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

  

Five of My Favorite Comic Book Doctors

Doing something a little different this time around.  Physicians are everywhere in comic books and it's always fun to see the medicine (good and bad) intertwined in the stories.  These are not necessarily the best doctors in the comics, just my personal favorites.

#5 - Thor

Thor's debut in Journey into Mystery #83.
Art by Jack Kirby and Joe Sinnott

Yes.  That Thor.  Originally, Thor's origin had Odin placing Thor into the body of partially disabled medical student, Donald Blake (the series finale to House, in my opinion, would be awesome if he found Mjolnir and became Thor).  If the name Donald Blake sounds familiar, there were references made to him in the Thor movie as being Jane Foster's ex-boyfriend.  Originally, Jane Foster was a nurse that worked with Blake and the two become involved.  Can you blame her?  "Hey there baby, not only am I a doctor but I am also the Norse god of thunder."  In the magic of retcons, this origin for Thor is no longer official continuity and Foster has become a doctor, herself.







#4 - Dr. Thomas Wayne

Thomas Wayne in Batman: The Long Halloween #9
Art by Tim Sale

Bruce Wayne's dad seems to have been a very well respected surgeon in the DC Universe, not to mention a renowned philanthropist (which is something given he lives in a city that epitomizes the dark side of any urban environment).  I've enjoyed Paul Dini's expansion of Gotham's old families in his Hush stories (another comic book physician, but one I find annoying at times).  Dini has portrayed a young Thomas Wayne as a womanizing, party-boy who is changed by his meeting with his future wife Martha Kane.

In current continuity (I think), Dr. Wayne was actually the first Batman, wearing a bat-themed costume at party one evening and stopping a crime.  The costume he wore hung in the Batcave until it was stolen by Dr. Simon Hurt who is also a doctor and actually a devil-worshiping Wayne ancestor also named Thomas (thanks to Grant Morrison).  Of late, Dr. Wayne has been revealed to be the Batman in the latest DC event, Flashpoint.  I hear good things about it but I am personally tired of these large story arcs.

Thomas Wayne as Batman in Flashpoint #1; Art by Andy Kubert and Sandra Hope

#3 - Dr. Soranik Natu

Soranik Natu in Green Lantern Corps: Recharge # 5; art by Patrick Gleason

This one may be one of my more obscure selections and proof I read way too many comics.  Natu is a neurosurgeon from Korugar, the home planet of Sinestro, former Green Lantern and later archnemesis of Hal Jordan, Green Lantern of Earth (don't ask me what his status is now, I didn't read Brightest Day).  Dr. Natu has also been revealed as the daughter of Sinestro and the niece of Abin Sur, the Green Lantern who gave the ring to Hal Jordan.  Last I heard, Natu was dating Kyle Rayner, another Green Lantern from Earth.  I think I like Natu because 1) how many times do you see an alien physician? and 2) how could would it be to be a physician with a Green Lantern ring?  I really hope Natu survives the upcoming revamp of the DC Universe.  She's good for Kyle and definitely one of the more interesting supporting cast in the Green Lantern saga.

#2 - Dr. Strange

Dr. Strange by Gabriele Dell'Otto

Dr. Stephen Strange was (yet another) neurosurgeon who was (yet again) arrogant and needed a lesson in humility.  Strange's hands are crippled in a car accident, ruining his ability to perform surgery.  Trying everything he can to get his hands fixed, Strange ends up in the Himalayas where, after proving the good in himself, he is taught the mystic arts by the Ancient One.  Strange is one of my favorite characters in the Marvel universe and definitely one of the most fun to play in Marvel Ultimate Alliance.  I love the following image from Let's Be Friends Again which nods to House.

Dr. Strange ala House, MD; art by Chris Haley of Let's Be Friends Again

#1 - Dr. Mid-nite (Pieter Cross).

With respect to former Dr. Mid-nites, Dr. Charles McNeider and Dr. Beth Chapel, Dr. Pieter Cross has been the greatest to hold the title of Dr. Mid-nite.  In a mini-series by Matt Wagner (one of my favorite comic writers), Cross is a physician/ urban crusader that reminds me of both the fictional Dr. Thomas Wayne and the real Dr. Paul Farmer.  After going after the Terrible Trio (a set of Batman villains) who are pushing a new drug on the streets, Cross is injected with the drug and gets into a car accident.  Initially believing he was blind, Cross finds that he can see in the dark (conveniently like the former Dr. Mid-nites) and assumes the Mid-nite mantle.  Later, he joined the JSA and has since become the DCU's go-to medical guy.  Mid-nite has had stories written by some of my favorite writers including Matt Wagner, Scott Beatty, and Geoff Johns (before his head got bigger than Hector Hammond's).

Dr. Mid-nite from the cover of JSA Classified #19; art by Rags Morales