June 21, 2010

Atul Gawande's Commencement Speech at Stanford's School of Medicine

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.
So why—in your heart of hearts—do you not quite feel that way?
The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.
I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”
I was stumped. The information was not anywhere in the textbooks.
“I don’t know,” I finally confessed.
“What kind of doctor are you?” he said.
I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.
This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.
It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.
But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.
Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.
Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reĆ«xpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.
But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.
When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.
You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.
When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.
You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.



Read more: http://www.newyorker.com/online/blog...#ixzz0rUyhYvRJ

June 19, 2010

Kuwait Health Initiative's First Newsletter

Kuwait Health Initiative's Inaugural Newsletter:

June Edition Includes:

In this edition:

Chairman's Welcome Address

KHI Introduction

Kuwait University Careers Day 2009

Green Hospital Workshop

Cancer Screening Practices Pilot Study

Guantanamo Bay and Medical Education: A Marriage of Convenience

Air Pollution in Umm Al-Hayman

Click on link below to read:

http://www.q8health.org/khi-newsletter/

June 07, 2010

Student BMJ: How to Present Clincal Cases

Education

How to present clinical cases

Presenting a patient is an essential skill that is rarely taught

  • By: Ademola Olaitan, Oluwakemi Okunade, Jonathan Corne
  • Published: 13 April 2010
  • DOI: 10.1136/sbmj.c1539

Clinical presenting is the language that doctors use to communicate with each other every day of their working lives. Effective communication between doctors is crucial, considering the collaborative nature of medicine. As a medical student and later as a doctor you will be expected to present cases to peers and senior colleagues. This may be in the setting of handovers, referring a patient to another specialty, or requesting an opinion on a patient.

A well delivered case presentation will facilitate patient care, act a stimulus for timely intervention, and help identify individual and group learning needs.[1] Case presentations are also used as a tool for assessing clinical competencies at undergraduate and postgraduate level.

Medical students are taught how to take histories, examine, and communicate effectively with patients. However, we are expected to learn how to present effectively by observation, trial, and error.

Principles of presentation

Remember that the purpose of the case presentation is to convey your diagnostic reasoning to the listener. By the end of your presentation the examiner should have a clear view of the patient’s condition. Your presentation should include all the facts required to formulate a management plan.

There are no hard and fast rules for a perfect presentation, rather the content of each presentation should be determined by the case, the context, and the audience. For example, presenting a newly admitted patient with complex social issues on a medical ward round will be very different from presenting a patient with a perforated duodenal ulcer who is in need of an emergency laparotomy.

Whether you’re presenting on a busy ward round or during an objective structured clinical examination (OSCE), it is important that you are concise yet get across all the important points. Start by introducing patients with identifiers such as age, sex, and occupation, and move on to the complaint that they presented with or the reason that they are in hospital. The presenting complaint is an important signpost and should always be clearly stated at the start of the presentation.

Presenting a history

After you’ve introduced the patient and stated the presenting complaint, you can proceed in a chronological approach—for example, “Mr X came in yesterday with worsening shortness of breath, which he first noticed four days ago.” Alternatively you can discuss each of the problems, starting with the most pertinent and then going through each symptom in turn. This method is especially useful in patients who have several important comorbidities.

The rest of the history can then be presented in the standard format of presenting complaint, history of presenting complaint, medical history, drug history, family history, and social history. Strictly speaking there is no right or wrong place to insert any piece of information. However, in some instances it may be more appropriate to present some information as part of the history of presenting complaints rather than sticking rigidly to the standard format. For example, in a patient who presents with haemoptysis, a mention of relevant risk factors such as smoking or contacts with tuberculosis guides the listener down a specific diagnostic pathway.

Apart from deciding at what point to present particular pieces of information, it is also important to know what is relevant and should be included, and what is not. Although there is some variation in what your seniors might view as important features of the history, there are some aspects which are universally agreed to be essential. These include identifying the chief complaint, accurately describing the patient’s symptoms, a logical sequence of events, and an assessment of the most important problems. In addition, senior medical students will be expected to devise a management plan.[1]

The detail in the family and social history should be adapted to the situation. So, having 12 cats is irrelevant in a patient who presents with acute appendicitis but can be relevant in a patient who presents with an acute asthma attack. Discerning the irrelevant from the relevant is not always easy, but it comes with experience.[2] In the meantime, learning about the diseases and their associated features can help to guide you in the things you need to ask about in your history. Indeed, it is impossible to present a good clinical history if you haven’t taken a good history from the patient.

Presenting examination findings

When presenting examination findings remember that the aim is to paint a clear picture of the patient’s clinical status. Help the listener to decide firstly whether the patient is acutely unwell by describing basics such as whether the patient is comfortable at rest, respiratory rate, pulse, and blood pressure. Is the patient pyrexial? Is the patient in pain? Is the patient alert and orientated? These descriptions allow the listener to quickly form a mental picture of the patient’s clinical status. After giving an overall picture of the patient you can move on to present specific findings about the systems in question. It is important to include particular negative findings because they can influence the patient’s management. For example, in a patient with heart failure it is helpful to state whether the patient has a raised jugular venous pressure, or if someone has a large thyroid swelling it is useful to comment on whether the trachea is displaced. Initially, students may find it difficult to know which details are relevant to the case presentation; however, this skill becomes honed with increasing knowledge and clinical experience.

Presenting in an exam

Although the same principles as presenting in other situations also apply in an exam setting, the exam situation differs in the sense that its purpose is for you to show your clinical competence to the examiner.

It’s all about making a good impression. Walk into the room confidently and with a smile. After taking the history or examining the patient, turn to the examiner and look at him or her before starting to present your findings. Avoid looking back at the patient while presenting. A good way to avoid appearing fiddly is to hold your stethoscope behind your back. You can then wring to your heart’s content without the examiner sensing your imminent nervous breakdown.

Start with an opening statement as you would in any other situation, before moving on to the main body of the presentation. When presenting the main body of your history or examination make sure that you show the examiner how your findings are linked to each other and how they come together to support your conclusion.

Finally, a good summary is just as important as a good introduction. Always end your presentation with two or three sentences that summarise the patient’s main problem. It can go something like this: “In summary, this is Mrs X, a lifelong smoker with a strong family history of cardiovascular disease, who has intermittent episodes of chest pain suggestive of stable angina.”

Improving your skills

The RIME model (reporter, interpreter, manager, and educator) gives the natural progression of the clinical skills of a medical student.[3] Early on in clinical practice students are simply reporters of information. As the student progresses and is able to link together symptoms, signs, and investigation results to come up with a differential diagnosis, he or she becomes an interpreter of information. With further development of clinical skills and increasing knowledge students are actively able to suggest management plans. Finally, managers progress to become educators. The development from reporter to manager is reflected in the student’s case presentations.

The key to improving presentation skills is to practise, practise, and then practise some more. So seize every opportunity to present to your colleagues and seniors, and reflect on the feedback you receive.[4] Additionally, by observing colleagues and doctors you can see how to and how not to present.

Top tips

  • Remember the purpose of the presentation
  • Be flexible; the context should dictate the content of the presentation
  • Always include a presenting complaint
  • Present your findings in a way that shows understanding
  • Have a system
  • Use appropriate terminology

Additional tips for exams

  • Start with a clear introductory statement and close with a brief summary
  • After your summary suggest a working diagnosis and a management plan
  • Practise, practise, practise, and get feedback
  • Present with confidence, and don’t be put off by an examiner’s poker face
  • Be honest; do not make up signs to fit in with your diagnosis
Ademola Olaitan, medical student1, Oluwakemi Okunade, final year medical student1, Jonathan Corne, consultant physician2

1University of Nottingham, 2Nottingham University Hospitals

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See “Medical ward rounds” (Student BMJ 2009;17:98-9, http://archive.student.bmj.com/issues/09/03/life/98.php).

References

  1. Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: Opinions of internal medicine clerkship directors. J Gen Intern Med 2009;24:370-3.
  2. Lingard LA, Haber RJ. What do we mean by “relevance”? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format. Acad Med 1999;74:S124-7.
  3. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74:1203-7.
  4. Haber RJ, Lingard LA. Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications. J Gen Intern Med 2001;16:308-14.

Cite this as: Student BMJ 2010;18:c1539

Thanks Joe for sharing the article!

June 06, 2010

Free OSCE Revision Videos

Click here to access OSCE revision lectures. They are by delivered by the guy who wrote the Pastest OSCE book. Apparently, they are easygoing and good for quick revision if you have spare time.

Thank you Noura for sharing the link and good luck with your exam!

June 05, 2010

What does a complex partial seizure look like?



This video illustrates what a complex partial seizure looks like. But what does this even mean? well let's have a close look !

Seizure (fit) is a transient neurological event caused by abnormal electric discharge of neurons within the cerebral hemisphere manifesting as a group of motor/sensory symptoms/signs known as seizure semiology. An individual is said to have epilepsy if he/she has ≥ 2 seizures. Epilepsy is a symptom of an underlying disease process rather than a disease on its own right.

Did you know that about 5% of the population has a single seizure at some point of their lifetime, and if we are to look at every 100,000 people in the UK, about 500 of them will have a diagnosis of epilepsy.

Seizures are often mistaken for syncope or fainting which might be accompanied by general jerkiness just like some seizures. Therefore, it is important to clearly and accurately describe what exactly happened during the event. A witnessed account of what happened is essential since seizures almost always result in memory impairment or loss of consciousness.

So, how can you describe a seizure? let's dissect the event:

PRODROME = alteration of behaviour/mood preceding the attack by hours.

AURA = symptoms occurring immediately before the attack (this is important to indicate a seizure and trace its origin within the brain. For example, unusual sudden strange smell and gut rising feeling localizes to the temporal lobe).

ICTUS = the event itself might present as violent jerky movement affecting the limbs to sudden attacks looking vacant.

POST-ICTUS = this is the period immediately after seizure symptoms. A seizure is often associated with slow recovery (> 5 min) leaving the individual confused and muddled for few minutes even after recovery.

Now we know how to describe seizures, we can move to the next part - classification of seizures. The type of seizure you saw in the video is described as 'partial'. Why is that?

The International League Against Epilepsy (ILAE) classifies seizures according to their origin of onset within the brain. A seizure can be 'generalized' or 'partial'. Generalized seizures arise from a subcortical structure and are associated with synchronized generalized abnormal neuronal firing involving BOTH HEMISPHERES and resulting in impairment of consciousness and bilateral motor manifestations. On the other hand, partial seizures arise from a FOCAL origin within the CEREBRAL CORTEX that may either remain localized or spread more generally to result in a secondary generalized seizure.

A partial seizure can be further classified into 'simple' and 'complex' based on the degree of consciousness. Patients filmed in the video are said to have complex partial seizures because they can't remember what happened and lost awareness of their surroundings. This is due to seizure activity originating in the temporal lobe involving the hippocampus and spreading to the contralateral temporal lobe resulting in amnesia. So, 'complex' means accompanied by alteration of consciousness.

The behavioural features illustrated in the video are involuntary and known as 'automatism' which occurs in 90% of complex partial seizures. As shown above, they present as fumbling movement, rubbing and chewing or as semi-purposeful limb movement (eg opening the curtins and putting on cloths) - other people won't even guess the individual is suffering from a seizure. However, patients experiencing a complex partial seizure often appear distant, staring and unresponsive.

I hope this brief article helped to explain the pattern of symptoms and signs shown in the video, and provided some clarification. Please do not hesitate to ask any questions related to the topic.

Marmots can teach us about obesity


Marmots Can Teach Us About Obesity

ScienceDaily (June 2, 2010) — A nutrient that's common to all living things can make hibernating marmots hungry -- a breakthrough that could help scientists understand human obesity and eating disorders, according to a new study by a Colorado State University biologist.

The study appears in the current issue of the Journal of Experimental Biology.

Professor Greg Florant discovered he could slowly release a molecule called AICAR into yellow-bellied marmots that activates a neurological pathway driving food intake and stimulates appetite. The pathway, which shuts down during hibernation, relies on an important balance between two energy molecules -- ATP and AMP. The lower the ratio between the two cellular molecules, the lower the energy in the cell and the more the appetite is stimulated.

Without this artificial stimulation, awake, hibernating marmots do not eat -- even when researchers place food in front of them.

"The experimental group started to feed because they thought they had this energy deficit," Florant said. "Then when the pumps dispensing the molecule finally stopped, the animals went right back into hibernation. That suggests to us that the animals are still sensing energy levels within cells during the hibernation period."

Tissue samples taken from marmots in Florant's lab allow researchers to identify biochemical processes and genes that are active during hibernation -- as opposed to genes that are active when they're feeding or engaging in other behaviors.

The American Physiological Society has called hibernators such as marmots, bears, woodchucks, hedgehogs and lemurs "medical marvels" because they can turn off their appetites and slow their breathing to a point that would be lethal to other animals.

Marmots typically hibernate for as many as six or seven months.

"You can't eat if you're asleep," Florant said. "We've discovered that perhaps nutrients within the brain, such as fatty acids, can alter the food intake pathway, which normally shuts down when marmots hibernate. The perceived drop in energy nutrients (i.e. low ATP) makes the animals think they've got an energy deficit and want to eat."

Florant said he'll conduct additional research this summer to determine whether the reverse is true: Can he stop the animals from eating when they're not hibernating?

His team will also identify neurons in the particular areas of the hypothalamus that are involved in food intake in animals. The hypothalamus is one of the master regulator areas of the brain and controls such activities as food intake, sex and temperature regulation.

"We know which neurons are driving this process," he said. "We're just trying to identify them within the marmot and distinguish what's different about the neurons in a marmot compared to a rat or other animal that does not go into hibernation."


G. L. Florant, A. M. Fenn, J. E. Healy, G. K. Wilkerson, R. J. Handa. To eat or not to eat: the effect of AICAR on food intake regulation in yellow-bellied marmots (Marmota flaviventris). Journal of Experimental Biology, 2010; 213 (12): 2031 DOI: 10.1242/jeb.039131

June 03, 2010

KIMS plans a meeting for interns

In light of changing the new regulations describing the pathway of specialty training in Kuwait, the Kuwaiti Institute of Medical Specialties (KIMS) arranged a meeting for the interns in order to address concerns regarding their future career plans (see pictures).




I thank Ali Mohsen for forwarding the above pictured documents from the facebook page of one of the junior doctors working in Kuwait.