Rethinking Medical Education

Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. About the only thing you can’t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.

Medical education and medicine are topics about which I often find myself thinking. I’m always interested in the questions of “Are we doing it the best way?”, “Is there a better way?”, “How do we adapt the fields to emerging changes?”, and so on. Too often I come to the conclusion that we’re not keeping up with advancements and, as Wayne Gretzky might have put it, we’re skating to where the puck is, and not to where it is going.  Continue reading

Abraham Verghese: A doctor’s touch

Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.

Link: Abraham Verghese: A doctor’s touch

IBM’s Watson enters medicine

IBM’s first TV commercial advertising Watson’s capabilities in medicine. I find this system incredibly fascinating. Medicine has evolved to the point where it is no longer possible to know every aspect of every disease. Watson promises to help doctors improve diagnosis and better tailor treatments to individual patients.

Watson’s technical specifications:

  • 90 IBM Power 750 servers enclosed in 10 racks
  • 16 Terabytes of memory
  • A 2,880 processor core
  • Linux system
  • While not officially disclosed by IBM, Watson is estimated to have cost $1-$2 billion
  • Uses “DeepQA”: a technology that enables computer systems to directly and precisely answer natural language questions over an open and broad range of knowledge

Thoughts on medical school and the USMLE

Well, now that the USMLE Step 1 and two years of medical school are out of the way, I thought I’d write a brief reflection on the experience including my thoughts on what was good, what was bad and how it can be improved. I’ve actually been meaning to write this for some time but my thoughts have been concentrated on other matters. Continue reading

iPhone Medical Software Round-Up

So I’ve decided to be productive on the plane trip home and write a review on some of the medical applications for the iPhone (which, by the way, is by far the best mobile platform on the market – in fact, about 90% of this review was written on an iPhone).

I’ll be reviewing five of the more useful applications this go around: Eponyms, DxSaurus, Lab Values, ECG Guide and iMurmur.

Eponyms (http://code.google.com/p/eponyms-touch/) – Medicine loves eponyms. Sure, we could call it reactive arthritis but we’d rather say Reiter’s Syndrome. Maybe it’s an ego thing with doctors, maybe not but that’s the system we have. Eponyms provides an easy-to-use, searchable index of medical eponyms with a description of each. Nothing more, nothing less. Example listing: Ball’s disease – Intracerebral leukocytosis, a potentially fatal complication of acute leukemia (especially AML) when peripheral blast cell count >100,000/uL; leukemic cells capable of invading through endothelium and causing hemorrhage into brain. Condition not generally seen with CLL or CML.

  • Pro: Very complete listing of 1,700+ medical eponyms, each of which includes a description that provides clinically-relevant information
  • Con: Information is incomplete in terms of pathogenesis / pathophysiology (though these may/ may not be clinically relevant)
  • Rating: 5/5
  • Price: Free for students, $1.99 for all others

Diagnosaurus DDx (http://www.unboundmedicine.com/store/iphone) – This is a differential diagnosis software package. The user can choose by disease, organ system or symptom and a list of differential diagnoses and etiologies are provided.

  • Pro: Provides a good list of differential diagnoses for the entered item, fairly comprehensive disease list.
  • Con: No hotlinking between diseases, no explanations provided on the etiology. The differential diagnosis lists are often incomplete and do not provide for the entry of multiple symptoms or organ systems. Thus, the differential diagnosis provided is a “shotgun” approach and needs filtering by an experienced clinician. These oversights must be corrected for this to be a complete software package for its intended purpose.
  • Rating: 2.5/5
  • Price: $0.99

Pocket Lab Values – Quick reference for medical lab values broken up into categories such as cardiology, CSF, drug monitoring, endocrinology, hematology, etc. The program allows for seaches, marking of favorites and a catalog of recent lab views.

  • Pro: Saves recent history of labs viewed. Provides explanations for each of the labs and quick links to Wikipedia, Medline Plus and Google for additional information as well as reference values in US and SI units.
  • Con: Information not as complete as that provided by other sources such as Bakerman’s ABC’s of Interpretive Laboratory Data, only 227 labs listed so not a complete reference.
  • Rating: 4.5/5
  • Price: $2.99

ECG Guide (http://www.QxMD.com) – This is a comprehensive ECG package providing everything from tutorials on ECG Basics to ECG Interpretation with segments, chamber enlargements, conduction and bundle branch blocks, arrhythmias and special pediatric cases.

  • Pro: Excellent explanations with sample ECGs provided for each. The criteria for the diagnosis is clearly spelled out and each ECG abnormality is fully explained in terms of appearance and mV/mm discrepancy. Many conditions are covered such as subtypes of Narrow Complex (Supraventricular) tachyarrhythmias, left/right bundle branch blocks, fascicular blocks, QRS axis assessment, Rotation assessment, Myopericarditis, Brugada Syndrome and many, many more.
  • Con: No quiz function for testing one’s understanding of the material.
  • Rating: 5/5
  • Price: $2.99

iMurmur (http://phalanxdev.com) – This is a great program for learning how to detect and correctly diagnose murmurs. The reference murmur list is long and includes such murmurs as aortic regurgitation, aortic stenosis, atrial septal defect, Austin-Flint murmur, Mitral regurgitation, Paradoxical S2 split and many others. The program includes reference recordings that can be listened to to teach you what the various murmurs sounds like as well as a quiz where a murmur is played and you are asked to make a diagnosis. It’s a great, easy and accurate way to learn your way around heart murmurs with the learning being reinforced with the quiz function. Highly recommended for anyone that needs to learn proper auscultation or for those needing to brush up on their knowledge.

  • Pro: Lots of reference murmurs, quiz function, stable application
  • Con: Requires headphones to listen
  • Rating: 4/5
  • Price: $2.99

See Part 2 of this review

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Imagine the possibilities

Do you ever wake up in the middle of the night with your mind racing and you’re unable to go to sleep? That happened to me last night after falling asleep and missing out on some much-needed entertainment. I woke up thinking about how the medical culture makes student doctors (better known as medical students) learn medicine and it occurred to me that maybe we’ve got it wrong.

Maybe we’re holding back progress from Day 1.

Maybe we’re serving the interests of tradition and not the interests of progress.

Maybe there’s a better way.

Think about the last time you needed to know something. For example, let’s say you were going to buy something on Amazon.com. Now, that product may be cheaper elsewhere and it may not be so what do you do? More than likely, you check a price summary website like pricewatch.com or you check your other favorite sites before ordering.

Now apply that to a hospital setting. The doctor is “pimping” the medical student for information and the student may or may not know the answer. Traditionally, the student will either be rewarded for knowing the answer to a random question or will be met with mild disapproval or ridicule for not knowing the 3rd step of the WHO clinical treatment guidelines for chronic flatulence. The physician will then likely provide the answer and move on with the case.

Stop. What are the problems with this scenario? How can the training interaction between the doctor and student be improved? What steps can be taken to improve the ultimate goals of patient care?

Now contrast it to this scenario. The same question is posed and our intrepid medical student doesn’t know the answer thus being met with mild disappointment. However, using the wonders of current database and integrative technology, our hero rapidly refers to the treatment guideline and, combined with his/her knowledge of medicine, is able to provide an answer to the pimping physician. The student has now not only learned real-time integration of new information but he/she has also learned clinical self-reliance, an important step in becoming an excellent solo practitioner. The supervising physician can then tweak the student’s response where necessary and further contribute to the patient care learning process (who knows, the student may even prevent the supervising physician from making a mistake). The final piece of the puzzle is now in place: clinical teamwork. This experience is then carried forward with the student learning to, when needed, integrate the PDA data device into clinical decision and share resulting treatment ideas to reduce errors and improve quality.

Errors which, by the way, contribute to the preventable death of ~195,000 Americans per year (as estimated by HealthGrades), injure an additional 1.5 million Americans and conservatively cost $3.5 billion a year not accounting for lost wages, productivity or additional health care costs. Studies also indicate that 400,000 preventable drug-related injuries occur each year in hospitals.  Another 800,000 occur in long-term care settings, and roughly 530,000 occur just among Medicare recipients in outpatient clinics.  The Institute of Medicine Board on Health Care Services Committee on Identifying and Preventing Medication Errors noted that these are all likely underestimates. (http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623)

Ron Zook, former coach of the Florida Gators, said that you learn more from failure than you do from success. Ron Zook was also fired after a few seasons. Let’s not follow Zook’s logic.

Some progressive schools like Florida State University are beginning this approach to bedside-integrated technological medicine and it should be expanded as rapidly as possible. This is the 21st century with an exponential increase in knowledge, technology and information access. We have to be willing to think creatively and integrate innovations if we’re going to do the best for our patients.

So for me, I’ll keep using my iPhone, Epocrates and Neph Calc as I learn clinical medicine. I’ve never been one to be stuck on tradition.

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