T. A. McNamee, MD – Brain Blogger http://brainblogger.com Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.6 Scrambling for a Career http://brainblogger.com/2010/04/16/scrambling-for-a-career/ http://brainblogger.com/2010/04/16/scrambling-for-a-career/#comments Fri, 16 Apr 2010 17:45:07 +0000 http://brainblogger.com/?p=4233 In the weeks after Match Day, the day that fourth-year medical students learn their fates for residency training, most medical students are reflecting on their results with joy, resignation, or despair. A handful of others are still reeling in the realization that their medical careers are going to look significantly different than they had planned.

I’m talking about the “Scramble,” the little-publicized event that occurs two days before match day for those students that did not match with any of the programs they had ranked. There are a number of reasons that this occurs, but frequently it is because some specialties are so highly sought-after that there are more students applying for a position than there are positions available to train them. Diagnostic radiology, for example, offered 141 first-year training positions in the 2010 match. 663 US seniors applied, implying that 522 aspiring radiologists are possibly soon to begin training to be a completely different kind of physician.

Upon learning that they didn’t match, the student (with the aid of their medical school administration) then identifies residency programs that still have positions available through the National Resident Matching Program (NRMP). If they’re extraordinarily lucky, a spot in their desired field will be open. If not, some hard choices need to be made in a short period of time. Should I be a surgeon instead? How about family medicine? Or maybe I’ll just do a transitional year while I mull things over? The process differs slightly from program to program, but within the next 48 hours the student and the program make contact, often through the Electronic Residency Application Service (ERAS), usually visit over the phone, and the remaining open slots are filled. Often the student and the program don’t even meet face-to-face. The assignment is sent through the NRMP, and the scrambled student then has an envelope to open with his or her colleagues on Match Day. And on that fateful day, while most students are discovering the where of their training, the scrambled students may still be coming to terms with the what, and perhaps the why.

Editor’s Note

The scramble is a chaotic process on several levels. The NRMP says it best, “Trust exists in the Match but not in the Scramble.” From a 2009 meeting, the NRMP outlines the downfalls of the current paradigm:

  • No consistent, orderly process for applications
  • For-profits clog programs’ email, phones, & faxes
  • No communication between applicants & programs
  • No separation between application & appointment
  • Applicants must make career decisions too quickly
  • No rules govern applicant & program behavior
  • No organization has stewardship of the Scramble

In an effort to sanitize the process, the NRMP recently voted to implement a Managed Scramble for the 2012 Residency Match. Under this new plan, all unfilled positions must be offered and accepted through the NRMP online system during Match week. With the Managed Scramble, “the NRMP assumes stewardship of the Scramble.”

References

NRMP. Advance Data Tables 2010 Main Residency Match, 2010.

NRMP. The Managed Scramble, 2010.

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Survive the A-Bomb, Die Prematurely from Stroke and Heart Disease http://brainblogger.com/2010/03/24/survive-the-a-bomb-die-prematurely-from-stroke-and-heart-disease/ http://brainblogger.com/2010/03/24/survive-the-a-bomb-die-prematurely-from-stroke-and-heart-disease/#comments Wed, 24 Mar 2010 12:00:53 +0000 http://brainblogger.com/?p=3750 The survivors of the World War II atomic bombings of Hiroshima and Nagasaki may have considered themselves lucky, at least at first. Shortly thereafter, however, those who didn’t die from radiation poisoning learned that the radiation from the bombings placed themselves and their children at increased risk of cancer. Now, they can add heart disease and stroke to their list of potential medical problems.

A recent article in the British Medical Journal (BMJ) examined the rates of death from heart disease and stroke in survivors of these bombings based on their distance from the epicenter and subsequent calculated radiation exposure. It found that those exposed to higher doses of radiation had an increased risk of both stroke and heart disease, with excess relative risk per gray of radiation of 9% for the former and 14% for the latter. Correcting for other habits known to be associated with both conditions had no impact on their findings, suggesting that the radiation alone was responsible for their findings.

While no one anticipates another atomic bombing, the results of this study are still relevant due to the widespread exposure of individuals to radiation from medical diagnostic tests such as CT scans. According to a publication from the Health Physics Society, the standard CT scan of the pelvis delivers approximately 10 mSv of radiation (by comparison, people are exposed to 3 mSv from natural background radiation yearly).  An angioplasty can deliver up to 57 mSv. Not only that, it has become increasingly apparent that even modern radiologic equipment is prone to failure, with recent reports of patients receiving several-fold greater doses of radiation than intended.  Once felt to be administered with doses of radiation too low to cause any long-term ill effects, such tests are likely to come under increased scrutiny as potential causative agents in cardiovascular disease.

Reference

Little, M. (2010). Exposure to radiation and higher risk of circulatory disease BMJ, 340 (jan14 1) DOI: 10.1136/bmj.b4326;340:b5349. doi:10.1136/bmj.b5349

Radiation Exposure from Medical Diagnositic Imaging Procedures: Health Physics Society Fact Sheet [PDF].

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Let the Matches Begin! http://brainblogger.com/2010/03/18/let-the-matches-begin/ http://brainblogger.com/2010/03/18/let-the-matches-begin/#comments Thu, 18 Mar 2010 14:50:47 +0000 http://brainblogger.com/?p=4221 Today is Match Day, the day when fourth-year medical students across the country learn their fate for the next three to five years, and possibly their lifetimes. It’s the day that the National Residency Matching Program (NRMP) announces the assignments of the students to their residency training programs that will develop the pluripotent medical student into a specialized professional. In short, it is one of the most important days in a medical student’s career.

The first match was in 1952 and paired graduating students into the 10,400 first-year residency slots available at the time. By 2009, that number had increased to 22,427. Even more dramatic was the rise in applicants, swelling from 6,000 in 1952 to 36,972 in 2009. Most of the increase in applicants is attributable to the increasing number of foreign-trained physicians, osteopathic students, and previous medical school graduates seeking retraining in another specialty.

U.S. seniors in allopathic medical schools seem to fare best in the match, with over 95% matching in a residency program in 2009. Osteopathic students and graduates match around 70% of the time. Prior U.S. grads and internationally-trained physicians only match 40-50% of the time. These numbers may be misleading, however, as every year there are a certain number of positions that are made available outside of the match and disproportionately affect international and osteopathic graduates, which may make their match rates appear artificially low. Even so, their increasing ranks coupled with the increasing number of U.S. allopathic medical students and the cap on the number of federally-funded residency programs make the situation for internationally-trained physicians especially challenging.

But for all applicants involved, Match Day is an exciting and nerve-wracking experience. So if you know a fourth-year medical student, be kind. They’re about to receive information that could change the course of their lives.

Reference

Results and Data – 2009 Main Residency Match [PDF]. NRMP. April 2009.

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Matchmaker, Matchmaker Make Me A Match – The NRMP Main Residency Match http://brainblogger.com/2010/02/15/matchmaker-matchmaker-make-me-a-match-the-nrmp-main-residency-match/ http://brainblogger.com/2010/02/15/matchmaker-matchmaker-make-me-a-match-the-nrmp-main-residency-match/#respond Mon, 15 Feb 2010 12:00:26 +0000 http://brainblogger.com/?p=3949 Each spring, thousands of medical students across the United States render their fate into one of the most bewildering processes of higher education: the National Resident Matching Program (NRMP). The program was developed in 1952 as a means to “relieve the pressure and inequity of free market recruitment, and to establish a uniform playing field with educational boundaries” with regards to residency training programs. Prior to this, the process of achieving a desirable residency spot was fraught with chaos, with multiple different application forms and processes, not to mention false promises and false information.

Conceptually, the matching procedure seems straightforward: assign medical students to residency programs in a way that streamlines the process and produces the best outcomes for all parties involved. Practically, however, it’s a bit more complicated. Fourth-year medical students apply to residency programs in the specialty (or specialties) of their choosing, usually via the Electronic Residency Application Service (ERAS) which is a standard computerized application form used by most residency programs across all specialties. The programs review these applications, select the candidates they’d like to meet and go through the standard interview process. The students then rank the programs in order of most desired to least desired and submit their lists electronically to the NRMP. The residency programs do a similar ranking of the students they’ve interviewed, and submit their lists as well. Through a complex computer program that possibly only its creators understand, the best “matches” are made in a manner that optimizes both the students’ and programs’ requests. Both students and programs are contractually bound to the outcomes of the match.

This would be a feat unto itself if it was that simple. The matching program also takes into consideration whether the students have registered as a couple, as in the case of married students who want to stay in the same location, whether the student has applied in two different specialties, and whether the specialty to which the student is applying needs a preliminary or transitional year (“internship”) following medical school before entering into their categorical program. The data processing required is mind-boggling.

And yet, somehow it works. So every March crowds of fourth year medical students anxiously await the envelope containing the program’s output that determines their destiny for the next three to seven years. Every March, dreams are realized or ruined with the opening of a single envelope. While it seems somewhat arbitrary that after years of difficult and expensive education the course of someone’s career comes in the form of a computer-generated assignment, for many it’s preferable to the vague and chaotic process of years past.

References

National Resident Matching Program.

Electronic Residency Application Service. Association of American Medical Colleges (AAMC).

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A New Look at Medical Errors in Residency Training http://brainblogger.com/2009/11/18/a-new-look-at-medical-errors-in-residency-training/ http://brainblogger.com/2009/11/18/a-new-look-at-medical-errors-in-residency-training/#comments Wed, 18 Nov 2009 13:47:46 +0000 http://brainblogger.com/?p=3409 It’s a phenomenon that medical educators have long suspected but haven’t been able to prove: a rise in medical errors when newly-hatched physicians begin their residency training programs in July. This suspected occurrence has been studied several times, but until recently, no conclusive evidence existed that it actually was true. For the first time, a study based in Australia has been able to demonstrate that this really does happen, but perhaps not for the reasons you’d suspect.

The study, published in the British Medical Journal (BMJ), looked at close to twenty thousand patients who received anesthesia-related procedures while under the care of trainees starting work for the first time at a specific Australian hospital over a five year period.

What they found was a noticeable spike in medical errors in July, but not just for the rookies. Even seasoned anesthesia residents made significantly more errors in July, at a rate similar to the newbies.

The reason for the errors, the authors postulate, may not just be related to lack of technical expertise. Given that the error rate was similar across all levels of training, it may have had more to do with the unfamiliarity of the environment and the pitfalls associated with it. The facility may have used materials that were different than the ones trainees had used in the past, policies related to a given procedure may have been different, even the staff would have been different, which may have affected how comfortable a trainee would feel asking for help.

So while lack of technical expertise may contribute to medical errors in residents, there are clearly other factors at play. Perhaps the next focus of our efforts to reduce medical errors among physician trainees should be to better familiarize our residents with their environment, materials, and staff well before their work is to commence.

Reference

Haller, G., Myles, P., Taffe, P., Perneger, T., & Wu, C. (2009). Rate of undesirable events at beginning of academic year: retrospective cohort study BMJ, 339 (oct13 1) DOI: 10.1136/bmj.b3974

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Post-Partum Psychosis – Rare but Real http://brainblogger.com/2009/10/01/post-partum-psychosis-rare-but-real/ http://brainblogger.com/2009/10/01/post-partum-psychosis-rare-but-real/#comments Thu, 01 Oct 2009 17:16:06 +0000 http://brainblogger.com/?p=3170 The existence of post-partum psychosis and post-partum depression has been hotly contested publicly. Tom Cruise’s denouncement of Brooke Shields’ diagnosis of post-partum depression is perhaps the most visible example of the controversy among laypeople, but in the medical literature the reality of both post-partum depression and post-partum psychosis is much more well-established.

The so-called “baby blues” are common, affecting 30-75% of new mothers (fathers are affected too). True post-partum depression is less common, affecting 10%, while post-partum psychosis afflicts around 1 to 2 out of 1000 new mothers. Other than the precipitating event, post-partum depression differentiates itself from standard depression by having a somewhat lower age of onset and lower incidence of suicide, while having a higher degree of obsessional behavior and anxiety. For obvious reasons, wild swings in hormones are thought to play a role, although no consistent pattern of hormonal alterations leading to depression has yet been identified.

As opposed to post-partum depression, post-partum psychosis differentiates itself from standard psychosis primarily by its precipitating factor: childbirth. Personal or family history of bipolar disorder is perhaps the strongest risk factor for the development of post-partum psychosis. Women with bipolar disorder who also have a family history of post-partum psychosis are at highest risk, with an estimated 570 of 1,000 individuals with this profile developing the disorder in the post-partum period. Early age at parenthood is also a risk factor for obsessional problems in the post-partum period. Women with one episode of post-partum psychosis are also at risk of recurrent mental illness, with 51% developing an illness in a non-childbirth associated setting, and 38% having a recurrent episode of post-partum psychosis with subsequent deliveries. The rarity of this disorder has precluded thorough testing of treatment methods, although electroconvulsive therapy (ECT) has shown some promise. In patients with pre-existing bipolar disorder or a history of psychotic episodes in the post-partum period, mood stabilizers such as lithium may reduce the rate of relapse.

The question remains as to whether the tragedy of the dismembered infant could have been avoided. Although little is known at this time about the mother’s medical history or medication use, the best answer we can give at this time is: maybe.

References

Seyfried, L., & Marcus, S. (2003). Postpartum mood disorders International Review of Psychiatry, 15 (3), 231-242 DOI: 10.1080/0954026031000136857

FAIRBROTHER, N., & ABRAMOWITZ, J. (2007). New parenthood as a risk factor for the development of obsessional problems Behaviour Research and Therapy, 45 (9), 2155-2163 DOI: 10.1016/j.brat.2006.09.019

Tam, W., & Chung, T. (2007). Psychosomatic disorders in pregnancy Current Opinion in Obstetrics and Gynecology, 19 (2) DOI: 10.1097/GCO.0b013e3280825614

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Mechanisms of Drug Tolerance http://brainblogger.com/2009/07/17/mechanisms-of-drug-tolerance/ http://brainblogger.com/2009/07/17/mechanisms-of-drug-tolerance/#comments Fri, 17 Jul 2009 13:00:00 +0000 http://brainblogger.com/?p=3067 New data emerging from the investigation of the death of Michael Jackson reveal that the iconic pop star was taking very high doses of sedative medications during the course of his career. At the time of his death, it was reported that he was taking at least ten tablets of the powerful sedative Xanax every night. Some report that this was an improvement over his previous ingestion of 30 to 40 tablets nightly.

To the uninitiated, doses that high would be lethal. To someone who had developed a tolerance to the medication, however, doses in that range may be necessary to achieve the desired effect. It seems to defy physiology that what would kill one individual would merely mellow out another, but therein lies the enigma of drug tolerance.

Certain medications, such as narcotic painkillers and sedatives such as Xanax, are known to create tolerance. In the case of opiate narcotics, this occurs at several levels within the body. Chronic use of opiate medications causes partial loss of function of its neural receptors’ ability to signal within brain cell. It also causes adjustment of the signaling systems within the cell, leading to alterations in its excitability. These changes, in turn, can indirectly affect the excitability of nerve cells throughout the body, further contributing to overall tolerance. Interestingly, the signaling systems involving cAMP also play a role in synaptic plasticity, leading to potential consequences of opiates on learning and memory. Combined, these changes lead to a blunting of the body’s response to a given dose of an opiate over time, and therefore an ever-escalating need for higher doses of opiates in order to achieve the same effect.

The development of tolerance to sedatives such as Xanax is less well understood, but may involve down-regulation of the benzodiazepine and GABA receptors within the brain. Reduction in the number of chloride channels within the cells and the resultant changes in the GABA receptors may also play a role. Chronic use may alter the gene regulation of the receptor itself. However tolerance to sedative medications occurs, it is known to occur swiftly, particularly with respect to their depressant effects.

While the amount of medications that Jackson was taking may seem shocking, it is a well-known consequence of chronic use of these medications. Unfortunately, while tolerance to the sedative effects of these medications may occur, tolerance to some of their other effects may not, frequently leading to illness, and in some cases, death.

References

Christie, M. (2008). Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction British Journal of Pharmacology, 154 (2), 384-396 DOI: 10.1038/bjp.2008.100

Bateson, A. (2002). Basic Pharmacologic Mechanisms Involved in Benzodiazepine Tolerance and Withdrawal Current Pharmaceutical Design, 8 (1), 5-21 DOI: 10.2174/1381612023396681

Miller LG. Chronic benzodiazepine administration: from the patient to the gene. J Clin Pharmacol. 1991 Jun;31(6):492-5.

Hutchinson, M. (1996). The behavioural and neuronal effects of the chronic administration of benzodiazepine anxiolytic and hypnotic drugs Progress in Neurobiology, 49 (1), 73-97 DOI: 10.1016/0301-0082(96)00011-1

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Time for a Change – Gender Reassignment http://brainblogger.com/2009/06/21/time-for-a-change-gender-reassignment/ http://brainblogger.com/2009/06/21/time-for-a-change-gender-reassignment/#comments Sun, 21 Jun 2009 12:08:16 +0000 http://brainblogger.com/?p=2866 I still remember him plainly: middle-aged, married, paunchy around the middle. He didn’t come in to the clinic because he was sick or had a chronic medical illness. He came in because he wanted to be a woman.

Gender reassignment was not something I had learned about in medical school. It was mentioned in passing, but there were no lectures about how to correctly dose estrogen for the male-to-female transsexual. I frankly had no idea what to do. I think my surprise and confusion were apparent, as the man blushed a little and suggested that I might want to refer him to a specialist.

Chastity Bono’s recent announcement that she will be transitioning from female to male reminded me anew what a deeply personal and difficult decision gender reassignment is. Medically, it’s complicated as well. Before even embarking on the anatomically-altering regimen, a great deal of therapy is recommended, as well as a “test run” living as the desired gender. Following that, hormones are begun. The regimen for a woman becoming a man is relatively straightforward: testosterone shots once every twelve weeks. Such a regimen produces increased facial hair, body mass index, a deeper voice, and enlargement of the clitoris, sometimes to the degree that intercourse is possible without surgery. It can have adverse effects on serum triglycerides and may cause acne.

A man wanting to become a woman faces a bit more complicated hormonal regimen, as not only does estrogen need to be added, but testosterone needs to be suppressed. Surgery to remove the testicles will obviate the latter, but is not a procedure that some are willing to undergo right away. This hormonal one-two punch will result in breast growth, increased subcutaneous fat, some decrease in upper body strength, and atrophy of both the testicles and prostate. Facial hair growth and voice depth will not change appreciably, however, and usually require additional procedures to mitigate.

The ultimate step in sexual reassignment is surgery. The most common type of surgery involves the removal of sex-specific organs; beyond that is genital reconstruction, which is significantly more complicated. After the entire process is completed, only 1 to 2 percent of postsurgical transsexuals experience regret.

As for my patient, I never saw him again after I referred him to another physician. Hopefully he is now a she, and is living a happy and fulfilling life.

References

Benjamin H. International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery Archives of Sexual Behavior, 32 (4), 299-315 DOI: 10.1023/A:1024086814364

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Medicate or Educate? – Just Pop a Polypill http://brainblogger.com/2009/05/28/medicate-or-educate-just-pop-a-polypill/ http://brainblogger.com/2009/05/28/medicate-or-educate-just-pop-a-polypill/#comments Thu, 28 May 2009 16:28:10 +0000 http://brainblogger.com/?p=2783 At this moment, a trial is underway in India. This trial, named the TIPS trial, involves a new medication — a so-called “polypill” — which contains three antihypertensive drugs, a statin, and aspirin. Its researchers enthuse that it may cut the risk of cardiovascular disease by half in healthy people. So far, the study has shown that the side effects of this medication are minimal, or at least not any worse than those of any of the individual components alone. It’s also demonstrated small but significant reductions in blood pressure and cholesterol. The bigger question is: why do we think we really need this medication in the first place?

What these researchers and others before them have done is taken a representative swath of humanity and labeled them as “healthy.” The JUPITER trial, for example, looked at using a statin for so-called “healthy” individuals and found that it reduced their risk of cardiovascular events. However, these people weren’t healthy. Average, yes; representative of the United States population, yes. Healthy, no. Seventy-five percent of the subjects in the JUPITER trial were overweight or obese and also had a blood test abnormality. Similarly, in the TIPs study the subjects did not have pre-existing cardiovascular disease but did have type 2 diabetes, increased waist-to-hip ratio, abnormal lipids, high blood pressure, or a history of recent smoking. In other words, not “healthy.” Notable, too, is the fact that each and every one of the things that renders these individuals unhealthy is almost entirely preventable with lifestyle modifications.

The fact that legitimate research is being conducted on this “polypill” is a sad commentary on the faith that the healthcare industry has in people to save themselves. Although the researchers in the TIPS trial point out that their medication is not intended to be a substitute for diet and exercise, as Dr. Clyde Yancy, medical director of the Baylor Heart Institute in Dallas, was quoted in Clinical Endocrinology News, “There is nothing more effective than modifying lifestyle, but people may tend to dismiss that concept if they believe a pill is lowering their risk of heart disease.”

In a few years, we’ll get the final results on the TIPS trial. I predict that it will show a benefit. I also predict that the drug will be heavily marketed to people who have had the power to lower their risk of cardiovascular disease in their own hands all along. It is up to us to decide if we want our health to be determined by our own efforts or those of the pharmaceutical industry.

References

Xavier, D., Pais, P., Sigamani, A., Pogue, J., Afzal, R., & Yusuf, S. (2008). The need to test the theories behind the Polypill: rationale behind the Indian Polycap Study Nature Clinical Practice Cardiovascular Medicine, 6 (2), 96-97 DOI: 10.1038/ncpcardio1438

Ridker, P., Danielson, E., Fonseca, F., Genest, J., Gotto, A., Kastelein, J., Koenig, W., Libby, P., Lorenzatti, A., MacFadyen, J., Nordestgaard, B., Shepherd, J., Willerson, J., Glynn, R., & , . (2008). Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein New England Journal of Medicine, 359 (21), 2195-2207 DOI: 10.1056/NEJMoa0807646

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Be a Doctor! The Hours are Great! http://brainblogger.com/2009/05/01/be-a-doctor-the-hours-are-great/ http://brainblogger.com/2009/05/01/be-a-doctor-the-hours-are-great/#comments Fri, 01 May 2009 15:07:42 +0000 http://brainblogger.com/?p=2710 Residency training in the United States has historically been a period of abusive hours and intense training. Until recently, there was no limit to the number of hours per week a resident could work. In fact, that has something to do with why they’re called “residents” in the first place: they practically lived in the hospitals in which they worked.

Then came the Libby Zion case, in which a young woman died while under the care of overtired residents. Suddenly America realized that it probably wasn’t a good idea to have inexperienced doctors taking care of really sick people on less than three hours of sleep per night. Enter the Accreditation Council for Graduate Medical Education (ACGME) which is charged with accrediting residency programs nationwide. As of 2003, the ACGME limited the number of hours a resident could work per week to 80, 88 if you were training to be a surgeon and then only under extenuating circumstances. If you were listening carefully at that time, you may have heard the cries of outrage from practicing physicians across the country. How could residents possibly learn enough in 80 hours a week? And after all, if we had to do it, then so should they!

As it turns out, however, caps on resident working hours were nothing new, having been in place across the Atlantic for quite some time. In the United Kingdom, for example, the resident work week is capped at 56 hours per week. And as of August 1, 2009, it’s dropping to 48.

As a program director, I believe I can provide my residents with the training that they need in 80 hours per week over the course of three years. 56 hours per week would take some very creative scheduling. But if I were limited to 48 hours per week, I don’t think that adequate training would be possible, at least not in three years. The British Medical Association seems to realize that and has written a paper outlining several options to address this problem, including extended training. Most options, however, entail added staff and costs. Moreover, most practicing physicians work more than 48 hours per week, according to a 2003 JAMA article. Any resident trained in a 48 hour work week environment would be in for a rude awakening once released into the “real world”.

Fortunately, I don’t have to worry about a foreshortened resident work week just yet. But if the ACGME is taking any cues from the training of British physicians, I may be in for a rude awakening myself in a few years.

References

Maintaining the quality of training in the craft specialties: managing EWTD implementation. British Medical Association. 2009.

E. Ray Dorsey, David Jarjoura, & Gregory W. Rutecki (2003). Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA, 290 (9), 1173-1178

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Who Gets to be a Doctor? http://brainblogger.com/2009/04/05/who-gets-to-be-a-doctor/ http://brainblogger.com/2009/04/05/who-gets-to-be-a-doctor/#comments Sun, 05 Apr 2009 13:19:41 +0000 http://brainblogger.com/?p=2608 I was intrigued by a recent article in the New York Times describing how a Swedish medical school admitted a student whom they later learned had done jail time for murder. Apparently Swedish universities aren’t allowed to do criminal background checks, and even if they were, the student in question had legally changed his name prior to his application to medical school. So now the murderous Swede is a medical student, and the school is wondering what to do with him.

In the article, many of his fellow medical students expressed harsh criticism of the school for admitting this student, if not outrage. But one student openly wondered who had the right to say that this person may not turn out to be a great doctor, in spite of his past misdeeds.

Who, indeed? After all, there are reports that some congressmen have prior convictions. George W. Bush may have been the first U.S. president to enter office with a criminal record. Even Bill Gates has a rap sheet, and I think it’s fair to say he’s doing pretty well for himself. Moreover, our country is faced with an imminent shortage of physicians, and declining interest in primary care. In light of such shortages, should we keep people who are willing and able out of medical school due to past offenses? And if so, where do we draw the line? Murder seems to be a likely exclusion criterion. How about rape? Assault with a deadly weapon? DUIs? Parking tickets? Domestic abuse? Animal cruelty? Fraud?

As anyone schooled in behavioral interviewing can confirm, the best predictor of future behavior is past behavior. A 2008 article published in the Annals of Internal Medicine found that physicians who had poor professionalism behaviors during residency were much more likely to face disciplinary actions as practicing physicians. In addition, a 2005 article published in the New England Journal of Medicine found that disciplinary actions by state medical boards were strongly associated with prior unprofessional behavior in medical school.

So to the extent that having a criminal record can be considered “unprofessional,” it seems that a criminal record — any criminal record — would be sufficient reason to keep someone from becoming a doctor. And if the Swedes don’t want to look for a record of criminal activity prior to admitting people to medical school, they’re going to have to make sure their medical licensing boards, as well as their citizens, are ready to suffer the consequences.

References

Altman, Lawrence. A Quandary in Sweden: Criminals in Med School. The New York Times, March 23, 2009: D1.

Papadakis M, Arnold G et al. Performance during Internal Medicine Residency Training and Subsequent Disciplinary Action by State Licensing Boards. Annals of Internal Medicine, June 3 2008. Volume 148, Issue 11, pp 869-876.

Papadakis, M. (2005). Disciplinary Action by Medical Boards and Prior Behavior in Medical School New England Journal of Medicine, 353 (25), 2673-2682 DOI: 10.1056/NEJMsa052596

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Father’s Milk http://brainblogger.com/2009/04/01/fathers-milk/ http://brainblogger.com/2009/04/01/fathers-milk/#comments Wed, 01 Apr 2009 18:27:56 +0000 http://brainblogger.com/?p=2277 There’s a great scene in Meet the Parents in which Ben Stiller’s character Greg is trying to convince his future father-in-law, played by Robert DeNiro, of his history of milking cats in Detroit. He claims it’s possible because cats have nipples. DeNiro’s character replies, “I have nipples, Greg. Can you milk me?”

In spite of the disturbing mental image this conjures, it actually is possible for men to produce breast milk. As DeNiro’s character so comedically noted, men do indeed have nipples. They also have the rudimentary breast tissue and ductal structure that would make the production of milk, called lactation, possible. What they lack is the proper combination of hormones to plump up the breast tissue and stimulate the production of milk.

The formation and proliferation of breast tissue is dependent on the hormone estrogen. Though generally considered to be a “female” hormone, men do produce small amounts of estrogen, as well. In men, its effects are usually tempered by the large amount of testosterone that they produce. The actual production of milk by the breast tissue is dependent on the hormone prolactin, which is secreted by the pituitary gland in the brain. Following the birth of a child, the pituitary gland increases its secretion of prolactin, enabling the new mother to begin producing milk for her infant. Stimulation of the nipples by the nursing infant also causes a spike in prolactin production.

Most cases of male breast formation and lactation in humans are the result of disease or medication side effects and not the need to feed their offspring. The medical literature is replete with reports of men developing breast tissue due to medications or medical conditions. Fat cells are known to increase the production of estrogen, so it’s not uncommon for obese men to develop more prominent breast tissue, known as gynecomastia. In addition, steroid use, cirrhosis, certain medications and certain herbal formulations may cause gynecomastia. Reports of males producing milk are much less common, and are usually seen in infancy when the baby’s overall hormonal status is in quite a bit of flux. And although multiple causes of increased prolactin secretion exist, such as from a pituitary tumor or side effect of a medication, men rarely get galactorrhea as a result.

So while male lactation is possible, it’s very rare, and almost never physiologic. And for those of you who are fans of Meet the Parents, please don’t try this at home.

References

Devidayal (2005). A Male Infant with Gynecomastia-Galactorrhea The Journal of Pediatrics, 147 (5), 712-712 DOI: 10.1016/j.jpeds.2005.06.026

van der Steen M, Du Caju MV, Van Acker KJ. Gynecomastia in a male infant given domperidone. Lancet. 1982 Oct 16;2(8303):884-5.

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Changing the Error of Our Ways http://brainblogger.com/2009/03/22/changing-the-error-of-our-ways/ http://brainblogger.com/2009/03/22/changing-the-error-of-our-ways/#comments Sun, 22 Mar 2009 15:30:27 +0000 http://brainblogger.com/?p=2548 BioPsychoSocial Health CategoryWe all have bad habits. I don’t sleep nearly enough, and by mid-afternoon I’m a basket case without an infusion of chocolate. I know I should probably sleep more and avoid sweets; in fact, I’ve known this for several years, but I’ve never felt motivated to change my ways. This human tendency has beleaguered health care professionals for ages: how do we motivate individuals to change their behaviors? Two recent studies may give us some ideas.

A recent study published in the Annals of Behavioral Medicine found that smokers who received anti-tobacco messages via their PDAs were more likely to try to quit smoking. In this study, one group received frequent messages about the adverse health consequences of smoking, while the control group received frequent messages about general stress or money concerns. In the end, 53% of those receiving anti-tobacco messages attempted to quit smoking, versus 19% in the control group. In addition, those receiving the anti-tobacco messages expressed significantly more worry about their smoking habits than those who did not. The researchers concluded that in order to get an individual to quit smoking, the key was to get the smoker worried about the health consequences of tobacco use.

TelephoneHowever, another recent study found that dieters were more likely to succeed with their weight loss if they had more frequent telephone contact with nutritionists. A study published in the Annals of Internal Medicine found that obese individuals who were trying to lose weight had more success with high-frequency telephone contact or high-frequency face to face visits with nutritionists than those who had neither. They did not include a group that had high-frequency contact with researchers regarding general stress or money concerns. The article does not mention what precisely was addressed during contact with the study participants other than “lifestyle counseling”, nor does it assess how concerned the study group was about the effect of obesity on their health. The researchers in this study concluded that the frequent contact may have played a key role in the study group’s success.

In both the smoking and the weight loss studies, success was due, at least in part, to frequent contact that addressed the behavior that needed changing. In the first study, the researchers concluded that it was “worry” that motivated the smokers to quit, and certainly those who received the anti-tobacco messages did indicate an increased level of concern about their habit. However, was it truly worry that motivated the change, or was it the frequent reminder about the behavior at issue? Would similar effects be seen in dieters if they received frequent reminders about the negative effects of obesity and a sedentary lifestyle on their overall health? Could it be that the frequent nudges about the undesired behavior, rather than “worry”, is the crucial factor to spur behavioral changes?

Given that between 50 and 75 percent of medical conditions are due to behavioral factors, learning how to motivate change could play a huge role in improving our health. I hope to see more studies that address precisely these issues.

References

Magnan, R., Köblitz, A., Zielke, D., & McCaul, K. (2009). The Effects of Warning Smokers on Perceived Risk, Worry, and Motivation to Quit Annals of Behavioral Medicine, 37 (1), 46-57 DOI: 10.1007/s12160-009-9085-8

Andres G. Digenio, James P. Mancuso, Robert A. Gerber, Roman V. Dvorak. Comparison of Methods for Delivering a Lifestyle Modification Program for Obese Patients: A Randomized Trial. Annals of Internal Medicine, Volume 150, Number 4 (February 2009), pp. 255-262.

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Carbon Monoxide Poisioning http://brainblogger.com/2009/03/15/carbon-monoxide-poisioning/ http://brainblogger.com/2009/03/15/carbon-monoxide-poisioning/#respond Sun, 15 Mar 2009 19:56:49 +0000 http://brainblogger.com/?p=2324 Health and Healthcare CategoryEvery year around this time there’s a news article about people dying from carbon monoxide poisoning, either from a faulty furnace or from sitting in a running vehicle with poor ventilation. A colorless, odorless, tasteless gas, carbon monoxide can build up to dangerous levels insidiously. Carbon monoxide is produced by the combustion of hydrocarbons, so is a frequent byproduct of the combustion of gasoline, kerosene, and oil. As you might expect, carbon monoxide levels are higher in urban and industrialized areas.

BloodBut how exactly does carbon monoxide cause problems? In humans, oxygen is transported to the body by attaching to hemoglobin, a protein found in red blood cells. Carbon monoxide binds to hemoglobin more easily than oxygen, and therefore displaces the oxygen from the red blood cells. In addition, carbon monoxide makes it more difficult for any other oxygen molecules the red blood cell may be carrying to get delivered to the rest of the body. In short, carbon monoxide poisoning mimics oxygen deprivation. There is, however, a condition due to carbon monoxide poisoning known as delayed neurologic sequelae which can’t be explained by poor oxygen delivery, and may have more to do with enzymatic changes in the brain induced by the carbon monoxide molecule. Carbon monoxide can also cause damage to the heart and can cause accumulation of fluid in the lungs, a condition known as pulmonary edema.

Symptoms of carbon monoxide poisoning can be vague and nonspecific. Frequently patients will present with confusion or symptoms directly attributable to oxygen deprivation, such as chest pain. Headaches, nausea and vomiting may also occur.

The diagnosis of carbon monoxide poisoning is largely based on a suggestive history or clear evidence of exposure in addition to elevated levels of hemoglobin bound to carbon monoxide, otherwise known as carboxyhemoglobin. In cases of chronic carbon monoxide poisoning, however, carboxyhemoglobin levels can be inaccurate, making the diagnosis in such circumstances quite difficult.

Treatment of carbon monoxide poisoning is premised on getting enough oxygen into the patient’s system to wrestle the carbon monoxide off of the hemoglobin. This is accomplished with delivery of 100% oxygen into the patient’s lungs via a face mask, or in more severe cases, via a breathing tube connected to a respirator. Hyperbaric chambers can deliver 100% oxygen at high pressures, making delivery of oxygen into the patient’s system even more effective.

Carbon monoxide poisoning is entirely preventable with the use of inexpensive detectors that can be installed in your home. And if you already have carbon monoxide detectors in your home, be sure to check the batteries.

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How Strong is Your Evidence? http://brainblogger.com/2009/03/13/how-strong-is-your-evidence/ http://brainblogger.com/2009/03/13/how-strong-is-your-evidence/#comments Fri, 13 Mar 2009 16:53:54 +0000 http://brainblogger.com/?p=2496 If you’ve had heart problems, chances are you’ve received some advice from your doctor on how best to care for your condition. Maybe you were advised to take an aspirin daily, exercise regularly, or cut down on the salt in your diet. Maybe you were handed a sheaf of prescriptions bearing foreign-sounding medication names with the assurances that they would help stave off future problems. And if you’re like many patients, you took the doctor at his or her word, assuming he or she was acting based on sound medical evidence. Unfortunately, that assumption may have been false.

The push in medical education for several years has been towards more evidence-based medicine; that is, we should teach our young doctors to recommend to their patients what has been scientifically proven to be beneficial. However, a recent study published in the Journal of the American Medical Association (JAMA) found that, at least with regards to cardiovascular problems, the vast majority of the medical evidence supporting current recommendations is weak. Researchers examined the current recommendations of the American Heart Association and the American College of Cardiology on 22 different cardiovascular topics. They graded the strength of the evidence supporting these recommendations from A to C, with A being the best evidence, and C being very little or weak evidence. Only 12% of the recommendations were in the A category. A staggering 45% earned a C.

There are many potential reasons for this, not the least of which is simply the lack of powerful data. The ideal medical study is a large, multicenter, randomized, double-blind, controlled trial funded by an organization with no vested interest in the outcome. The closer a study comes to this ideal, the stronger the evidence is to support its findings. However, many studies fall short of this ideal on numerous fronts. They involve a small or restricted subgroup of patients. They’re performed at only one medical center. They’re funded by the company that makes the medication or device being studied. Any of these shortcomings call the results of the study into question and weakens the strength of the evidence. Can these findings be applied to a larger or less restricted population? Can the results be reproduced at a different hospital? Are the researchers biased towards finding a positive outcome for the company that funds their research?

So should you ignore the majority of what your doctor says for lack of strong evidence? Not necessarily. Most doctors are simply working with the best information they have, even if the data supporting it is weak. What studies like this highlight is the need for better research to ensure that our recommendations are based on sound scientific evidence.

References

P. Tricoci, J. M. Allen, J. M. Kramer, R. M. Califf, S. C. Smith (2009). Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines JAMA: The Journal of the American Medical Association, 301 (8), 831-841 DOI: 10.1001/jama.2009.205

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