Tuesday, March 31, 2009

Neurology Consult Service and Neurosurgery

I will be spending the next three weeks on various inpatient neurology teams: consult service this week and next week, and then inpatient neuro the last week. There is not much difference between the consult and inpatient services in terms of what we do. The main thing that distinguishes them is whether neuro is the primary team that admits the patient (inpatient), versus the secondary team that comes to see the patient at the request of the primary team (consult). Most of the consults are made by the surgery and medicine teams for patients with delirium. It's not the most interesting patient population in the world, because we had plenty of delirious patients when I was on medicine and surgery. But it's ok.

Yesterday morning, I had neurosurgery clinic, and that was a good experience for a couple of reasons. First, I got out of having to go round on the consults. Second, the patients were not seeing a surgeon for delirium! The surgeon had a cool operation planned for that afternoon, which she said I could scrub for if I wanted. I got permission from my resident to go scrub, and it was one of the most amazing things I have ever seen since I started medical school.

The patient was a teacher who began having headaches several months ago. The headaches got worse and worse, and he also started having seizures even though he had never been diagnosed with epilepsy before. An MRI of his brain showed that he had an enormous tumor. The surgeon had already operated on him once but couldn't get all of the tumor out because it was too close to vital brain structures. So the patient had come back to have a special surgery done where a neurologist would help the neurosurgeon figure out how much tumor debulking (removal) could be done without affecting the patient's mental functioning.

Although the patient had gotten local anesthetic, he was awake while the surgeon was working on removing the tumor. He had to be awake so that the neurologist could test his cognition. While the surgeon was cutting away slices of his tumor and brain, the neurologist had him doing tasks like counting, identifying pictures on notecards, reading words, and performing mathematical calculations. At one point, the patient was counting, "20, 21, 22, 22, 22, 27...." When that happened, the neurologist told the neurosurgeon not to cut any deeper. There was still tumor left, but the surgeon couldn't remove any more of it without putting the patient at risk. So at that point they starting closing the wound and the surgery was over.

One thing you may be wondering is whether the patient was in a lot of pain while the surgeon was cutting into his brain. Although all of your body's pain receptors go to the brain, there are no pain receptors in the brain itself. So once the surgeon had removed the patient's scalp, skull, and dura (the tough covering of the brain), the patient didn't feel any pain in his brain. Also, after the neurologist told the neurosurgeon to stop cutting, the anesthesiologist did put the patient to sleep so that he wouldn't have any pain while they were replacing his skull and scalp.

Today was a regular day on consult service, and as I said before, we mainly got a bunch of delirium consults. I did an H&P (history and physical) on one patient, which can be a pain sometimes if the patient is delirious. That's because they aren't the most reliable historians, and sometimes they don't want to cooperate with being examined. But I didn't have any problem with that today. Also, I don't have to preround tomorrow because I have a second morning of neurosurgery clinic. That's the last opportunity I will have to escape being on consult, unfortunately.

I should mention that I really like my senior resident, but the attending seems kind of unenthusiastic about neurology and even life in general. I'm feeling like this could be a long two weeks.

Friday, March 27, 2009

LCME Site Visit and Neuro Rotation

Case's LCME review began on March 22. (Remember, the LCME is the organization that accredits all American and Canadian allopathic medical schools.) The review took place over several days because the committee members had to meet with various faculty, administrators, and students on both campuses. I attended the clinical student meeting, which was held over at Case during lunchtime on Wednesday. Since I was scheduled to have outpatient neurology clinics that day, I was given permission to leave the morning clinic half an hour early and come back to afternoon clinic an hour late. Unfortunately, somehow no one told my afternoon preceptor that I would be late, so I had some explaining to do once I got to his clinic!

After all the flurries of emails we got from the administration, the meeting itself was kind of anticlimactic. There were two other CCLCM upperclassmen, as well as several UP upperclassmen and several reviewers. I think the reviewers are all administrators of some type at other medical schools. Most of the questions they asked us were pretty basic things, like who we would contact if we got stuck by a needle (depends on the hospital, but at CCF, you call the exposure hotline). Surprisingly, the reviewers wanted to know if our rotations required more than 80 hours per week. That work-week limit is actually for residents, not medical students, but Case has an 80 hour work-week rule in place for us anyway. We also got asked about why the OB/gyn rotation had received such low evaluations by M3s and M4s in both programs. I haven't done OB/gyn yet, so I couldn't add much to this discussion. But I was already dreading it based on the horror show stories I've heard from friends, and today's discussion didn't do much to allay my fears. :-P

It will take a couple of months for the reviewers to decide whether our school can be reaccredited. Once the LCME decides that we've passed muster, Case will be accredited until the 2016-2017 academic year. That's a long time. To put it in perspective, I will be done not only with residency but even with fellowship by then, assuming I do a fellowship.

This week, I also had some neuro peds clinics that were kind of awkward. Since I haven't had peds yet, I don't know very much about the development of children, and the pimping was pretty painful for me. One child's parents had brought their 14-month-old toddler in because the child wasn't walking yet. The attending asked me in front of the parents if this was normal or not. Beats me! I have no idea what age children normally learn to walk. It's not like I have any kids at home to study! (For the record, children learn to walk around age 12 months, but it is not considered to be a problem unless they're still not walking after around 15-18 months.)

On my last day in the headache clinic, I had a patient with trigeminal neuralgia. This is a pain syndrome that occurs in the distribution of the fifth cranial nerve (the trigeminal nerve). The patient gets an intense, shooting pain down one or more branches of the nerve. Commonly, the second branch (V2), which innervates the middle of the face, is affected. (See picture.) It's not known exactly why trigeminal neuralgia occurs, but it may be associated with a blood vessel compressing the nerve. When I examined the patient, I unfortunately reproduced her pain, even though I tapped her face lightly.

One other thing I learned was that I haven't been using the reflex hammer correctly. My preceptor explained that it should be more of a movement in the wrist, and I've apparently been using my entire arm too much. I practiced on several patients, and she said I am starting to get the hang of it. Who ever knew that hitting people's tendons with a hammer could require such perfection of technique!

Tuesday, March 24, 2009

Starting Neuro Rotation

This is my first week on neurology. So far, it's been really intense! Not that I expected it to be a cakewalk, but the Block III* administrator went out of her way several times to warn us about not missing conferences, and to emphasize that we have to go straight from the conferences to our clinical responsibilities. We have conferences twice a day (morning and noon), and I'm on outpatient this week, so there's really not any downtime for me to read about my patients or catch up with my logs. I feel frustrated, because by the time I get home at night, I've already seen too many patients to even remember them all.

I went to talk to my physician advisor about this problem, because it was making me feel a little stressed. Now, my PA is not the type of person who would ever condone slacking, but she did suggest that I could probably take a little time here and there to chill out and read. We agreed that I certainly should not ever miss any of the required clinical time or the teaching conferences specifically created for the students, but that maybe missing the resident-oriented conferences once in a while might be ok. I thought that was a fair compromise, and it is helping me relax and enjoy the rotation a little more.

The actual clinic part has been pretty interesting so far. There are several different kinds of specialized neuro clinics, and I think it's kind of random which ones we get assigned to work in. Some of the other students are doing Parkinson's or MS clinics, which I didn't get. But I have a couple of days of headache clinic, and it's really interesting. There is a program at CCF called IMATCH, which is for patients who have chronic headaches. It's common to see patients with medication rebound headaches. These are chronic headaches that are due to taking too much pain medication. If the patient tries to stop taking the medications, the headaches come back with a vengeance, so they keep taking more and more of them. That just feeds the vicious cycle.

IMATCH patients spend three weeks coming to the headache clinic. In the first week, they start by getting a multidisciplinary evaluation by neurologists and psychologists. This is to help determine what kind of help they will need to overcome their headaches, or at least to learn to manage the pain to a tolerable level. For the rest of the first week, the patients lie in a dark room, where they get IV infusions of pain medicine. This is tapered down over time to help break their dependence on pain meds. Patients also get physical therapy and counseling to help them cope better with the discomfort and manage headaches more effectively.

For the record, I have a lot of sympathy for people who have migraines. I get migraines myself, but sometimes I have to go out and do things anyway even though I have a migraine. If I take medicine to abort the headache to a more dull pain, I can usually do my work even with that background level of pain. It's not the most comfortable, but it's doable. So I asked my preceptor how bad a person's migraines have to get before they become so crippling that the patient can't function normally anymore. She told me that the difference between me and the patients who get seen at the clinic is that I have pain, but they have a pain syndrome. The pain controls their lives, and they feel too helpless to live their lives normally. She also explained that it was important to make the patient's expectations more realistic. Even when I take pain medications, I understand that the headache may not go away completely, and I don't expect to be completely pain-free. Apparently some patients have difficulty coping with any pain at all.

I have one more day in the headache clinic this week. Even though the headache clinic is really interesting, I'm kind of disappointed that I won't get to do all of the other clinics too. But I'm glad that I had some time to see how the IMATCH program works. Plus, the preceptors who work in the headache clinic are really good and like to teach. I can already tell that neurologists are impressively smart and knowledgeable about medicine.

*Note that Block III in the new curriculum is an eight week block for neurology and psychiatry. I am part of the last group of students going through the old curriculum, which didn't have a Block III, but we are taking these two rotations with the first group of students going through the new curriculum. Don't worry about it if you're confused, because all of us are, too. :-P

Saturday, March 21, 2009

Master CCLCM Match List

This post contains the combined match list for all CCLCM graduation years by specialty and hospital. I will keep updating this list as future classes match.

-Cleveland Clinic (2009)

-Yale (2009)

Emergency Medicine
-Cincinnati (2009)

General Surgery
-Brown (2009)
-Wash U (2009)

Internal Medicine
-Beth Israel (Harvard--2009)
-Cornell (2009)
-Duke (2009)
-Michigan (2009)
-Stanford (2009)
-UNC (2009)
-Vanderbilt (2009)
-Yale (2009)

-Emory (2009)
-George Washington (2009)

-Beth Israel (Harvard--2009)
-U. Hawaii (2009)

-Cleveland Clinic (2009)
-UCSD (2009)

-Hospital for Special Surgery (Cornell-2009)
-UCSD (2009)
-Utah (2009)

-Mass General (Harvard--2009)

-CHOP (U Penn--2009)
-Duke (2009)

Rad Onc
-Rochester (2009)

-U Penn (2009)

-Cleveland Clinic (2009)
-Wake Forest (2009)

Friday, March 20, 2009

End of Rads

On Wednesday, I finished writing my teaching case report, which is on something kind of esoteric that the attending will hopefully find interesting. I'm still not at all enthusiastic about rads, but I can honestly say that I feel a little more comfortable with reading films. So at least that's something--not that it makes me feel any better about having my circadian rhythm knocked totally out of whack because of sitting in a dark room all morning. Adding to my general sense of misery, it seems like the UH radiology department is one giant petri dish these days. Whatever it was that was going around has now come around to me, and I've been sick all week.

At least it's over now. I'm sure in another week or two I'll be on call, and I'll start looking back on these last two weeks as some kind of nirvana of getting out by 1 PM every day. But wow, as important as knowing how to read films is, I can't imagine a specialty that could possibly be more effective at inducing me to fall asleep instantly than radiology. I honestly don't know how people do it for an entire career. But the radiologists have my utmost respect, not only because they enjoy this stuff, but because they have an extremely impressive command of anatomy. In particular, they have a very good sense of where tiny objects like blood vessels are located in three-dimensional space, which is something that I often don't quite have the knack for.

The LCME site visit starts this weekend, and the administration is tense on both campuses. All week long, Dean Franco has been sending us emails about LCME things, reminding us about what we have to do, how to act, etc., over and over. I've reached the point where I don't read the emails any more. It's not like an LCME site visit is something you can study for, and it's not like I'm going to jeopardize Case's accreditation by behaving unprofessionally at the meeting!

Thursday, March 19, 2009

2009 CCLCM Match List

Match Day! Things were pretty quiet in the UH radiology department today, since all of the M4s were gone for match day. We found out today how our own first graduating CCLCM class did in the match. All of the students matched.* For those who are interested, here is the much-anticipated 2009 CCLCM Match List:

-Cleveland Clinic


Emergency Medicine

General Surgery
-Wash U

Internal Medicine
-Beth Israel (Harvard)

-George Washington

-Beth Israel (Harvard)

-Cleveland Clinic

-Hospital for Special Surgery (Cornell)

-Mass General (Harvard)

-CHOP (U Penn)

Rad Onc

-U Penn

-Cleveland Clinic
-Wake Forest

*You may have noticed that there are only 29 CCLCM students who entered the match. One student in the first class left med school at the end of the first year, and two others have postponed entering the match in order to earn additional degrees.

You may also be interested in reading the Cleveland Plain Dealer's article about the first CCLCM match.

Friday, March 13, 2009


This week, I started a two-week radiology elective at UH. I had wanted to do it at CCF, but the radiologists there only let people do rads for four weeks. I can't do four weeks since I have to start my next core block of rotations in two weeks. This was probably a blessing in disguise, because radiology has to be the most boring rotation I have ever done.

Picture this: we come in at 8 AM each morning for an hour-long conference that mainly consists of people throwing films up and droning on about them. The room is nice and warm and dark. Actually, so are the rooms where the radiologists read the slides. Some of the residents enjoy teaching, but many basically ignore us. So I've been spending most of my mornings either reading or dozing off, depending on my inclination.

At noon, there is a second conference, similar to the first. By then, I am usually too hungry to doze off, so I read my radiology case book. This is not a required book. I just bought it on my own so that I could hopefully learn something about radiology. After lunch, all of the med students clear out. That is the best part of each day.

So far, I have rotated through ultrasound, chest imaging, ER/bone, nuclear medicine (by far the most interesting), and CT. But overall, the interesting : boring ratio is way too low for this rotation to be of much use. It's not just me who feels this way--one of the other med students dropped the rotation altogether a couple of days ago.

Besides boring me to death, this rotation is totally disrupting my circadian rhythm. After I've been dozing off in a dark room all morning, it's not so easy to fall asleep at a reasonable hour that night!

Friday, March 06, 2009

CAM Paper Part IX: Conclusion and References

Although some physicians may be skeptical about the benefits of CAM, they should still educate themselves about CAM for several reasons. First, a significant proportion of patients seen in a primary care setting would like to try CAM or are already using it. These patients may ask their physicians for advice about CAM therapies they have seen on the internet or heard about from friends. One survey study found that patients who use CAM expect their physicians to be knowledgeable about CAM and to make referrals for CAM treatments as appropriate.(4)

Second, patients are often misinformed about CAM modalities, and they are at significant risk of making misguided decisions based upon unreliable information.(2) Informed physicians are in a better position to empower their patients to make informed decisions about the pros and cons of CAM. Physicians can also play a significant role in guiding patients away from harmful CAM therapies, as well as steering them toward alternative CAM therapies that do not interact with conventional drugs that patients may also be taking.

Finally, a physician who is indifferent or openly negative about CAM may undermine the trust between patient and physician by making it difficult for the patient to initiate a discussion about CAM. There is evidence that younger physicians tend to regard CAM more positively compared to older physicians, which may facilitate discussion of CAM by younger physicians.(3) However, all physicians should be prepared to objectively discuss CAM with patients, even physicians who are skeptical about the benefits of CAM. Approaching patients who inquire about CAM with a nonjudgmental attitude provides the physician with an opportunity to improve the therapeutic relationship while educating the patient.

1. Barnes PM, Powell-Griner E, McFann K, Nahin RL: Complementary and alternative medicine use among adults: United States, 2002. Seminars in Integrative Medicine 2004; 2: 54-71

2. Ernst E: How the public is being misled about complementary/alternative medicine. J R Soc Med 2008; 101: 528-530

3. Sewitch MJ, Cepoiu M, Rigillo N, Sproule D: A Literature Review of Health Care Professional Attitudes Toward Complementary and Alternative Medicine. Complementary Health Practice Review 2008; 13: 139-154

4. Ben-Arye E, Frenkel M, Klein A, Scharf M: Attitudes toward integration of complementary and alternative medicine in primary care: Perspectives of patients, physicians and complementary practitioners. Patient Education and Counseling 2008; 70: 395-402

5. Riccard C, Skelton M: Comparative analysis of 1st, 2nd, and 4th year MD students' attitudes toward Complementary Alternative Medicine (CAM). BMC Research Notes 2008; 1: 84

6. Moyer CA, Rounds J, Hannum JW: A meta-analysis of massage therapy research. Psychol Bull 2004; 130: 3-18

7. Ernst E: Chiropractic: A Critical Evaluation. Journal of Pain and Symptom Management 2008; 35: 544-562

8. Keating JCC, K. H.; Grod, J. P.; Perle, S. M.; Sikorski, D.; Winterstein, J. F.: Subluxation: dogma or science? Chiropractic & Osteopathy 2005; 13: 17-26

9. Miller K: The evolution of professional identity: the case of osteopathic medicine. Social Science & Medicine 1998; 47: 1739-1748

10. Gevitz N: Center or Periphery? The Future of Osteopathic Principles and Practices. J Am Osteopath Assoc 2006; 106: 121-129

11. Ernst E: Acupuncture – a critical analysis, Journal of Internal Medicine, Blackwell Publishing Limited, 2006, pp 125-137

12. Martin DP, Sletten CD, Williams BA, Berger IH: Improvement in Fibromyalgia Symptoms With Acupuncture: Results of a Randomized Controlled Trial. Mayo Clinic Proceedings 2006; 81: 749-757

13. Shapiro K: Natural Products: A Case-Based Approach for Health Care Professionals. Washington, D.C., American Pharmacists Association, 2006

14. Clark K: Nutrition Strategies for Managing Joint Pain, The Professionals’ Guide to Diet, Nutrition and Healthy Eating IDEA Health & Fitness Association, 2004, pp 62-65

15. Wheatley D: Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability. J Psychopharmacol 2005; 19: 414-421

16. Westfall RE: Use of anti-emetic herbs in pregnancy: women's choices, and the question of safety and efficacy. Complementary Therapies in Nursing and Midwifery 2004; 10: 30-36

Thursday, March 05, 2009

CAM Paper Part VIII: Herbal Remedies III

Several herbs are used to treat nausea, most commonly ginger, peppermint, and cannabis. All three have been shown to have mild anti-emetic properties for chemotherapy, motion sickness, and post-operative nausea. Only ginger has been shown in clinical trials to be effective for morning sickness, but anecdotal reports suggest that peppermint and cannabis smoking are also effective for morning sickness. Cannabis in particular has a long history of being used to treat chemotherapy-induced and HIV drug-induced nausea. Ginger and peppermint should be used cautiously in pregnancy due to a possible risk that they promote menstruation. There does not appear to be any contraindication for the use of cannabis in low to moderate doses.(16)

Cold and Flu
The most popular herbal remedy used to treat cold symptoms is echinacea; in fact, echinacea is the most popular herbal remedy on the U.S. market in general. Although it is very popular and has a long history of use, echinacea may not be very efficacious against cold symptoms. Some studies did find that echinacea could shorten the duration of a cold by one or two days. In addition, there is no evidence that echinacea can be used prophylactically to prevent colds. There are few side effects due to echinacea, but people who are allergic to ragweed and other pollens may be at risk of having an allergic reaction.(13)

Other popular natural products use to treat colds include vitamin C and zinc. These two agents may provide a modest decrease in cold symptoms, but the evidence in favor of either agent is not very strong. Vitamin C is generally safe, although it may cause GI symptoms at very high doses. Zinc can cause anosmia (loss of the sense of smell) if taken intranasally. As with echinacea, neither zinc nor vitamin C can be used as a prophylactic to prevent catching a cold.(13)

Common natural products used to treat the flu include elderberry and ginseng. Elderberry appears to have reasonably good efficacy in reducing the duration of flu symptoms based upon the results of two clinical trials. The main side effect is GI symptoms. Ginseng may be useful as prophylaxis against the flu based on two preliminary trials. However, it has some potentially troublesome side effects, including insomnia and possibly cardiac effects. Oscillococcinum is a popular homeopathic remedy used to treat the flu. Since it contains no active ingredient and is considered to be a placebo, there is no contraindication against it.(13)

Cholesterol Reduction and Cardiovascular Disease
Common natural products used to lower cholesterol include dietary oats, psyllium fiber, soy, plant sterols, policosanol, garlic, and omega-3 fatty acids. The effect of eating oatmeal is very mild, yielding a drop in LDL of about 6 mg/dL. One clove of fresh garlic per day can lower total cholesterol about 5%. Psyllium, plant sterols and soy can decrease LDL about 10%. Policosanol, a waxy substance that can be made from beeswax, can decrease LDL around 20%, and also increase HDL about 20%. Omega-3 fatty acids are used to lower triglycerides. None of these compounds has any major side effects, but policosanol, garlic, and omega-3 fatty acids could possibly increase some people’s risk of bleeding.(13)

Along with garlic and omega-3 fatty acids, other compounds used for primary and secondary prevention of cardiac disease include coenzyme Q10, hawthorn, arginine, and carnitine. Coenzyme Q10 decreases blood pressure and improves heart failure symptoms, and has few side effects. It should not be used concurrently with doxorubicin. Hawthorn appears to improve heart failure symptoms and increase exercise capacity. It may potentiate the effects of digoxin. The amino acids arginine and carnitine are well-tolerated and improve exercise capacity in patients with heart failure. Vitamin E should not be recommended, as it does not decrease the risk of cardiovascular disease. In fact, the mortality rate increases with high dose vitamin E.(13)

Wednesday, March 04, 2009

CAM Paper Part VII: Herbal Remedies II

Benign Prostatic Hyperplasia
Saw palmetto extract can be used to treat benign prostatic hyperplasia (BPH). It inhibits 5-α-reductase, the same enzyme inhibited by the prescription drug finasteride, thereby preventing the conversion of testosterone to dihydrotestosterone. Studies show that saw palmetto is efficacious and generally well-tolerated. Other natural products used to treat BPH include pygeum and stinging nettle. Pygeum works by a different, poorly understood mechanism. The limited published data support its efficacy, and it is well-tolerated. There is no evidence to support the use of stinging nettle for BPH.(13)

Menopause Symptoms
Black cohosh and soy are two commonly used natural products that may provide some relief to post-menopausal women suffering from symptoms like hot flashes, night sweats, vaginal dryness, mood disturbance, and poor sleep. Soy, as mentioned previously, has few side effects except that there is potentially a risk in women with a history of breast cancer due to the phytoestrogens. Black cohosh is thought to work by stimulating estrogen receptors, although it is not an estrogen analog. As with soy, there is a possible risk due to black cohosh in women with a history of breast cancer. In addition, black cohosh has been associated with liver damage in rare cases. Other natural products sometimes used to treat menopausal symptoms include dong quai and evening primrose oil. Neither of these extracts has been shown to have any efficacy.(13)

Although bioidentical hormone replacement therapy (BHRT) is actually a synthetic product, some women prefer it since the hormones are identical to the hormones present in pre-menopausal women. In contrast, prescription drugs like Premarin, which actually is a natural product, contain different estrogens that are not present in humans. BHRT is customized for each woman, which may help decrease the incidence of side effects. As with conventional hormone replacement therapy, BHRT should be used at the lowest possible dose for the shortest required amount of time. The risks of BHRT are thought to be similar to the risks due to HRT, possibly including increased chances of cardiovascular events, breast cancer, endometrial cancer, and clots.(13)

St. John’s Wort is a popular natural product used to treat depression. The extract contains several compounds that are thought to affect mood, probably by inhibiting reuptake of monoamines. This mechanism of action is similar to the mechanism of TCAs. However, there is also evidence that the active components of St. John’s wort affect other neurotransmitters like GABA and glutamate as well. There is evidence that St. John’s wort is effective in mild to moderate depression, but not in severe depression. Common side effects include GI upset, skin reactions, and sexual side effects. More worrisome is that St. John’s wort has many interactions with other drugs since it induces multiple CYP 450 enzymes. St. John’s wort may also be teratogenic and should not be used by pregnant women. Finally, since St. John’s wort prevents the reuptake of serotonin, it should not be used along with serotonergic prescription drugs such as MAOIs and SSRIs because of the possibility of serotonin syndrome.(13)

Other natural products that are used for depression include SAMe, inositol, and omega-3 fatty acids. The data for SAMe suggests that it has some efficacy in depression, but SAMe can cause a manic episode if it is taken by bipolar patients. The data on omega-3 fatty acids also are suggestive of efficacy in depression. However, the data for inositol are too preliminary for it to be recommended currently. Regardless of which agent is given, any patient with depression, especially major depression, requires psychiatric care.(13)

Insomnia and Anxiety
The sleep-inducing properties of kava kava are well known. Kava kava extract rapidly induces sleep and does not seem to cause any long-term side effects during the day following its use. Although kava kava appears to be efficacious in treating anxiety and insomnia, it has been banned in several countries due to its potential to cause serious side effects. Specifically, several case reports of patients who developed hepatitis severe enough to require a liver transplant have been published. At this time, kava kava is still available in the United States as an unregulated dietary supplement. However, it should not be used by alcoholics or other patients who have liver disease.(15)

Valerian is a safer and therefore more promising alternative to kava kava for insomnia and anxiety. It appears to induce a natural sleep pattern after being used for several weeks, and there is no evidence that it is habit-forming or has any significant side effects other than causing vivid dreams. The one potential downside of valerian is that the onset of action is several weeks, and patients may need to use a stopgap hypnotic like a benzodiazepine while waiting for the valerian to take effect. However, although valerian does not seem to effectively induce sleep acutely, it does aid with maintaining good sleep patterns over the long term. It also appears to decrease sleep latency and increase the amount of slow-wave sleep, both of which promote a greater feeling of being well-rested the following day. These qualities may make valerian useful as a treatment for chronic insomnia, especially in the elderly.(15)

Another promising herbal treatment for insomnia and anxiety is aromatherapy with essential oils like lavender and chamomile. Lavender is commonly used as the oil rather than ingested, while chamomile is usually ingested as a tea. In both cases, it appears to be inhalation of the essential oil that produces the hypnotic effect.(15)

Tuesday, March 03, 2009

CAM Paper Part VI: Herbal Remedies I

Herbal remedies and other natural products were used by 19% of adults during the past 12 months according to a 2002 survey.(1) The ten most commonly used herbal remedies were echinacea, ginseng, ginkgo biloba, garlic supplements, glucosamine, St. John’s wort, peppermint, flax and fish oils, ginger, and soy.(1,13) Other commonly used herbal remedies include chamomile, bee pollen, kava kava, valerian, and saw palmetto.(1) Some common natural products are described below in relation to the conditions they are used to treat.

Ginkgo biloba is an extract from the leaves of the ginkgo tree that contains multiple natural products. It is used to treat Alzheimer’s dementia instead of or along with acetylcholinesterase inhibitors like donepezil. Studies have found that modest memory improvement can occur with use. The mechanism of action of ginkgo biloba is not known, but it is thought to be related to the extract’s anti-inflammatory properties. In addition, the flavonoid component of the extract is an antioxidant that scavenges the free radicals thought to be involved in the pathology of dementia. The most commonly reported side effect of ginkgo biloba is gastrointestinal symptoms. However, ginkgo biloba antagonizes anti-platelet factor, thereby inhibiting platelet aggregation. Thus, physicians should be aware of the potential for bleeding with ginkgo biloba use, especially if the patient is taking anticoagulants. In addition, gingko should be discontinued for several days before the patient undergoes elective surgery.(13)

Other natural products sometimes used for treatment of dementia include huperzine A and high dose vitamin E. Huperzine A is a natural acetylcholinesterase inhibitor that appears to be as effective in treating dementia as prescription acetylcholinesterase inhibitors. There is some evidence that high dose vitamin E may slow dementia progression. However, the doses required for this use are toxic. Thus, vitamin E should not be recommended to patients for the treatment of dementia.(13)

Glucosamine and chondroitin are the most popular natural products used to treat arthritis. Both are normal components of cartilage. Glucosamine may stimulate synthesis of proteoglycans and glycosaminoglycans by chondrocytes, as well as inhibit cartilage breakdown. Chondroitin also stimulates chondrocytes to synthesize cartilage components, as well as having anti-inflammatory properties. Not only do both supplements show efficacy against pain in clinical trials of moderate to severe osteoarthritis, but glucosamine may even retard progression of the disease. Since they have different mechanisms of action, glucosamine and chondroitin are often used together. The onset of action for both compounds requires several weeks, and patients should take other pain-relievers such as NSAIDs in the interim. In addition, diabetic patients taking glucosamine may have an increase in blood sugar levels. Chondroitin appears to have some anti-coagulant activity, and this should be considered in patients taking prescription anticoagulants. Chondroitin is contraindicated in men with prostate cancer since one of its components (versican) is overexpressed in prostate cancer.(13)

Other natural products used in the treatment of osteoarthritis include S-adenosylmethionine (SAMe), capsaicin, avocado/soybean oils, and omega-3 oils. SAMe appears to be effective for symptom reduction. However, it is expensive, and the quality of supplements is highly variable. In addition, SAMe should be avoided in patients who are taking other serotonergic drugs, as well as in patients with bipolar disease. Capsaicin is effective for relieving limb osteoarthritis and other musculoskeletal conditions. Its biggest advantage is that it is topically applied. Avocado/soybean oils appear to be beneficial for osteoarthritis, have no side effects, and can be used along with glucosamine/chondroitin.(13) Omega-3 fatty acids are found in fish and flaxseed oils. There is some evidence that they have anti-inflammatory effects. Although osteoarthritis is not initially an inflammatory disease, many patients do develop an inflammatory component as the disease progresses. Omega-3 fatty acids may have an anti-coagulant effect in high doses (over 3 grams), which should be considered in patients on prescription anti-coagulants.(13,14)

The most common supplements taking to prevent onset or progression of osteoporosis are calcium and vitamin D. However, natural products like soy and ipriflavone are also used. Ipriflavone has the strongest evidence in favor of its use, but its effects are significantly less than those of prescription drugs like bisphosphonates. In addition, ipriflavone may increase the concentration of other drugs by inhibiting cytochrome P450 enzymes, and it can cause lymphocytopenia in some patients.(13)

There is less evidence in favor of increased consumption of soy-based foods for decreasing the risk of osteoporosis. However, soy consumption has multiple other benefits. These include improvement of post-menopausal symptoms and a decreased cholesterol level. In addition, there are no side effects due to eating soy, with the possible exception of women with a history of breast cancer due to phytoestrogens present in soy. In general, natural products like ipriflavone and dietary supplements like soy can be used to help prevent development of osteoporosis. However, women who already have osteoporosis will almost certainly require a prescription drug like a bisphosphonate.(13)

Monday, March 02, 2009

CAM Paper Part V: Acupuncture

Although the practice of acupuncture is commonly associated with traditional Chinese medicine, there is evidence that acupuncture actually dates back several thousand years in the histories of both Eastern and Western medicine. The Chinese conception of acupuncture revolves around the idea of qi, or vital energy. More specifically, traditional Chinese medicine holds that health is a state of balance between two opposing forms of qi called yin and yang. According to this theory, each person inherits a form of qi that circulates throughout 14 meridians (channels) in the body, thereby nourishing and defending it. Diseases are thought to be caused by a disturbance or blockage of qi, which leads to an imbalance of yin and yang. Thus, the purpose of acupuncture is to correct this energy disturbance and bring yin and yang back into balance.(11)

Several theories have been proposed to explain how acupuncture alleviates pain, and there is some evidence in the literature that supports these ideas. Examples include stimulation of A delta fibers in the skin, activation of enkephalin-producing interneurons, release of endorphins, activation of descending pain control pathways, and modulation of the pain control center in the brain. In addition, modern practitioners sometimes associate yin and yang with the sympathetic and parasympathetic divisions of the autonomic nervous system.(11)

Acupuncture involves inserting fine needles into any of 365 specific points on the meridians. (The number of points was chosen to correspond to the number of days in a year.) Needles may be used alone therapeutically, or they may be used along with electrical stimulation, ultrasound, or heat. Conditions that are commonly treated with acupuncture include back pain, myofascial pain, and arthritis. There is some evidence that acupuncture is useful for treating some forms of pain and certain other conditions, including fibromyalgia, nausea and chronic back pain.(11,12) However, other conditions do not appear to be effectively treated with acupuncture, such as headaches.(11)

Despite the existence of multiple studies showing improvement in several conditions after acupuncture treatment, there is a strong possibility that acupuncture is mainly effective due to the placebo effect. The original acupuncture studies showing efficacy were necessarily performed unblinded; that is, both the patient and the acupuncturist knew whether or not the patient had received acupuncture. However, when sham acupuncture is used as a control in acupuncture-naïve patients (a single-blinded design), most studies show no difference in improvement between the groups. Patients who choose to try acupuncture commonly cite the possibility that it will help, curiosity, and their belief that conventional medicine will not help. Thus, it appears that the patient’s beliefs about the effects of acupuncture have a strong effect on their subjective perception of pain.(11)

I was able to observe the importance of patient belief in the effectiveness of acupuncture. Those patients who had the most confidence in the treatment reported the greatest relief of their symptoms. The acupuncturist, a practitioner of traditional Chinese medicine, mainly treated patients suffering from chronic pain conditions such as osteoarthritis. He attributed his patients’ problems to “weakness” in certain organs, especially the liver, kidneys, and heart. Beyond that, the acupuncturist did not really explain the causes of the patient’s problem or how his therapies worked. He did not ever mention concepts such as qi, yin, and yang. In fact, when patients directly asked him how he knew a particular organ was weak, he would respond that his diagnosis was based on prior experience. Essentially, he was asking the patients to trust his judgment without any explanation at all. Unsurprisingly, the more skeptical patients did not benefit as much from their treatments.

Each acupuncture treatment began with an examination of the patient’s energy. If the acupuncturist felt that the patient’s energy was low, he would have the patient go into a special room set aside for raising energy. Here, the patient would be asked to hold a metal bar in each hand. The metal bar was connected to a machine that provided electrical stimulation. The patient would sit holding the bars for several minutes, and would then be moved to another room for the acupuncture treatment. After having the patient lie down, the acupuncturist would insert needles one by one, usually in the patient’s feet, legs, hands, and arms. Some patients also got needles in their ears, forehead, and neck. It was not made clear how the acupuncturist decided where the needles were needed. Finally, the needles were connected to a machine that provided electrical stimulation.

Along with needles, the acupuncturist used several other modalities. For example, he asked one patient whom he diagnosed with a weak heart to take a Chinese herbal remedy that he said would strengthen her heart. The bottle’s label was printed in Chinese, and there was no way for the patient or me to know what was in it. She asked him what it did, but all he would say was that it would help her weak heart. Another patient who was diagnosed with a weak liver was treated with a magnet placed over the right side of her abdomen. The acupuncturist also manipulated this patient’s energy level by passing his hands over her body without touching her. This patient had full faith in the efficacy of acupuncture, and she reported having significant pain relief.

I came away from this experience feeling very skeptical of acupuncture for at least two reasons. First, unlike the chiropractor, the acupuncturist made no pretense of being a physician or using science in his treatments. His diagnoses of weak organs do not have any correspondence with any diseases recognized in Western medicine. Even more discomforting, the acupuncturist made no effort to offer explanations or education. In fact, he discouraged patient questioning by simply saying that he knew what he was doing based on experience. It is possible that this implicit command to just trust him was at least in part a cultural disconnect, but his attitude would probably not be acceptable to many Western patients.

Friday, February 27, 2009

CAM Paper Part IV: Osteopathy

Osteopathy is now regarded as a part of conventional medicine. Osteopathic physicians, who make up approximately 5.5% of American physicians, are fully licensed in all 50 states and have the same scope of practice as allopathic physicians. In addition, there is no longer a significant difference between allopathic and osteopathic medical school curriculums, and osteopathic principles like holistic medicine have been adopted by allopathic physicians.(9) However, since osteopathy arose as a competitor to allopathic medicine in response to the inadequacies of allopathic medicine of that time, a discussion of osteopathy is still appropriate here.

Andrew Taylor Still, the founder of osteopathy, was deeply affected by the inability of allopathic medicine to save his children from dying of meningitis. He became a harsh critic of many then common medical practices like blood-letting and purging, which he felt did more harm than good. Several of the principles advocated by Still continue to form the philosophical basis of osteopathic medicine today. These include focusing on health rather than disease, treatment of the entire patient rather than a reductionist approach, and relating the structure of the body to its function.(9,10) In the early days of osteopathy, practitioners treated patients with musculoskeletal manipulation (osteopathic manipulative treatment, or OMT) in order to restore their structural integrity and thereby their health. Still and other early osteopaths were opposed to the use of drugs, although osteopaths later acknowledged the importance of teaching pharmacology to their students and noted that drugs were useful and even necessary in some situations.(9)

Osteopathic principles and practice are heavily intertwined with competing medical systems. For example, although allopathic medicine is widely considered as following in the tradition of Hippocrates, the reductionist perspective that has historically characterized allopathic medicine was actually espoused by a second school of medicine that was the rival of Hippocrates. In contrast, the osteopathic principle of restoring the natural condition of the body to promote health is more in keeping with the ideas espoused by Hippocrates.(9) Second, many of the ideas held by Still were also held by Palmer, the founder of chiropractic, including an aversion to the use of drugs, rejection of the microbial theory of disease, and the belief that manipulation could be used to treat all human diseases.(7,9) In fact, some evidence suggests that Palmer learned his manipulation techniques from Still.(7) In spite of these similarities, osteopathy, unlike chiropractic, evolved over time to become part of conventional medicine.

In modern osteopathic practice, there continues to be overlap between osteopathy and these two other medical systems. An osteopathic physician’s office and practice are indistinguishable from any allopathic physician’s office and practice. Patients come in with the same complaints of sore throats and back pain. However, there is potentially some difference in how osteopathic and allopathic physicians treat patients who present with musculoskeletal pain. This is because an osteopathic physician may choose to use OMT along with or instead of muscle relaxing-drugs.

Upon observing an osteopathic physician perform OMT, I was struck by how similar it is to chiropractic musculoskeletal manipulation. In addition, the osteopathic physician and chiropractor used the same accessory modalities to treat patients with musculoskeletal pain, including heat, cold, and ultrasound. However, this osteopathic physician rarely performs OMT in his practice, in keeping with published reports that only a minority of osteopaths commonly treat their patients with OMT.(10) He pointed out that the current health care system often makes it financially and temporally impractical to perform OMT even when it would be helpful. For example, he is not able to bill many HMOs for OMT. Also, he does not have time to perform OMT when he must book patients every 15 minutes in order to keep his practice solvent.

Thursday, February 26, 2009

CAM Paper Part III: Chiropractic

Chiropractic was defined by Daniel Palmer, its founder, as “a science of healing without drugs.” However, the underpinnings of chiropractic are not rooted in science. In fact, Palmer himself noted that chiropractic ideas could not be researched or subjected to experiments, and he considered chiropractic to be akin to a religion.(7)

The theory behind chiropractic is that disease is caused by spinal subluxations.(7) In medicine, subluxation is the term for a partial joint dislocation. However, this word is used differently in chiropractic, where a subluxation is a more abstract construct that refers to functional or structural changes in the musculoskeletal system. These changes are thought to compromise the integrity of the nervous system, thereby affecting the patient’s organs and health.(8) Palmer furthermore wrote of what he called innate intelligence, which is related to the body’s ability to heal itself. This innate intelligence cannot function properly in the presence of subluxations. Thus, the goal of chiropractic is to detect and correct subluxations via spinal manipulation in order to allow innate intelligence to flow freely throughout the nervous system.(7,8)

Currently, there are two basic camps of chiropractors, the so-called “straights” and the “mixers.” Straights continue to accept the ideas of Palmer, including his theories of innate intelligence, subluxation as the cause of all disease, and spinal manipulation as the cure for all disease. Thus, the straights use only spinal manipulation to treat their patients, and they do not work with conventional physicians. In contrast, mixers view themselves as more of musculoskeletal pain specialists, especially for the treatment of back pain. They use other forms of treatment along with spinal manipulation, and they are more likely to work with the medical establishment. Early in the history of chiropractic, Palmer claimed that mixers were essentially defiling its tenets, but today, mixers comprise the majority of chiropractors.(7)

Spinal manipulation, also called adjustment, is performed by applying a force to a specific joint with the intention of moving vertebrae beyond the normal range of motion, but not far enough to cause damage. These manipulations are believed to break down adhesions in joints, affect mechanoreceptors in the joints, inhibit C-fiber-mediated perception of pain, and/or modulate function of the central nervous system.(7) A clicking sound often occurs during an adjustment as the stuck joint is released.(8)

Most patients who visit chiropractors are self-referred, and many of them come to chiropractors due to the inability of conventional medicine to adequately treat their pain. Chiropractors who are mixers mainly treat chronic pain caused by musculoskeletal problems, especially back and neck pain. Along with spinal manipulation, they may also use heat, cold, electrotherapy, herbal remedies, nutritional supplements, massage, meditation, and other non-pharmaceutical therapies. Mixers may also use conventional diagnostic tools such as radiographs and blood or urine analysis. Compared to straights, mixers are more willing to acknowledge that part or even most of the effect of chiropractic is due to the placebo effect. Unlike straights, mixers are also more willing to accept the idea that immunization is beneficial.(7)

The chiropractor with whom I worked was easily identifiable as a mixer. Along with spinal manipulation, he made use of heat and cold, massage, ultrasound, electrotherapy, and herbal remedies. For example, he recommended echinacea and high dose vitamin C to one patient with bronchitis. In addition, he openly acknowledged that certain conditions were better treated by allopathic or osteopathic physicians, and noted that pharmaceuticals were necessary in some circumstances. In keeping with his general open-mindedness toward conventional medicine, he presented himself as a chiropractic physician, and even stated that he considered chiropractic to be mainstream rather than alternative medicine. Finally, he described the science coursework he had taken in great detail to one of his patients and me, particularly emphasizing his training in physics and biomechanics. If he believed in Palmer’s ideas about subluxations or innate intelligence, he did not at any point indicate that.

The patients whom this chiropractor treated were mainly chronic pain patients. At the beginning of a session, he would test each patient’s range of motion and ask the patient to rate his or her pain level on a scale of 0-10. Next, he would palpate the patient’s vertebrae one by one, asking the patient if there was any pain at each level. Then he would begin adjusting the patient’s spine. Several patients were elderly and had arthritis, especially back and joint pain. These patients were treated with a mixture of lumbar spinal manipulation, heat, cold, ultrasound, and massage. There were also a few patients who had been rear-ended in car accidents and were suffering from whiplash. The treatment for whiplash was similar, except that the chiropractor focused more on manipulating the cervical spine rather than the lumbar spine. At the end of each session, the chiropractor would again ask the patients to rate their pain on a scale of 0-10. In every case, the patient’s pain had diminished, sometimes all the way down to the zero level. The patients generally agreed that the treatments were helpful.

Wednesday, February 25, 2009

CAM Paper Part II: Massage Therapy

Massage therapy (MT) is defined by the American Massage Therapy Association as including manual soft tissue manipulation that can involve holding, causation of movement, and/or application of pressure to the patient’s body; these manipulations must be done for the purpose of improving the health and well-being of the patient. MT can have many forms, with wide variations in duration of treatment, types of touch, apparatus used, and body sites treated. In addition, MT has been studied as treatment for a large number of illnesses and symptoms, including anxiety, depression, pain, rheumatologic diseases, asthma, migraine headaches, MS, PTSD, diabetes, cancer, and even HIV.(6)

Several theories have been proposed to explain why and how MT provides benefit to patients. The most commonly cited hypothesis is the gate control theory of pain reduction, which suggests that the more quickly transmitted pressure stimulus interferes with the slower pain stimulus, thereby decreasing pain reception by the brain. This could explain why MT improves subjective perception of pain. Another common idea is that MT may shift the autonomic system from a predominantly sympathetic state to a predominantly parasympathetic state. Effects of MT like slower heart rate, reduction of stress hormones, and a feeling of calmness could be explained by this theory. Other proposed explanations for the mechanism of MT include increases in serotonin levels, mechanical effects that reduce adhesions and fibrosis, indirect effects via improvement of sleep, and the one-on-one personal attention that occurs during a MT session. This last hypothesis is particularly interesting because it may also explain the efficacy of psychotherapy in improving many of the same symptoms.(6)

Anecdotally, the patients whom I observed having MT were very enthusiastic about its benefits. One patient came to the massage therapist because of a sinus headache. She stated that the treatment improved her symptoms of sinus pain and pressure, as well as decreasing the bags under her eyes. The therapist treated her by applying deep pressure with a circular motion over the patient’s ethmoid, maxillary, and frontal sinuses. She also manipulated the patient’s facial skin by using shallower touch and applying a cream. Throughout the treatment, the therapist spoke with the patient, explaining what she was doing and even telling us about her personal theories concerning how MT works. Furthermore, the atmosphere in the room promoted relaxation with soft lighting, plants and pictures suggestive of a natural setting, a warm massage table, and aromatherapy.

Tuesday, February 24, 2009

CAM Paper Part I: Introduction

Complementary and alternative medicine (CAM) can be defined as a diverse group of therapies and products that are not considered to be part of conventional medicine. Patients may use CAM to treat a wide variety of conditions, including back problems, colds, neck problems, joint pain, anxiety, depression, rheumatologic problems, digestive problems, chronic pain, insomnia, and other chronic conditions.(1)

Currently, CAM is very popular with patients. A national health interview survey found that in 2002, 36% of American adults had used some form of CAM within the previous 12 months, not including prayer. According to the survey, the most common non-prayer CAM modalities used by patients included natural products, deep breathing exercises, meditation, chiropractic, yoga, massage, and nutritional therapies. Interestingly, prayer for improved health, performed either by the patient or by others on behalf of the patient, was by far the most commonly used form of CAM. Inclusion of prayer as a CAM modality increased the percentage of adults using CAM in the past 12 months to 62%, and the percentage using CAM at any point in their lives to 75%. The popularity of CAM may stem at least in part from patient dissatisfaction with conventional treatments for chronic conditions such as pain.(1)

Multiple surveys suggest that physicians, medical students, and other healthcare providers have limited knowledge about CAM, although some studies have found that physicians would like to learn more about CAM.(2-4) In addition, physicians tend to have more negative attitudes about CAM compared with other healthcare providers like nurses and pharmacists.(3) There is some evidence that the attitudes of medical students toward CAM tend to become less positive as they get further along in medical school and become more entrenched in the conventional medicine model.(5) This may help explain why only about one quarter of surveyed patients reported that they had tried CAM because their physician had suggested that they try it.(1)

Unfortunately, patients themselves are often misinformed about CAM.(1) The rise of the internet has generated a confusing information overload, much of which can mislead patients and possibly even harm their health.(2) Patients commonly self-medicate with CAM and often do not tell their doctors or pharmacists about the nutritional supplements and herbal remedies they are taking.(1-3) Furthermore, physicians opposed to CAM may overstate the case that all CAM is useless, while practitioners of CAM may overstate the curative powers of CAM or claim that the medical establishment wants to suppress CAM.(2)

As a result of the proliferation of misinformation and lack of reliable information about CAM, patients often hold misguided beliefs about CAM therapies.(2) For example, many patients believe that “natural” equates with “safe.” However, herbal remedies and other natural products may interact with prescription drugs, as well as have toxic effects of their own.(2,3) In addition, many patients believe that using CAM therapies will save money. However, the few studies done on this subject suggest the opposite, namely that use of CAM increases costs for healthcare compared to conventional healthcare alone.(2)

This paper will review some of the more popular forms of CAM, including both the theory and practice of these therapies. It will not be possible to cover every form of CAM that patients might discuss with their physicians. However, my hope is that this paper will be a good starting point to help educate current and future healthcare providers about CAM. Although prayer for improved health is the most common form of CAM, it will not be covered here in order to focus in greater detail on several of the physical and chemical CAM modalities that are popular among patients.

Monday, February 23, 2009

Complementary and Alternative Medicine

This week, I started an unlisted elective in complementary and alternative medicine (CAM). An unlisted elective is one that is not listed in the Case elective course catalog. With the school's permission, you create it yourself. The impetus for me to want to study CAM was that I have had multiple patients in clinic asking me about herbal remedies, acupuncture, and the like. I have to admit that I am woefully ignorant about these subjects, and so were many of my attendings. Even though some doctors think that alternative medicine is bunk, my experience is that a lot of patients believe in it, so I thought I should at least understand a little about it.

For the elective, I am reading a book about herbal remedies used for various purposes and some articles about the history of alternative medical systems like osteopathy and chiropractic. I am also spending some time shadowing an osteopathic physician (to see manipulation), a chiropractor, an acupuncturist, a massage therapist, and an herbalist. At the end, I will write a ten-page paper about all of these alternative therapies. Since so many people are interested in CAM, starting tomorrow, I will post each section of the paper online, including my references.

For those of you who want to learn more about CAM, please keep in mind that there is a lot of biased and self-serving misinformation about CAM out there on the internet. (Actually, there is plenty of misinformation about medical topics in general, but it's especially problematic for CAM.) If you would like to consider using CAM therapies for your own health care needs, I recommend that you discuss CAM with your physician. In addition, you should educate yourself about CAM by only visiting websites that provide reliable, evidence-based information for consumers.

One of the best sites I've seen is hosted by the National Institutes of Health (NIH). NIH is a government research organization that funds much of the medical research done in the United States, including clinical trials. You can find a great deal of reliable information about many types of CAM by visiting the NIH's National Center for Complementary and Alternative Medicine webpage.

Friday, February 20, 2009

Done with Preventive Medicine

After a small snafu with getting my answers uploaded, I was done with the online test by Monday night. It's pretty much all about hypertension. My advice for other Case students taking this elective is to only read the module on hypertension and then do the test. The other modules are not very helpful for answering the test questions. It's also not necessary to read all of the linked additional readings.

I hope it doesn't sound like I think this elective is fluff just because it wasn't organized the most efficiently. Actually, it helped reinforce some things I had learned in my medicine rotations, which is good because preventive medicine is covered on Step 2. Plus, I learned a few new things too, the most surprising of which is that there is conflicting evidence about the utility of restricting salt intake in hypertensive patients.

Even if the effect of restricting salt intake on blood pressure is small, it's probably still a good idea to encourage people to eat less salt, because American diets are ridiculously high in sodium. But getting patients to restrict their salt intake is very difficult, because there is a lot of salt in just about every processed food in existence. Try looking at some nutritional labelings on the packages even for sweet things like tomato sauce and cookies the next time you're in the supermarket, and you'll see what I mean. It doesn't help that food without salt tastes bland to most people, either.

Friday, February 13, 2009

Phlebotomy and Online Preventive Medicine

On Tuesday, I took an optional day-long course at CCF to learn how to draw blood. It was free, and phlebotomy seems like a useful skill to have, so I figured why not. There were four of us who did it. First, we were shown the different types of needles and tubes for collecting blood. Then we each went out with a phlebotomist to draw blood on actual patients. Each time you draw blood, it is called a "stick." We had to get eight sticks to be certified. My phlebotomist didn't have very many patients on his list, but two of them let me draw their blood and I got them both on the first try. Then I got my last six sticks on some of the other phlebotomists who were coming in to change shifts. There was one I couldn't get, but I thought getting 7 out of 8 sticks was pretty good for a novice like me!

I'm doing an online elective this week and next week so that I could go out of town. It's on preventive medicine, and there are a bunch of modules we are supposed to read, followed by an online test that we have to take. The online test has 31 questions, which looked pretty scary until I realized that the first 15 are in groups of five that go together, and the last 16 are in pairs with one multiple choice and one essay. It's going pretty fast. I already am pretty much done with the whole test. The modules are another story. They are really long, and they have different reports and articles linked to them. It would take a lot longer than two weeks to read them all, so I decided to start working on the test and then just read the relevant parts of the modules as I went along. That made things a lot more efficient.

We had an afternoon seminar today on biomarkers, which I missed since I'm not there. I can't say I'm terribly broken up about this. :-)

Friday, February 06, 2009

Last Week of Toxicology

This was my last week of toxicology. We each had to give a 40-minute presentation today. Mine was on alcohol withdrawal. It turned out to be a really good topic, since I had at least one alcoholic patient on my medicine rotation who we thought might be having withdrawal. The problem with hospitalizing alcoholic patients is that since they can't get a drink in the hospital, they can start going through withdrawal a day or two after they get admitted. Alcohol withdrawal is a serious problem, and it can kill the patient. The worst symptoms come with delirium tremens and include seizures, delirium, hallucinations, nervous system dysfunction, and electrolyte disturbances. Of course, fortunately not all patients get delirium tremens. But the ones who do need supportive care.

I also gave a brief presentation yesterday about absinthe, which is a drink made from wormwood extract. It is said that the artist Vincent Van Gogh was under the influence of absinthe when he cut off his ear. There are several alkaloids (chemicals) in wormwood that could cause the symptoms of "absinthism" (seizures, hallucinations, problems walking). But it turns out that the major ingredient in absinthe is alcohol! No wonder these people were stumbling around like drunks and hallucinating. They were alcoholics! It is still not legal to make absinthe in the United States, but they do have it in Europe.

Next on the agenda is preventive medicine, which is an online elective that is really an excuse for me to get out of Cleveland for a couple of weeks.

Wednesday, February 04, 2009

An Artificial Asthma Attack

Over the last couple of weeks, I've been getting increasingly short of breath while walking. Now granted, I'm not currently in nearly as good of shape as I was before med school, but I'm still in good enough shape that I should be able to walk a mile without getting short of breath!

So I went to the doctor, and I ended up getting some lab work, a chest x-ray, an echo, an albuterol inhaler, and an appointment for lung function tests. These tests measure how much air you can inhale and exhale by having you breathe a full breath of air in and out of a machine with your nose pinched shut. The machine measures the speed and amount of air you're moving.

Today was the day that I took the lung function tests. One of these tests is called a methacholine challenge, and its purpose is to see if the patient has asthma. How, you may ask, is the test performed? Well, the patient inhales a drug (methacholine) in periodically increasing amounts. After each dose, they have to keep inhaling and exhaling air into the machine to measure their lung function. Meanwhile, the tech administering the test watches to see if the patient's airways close up enough to diagnose them with asthma.

When I tried it, the first few doses weren't that bad. By the fourth dose, my chest was starting to feel a little tight. The fifth dose was absolute agony. The woman giving me the test asked if I thought I could still hang on long enough to inhale and exhale into the machine. I felt like I was seeing stars a little, but I nodded and did what I could. She then gave me albuterol, which is a medication that opens the patient's airways again. If they have asthma, this should lead to a recovery of lung function to the level it was at before starting the methacholine challenge.

Inhaling that albuterol helped me tremendously. It also made my heart start pounding (side effect), but being able to move air in and out of my lungs freely was more than worth a few palpitations. When the entire test was over, the tech showed me the graph of my lung function test, which was textbook beautiful for asthma.

Now that I've been officially diagnosed with asthma, I have to start using an inhaled steroid and taking a pill, both for prophylaxis. In other words, these medications won't stop an asthma attack that is already taking place, but they will prevent future attacks. I'll still have the albuterol inhaler to use in case I have more attacks.

The most indelible impression that this test made on me is that I will never order a methacholine challenge for a patient unless I think it's absolutely necessary. Feeling like you can't breathe is extremely unpleasant.

Friday, January 30, 2009

Week 3 of Toxicology

This week has gotten surprisingly busy. I've been reading for tox, working on my research protocol (though not as much as I would have liked), and finishing my research fellowship application. I'm still really enjoying tox. Wednesday we had a big snowstorm, and the resident and the other med student couldn't get over to Case. So I was the only one who made it in, and the attending and I went over that day's cases. We had a bunch of adult patients who tried to overdose on anti-psychotic drugs. I've gotten to know the psych drugs pretty well on this rotation, because they seem to be one of the more popular classes of drugs that people take when they try to commit suicide.

On Thursday, there was a mock LCME re-accreditation visit for Case. LCME is the organization that accredits medical schools, and Case is due for its re-accreditation visit in March. Most of the meetings are with faculty and administration, and then there are two meetings with students. The first one is for M1s and M2s, and the second one is for M3s through M5s. There were four of us, one M3 and one M4 each from the UP and CCLCM. We got asked about things that students had complained about in the survey last spring, like the OB/gyn rotation and student health services. Other questions were things like what we would do if we got stuck with a needle (call the exposure hotline) and what goes into our dean's letter if we have to remediate a competency (beats me, and I plan to never have to worry about this). I think now I am going to be asked to go to the real meeting too.

This afternoon I had my Friday research seminar at CCF on medical decision making. The first half on prediction tools was really interesting, and the second half on cost-analysis gave me a nice hour to daydream. At least I didn't fall asleep, which is more than I can say for a few of my classmates. ;-)

Friday, January 23, 2009

The Best of Toxicology

I am now halfway through this toxicology rotation, and I really love it. It's mostly didactics and not very much clinical stuff, but the subject is really interesting, and the attending has all kinds of cool stories to tell. For example, he testified for a criminal trial where someone poisoned the defendant. That was definitely cool. He also gets to travel around a lot. Monday he'll be doing consults, so we're going to go with him. I'm looking forward to that. We're also each going to do a presentation at the end on some kind of tox topic. Mine will be on alcohol withdrawal.

We spent Monday morning in the attending's lead clinic. This is an outpatient clinic where he sees kids who have lead poisoning, usually due to ingesting or inhaling lead-based paints. If their lead levels are high enough, he chelates them. (Chelators are chemicals that bind to lead so that the body can excrete it.) Since a lot of the buildings in Cleveland are relatively old, especially in the poorer areas of town, there is still a lot of lead-based paint here. One family had three little girls, all with almost the same names. The nurse practitioner was having trouble remembering which one was which, but the funniest thing was that the girls' mother was having the same problem.

Today's afternoon seminar was on the art of physical diagnosis, or rather, how this art is being lost because of the dependence on technology. We didn't actually practice any physical diagnosis, mind you, just talked about how we don't really learn it. Again, it's an important topic to think about, but three hours of it is really not necessary.

Friday, January 16, 2009

Starting Clinical Pharmacology and Toxicology

This was the first week of my clinical pharmacology and toxicology rotation. There are three of us on the rotation: an emergency medicine resident from Metro, a fourth year from the UP, and me. It was kind of a funny week, because the attending was out of town. He had left us a packet of questions to do, and he also wanted us to spend some time listening to the poison control nurses field calls. Other than that, we were pretty much on our own. We also took pictures to get University Hospital badges, which we still haven't gotten. The stupid part is that the badge expires at the end of the month, and I'm coming back to UH in March for my radiology rotation. But they said I'd just have to get another one then.

These questions are pretty hard. The poison control nurse I worked with commented that they were similar to the questions she had on her certification exam. I listened to calls with her for two days. Most of them were for pill checks, where people magically find some unlabeled pill and call the poison control center to get it identified. First of all, it would never occur to me to call the poison control center if I found a weird pill. Second of all, who just takes pills that random people give them? Most of the legitimate calls were either for toddlers who got into medications and household products, or for adolescents and adults who were trying to commit suicide. Amazingly, a lot of people try to commit suicide by overdosing on acetaminophen (Tylenol). That's an incredibly bad way to kill yourself. It takes three or four days for you to die of liver failure, and you feel really, really bad the whole time: excruciating stomach pain, nausea, vomiting.

Today's seminar was on meta-analysis. This one might have been the very worst of all, not the least of which because it went over time due to yet another ridiculous and pointless group activity. I hate to be rude, because I know these people are giving us their time. But there has to be some less painful way for us to learn this material.

Friday, January 09, 2009

Research Protocol and Funding

This was my last week on research. I'm still not done writing my protocol, but at least I have a project more or less planned out. It's definitely going to be on trying to predict delirium in geriatric patients. I'm also working on my application for the medical student geriatrics research fellowship.

Yesterday, I met with one of the fellows about writing a protocol for a second project that sounds pretty cool. That would be a retrospective project, meaning that we'd be looking at data that have already been collected. He would use the results to support his application for funding to do a prospective trial, where new data would be collected. So it looks like I'm probably going to have two projects for my research year, which could be a good thing if I get two publications out of it. I don't know when I'm going to get around to writing that proposal though, because now I'll have to start doing work for my next rotation.

Other than that, it hasn't been a terribly exciting week. We've been trying to figure out where people are smoking that makes the cigarette smell drift into the med student office, but we haven't been able to find them so far. The funny thing is that apparently the people on the floor above us can smell it too, because someone who works up there came down to our floor to find out if it was one of us! I think whoever it is must be smoking outside next to a vent. There's no way anyone could smoke inside any of the CCF buildings without setting off the fire alarm. Believe me, people have tried!

Friday, January 02, 2009

Slow Week

This has been another slow week as far as research goes. (Are you seeing a trend here?) We did have one patient to assess for delirium on Wednesday, but she was still intubated and sedated in the ICU today, which means that we basically didn't do the assessment at all. Next week I will be having a meeting to discuss the specifics of my project and hopefully get ready to apply for funding. The geriatrics grant that I want to apply for has a deadline in a month, so I need to get cracking on that. Nothing else exciting is going on except that I ordered my books for the rest of my rotations. I'm really looking forward to starting pediatric toxicology the week after next.

Friday, December 26, 2008

Research Training

This has been another slow week. My PI and I have decided that I'm definitely going to do the delirium research. Coincidentally, my class got an email earlier in the week from the CCLCM research coordinator with a link to that same geriatric research fellowship for med students. Like I said, it's only for three months, but funding is funding, and I'll be applying for another fellowship anyway. Other than that, not much is going on. Most of the first and second years are gone on vacation, so it's pretty dead here. I finished my research training on Tuesday and ran some errands. I have also been going to do post-operative delirium assessments with one of the research fellows. These patients are not demented, so it's a lot easier running the mini-mental on them than it was on the demented patients I was seeing during my geriatrics rotation!

At least it is finally warming up. Last weekend we had an ice storm and temperatures in the single digits with a -25 degree windchill. Today it's like 60 degrees. Cleveland has the craziest weather. It's no wonder that everyone I know is sick.

Friday, December 19, 2008

First Week of Research

This has been a very slow week. I've been working on writing a research proposal for my research year, which will be next year. I want to do a project on developing a screening tool that predicts which patients are at highest risk for developing post-operative delirium. If my PI goes for it, I'm also going to apply for a geriatrics research fellowship. It's only for three months, but hey, money is money. Fortunately my PI can afford to pay me even if I don't get it. A lot of people in the research group are out of town, including the person I need to talk with, so I have a lot of free time. I think I've watched about half a dozen movies this week, which is probably more than I've watched during the rest of the whole year put together!

It's snowing like crazy right now. Someone told me that this is going to be a bad winter, and so far, it looks like they're right.

Friday, December 12, 2008

End of Geriatrics

I'm now officially done with geriatrics. This week was similar to the first week: seeing inpatients in the morning and outpatients in the afternoons. I did get to observe a driving test one morning, which was an interesting experience. A psychologist conducts the interview, and if the patient passes that portion of the exam, then they go out into the lot for a driving test.

The patient was a very sweet man who insisted that he could drive just fine, and he didn't understand what the fuss was all about. He seemed perfectly normal to me when we were chatting before the interview. The psychologist performed the mini-mental on him, and he got all of the questions right except for missing a couple of items on recall. Then the tests got harder. The psychologist asked him to name as many animals as he could, look at pictures, and answer other questions. As I watched and listened, it became apparent that this man really was mildly demented. The questions he was struggling with were mental tasks that no one should have had trouble doing.

In spite of performing poorly on several of the tests, the patients still insisted that he was fine to drive. This is an example of lack of insight, which is common in Alzheimer's patients. In other words, he did not recognize his own loss of memory and other cognitive abilities. Patients with some other forms of dementia (non-Alzheimer's) do sometimes retain insight and are aware that their thinking has declined.

Ultimately, the psychologist asked him about things like how many tickets he had gotten recently, and how many accidents he was in recently. It turns out that there were some of each. The patient's cognitive decline was apparent enough that no driving test was necessary. He was told that he had to give up his license, which unsurprisingly upset him. It was very sad.

The only other new thing I did this week was to go to UH to do some consults on inpatients. I hadn't ever rotated at UH before, and it was very trying. First of all, they don't have electronic charts. You wouldn't think that would matter very much, but it does when you're trying to read about a geriatric patient whose chart weighs more than you do! It didn't help that a bunch of papers were randomly stuffed in there every which way, and half the notes were scrawled in chicken scratch that I couldn't read. Making sense of it all was hard enough that I only saw two patients all afternoon, even with staying an extra hour. (The attending wanted me to stay even longer, but I had more than run out of patience by then.) All in all, this experience made me greatly appreciate how much nicer it is to use electronic medical records like they have at the VA and at CCF!

Friday, December 05, 2008


This week, I have been rounding at the VA in the mornings, and then going to Elderhealth in the afternoons. Elderhealth is a community center where UH has an outpatient facility for geriatrics patients. There is a general geriatrics clinic similar to the one at the VA, and also geriatrics subspecialty clinics.

Monday afternoon, I worked with a geriatric psychiatrist. Well, to be more exact, I shadowed a geriatric psychiatrist. This was my least favorite day. Not only did I not get to do anything, but some of the team members were kind of patronizing toward the patients. Tuesday, I worked with a geriatric neurologist. That was a lot more fun. The attending was cool, and he had me interview and examine a challenging patient who had several findings. He also had me write a note, which was less fun, because they don't use electronic medical records at Elderhealth. My patient's chart must have been at least two inches thick. I hadn't realized how spoiled I became at CCF (and even the VA), where we have electronic charts!

Wednesday, I worked with a general geriatrician who also goes out to nursing homes. She was great also, letting me see patients and teaching me a lot. Thursday I went with her to the nursing/retirement home. It was a lot nicer than I expected. If I had to be in a retirement or nursing home some day, I wouldn't mind living in this one. They had a computer room, a library, even a beauty shop, all on site. The patients all knew my attending and were excited about us coming to visit. I spent most of my time interviewing a couple of her patients who she thought would be interesting. One of them had no short term memory. It made having a conversation kind of frustrating, because she could tell me things from decades ago, but she couldn't remember what we had discussed a few minutes ago. I spent a lot of time telling her over and over again who I was and what medical school I attend.

Today I was at the VA all day. We have a new inpatient attending who is into teaching. He pimps us a lot, but it's mostly stuff we should know, like blood pressure drugs. Our patients were on two different floors, and he likes taking the stairs, so I got to spend some more time on the VA stairmaster. The other good thing about him is that he finishes rounds quickly.

I guess winter is here. It's been kind of flurrying every day, and now the snow is sticking. Definitely time to pull out my snow boots.

Friday, November 28, 2008

VA Stairmaster and Hospice Week

This was a short week because of Thanksgiving, but a lot was packed into it. On Monday after geriatrics rounds, I went around with the chaplain and the Hospice nurse practitioner to visit the Hospice patients. Two of them wound up dying within half an hour of one another. Somehow, it didn't seem as bad as some of the other patient deaths I have seen. I think a lot of it was that they were comfortable and the families were there. Also, they all had time to prepare. It was sad, but not depressing.

Tuesday I had my own consult, and it was a tough one. The patient has stage 4 lung cancer with metastasis to the brain, which has caused seizures and dementia. So he really doesn't understand what is going on. But I did my best to explain what Hospice was to him, and he agreed to have a Hospice nurse come out to his home. Wednesday we had a patient who didn't speak much English, but fortunately his family was there to translate. They decided to take him home to his native country to die, which seemed sensible to me. Dying in a hospital is so undignified, especially if it's in the ICU.

The Hospice nurse wrote me an incredibly nice evaluation for my portfolio. She was really upset though when I told her that I didn't want to do medicine and was thinking of doing something with less patient contact. She told me it would be a waste of my talent at working with patients. Considering how much I hated my medicine rotation, it always surprises me when someone says this to me. It makes me doubt myself a little. But I keep thinking about how only five weeks of inpatient medicine made me so miserable, and how the residents were so miserable, and I just don't think I can do it for three years.

I was off on Thursday for Thanksgiving. Friday was a holiday for the UP students, but not for us. So I was the only student who showed up, and I was running around frantically trying to help the nurse practitioner cover the other students' patients. She wanted me to stay in the afternoon too. But I told her that I had to leave at lunchtime because we have classes on Friday afternoons. That is usually true, but we didn't actually have class today because it was our free Friday afternoon. (We get one free Friday afternoon each month.) I was annoyed that she expected me to stay in the afternoon. It made me feel like she was taking advantage of me. I had already come in for the morning even though I could have easily gotten away with not coming in at all. It was enough. I care deeply about doing the right thing, but that doesn't mean there are no limits to what people can ask of me.

I forgot to describe the VA "Stairmaster" last week. The hospital is six floors tall, and the Stairmaster is actually one of the stairwells. The walls in that stairwell have been painted with motivational exercise statements and pictures. There are also colorful charts telling you how many calories you burn doing various activities, depending on your weight. One of the UP fourth years who had rotated at the VA before had told me that they play music in this stairwell sometimes, but I hadn't heard it before. Well, on Monday, they had turned on the music. Since the Hospice patients are on more than one floor, I had several opportunities to go up and down the VA Stairmaster. They played all kinds of things, from country to pop to jazz. Every time I went into the stairwell it was a completely different genre. I was thinking last week that the VA Stairmaster was kind of silly, but now that I've been in there with the music playing, I like the idea. They should post a schedule for what they plan to play when, though. I have decided that I really don't like climbing stairs to jazz!