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My Medicine

In the first installment of this series, I discussed the challenges faced by those learning the art and science of medicine, which is to say, everyone (or at least, everyone who is still willing to learn and adapt to the growth and evolution of knowledge in medicine). It is the uncertainty and the complex mechanism by which knowledge changes that necessitate that physicians actively organize and seize control of the ways they learn. Additionally, medicine is a high stakes endeavor, one in which accuracy and precision of information are paramount, and one in which a common mantra is “trust no one.” As such, individual physicians need to establish a fulcrum across which to balance different sources of information and learning. The fulcrum, in my opinion, is the physician’s notebook.

What do I mean by “notebook?” The notebook can be any means by which a student, resident, fellow or attending organizes his or her thoughts. In most cases, this is a written medium which will allow the user to either write, draw, or type information as a means of immediately aiding the storage of memory in the brain and providing a visual map by which to trigger the accessing of memories. This medium should be portable and easily accessible or it won’t be used. Finally, the notebook should be expandable, as the duration of time during which a physician must learn is limited only by lifespan (unlike a notebook used in grade school or college for a specific course). Here, I describe three potential methods that one might use to seize control of one’s learning.

The Moleskine aka “Token of Nostalgia”

The most common method that physicians use to take notes are physical notebooks. These are typically small enough to fit into the breast pocket of a physician’s white coat, often the only pocket with a standardized size across various white coat brands (the side pockets vary greatly in size). In my imagination, the “Golden Age of Medicine” is populated primarily by well-groomed, male physicians who mostly look like Don Draper except that some have more white hair and most are alternating between business suits or long white coats. Nestled somewhere between the penlight and fountain pen rests the Moleskine, a thin leather bound notebook. The company that has the trademark for the name Moleskine has advertised this little notebook as being so much more: in describing the many famous and brilliant people who have jotted down ideas and drawings on its pages, the Moleskine is somehow supposed to inspire brilliance in the rest of us. This notebook fits so well with the traditional culture of reverence and nostalgia within Medicine that it is found in most if not all medical school bookstores.

These little books are useful for their portability and easy accessibility. Furthermore, they require only a pen and (at least) legible penmanship. Notebooks are generally cheap, though the premium brand-name Moleskines usually cost $8-12 each (varies based on size and merchant). Of all the methods of taking notes, this one requires the least amount of startup time. However, all pen-and-paper solutions have serious disadvantages. Perhaps the most prominent is expandability: all paper notebooks are limited by the number of pages available, which means that the notebook will at some point reach its maximum capacity and become a static entity. In this situation, it remains a useful resource for referencing and memory augmentation, but it no longer has the ability to help one grow one’s knowledge base or chart that growth. Furthermore, notebooks require good handwriting: most physicians have atrophic penmanship which is worsened by fatigue and the prevalance of electronic medical records. Paper notebooks also require exceptional planning skills in laying out an effective organizational scheme prior to starting the notebook, otherwise accessing information in the notebook becomes an exercise in random searching. Lastly, if lost or misplaced, a paper notebook is gone forever and cannot be easily replaced.

Personal Experience: Throughout medical school, I used Moleskine notebooks to take notes and by the end went through at least three. I was frustrated by the lack of growth capacity. Accordingly, an alternate solution I tried revolved around the “Pocket Medicine” series: the portable book is actually a small binder, and a few stationary stores actually carried extra lined paper inserts that matched the size of the printed pages. I thought this was an elegant solution as it allowed me to take notes and “insert” my knowledge into the handbook. Over time, this expansion capacity was still not enough, and my fear of losing the notebook prompted me to seek out other solutions.

The iNotebook aka “A walk in the clouds”

As iPads and iPhones (and to a lesser but still considerable degree, other tablet computers and Android phones) become ubiquitous throughout the physician population, the possibility for new electronic methods of notetaking grows exponentionally. When I was a third year medical student, iPhones and iPod touches were still uncommon, and pulling out one of these iDevices in front of an attending on rounds was still considered rude and taboo. However, there is now a well-developed ecosystem of medical apps and resources available for these devices that make them useful for information acquisition in the clinical setting. While there are still some concerns regarding the ability of electronic devices to distract physicians from clinical care duties, the overwhelming momentum is towards the acceptance and adoption of portable technologies into medical practice. Furthermore, medical schools and residencies have discovered educational and clinical training value found in these devices, or at least they are willing to invest money to buy these devices for their students and residents with the expectation of educational potential.

With regards to serving as “notebooks,” the iPad and iPhone, particularly as a pair, are a potent combination. In addition to providing storage and reading capacity for electronic textbooks and papers from research journals (think of the numerous e-mails one receives everyday with an attachment to some review or study), the iPad additionally services as an effective content creation device with the appropriate peripherals. Many people find it difficult to use the glass keyboards of Apple’s devices, and few would argue that typing performance on the glass keyboard can match a physical keyboard. Accordingly, a Bluetooth keyboard is an essential add-on, and numerous elegant solutions have been developed including the Clam Case and Logitech’s Keyboard Folios (solar and standard), most typically increasing the overall investment by $80-150. With these keyboards, the iPad effectively becomes a “netbook”: a laptop with a slightly smaller keyboard (which might impeded some people with big hands), smaller hard drive, and longer battery life. However, the iPad is much more effective than a true netbook because it does not have the startup latency of laptops: most if not all of the tablet computers activate within fractions of a second and can allow one to start typing seconds later. In addition to allowing rapid access to a typing interface, many apps on the iPad and other tablets allow for alternative forms of note-taking: drawing with a finger or stylus, a mixture of drawing and typing in flow charts, and recording audio.

Unlike paper notebooks, notetaking on a tablet computer can be organized and reorganized in a much more malleable fashion. The initial planning stage is less important because information can be readily modified and moved, a feature not present in paper notebooks (there is no readily accessible “copy-paste” feature in the analog world). Simple text editors allow for the creation of innumerable text files, while more complex cloud-based notetaking programs often include content search capabilities, tagging (by keywords), and nesting of files within folders.

Where does the smartphone fit into this? If the smartphone uses the same operating system as the tablet computer, often shared applications can also share data, particularly if one uses a cloud-based storage solution such as Dropbox, iCloud, Microsoft’s SkyDrive, or Google Drive. Accordingly, if one doesn’t have the tablet available (or have the time to pull it out), one can still access all of the same files on the smaller screen of the smartphone (which most people will carry around all the time). This reduces the time required to access notes and more closely approximates the time it would take to flip through the pages of a paper notebook.

There are disadvantages to the tablet computer-smartphone solution as well. First, this solution is expensive: both tablet computers and smart phones cost hundreds of dollars (an iPad, iPhone, and Bluetooth keyboard will probably cost the user about $1000, not including the monthly service fees for the iPhone). Secondly, the data input is reliant on the larger device: typing on an iPad Bluetooth keyboard for the average computer user is likely to be nearly as fast as on a full-sized keyboard, but this requires that the user have a flat surface on which to rest the device. Practically, this means that the user needs to be seated or standing at a counter, such as at a nursing station or using the height-adjustable table at a patient’s bedside. This also means that the user needs to carry both the iPad and keyboard with him or her into the clinical setting. While there are some people who have modified white coats to include iPad-sized pockets, this may not be the most comfortable solution. For physicians that normally carry brief cases or shoulder bags (e.g. Neurologists), carrying a tablet is not an issue. Thirdly, this solution is energy-based, so battery life becomes a consideration. However, iPads and iPad-compatible Bluetooth keyboards generally have exceptionally long battery lives.

Personal Experience: This is the solution that I use at this time, and quoting the late Steve Jobs, “It just works.” I use a Clam Case with my iPad 2 to type my notes. I carry the iPad in a Fossil city bag which fits both the iPad as well as my various diagnostic tools in a non-bulky fashion. I use DropBox as my cloud-based storage solution with Elements as my simple text editor for notes (which is fast, has folders for organization, and keeps my files accessible instantly without an Internet connection on my iPhone, iPad, computer, and on the web on the Dropbox site). I use Papers for handling journal articles, iAnnotate for other PDFs, and Kindle and the iBooks apps for medical textbooks. I generally pull out my iPad/Clam Case during conferences and lectures to take notes, and when I’m on clinical duty and need to check something I pull out my iPhone to quickly access the notes. In my case, the additional weight of the devices is justified by the iPad’s additional uses on the wards and in the clinic: I also use my iPad/Clam Case for writing progress, admission, consultation and clinic notes, and while rounding it is additionally useful for placing orders and checking labs and imaging test results. A laptop, even a small one, would be more cumbersome for the ward-specific tasks (placing orders, checking the electronic medical record while standing/walking), and most do not have the equivalent battery life or short activation latency.

Of note, there are a variety of other methods of using a smartphone and a tablet. There are several cloud-based note taking services such as Evernote, Notability, SimpleNote, etc. For me, I wanted a service that would allow me to access some version of my notes off-line on any device, so a DropBox based solution was the best for me.

The Collaborative Notebook aka “WikiMedicine”

One idea that I have reencountered is the collaborative notebook. That is, a centralized website where several individuals within a field can post and edit files or pages and pool together a considerable amount of knowledge and learning. One example of this that was recently presented to me is HemOnc.org, a wiki-style site that serves as a resource and quick reference for hematologist-oncologists. On the site, one can find chemotherapy protocols, comparison charts between various medications, and references to the primary literature used to guide the design of protocols and selection of medications. This is one such example of a free, non-subscription based site that can be created by physicians for physicians for the storage, growth and dissemination of practical knowledge.

One major advantage of this model is that knowledge can grow rapidly when it is shared. The collaborative effort brings together information much more quickly as each individual is contributing information and is exposed to a different set of patients, different literature, and different perspectives. Another advantage for a web-based solution is that the information can be accessed and modified on a variety of platforms, including on the computers in a clinic or hospital as well as on personal devices such as smartphonese, tablets, laptops, etc. This information can sometimes be automatically backed up to a physical hard drive so that it is not only living in the Internet ecosystem.

This type of model also has unique challenges. Collaborative sites by necessity require more moderation in order to monitor and regulate quality of information. Web-based solutions require an Internet connection which surprisingly can be hard to find in the wireless dead zones of various hospitals and medical schools. Also, websites sometimes require hosting fees and sometimes minimal knowledge of programming (or at least managing basic website types such as wikis and weblogs).

Conclusions

These are only a few methods by which one can keep a notebook as a physician. Regardless of one’s choice, the main objective is to help one take control of one’s learning and the shaping of one’s mind as a complex diagnostic system. This is an important step towards gaining more autonomy as an individual clinician and more effectiveness in treating one’s patients.

The Context

Today, one of the our attendings gave a solid overview of the major families of dementias. With the skills of a talented and effective instructor, he queried the audience of residents and students to help him fill out the content of a table designed to help differentiate between the presentations, test findings, and treatments for the different types of diseases. He was able to keep the audience actively engaged and participating, but at one point he asked a question that was met with silence. I volunteered the answer, and he turned to me, somewhat surprised that anyone knew the answer. I explained (that he shouldn’t be so impressed): he had mentioned the answer in a previous talk given several months ago, and I just happened to have a set of notes from that discussion open on my iPad which I was annotating and expanding with the lessons learned from today’s talk.

While it’s not so impressive that I was able to ascertain the answer, impressing someone was not the point for me: the fact is that I had that information and was able to quickly access it, even if it wasn’t readily accessible in my own brain’s memory bank without the assistance of my notes. This raises a major question for lifelong students of medicine: Is it better to try and store as much information in one’s memory as possible knowing that there will be limitations on the amount of information that can be remembered, or is it better to store some (perhaps a large proportion) of that information somewhere it can be easily and quickly referenced? If secondary storage of information is worthwhile, then should clinical information be trusted to a few easily-accessible resources (e.g. a pocketbook, online medical search database) or should it be digested and recorded into a personal notekeeping device (i.e. a notebook)? To approach these questions, we must first understand the nature of knowledge and how it is gained.

free your mind

The Student’s Dilemma

While we would like to think of knowledge learned as being the truth and that truth is an absolute, for better or worse the learning of medical knowledge is not this simple. Since medicine is based on scientific principles, there is a constant effort to strive for refinement of knowledge towards the best approximation of the truth, but in the mind of a humble scientist there is also the necessary acknowledgment that a better or more truthful explanation may arise to refute his or her prior claim. Simply stated, medical knowledge changes, evolves, and hopefully improves with the advance of medical science. Nonetheless, there is also the knowledge derived from practical experience (or story or wisdom) that enters the learner’s mind in the form of a “gospel” taught by more senior physicians. In many ways, this information is equally important and perhaps carries equal weight because this information is based on direct encounters with individual people that have the full force of a clinician’s mind reviewing the entirety of their unique cases. Nonetheless, something that is gospel must be preached (with strong language, without wavering, and lacking an acknowledgment of uncertainty), and one only has to preach when there are those who do not believe what is being said. In other words, truth does not need to be questioned, but this does not fit the description of anything in medicine. As such, physicians and patients alike must live and function with great uncertainty regarding what is known, what is not known, and whether or not what is “known” is actually meaningful (or “truthful” as charted against a constantly changing measure of what is true).

I will give an example here: I remember either a Neurology attending or fellow once explaining to me that the mild weakness found on ipsilateral limbs in a patient with a unilateral stroke could be explained by involvement of the fibers descending in the anterior corticospinal tract (which travels ipsilaterally and does not cross in the medulla). This descending fiber tract contains somewhere between 10-20% of the corticospinal tract fibers, varies in size between individuals, ends in the thoracic cord, and likely provides innervation to muscles of the neck and upper limbs. Anatomically, this explanation seems to make some sense. I asked another senior Neurology attending this question in a different patient with a similar presentation, and he stated definitively, “It never happens.” In perusing various Neurology textbooks, I cannot find any information corroborating the first explanation. The traditional textbook that most clearly addresses this question, Neurology: A Queen Square Textbook”, states “Of corticospinal fibers, 10% remain uncrossed, their neurones of origin outlining an ipsilateral somatotopic map, a point of little apparent clinical significance.” Why then, does this fiber tract even exist? There are some studies that suggest that the presence of this “accessory” pathway may aid motor recovery from lateral corticospinal tract damage as in stroke [1] or spinal cord injury [2].

A common response among learners to these conflicting messages is to give up. The tendency is to lose faith in attempting to achieve the ability to “know.” Accordingly, many choose to defer to those who do “know,” or at least believe they do. The appeal of following guidelines stems from this tendency: in theory, a panel of “experts” have pooled together their knowledge and provided recommendations to follow. In this climate of uncertainty, most people choose to follow. But what makes the experts “experts” in their fields? Often they are the physicians, scientists, or physician-scientists who are pursuing active research or have extensive experience with a particular clinical issue. At best, they are driven in their desire to know by the awareness of the incompleteness and changing nature of knowledge and also by the idealistic hope that it is possible to improve knowledge and thus improve the practice of medicine. Ideally, they additionally generate new evidence to contribute to the current knowledge of disease and treatment in the form of clinical trials, updated reviews, case series, and more. At worst, they may be the ones who are simply preaching the loudest and most forcibly.

I, and many others, would argue that this method of learning and practicing medicine is too passive and not sufficiently adaptive. Consulting (to the exclusion of other sources) searchable databases such as UpToDate potentially leaves one’s mind at the mercy of a few opinionated authors. It is not enough to practice medicine as directed by the Cochrane reviews alone. It is no longer enough to practice medicine based only on the anecdotal and experiential wisdom passed down by prior generations of physicians. And it is largely impractical for any individual physician to stay abreast of the latest developments in every field of medicine, let alone in his or her own field with regards to the numerous studies being published every week. Not surprisingly, it is important, then, to find a balance between all of these sources and types of information and information acquisition.

The Notebook

In my opinion, a notebook is the most essential piece of a physician’s armamentarium. It is more important than the stethoscope, scalpel, or any other tool. Why? The notebook represents a projection of the physician’s mind, and no matter the specialty, the physician’s mind is still his or her greatest asset and most effective tool in treating patients. The notebook serves a number of important roles for the physician:

[1] Facilitation of memory encoding

A lot of educational theory and research is based on the many ways different individuals learn, particularly with regards to methods emphasizing visual, auditory, and tactile sensation. Incorporating multiple modalities, such as writing notes while listening to a lecture and watching a slide presentation, is thought to improve memory retention. Accordingly, it helps to write down what is learned, whether on the wards, at the white board, during morning report or noon conferences, or at grand rounds or conventions, as this should help you more firmly implant the knowledge into your hippocampi.

[2] A database of references and the knowledge “family tree” (e.g. lineage)

Because of its origins and the way knowledge works within medicine, the lineage of knowledge remains an important distinction that marks one’s identity as a physician. Since much of medical teaching is based on the experiences of physicians whose careers may last half a dozen or more decades, one’s teachers inspire considerable reverence from the trainees who follow them. However, physicians may encounter several “schools of thought” throughout different stages of training and may find that their own minds are battlegrounds between competing ideologies. Accordingly, I find that it is very important to chart and document from whom one learns a new tenet of medicine (be it a resident, fellow, senior attending, clinical trial, visiting lecturer, clinical trial, review article, textbook, etc.). In the aforementioned example, I cannot remember who asserted to me the notion that damage to the anterior corticospinal tract can result in ipsilateral weakness. As such, I cannot ask him or her how that knowledge was obtained, and it thus holds little water against the assertion of the other attending or my current review of the available literature. If you keep track of your learning and keep references to your sources (e.g. the name of a physician who gave a lecture), it is possible to track how your thinking and understanding of the field evolves over time, particularly when new data is incorporated from new studies or encounters with physicians trained in another school of thought.

[3] A launchpad for inquiry

Sometimes the hardest thing to remember is a question. And yet, as physicians, questions arise in our minds constantly: much of our role as clinicians mimics the modus operandi of the detective. Furthermore, the ingrained abundance of intellectual curiosity is one of the distinguishing features that differentiates physicians from other health care providers. Nonetheless, our attention is also constantly bombarded by numerous competing interests (pages, e-mail messages, patients and families, other care providers, etc.). There are countless times that I had a question I wanted to ask someone giving a talk which vaporized prior to the talk ending and also numerous occasions when I identified something I wanted to look up which I later forgot about. In order to help further develop your own knowledge base, improve the care of your patients, and perhaps even generate questions that might advance the field as a whole, it helps to write down the questions that come to mind as soon as they arise. This can help identify knowledge areas that you can expand and enrichen, detect problems in your clinical practice that might be useful to address (e.g. Why isn’t there a standardized protocol for (blank) here?), and develop potential ideas for research.

[4] A map of the mind

Last but not least, the notebook can serve as a measure and organizational tool for the knowledge one has already acquired. Keeping one’s thoughts and memories organized is a very important precursor to developing an easily and quickly accessible knowledge bank. The primary objective is to make your brain an efficient and effective database of knowledge and to use that knowledge to guide actions (e.g. the practice of medicine) in a meaningful way. The notebook should not serve as a replacement for the mind’s memory stores, but rather, it should serve as a visual aid (to trigger memories of learning from direct visualization and also to help guide a mind-only “memory palace”-style search if the notebook is absent) and as a hierarchical “site map” or “table of contents” that helps you keep track of what you know so far and what you don’t know.

I hope I have at least begun to convince you that the notebook and the active engaging and recording of lessons learned are essential for physicians at all levels of training. In my next installment of this series (The Battle for Your Mind), I will discuss different methods modern physcians can use to keep notebooks.

References:
1. Shelton, F, and Reding, MJ. “Effect of Lesion Location on Upper Limb Motor Recovery After Stroke.” Stroke. 2001; 32: 107-112.
2. Priestly, JV. “Promoting anatomical plasticity and recovery of function after traumatic injury to the central or peripheral nervous system.” Brain (2007) 130 (4): 895-897.

I carry my iPad with me to work, the hospital, every day. Dozens of people have asked me whether or not I like it and have found it useful. This post is a detailed response to those questions and has a series of app recommendations.

My training in medicine is taking place during a major transition point with regards to information technology. While electronic documentation systems are in high demand but are lacking in quality, utility, and universality, personal information technologies are rapidly evolving. Many quintessential medical textbooks are now digitally accessible for medical students and residents through the libraries of their academic institutions, reducing the need to purchase or update textbooks. Rapid access to specialized and obscure medical information is now available through subscription services such as UpToDate, a medical encyclopedia with a powerful search engine that helps physicians at all levels of training access and share knowledge that might otherwise require consults or in-depth literature searches to obtain. And finally, many physicians now carry portable computers, whether in the form of smartphones, or more recently, tablet computers such as the Apple iPad. Previously, I wrote about my efforts in using an iPod Touch as a medical information device during medical school. During this year, my first year of residency, I have been greatly aided by the iPad I received as a wedding gift just prior to the start of my intern year: with it, I have been able to more rapidly expand my medical knowledge, build my teaching repertoire, and quickly access pharmacopeia and medical calculations, all of which have helped facilitate patient care. Below, I highlight the areas in which this device has helped me.

Building Knowledge

Aji Annotate PDF Reader – If you can save a digital document as a PDF file, then that can become a page in your digital library forever. Through a meticulous team effort during medical school, my friends and I managed to compile several medical textbooks through our university access to AccessMedicine and MD Consult, giving me instant access on my iPad to Harrison’s Medicine, the Osler Handbook of Medicine, Adams and Victor Principles of Neurology, and many more. This app has a smooth reading interface, but best of all, it SEARCHES THE TEXT. This app, with these customizable sources of information, have helped guide me many times with initial treatment decisions for a variety of my patients when I am confronted with a medical problem with which I am not very familiar.

Articles – Though not an information source designed to be relied on for making treatment decisions, Wikipedia still remains a rapid and useful resource for reminding oneself of rare clinical entities and eponyms and snippets of medical history. In many ways, it is like a Cliff Notes version of an entry-level medical school textbook. Of all the Wikipedia viewers, Articles may have the most beautiful and easy to use interface, and it is easy to save and organize bookmarks for future viewing.

Papers – When you need a high quality, evidence-based answer, one often must resort to the classic past time of gluttons for punishment: the literature search. This app designed by graduate students makes the process a lot easier and saves a lot of trees: it has a built-in composite search engine that searches several libraries (PubMed, Google Scholar, etc) according to your specifications for your search terms. When you find papers of interest to your question, you can import them into the app for storage and reading (it serves as a PDF reader). For me, whenever a resident or attending hands me a paper to read, I look up the paper, import and sort it into this app, then recycle the printed article. This is yet another helping hand to reducing the “too many pieces of paper in the white coat pocket” dilemma.

Videos – This built-in Apple app has at least one amazing, readily-accessible application: the storing and viewing of NEJM procedure instruction videos. Don’t remember how to perform a lumbar puncture? Haven’t placed a central line since intern year? Just go onto the NEJM website, download the videos, and then watch them when you need to to help prepare for the procedure to be performed (usually under supervision, of course, but it helps to have a reminder of the steps and the supply list).

Kindle – Though many textbooks are available through medical school libraries of training institutions, many other books are still not available. Some of these are available for the Kindle app, making this yet another portal for accessing advanced medical knowledge.

Everyday Tasks

Mediquations – The author of this app has done an amazing job of frequently updating his app with the most useful equations, scores, and data cards used in medicine. Of all the apps I use on a daily basis, this is one of the most frequent. Cheers.

Micromedex – This iPad-native app provides an excellent pharmacopeia for any medical provider. At this time, I actually prefer it to Epocrates with regards to faster and more automatic updating and also smoother operation (with no invasive “news bulletins” and notices). I use this app daily, either on the iPad or iPhone, to determine medication dosing and scheduling, adverse effects, drug interactions, and cost.

Citrix Receiver and similar apps – Several hospitals, including the two in which I train, are already beginning to use iPads to access the hospitals EMRs, allowing for quick access to laboratory and imaging data, placing orders, and even writing notes (perhaps somewhat more slowly unless one is adept with the glass keyboard, which I have grown accustomed to).

Facilitating Communication

Sign-N-Send – This app is definitive proof that the gods are merciful. To illustrate how firmly entrenched part of medicine is in the Stone Age of technology, fax machines still remain a primary form of hospital-to-hospital communication. Furthermore, residency programs and hospitals as employers send interns and residents dozens of forms to fill to be completed and faxed back. NOBODY HAS A FAX MACHINE AT HOME (except those of you who have physicians for parents). Normally, I would have to print out the form, fill it out on paper, scan it, and then email it back. This app allows one to open up, download, or import from the web forms in PDF, and it allows the user to type on the form or sign with a finger or stylus (allowing for zooming to make signing easier).

Mail – Academic medicine is firmly entrenched in the world of email – if you don’t check your email often, you fall behind very quickly. Forms need to be signed, rotation needs to be requested, and opportunities are offered without being advertised elsewhere. Check your email, often and much!

WordPress – Writing is one of my careers, and it is a personal commitment. Writing about medicine can be a dangerous past time, especially keeping a medical weblog as more conservative, old-fashioned physicians and others do not believe in sharing or expressing the medical and healing experience with the general public. HIPAA and “professionalism” are sometimes used improperly as a club to silence those who aspire to express something fascinating about this field and our unique roles in the lives of our patients. Nonetheless, those of us who seek to communicate across worlds need the tools to do so, and this is one of them.

Twitter – As with this weblog, I find that it may become increasingly more useful for physicians to communicate with the general public to improve health literacy, help them understand our intentions and our missions, and serve as leaders and movers in our communities, local and beyond. Twitter and other social networks help facilitate this form of communication, and I hope in some small way to take part in that process.

Teaching

Elements – In medicine, we take an oath to teach – it is directly stated in the Oath of Hippocrates, the most classic mantra of medicine. When I learn, I take notes, and what I learn, I reformulate and build upon to develop my own lessons and methods of teaching. Moments of inspiration can be unpredictable, and so Elements serves me well: it is a text editor that imports my documents to my Dropbox account, a cloud data storage service. With my notes always accessible (on my iPad, iPhone, or computer), I can constantly build upon my personal rendition and ways of understanding medicine, and then I can share these with my students with one of these devices in front of me as an outline and reminder.

Aji iAnnotate PDF Reader – Not only does this app provide storage for text for me to read and learn, but I also have access to scanned anatomy images and other diagrams that can be used to teach students and patients. Visual aids are always powerful tools to augment learning, and there are a million ways one can use a data storage device to help teach (e.g. diagrams of treatment algorithms, presentation slides, anatomy images, etc.).

Of note, I am aided by the fact that I am a budding Neurologist, and I carry a small satchel with me to work at all times, thus allowing to carry the iPad. I had dedicated myself to the “only what I can carry in my white coat” doctrine of minimalism until I received this surprise present, thus prompting me to return to the tradition of doctors carrying bags of useful tools. This is a most useful tool, and one that will have increasingly more creative uses.

The words spoken by physicians carry weight and significance, but as first year residents we might not always appreciate and effectively use this fact. Too often we are prompted to go to the bedside of a patient by a nurse’s page or request stating “The patient wants to speak with you,” often without further explanation divulged.  At 3AM, it is easy for us to attribute these calls to laziness on the part of the nurse. However, nurses often feel disempowered: in many hospitals, physicians rarely take the time to share their treatment plans or diagnostic explorations with the nurses who are charged with handling the logistics and details of minute-by-minute patient care, and patients in these settings often do not trust or expect their nurses to have the answers to their questions. To further worsen matters, at my hospital nurses are typically given the task of discharging patients which includes reviewing medication lists and upcoming appointment times. “Discharging,” however, should also include debriefing patients on their hospitalization, their illnesses, and their immediate (if not long term) outpatient treatment strategies. Although sometimes quite experienced and knowledgeable, many of our nurses are not necessarily equipped with the general medical knowledge or knowledge specific to individual patients to carry out this task. Furthermore, my hospital’s Medicine service discharge paperwork does not include an area for patient instructions (the Emergency Room does include instructions in their discharge papers).  To make matters worse, interns receive little to no training on how to properly discharge or educate patients. As with the emphasis on the dismount from the balance beam in gymnastics, the discharge process can make or break a performance –  in this case, the performance is the sustaining of the patient’s recovery from illness beyond the hospitalization.

Patient education by physicians, even in brief measures, can be a powerful tool for enacting change. For example, in tobacco cessation counseling, the mere act of advising patients against tobacco use without extensive explanation or justification can significantly increase the odds of a patient quitting tobacco. In much the same way, most of the patient education I deliver on the inpatient services occurs through repeating teaching points during brief daily encounters. I would love to be able to spend fifteen to twenty minutes sitting down with each patient at the time of discharge to debrief and educate them, but in reality, the time demands of my intern year have only allowed me to debrief the patients with the most critical needs for further education. Fortunately, in my residency program, many of the second and third year residents are proactive and see patient teaching as one of their responsibilities, so most patients will receive some degree of teaching from either the intern or resident (and sometimes the hands-on attending).

I continue to search for my strengths and passions among my evolving roles as a young physician: by necessity we wear many hats, but we choose which skills to hone and use most often. There is much interest in medical writing and journalism at this time because for many years there was an incredible dearth of adequate, accurate reporting of medical science discoveries and treatment changes and their impact on health. There is a growing influx of medical writers who are better educated and more familiar with medicine. In theory, this should have a powerful impact on educating patients and the general public. However, I worry that just as physicians are spending more of their time in front of the computer screen instead of by the bedsides of their patients, we may also spend too much time writing words and advice instead of speaking to and educating our patients, their families, and our communities in person (except in the context of increasingly brief hospital stays and primary care visits).  A piece of paper or words on a screen do not carry the same weight as words delivered through the voice of a trusted advisor, a professional and known expert – your physician.

To this end, health education, through teaching patients and their families directly and through teaching students and medical professionals to teach more effectively, may become an important component of my personal mission in medicine. We need to get out there more, and by “out there,” I mean out of our offices and hospitals and into the lives of the people whom we are entrusted to treat and heal.

Traditionally, the fourth year of medical school is often a “diastole” year: most of the required and time-intensive clerkships have been completed, students scatter to all corners of the country for away rotations, and the focus is less on grades and more on “Where am I going next?” For me, fourth year has not been much of a break. After an intense six-month marathon through Internal Medicine, Family Medicine, and Surgery, I then tackled my sub-internship on the Stroke Service in July (one of the busiest services in the hospital that ranges from the ED to the Neuro-ICU to the Med-Surg floors to the clinic), the USMLE Step 2 CK in August, three months of away rotations at Harvard hospitals, and then an epic cross-country interview season spanning four months. Last month, I returned to a “normal” 7-9 hour workday/5-6 days per week schedule collecting data from electronic and paper medical records for my research project. Finally, this month has given me a chance to breathe, reflect, and start building some tools for future learning, practice, and teaching based on the knowledge and wisdom I have collected over the past three and a half years of medical school.

Then again, this month could also mark the beginning of the great washout: this spring is the time when medical students start to rapidly lose all of the information they have crammed into their heads for three years. Most medical school teaching is structured to accommodate the same faulty principles of learning in college: it is heavily didactic and encourages students to cram and purge (after the test). Accordingly, a lot of medical students show up at the beginning of July at their hospitals with only the shadow of knowledge they had acquired in previous years. The knowledge is eventually unearthed and solidified with greater amounts of patient care experience, but this transition can be rough (in teaching hospitals with lots of supervision and redundant capacity, this is mostly rough on the learner, not the patient).

The utility of the Advanced Clinical Teaching course for me is very similar to that of the Psychology of Leadership course I took during my senior year of college: these courses provide me with the tools by which to improve my own performance and that of my team. By learning to teach more effectively and by developing “canned talks” on methods of understanding instead of pure detail, I am building a scaffold, a neural network, in my own brain within which to organize and sort the details of my past and future learning. When faced with daunting amounts of work and stress, it is easy to resort to lowest common denominators and instinctual (and often counterproductive or inefficient) methods. “Daunting amounts of work and stress” is a pretty good description for the next stage of my training: internship and residency. If nothing else, my prebuilt scaffold will facilitate better instinctive behavior: I can find the right answer, the right diagnosis, the right treatment faster and better than if I had no structure at all.

For better or worse, none of my ranked programs are “easy” programs, and I expect to work hard and work long hours in exchange for amazing learning experiences with excellent clinicians and teachers. I don’t expect to have the same sort of reading time I have had in medical school or the same amount of time to prepare presentations for my teams, so my methods of learning and teaching have to be honed to a sharp point before starting my internship.

I am very happy that I have developed what I believe is a good series of 15-minute wards/whiteboard based talks focusing on key topics in Neurology. These talks are designed both for medical students and interns who do not plan to pursue Neurology training as well as though who may be developing an interest in Neurology. The aim is to develop methods of understanding and provide an anchor for future self-directed learning, not deliver large amounts of detail. My current teaching portfolio currently includes:

• Introduction to Neurology
• Altered Mental Status (Differential Diagnosis/Initial Approach)
• Stroke (Recognizing the Signs/Stroke Mimics/Approach to Treatment and Management)
• Headaches (Differential Diagnosis)
• Increased ICP (Differential Diagnosis/Approach to Treatment and Management)
• Seizures (Differentiating Causes of Loss of Consciousness/Differentiating Causes of Transient Neurologic Deficits/Determining When to Treat)
• Spinal Cord Disorders (Differential Diagnosis)
• The Essential Neurologic Examination (for the Non-Neurologist)

Future topics in Neurology I hope to cover before intern year:
• Vertigo (Differential Diagnosis)
• Dementia
• Movement Disorders
• Multiple Sclerosis

I also hope to develop talks for major topics in Internal Medicine before intern year begins. If nothing else, I hope to have a foundation upon which I can rebuild what I have learned and rapidly incorporate new knowledge as new patients arrive at my door.

Lately, I have become inordinately excited about the prospect of pursuing the very new field of Endovascular Surgical Neuroradiology (aka Interventional Neurology) as a potential career pathway. A few weeks ago, my major three interests were Pulmonary-Critical Care, Interventional Cardiology, and most recently, Neurology. This new field seems to encompass several of my medical interests, all of which I might feel sad to abandon if I had to choose one over another. But now I wonder: how deep does this new interest of mine find its roots?

I believe that the various fields in medicine often attract people with similar interests and personalities (that extend beyond basic stereotypes). I have worked with doctors in a few fields so far that have impressed upon me particular styles and characteristics. For example, my fiancée loves mystery novels and puzzles (e.g. Sudoku, crossword puzzles, Bejeweled, etc.): I think this detective and puzzler archetype fits in nicely with Neurology in which the physician both methodically and insightfully unravels the mysteries of the injured or dysfunctional brain. In Cardiology, I find the doctors are much like cowboys: there’s an aggressiveness and pervasive confidence (especially given the many successes in the field), and in the Catheter Lab, it’s possible for a single doctor (with the help of a scrub nurse or other assistant) to save a person’s life (unlike in many surgeries, where the effort is much more team-based). Psychiatry has presented a variety of personality types and working styles to me, but the common theme I have found is the storyteller core: at the center of their interests, these doctors are interested in the elaborate life stories of their patients, and they often relate to others through telling their own life stories. Lastly, Infectious Disease physicians are the true biologists willing to confront the intrusion of nature into our lives: while other doctors might find fascination in disease marking the body’s failure to function properly, these ID doctors find a world of wonder in the numerous, rapidly-adapting microorganisms that wage war upon our bodies.

I have not been sure how my prior interests could connect with my future pursuits: in other words, I have not known how to draw strength and energy from the things that have interested me all throughout my life thus far. I don’t necessarily see myself at this time as the detective or the cowboy. What sort of things have I really liked and enjoyed that might reflect a core, underlying mode of operation?

Video games. I have always liked playing video games, despite my father’s constant insistence that I would fail out of school at the rate I played them. In particular, there is one long series of games that I have always enjoyed that I feel serves as an amusing, if not fairly accurate, allegory of why I am suddenly so passionate about this new field of medicine: The Legend of Zelda.


For those unfamiliar with the classic Nintendo-console series, each installment features the Hero’s Journey of a young, ordinary man with an extraordinary task and destiny (to save his homeland from evil and ruin). The series follows his journey as he fights his way through a variety of dungeons and fortresses, usually solving environmental puzzles and picking up new tools and allies along the way as he tries to reach his objective. To my surprise, the adventure parallels that interventional path to treatment of vascular diseases and highlights some of my core personal interests that can be applied to medicine!

Step 1: You have been summoned by the Great Deku Tree!

One of the biggest obstacles to the treatment of stroke is the time it takes for its victims to realize that they are suffering from one. Time is brain (much like “Time is muscle,” the slogan of cardiologists treating heart attacks), and there always exists the problem that something must be done before it’s too late! At this time, the main FDA-approved treatment is the intravenous use of tPA or tissue plasminogen activator in ischemic strokes (the vast majority of strokes), an enzyme that breaks up clots but must be used within three hours of the start of symptoms. After that point, tPA can actually increase the potential hemorrhagic conversion of an ischemic stroke, changing the nature of the disease from a vessel occlusive disease (i.e. nutrient/oxygen-started brain) to a bleeding disease (i.e. bleeding into the brain tissue and causing direct damage and mass effects). New interventional treatments (discussed below) can extend the treatment window to 6-8 hours or more. Nonetheless, time is of the essence!

It is important that family members and friends recognize common symptoms of stroke because patients are often in denial of the severity or implications of their symptoms. You can save the life of a loved one this way!

Step 2: Go, Epona, go! We have no time to lose!

It breaks my heart, but I understand why many (poor) people avoid calling the ambulance: the bills can be very expensive! ($1000+) However, if there’s one instance when it is absolutely necessary to get an ambulance ride as opposed to calling a friend or family member or driving oneself to the ED, it is with a suspected stroke (even more so than with heart attacks, in my opinion, since a heart can be augmented or replaced unlike the brain). Furthermore, calling an ambulance gives the medical team advanced notice that you or a loved one might be having a stroke, thus speeding up the arrival of treatment and avoiding the necessity for triage upon arrival in the ED. Stroke Team Activation! (At this time, if I were an Interventional Neurologist and was at home, I would get paged and would be rushing to the hospital. If I were at the hospital, I would be getting the CT scan, tPA in the ICU, and Catheter Lab ready for possible treatment.) Every minute counts.

Step 3: You have received the Map!

One of the first things that needs to be determined upon arrival is the nature of the stroke: is it an occlusive (ischemic) stroke or a bleeding (hemorrhagic) stroke? 80-85% of strokes are ischemic, and those are the ones that can be treated with tPA and interventional techniques. Hemorrhagic strokes are treated differently, but if you give these patients tPA, the damage gets even worse since you are giving a medication that breaks up clots (that would otherwise stop the bleeding)! So, noncontrast head CT, stat!

If the patient arrived within three hours of the onset of an ischemic stroke, we can treat with tPA in the Intensive Care Unit (stroke patients require specialized care in the first 24-72 hours that differs from most patients, such as keeping the bed flat, aggressive temperature control < 99°F, tight control of blood glucose, maintaining “permissive hypertension,” etc.), open up the blockage, and minimize any damage. However, what happens if the patient arrives after the three hour deadline? Then we have to assess whether an interventional procedure is possible and indicated. Where is the occlusion? Let’s take a look!

Angiography allows interventional neurologists to determine where a blood vessel is occluded by a clot, thus setting the goal for an interventional procedure. The angiogram provides a “map” to the occluded vessel, and the interventionalist can maneuver a microcatheter through the blood vessels to either deliver tPA directly into the clot (to minimize hemorrhagic conversion or damage elsewhere) or use a mechanical device to break up or pull out the clot. Is the patient aware of the procedural risks and the consequences with and without interventional treatment? Does the patient consent? Yes? Let’s go!

Step 4: Over, sideways, and under

My favorite games usually involve environmental puzzles: given the tools you have, you need to figure out a way to get from point A to point B, often requiring some maneuvering and finesse. To me, this embodies the practice of interventional techniques: you have to thread a thin wire through the blood vessels of the body, around twists and turns, beyond bifurcations (forks in the road), and into the areas of occlusion or damage. This is not always a straightforward process, and this is where skilled hands are an asset! I have been complimented various times throughout my life (including by physicians) about my hand skill and motor coordination, but I have little interest in Surgery as a potential career path and lifestyle. Nonetheless, I would like to use my hands to help heal and treat those suffering from disease, and interventional procedures may offer me this chance.

Step 5: The Final Boss

Upon arriving at the site of injury, the moment of truth presents itself: will I succeed in breaking and removing the clot without complication and collateral damage? How can I best accomplish this goal in this situation?

So far, the options of intra-arterial thrombolysis (with tPA), mechanical clot thrombolysis, and clot retrieval. All of them constitute precision strikes on the culprit clot.

Step 6: Success!

The clot has been removed, and the vessel has been revascularized! The patient can be sent back to the ICU for post-treatment care. During my time with the Stroke service, I had the chance to witness the marked difference in outcome between a patients who received tPA in time and those who were not able to be treated due to their arrival after the three hour deadline. Many people survive strokes without treatment, but it is not just a matter of life and death: it is also a matter of disability and quality of life after the stroke, as many people are permanently disabled (physically and/or mentally) by strokes, the leading cause of long-term disability worldwide. Interventional techniques offer hope of extending the treatment window and reducing the overall mortality and morbidity from the disease.

Nonetheless, the medical care does not end there. Patient education and secondary prevention of stroke is essential to prevent the ordeal from occurring again. Or ideally, we can prevent the strokes from ever happening in the first place with primary prevention and care!

Conclusion

This has been a light-hearted approach to exploring how my past interests reflect core objectives that I can achieve in my future career and engrained principles and character traits that I would like to draw upon to make each day a worthwhile adventure. Perhaps for the first time, I am thinking less about the professional experience in each field based on current standards and practices and more about what things can be in the future.

And to the future of medicine and those I hope to save, I will bring:

The resolve to protect without hesitation,
the strength to endure in the face of everlasting darkness

A month and a half into third year, I am currently having conflicted notions about my desired career path into medicine. I am very much in love with medicine so far: the issue is that the pathway I thought I would pursue within medicine is now being challenged by a new passion. There are many factors that might inspire a medical student to select one field or another. Given my background of my mother’s cancer, it might seem natural for me to select Hematology-Oncology. However, despite my interest in caring for very sick patients and dealing with end-of-life issues, Heme-Onc never seemed to rest comfortably in my concept of a career for reasons of which I still may not be fully aware. Later, finding personal experience as a motivation (e.g. childhood asthma), gaining knowledge through basic science research in the field, and finding inspiration in the doctor-patient relationships exhibited by one very talented pulmonologist and her patients, I was drawn to Pulmonary-Critical Care Medicine as a potential career path. I can relate very well to patients who do not take easy breaths for granted, and the Critical Care aspect intrigues me with respect to the procedural aspects and the constant imperative to provide some level of care to one’s patients. Additionally, there also was the added amusement and benefit of being able to introduce myself as “Dr. L(e)ung!” At the same time, my shadowing experiences with an Interventional Cardiologist attracted my desire for immediate gratification in the ability to save lives by performing direct, hands-on interventions (balloon angioplasty and stenting).

However, each of the fields, although interesting, do not quite stimulate my sense of wonder. To my surprise (and almost to my chagrin), I have recently fallen in love with many aspects of the field of Neurology. I chose to do Neurology as my first rotation so that I could “get it out of the way” and cut my teeth on a field to which I was not particularly attracted. In truth, however, I have always found many subjects in Neurology fascinating but have repressed my interests and avoided the field due to a very poor quality course in Behavioral Science during my undergraduate years and very disorganized coursework in Medical Neuroscience. Furthermore, I was turned off by the (wrong) assumption that there are few treatment modalities available in a neurologist’s arsenal for treating neurological diseases as compared to other fields (primarily, cardiology and pulmonology). However, my recent tour on my hospital’s new Stroke Service has convinced me otherwise. Indeed, neurovascular diseases fascinate me more so than any other area within Neurology. Nonetheless, trying to catch patients in the 3-hour window within which tPA can be used to dissolve blood clots seems to be an intervention with many non-medical impediments. For my attending physician, trying to streamline that road from a patient’s first symptoms to her arrival in the Stroke Unit is a logical and meaningful objective at this time. However, what would be the great battles to fight 6-10 years from now when I first enter the field as a fully-trained specialist or subspecialist?

Taking a page out of the book of my fiancée, I have found one potential answer to my search for the perfect field and fit: a synthesis of several of my interests – Interventional Neurology. The field involves the treatment of neurovascular disorders with percutaneous interventions such as carotid stenting (to revascularize occluded carotid arteries), aneurysm coiling (to seal off potentially hemorrhagic vessel wall dilations), and intra-arterial thrombolysis and direct clot removal (to treat thrombotic or embolic strokes after the 3 hour tPA administration window, thus increasing the time available to directly treat ischemic strokes). This is a very new field with many names, and most trainees come from Neurosurgery or Neuroradiology backgrounds. However, there is an emergence of the notion that Neurologists with interventional training can also contribute greatly to the multidisciplinary field by providing the knowledge to treat and manage the neurological/medical aspects of neurovascular diseases as well as the preoperative and postoperative needs of these patients (e.g. neurocritical care background not provided by Neurosurgery or Neuroradiology). Interventional Neurology, recently approved in 2006 by the Accreditation Council for Graduate Medical Education (ACGME) as Endovascular Surgical Neuroradiology, was developed to include Neurology trainees as well as Neurosurgery and Neuroradiology-trained physicians. From the Neurology entry point, the fellowship would require:

3 years of Neurology
2 years of Neurocritical Care (or 1 year of vascular/stroke fellowship)
1 preliminary year of Neuroradiology* (may be incorporated into the ESN fellowship)
3 months of Neurosurgery

The fellowship itself is usually a 1-2 year program. That does mean my training would last 7 years, but if it is for something about which I am madly passionate, I think it would be well worth it. This new field appeals to me for a variety of reasons:

1. The (neurovascular) diseases are intellectually stimulating and fascinating. Furthermore, stroke is the leading cause of long term disability in the U.S. and around the world, and in the future may replace cardiovascular disease as the number one killer worldwide.

2. The critical care background would give me the knowledge and training to work in Intensive Care Unit settings, one of the areas in hospitals in which I feel most at home. I like working with very sick patients, I am not turned off by the presence of ventilators or the process of dying, and I like the team work in ICUs (especially the ICU nurses who are pretty awesome).

3. Performing direct interventions excites me, especially since it would give me the opportunity for me to use my hands without forcing me down a surgical path. Furthermore, endovascular intervention seems to be the logical next step in the advancement of the treatment of cerebrovascular diseases like stroke. Given the success Cardiology has found with angioplasty and stenting, Neurology seems poised for great advances, hopefully in the form of Interventional Neurology.

4. The field is very, very new. This hopefully would give me numerous opportunities to teach and train other physicians in the science and procedural aspects of the field as well as opportunities to research and develop new methods and principles of treatment.

5. While I don’t like the idea of excessive pride in physicians, I would still like to be proud of the work I do. While I would find pride in other fields, there is something incredibly compelling about the brain and its growing primacy in our developing understanding of life and consciousness. As Dr. Wiese noted: in acute care situations in Medicine, the lungs and the heart provide vital functions to provide oxygen to brain. The lungs and heart are incredibly important organs without which a person cannot live. However, they are still supporting players to the brain, the captain of the team. I have not neglected to notice that Neurologists are paid less than Pulmonologists and Cardiologists, partly based on that very idea of what can be done for the patient (with procedures and imaging being reimbursed for more than pharmacological treatment or physical examination). I would be proud of any efforts I might take to demonstrate and establish the truth that Neurologists can do incredible things, including interventional treatments, for their patients, as much as any Cardiologist or Pulmonologist.

Of course, two months ago I was fairly comfortable with the notion of going into Pulmonary-Critical Care Medicine. Will Interventional Neurology be a fleeting passion, or will it even be a plausible path? If nothing else, the idea excites me. A lot.

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