My fellow medical students, interns, residents and attendings: I am not a medical student but an emeritus professor of Obstetrics and Gynecology at the University of Miami Miller School of Medicine, and also a voluntary faculty member at the Florida International University Herbert Wertheim College of Medicine. I have a great deal of contact with medical students and residents. During training (as student or resident), gaining confidence in one's own abilities is a very important part of becoming a practitioner. This aspect of training does not always receive the necessary attention and emphasis. Below I describe one of the events of confidence building that has had an important and lasting influence on my career as an academic physician. I graduated from medical school in Belgium many years ago. I came to the US to do my internship in a small hospital in up state NY. I was as green as any intern could be, as medical school in Belgium at that time had very little hands on practice, as opposed to the US medical graduates. I had a lot of "book knowledge" but very little practical confidence in myself. The US graduates were way ahead of me. My fellow interns, residents and attendings were really understanding and did their best to build my confidence and never made me feel inferior. One such confidence-building episodes I remember vividly. Sometime in the middle part of the one-year internship, I was on call in the emergency room and was called to see a woman who was obviously in active labor. She was in her thirties and had already delivered several babies before. The problem was that she had had no prenatal care at all and there was no record of her in the hospital. I began by asking her some standard questions, like when her last menstrual period had been and when she thought her due date was. I did not get far with my questioning as she had one contraction after another and she was not interested in answering. Soon the bag of waters broke and she said that she had to push. The only obvious action for me at that point was to get ready for a delivery in the emergency room. There was no time to transport the woman to the labor and delivery room. There was an emergency delivery “pack” in the ER, which the nurses opened for me while I quickly washed my hands and put on gloves. Soon after, a healthy, screaming, but rather small baby was delivered and handed to the pediatric resident who had been called. At that point it became obvious that there was one more baby inside the uterus. Realizing that I was dealing with a twin pregnancy, I panicked, as in my limited experience during my obstetrical rotation some months earlier I had never performed or even seen a twin delivery. I asked the nurses to summon the chief resident, who promptly arrived to my great relief. I immediately started peeling off my gloves to make room for the resident to take my place and deliver this twin baby. However, after verifying that this baby was also a "vertex" without any obvious problem, he calmly stood by, and over my objections, bluntly told me “you can do it”, even though I kept telling him that this was a first for me. I delivered this healthy, screaming twin baby in front of a large number of nurses and doctors crowding the room, only to realize that this was not the end of it and that indeed there was a third baby. Now I was really ready to step aside and let the chief resident take over. However he remained calm and again, stood by and assured me that I could handle this situation. I am not even sure how many triplets he had delivered himself as they are not too common. Baby number three appeared quickly and also was healthy and vigorous. What a boost to my self-confidence that was! I only delivered one other set of triplets later in my career and that was by C-Section. All three babies came head first. If one of them had been a breech the situation might have been quite different. What I will never forget is the implied lesson in confidence building the chief resident gave me. I have always remembered that. In fact I have put this approach in practice numerous times when the roles were reversed later in my career as teacher. Often in a somewhat difficult situation at the bedside or in the operating room, a student or more junior doctor would refer to me to take over and finish a procedure he or she did not feel qualified to do. Many times I would reassure and encourage that person to continue while I talked him or her through it. Many of these junior doctors have told me afterwards how they appreciated this confidence building. Of course one has to be careful to balance this approach with patient safety and I have never delegated responsibility in critical situations and have often taken over when a junior doctor was having trouble. Those interested, can read more about my experiences in the US and a number of other countries, in a free e book, entitled "Crosscultural Doctoring. On and Off the Beaten Path" can be downloaded at this link. Enjoy!
DR William LeMaire
over 7 years ago
This video tutorial has been made for use with Medical Student Apps: Chest Xrays, an application for the iPhone and iPad. Download the app here for free: htt...
over 7 years ago
http://www.acadoodle.com The different leads of the ECG examine cardiac electrical activity from different perspectives. In this video we teach you the perspectives of the 12 ECG leads on cardiac depolarosiation and repolarisation. We consider the 12 leads in two groups of six, with the six chest leads (V1-V6, also referred to as the precordial leads) examining the flow of cardiac depolarisation and repolarisation in the horizontal plan and a second group of six leads (the standard leads and augmented leads) which examine these events in the vertical plane. For the experienced practitioner, looking at different areas on the ECG readout is like looking at different anatomical regions of the heart. Also, understanding the lead perspectives is crucial in the interpretation of cardiac arrhythmias. Acadoodle.com is a web resource that provides Videos and Interactive Games to teach the complex nature of ECG / EKG. 3D reconstructions and informative 2D animations provide the ideal learning environment for this field. For more videos and interactive games, visit Acadoodle.com Information provided by Acadoodle.com and associated videos is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information provided by Acadoodle.com and associated videos is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
almost 8 years ago
What is Problem Based Learning? During my time at medical school, I enjoyed (at times) a curriculum delivered through the traditional model. As the name suggests, this is an approach experienced by the majority of doctors to date. The traditional model was first implemented by the American Medical College Association and American Academy of Medicine in 1894 (Barr, 2010) and has been used by the majority of medical schools. It traditionally consists of didactic lectures in the initial years covering the basic sciences followed by clinical years, where students learn clinical medicine while attending hospital placements. Is It Better? A few years after my graduation I found myself teaching at a university which had fully adopted the use of problem based learning (PBL) in the delivery of their curriculum. PBL is a philosophy of teaching that has increasingly been used in medical education over the past 40 years. It has rapidly been replaced or supplemented in medical education as opposed to the traditional model. PBL seeks to promote a more integrated and active approach to learning right from the first year with less reliance on didactic lectures. Having been involved in these two different approaches to medical education, I was interested to explore what the evidence was for and against each. For the purposes of this blog, I have looked at four specific areas. These include student attitudes, academic achievement, the academic process of learning and clinical functioning and skills. Student Attitudes Student attitudes to PBL have been highly featured in studies and many show that there is a clear favourability towards this philosophy of teaching. Blumberg and Eckenfel (1988) found that students in a problem based preclinical curriculum rated this three times higher than those in the a traditional group in terms of what they expect to experience, what they would like, and what they actually experienced. Heale et al (1988) found physicians in the problem-solving sessions rated a Continuing Medical Education short course higher compared to others who attended traditional lectures and large-group sessions. Vernon and Black (1993) performed a Meta analysis on 12 studies that looked at attitudes and towards PBL and found PBL was favored in some way by all studies. PBL appears to be preferred by the majority of students at a range of academic levels. However, Trappler (2006) found that converting a conventional curriculum to a problem based learning model for part of a psychopathology course did not show complete favourability. Students preferred the conventional lectures given by experts, rather than PBL groups run by mentors and not experts. They did however show preference towards PBL small group sessions run by experts Academic Achievement Academic achievement is an important factor to assess. Vernon and Blake (1993) compared a number of studies and found that those, which could be compared, showed a significant trend favouring traditional teaching methods. However, it was felt this might not be reliable. When looking at the heterogeneity of the studies there was significant variation that could not be accounted for by chance alone. Interestingly, they found that there was significant geographical variation across the United States such that New Mexico showed consistently negative effects and Michigan State showed consistently positive. Other studies have shown that the traditional method may show a slightly better outcome when assessing academic achievement. Schmidt et al (1987) looked at the same progress test taken among students in six different Universities in the Netherlands and found that those taught by a traditional approach showed slightly better outcomes. Baca et al (1990) compared performances of medical students in two separate tracks, one PBL the other a traditional model. Baca et al found that PBL students scored slightly lower in the National Board of Medical Examiners (NBME) examinations. Dochy et al (2003) conducted a meta analysis comparing 43 studies and found that when considering the effect of PBL on the knowledge of students the combined effect size is slightly negative. The academic process of learning It is important in medical education to enable people to continue life long learning, to overcome problems and fill in knowledge gaps. Coles (1990) and Entwistle (1983) found that PBL students would place more emphasis on understanding and meaning compared to just rote learning, seen more in those taught by a traditional approach. Students on a PBL course also place more focus on using resources such as the library and online sources rather than those taught in a traditional approach (Rankin, 1992). Students taught by a traditional model place more emphasis on the resources supplied by the faculty itself. It has also been shown that students who learn through a process of problem solving, are more likely to use this spontaneously to solve new problems in the future compared with those taught in a traditional way (Bransford et al, 1989). Clinical functioning and skills Clinical competence is an important aspect in medical education and has been measured in studies comparing PBL and traditional methods. The traditional model focuses acquisition of clinical competence in the final years of a program with hospital placements. In a PBL course it may be more integrated early on. There are however, only a few studies that look at clinical competence gained in undergraduate PBL courses. Vernon and Blake (1993) compared some of these studies and found that students obtained better clinical functioning in a PBL setting compared to a traditional approach. This was statistically significant, however there was still significant heterogeneity amongst studies and for conclusive results to be made 110 studies would have to be compared, rather that the 16 samples they were able to use. They also found that in contrast to the NBME I giving better results in the traditional model, PBL students score slightly higher in NBME II and federation licensing examination which related more on clinical functioning than basic sciences. On reflection, this evidence has indicated to me that PBL is a very valuable approach and it has a number of benefits. The traditional model in which I was taught has provided a good level of academic education. However, it may not have supported me as well as a PBL course in other areas of medical education such as academic process, clinical functioning and satisfaction. On reflection and current recommendations are for a hybridisation of the PBL and traditional approach to be used (Albanese, 2010) and I would support this view in light of the evidence. References Baca, E., Mennin, S. P., Kaufman, A., and Moore-West, M. A Comparison between a Problem-Based, Community Orientated track and Traditional track Within One Medical school. In Innovation in Medical Education; An Evaluation of Its Present Status. New York: Springer publishing Barr D. (2010) Revolution or evolution? Putting the Flexner Report in context. Medical Education; 45: 17–22 Blumberg P, Eckenfels E. (1988) A comparison of student satisfaction with their preclinical environment in a traditional and a problem based curriculum. Research in Medical Education: Proceedings of the Twenty-Seventh Annual Conference, pp. 60- 65 Bransford, J. D., Franks, J. J., Vye, N. J., & Sherwood, R. D. (1989). New Approaches to Instruction: Because Wisdom Can't Be Told. In S. Vosiadou & A. Ortony (Eds.), Similarity and Analogical Reasoning (pp. 470 297). New York: Cambridge University Press. Coles CR. (1990) Evaluating the effects curricula have on student learning: toward a more competent theory for medical education. In: Innovation in medical education: an evaluation of its present status. New York: Springer publishing; 1990;76-93. Dochy F., Segersb M., Van den Bosscheb P., Gijbelsb D., (2003) Effects of problem-based learning: a meta-analysis. Learning and Instruction. 13:5, 533-568 Entwistle NJ, Ramsden P. Understanding student learning. London: Croom Helm; 1983 Heale J, Davis D, Norman G, Woodward C, Neufeld V, Dodd P. (1988) A randomized controlled trial assessing the impact of problem-based versus didactic teaching methods in CME. Research in Medical Education.;27:72-7. Trappler B., (2006) Integrated problem-based learning in the neuroscience curriculum - the SUNY Downstate experience. BMC Medical Education 6: 47. Rankin JA. Problem-based medical education: effect on library use. Bull Med Libr Assoc 1992;80:36-43. Schmidt, H G; Dauphinee, W D; Patel, V L (1987) Comparing the effects of problem-based and conventional curricula in an international sample Journal of Medical Education. 62(4): 305-15 Vernon D. T., Blake R. L., (1993) Does Problem-based learning work? A meta-analysis of evaluated research. Academic Medicine.
Dr Alastair Buick
almost 9 years ago
I have recently spent a few days following around registrars on military ward rounds. It has been a fantastic experience for learning about trauma care and rehab, but more importantly it has shown me just how vital team spirit is to modern health care! The military ward round is done once a week. It starts with a huge MDT of almost 40 people, including nurses, physios, registrars and consultants from all of the specialities involved in trauma and rehab. The main trauma ward round team then go to speak to all of the patients in the hospital. The team normally consists of at least one T+O consultant, one plastics, two physios, two nurses, 3 registrars and a few others. This ward round team is huge, unweildly and probably very costly, but those military patients receive a phenomenal level of care that is very quick and efficient. Having then compared this level of care with what I have experience on my 4th year speciality medicine placement, I now feel the NHS has a lot to learn about team work. I am sure that everyone working in healthcare can relate to situations where patients have been admitted under the care of one team, who don’t really know what to do with the patient but struggle on bravely until they are really lost and then look around to see who they can beg for help. The patient then gets ping-ponged around for a few days while management plans are made separately. All of the junior doctors are stressed because they keep having to contact multiple teams to ask what should be done next. The patient is left feeling that their care wasn’t handled very well and is probably less than happy with the delay to their definite treatment. The patient, thankfully, normally ends up getting the correct treatment eventually, but there is often a massive prolongation of their stay in hospital. These prolonged stays are not good for the patient due to increasing risks of complications, side effects, hospital acquired infections etc. They are not good for the health care staff, who get stressed that their patients aren’t receiving the optimum care. The delays are very bad for the NHS managers, who might miss targerts, lose funding and have to juggle beds even more than normal. Finally, it is not good for the NHS as a hole, which has to stump up the very expensive fees these delays cause (approximately £500 a night). There is a simple solution to this which would save a huge amount of time, energy and money. TEAM WORK! Every upper-GI ward round should be done with the consultant surgeon team and a gastroenterologist (even a trainee would probably do) and vice versa, every Gastroenterology ward round should have a surgeon attached. Every orthopaedic ward round should be done with an elderly care physician, physio/rehab specialist and a social worker. Every diabetic foot clinic should have a diabetologist, podiatrist, vascular surgeon and/or orthopaedic surgeon (even trainees). Etc. etc. etc. A more multi-disciplinary team approach will make patient care quicker, more appropriate and less stressful for everyone involved. It would benefit the patients, the staff and the NHS. To begin with it might not seem like an easy situation to arrange. Everyone is over worked, no one has free time, no one has much of a spare budget and everyone has an ego. But... Team work will be essential to improving the NHS. Many MDTs already exist as meetings. MDTs already exist as ED trauma teams, ED resus teams and Military trauma teams. There is no reason why lessons can’t be learnt from these examples and applied to every other field of medicine. I know that as medical students (and probably every other health care student) the theory of how MDTs should work is rammed down our throats time after time, but I personally still think the NHS has a long way to go to live up to the whole team work ethos and that we as the younger, idealist generation of future healthcare professionals should make this one of our key aims for our future careers. When we finally become senior health care professionals we should try our best to make all clinical encounters an MDT approach.
over 8 years ago
Great people make mistakes. Unfortunately, medicine is a subject where mistakes are not tolerated. Doctors are supposed to be infallible; or, at least, that is the present dogma. Medical students regularly fall victim to expecting too much of themselves, but this is perhaps not a bad trait when enlisting as a doctor. If it weren’t for mistakes in our understanding, then we wouldn’t progress. Studying a BSc in Anatomy has exposed me to the real world of science – where the negative is just as important as the positive. What isn’t there is just as important as what is. If you look into the history of Anatomy, it truly is a comedy of errors. So, here are three top mistakes by three incredibly influential figures who still managed to be remembered for the right reasons. 3. A Fiery Stare Culprit: Alcmaeon of Croton Go back far enough and you’ll bump into someone called Alcmaeon. Around the 5th century, he was one of the first dissectors – but not an anatomist. Alcmaeon was concerned with human intellect and was desperately searching for the seat of the soul. He made a number of major errors - quite understandable for his time! Alcmaeon insisted that sleep occurs when the blood vessels filled and we wake when they empty. Perhaps the most outrageous today is the fact that he insisted the eyes contained water both fire and water… Don’t be quick to mock. Alcmaeon identified the optic tract, the brain as the seat of the mind (along with Herophilus) and the Eustachian tubes. 2. Heart to Heart Culprit: Claudius Galen Legend has it that Galen’s father had a dream in which an angel/deity visited him and told him that his son would be a great physician. That would have to make for a pretty impressive opening line in a personal statement by today’s standards. Galen was highly influential on modern day medicine and his treatise of Anatomy and healing lasted for over a thousand years. Many of Galen’s mistakes were due to his dissections of animals rather than humans. Unfortunately, dissection was banned in Galen’s day and where his job as physician to the gladiators provided some nice exposed viscera to study, it did not allow him to develop a solid foundation. Galen’s biggest mistake lay in the circulation. He was convinced that blood flowed in a back and forth, ebb-like motion between the chambers of the heart and that it was burnt by muscle for fuel. Many years later, great physician William Harvey proposed our modern understanding of circulation. 1. The Da Vinci Code Culprit: Leonardo Da Vinci If you had chance to see the Royal Collection’s latest exhibition then you were in for a treat. It showcased the somewhat overlooked anatomical sketches of Leonardo Da Vinci. A man renowned for his intelligence and creativity, Da Vinci also turns out to be a pretty impressive anatomist. In his sketches he produces some of the most advanced 3D representations of the human skeleton, muscles and various organs. One theory of his is, however, perplexing. In his sketches is a diagram of the spinal cord……linked to penis. That’s right, Da Vinci was convinced the two were connected (no sexist comments please) and that semen production occurred inside the brain and spinal cord, being stored and released at will. He can be forgiven for the fact that he remarkably corrected himself some years later. His contributions to human physiology are astounding for their time including identification of a ‘hierarchal’ nervous system, the concept of equal ‘inheritence’ and identification of the retina as a ‘light sensing organ’. The list of errors is endless. However, they’re not really errors. They’re signposts that people were thinking. All great people fail, otherwise they wouldn’t be great.
about 8 years ago
In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992
Dr Emad Sidhom
almost 8 years ago
http://www.acadoodle.com Atrial fibrillation is the commonest cardiac arrhythmia encountered in clinical practice. In this condition, chaotic electrical impulses, generated from multiple sites within the atria and pulmonary veins, result in irregular depolarisation of the ventricles with a resulting irregularly irregular heartbeat. Recognition of atrial fibrillation on the ECG is a crucial skill as the arrhythmia increases the risk of stroke and heart failure. These complications are preventable with appropriate treatment. Atrial flutter is a common arrhythmia which arises by a very specific mechanism. This arrhythmia is easily missed on the ECG. Acadoodle.com is a web resource that provides Videos and Interactive Games to teach the complex nature of ECG / EKG. 3D reconstructions and informative 2D animations provide the ideal learning environment for this field. For more videos and interactive games, visit Acadoodle.com Information provided by Acadoodle.com and associated videos is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information provided by Acadoodle.com and associated videos is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
almost 8 years ago
By Genevieve Yates One reason why I chose to do medicine was that I didn’t always trust doctors – another being access to an endless supply of jelly beans. My mistrust stemmed from my family’s unfortunate collection of medical misadventures: Grandpa’s misdiagnosed and ultimately fatal cryptococcal meningitis, my brother’s missed L4/L5 fracture, Dad’s iatrogenic brachial plexus injury and the stuffing-up of my radius and ulna fractures, to name a few. I had this naïve idea that my becoming a doctor would allow me to be more in charge of the health of myself and my family. When I discovered that doctors were actively discouraged from treating themselves, their loved ones and their mothers-in-law, and that a medical degree did not come with a lifetime supply of free jelly beans, I felt cheated. I got over the jelly bean disappointment quickly – after all, the allure of artificially coloured and flavoured gelatinous sugar lumps was far less strong at age 25 than it was at age 5 – but the Medical Board’s position regarding self-treatment took a lot longer to swallow. Over the years I’ve come to understand why guidelines exist regarding treating oneself and one’s family, as well as close colleagues, staff and friends. Lack of objectivity is not the only problem. Often these types of consults occur in informal settings and do not involve adequate history taking, examination or note-making. They can start innocently enough but have the potential to run into serious ethical and legal minefields. I’ve come to realise that, like having an affair with your boss or lending your unreliable friend thousands of dollars to buy a car, treating family, friends and staff is a pitfall best avoided. Although we’ve all heard that “A physician who heals himself has an idiot for a doctor and a fool for a patient”, large numbers of us still self-treat. I recently conducted a self-care session with about thirty very experienced GP supervisors whose average age was around fifty. When asked for a show of hands as to how many had his/her own doctor, about half the group confidently raised their hands. I then asked these to lower their hands if their nominated doctor was a spouse, parent, practice partner or themselves. At least half the hands went down. When asked if they’d seek medical attention if they were significantly unwell, several of the remainder said, “I don’t get sick,” and one said, “Of course I’d see a doctor – I’d look in the mirror.” Us girls are a bit more likely to seek medical assistance than the blokes (after all, it is pretty difficult to do your own PAP smear – believe me, I’ve tried), but neither gender group can be held up as a shining example of responsible, compliant patients. It seems very much a case of “Do as I say, not do as I do”. I wonder how much of this is due to the rigorous “breed ’em tough” campaigns we’ve been endured from the earliest days of our medical careers. I recall when one of my fellow interns asked to finish her DEM shift twenty minutes early so that she could go to the doctor. Her supervising senior registrar refused her request and told her, “Routine appointments need to be made outside shift hours. If you are sick enough to be off work, you should be here as a patient.” My friend explained that this was neither routine, nor a life-threatening emergency, but that she thought she had a urinary tract infection. She was instructed to cancel her appointment, dipstick her own urine, take some antibiotics out of the DEM supply cupboard and get back to work. “You’re a doctor now; get your priorities right and start acting like one” was the parting message. Through my work in medical education, I’ve had the opportunity to talk to several groups of junior doctors about self-care issues and the reasons for imposing boundaries on whom they treat, hopefully encouraging to them to establish good habits while they are young and impressionable. I try to practise what I preach: I see my doctor semi-regularly and have a I’d-like-to-help-you-but-I’m-not-in-a-position-to-do-so mantra down pat. I’ve used this speech many times to my advantage, such as when I’ve been asked to look at great-aunt Betty’s ulcerated toe at the family Christmas get-together, and to write a medical certificate and antibiotic script for a whingey boyfriend with a man-cold. The message is usually understood but the reasons behind it aren’t always so. My niece once announced knowledgably, “Doctors don’t treat family because it’s too hard to make them pay the proper fee.” This young lady wants to be a doctor when she grows up, but must have different reasons than I did at her age. She doesn’t even like jelly beans! Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/
Dr Genevieve Yates
about 8 years ago
http://www.acadoodle.com In this video we review the nomenclature of the ECG readout. You will learn that the deflection produced by atrial depolarisation is termed a P wave while ventricular depolarisation produces the qrs complex. You will also learn the correct nomenclature of individual deflections within the qrs complex and some important terms used in ECG analysis. Acadoodle.com is a web resource that provides Videos and Interactive Games to teach the complex nature of ECG / EKG. 3D reconstructions and informative 2D animations provide the ideal learning environment for this field. For more videos and interactive games, visit Acadoodle.com Information provided by Acadoodle.com and associated videos is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information provided by Acadoodle.com and associated videos is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
almost 8 years ago
Medical blogging is blogging in the field of medicine. It is a relatively recent addition to the medical field. While its closest predecessor medical journalism; is about 300 years old, medical blogging is currently about a decade old. This blogpost aims at exploring the field of medical blogging and comparing it to related disciplines when relevant. It examines some opinions of bloggers, and reviews some medical blogs aiming to infer reasons for blogging, derive technique or outline of blog and hopefully arriving at a conclusion to the future prospects of medical blogging. Medicine is the practice of the art and science of healing 'ars medicina'. It is a branch of applied science, which started probably in the pre-historic era. The practice continued to flourish, specialise, sub-specialise and sub-sub-specialise. The word blog is most probably derived from the contraction of the words 'web log' which is a form of website that is more interactive, allowing comments, tagging,and is displayed in counter-chronological order from the most recent at the top of the page. The term 'blog' is currently used as a noun as well as a verb. The aggregation of blogs is named 'blogosphere', and the blog writer is named 'blogger'. There are single author blogs and multi-author blogs, they are as diverse in there content as the diversity of the bloggers, with regards to form they can be written text, images, videos, sounds or combination of more than one medium. The term 'blogroll' is referred to blogs followed by a person. Blogging is just more than a decade old now. However, the number of blogs have been increasing exponentially at times. The concept of blogging is considered as one of the components of the concept of web 2.0. Medical blogs refer to blogs that are primarily concerned with medical/health subjects. The name 'medical blog' is derived from content based taxonomic classification. Medical blogs can be classified by author, there are blogs by physicians, nurses, patients, medical institutions, medical journals, and anonymous blogs. They can be classified by target audience as either to other doctors, patients and carers, general public or a combination of more than one target. There are also medical blogs by patients or patient blogs that expresses their viewpoints. A study examined medical student blogs and concluded that they might be beneficial for students to reflect on their experience (Pinilla et al, 2013). The Nephrology Dialysis and Transplantation (NDT) made it own blog (El Nahas, 2012). The American Journal of Kidney Disorder (AJKD) made its own official blog (Desai et al, 2013). During the same year, the American Heart Association and American Stroke Association launched their official blog (Sanossian & Merino, 2013). Pereira discussed the blogs by neurosurgeons (Pereira et al, 2012). In the BMJ doc2doc blogs, they do not have to meet certain number of word count but will have to be reviewed prior to publication. KevinMD requires blog posts to be of maximum five hundred words, Medical-Reference require a minimum of one thousand words. Meducation requires a blog post to vary between 1500-3000 word. Independent blogs may show more variation in the number of words per blog post. Some blogs are predominantly in text format, other may combine multimedia or get linked to other medical blogs. The BMJ doc2doc tentatively recommends blog posting to be in the frequency of one to two blogs/month. Chrislyn Pepper, a medical blog writer, (2013) states that medical blogging can aim to be 'three blogs of 300+ words each week and three to four short blogs of less than a hundred words five days per week.' Medical bloggers seem to have various reasons to blog, some communicate clinical data to fellow doctors, in this case some blogs seem to resemble research or review articles in content and language which can contain medical jargon. There are diagnosis blogs that were studied by Miller and Pole (2010). The comparison between the electronic predecessors of blogging including Electronic Bulletin Board, USENET, and emailing in addition to the why of blogging in general has been discussed by Mongkolwat (Mongkolwat et al, 2005). Some put their hypotheses forward, others share clinical experience or discuss a clinical matter. Some bloggers direct their attention to the general public providing information about medical topics. Some discuss issues which can be difficult to be put in research topics. Dr Rob discussed that importance of medical blogging as an equivalent to the concept of democracy in an online world. Doctor Blogger website offers 10 reasons for medical blogging including public education, correction of misconceptions and establishing a name. For the medical blogger's direct benefit Medical Rant blog offers an overview of personal benefits from medical blogging including stimulation of thought and stimulation of academic writing. Dr Wible seems to use her medical blog to promote a standard of care that seems to be a mix between the medical model and the befriending model of care. Another study examined the young adults blogging and concluded that powerlessness, loneliness, alienation, and lack of connection with others, where the primary outcomes of young adults as a result of mental health concerns (Eysenbach et al, 2012). Wolinsky (2011) enquires whether scientists should stick to popularizing science or more. Medical blogs are essentially online activity which renders them immediately accessible to any area with internet connection, they are paperless by definition which makes them more environment friendly. The medical blogs are open access by default which adds to the accessibility, and they are decentralised which decreases control over the control and seems to accentuate diversity. As compared to peer reviewed journals, medical blogs seem to be less referenced, are hardly ever taken as academic writing, the process of peer reviewed medical blogs is minimal if any, and they do not get reflected on resume or be considered as publication, though the term 'blogfolio' started to become a watch word. It seems hard to base clinical decisions on medical blogs. However, medical blogs can offer more diversity into research and non-research medical topics. They are published online with no delay or review time, they can comment on the most recent advances in the medical field or most contemporary issues instantaneously. Very recently, citing blogs seems to become a bit accepted. BMJ Journals have their dedicated blogs Some online resources give a comprehensive outline on blogging in general and medical blogging in particular including video interview with a medical blogger Michelle Guilemard in her blog makes a valid point of how medical blogging can enhance career. Medical Squid also highlighted medical blogging as a career Kovic et al (2008) conducted a research on the medical blogosphere an concluded that 'Medical bloggers are highly educated and devoted blog writers, faithful to their sources and readers'. Miller & Pole (2010) concluded that 'Blogs are an integral part of this next stage in the development '. Stanwell-Smith (2013) discussed the aspect as an important tool to communicate with patients. The blur between academia and blogging was discussed in research blogs. (Sheema et al, 2012). During the same another study discussed the impact of blogging on research (Fausto et al, 2012). While Baerlocher & Detsky (2008) warn in an article against the hazards of medical blogging due to potential breach of confidentiality. After an exhaustive study of the content of weblog written by health professional, Lagu reached the concern of breaching of confidentiality (Lagu et al, 2007). Rebecca Golden (2007) cites the perils of medical blogging she concludes her article saying 'Science has a peer-review process for a reason'. Brendan Koerner (2007) in wired magazines posted an article about the problems of giving medical advice via blogging. Dr Val Jones makes a point by concluding that social media provide the 'allure of influence'. Thomas Robey (2008) offers arguments for and against medical blogging, including confidentiality, and ruining personal reputation on the negative side, while enhancing democratization of conversation and having a creative outlet on the positive side. Brendel offers an intriguing discussion to whether it would be ethical or not to monitor patients' blog to determine their health status. (Brendel, 2012). O'Reilly voiced in 2007 the need for blogging code of conduct. The GMC published guidance on the use of social media by doctors and it included blogging as a form of social media. The Royal College of General Practitioners also published the social media high way code to offer guidance on social media including medical blogging. There is also the medblog oath online. Flaherty (2013) argues that blogging is under attack by micro-blogging, and that it is in its deathbed. Mike Myatt in his article Is Blogging Dead, discusses various views about blogging in an era of micro-blogging The Royal College of Psychiatrists recently introduced a number of blogs including the president's blog, overseas blogs and other blogs. The medical blogging seems to occupy a middle space between the quick micro-blogging and the thoughtful research article. Its diversity and freedom are its strongest tools and can have the potential to be its worst enemies. One wonders whether the emergence of guidelines for medical blogging – given the seriousness of the content – would save medical blogging and elevate it to the next level or change the essence of it. After all, the question is how much the medical field which is a top-down hierarchy accept grass-root movement. Freedom of expression is probably at the heart of blogging. It would be logistically impossible to impose rules on it. However, guidelines and code of honour may help delineating the quality of medical blogs from each other. This post is previously posted on doc2doc blogs. Bibliography & Blogiography Brendel, D. Monitoring Blogs: A New Dilemma for Psychiatrists Journal of Ethics, American Medical Association, 2012, Vol. 14(6), pp. 441-444 Desai, T., S.M.A.N.V.S.K.T.J.K.C.K.B.E.J.K.D. The State of the Blog: The First Year of eAJKD Am J Kidney Dis., 2013, Vol. 61(1), pp. 1-2 El Nahas, M. An NDT blog Nephrol Dial Transplant (2012) 27: 3377–3378, 2012, Vol. 27, pp. 3377-3378 Eysenbach, G., B.K.M.M. What Are Young Adults Saying About Mental Health? An Analysis of Internet Blogs Journal of Medical Internet Research, 2012, Vol. 14(1) Fausto, S. Machado, F.B.L.I.A.N.T.M.D. Research Blogging: Indexing and Registering the Change in Science 2.0 PLoS one, 2012, Vol. 7(12), pp. 1-10 Lagu, T, K.E.J.D.A.A.A.K. Content of Weblogs Written by Health Professionals J Gen Intern Med, 2008, Vol. 23(10), pp. 1642–6 Miller, EA., P.A. Diagnosis Blog: Checking Up on Health Blogs in the Blogosphere American Journal of Public Health, 2010, Vol. 8, pp. 1514-1518 Mongkolwat, P. Kogan, A.K.J.C.D. Blogging Your PACS Journal of Digital Imaging, 2005, Vol. 18(4), pp. 326-332 Pereira, JLB., K.P. d.A.L. d.C.G. d.S.A. Blogs for neurosurgeons Surgical Neurology International, 2012, Vol. 3:62 Pinilla, S. Weckbach, L.A.S.B.H.N.D.S.K.T.S. Blogging Medical Students: A Qualitative Analysis
Dr Emad Sidhom
over 7 years ago
http://www.acadoodle.com Contraction of the atria and ventricles is tightly coordinated by a wave of depolarisation spreading through the muscular walls of these chambers. The depolarisation wave reflects movement of charge across cardiomyocyte membranes and is in effect an electrical current spreading through the heart. Following contraction, cardiac muscle returns to a resting state and this is associated with reversal of the movement of charge across the myocyte membranes, this second wave of electrical activity is termed cardiac repolarisation. The leads of the ECG machine are designed to detect and record these two waves of cardiac electrical activity. The depolarisation and repolarisation waves spread through the heart in a highly predictable pattern and to understand the ECG readout, the pattern of spread of cardiac electrical activity needs to be understood. Acadoodle.com is a web resource that provides Videos and Interactive Games to teach the complex nature of ECG / EKG. 3D reconstructions and informative 2D animations provide the ideal learning environment for this field. For more videos and interactive games, visit Acadoodle.com Information provided by Acadoodle.com and associated videos is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information provided by Acadoodle.com and associated videos is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
almost 8 years ago