Blog | Thursday, November 17, 2011

Penrose box


Once we think outside the box, aren't we just inside a larger box? Once the ideas of one box leap outside, might we not be in another box?

I've been a professional student for (too) many years, but the education that I took for granted ended the day I started as attending. The dreaded morning report hosted by harried if dedicated clinicians, the complex grand rounds elucidated by leaders in medicine, noontime and core conferences in a multitude of subjects that were a constant time pressure in residency were rudely stolen the day I graduated. Within months of being a junior attending I was academically starved. Thus I started looking for other opportunities, seeking out the rounds I used to loath, traveling to conferences in far cities, and looking up events that just sounded interesting.

This week I attended the Illinois Transdisciplinary Obesity Prevention Program's (I-TOPP) Inaugural Biennial Symposium, which covered factors from the microscopic to the transnational of how obesity can be prevented in children. I'm an adult nocturnist. The youngest patients I see are 19, and the only preventative medicine I do is of a more acute nature, as in preventing my patients from stopping oxygenating or perfusing. What's the point of going to something that I would be unlikely to have any "need" of. Knowledge isn't like that, it is insidious, flashes of brilliance (or snippets of insanity, depending on your point of view) occur while learning the most unlikely and seemingly unrelated things.

The symposium was opened by an epidemiologist at the Centers for Disease Control, Dr. Cynthia Ogden, who went through the data of childhood obesity and problems with the precision and accuracy of that data. Obesity in children is a huge problem, but may fortunately have plateaued. However those children are an added source of patients to an already growing cohort of obese older adults.

Obesity is often simplified as energy in (EIN) greater than energy out (EOUT), which to most clinicians, including myself, means eat fewer calories and expend more. However as I learned, this is a gross oversimplification, not of the equation, necessarily, but of the complex and multitudinous variables that contribute to both energy in and out, including (but certainly not limited to) calorie source, quantity, timing of consumption, genes, gut microbiota, being breastfed, psychosocial factors, location, economics, and many more. These variables are further defined by confusingly dependent and independent equations that have yet to be defined.

Genes! Impossible! Not according to Dr. Molly Bray, who examines genes in obesity. She told us about her and others research into genes that not only affect metabolism but behavior driving the obese to not only have decreased satiety but to shy away from exercise. Phenotypically these genes are environmentally dependent. In times of food scarcity they are genotypically pervasive but phenotypically absent, however when an "obesiogenic" environment presents itself, so too does the obesity phenotype.

One of the genes that has been discussed extensively is fat mass and obesity-associated protein (FTO). FTO encodes for proteins which can demethylate DNA, or promote gene products. This is an amazing concept, since dietary choices, if they are indeed choices and not mandated by genetic and environmental factors, produce concentration gradients of carbohydrates, lipids, and proteins which can interact directly with DNA, and therefore for may affect FTO and therefore drive demethylation.

My conjecture is that this then in turn could produced a cascade effect on other genes involved in metabolism, cellular protein production, and behavior that would drive an organism toward obesity with different velocities. You are not only what you eat but you are regulated by it as well. It is as if the lumber and mortar have to be the building supervisor as well.

The next invited speaker, Dr. Madeleine Sigman-Grant, discussed the development of the All 4 Kids Program, a community-based intervention in pre-schoolers to prevent obesity designed using a Logic Evaluation Model. I don't deal with preschoolers in a professional capacity nor am I planning any community interventions anytime soon. But it was a rewarding and interesting experience to see how someone worked through a Logic Evaluation Model to develop a preventative health intervention.

Dr. Stephen Matthews spoke on spatial polygamy, which is less risque than it sounds. The concept of spatial polygamy refers to individuals having multiple spatial interactions depending on the map technique used. Thus we are defined by ZIP codes, voting districts, census demographics, street addresses, telephone numbers, and e-mail addresses that redefine associations between individuals and their spatial or temporal dependence. Thus it is important to understand the source of our mapping data and the limits thereof.

This creates an interesting parallel in hospitalized patients. Their physical location in the hospital has little to do with their "therapeutic distance" from their physician. Therapeutic distance would be defined as the time between a patient having a need and it being taken care of. Two patients in the same room may have vastly different care demographics and therefore therapeutic distance, even if they are physically adjacent.

The patient with the in-house hospitalist versus the traditional internist on-call from home may have significantly different response times to pages. The comanaged patient may or may not be more therapeutically isolated depending on how clear the nursing staff is on the division of duties between the physicians caring for the patient, i.e. if they don't know who to call, they will take longer to get the right physician to solve the problem.

Despite not being "my area" I certainly took a step outside my box, which would have expanded to include this new information, thus creating a new and larger box. Sometimes the box doesn't change but leaping outside the box in one area just places us within familiar and useful territory in another. Each day of our lives should be a leap outside of our old box, but within a new and larger box. The only way to achieve that is through the core competency of lifelong learning that is no longer quite such a continuous feed after entering the post-postgraduate world.

ACP Member Mike Aref, MD, PhD, 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. This post originally appeared at his blog, I'm dok.