RMstudents Technology meets medical education

The following are the most popular Medical Pastiche posts from 2008:

1: "Hi, everybody!" -- Dr. Nick Riviera as the Model Consumerist-driven Physician

2: 7 Famous Medical TV Shows

3: Healthcare Concept Map

4: 13 Somewhat-forgotten Medical TV Shows

5: Adverse Selection in Health Insurance _uacct = "UA-569368-3"; urchinTracker();

(Part One)


(Part Two) _uacct = "UA-569368-3"; urchinTracker();

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In light of a recent opinion piece, commented on by others, it deserves to be shown, through game theory, how two groups of physicians (specialists and generalists) are being pitted against each other by a third party, namely the federal government through CMS through the RVS Update Committee (RUC).

Game theory helps to predict and explain interactions in social decision-making. The classical problem is the "Prisoner's Dilemma" wherein two prisoners are pitted against each other by a third party seeking to expose the crimes of the imprisoned through betrayal of each other.

The incentive for prisoner A to betray prisoner B is the possibility that if the betrayer (prisoner A) is alone in betraying the other, prisoner A will go scot-free while the other prisoner receives the full prison term. If both prisoners betray each other, they both go to prison, but both receive a shorter prison term.

Do physicians cooperate or do they betray each other?


Generalists fight RUCGeneralists betray
Specialists fight RUCThe broken system is removedGeneralists' pay increased
Specialists suffer
Specialists betrayGeneralists suffer
Specialists' pay increasedRUC is maintained
All physicians suffer

Rather than cooperating with each other to get rid of a corrupt payment system which favors certain groups of physicians versus others in a budget-neutral fashion, these groups of physicians fight each other to get a larger piece of an increasingly smaller pie.

The only real winner is the government at the expense of all physicians.

Unlike the original prisoner's dilemma, the medical game is not over yet. Physicians still have time to set aside past wrangling over the payment system and to fight the RUC. _uacct = "UA-569368-3"; urchinTracker();

The original is here. _uacct = "UA-569368-3"; urchinTracker();

Check out the weekly best of medical blogs at Grand Rounds. My featured post is about surgery in Afghanistan. _uacct = "UA-569368-3"; urchinTracker();

Leishmaniasis is one of many infectious diseases that you would rarely see in the United States but would see quite often in countries such as Afghanistan.

The above photo shows a young Afghan male with cutaneous leishmaniasis on his forearm caused by a bite from an infected sandfly. The incidence is so high that the mobile pharmacy, pictured below, stocks medications specifically for this type of infection.I am not sure what happened to my patient. The mobile clinic was in the countryside outside the capital, far away from any form of follow up. The medications probably worked to take care of this single illness. But what of his next illnesses or his future? Will he grow old like the elders of the village, deciding matters inconsequential as the long years pass?Here are some children from the village who came into the clinic because, well, they saw segments of worm in their feces. Obviously, they were given the appropriate treatment for their problem. But, it is heartbreaking to know that, even after getting appropriate treatment, they were still missing what is necessary to be truly healed and fully satisfied in this life.

Flashback: Echinococcosis. _uacct = "UA-569368-3"; urchinTracker();

A medical student's first surgery is always the strangest. And the most memorable.

Mine is a case of an excision of a Baker Cyst from a middle-aged Afghan man.
Image from eMedicine.
The anesthesiologist performs flawlessly. The pharmacodynamics are wonderful, an injection into spinal fluid; the blade of the knife, capable of inflicting excruciating pain, is profoundly unnoticed.

Pick-ups demarcate my intended target. I am fixed on the goal. Scalpel handle in hand, I move the blade across the patient's popliteal epidermis in a textbook-perfect, straight line.

No blood. I thought people bleed when they are sliced open.

I try harder, thinking that this patient's skin is more akin to an elephant's hide, or perhaps a well-done steak.

Still nothing.

"For a first-time cutter I suck pretty bad," I thought to myself. The Afghan surgeon points to the skin in desperation, indicating to me in English that I need not be delicate. "The definition of insanity is trying the same thing and expecting different results," I thought to myself.

Enlightenment descends upon us as the blade is examined. The curved side is blunt, the flat side is sharp. How counter-intuitive. Is this some sort of ritual hazing by surgeons?


The Afghan surgeon, one of maybe a handful of Afghan surgeons, guided me through the case. Cut here. Tie this. Cut here. Use scissors like this. Et cetera.

See one. Do one. Teach one. I skipped the first step. I'm not quite ready on that last one.

Surgery. You are given permission from the patient to take a knife and cut into their flesh, prying layers of fascia apart, inserting various metal tools, removing pieces of tissue, and stitching everything back together using thread and needle.

What a bizarre experience. _uacct = "UA-569368-3"; urchinTracker();

It is the same story you hear from child abusers who bring in their children to be seen by physicians, such as

• "my [5 month-old] was jumping up and down on the bed and fell off, breaking his arm"

or

• "my [2 year-old] was playing around in the kitchen and put his hand on the stove."

According to the father in this child's case, "he knocked over a container of water from the stove onto himself."

In actuality, he was likely held upside down and lowered into a pot of boiling water.

I don't know if the father was trying to kill the child by scalding and drowning him. Was he trying to rid his family of the shame and burden of a child with some cognitive impairment? If he was, what stopped him? The screams muffled in the water? The writhing as the child struggled to survive? The guilt of it all?

In Afghanistan, there is no DHFS or government agency that steps in and assumes care of children in these abusive circumstances.

Whether you are in New York City or in Kabul, there will always be the terrible evil that all humans are guilty of, in one manifestation or another.

It is cases like this one--seeing the little ones in distress and suffering-- that has moved me towards serving pediatric populations. _uacct = "UA-569368-3"; urchinTracker();

The TV show "LOST" is a rich source for the "Medicine in Media" series. This is part two of many.

Bedside rationing is a controversial concept involving the rationing of resources by physicians in order to maximize the potential benefits of those resources. The following clip features a scene in an E.R., which although dubious due to such things as an intern being completely unable to intubate a patient, an orthopedic resident acting as an emergency medicine attending, and Dr. Shephard as the only capable physician available in an emergency room, illustrates how limited resources forces critical decisions which can negatively affect patients' care.

Other scenes in the clip illustrate some of the problems associated with particular ways of communicating news with patients, and how the doctor-patient relationship can be affected when the physician becomes personally attached to the patient.

View the clip below:


part one _uacct = "UA-569368-3"; urchinTracker();

The "Decalogue" ("Dekalog" in Polish) is a remarkable series of ten one-hour TV shows, created by Krzysztof Kieslowski and Krzysztof Piesiewicz in the late 1980s, which are themed on each of the ten commandments. It is a masterpiece of cinema.

This first clip details the relationship between a surgeon and his patient. Originally, this particular episode centered on infidelity and covetousness, but the purpose here is to show the inappropriateness and unprofessionalism of going beyond the normal doctor-patient relationship.

View the first clip below:



Evidence-based Medicine vs. Physician's IntuitionThis second clip details the conflict between evidence-based medicine and a physician's intuition. Although slightly more convoluted, this clip can be summarized as such: a female patient, who is married to a hospitalized patient who is "mortally ill", is seeking advice in making a decision whether to abort a fetus conceived with another man. The dilemma is: if her husband is going to die soon, she will keep the baby; if her husband is going to live, she will abort the baby. The physician at first gives only evidence-based advice, that the husband has a 15% chance of survival. Not satisfied with making a decision on less than certain data, the wife pesters the physician for certainty, at which point the physician swears to a certainty that is not based on medical science. Although not shown, the husband does survive the illness, pointing out the problem of promising certainty in a less-than-certain profession.

View the second clip below:
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The TV show "LOST" is a rich source for the "Medicine in Media" series. This is part one of many.

A main character of LOST is a spinal surgeon with remarkable diagnostic and procedural skills.

This first clip is a case where the patient, James "Sawyer" Ford, presents to Dr. Shepard with chronic headaches. Through the history and physical, Dr. Shepard diagnoses the patient with presbyopia and subsequently prescribes reading glasses.

What about the physician's bedside manner? Consistently terrible: he chooses to embarrass the patient by asking shameful sexual history questions in front of others, he does not explain the diagnosis, and he has a very domineering attitude over the patient.

Even more shocking, which bolsters the show's status as a work of fiction, is the idea that an orthopedic surgeon can diagnose presbyopia.

Watch the clip below:


part two _uacct = "UA-569368-3"; urchinTracker();

Pareidolia is a feeling or sensation in response to the realization that a particular stimulus is significant. Rorschach tests explore this phenomenon, and psychologists use the tests to understand a patient's personality. I experienced it while viewing an image from a blog post about strange weather events.

My first reaction: peripheral blood smear absent white blood cells. _uacct = "UA-569368-3"; urchinTracker();

Pareidolia is a feeling or sensation in response to the realization that a particular stimulus is significant. Rorschach tests explore this phenomenon, and psychologists use the tests to understand a patient's personality. I experienced it while viewing a map from a blog post about strangely colored beaches.

To me it looks like lobular lung tissue as it appears upon gross inspection of a cross-section of tuberculous lung tissue. Visceral pleura and caseating granulomas are noted. _uacct = "UA-569368-3"; urchinTracker();

Today, Google has announced a U.S. geographic influenza-statistics tracking section on their Google.org site, accessible here.

The most important point: Google search trends predict CDC data two weeks before data are available from the CDC.

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A family medicine physician gave me some poignant advice at a point in my life when I was considering surgery as a specialty choice:

Knives Before Wives
It is likely possible that (male) surgeons are just as able to love/lead/serve/please their wives as their non-surgical colleagues. I am sure that work-hour restrictions have helped relieve some of the strain on the marriages of the resident surgeon and wife. I am sure that some surgeons take their sacrificial dedication to surgery beyond the limits while others are able to balance personal lives with their professional lives.

It does go without saying that anyone considering a career in surgery needs to evaluate how he would survive and thrive in an environment that requires the giving of his life in that service.

Eight months from now, I will be rotating on the surgery service as a fresh third-year. Perhaps it will not be as bad as most people say. _uacct = "UA-569368-3"; urchinTracker();

The following is a guest post from Scott Cameron, a second-year medical student at UIC:

Reporting live from the Edelstone computer lab

It appears that an army of M1s worn down and exhausted from recent exams are inadvertently laying a trap for all of you M2s with your comfortable schedules and easy weekends.

Not long ago, loud blasts broke out here as a M1 began launching heavy artillery rounds wildly about the lab. So far he's done a flawless job of coating every surface in a 10 foot vicinity with some not-so-innocuous pathogen. I'm trying to hide myself behind this monstrosity of a computer monitor (thank you to whoever bought these Macs). Ten minutes into the attack, and an ambush from behind began with light machine gun fire; good thing her computer is taking most of the damage. As I write, a third student has entered the room and is now scattering viral land mines all over her keyboard. Hold on, it looks like she's going to try to do a little more damage before she leaves...oh boy, there goes the printers.

My guess is that a good 60% of this lab is now an infectious minefield.

And that's only in the last thirty minutes. I haven't seen one person cover their mouth this whole time.

Care about your classmates? Cover your mouth. And for all of you healthy students out there, don't forget to wash your hands.

This has been a friendly reminder/unwanted spam/moderately-amusing diversion brought to you at the expense of my pharmacology studies. Hate me if you want, you'll thank me when you're not sick during finals.
-Scott
If you would like to have a blog post featured here in "The Second Opinion" section, please email me at pzavislak@gmail.com. _uacct = "UA-569368-3"; urchinTracker();

From the British film Carry On Doctor:


(Thanks, NHS Blog Doctor.) _uacct = "UA-569368-3"; urchinTracker();

The 1995 film HEAT is replete with contrasts. It investigates oppositional characters: the cop and criminal, the unfaithful wife and faithful wife, the repentant felon and the unrepentant, the guilty and the innocent, the dangerous and harmless, et cetera.

The film also shows the worlds of the legitimate, for lack of a better word, and the illegitimate physician.

There is the emergency physician who tends his department, serving the public at large without caving into the excessive demands of patients, even a panicked police detective whose daughter attempted suicide.

There is also the freelance, illegitimate physician who abets dangerous criminals, ones who are prominently displayed on the "six o'clock" news for having killed several police officers in a daytime downtown shootout. Physician autonomy and motivations to practice medicine are the key contrasts between these two physicians.

View some clips from the film below:
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Everything I learned about proper physician behavior comes from films. Ok, that's a lie. But, a substantial amount can be gleaned by the attentive viewer. In the Medicine in Media spotlight this week, the professionalism of "old-school" physicians is shown through the late 1970s comedy "Airplane!"

There are several important points to watch for:

• The physician is readily available and does not refuse to serve his patients' needs
  
• The physician maintains the patient's modesty at all times by draping a cloth over sensitive areas
• The physician takes a role in leadership during crises
• The physician is cool, calm, and collective; his appearance and demeanor make the viewer conclude that this person must be a doctor
  
• The physician is the person that all others look to for decision-making
• The physician is eminently knowledgeable in all areas of medicine.
  

View some clips from the film below:
And feel free to add your comments! _uacct = "UA-569368-3"; urchinTracker();