Previously, I discussed the merits of the ClamCase, an innovative and useful keyboard case for the Apple iPad. Of all of the higher end and pricier keyboard cases, it definitively remains one of the best options available for the production of written content on the iPad. During the past seven months, I have written numerous admission, consult, and progress notes every day I have worked in the hospital, and I have additionally written weblog posts and numerous e-mails. I often had a hospital computer open to an electronic patient record while having the iPad open to a new word processing file which would allow me to type notes and read simultaneously. Unlike a laptop, the iPad with a keyboard case allows for instantaneous access for quick tasks at the bedside and while rounding (such as typing in an order in tablet form with one hand holding the device and the other hand tapping the screen and typing) while also allowing for comfortable word processing and reading. The combination of the ClamCase and iPad 2 essentially replaced my old laptop (a previous generation of MacBook of the black plastic variety) except for the occasional Photoshop task or for iTunes file synchronization and backup.

However, there are a few important disadvantages of the ClamCase which may or may not be generalizable across the product line. First and foremost, the battery life of the device is variable. Initially, I did not have to charge the keyboard for days at a time, but about five months into its lifespan I discovered that it was losing its charge during the course of a day’s work. After some weeks of experimentation, I have not found consistent behavior of the battery in response to overnight charging and roughly comparable usage each day, leaving me with some degree of anxiety as to whether or not it will keep its charge during a particularly busy day of consults and admissions. I suspect that this is the result of me not treating the battery correctly, but most people do not maintain good battery charging practices which makes me wonder how often customers have difficulty with the battery for this keyboard case.

There are a few other additional small and surmountable issues. The case is heavy: the weight of the device essentially doubles the weight of the iPad. The four protective pads on the keyboard side of the case which elevate the keys off table surfaces when flipped into a video viewing mode quickly lost their adhesive and tore off easily. The keyboard additionally has very nice laptop-style keys, but some do become slightly sticky with time, sometimes causing the keyboard to produce a string of repetitive letters which sometimes would require exiting from an app to interrupt. Over time, this has become a more frequent occurrence. Lastly, on a purely cosmetic level, my white version of the keyboard case very easily stained on the bottom surface within a week of ownership.

In summary, the ClamCase has been an incredible boon to my productivity on the hospital wards, but after seven months my particular device has aged and is starting to run into difficulties. Some user reviews have commented on issues with maintaining the battery’s charge and not being able to trust the green/amber indicator light. If I had assurance that the battery issues has been fixed, I would certainly purchase another ClamCase, but in the mean time, I have started to look into alternative options.

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.

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.

Today marks the end of the 2012 American Academy of Neurology annual meeting. I spent this past week (also my final week of vacation as a junior neurology resident) attending courses and lectures, perusing posters, meeting other neurologists, and trying to absorb as much neurology as possible in this short amount of time. AAN hosts the largest conference for neurologists around the world and is typically attended by 10,000 to 20,000. While some of the more advanced and groundbreaking science may gravitate toward the specific subspecialty society conferences (e.g. stroke, epilepsy, etc.), this conference is a fantastic opportunity for neurology residents to broaden their perspectives on the field.

These are the highlights from my week at the AAN annual meeting:

[1] Acute Central Nervous System Infections – Infectious Diseases – This course organized by Larry David of the U. of New Mexico provided a brief overview of acute meningitis and encephalitis, the approach to diagnosis and treatment of these diseases, and the practical wisdom and experience used to help one differentiate between various syndromes. In particular, I found value in the emphasis on poor sensitivity of the classic signs of meningitis in elderly patients, the relatively high incidence of undetected nosocomial and multi-drug resistant meningitis in ICU patients with fever and altered mentation, the use of fluid resuscitation in preventing cerebral ischemia in meningitis, and an outlining of an approach to selecting diagnostic tests in encephalitis.

[2] Stroke in Children and Neonates – Vascular Neurology – This course organized by Lori Jordan of Vanderbilt University spanned the current body of knowledge on pediatric stroke as well as provided insight on the interventional trials being pursued, including the use of intravenous thrombolysis in acute stroke in children. While this course was primarily for the benefit of my wife (who is training as a pediatric neurologist), it was interesting to see what lessons the pediatric neurologists drew from the experience of adult stroke neurologists. In particular, the notion that stroke units (one of two interventions in acute stroke that has evidence for outcome benefit, the other being intravenous thrombolysis) were developed as a result of the use of IV tPA (a medication with limited effectiveness and very limited use throughout the country) is an interesting perspective.

[3] Catching up with Tulane’s Neurology department – It was nice having a few hours to catch up with Sheryl Martin-Schild (the director of the Stroke Program at Tulane University Medical Center) and some of the residents and attendings of the Neurology department, the program within which my interest in neurology initially developed. When I was a student, the department was in a state of recovery but appears to be growing quite nicely now. Perhaps not entirely surprisingly (given the high number of acute stroke and hemorrhage cases), several of the residents are pursuing further training in critical care.

[1] Presidential Plenary Session – Stroke Prevention – While there were several interesting talks at this session, the one of greatest relevance and interest to me was a relatively straightforward statement by Ralph Sacco who recently stepped down as the President of the American Heart/Stroke Association, the first neurologist to hold that position. He spoke at length about both medical and lifestyle risk factors for stroke. He made the logical statement that racial/ethnic disparities in long-term stroke outcomes can be eliminated by addressing these risk factors, and he showed the evidence to prove this.

[1] Neurotoxicology – General Neurology, Neuromuscular – This was a very interesting talk organized by Herbert Schaumberg of the Albert Einstein College of Medicine that introduced me to several clinical entities I was not well aware of before including cobalt neurotoxicity from metal-on-metal hip prostheses, drug-induced myoclonus in end stage renal disease (including with gabapentin, morphine, and even propofol), bismuth myoclonic encephalopathy, and fibrous myopathy from intramuscular injections. I also finally learned how to differentiate between ciguatera and scromboid toxins.

[2] Contemporary Issues Plenary Session – Immunology, Vascular Neurology – 500 cases of NMDA encephalitis, Imaging in Acute Stroke – Any talk claiming data on the outcomes for over 500 patients with NMDA encephalitis can easily capture the interest of a room full of neurologists, which this one did – a very, very large room. The other talk that caught my interest was a brief discussion by Maarten Lansberg of Stanford University of the current imaging modalities used in acute stroke. While this talk did not provide much new data, it was refreshing to have a focused review of the current recommended approach to using noncontrast CT scans, perfusion imaging, vessel imaging, and MRI in the acute setting.

[3] Neuro-Ophthalmology and Vestibular Lab – The examination of the eyes is one of the hardest parts of the neurologic examination, and I recognize this as one of the areas where I need a great deal more practice and refinement. Fortunately, this session was there to serve this need. While the lab/workshop sessions are relatively expensive, this provided me with very useful practical knowledge and skills, more so than any other session during this conference. The workshop had about a dozen stations where those taking the course could work directly with experienced neuro-ophthalmologists to refine examination skills, develop methodical approaches, and pick up a few new maneuvers. For me, I was able to refine confrontational visual field testing, the head impulse maneuver, the Dix-Hallpike and Epley maneuvers, and pupillary reaction testing, and I furthermore learned a few new methods of demonstrating psychogenic vision loss.

[1] Neurologic Complications of Medical Disease – General Neurology, Neuromuscular, Vascular Neurology – This course organized by Neeraj Kumar of the Mayo Clinic was a very neat and extensive session covering a variety of medical conditions. I took this course knowing that next year as a senior neurology resident I will be running the consult services and will have greater involvement in directing the care of patients without primary neurologic disease but with severe neurologic deficits and symptoms related to the dysfunction of other organ systems. The course provided overviews of rheumatologic diseases causing peripheral nervous system dysfunction, neurosarcoidosis, nutrient deficiencies, gastrointestinal diseases with neurologic symptoms, systemic malignancies and cancer treatments causing neurologic dysfunction, and finally systemic diseases causing ischemic stroke and intracerebral hemorrhage.

[1] Practical Issues with Botulinum Toxin Use in Neurology – Movement Disorders – I have had no direct experience thus far as a resident with the use of botulinum toxin in neurologic conditions, so I took this course with the hope of having an introduction to its use. Furthermore, as a junior resident with predominantly inpatient ward duties, I have minimal exposure to neurologic movement disorders (which is an outpatient subspecialty within neurology). One major caveat for this course was that the various speakers all had several financial conflicts of interest related to the pharmaceutical companies that manufacture formulations of botulinum toxin; many off-label uses of the medications were discussed. Nonetheless, I particularly found value in the introduction to various dystonias and an overview of the different presentations of spasticity after stroke. Listening to one of the principal investigators for the trials related to botulinum toxin as a therapy for chronic migraine was also very interesting, particularly in his discussion of the pathophysiology and the distinctions he made between chronic migraine and other types of chronic headache (chronic tension-type headache, rebound analgesia).

I presented at AAN two years ago as a medical student. I only had enough time and money to present my work and did not get to explore much to the conference’s many educational resources. This time, my goals were focused entirely on education and broadening my own perspectives, with regards to differential diagnosis (learning about less common clinical entities), approaches to diagnosis and treatment, and the development of a career pathway. For numerous reasons, I wish that all residency programs would send their residents to AAN every year as it is a fantastic opportunity for growth and learning.

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