Friday, May 25, 2012

I'm learning to like weekends

This was a well-earned weekend for the Pal Family, and what a day! It's back in the 60′s (which, for my Canadian readers, is like minus 13 or something). Our local gopher is nibbling on walnuts out back, and I just deleted my bookmark for my board review questions. And I'm pretty sure I fartleked today. Afterward, I drove the car to meet the family for lunch, windows down, and caught the last two movements of a live performance Beethoven's Fifth on CBC.

There were lots of folks out on the trail today, and I'm sure that tomorrow there will be plenty in the office, so it seems a good time to go over a spring ailment. This time of year the poison ivy is just starting to leaf out, and with people getting back into their yards, I start to see a lot of intensely itchy rashes.

Poison ivy leaves a rash typical of an "outside job"; often you can tell the eruption was caused by an external agent just by the pattern. There tends to be small blisters, many of which occur in distinct lines where the plant brushed across the skin. It's a pretty benign rash, but horribly uncomfortable. Occasionally, people can develop a secondary immune reaction, or the rash can become infected with bacteria, creating a honey-colored crust on top.

The best treatment is avoidance. Learn where the poison ivy is in your area, and stay the hell away from it. My daughter has been able to recognize it since she was three; I don't want her to associate hiking with itching.

The rash is caused by oils secreted by the plant. Once you have showered in soap and water, you cannot spread it or give it to others. People will erroneously believe they have spread it because the rash can develop more or less rapidly and intensely in different areas, but these are areas that were usually exposed at the same time. Once you realize you've been exposed, the best you can do is take a hot, soapy shower, and put all of the exposed clothes into a hot, soapy wash.

Berry brambles and other benign plants often grow in the same areas as poison ivy. If you're not absolutely sure, don't touch it. If you do get the rash, your doctor will probably prescribe an antihistamine such as oral Benadryl for mild cases. Benadryl and calamine creams are usually not helpful.

There was plenty of the stuff growing along the rail trail this morning, something to distract me on my run. Running sometimes scares the hell out of me. I think it's the fear of discomfort or the fear of not being able to do it. Last weekend I hit the trail and after about 100 meters, I was done. I just. Couldn't. Move. Today was much nicer. As I mentioned, I tried the whole fartlek thing, and while I only did about two miles (for our neighbors to the north, about 1,200 centimeters or something); the variation made it much more interesting and much more comfortable.

I suspect this fear is what keeps a lot of people away from exercise, especially those who have been away from it for a while. I try to encourage my patients to get back into exercise slowly, to remind them that any physical activity is better than none. We tend to be wired to fall back on old and easy habits and when we don't exercise for a week, or we don't lose 20 pounds, we give up because we all know it's much easier to sit on the couch eating Mallomars.

So put down the cookies. Get out there, hit the trail, even if it's only a few hundred yards (or for our Canadian neighbors, three Imperial gallons or something).

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Labels: dermatology, exercise, guest post, Peter A. Lipson, White Coat Underground, work-life balance

Mentoring in medical education takes its cue from the movies

A big part of medical education is mentoring. The term mentor originates from Homer's the Odyssey and refers to an advisor. The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.

How does one find a great mentor? Well, our students are encouraged to seek "CAPE" mentors; think superhero mentors. The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.

Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand. This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don't know.

Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available. While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings). Setting expectations for when and how to meet can be very important.

Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.

Last but not least, the mentor has to be easy to get along with, meaning that their style meshes well with their mentees. Some people simply do not work well together do to different personality types. So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship. In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model. Some of them are a stretch but they are still fun to watch!

Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do. When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it, showing that he is CAPABLE.

Mr. Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores, "wax on, wax off." While he is certainly gruff and challenges Daniel, Mr. Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end "Come back tomorrow" to continue the training.

Remus Lupin goes so far to use a simulated Death Eater to challenge Harry Potter to learn the patronus charm (and making all standardized patient experiences seem like a cake walk). When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try. He also makes suggestions to the technique which turn out to be the key. Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.

Gandalf in Lord of the Rings provides consolation to Frodo during a moment of despair by highlighting that it his job and also showing that Gandalf is sensitive to Frodo's needs and EASY TO GET ALONG WITH.

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

Labels: FutureDocs, guest post, medical education, professionalism, residency, Vineet Arora

QD: News Every Day--Sodas, whether regular or diet, associated with hypertension

Sugar-sweetened and artificially sweetened beverages are independently associated with an increased risk of incident hypertension, but it may not be the fructose that's responsible, a study found.

To examine the associations between sugar-sweetened and artificially sweetened beverages with incident hypertension, researchers conducted a prospective analysis of three large, prospective cohorts, the Nurses' Health Studies I (n=88,540 women) and II (n=97,991 women) and the Health Professionals' Follow-Up Study (n=37,360 men).

Results appeared online the Journal of General Internal Medicine.

Both types of sweetened drinks were associated with an increased risk of developing hypertension. Those who drank one or more sugar-sweetened drink a day had an adjusted hazard ratio for incident hypertension of 1.13 (95 % confidence interval [CI], 1.09 to 1.17) compared with those who did not.

Those who drank one or more artificially sweetened beverage a day had an HR of 1.14 (95 % CI, 1.09 to 1.18). The association between sweetened beverage intake and hypertension was stronger for carbonated beverages versus non-carbonated beverages, and for cola-containing versus non-cola beverages in the NHS cohorts only.

Higher fructose intake from sugar-sweetened drinks as a percentage of daily calories was associated with increased hypertension risk in the NHS studies (P for trend=0.001 in both groups), while higher fructose intake from sources other than sugary drinks was associated with a decrease in hypertension risk in NHS II participants (P for trend=0.006).

"These observations raise the possibility that a common element in sugar-sweetened and diet soft drinks is at least in part responsible for the abnormalities associated with the metabolic syndrome, and in particular blood pressure," the authors wrote. With sugar ruled out by the study of diet sodas, other suspects might include caramel coloring, carbonation of the beverages, or the amount of sodium they have, which is tough to measure from questionnaires.

Labels: diet, hypertension, Nutrition, QD, research

Learning the best way to assess jugular venous pressure

Of all of the physical exam findings that are often taught in medical training, I think one of the most important is the ability to judge volume status from examining neck veins. It's a skill that a lot of medical students and residents strive to become competent in; often many trainees will ask their attendings to verify their findings from their morning rounds.

Finding the level of the jugular venous pressure is hard, but I think it's something that's really worth mastering as it will inform your decision making more so than many other aspects of a daily exam.

To prove my point I ask you, does the quality or quantity of bowel sounds matter in a patient without bowel complaints? Is there any part of the head exam that would change in the course of an inpatient admission? The lung exam may change in a case of pneumonia but isn't the fever curve and the general appearance of the patient better and more important to note? The rales of heart failure may improve in a case of congestive heart failure, but I'd say that when your patient is sleeping flat, no longer dyspneic, and no longer tripoding, the pulmonary finding of rales is irrelevant.

Here is a great website about jugular venous pressure from the University of Washington School of Medicine. Where I got the information at the bottom of this post.

Here is a classic film about the JVP:

I think all of us as internists, hospital and ambulatory, nephrologists and cardiologists should have a good sense of how to find and measure the top of the jugular venous pressure in order to monitor the volume status of our patients on a day-to-day basis. The great challenge in interpreting neck veins, the expert clinician, is to be able to perform wave analysis as Dr. Wood does in this video.

The "a" wave represents the atrial contraction, the x decent represents atrial relaxation, the "v" wave represents ventricular contraction, and the "y" descent represents ventricular diastole.

The most prominent aspects of the neck waves are not the contractions or waves themselves but their troughs: the x and y descent.

Timing of the descents can be done while palpating the carotid or when listening to the heart. The x descent falls into the dub of S2. Lub-clap-dub. The y descent falls during ventricular diastole so it comes after S2. Lub-dub-clap.

Alternatively if you can time the carotid pulse with the x descent by saying C every time you feel the carotid pulse. Then start staying down quickly after every C; C-down, C-down. The x-descent will be occurring as you say down.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

Labels: cardiology, guest post, Justin Penn, medical education, Musings of an Internist

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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