Medical School 2020, Year 2, Week 23

From our anonymous insider…

Neurology week is shortened by two days of snow cancellations (the hospital and rotations for M3 and M4 students are on a normal schedule).

A 45-year-old neurologist with a British accent lectures on neuromuscular disorders such as Parkinson’s disease, Huntington’s disease, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease), and Multiple Sclerosis. Gigolo Giorgio asked about why deep brain stimulation (DBS) works for certain conditions? Neurologist response: “All of DBS is voodoo. There is not real science behind it, but it works. We just do not know why.”

He teaches us about tardive dyskinesia, a permanent movement disorder after exposure to antipsychotics. In a healthy person, dopamine from the substantia nigra (black pigmented neurons in the midbrain) acts to facilitate muscle movement via stimulation of the basal ganglia, a network of neurons located deep in the brain (“deep nuclei”). Antipsychotics block dopamine signaling, an attempt at reducing the symptoms of bipolar disorder and schizophrenia. This can have the same effect as damaging the substantia nigra, as happens in Parkinson’s disease. “Tardive dyskinesia happens after long-term use of the drug. We believe it is the brain trying to rewire around the drug. There are lawyers filling courtrooms around the nation suing doctors and pharmaceutical companies for this. There are more lawyers focusing on it than neurologists!”

He concluded: “The history and physical exam are are a dying artform. Some conditions, such as Guillain-Barré, you see nothing on imaging. Surgical residents, if they even have a stethoscope, put the diaphragm on the “Surgeon’s triangle” — where they can hear the abdomen, heart and lungs in one place. I ask what they got out of it and they respond, ‘Umm, they are alive.’ The answer is in the patient. You should know what is wrong with 95 percent of patients after taking the history. If you leave the room without knowing, DO NOT order tests. Go back in and take a good history, then do a good physical, and then order those unnecessary $5,000 imaging studies.

A 55-year-old neurologist reads through slides on seizure disorders. Several students doze off or check social media. She went five minutes over the 10:50 am official end time. The next lecturer, a 75-year-old neurologist, had snuck into the room five minutes early for the 11:00 am block and blurted out, “Are you done? I’ll just do this another day.” She then storms out. We have found a reason to have a PhD block facilitator in our lectures. She ran out of the third floor classroom and managed to corral the senior citizen on the first floor.

Despite a late start time due to the chase scene, the older neurologist did not disappoint. She lectured on myelopathies (disorders of the spinal cord). She ignored her uploaded powerpoint and used the chalkboard. We started with basic anatomy of the spinal cord and its blood supply. She asked, “Does anyone surf?” Buff Brad raises his hand. “How do you surf?” He slowly responds, “I wade out on my stomach, then pop up.” She responds: “You are clearly a novice. First time surfers lay on their stomach and extend their back as they surf out to catch the next wave. This prolonged hyperextension of the spine causes compression of the anterior spinal artery in what is termed Surfer’s myelopathy, potentially causing permanent paralysis.” The class laughs. [Correct technique is a yoga-style pose on one’s knees.] She concludes: “My husband died, so I have no one to not listen to me except medical students. It is such a pleasant surprise you are all listening to me.” In the Age of Universal Offense, students were divided over her lecture. Everyone agreed they learned a great deal, but some were turned off by her sense of humor.

Wednesday morning, our chief of neurosurgery, a man in his 50s (see Year 1, Week 15), lectures for two hours on traumatic brain injury (TBI). The IT staff as usual comes in before the lecture to to ensure that the required-by-regulation PowerPoint slides were ready and that the video is recording. The Chief: “I don’t think I will be using it at all. PowerPoint is a way to present material you do not know.” He made chalk drawings on the blackboard.

Any patient presenting for TBI will be scored using the Glasgow Coma Scale (GCS), which evaluates the patient’s eye, verbal and motor responses to stimulus. “Glascow Coma Scale is like the SAT. You get a score for just showing up. Glascow Coma Scale starts at 3. Don’t say 2 to an attending. You’ll sound like an idiot.” Pinterest Penelope wrote this advice down. The Chief: “What are you doing? Pens down and listen.” [Editor: Research shows that students who take notes learn more, even if they later discard those notes. See “The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking” (Mueller and Oppenheimer 2014, Psychological Science) and its references.]

Gigolo Giorgio was startled by the Kernohan’s notch phenomenon. Kernohan’s notch phenomenon typically occurs due to a hematoma (extravascular blood in the brain) causing the uncus, an inferior lobe of the brain, to herniate through the connective tissue floor of the brain into the brainstem canal. Nerves exiting the brainstem, namely CN III that innervates muscles of the eye, are compressed and lose function. “If the pupil is dilated on the left side, I go in on the left side, right?” However, occasionally the uncus can push the midbrain to constrict the contralateral CN III instead of the ipsilateral CN III. “I can operate on the wrong side of the brain because of this false localizing sign,” he continued. “This was not unheard of before we had stat CTs commonplace in hospitals.”

The Chief: “Medicine is a language. Isn’t medical school so easy compared to crazy particle physics you did in undergrad. If you approach it just like a language it is not that difficult. Medicine is learning to convey complex data in succinct phrases. If a resident calls me and says there is 4mm midline shift after trauma I am going to run out of bed. If a resident says there is a 1mm midline shift with a small hematoma, I am going to say, ‘Yep that’s a old alcoholic brain that is compensating for a subdural swell. We can deal with it tomorrow.’ I just downloaded a lot of information quickly. Practice presenting patients, that is what we will be evaluating you on in rotations.”

Straight-Shooter Sally: “I don’t think I learned much for Step 1 [the exam we’re taking this summer]. He did not get past his 2nd PowerPoint slide, but who cares.”

[The neurosurgeon’s life was also educational for us. His wife loyally managed the home front, including two kids, through a 7-year residency. As soon as the surgeon began earning a surgeon’s wage, she went down to the courthouse and shed the husband while keeping the kids and his income.]

Our patient case: Jimmy, a 69-year-old recently retired internist, was celebrating his 50th wedding anniversary with a trip to Scotland. “We were traveling with a group tour. I started to feel terrible. I was vomiting and felt weak. I was getting on the next train when I fainted. I initially attributed it to dehydration.” He continued, “When we were walking on the cobblestone paths in one of the beautiful small towns, I started to see double. I did not know which of the two people in front of me was real. As physicians we know double vision under the context of systemic symptoms is a serious concern, but denial is powerful. Because I did not want to ruin our wedding anniversary, I tried to hide the symptoms from my wife. We had been waiting so long for this trip and my retirement.”

His wife interjected, “I made us fly home early. He just looked weak. He was barely eating.” Once back, their son, also an internist, realized something was amiss, and interrogated Jimmy. GI symptoms are rare for Lyme disease, but the presence of diplopia, malaise, and hiking in endemic areas prior to the overseas trip caused the son to immediately suspect disseminated Lyme disease. The family took him to the ED.

Lyme disease is a tick borne illness caused by the Borrelia burgdorferi that is easily treated with antibiotics. Lyme disease is divided into three phases: early localized, early disseminated, and late disseminated. Jimmy never had the classic early localized symptoms of the “bull’s-eye” rash (erythema migrans), present in 80 percent of patients. Early disseminated Lyme disease occurs weeks to months after the initial tick bite. Jimmy’s double vision was caused by inflammation of peripheral nerves (peripheral neuropathy). He was also diagnosed with myocarditis (heart muscle inflammation) and atrioventricular (“AV”) heart block, under-diagnosed complications of early disseminated Lyme disease.

Jimmy arrived at the ED and was worked up for Lyme disease only due to the persistence of the internist son. “They were trying to work him up for a MI [myocardial infarction] and PE [pulmonary embolism]. I kept saying, ‘no, no get Lyme serology’.” Once the test came back positive, he was started on doxycycline (antibiotic). His EKG showed mild AV block, and he was placed on cardiac monitoring. Over the course of five days, his symptoms improved remarkably, and he was discharged on day seven.”

Gigolo Giorgio: “Why is there not a Lyme vaccine?” The internist son: “There was a Lyme vaccine. [FDA approved in 1998] GSK withdrew it after the early 2000s vogue for class action lawsuits against vaccine manufacturers. There is a new product in development using injected antibodies against burgdorferi bacterium that would protect for one season and then wear off. Has anyone gotten IVIGs [intravenous immunoglobulins] before traveling? They hurt! Great business model though. Europe is further in testing the vaccine now even though the US had it first.” Another physician in the audience jumped in: “All my horses and dogs have the vaccine!”

[Editor: Mindy the Crippler, our Golden Retriever, got Lyme vaccines in 2014, 2015, and 2016. In 2017, less than a year after the most recent shot, she got… Lyme disease. This is in the tick-plagued hell of the western Boston suburbs (“woodsy”).]

During lunch, we split into small groups in small groups to talk with M4s about Step 1 and the match process. My group was led by two women who are both applying to Ob/Gyn. Step 1 exam is an 8-hour exam with seven 1-hour, 40-question blocks and a 1 hour optional break split between each block. It costs $610 to register for the exam. “Do not study First Aid or any textbook,” said the Florida native “Just do questions on UWorld, and go over each answer.” She explained that she cried in the middle of Step I. “I had to call our school counselor for support.” The Bostonian, engaged to a recent graduate of the school visiting for support, described her Step 1 experience: “I had to get my fiancé to hold me [fortunately, he’s one year ahead of her in his medical training]. I threw up the breakfast he made me. Fortunately, he packed me sandwiches and granola bars so I did not take the exam on an empty stomach.”

After the M4s left, we stayed to consume the catered sandwiches and chat. Anita led the discussion: “Now no one can deny that our president is a racist pig.” [Donald Trump had recently characterized Haiti as a “Shithole”] Anita explained that she preferred immigrants from unsuccessful countries: “We want immigrants who understand hardship. They will be grateful, educate us, and create jobs.” Why not a merit-based system? Anita did not want immigrants taking the high-paying jobs. [Editor: like hers!]

Jane and I attend a late afternoon reception for applicants to our medical school who have come for final interviews. Most were fresh out of college and wanted to know about research opportunities at our school as well as nightlife (they don’t seem to have an accurate estimate of how much time they’ll have for partying). Some of the male applicants asked about the dating scene. The female applicants gathered around Southern Steve. We’d spread the (completely false) word that he had invented a successful medical device in between college and medical school and the women wanted to know more about him.

Thursday night means Burgers and Beers. Tonight we celebrate Sarcastic Samantha graduating PA school and finishing her Board exam. She will not get her results for two weeks, but is already excited about starting work: “I am 27, and have never had a real job!” U.S. labor force participation will not be growing, however, because my college friend who works as a project manager at Amazon exiting to “travel and reflect,” as soon as his stock options vest in March. “I do not respect or want to become any of my bosses,” he explained, adding that eventually he wants to work in the nonprofit sphere.

[Editor: Nobody gave him the standard briefing “If you have a job without aggravations, you don’t have a job.” Even sadder, apparently nobody told him about SSDI!]

Samantha plans to search for puppies if she passes her exam. “It takes several months to get all the licences and paperwork processed to begin to practice.” Luke wants to stick with their beloved cat. “I do not want a dog. Samantha wants a dog. So… we compromised and we’re getting a dog.”

[Editor: They’re using the same “one-woman, one-vote” system that we have in our house!]

I ask Samantha and Luke, “When are you going to have kids?” My plan is to have kids after Luke gets into residency and I have a job there. I do not want to be moving and searching for a new job in a foreign city while pregnant.” Luke: “I don’t want kids soon. Samantha wants kids soon. So… we’ve compromised and will have kids soon.”

Friday’s 2.5-hour weekly ethics seminar is taught by the 55-year-old director of our Masters in Public Health program. The topic is “Social Determinants of Health.” We had been assigned the first 30 minutes of the seven-part PBS documentary series Unnatural Causes: Is Inequality Making Us Sick? (2003). “Power, typically framed in political terms, is the ability to control an individual’s destiny,” she opens. “Power is used in public health as a goal because this is destroyed in a lot of communities and groups.”

[Editor: The government spends $trillions on Medicaid and then spends $millions funding a documentary about how Medicaid doesn’t work?]

MPH director: What did you take away from the video?

Orthopod Oliver: More money, less problems.

Pinterest Penelope: I was shocked by the discrepancy. CEO has 10 years longer to live than workers.

Straight-Shooter Sally: I was surprised that the discrepancy is not just low versus high income. Middle class is also on the scale.

MPH lecturer: “The video cited the famous Whitehall study of british civil servants in 1967 and 1985. People theorized that the CEO would die prematurely due to a heart attack from stress. What we found was the idea of a social gradient of health.” The low-level workers were the ones to drop dead first. [Editor: Another great argument for collecting welfare rather than meekly taking one’s place at the bottom of the bureaucratic pyramid!]

She emphasized that the term health disparity is out of fashion. “Health disparities is about what communities do not have. There is a certain victim-blaming mentality in this terminology. We now use the term health equity because everyone deserves the right to health. Health inequalities must be addressed to achieve health equity.”

Donald Trump’s proposed border wall might be the biggest public health improvement since the USDA stopped promoting carbohydrates via its food pyramid, according to our lecturer: “In public health there is something called the Latino paradox. As people settle in LA from Mexico and South America, they acclimate to US culture. We know their health declines. They no longer have the support system of, say, their small Guatemalan town. We think our lifestyle and communities are great, but in a lot of ways it is not. Our kids eat fast food, don’t exercise, don’t have strong community and family ties. They come from a good diet, strong ties, little screen time, etc. Their health declines as they try to live the American dream.”

Empowered by Oprah’s speech at the Golden Globes, Anita changed her cover photo to a Lord of the Rings frame reading “The Age of Men is Over.” Her next post:

In response to the escalation of hateful incidents since the 2016 national election, the National Abortion and Reproductive Rights Action League is pleased to offer a Bystander Intervention Training. Join us to learn how to step up and be supportive when fellow community members are facing harassment and hate speech. This training will provide a grounding in the principles of nonviolence and de-escalation, followed by interactive scenarios where we practice our new skills. …

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Winter formal begins at 8:00 pm, but our class, dressed in tuxedos and ballroom gowns, gets delayed at a pregame. While most play beer pong, Jane, Buff Brad, his girlfriend, and I play couples pool at the bachelor pad apartment. Faculty begin leaving when we arrive around when “Get Low” comes on. I never understand why they play hip hop music at this formal. Faculty might enjoy themselves more if they could partake in the dancing. No one threw up to my knowledge but several people fell down dancing and taking selfies in front of the photo backdrop.