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.

Anomia is the inability to generate the name of an object or item presented to a patient. Confrontational naming is often tested as a standard portion of the neurologic examination of mental status. While there are several standardized tools for testing of naming ability (such as the Boston Naming Test and the NIH Stroke Scale naming cards), many Neurologists and other practitioners use readily available everyday objects to test patients at the bedside or in the office. There is a distinction made between “high frequency” and “low frequency” names; individuals with naming ability will lose the ability to identify low frequency objects first, meeting criteria for a “mild anomia” which may indicate a degree of subtle cognitive deficit.

The two objects I have seen physicians use most often at the bedside are wrist watches and pens (followed by eye glasses for those who wear them). The physician will first start by asking the patient to identify the entire object (e.g. watch, pen) and then ask them to identify specific parts. However, not surprisingly, there is considerable variation in the design of watches (especially between analog and digital watches) and pens (spring-loaded pens versus capped pens), and there is likely some variability in cultural knowledge regarding the ability to identify the “low frequency” components of each.

However, sometimes even physicians will make mistakes in identifying the individual parts of each object! If you plan to use either object for testing naming, use the following as a guide:

Watches (analog)
Physicians are more likely to wear analog wrist watches which are seen as more professional than digital watches (which typically are worn by children or for sport situations). I focus on analog watches here.

Band – also known as the bracelet or strap, this is a high frequency component that is used to secure the watch to the wrist

Face – medium to high frequency component, the part of the watch with the numbers and markers. The surface under the watch hands is called the dial.

Hands – medium to high frequency component, the linear bars that turn and point toward the individual numbers which are used to designate the current time

Marker – low frequency, the design element that designates time intervals (five minute intervals, fifteen minute intervals, hours), often a small dot or line

Crown – low frequency, the cap on the side of the watch that is pulled up in order to alter the date wheel or time setting. The cap sits atop the stem and tube.

Stem and Tube – very low frequency, invisible when the watch is in a normal functioning position. This component sits under the crown and is only visible when the crown is pulled outwards. This connects to the internal mechanisms that adjust the date wheel and time.

Crystal – low frequency, the clear covering sitting above the face of the watch.

Bezel – low frequency, the outer ring with indentations or numbers that count or providing markings from 0 to 60. The bezel holds the crystal in place and also provides a time reference for divers to help them determine how much air remains in their tanks. There is considerable variation in bezel designs which are sometime fixed or they can rotate clockwise, counterclockwise, or both.

Date Wheel – low frequency, an indicator for the date of the month. Sometimes the date wheel window will have a magnifying lens above it called the cyclops.

Lug – very low frequency, the metal pieces that project from the main body of the watch and secure it to the band (specifically, the band end piece)

Case – also known as the casing, low frequency, the back of the watch which is lifted off to access the internal workings of the watch and battery compartment. The casing sometimes will have the model and serial number listings (if not located on the lug).

There are many different pens used by physicians, the most complicated being fountain pens which have dozens of components (nibs, cylinders, ferrules, feeds, levers, derbies, screw rings, press bars, sacs, etc.). However, considering how often pens are lost and “borrowed,” most probably rely on a steady supply of cheap, disposable pens. For simplicity, I’ll demonstrate names with a push-button pen here.

Point – also known as the tip, high frequency, the part of the pen through which ink is delivered to the page

Clip – medium to high frequency, the part of the some pens that will hold the pen in place in a (white) coat pocket

Barrel – low frequency, the main body of the pen (with many different names depending on the type of pen)

Push Button – medium to low frequency, the part of the pen that is pressed to exposed the point

Joint – low frequency, the part between the upper and lower halves of the body of the pen which connects them

Since most physicians are unlikely to deconstruct their pens at the bedside, I won’t describe the thrust tube or ink cartridge.

Tonight, I am completing my first two week stint as the Neurology night shift resident at my hospital. For better or worse, I did not have any night float experience as a Medicine intern (plenty of long and painful on-call shifts, but no long consecutive stretches of nights), so these two weeks have been an interesting, exploratory experience for me. I have a total of two months of the night float rotation during my residency, so I have plenty more time to perfect my strategies for both maintaining the best possible patient care and making the best use of the time. I have picked up a few pearls that might help other residents who also will be filling this role:


[1] The Plan and Pickup

As detailed in my last post, signout is an extremely important process and is the initial and primary means of high-yield information gathering for the night shift resident. Day residents are often tired and worn out by signout time, making it difficult to execute an effective delivery of all of the important details that a night shift resident covering all of the patients requires. Accordingly, it is the night shift resident’s job to ask the important questions when important information is left unsaid.

Of the many details that are valuable, I find that there is special significance in the day team’s plan of action for the patient. The night shift resident’s job is sometimes viewed as a “float” position where one simply tides the patients over until the next morning when active patient care can continue; the job in that case is very passive and only activated in reaction to new developments. Sometimes the team’s plan for the patient is glossed over during a signout process or even omitted. However, the night shift resident covers half of the twenty-four hour day, and much can be done during that time (albeit in smaller, discrete measures, given that the night shift resident is covering a much larger patient census). Sometimes medication titrations started during the day (e.g. for blood pressure control or diuresis) can be continued during the night. Sometimes a new therapy or plan started during the day shift might result in a less desirable outcome, requiring that it be reverted back to the original regimen during the night shift.

Inevitably, small details of care are omitted from signouts, whether intentionally or unintentionally. Nonetheless, the night shift resident can assess the team’s plan and pick up where they left off by following up on ordered studies, touching base with collaborating services or nurses, etc.

[2] The Preemptive Measures

Anticipation is a valuable skill. Being able to predict needs and requests can save valuable time. For example, at my current hospital, the order set for cardiac telemetry does not include a system to indicate whether or not the patient can leave the hospital floor without telemetry when being transferred to another part of the hospital for testing (e.g. Radiology). Residents have to manually type in a text order to give the nurses permission to release patients to the transport team. Accordingly, whenever I start my night shift, I look to see which patients are scheduled for overnight tests, determine whether it is reasonable for them to be off cardiac telemetry monitoring for a period of time, and then indicate such in the ordering system. Placing a few orders and touching base with nurses early in the shift helps prevent the potential slowing down of care delivery when one is dealing with multiple consults, admissions, codes and triggers, and other unpredictable developments.

[3] The PM Rounds

For me, there is great value in laying eyes on each patient. Unfortunately, the 8PM start time for my night shift is past the bedtime for many patients, so they are hidden behind curtains in dark rooms. Nonetheless, I make a concerted effort to locate all patients and mentally store an image of where patients are and what they look like (if I can see them). That way if something happens later requiring me to rush to the bedside, I know exactly where to find each patient. I try to lay eyes on the patients whose clinical statuses are more likely to change, and I examine the patients who are quite sick and are already changing in stability. With regards to examinations, I find that it is important to think about the patient’s pathology, their baseline examination, and the likely changes that one might see with the most likely complications. For example, a patient with a large cerebellar hemorrhage might develop brainstem abnormalities or depressed level of consciousness on examination, so that’s what I would look for as an indicator of worsening clinical status and a trigger for intervention.

[4] The Face Time

The geography of my night is unfortunately split between three locations: three floors in three different buildings, separated by a series of bridges and elevators. Furthermore, the Neurology floor is on the top floor of one building and the Emergency Department is on the bottom floor of another. Accordingly, I find it useful to split up my night into segments where I can minimize my migration from one section to another. Generally, I spend the first four to five hours of my twelve hour shift on the floor where most of my department’s patients are located. This is the start of the nursing shift as well, so there is more activity, more requests, and fresh pairs of eyes reviewing the orders and the patients themselves. The night shift is the best time to get to know the nurses in a hospital with regional admissions: there’s only one doctor on the floor, and that’s me! During those first few hours, I can be a useful resource to the nurses, both by providing some insight conveyed by the physician teams and by helping to facilitate the care ideas generated by the night nurses. Putting in this face time early in the rotation is quite valuable, too, because one develops relationships of trust with the nurses and can better triage requests and nurse assessments when brought to one’s attention later. After the floor patients quiet down, I usually migrate down to the call room which is closer to the Emergency Department where I can more easily set up camp, eat and drink, write notes, and run to either the floor or the ED as needed.

[5] The Quiet Place

Although the hospital is quieter at night (literally), there is still a cacophony of telemetry beeps, yelling and moaning patients, and chatter. A large part of a physician’s job is documentation, and writing well requires mental focus. For me, I can generate clinical documents much faster if I can find a quiet place, be this the call room, a quiet hallway, or an empty conference room. Finding a quiet space and making it a frequent stop during the night shift can help improve efficiency when the admission and consult notes start piling up. Some people prefer to work to music, so finding a room with a computer where one can play Pandora or an iPhone/Android on speaker can help facilitate the written work that needs to be done.

[6] The Energy Food

Shifting to the night schedule can screw up one’s gastrointestinal clock. I eat breakfast and dinner at the usual times, but I have switched lunch to a post-midnight meal so that I don’t have to wake up in the middle of my daytime nap to maintain my calorie intake. However, despite changing over to the night schedule with my meals, my stomach continues to growl constantly and loudly between 4AM and 7AM, or until whenever I can next eat.

The most important thing with regards to food and drink is to keep up one’s energy levels and hydration. As an on-call intern, I spent my on-call budget on a cache of Life Waters; I would keep four or five bottles in one of the physician conference rooms, and then I would down one bottle at a time to stay hydrated throughout the night. Now, as a night shift Neurology resident wandering between different floors and buildings, I keep close tabs on the water machines and on my supply of food (whether in my bag, locker, or the conference room fridge) so that I can snack throughout the night and stave off hunger and dehydration. Everyone has different preferences for on-call food: make it tasty and energizing!

[7] The Rally

Inevitably, fatigue ensues. With fatigue comes a loss of willpower and the onset of complacency. When the hours wear on and one is nearing the end of the shift (particularly in the 4-8 AM hours), it is important to buckle down and push through. Stretch, snack, or take a quick power nap to reenergize and refocus. The end is near: race to the finish!

Hopefully, these tips will be useful to those who will be doing the night shift, which is to say, virtually all residents now that the 16 hour work day restrictions have come into effect for interns. However, don’t be a night float and just muddle through through the night. Be a night rider!

Do you have other tips or strategies for surviving and adapting to the night shift? Please post your comments and suggestions below.

With the advent and evolution of work-hour restrictions, the importance of the signout as a learned skill and a necessary aspect of patient care has grown considerably. The signout or “pass off” is viewed by some senior physicians as a necessary evil (with the emphasis on “evil”), but as work shifts for residents become shorter and the population of hospitalists expands, it becomes ever more important to learn how to do a signout right.

What is a signout or pass off?

By its nature, it is:
[1] A temporary yielding of responsibility for a patient’s care to another physician.
[2] A process by which one prepares the covering physician to perform at maximum capacity as if he or she were the primary physician directing the care of one’s patient.

These two aspects of the signout are essential and intertwined; one cannot exist without the other. Some residents eagerly throw the responsibility for their patients at a fellow resident without adequately preparing them for anticipated or potential overnight complications. On the other hand, some residents overprepare their night shift colleagues, poring over every lab value and detail, while also signing in from their home computers to update electronic signouts and notes. The best strategy is to find the right balance of information transfer and a secure handing over of patient care responsibility.

Granted, it takes two to tango: signout requires both an effective transmitter of information and an actively engaged recipient. The person receiving the signout needs to know what questions to ask and needs to know when to jump in regarding a clarification or to keep things on track when the other resident starts to lose steam and digress.

What are the essential elements of the signout?

While some residency programs and hospitals are trying to standardize signout processes and even study their efficacy, the current process lacks standardization across programs and hospitals. Nonetheless, a few key details form the backbone of a solid signout. Signout can take a long time and is often interrupted by pages and requests, so the most important information that requires verbal transmission must be shared first.

[1] The Red Highlighter – “Which patients are the sickest? Which patients are changing in condition?”

Identifying the sickest patients alerts the on-call resident to the patients who need to be re-evaluated more frequently or who are most likely to have complications or changes in condition overnight. This helps the resident prioritize his or her time and also potentially evaluate these patients early during the shift so that reevaluations later can be compared to a baseline examination.

[2] The Code Status – “Which patients are DNR/DNI? Are any patients CMO?”

Night shifts in particular can be chaotic, and nothing is more chaotic than a Code. Accordingly, the algorithms underlying Codes are meant to provide order and structure for a situation where interventions must be rapidly delivered. However, not all of these interventions are desired by the patient, and so the Code Status must be the hand that stays the trigger finger in these cases.

Identifying patients who are “comfort measures only” and may likely pass during the shift helps the on-call resident prepare, particularly if he or she has questions regarding the cause of death (which will have to be documented and can be an ardurous process).

[3] The One-Liner – “Mr. T is a 43 year old man with a history of hypertension, coronary artery disease, and diabetes presenting with intermittent substernal chest pain for one day, most likely representing acid reflux.”

This skill is learned by medical students, but it still requires honing and perfection throughout residency and beyond. It is important to be able to convey key details of information in a compact amout of time and space. This includes age, pertinent past medical history, the presenting complaint, and the suspected diagnosis.

This is also a common area which can balloon in size and detail: the entire past medical history does not need to be conveyed, only the important aspects. Nonetheless, these details can be important, and it helps to provide some detail in a written version of the signout. For example, it helps to know the left ventricular ejection fraction for a patient with Congestive Heart Failure, that a patient with chronic renal insufficiency has a baseline creatinine of 1.6, that a patient with CAD has coronary stents, and that a patient with a prior left MCA stroke has residual right arm and face weakness.

[4] The Plan – “He is being ruled out for myocardial infarction and evaluated for other causes of chest pain.”

The “second line” following the one-liner should indicate what is being done for the patient. In particular, night shift residents are often called to the bedside to update patients and their families regarding the medical team’s plan of action because that is the time when family members are off work and can visit their loves ones in the hospital. This information also helps the night shift resident think about the direction of the patient’s care and potentially offer contributions in the form of suggested investigatory testing, additional history taking from the patient, or collecting collateral information from visiting family members. This can empower night shift residents to continue the work of the day time.

[5] The To-Do’s – “He has cardiac enzymes pending at 2000 and 0400.”

This part is a no-brainer. If there are specific tests to follow up or re-evaluations that must be done at a particular time, this should be communicated clearly and concisely. A plan of how to react to potential data points is also important here. For example, what should be done if the patient’s lungs have more crackles than before? What should be done if the patient’s blood pressure drops below a desired range?

[6] The Contingencies – “If he has recurrent chest pain, reassess, check his telemetry, and consider a repeat ECG. If his cardiac enzymes turn positive, call the Cardiology fellow and consider Heparin.”

Part of the day resident’s job is to anticipate potential problems or complications that might occur based on his or her current knowledge of the patient and the suspected disease process. This should accordingly be communicated to the night resident, and they should plan together how to react to these situations. In some places, these are called “disaster rounds” where the residents discuss worst-case scenarios and develop plans on how to deal with them.

This how-to guide should provide some structure and tips on how to make signouts systematic and effective. Signouts will continue to be a part of practicing medicine, wherever and whenever one is involved in patient care. Are there other aspects of the signout process not listed here that you believe are important to include? Has your program developed signout strategies that are particularly helpful or effective?

[ Introduction and Background ]
Tablet computing has grown at an incredible rate over the past year. Surprisingly, even physicians and hospitals have adopted this technology in relatively large numbers, considering that many hospitals and clinics continue to rely on paper-based charts, fax machines, and ledger-style appointment tracking. Some hospitals transmit blood draw orders by having them placed in a computer by a physician, printed out by a nurse, and dropped in a paper slot for a phlebotomist to collect. In spite of this archaic backdrop, the iPad in particular has blazed a trail to the bedside of the patient. A number of medical schools and residency programs are actually buying iPads for their students and residents, sometimes with and at other times without a clear idea as to how the tablets would be used. One thing is certain: that tablet computing has made its inroads into the medical community, and it is here to stay.

While tablet computers have a variety of uses for consumption by medical trainees such as reading textbooks (whether through the Kindle or iBook stores, individual apps developed by big publishers, or through interactive textbooks that are being developed) and watching instructional videos (e.g. how to perform an arterial blood gas), production of new content has major barriers. In particular, most people do not find the glass keyboard of the iPad comfortable enough to type anything longer than a short e-mail. Even for me, someone who has used computers since an early age with good manual dexterity, I find that even the iPad 2 with its faster processing speeds and reduced typing-key-to-screen delay is too cumbersome and can be a hindrance to efficiency, an achievement so rarely acquired in health care delivery settings. I have tried using text expansion and templates to speed up the process, but writing an admission or consultation note remains a chore.


[ Hypothesis ]
Accordingly, I was very excited to discover the ClamCase, a keyboard case for the iPad and iPad 2. Unlike other keyboard cases, it has a hard shell and seamless method of connecting the Bluetooth device to the iPad. I suspected that this device might succeed where others might not: in facilitating a rapid means of text input in the medical setting into a device that is built for speed and convenience.


[ Results ]
The ClamCase, as one might expect from the name, has two halves like the shell of a clam. The iPad snaps into place in the top half: two lips hold the iPad tightly into place. The top half has indentations to allow for head phones and the charger to be plugged in; recesses for the power, orientation, and volume buttons to be accessed; and a cutout for the rear camera to take pictures and video. Unlike with some other cases, the alignment is perfect. The bottom half houses the recessed keyboard, two indicator lights, and rubber bumpers on the top and on the bottom to protect the iPad screen and provide friction on the bottom to prevent sliding. The bottom half has a small USB port for charging with the cable provided (which can be plugged into the same AC adaptor as that used by the iPad). The two halves are connected by a tight hinge which feels very sturdy.

The case itself has a spectrum of orientations. When completely closed, it provides full back, front, and edge protection for the iPad as though it were a laptop. It can then be pulled opened and angled in the same way (90 to 120 degrees) as a laptop. However, it doesn’t stop there: the hinge rotates a full 180 degrees, allowing you to use the keyboard face of the bottom half as the support/stand for the device, allowing for easy access to the screen when reading at a table or watching a video. Finally, the case can be fully folded back and used as a tablet held in one hand and directed with the other.

The case does have some weight and nearly doubles the weight of the iPad. Of note, much of the weight is in the top half of the case, meaning that tilting the screen too far back while it rests on a slanted surface that the rubber grips can’t hold as well (like a lap) can cause it to topple over if one isn’t careful.

The case comes in three colors: white, black, and a limited edition aluminum/brushed metal finish.

Typing on the keyboard is surprisingly pleasing. The keyboard is notably smaller than a full-sized keyboard, but this is the same trade off one would find with a netbook of a similar size. After a few minutes, I found that I could easily touch-type the way I would with a full-sized keyboard.

The Bluetooth connection between the keyboard and iPad is one of the best features. After the initial setup, the keyboard connects to the iPad 2 automatically. Like other magnet cases, the iPad 2 activates the lock screen or turns on when the case is opened. After clicking any key on the keyboard, the keyboard emerges from its “sleep” or “suspend” mode and immediately connects to the iPad as indicated by the flashing Bluetooth symbol at the top right of the iPad screen. After a couple of seconds, the synchronization is complete, and one can start typing. As expected, the keyboard returns to a sleep mode when it has not been used for some period of time. It is possible to turn on and off the keyboard as well when one does not want to accidentally press the keys (for example, when using the case in tablet mode wherein the keys would be resting against a surface such as one’s forearm).

Lastly, the keyboard offers a number of features that would be missing from a non-keyboard case: keyboard commands (such as copying, pasting, cutting), arrow keys, easy access to numbers and letters and punctuation on the same spread, and finally special characters (such as accents).

[ Discussion and Conclusions ]
While all keyboard cases would add much needed ease of use and additional functionality to the iPad, the ClamCase appears to stand ahead of the crowd. After inserting the iPad into the case, the device and case truly feel unified. One does not need to keep plugging and unplugging the iPad from the keyboard. Many other cases have a “pasted-on” feel to the keyboard which might add extra bulk but very little form factor or protection, but the ClamCase makes one forget that this isn’t actually a traditional laptop. The landscape orientation feels much more natural for word processing than does the portrait orientation used by some other keyboards, an orientation that is better suited for stylus writing on the screen.

The convenience, utility, and form factor do come at a price, though: $150 for the iPad and iPad 2 versions. Most keyboard cases come at a price ranging in the $50 to $150 range. Nonetheless, while some balk at the idea of spending more money on an already expensive device, the money could be very well spent if the added functionality is worth it. For me, my impression thus far is that the added value of a solid keyboard for generating medical notes (in the setting of a medical record system that lacks text expansion, a medical team structure that suffers from long rounding times and frequent activities that removes one from the ward computers, and a service that has a high admission and consultation rate) is well worth this price.


In a time when defensive practice conflicts with prudence and established practitioners bemoan the current state of the profession in light of a more glorious past, there are few consistent models representing the ideal physician for those training in the medical art. This is not to say that there are no heroes: there are numerous role models among practicing physicians and teachers. However, the medical field as a whole does not not cultivate an ironclad internal philosophy in the same way that one might find in a military academy or a successful company. Senior physicians might argue that the highly intellectual nature of medicine precludes a simplification of the core values underlying medical practice. However, all effective organizations have an infrastructure of core values that its members must aspire to and uphold at any cost. The medical profession’s core values suffer from adulteration by third parties that try to dictate how physicians should practice medicine and what doctors should be. If we cannot decide for ourselves the principles that we must follow, then others will, for better or worse.

We must know the essential qualities of an ideal physician. But where can we find them? Certainly not in popular culture. Physicians of the past had Marcus Welby; we have Gregory House and the fickle white coats of “Grey’s Anatomy.” But we also cannot rely on other external influences including our teachers (physicians who trained in a different era) and our patients. We must see beyond the nostalgia of our predecessors and the approval of our patients and their families to determine the true core values underlying the makings of the ideal modern physician.

[1] Excellence

The first measure of a great physician is excellence in clinical judgment: the accuracy of diagnostic methods, the thoroughness of approach, and the effectiveness of proven clinical decision-making principles. This obviously arises with the necessary prerequisites of intelligence, intellecutal curiosity, and well-developed logic and critical thinking skills. What follows, and is just as essential, is the ability to carry through the plans of action dictated by the clinical reasoning process, whether through coordination of care, the administration of pharmacotherapy, or the application of steel to the diseased body. Merely having good clinical reasoning and technical skills is not enough, however. The tireless compulsion to perform at maximum capacity is the true meaning of excellence.

However, always striving to deliver the best care possible should not be equated with ordering every test and calling every consultant. Rather, there is a careful balance between acting prudently and aggressively taking action.

[2] Compassion

A great physician enters this profession with a love for humanity. A great physician, despite the hardships of training and temptation of cynicism, never loses this love for his or her patients. Compassion is a core value of humanity as a species, and it is the primary fuel for the physician’s mission. For the modern physician, compassion represents the underlying emotional connection formed with each patient despite the bureaucracy, paperwork, and lack of time, and this connection is the fundamental basis for healing.

[3] Loyalty

The modern physician never works alone. Health care delivery, with the practice of medicine at its center, is reliant on teamwork. Loyalty means a great deal to the physician. It represents his friendship, support, and guidance of other care providers such as nurses and technicians. It represents the development of camaraderie within a specialty field among fellow residents and among physicians as a category. It represents respect for his mentors and teachers and the carrying of their messages and teachings to future generations. And it also represents the commitment to help fellow physicians see their mistakes and correct them in a supportive manner. (This last one, in particular, is incredibly important because past generations of physicians did a poor job of internal policing and correction, thus allowing the encroachment of outside parties who inevitably tend toward seeking punishment for mistakes instead of re-education or reform.)

[4] Fortitude

While our forebears wax poetic about the hardships of their storied early careers, it is important to understand that these comparisons are as based in reality as the practice of phrenology. The practice of medicine is constantly evolving and introduces many new challenges while attenuating others. Whereas physicians in the past may have worked longer shifts for more continuous stretches of days, they also did not have the same burden of paperwork, the complexities of care coordination, or even the complexities of addressing the wishes and perceived needs of patients (i.e. paternalistic care is much easier to deliver, but it is not better). Nonetheless, the underlying message is valuable: the willingness to persevere against hardship is a core value for physicians, because our jobs are not easy. We cannot give up once we have picked up the mantle for our patients. This is not to say that resident physicians should not complain about abuses and injustices or strive to make improvements in their lives, but often it is necessary to hunker down and push through the barriers, shoulder to the wall.

[5] Honesty

Last but not least, the practice of honesty is a core value of the modern physician. There are numerous occasions within the lives of a young physician when she is called upon to lie, bend, or obscure the truth: when a colleague makes a mistake but she must document her findings accurately and diplomatically, when a more senior colleague or attending physician comes to a conclusion that she does not agree with, or when it is requested by a family member or senior colleague that a suspected diagnosis not be revealed to an inquisitive patient. Nonetheless, there is no way to gain the trust of one’s colleagues and one’s patients if honesty is ever compromised. A forgotten exam maneuver should never be filled in with a fabricated finding. A question regarding the possibility of cancer as a possible explanation should never be sidestepped. The foundation of integrity is trust, and trust cannot be earned without consistent demonstration of honesty. A modern physician must be all of these things.

Do you have other ideas for core virtues modern physicians should have? If so, please write back in the comments section!

Over the past few weeks, I have reflected in great detail about the way I live my life: as a man, husband, friend, trainee, physician. Challenges inevitably stimulate growth, even if the new growth requires the burning away of old habits and beliefs. The past year and a half of my new career as a physician has provided numerous challenges, and accordingly I must find ways to change and grow. With the turning of the year, there are three areas of improvement that call upon my resolve.


As a senior at Harvard College, I took a course taught by Psychology professor Tal Ben-Shahar on the Psychology of Leadership during which a key theme was the cultivation of energy. A number of researchers in the business realm studied the habits and behaviors of high-stress/performance professionals (Olympic athletes, FBI hostage rescue operatives, trauma surgeons, etc.), and they found a unifying principle: that time is a limited resource, but energy can expand and grow. Performance failures are often attributed to the lack of time, but a significant part of the effectiveness of performance during a finite time period is related to the energy levels of the performer. This intuitively makes sense: at the end of a long work shift, every task, no matter how simple, takes longer and is more prone to error. Accordingly, improvement in performance should focus more on maintaining, growing, and effectively using one’s stores of energy and less on “time management.”

However, cultivating energy in the setting of medical residency training is very difficult. Over the past year and a half, part of my psychological programming has centered on self-preservation through protection of apparently limited energy stores. Time for sleep became more precious than ever. Forgoing social engagements for quiet nights at home became the rule. A constant reminder of the burden of fatigue played out in the form of a memory of a previous teacher’s only slightly hyperbolic experience: “After residency, I slept for three months.” A premedical advisor, a resident at the time, told me, “When you train in medicine, you can only bring one other thing with you, such as a hobby. For me, it was my marriage.” After each thirty hour or more on-call shift, my first priority was to sleep and allow my brain to heal, expecting that any deviation from this would result in worsening performance during subsequent work days and overnight shifts with accompanying demoralization.

Now, I am reevaluating this world view. I know there are physiologic bases for energy and fatigue. If nothing else, I have certainly performed enough Neurology consults for “weakness” that end up being medical evaluations for severe fatigue. There are limits to what the human body can routinely do. However, is routine the operative word? Can you change the human body’s routine to gradually require more and more energy mobilization and expenditure? Perhaps fatigue and chronic “sleep debt” are less a function of a depleted pool of energy, but rather, they represent a diminution of the means to quickly access energy stores. Am I still suffering from fatigue accummulated during my intern year, or am I “out of shape” with regards to acquiring energy? If so, what is the physiologic basis by which the body can be trained to more quickily mobilize stored energy? Can it be traced to an enzymatic process? At this time, I am managing to exercise on my elliptical machine almost every day, even if only for short bursts, yet even a fifteen minute session can keep me awake for hours in the evening working on projects and having meaningful conversations with my wife when otherwise I would sink deep into the couch and watch television.

Granted, there is a distinction between energy and willpower that I will not discuss in detail now. For the time being, my resolutions follow:

[ ] Learn to cultivate energy
[ ] Train to mobilize energy stores

– Exercise on the elliptical machine daily
[ ] for 7 days, [ ] for 14 days, [ ] for 1 month, [ ] for 3 months, [ ] for 6 months, [ ] for 1 year


Many people find benefit in learning the art of meditation. It is not hard to see why this might be useful: we are constantly bombarded with information and sensory stimuli. For example, I can count seven electronic screens in the room where I am writing this entry, four of which are within my range of peripheral vision, three of which having shifting/rotating images. In addition, our interconnected world is filled with strong emotional stimuli: sensationalist news reports written to inspire a passionate response, Facebook photograph uploads of parties and weddings and gatherings that you wish you could attend, and status updates whether through social networks, e-mails, text messages, or more frequent (and incredibly inexpensive) cell phone calls. As with sleep, there is a strong desire to disconnect with the world and find a moment and place of peace.

As for me, I am terrible at meditation. Closing my eyes, counting, and other mind tricks are not enough to quiet my brain. When I wake up in the middle of the night, my mind immediately jumps to the tasks for the next day, including orders I need to place in the hospital, patients and colleagues I need to call or e-mail, and measures I need to take to make the day slightly more manageable. During intern year, I spent both my waking and asleep hours at the hospital: my dreams often involved walking the hospital corridors and running to Code Blues.

Nonetheless, I would like to find ways of calming the mind. One way I hope to do this is by rediscovering hobbies and pasttimes and exploring new ones. One disheartening development related to medical school and residency training was the loss of hobbies, including music and sports. And yet, a great deal of the benefit of these activities is the switching of focus from agitated and worrisome thoughts to a singular purpose, whether to create beautiful melodies, perfect a form or dance routine, or win a game.

One unexpected activity I have adopted is woodcarving, specifically whittling. For some time I have longed for an activity that uses the fine dexterity of my hands and also one that can produce something. One game I used to play as a younger man was to peel the skin of apples in a single uninterrupted spiral. I find much charm in this quote attributed to Michaelangelo: “Every block of stone has a statue inside it, and it is the task of the sculptor to discover it.” There is a beautiful simplicity in the art form: a block of wood, a knife, and a very small repertoire of cutting techniques that can be learned intuitively. So far, I have spent the past week gradually carving away at a small block of basswood to make the traditional first project which requires that one learns a few basic techniques: an egg. While I have only aspired to carve for ten minutes each day, I find myself cutting for longer periods of time as my mind quiets, relaxes, and finds some serenity.

[ ] Find serenity

[ ] Learn basic techniques of whittling/small woodcarving
[ ] Carve an egg
[ ] Carve a set of calipers
[ ] Carve a scholar’s rock
[ ] Carve a cheese knife
[ ] Carve a rabbit


For most of my life, I have followed the path of the jack-of-all-trades. I have often enjoyed the ability to learn new skills quickly, but mastery has not often been part of my trajectory. This has partly been due to having a wide variety of interests and a limited amount of resources (e.g. not having the money to have music lessons at an early age). Nonetheless, my career trajectory is moving me towards subspecialization, most likely in the field of Vascular Neurology, the field that is concerned with the treatment of stroke. Part of my passion for stroke comes from the fact that I have interest in many aspects of it: the disease pathophysiology (the many etiologies), the emerging and changing acute and neuroprotective treatment modalities, the need for better public health methods to get people to the hospital faster, the variety of care delivery strategies that different centers have established, and the great deal of research going into stroke rehabilitation and adaptation to post-stroke disability. Nonetheless, as my training progresses, it will help if I can explore this field with the aim to find a point of focus for my energy and intellectual desire. As such, my resolutions this year are:

[] To develop a point of focus

[ ] To find a concept of stroke that is not well understood and prepare to study it
[ ] To find an aspect of stroke care that can be improved upon and develop a means to achieve improvement

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