With Phase IIB completed we’re closer to clerkship (C, D, and E remaining!), and also that much closer to being graduated. Being done is a great feeling! Now for a relaxing Christmas break and some restoration before the new year brings with it the core internal specialties: Cardiology, Respirology, and Nephrology. But before that, baking, reading, and sleeping. Merry Christmas all!

Let me be clear: bipolar is a disease listed in the Diagnostic and Statistical Manual (DSM). It is diagnosed by psychiatrists, and treated with medication. There’s no question of its legitimacy as a medical condition. But having had the opportunity yesterday to interview a standardized patient with bipolar disease, I was awakened to the idea that these patients often disagree about being ill.

As the name suggests, bipolar involves alternations between the two extremes of mood: depression and mania. No doubt you’ve heard of and could recognize depression, but do you know what mania looks like? Manic patients are incredibly friendly and likeable; they have an elated, un-deflatable mood, and are very busy people. They rarely sleep, eat copiously, and socialize even more than they eat. They’re relatively disinhibited, and will make friends with strangers, spend money freely, and will try any new activity (including drugs). True mania is accompanied by delusions –  usually delusions of grandiosity. The typical manic believes that they are an especially remarkable person and that they will accomplish legendary success.

The “problem” with mania, is that in the extreme it can be profoundly damaging. In an episode of mania, a bipolar patient may spend all of their money, or make new sexual contacts that they later regret. Jobs are lost, relationships are strained, and medical illnesses are worsened because often the manic forgets to take their medication. Manic patients are sometimes arrested for their indiscretionary behaviour.

Bipolar disease is treated with mood stabilizers. When effective, these drugs reduce the frequency of both depressive and manic episodes. The reality is, however, that many bipolar patients don’t want to take them! The personal perception of mania is such a positive, exhilarating experience that people with bipolar look forward to, and try to prolong their manic episodes. Those who are artists have their most creative moments when manic, and those in business make the most of their money.

So whose assessment of “ill” trumps the other? It’s a very difficult question. Legally, there is guidance available to assess whether a patient is capable of making their own decisions or not. Mostly this involves determining whether the patient fully understands the options available to them, and the consequences of each one. If incapable, patients can be legally held and provided with the treatment that they need.

All of this leaves me asking the question: who am I to deem that you are too happy? When does it become the doctor’s right to decide your mood? And yet at the same time, doesn’t your doctor have the responsibility to look out for you, and advocate on your behalf when you are incapable of doing so? Even if that means protecting you from yourself?

I present all this solely to ask the question. I don’t have the answer. I’m confused and unsure about it. But asking the question is an important first step. I welcome your ideas!

Anorexia is a high-profile psychiatric disorder; most people know about it – or at least, they think they do. Today’s lecture on eating disorders challenged many of my pre-concieved notions about anorexia nervosa. Here are a few points that I found interesting/significant:

1. 12% of people with anorexia will die from the disorder. This disease is far more serious than just low self-esteem about body weight/shape.
2. Some anorexics engage in binge-eating and purging (such as self-induced vomiting). This behaviour is not restricted to just bulimia, but is seen in anorexia also.
3. There’s an element of “psychosis” in anorexia. Psychosis is believing/perceiving something that isn’t real. Most anorexics will deny that they are underweight. When asked to outline her reflection in the mirror, one woman with anorexia drew the line three inches too wide on either side. Anorexics truly perceive (see and feel) that they are overweight!
4. The prevalence of anorexia is not increasing. Although Western culture’s preoccupation with beauty in thin-ness contributes to the maintenance of anorexia in already ill patients, it has not driven up the incidence.
5. Gay men are particularly susceptible. There are ten times as many women with anorexia nervosa as men. But a particular sub-group, gay men, are especially susceptible to this disease. The reason is presumably gay culture’s preoccupation with body shape/size.
6. There’s a strong genetic component. If you have an identical twin who has anorexia nervosa, there’s a 70% chance that you’ll get it too. That’s pretty strong for a disease that we usually consider as having environmental triggers.

Today was the first day of Psychiatry block. One day’s impression: engrossing, perplexing, and not like anything I’ve done before.

This afternoon we broke into small groups to practice the psychiatric interview. It took place at the hospital. After greater than an hour of conversation with a woman who was describing significant symptoms of depression, I felt quite involved in her story. I was disquieted by her lack of self-worth. Pangs of empathy welled up when she began to cry, and the urge to hug required active suppression. What a wretched affliction this poor woman is enduring, I thought.

It wasn’t until after the interview that I found out from my colleagues that she was acting. She was not a patient! Rather, she was a ‘Standardized Patient’, performing a role written for her by our psychiatrist instructors! What a fool ! I feel completely taken-in! She sure did her job well.

In normal circumstances, I might have watched a movie on a Friday night. Two days ago, however, I spent my Friday night watching cardiac surgery! It was incredible.

(Disclaimer: This paragraph gets technical. Please skip to the next paragraph if you don’t find it interesting!) The procedure on the board for the cardiac OR was a triple-bypass, technically known as coronary artery bypass grafting (CABG). The CABG (pronounced “cabbage”) procedure is used as a treatment for coronary artery disease (CAD). CAD is a decline in the ability of the coronary arteries to deliver oxygenated blood to the heart. During the CABG procedure, vessel grafts are attached to provide an alternate route for blood to flow from the aorta to the heart muscle. The grafts themselves are harvested from the arm (the radial artery), the leg (the saphenous vein), and from within the thorax itself (the mammary artery).

The cardiac surgeon herself was a walking contradiction. After scrubbing into the OR, she began jovially chatting with the nursing staff and walked over to introduce herself to me, the observer. She graciously talked me through the procedure I was about to see (a generous move, as not all surgeons will waste time on a mere observer). My initial impression was of a wizened woman with a great sense of dignity and compassion.

Not long later, however, and that same surgeon split a man’s chest open with a Black-&-Decker saw, and then used the full force of her body weight to rip open the rib-cage! Her personality also changed with scrubbing. In contrast to the pre-surgery woman, the during-surgery woman was frighteningly efficient, scrupulously precise, and inflexibly demanding of her team to do their jobs no short of perfectly. She displayed the stereotypical “surgeon’s personality”, which the speciality of cardiac surgery is especially noted for. I do wonder whether her self-assuredness and intense drive for excellence were both necessary to succeed as a woman in what, in her training days, was a male-dominated field.

It’s cliche, but true: There’s nothing else quite like seeing a living heart, beating within a man’s chest. Additionally, if you look to the sides of the heart, you can see the lungs inflating and deflating with each breath. You can see the diaphragm ballooning up and down, and you can even pick out the nerves to the diaphragm descending on either side of the heart’s chamber (the pericardial sac). Anatomy is wondrously beautiful, especially in a living body.

Bypass surgery is also remarkable, in that during the procedure the heart must be stopped. Blood is redirected through tubes to a bypass machine next to the OR table where it is oxygenated and sent back to the body via the aorta. The heart is completely cut from the circuit. This permits the surgeon to administer a drug that stops the heart so that she can do her work. Once the grafts are installed, normal blood flow is restored and the heartbeat returns. During Friday’s procedure taking the patient off the bypass machine proved tricky, and at one point electric paddles were needed to rescue the heart from fibrillation (random, non-productive contractions). Thankfully, the surgery ended well, and he’ll likely be alright. In fact, once healed he’ll have a heart in his chest with rejuvenated blood supply!

The hand is distinctly human. A thorax is just a thorax, and a shoulder is just a shoulder. In contrast, like the heart, brain, or face, a hand is not just a hand. It’s somebody’s hand.

When prosecting the hand tissue, as we did today, it’s troublingly difficult to dissociate yourself from the gruesome reality of the task – cutting apart a person’s dead body. I felt again deeply accusing guilt of invasion, and violation.

What work did he use his hands for? Perhaps he played an instrument with them. Perhaps he penned words that have out-lasted the hands that formed that. Whose hands did he lovingly hold in his?

Now his final handshake: … me, with my stinging scalpel. I greet him again in those hands, human even in death. I’m sorry for putting you through this. I’m sorry for keeping you here. Thank you, for this last meaningful action of your – always your - hands.

A great deal of research is done on how to educate medical students. Our government, and the medical schools themselves, have a lot of money invested in the process. The Canadian public depends on that investment having a productive return in the form of competent, quality doctors.

The challenges of medical education are many. Each medical student arrives from a unique background; how can we draw on students’ previous skills and knowledge while bringing them all to the same place of medical competence? Similarly, each medical student is preparing for a different career. The  teaching required to prepare a student for General Practice might be quite different than that needed by a Specialist. How can a single curriculum sufficiently address both? The universe of medical knowledge is simply too vast to be given justice in four years – choosing which information is most important can be a real challenge.

There is currently a paradigm shift occurring in the research of medical education. New studies are showing that the century-old approach of didactic lectures is ineffective. Someone once said that a lecture is: “the process by which the notes of the lecturer become the notes of the student without passing through the mind of either“. There’s some truth to that.

As an alternative to having a lecture, educators are suggesting a team-structured, problem-solving session. Ever since McMaster started the trend, all medical schools have incorporated this approach to some degree in the form of “Problem-Based Learning”. Although the Mac kids seem to love it, the rest of us are a little more hesitant. We prefer our lectures! So do the instructors. Nonetheless, Queen’s and other schools are doing their best to apply the new conclusions in education research, without sacrificing the best aspects of the strong curriculum we have right now!

This past week we studied Ophthalmology. The challenges of conveying a broad overview to Ophthalmology in a single week are a small-scale representation of the challenges in overall medical education. Having now completed the week, I can say appreciatively that the Queen’s Ophthalmology Department delivered the most excellent teaching I’ve encountered. It was incredibly well done. Here’s how they did it:

• Acquisition: Through a series of online videos, and a recommended textbook, students were required to prepare for each session by obtaining the relevant background knowledge independently.
• Application: Each morning we met in teams to discuss clinical cases. We would decide on our approach to each patient, and ask for necessary investigations. As decisions were made, the facilitator would reveal new information that eventually led us to a diagnosis and constructing a management plan.
• Clinical Skills: We finished off the week with a session to learn the necessary skills to examine the eye. The Opthalmology Clinic in Kingston closed their doors to patients for the afternoon, and instead invited us into their department, where in groups of twos and threes we learned from the Ophthalmologists directly the techniques we need to know to examine the eye.

From my perspective, the Ophthalmologists’ approach was highly successful, and  I feel it serves a good model for how medical education should be done in general.

There’s no question about it; H1N1 is sweeping through Ontario, and has been for a few weeks now. You’ve probably already heard that Ontario government has released the vaccine, and is dispensing it across the province. I would strongly encourage you to consider getting yourself vaccinated.

Most of my readers are young, and mostly healthy. As such, the need to protect yourself from flu is not pressing. If you contracted H1N1 today, it would likely only mean missing a few days of school or work. So why get vaccinated? Because the flu pandemic is spread by droplet contact from person-to-person. Vaccinate yourself so that you’re not just another person in the long line of transmission. Because that line ends with people who are more susceptible, and who are going to die from it. Vaccinate yourself on behalf of Ontario’s elderly, the immunosuppressed patient who uses the pay-phone after you, the pregnant woman next to you on the bus, and the cancer patient. Getting the H1N1 vaccine is the socially responsible thing to do.

Find an Ontario vaccination clinic near you at this website. Vaccination schedules will vary by region, and in most regions where there are limited supplies of the vaccine, you will be prioritized according to your risk. First to be vaccinated are those in danger themselves, and second those who have susceptible close contacts (e.g. health care workers). If neither of those are you, be prepared to wait a bit for your vaccine. Keep checking back, however, because eventually there should be enough for everyone.

There have been rumours and anxiety going around about the safety of the vaccine. As always, be discerning about where you get your information. Those organizations most-equipped to assess the quality of the H1N1 vaccine have pronounced it safe, and effective. In general, vaccines are the safest medications around. That being said, the vaccine is likely to give you a sore muscle at the injection site, and perhaps a headache, fever, and flu-like symptoms for a day or two. This is not the flu, but rather your body’s immune system responding. Take Tylenol for your symptoms, and you shouldn’t be held back. Ultimately, a day or two of headache, and a sore shoulder are far better than having the flu itself, which can last more than a week!

Do it for your grandparents, for your nieces and nephews, and for the many Ontarians depending on you to do your part. Get your flu vaccine.

Cute kid, right ? Take another look. Notice anything not quite right? Although easily missed at a subtle glance, you should see that this boy’s eyes are pointing in different directions. (If you want to confirm, look for the two shiny spots of reflected light from each eye, and observe how they overly different locations). Mal-alignment of the eyes is called strabismus. It’s fairly common, seen in 2-4 children of every 100.

Aside from the aesthetic implications (kids with strabismus are sometimes presumed to be intellectually slow because of their appearance, despite that there is no association between strabismus and cognitive ability), strabismus is a dangerous condition in children. When adults develop strabismus, they report double vision; each eye is looking in a different direction, there are two unique visual inputs to the cortex, and the brain perceives two simultaneous visual representations of the visual field.

In contrast, children whose visual maturation is not yet complete (before age 7-9) are able to suppress the input from one, or both eyes. Chronic suppression over time leads to irreversible loss of visual circuits in the brain. The result is irreversible loss of vision in one eye. This is called Amblyopia. It can be caused by strabismus, as described, or other causes including congenital cataracts, retinoblastoma (an eye tumour), or refractive errors. Amblyopia is the greatest cause of monocular (one eye) blindness in people under 45 yrs old.

Importantly, Amblyopia is painless, and has no symptoms. The only way to detect Amblyopia, is by an objective test of visual acuity. You may notice a strabismus (which can result in Amblyopia) like the picture above, but often the cause of Amblyopia is just as unnoticeable as the result. Can you imagine discovering that your child has become permanently blind in one eye, and worse, that it could have been prevented? The important public-health message about Amblyopia, therefore, is that children should have their vision checked regularly by a health-care professional. This is equally true for the pre-verbal child.

In case you’re curious, treatment for Amblyopia involves reversing the cause when possible (e.g. fixing the strabismus with surgery), and then patching the good eye such that the brain is forced to receive input from the Amblyopic eye. This preserves, and strengthens, the brain circuitry from the affected eye.

(Yes, we’re on Ophthalmology this week! And I love it!!)

One of the more benign conditions I saw in the ER last week, was a 3-month baby with a hair tourniquet. A strand of someone’s (usually the mother’s) hair becomes entangled around a toe such that blood-return through the veins is impeded. The toe swells up, and becomes acutely painful. Thankfully, it’s usually recognized, easy to treat, and rarely causes permanent damage. The ER physician used a magnifying glass and forceps to carefully remove the offensive hair. With no further risk of blood-flow restriction, swelling decreases in the toe over a period of a day or two. Perhaps some readers will have heard of this condition before, since I’m told it’s fairly common.