Thursday, June 15, 2006

Caffeinated Antidote?

So, by now, you must be thinking "Gee DocSurg, what is it that gets your aggravated a@* out of bed in the morning?" Thanks to the wonders of the internet, now you get to find out: Coffee! Black, stand-up-your-spoon-in-it mud! Java. Joe. Ink. Perk. Jitter Juice. You get the picture. I love a large cup of hot coffee in the morning, and it's got to be dark and black --- no communist lattes, espressos, cafe au laits or other namby-pamby so-called "coffee" drinks --- just plain coffee. And it had better be caffeinated, dammit, or you get to hear me say dammit all morning long! On the flip side of the day, I occasionally indulge in a good glass of wine -- but for sheer relaxation, a dirty martini is just the perfect thing. But wait! Isn't coffee supposed to be bad for you? Aren't martinis a one-way street to cirrhosis?

Au contraire, mon frere! Some smart guys decided to look at heavy drinkers who happened to drink a fair amount of coffee, and found that cirrhosis was far less frequent in java junkies than non-coffee drinkers. As Napoleon Dynamite would say, "Yessssss!"

Curious line of research, don't you think? Maybe the researchers were bored, pounded a few drinks, and while nursing their headaches the following morning with the ebony elixir of life decided, "What the heck, I'm sure we can get some grant money to study this!"

Actually, given that only about a quarter of all alcoholics develop cirrhosis, and given that we don't really understand why they do and the others are spared, this line of research opens up some interesting avenues for further investigation. Is this the result of the holy chemical, caffeine? Does it reflect that perhaps coffee drinkers were more likely to be more affluent, and therefore able to maintain better nutrition along with steady coffee intake? Although the studies will take some time to come to fruition, hopefully the smart guys in lab coats are on to something here.

As an aside, a few years back I read a wonderful short book called The Devil's Cup, by Stewart Lee Allen (just goes to show you how obsessive I can be). It's a fun, sometimes funny, always interesting read -- a "coffeecentric" view of history and geography, so to speak. And if your friends can't tell that you're hyped to the gills with 10 cups of "fully leaded" every morning, go to Think Geek to get t-shirts, mugs and more plastered with the caffeine molecule (see above) so they can be fully warned.

Tuesday, June 13, 2006

Grand Rounds

Grand Rounds is being hosted over at The Haversian Canal this week --- check it out!

Sunday, June 11, 2006

Virtual Patients -- Pacer or Porsche?

Back in the stone ages when I was a medical student, we learned how to take a patient history by, well, sitting down with a real live patient and figuring it out on our own. There was a very large public hospital affiliated with the school, and there was never a lack of patients to see. We had role models, to be sure -- primarily the interns, but also the more senior residents and occasionally even the attendings -- and some were better role models than others. We did have "standardized patients" only for one day -- the tricky, awkward experience of learning how to do pelvic exams.

I would say that my classmates and I got good at taking histories (the first step in trying to figure out what is ailing a patient) and doing physical exams because we had to, as the volume of patients we were intended to see dictated a need for efficiency. We each learned the most effective way to accomplish the task that suited our own personality and personal skills. As we progressed through the 3rd and 4th years of school, that skill became second nature, and served us well as we progressed into residency. I would also say that the H&P process for me has continued to evolve, as I learn more about myself and about how best to interact with certain types of people. Most of the time, it's (almost) as fun of a process (for me) as surgery.

Apparently, my medical school experience is not reproducible today, for a large number of reasons. Students are not thrown into the water not quite knowing how to swim, and they are not generally expected to follow large numbers of patients during their clinical rotations. Ah, well, progress. They still need, however, to learn the ropes when it comes to communicating with patients -- and where there's a need, there will be somebody who is smart enough to try to meet that need. Some members of the Association for Surgical Education came up with the idea of computer generated, interactive patients to help students learn these skills, and published their findings in this month's American Journal of Surgery: The use of virtual patients to teach medical students history taking and communication skills

In the virtual scenario, a life-sized VP (virtual patient) is projected on the wall of an examination room. Before the virtual encounter, the student reviews patient information on a handheld tablet personal computer, and they are directed to take a history and develop a differential diagnosis. .... The VP is programmed with specific answers and gestures in response to questions asked by students. The VP responses to student questions were developed by reviewing videotapes of students'’ performances with real SPs (standardized patients). After obtaining informed consent, 20 students underwent voice recognition training followed by a videotaped VP encounter.

Initially, the VP correctly recognized approximately 60% of the student'’s questions, and improving the script depth and variability of the VP responses enhanced most incorrect voice recognition. Student comments were favorable particularly related to feedback provided by the virtual instructor. The overall student rating of the virtual experience was 6.47 ± 1.63 (1 = lowest, 10 = highest) for version 1.0 and 7.22 ± 1.76 for version 2.0 (4 months later) reflecting enhanced voice recognition and other technological improvements. These overall ratings compare favorably to a 7.47 ± 1.16 student rating for real SPs.
Of course, an old codger like myself would say the students compared the virtual patients favorably in comparison to standardized patients because they had not yet had the chance to interact with real patients! Sort of like driving a Porsche in a video game compared to driving a real AMC Pacer --- when the real Porsche is in the garage with the keys in it, waiting for you to take it for a spin!

Don't get me wrong -- I'm not a Luddite, and certainly think that anything that can help students become better communicators, and therefore better physicians, is a good thing. Other virtual learning experiences, particularly in surgery, have come into wider use in recent years. I guess I would be more inclined to push medical students to overcome their inhibitions, their shyness, their natural desire to avoid looking stupid, and have them interact with real live patients. The information that was gathered by the student's history and physical was valued in my learning experience, so I felt that I had a role to play in the patient's care, rather than being an interested bystander. Today's medical students should feel the same way.

Saturday, June 10, 2006


Finally, a day off. Of course, that didn't keep me from waking up at 5:30, with DogSurg shoving his wet nose in my face, wanting to go on his morning walk. After a great hike in the hills, I sat down with the paper --- and honest to goodness had coffee spewing out of my nose in laughter while reading this great retort ( in response to the letter "Where have the hippies, their idealism gone" -- about 1/3 the way down the page here). I do not know who Martha Rudman is, and certainly don't envy her early life experiences, but by does she speak with authority on the subject. I grew up in the immediate aftermath of the so-called "hippie age," graduating from high school in 1980, and grew weary of hearing -- from teachers, from the TV news and programs, from the newspaper, from EVERYONE -- that the "60's generation" was the only group that mattered, or would ever matter. At the same time, I could see the same things that Ms. Rudman so aptly points out:

I was one of those hippies, and I can guarantee you we didn't change one thing, unless you consider wearing long hair even if it cost us jobs, rarely bathing even if we had fleas, and constantly mooching off of friends, relatives and strangers to be "social consciousness, awareness and regime change."
It has always seemed rather childish to me for that group to lay claim to all sorts of "changes" which were well on their way prior to, and continued long after, their communal temper tantrum -- while at the same time downplaying the major trash left in the street after their parade (drug use with resultant disease, just to name one). It's worth the time to read.