultural change, you cannot create policies that dictate people's values.  The values need to be internalized by all.

I would have really liked to hear Dr. Gawande's ideas for integrating discussion of these values in medical school.  At my own school, there is already a significant amount of time devoted to exploring values of medical practice so it would not be difficult to begin such discussions.  If any effective culture change is to be made, medical education must definitely be a target area.  After all, this is where a physician's enculturation begins.    
     

"Cowboys vs. Pit Crews" - Dr. Atul Gawande Speaks at the University of Akron

Dr. Atul Gawande at the University of Akron,
taken from my "wonderful" camera phone.

Last night, I had the incredible fortune of listening to Dr. Atul Gawande speak again, this time at the University of Akron.  The talk was a little different than the one I heard earlier this year at the Cleveland Clinic but still had some of the same core messages.  As I have said before, one of the things I really enjoy about Dr. Gawande is that he refrains from getting into politics and, in truth, I believe this is a large part of his appeal as a writer.  In fact, I am fairly certain that he is not really interested in the politics.  He is interested in solutions and that is what he looks for and reports on in his writing. 

One of the core messages that Dr. Gawande has spoken and wrote much about is just how complex healthcare has become as it has advanced the science behind medicine.  He cited a study from a collegue: in 2000 the average patient saw 15 doctors at the hospital to resolve their issue.  But the problem is not so much the number as the lack of coordination.  Dr. Gawande talked about how physicains have been historically trained as "cowboys" who act independently of other physicians.  I believe this is deep seated belief not only in the professional culture but in the cultural perceptions of medicine among our patients.  To make my point, I will point to Sir Luke Fildes famous painting The Doctor.

The Doctor by Sir Luke Fildes

This is one of my favorite paintings with medicine as its subject and the history of the painting has been covered wonderfully by Dr. Abraham Verghese in an article for The Atlantic.  What I want to draw your attention to is that the physician in the painting.  He is a singular man, deep in thought over the conundrum of his patient.  This is the iconic "medical detective" that dominates depictions of brilliant, heroic doctors in art and literature from Martin Arrowsmith to Gregory House.  This is the kind of doctor that every patient wants and every doctor wants to be and it is remarkalbe to me that this has not changed much in the 120 years this painting has existed. 

But I think the picture should be very different if it were commissioned today.  I believe Dr. Gawande would agree because as he said last night, we can no longer have "cowboys" with the complexity of healthcare today.  Instead, we need teams of physicians, nurses, and other healthcare workers caring for patients in a coordinated fashion.  Those fifteen doctors who see you at the hospital need to be talking to each other.  We need "pit crews", says Dr. Gawande.   If Sir Fildes were to make his painting today you might see a group of doctors, pharmacists, and nurses huddled together, hopefully with the child's parents as part of the discussion.  Instead of The Doctor, we would have The Healthcare Team (The Doctors has been taken by a television talk show of incredibly photogenic physicians and again, I would be remiss to not include pharmacists, nurses, and the patient's family).

The "pit crew" or healthcare team is at the center of Dr. Gawande's vision of a systems-based approach to medicine.  He illustrated in several stories that where outcomes go bad is not when patients see an individual specialist but in between.  Each doctor assumes another one will check these lab findings or start the appropriate antibiotic prophylaxis.  But in the end none of them do and easily prevented complications arise.  When I say easy, I mean stuff medical students like myself even know because it has be stressed to us that much in our training.   

Speaking of which, my studies seem to never end.  For the sake of keeping my ideas succint and my time studying optimal, I will leave you with these initial thoughts of mine for now.  I will likely have at least another follow up post with some more ideas from this talk.

TO BE CONTINUED...

Something Borne Out of Frustration

Great Links for Medical Students

Of late, I have had to supplement my education with some online resources.  Here are three great links I have increased my frequency of use in the past week (just started hematology/oncology and I have a physical skills proficiency exam coming up).

The Internet Pathology Laboratory
Mercer University of School of Medicine, hosted by the University of Utah Eccles Health Sciences Library.
This one comes recommended from First Aid for the USMLE Step 1.  It's a great resource full of great slides of both normal and pathological findings.  Currently I am using it to study anemias.

The Medical Biochemstry Page
themedicalbiochemistrypage.org, LLC
I used this website a lot in my undergraduate education and during my biochemistry course in medical school.  It has updated a lot since then.  It is wonderfully comprehensive and often explains step-by-step the mechanisms behind pathologies in biochemical pathways.

A Practical Guide to Clinical Medicine 
University of California, San Diego
I just found this recently.  If you medical school is like mine, there isn't a whole lot of time spent on teaching what the purpose beyond the manuevers of physical examination and the required textbook is marginally helpful.  This is a great site and I am definitely reviewing with it for my upcoming proficiency exam.

Four Batman Villains with Medical Degrees

Lately, I have been working on getting through Batman: Akrham City when I have time (which is not much). One of the major villains of the game is Dr. Hugo Strange who has been the mastermind behind the development of Arkham City.  I've come to realize that there are an inordinate number of Batman villains with medical degrees, let alone an army of comic book supervillains that have higher degrees. Interestingly enough, most of evil physicians are either surgeons or psychiatrists. Luckily, I do not have much interest in either specialty. Here is more on five Batman villains that are physicians.


1. Dr. Hugo Strange

Dr. Hugo Strange, from the teaser trailer for Batman: Arkham City

Not to be confused with Dr. Stephen Strange, one of my favorite Marvel characters, Hugo Strange is a psychiatrist that, in the classic stories, is obsessed with Batman and deduces his true identity (an element preserved in Batman: Arkham City). Although Strange is a genius, he is also a little psychotic and even dressed up as Batman. Another one of the classic Dr. Strange stories is his involvement in the creation of what has become known as the Monster Men. This hearkens back to the original Batman comic series in the 1940s and has been retold and referenced over and over again.

For the most part, Hugo Strange has been largely unknown to the general public but I imagine that Batman: Akrham City will solidify his legacy as one of Batman's greatest adversaries. One of my favorite appearances of Dr. Strange was in a television show that defined my child hood, Batman: The Animated Series. In the episode, "The Strange Secret of Bruce Wayne", Strange runs a sham spa for wealthy and prominent individuals to learn their secrets using a machine he has developed. When he discovers that Bruce Wayne is secretly Batman, he tries to auction off the information to Joker, Two-Face, and Penguin, a nod to a similar storyline from the comics. Batman being Batman, cleverly discredits Strange and gets the rogues to turn on him.

 Dr. Matthew Thorne, the Crime Doctor

The Crime Doctor, art by Bob Kane

This one is a little more obscure.  In Post-Crisis contunity, the Crime Doctor is the brother of crime boss Rupert Thorne.  He is a physician that treats criminals for money. 

I mostly know this one from Batman: The Animated Series from the episode "Paging the Crime Doctor."  The wonderful creators of the show did a retake on the character (as they did for many of the Batman villains) as a former classmate of Dr. Thomas Wayne, Batman's father, and Dr. Leslie Thompkins, one of the few people to know that Bruce is Batman.  Thorne lost his license to practice and is working for his brother Rupert to get it back.  

 

Dr. Thomas Elliot, Hush

Thomas Elliot is a childhood friend of Bruce Wayne that is both spiteful for Bruce's father saving the life of his mother and is envious of the life he leads.  Elliot tried to kill his parents when he was a young boy by cutting the brake lines in his father's car.  While his father died, his needy mother survived and he was forced to care for years.  Elliot hated the Waynes for his fate and, once he figured out that Bruce was Batman, he planned a very elaborate revenge. I am not going to lie.  I am not really a huge Hush fan.  I know a lot of people think that Jeph Loeb and Jim Lee's Batman: Hush is one of the greatest Batman stories ever.  Personally, it was another Jeph Loeb parade of charaters that was prettied up by Jim Lee's art.  It isn't bad but it isn't amazing either.  The subsequent Hush story lines have been just okay, too.  Usually he tries to come up with another elaborate plan that fails miserably, all while he constantly quotes Aristotle and further explorations of his mommy issues are flashbacked on.  That being said, I think that Paul Dini's retake of the character in Batman: Arkham City has some potential and perhaps he won't seem so stupid in the New DC Universe.

Hush, art by Jim Lee

Dr. Simon Hurt 



This guy actually has a bunch of names and his true identity is still a little obscured, probably on purpose given that he is one of Grant Morrison's characters.  Well that's not entirely true.  Grant Morrison actually took a very minor character from Batman #156 ("Robin Dies at Dawn") and gave him a name and a time spanning role in the DC Universe.  Hurt is the doctor who conducted the isolation experiment on Batman from "Robin Dies at Dawn".  In Batman: R.I.P, it was revealed that this was in reality a way to implant psychological cues in Batman's head.  I will probably leave it at that because explaining Grant Morrison's origin for why Dr. Simon Hurt is an apparently immortal ancestor of the Wayne family ties into a bunch of very complicated storylines that all tie into one another.  Suffice it to say it has to do with pretty much everything Grant Morrison has wrote for DC in the past six years.



Dr. Simon Hurt, art by Tony Daniel

Trichomonas: Wreaking Havoc Since the Mesozoic

This is appropriate since I just posted about dinosaurs. I was going on Wikipedia to read about Trichomonas and this picture was in the article:

This is an artist's rendering of a Tyrannosaurs Rex with a trichomonas infection based on an actual finding of a jawbone with lesions suggestive of such an infection. In humans, Trichomonas vaginalis usually infects women through sexual transmission. It causes green, foul smelling discharge.

The Dinosaur Doctor

Like anyone else with a childhood, there was a period of time where I loved everything and anything that had to do with dinosaurs. I read everything I could about them, checked out movie after movie from the library, and had tons of toy dinosaurs. I can safely say that dinosaurs were my gateway into science. It was my first foray into self-motivated, investigative learning. I learned a lot about the scientific process and biology, in particular. I learned all my Greek and Latin roots from all the dinosaur names, something that has proven immensely useful in medical school.

When I was about seven or eight my parents got me The Humongous Book of Dinosaurs. The title says it all. It actually was a collection of the magazine Dinosaurs!, a publication that was actually the basis of one of my oldest friendships.

One of my favorites sections in the series were the comics of the history of paleontology. Naturally, the first comic was of the first true dinosaur ever discovered, Iguanadon. The discoverer is an interesting man, himself, as paleontology and geology were actually his hobbies. His official profession was medicine. Dr. Gideon Mantell was a somewhat successful physician who had always been interested in science. He had taught himself anatomy and wrote a couple books before formally getting his medical education and membership into the Royal College of Surgeons. In his spare time, he pursued his interests in geology. Inspired by the fossil findings of Mary Anning (one of the most underrated women in scientific history - she discovered the first ichythosaur, plesiosaur, and pterosaur), Mantell searched his local quarries and was able to recover the fossil teeth of a previously unidentified creature.

Mantell eventually named the creature Iguandon, which means "Iguana tooth", subsequently heralding the study of dinosaurs that has captured the imagination of people everywhere. Mantell went on to become an authority on prehistoric reptiles but not without drama in the form of Sir Richard Owen, a rockstar douchebag of paleontology with a knighthood that tried to take credit for the discovery of Iguanadon. After Mantell died, Owen had a section of his spine removed and preserved for storage at the Royal College of Surgeons. In a way, Mantell had the ultimate last laugh on Owen as fossil evidence has supported Mantell's conception of what Iguandon and other dinosaurs looked like, disproving Owen's belief that they appeared as large, mammal-like lizards.

Personally, Mantell will always be an inspiration to me. When I learned as a kid that he had turned his home into his own personal museum, I sought to do the same with my own room. Even today, I will always remember him as a true man of science, who was not limited by his lack of formal training in other fields. Dinosaurs still fascinate me and, one day, I want to go on a real fossil hunt. I can only hope to get as lucky as Mantell did.

Radion Bullet vs. Rabies Virus

The radion bullet from Final Crisis that was used to kill Orion and then used on Darkseid looks a lot like the rabies virus:

Found at My Medical School's Library Book Sale

I found some real gems at my school's library book sale this week. Now if I only had time to read them all! Not pictured is an apparently rare book by Dr. J Willis Hurst, a famous cardiologist, entitled Teaching Medicine: Process, Medicine, and Habits.

Who Teaches the Teachers?

I just finished reading Dr. Atul Gawande's recent essay "Personal Best" in The New Yorker. Continuing with his theme of performance improvement in health care, Dr. Gawande explores the value of coaching in medicine. Citing examples in sports, musical performance, and public education, Dr. Gawande makes a clear distinction between the coaching model and the traditional pedagogic model. In the traditional pedagogic model the assumption is that there is a point where an individual has enough expertise to not only determine what his or her weaknesses are but also how to approach improving on those weaknesses. The coaching model does not hold this assumption and says that an additional expert perspective allows individuals to continue to improve when their own capacity for self-perfection has reached a limit.

As a medical student, I am always intrigued by Dr. Gawande's ideas for the field I have chosen. However, this particular article has struck another chord with me in another field that has been an interest of mine for a long time: education. In the article, Dr. Gawande writes about the Kansas Coaching Project that advocates coaching to improve teacher performance over policy-making that punishes under-performing teachers and school systems. The project appears to have merit and would probably benefit many school systems.

The concept of peer-coaching in education is not really new to me. As a tutor in various subjects over the years, I have had been lucky to work in some well organized programs that either hold regular staff meetings, assign personal supervisors, or both to discuss ideas on what is and is not working in tutoring sessions. Like the Kansas Coaching Project, I could hear about aspects of my tutoring that could use improvement, even if it was minor. Sometimes, I would play coach, too, and share some of my own creative strategies for getting students to understand material.

As a tutor, I believe I was more receptive to an outside perspective because I knew I was not a professional teacher. I have never taken any kind of education class in my life and most of my ideas for tutoring are derived from a self-analytic experience as a student. I would imagine that professional educators might not always be receptive to the idea of someone coaching them. As Dr. Gawande notes, recognized experts who have years of training and experience behind them might feel that the days of testing and being observed are far behind them.

But what about teachers in higher education, which consists almost exclusively of those with PhD's (and in the case of medical schools like mine, many teachers have at least an MD)? Unless their field of study is actually education, college and graduate school professors usually have received little or no formal training in education. Again, another assumption is made that is akin to the first assumption of the traditional pedagogic model. It is believed that after years of experience and training as an expert in their respective fields, professors are capable of finding the best ways to impart knowledge to others.

But ask any of my fellow classmates at my medical school and you will find out that this is definitely not true of all professors. In fact, there will probably be a general consensus on which professors students feel are good and which ones are bad. What makes the difference between these kinds of teachers? There are many factors. Perhaps one day I will catalog them as I explore my interest in medical education but, for now, let me give you a for instance. The following is from a paper on cognitive load theory in health professions education by Jeroen J G van Merrienboer and John Sweller:

This could be any slide in an anatomy lecture on the lungs. On the left is a non-integrated format with lots of text, some of which is redundant. To the student there is a lot of visual information to take in and couple that with a professor who is speaking while this slide is displayed and the student can become overwhelmed as their attention is split between the professor and the slide. The extraneous cognitive load needs to be decreased. Note that the slide on the right still imparts the same information about the branching of the lung bronchi but reduces the amount of unnecessary description. The visual information is reduced and the students can allot their attention to the auditory information coming from the lecturer and not feel overloaded.

One thing that students may notice about a bad professor is that he or she may consistently use slides like the one on the left and their lectures become unproductive. It seems so minor a thing, the design of lecture slides. Arguments could be made that the attention should be devoted to the lecturer while actually in the lecture. But in the end, it is only natural for the mind to give attention to new stimuli that is presented to us.

If coaching can improve the performance of teachers in public education by pointing out things like ineffective slide design, those in higher education can certainly benefit from the same. Right now, students and teachers in higher education are enculturated into what I call an academic machismo. The prevailing belief is that if you just power through a lecturer's shortcomings and memorize what is on the slide over and over again like doing reps with free weights then you can be an intellectual strongman.

As a tutor, I have given many talks with students that this is not necessarily effective. Students need to be encouraged to think about how they learn and what are the best strategies to employ for themselves. Teachers need to remember what it was like to be a student and think about what kind of lectures they enjoyed. I will concede that this not always easy for teachers. In their mind, the concepts students may struggle with are commonplace for them. But this is what coaching could do for professors at universities or medical schools. In the end, it will be the students who benefit and that does not seem so lofty a goal for any institution.

Works Cited

Gawande A. "Personal Best." The New Yorker. 3 October 2011.

van Merrienboer JJG, Sweller J. Cognitive load theory in health professions education: design principles and strategies. Medical Education. 2010; 44: 85-93.

Afterword
To the writers of the articles I have discussed should, you ever come across my lowly blog, I hope you will view my inclusion of your work as admiration of the deepest form and a free promotion of all your work.

Virulence Factor: Will Power

Currently, I am in the midst of studying viruses in medical school. Being the comic book geek that I am, my studies have reminded me of a certain member of the Green Lantern Corps:

Meet Leezle Pon, Green Lantern of Sector 119. Not only is he the smallest member of the Corps, he is a super-intelligent smallpox virus. Seeing as how it is debatable whether viruses are even true organisms, it is amazing that Leezle Pon has a name, a gender assignment, sentience, and the will power to overcome fear that is requisite of all Green Lanterns. If you still are not amazed, take into account that Leezle Pon has an archnemesis: Despotellis, another intelligent virus who is responsible for the death of Leezle Pon's partner (must have been some interesting stakeouts).

If you are wondering what creative mind came up with such a concept as a Green Lantern smallpox virus, look no further than Alan Moore. That's right. The same Alan Moore who is the genius behind Watchmen, V for Vendetta, The League of Extraordinary Gentlemen, From Hell, and much, much more. Leezle Pon was not the only weird Green Lantern Moore created for the Corps. Perhaps even more famous is his creation of Mogo, a Green Lantern who is an entire sentient planet.

I'm Very Proud of This

Topical Glutamine?

Don't get me wrong. I am a big Scott Snyder fan. American Vampire is one of the most interesting takes on vampires in a long time and his run on Detective Comics is one I will always remember. However, as a medical student, I could not help but notice a weird medical factoid that showed up in The New 52's Swamp Thing #1. In the opening pages, we find Dr. Alec Holland, brilliant botanist and former Swamp Thing, doing some good ol' hard labor, presumably to put his life as Swamp Thing behind him. Holland has apparently been doling out medical advice to his coworkers, telling one man to put cabbage on his knee to relieve the joint pain because cabbage is a good source of glutamine.

This set off a red light in my head. Glutamine for joint pain? Glutamine is not an anti-inflammatory and is not available in topical form (however, cabbage is indeed a good source of glutamine). Glutamine is medically used to maintain nutrition in people with short bowel syndrome and is often available as a supplement for muscle growth.

I really think that Mr. Snyder meant glucosamine. Glucosamine is a biochemical precursor to glycosaminoglycans which is a major component of joint cartilage. It is believed to have some anti-inflammatory action and can be applied topically. However, glucosamine is available over the counter so the construction would not need to go see a doctor and get a prescription. But at least Dr. Holland looked smart to the layman and earned his respect, right?

Interestingly enough, I came across a POEM (Patient-Oriented Evidence that Matters) that said that glucosamine and non-steroidal anti-inflammatory drugs (NSAIDS, like aspirin and ibuprofen) had no greater effect than placebo when used for knee osteoarthirtis (NSAID = glucosamine = chondroitin = placebo for knee OA, Essential Evidence Plus). So maybe it did not matter that Dr. Holland mixed up glutamine and glucosamine, after all.

.

Contagion: Go See It.

SPOILER ALERTS

Watching Contagion last night was probably the most appropriate way to herald my study of viruses in my Infection and Immunity course. The film was well done and the cast gave great performances. Jude Law and Kate Winslet played my favorite characters. As always, I like to judge these types of movies by their scientific accuracy. I was relieved to see that viruses and bacteria were not mixed up at all (as I have sadly seen in many comics and movies). Terminology that was thrown around was certainly correct (glycoproteins, valence, etc.) although I would need another listen to double check for anything that didn't really match up.

What is really great about Contagion and what sets it apart from similar movies is that it portrays the epidemic from multiple points of view. Each character's story deals with a different aspect of how epidemics are dealt with and responded to and each story is tangential to the story of the other characters. I especially liked the glimpse into epidemiology (a field whose members are either hit or miss with me). I really enjoyed Kate Winselt's portrayal of a no-nonsense Epidemic Intelligence Service officer and I hated to see her go relatively early.

Biological science fiction has been uncommonly good this summer between Contagion and the surprisingly-not-disastrous Rise of the Planet of the Apes. I hope Hollywood decides to keep up this level of plausibility and good storytelling.

A Great Find

First of all, I did not even know that Roueche had a second volume for the Medical Detectives. That's probably because they've only kept the first one has been reprinted. I found this on Amazon last week and it came in the mail today. I'm really excited to check out.

Good Episodes of House, M.D.: Occam's Razor

From a medical science standpoint, this is a pretty solid episode (there are the usual missteps that I chalk up to television being television). The patient, Brandon, presents with an unusual set of symptoms that the team cannot explain with one disease. House initially proposes that there are two processes going on: a sinus infection and hypothyroidism. Foreman brings up Occam's Razor, the philosophical principle that has been adopted in medicine as "the simplest explanation is often the most likely one." The principle of Occam's Razor is actually more accurately described as, when facing competing hypotheses, the one that makes the fewest new assumptions should be selected.

Anyway, Brandon starts to feel a little better and then his white blood cell count drops dangerously low and is put into isolation. After finding inspiration in almost picking up the wrong bottle on a Vicodin run, House spends quite a bit of time considering a new hypothesis. He admits that the principle of Occam's Razor still held and that colchicine poisoning due to a pharmacy mix-up for cough medicine explains all the symptoms. Additionally, Brandon got worse because someone continued to give Brandon his "cough medicine". The team hits a snag when Brandon's mother claims that the cough medicine was a round and yellow pill, just like the correct pill at the pharmacy. After some moping around and doubt, House sees that Brandon's worsening condition matches the progression of colchicine poisoning and bluffs that Brandon must have used ecstasy in the past which might be cut with with colchicine. The treatment for colchicine poisoning is started and Brandon improves.

Meanwhile, House, dissatisfied with the ecstasy explanation digs through the pharmacy for the different forms of colchicine. In another scene, Brandon comments on how the cough medicine Cameron gives him has a letter on them which his old ones do not. In the pharmacy, the determined House finds the colchicine pill that looks similar to the cough medicine.

On a side note, one of my favorite clinic patients appeared in this episode:

http://www.youtube.com/watch?v=BiAyIBoQiRo

The House of God Chronicles: The American Medical Dream

I've gotten quite far in the The House of God but today I am revisiting something I read last week from early in the novel:     

      "I don't get it," I said.  "This isn't medicine, this isn't what I signed up for.  Not writing orders for cleanouts for the bowel run."
      "Bowel runs are important," said Fats
      "But aren't there normal medical patients?"
      "These are normal medical patients."
      "They can't be.  Hardly any of them are young."
      "Sophie's young; she's sixty-eight."
      "Between the old people and the bowel rins, it's crazy.  It's not at all what I expected when I walked in here this morning."
      "I know.  It's not what I expected either.  We all expect the American Medical Dream - the whites, the cures, the works.  Modern medicine's different: it's Potts being socked by Ina.  Ina, who should have been allowed to die eight years ago, when she asked, in writing, in her New Masada chart.  Medicine is 'bedrest until complications,' Blue Corss payments for holding hands, and all the rest you've seen today, with the odd Leo thrown in to die."

A friend of mine who is a resident told me that the majority of patients will get better no matter what you do for them.  The remaining minority are the ones who depend on intervention and those are the ones that we trained to treat in medical school.  These are the exciting cases.  The ones that really make us feel like we accomplished something.   

Bond Villains and Their Medical Problems

So after posting about Dr. No the other day, I realized that most Bond villains have medical problems.  Naturally, Fleming and the people at EON did this to contrast the villains with the suave and fit 007.  Interestingly enough, Osama bin Laden also had health problems and lived in secret lairs and many have drawn comparisons to the deceased terrorist leader and Bond villains.

Today I will be discussing the health of Le Chiffre, the villain from Casino Royale.  In the novel, he seems mostly described as a very unattractive man who uses a Benzedrine inhaler (a racemic mixture of amphetamine).

In the recent Daniel Craig film, Le Chiffre (played by Mads Mikkelson) seems to have suffered an eye injury in his past and his tears contain blood.  This is a condition called hemolacria, a rare disorder with different causes.  One of the good lines in the film is when Le Chiffre explains his condition to a man he is playing poker with on his boat, "Weeping blood comes merely from a derangement of the tear duct, my dear General. Nothing sinister."


Just conveniently sinister-looking.

Background on my Background

The painting for that makes up the background of this blog is The Agnew Clinic by Thomas Eakins, realist painter from Philadelphia.  There is a great deal of history behind the piece.  The subject of the piece is Dr. David Hayes Agnew, a fairly well known surgeon and professor at the University of Pennsylvania.  Dr. Agnew was operating surgeon to President Garfield when he had been fatally shot in 1881 and is author of several texts including The Practice and Principles of Surgery. 

The painting was commissioned to honor Dr. Agnew's retirement and is of great importance, itself.  It was Eakins' largest work and cost $750.  The painting is so realistic that every person in the painting can be identified except the patient.  Eakins' decision to portray the patient as a partially nude woman in a room full of men was controversial and the piece was rejected or criticized at exhibitions.  

Julius No, M.D.

So last night I was re-watching the first James Bond film Dr. No.  Afterwards, I decided to find out what he was a doctor in since it was not really mentioned in the movie.  According to the novel biography, Dr. No attended a medical school in Milwaukee (Medical College of Wisconsin?).  It is unclear if he finished his studies but he seems to have adopted the title of Doctor anyway (as I sort of guessed).

Whatever medical school Dr. No attended must have been digging from the bottom of the barrel.  Not only was Julius No a mad scientist with a criminal history but both his hands were prosthetic.  I would have liked to see him practice.

One final note.  All Bond villains seem to have some sort of medical abnormality.  Besides having no hands, Dr. No also has dextrocardia which means that his heart points to the right instead of his left as most people do.  This is a congenital condition that arises around the third week of embryonic development.

The House of God Chronicles

So lately I've been reading Samuel Shem's The House of God, which has been more or less dubbed the Catch-22 of medicine.  Samuel Shem is the pen name of Dr. Stephen Bergman, a psychiatrist who wrote The House of God in response to his internship year at Beth Israel Hospital.  I heard about this book from a friend at Ohio State University College of Medicine who is currently on his rotations.

I have decided to do something different with this book.  Rather than wait until I am done with it I want to chronicle my reading through the book as it happens, putting up excerpts and sharing my thoughts.  I feel this makes sense because not only does it keep me writing but I also anticipate that I will have a lot to say about this novel.  In fact, I probably should have done this with many of the novels I have read previously that deal with the training of a physician.

One of the things I love about the book already is the colorful colloquialisms that the narrator, Dr. Roy Basch, and his peers have.  One of the first ones is Slurpers.  The following except illustrates the meaning:

     The House medical hierarchy was a pyramid---a lot at the bottom and one at the top.  Given the mentality required to climb it, it was more like an ice-cream cone---you had to lick your way up.  From constant application of tongue to the next uppermost ass, those few toward the top were all tongue.  A mapping of each sensory cortex would show a homonculus with a mammoth tongue overlapping an enormous portion of brain.  The nice thing about the ice-cream cone was that from the bottom, you got a clear view of the slurping going on.  There they were, the Slurpers, greedy optimistic kids in an ice-cream parlor in July, tonguing and tonguing and tonguing away.  It was quite a sight.


I love this.  The humor is in the stark truth of it.  As students we are encouraged to start "networking" early for opportunities, recommendations, etc.  The term "networking" has a benign enough connotation and, truthfully, it is important.  However, medicine has historically been notorious for the cut-throat competition between trainees and subordinates.  The bar is constantly being raised by the more shameless but ambitious peers who progressively escalate "networking" into ass-kissing or "slurping".  It becomes less about merit and more about charisma---how well you can work people.  One of my top priorities as a student is learning to become good at what I am doing.  It is frustrating sometimes when that does not seem to count as much as how many people I know out there.  Still, I decided a long time ago to stick to my guns and hope that the people that recognize my work will be the kind of people I want to work with.

Pharmacology Review via The X-files

I know it seems like I've been watching a lot of TV lately but I've been working on another book and my project for my externship.   I was watching the episode  "Eve" of The X-files and, despite the myriad scientific mistakes, I found a minor medical mistake that I can't let go of.  During the episode, Mulder mentions that traces of digitalis are found on the victims that is from a South american plant and used as a paralytic.  Mulder is clearly referring to curare, not digitalis.  Curare is a nicotinic acetylcholine receptor antagonist, blocking the signals for muscle contraction.  Curare is used in arrows by indigenous South Americans to paralyze victims/prey.

That being said, digitalis is from the foxglove plant as mentioned in the episode.  However the foxglove plant is found in Europe, Asia, and some of Africa.  It contains a cardiac glycoside that inhibits the Na+/K+-ATPase.  This removes the Na+ gradient that is necessary to drive Na+/Ca2+ exchange.  Ca2+ remains in the cardiac myocyte prolonging contraction.  Digitalis has been used in congestive heart failure in the past but has been replaced with much safer medications.

Now, I probably couldn't let this go because pharmacology and physiology are some of my favorite aspects of medicine.  That doesn't mean the episode was not enjoyable (in fact, it was highly enjoyable).  As an avid fan of science-fiction, suspending disbelief and forgiving understandable mistakes is routine for me.  What I really am there for is the story and the characters.

Good Episodes of House, M.D.: The Pilot

I actually started watching House, M.D. during reruns of the second season.  Even in high school, I recognized how far-fetched some of the portrayals of medicine were but also appreciated that the show was much smarter than most medical dramas (especially Grey's Anatomy).  Mysteries have always been my thing and I always love a good detective-type character, especially those who pay homage to Sherlock Holmes like House does (think about it: House = Holmes, Wilson = Watson; maybe the fellows = the Baker Street Irregulars?)

My mom got me the first season for my birthday which I found really good.  Of course, you need to suspend your disbelief on a couple things:
1) No real hospital administrator would tolerate Dr. House.
2) Technologists and nurses handle a lot of things like MRIs and blood draws but there needed to be a vehicle for conversation for the fellows with each other, the patient, and/or House.
3) Princeton-Plainsboro has an interesting set up that appears to give its doctors a salary and make them do clinic duty.  I have not really encountered such a setup but it provides for good television.

Once you get over that, the process of coming up with a differential diagnoses and  thinking through medicine is actually quite good (at least for television which never shows this part).  A few years ago I started following the blog of a doctor who evaluates all the House episodes for their medical merit (http://www.politedissent.com/).  It has been really helpful as a student to read his stuff and sort through the crap of each episode.  He also reads comics which is awesome.

In the pilot episode, a woman named Rebecca Adler (another Holmes reference to Irene Adler, the only woman who ever got the better of him) becomes aphasic and seizures during class.  The aphasia goes away eventually but no one seems to be able to find out what's going on with her which is how she comes to House. After several missteps, avoidance of patient contact, and illegal breaking and entering, House leaps to the idea that she has a tapeworm from eating pork products (which I am guessing wasn't really considered because she was assumed to be Jewish because Wilson lied about his relation to her but it could have also just been that pork triggered tapeworm in House's mind which really is the way it works sometimes).  The medicine, itself, is a little haphazard with inferences made on the smallest of details but to be honest, I've seen worse in real life.  The reality is that there is a lot of uncertainty in medicine and House navigated it in his own way that is conveniently entertaining for television.  

History Lesson

As part of a summer reading assignment for school, I just finished The Immortal Life of Henrietta Lacks by Rebecca Skloot.  If you have not heard, this book is about a woman whose cervical cancer cells were harvested and cultured into an immortal cell line known as HeLa.  As the first human cells that could be cultured indefinitely, Henrietta's cells opened up research avenues to numerous medical discoveries and innovations including the polio vaccine, HIV treatments, and breakthroughs in understanding cancer.  However, the  book itself is only partially a recounting of the scientific advances brought about by Henrietta's cells.  Skloot also reports on her investigations into finding out who exactly Henrietta Lacks was, why her cells were taken without informing her family what they would be used for, and her own personal friendship with the Lacks family today.

Skloot has certainly earned my respect as a science writer.  Her explanations are clear and complete.  I was very grateful be reading what I felt was a very fair and balanced work, presenting multiple perspectives on what had happened surrounding Henrietta Lacks and her cells.  The book informs the readers  on the the bioethical issues but refrains from getting preachy or persuading action.  As a reader, I felt I was allowed to appreciate the history and whatever lessons I can learn from it are up to me.

Oh and of course, because a comic book character was referenced  in the book, I had to show who Hela the Marvel character was:

Hela on the cover of Thor #150, art by the one and only Jack Kirby

In the comics, Hela is the daughter of Loki and goddess of death (Skloot and Henrietta's daughter Deborah found this interesting).

TV Doctors: Dr. Tobias Fünke

David Cross as Tobias 

Today I am doing something new.  Lately I've been thinking about TV doctors.  Yesterday, I rewatched the first episode of Arrested Development which features the hilarious David Cross as Dr. Tobias Fünke, one of the funniest TV doctors (although his licence has been taken from him and he doesn't really practice during the show's run).


Tobias' record is impressive and perhaps that's the humor in it.  He was a chief psychiatry resident at Massachusetts General Hospital (one of the most prestigious hospitals in the nation).  Tobias was additionally trained in psychoanalysis and psychotherapy making him an "analrapist".  Tobias lost his licence when he gave CPR to a man that was not really having a heart attack.  I am not sure if a doctor can lose his licence over something like this but then again, most doctors are well trained enough to tell the difference if someone is having a heart attack or not.  Given Tobias' oblivious nature, I can probably safely assume there is more to his loss of licence (like his oblivious nature). 

 

                                     

On Being a Medical Detective

The following is a recommendation I just wrote for this book:

Although written for a wide audience, Dr. Lisa Sanders’ Every Patient Tells a Story is a book that medical students will find not only entertaining but highly relevant to their education.  In her book, Dr. Sanders identifies and expands upon the essential elements that lead a doctor to diagnosis including the patient interview and the physical exam, fading arts that I know at least NEOMED has been trying to revive.  Throughout the book are stories from Dr. Sanders’ Diagnosis column in New York Times Magazine as well as some from her own training and practice that show that each element is important but it is the integration of the elements that lead to solving complex cases.  Sanders also shows how vital (almost literally) it is to be cognizant of one’s own thinking process in coming up with differentials and is refreshingly honest about being wrong in medicine.  These messages serve as a great supplement to many core themes of the longitudinal 

course at NEOMED.

Additionally, Every Patient Tells a Story (as well as many other medically-inclined books) will do something that I do not think happens enough in medical education: orient students to where medicine today has come from and where it is going.  As medical students, much of what we do seems to be learning from test to test.  But there is always a point where a medical student wonders, “Why is it important that I learn this?”  What it seems we have little time for is finding out what is out there in the field today and how classroom knowledge is part of that.  What are the issues?  What is being done?  What have people already tried?  Books by physician-writers like Dr. Lisa Sanders, Dr. Atul Gawande, Dr. Jerome Groopman, and many others already seek to answer these questions for the public-at-large in plain language.  A medical student up to his eyes in his studies can experience even more excitement than the average person as he reads these works and finds he understands a process or recognizes a disease from class.

Now, while I do believe every medical student should try to read this book, I hesitate to recommend that Every Patient Tells a Story be made into required reading in the sense that every student in the class must read this book at the same time whether it be during the academic year or over the summer break.  My reasoning is this: forcing students who already feel there is a high volume of studying to be done can make them antagonistic toward the reading and the gain becomes diminished.  In high school, I had an English literature teacher that found required reading to be a necessary evil and wanted to remind us that great reading could be done for pleasure.  One day, he rolled in a cart with copies of Ken Kessey’s One Flew Over the Cuckoo’s Nest and told us that anybody that was interested in reading the book could have a copy.  Another time he did the same thing with J.D. Salinger’s Catcher in the Rye, telling us that Salinger would hate it if he forced us to read this book.  Frequently he would bring in reading list from various sources – the 100 best novels, the 100 best non-fiction, etc.  “These are important books,” he would say.  “Just because we don’t read it in class doesn’t mean you shouldn’t.”  When classes would reconvene after breaks he would ask us if anybody read anything interesting and we would all sit around and talk about what different things were read outside of the curriculum.

I believe the same philosophy can be applied in medical education.  The greatest service to medical students would be to inform them of what books are out there and what they are about. Rather than have all students read the book at the same time, I would like to see Dr. Sanders’ book be part of an independent reading assignment where the student may choose a book from a list of several and share his or her thoughts on the work in the small group sessions.  In this way, every student can feel that there was some personal value in the choice he or she made and has unique thoughts to share with a group of people who did not necessarily read the same work.  Fellow group members benefit by getting informed about a book they may not have read.  This, I feel, would truly create a good vehicle for discussion amongst students about many of the themes of the longitudinal course at NEOMED.         

The Handi-Capped Hero

Gregory Iron, the Handi-Capped Hero

One of the cool things for a medical student is to see things that you learn about in the classroom applied in real life.  Indeed, we almost hunger for such moments as reminders that there is a whole world outside the lecture hall where this information matters.  Usually, we see these cases in our clinical site visits while we are still in the first two years.  

I ran into an interesting case at a wrestling event in Lakewood a few months back.  In one of the matches, a wrestler named Gregory Iron came out.  I suppose it assumed most of the audience knew about Iron and his trademark gimmick but since it was my first time at an Absolute Intense Wrestling event I didn't know much about him.  I noticed there was a handi-capped sign on his trunks and wondered what that had to do with anything.  Then I noticed his right arm.  The forearm muscles seemed a little wasted when compared to the left arm.  Also his wrist seemed fixed in a flexed position.  I leaned over to my friend who had brought me to the show and asked him if there was something wrong with his hand.  He wasn't sure.  At first, my inexperience made me think of brachial plexus problems I had seen in my anatomy course.  It was very plausible that the injuries that cause such problems could be sustained in a wrestling match.

But Iron's arm was also flexed and seemed fixed that way.  That wasn't consistent with a brachial plexus problem and, as I would learn later, not consistent with peripheral nerve problems in general.  The increased muscle tone (hypertonia) in his right arm suggested an upper motor neuron deficit.  Upon doing some research on Iron, I found that he had cerebral palsy that affected his right arm (meaning the lesion was affecting his left primary cortex in the areas that are responsible for arm movement).

Iron, himself, is an impressive guy, especially for how athletic he is even with his problems in his right hand and arm.  Indeed, the wasting in his right arm is subtle and the movement in the ring is constant so that you might not have noticed the deficits.  I have always had an eye for noticing details but I am pleased that my education seems to be continuing to increase my ability to interpret the meaning behind the details accurately.  This is my bread and butter and what I love about the clinical problem solving in medicine.  

Checklists: Agents of Better Outcomes and Cultural Shifts

Right before I left for Washington, DC, I finished Dr. Atul Gawande’s last book, The Checklist Manifesto.  Unlike his previous books, this was not a collection of essays but rather was an account of Dr. Gawande’s exploration into the idea of using a checklist to reduce disastrous outcomes that can be avoided if certain simple steps are not overlooked.  Dr. Gawande looks to many other professions, especially airplane piloting, where checklists have found great success and advocates for their use in all professions, including his own.

In addition to making operations going smoothly, Dr. Gawande discusses how checklists have facilitated communication, particularly in the operating room where he works.  This idea struck an even greater chord with me.  A simple thing like a checklist was not only improving end results but it was doing so by introducing a cultural shift.  For the longest time, I have recognized cultural shifts to be very difficult.  Cultures can be extra-resistant when it seems that shifts are being mandated and seem to enjoy being the subject of more random forces.  However, by creating the checklist and making nurses responsible for them, Dr. Gawande had been able to see shifts in the dynamics between surgeons and nurses where there was once a culture of silence.  It would seem that culture will change in small doses and that gives me hope for areas where there really needs to be changes in professional culture such as medical professional culture.

I also enjoyed Dr. Gawande’s discussion as to why some doctors where resistant to the idea of a checklist, itself.  In short, it can be summarized into vanity.  Checklists do not seem necessary to people who have years of training and yet, Dr. Gawande argues that checklists allow doctors to get the no-brainers out of the way so that energy can be focused onto the higher level thinking.  I am all for something that lets me do that.  And to be perfectly honest, “brilliant” TV doctors such as House could prevent and maybe even solve cases quicker if they kept checklists for procedures.  Don’t get me wrong, I love the show (or at least the first three seasons) but the show represents a lot of what is inefficient and counterproductive in medicine today.

The Hot Zone

Next week I am going to Washington DC so I thought it would be appropriate to post about The Hot Zone.  I read this back in high school before I came up with the idea for The Physician's Library but I definitely believe it belongs on this list of must-read books for anyone interested in medicine, especially infectious diseases.

Normally, I am pretty wary of popular science writers but Preston is really, really good.  He's very thorough and informative, researching his subjects very meticulously.  It's actually hard to believe he isn't a scientist, himself (he actually has a PhD in English so technically he's Dr. Preston).

If you don't know, The Hot Zone is about the Ebola virus, one of the most violently deadly infectious diseases in our world.  The book reads like a suspenseful novel and the scary thing is that Preston has not had to embellish in the slightest.  The book includes a very good history of what we know about the virus and recounts an incident where a strain of Ebola was found in a monkey house in Reston, VA, a city near Washington DC in 1989.  Luckily, Ebola Reston was found to be non-pathogenic to humans.

Comic Book Patients: Thom Kallor

Starman/ Star Boy

Condition: Schizophrenia

Thom Kallor as Starman by Alex Ross 

If you read comics or if you ever will, you will start to notice that there are plenty of comic book characters with interesting medical conditions (how half of them got their powers is related to their medical conditions).  

Since I am currently studying brain, mind, and behavior, I thought it would be appropriate to talk about Thom Kallor better known as Star Boy of the Legion of Superheroes and Starman (one of many).  As Starman, Thom has traveled back in time to the 21st century with a secret mission.  Due to the primitive medicine of our time, Thom's condition becomes symptomatic and he is revealed to have schizophrenia.  Apparently, there's no better way to hide a secret mission in a world full of telepaths than to assign it to a schizophrenic man (what a plot device!).

Starman seems to exhibit the cognitive and disorganized symptoms of schizophrenia.  These include incoherence, looseness of association, and impaired attention.  Arguably, these symptoms are some of the more entertaining ones that have been seen.  Schizophrenics can also exhibit hallucinations and delusions (positive symptoms which can also be entertaining but also scary at times) or be more passive as if they were not really in their own heads (negative symptoms).  

It is true that schizophrenics do not always respond to modern medications and typically these medications are best at  reducing the positive symptoms (Geoff Johns did his homework).  Today, guidelines recommend managing schizophrenia with a class of drugs called atypical antipsychotics which include clozapine, risperidone, and olanzapine.  The exact mechanism of these drugs is not quite clear but all target dopamine pathways, probably antagonizing dopamine receptors.

The success of antipsychotics has supported the dopamine hypothesis to explain schizophrenia.  Dopamine is a neurotransmitter found in many areas of the brain.  It is believed that the excessive release of dopamine in the mesolimbic pathway leads to the positive symptoms of psychosis.  This is further supported by the fact that cocaine and amphetamines, drugs that cause higher levels of dopamine to be present in neural synapses, can induce psychosis.  

Glutamate is another neurotransmitter of interest in schizophrenia.  The glutamate hypothesis of schizophrenia proposes that lower levels of glutamate binding to NMDA receptors in the brain can explain both positive and negative symptoms of schizophrenia.  Drugs that antagonize NMDA receptors such as PCP and ketamine have been shown to induce psychosis.

Finally, on an interesting note to all you legalizers out there, use of cannibis (i.e. marijuana) has been linked to risk of earlier onset of schizophrenia.  Of course these links are somewhat controversial (if you think there are no scientists that smoke weed out there then you must live in Disney World) but at least one study shows that people with a certain polymorphism in an enzyme known as catechol-O-methyltransferase (COMT) are more susceptible to psychosis with use of cannabis in early adolescence.

Thom Kallor in Justice Society of America #12; pencils by Dale Eaglesham, inks by Ruy Jose, and colors by Alex Sinclair