Extraocular Muscle Movements - Function Explained

Usually, anatomists and clinicians share the same base of knowledge regarding how the body functions. However, as I was doing Step I practice questions today, I came across a question that referred to the functions of the extra-ocular muscles. As I flipped through First Aid for the USMLE Step 1, I noticed that the section on extra-ocular muscles had been visited by me before:

Abduction:
Inferior oblique
Superior rectus
Inferior oblique
...

Apparently, I had reviewed this topic at various times and found varying results from different sources. I decided to end this once and for all with the med student's almost authoritative resource: Wikipedia. The page that came up was helpful, but Wikipedia posed more questions than it answered. Apparently, clinicians in the past believed that the obliques adducted, while anatomists begged to differ. Luckily, a reference to a British Medical Journal article resolved the issue: the anatomists won, the obliques abduct.

It is interesting to see how someone's mistake if inculcated enough can become dogma. Simply by looking at the muscles, as was pointed out to me, the actions are apparent. As the obliques attach on the temporal aspect of the orbit, when they contract, the orbit will rotate against the force around its axis. In other words, the eye will abduct. How clinicians missed this for apparently a long time is beyond me. However, the British have a theory:

Our final conclusions, and what is now our policy for instruction on this muscle, is as follows. The superior oblique, acting in isolation, turns the eye down and out. However, if it was tested clinically by the patient being asked to look down and out, its action could be mimicked by the combined action of inferior and lateral recti. This is particularly so as the inferior rectus acts most effectively when the eye is abducted (looking laterally). Thus if the patient is asked to look down and in, these muscles are excluded and the problem is solved. Essentially we are testing the ability of the superior oblique to look downwards.
The confusion, which I hope the above clarifies, is compounded by some ophthalmologists being so used to testing the muscle by asking the patient to look down and in that they have forgotten that the isolated action is down and out.

Ah ha! So it was the ophthalmologists' fault! Well, well. Mystery solved!

Updated 2015-12-08

Colas and Chronic Kidney Disease

Does drinking colas increase one's risk of chronic kidney disease (as compared to non-cola carbonated drinks)? According to this article, it does. A group from the NIH did a case-control study looking at about 500 patients with chronic kidney disease (CKD) compared to normal patients. They found that the odds ratio of having CKD if one drank more than two colas per day to be around 2, after controlling for other factors. However, the same effect was not found if subjects drank non-cola sodas (Sprite, I presume?).

Apparently, there was anecdotal evidence that this was the case prior to this study (see image at left). However, the summary of the paper left me with a few questions. First, I happen to like a carbonated cola drink myself, so perhaps I am biased, but this study merely links CKD to poor diet, rather than proving anything. If the researchers are serious about this, they should do a randomized, double-blind, placebo-controlled, yada-yada trial and prove that cola causes CKD. That is probably harder to do in practice, but still, it must be done for the results to really say anything.

Second, why is the NIH spending money on this? While CKD is an important cause of morbidity and mortality in this country, did we really need to spend this money proving that Coke is bad for people with kidney disease, most likely due to diabetes? I would hope CKD patients would know to abstain from such things (unless I guess if they are on dialysis, but that's another story). Since in an abstract sense federal funding is fungible, this money could have been better spent raising awareness about diabetes and CKD and improving diabetes education. Maybe I am wrong, but that is where the real need is.

CNN Wants Patients To Sue Doctors

The fine journalistic minds at CNN have produced this masterpiece article, entitled "Should I sue my doctor?" The article discusses one case in which a woman who was undergoing a hysterectomy had a complication (it appears one of her ureters were nicked). Now, I'm no surgeon but I believe this is a common complication of the procedure. And, as expected, the article explains as much. In fact, it is so common that even most lawyers the patient (a physician herself) went to see refused to take the case. Luckily, from the surgeon's point of view, the patient does not have much grounds to sue (I'm assuming the patient signed a consent and the doctor was not grossly negligent).

So what's the problem? The whole premise of the article, especially the title! Even though the entire story is an anecdote about when a patient should not sue their doctor, CNN perpetuates the notion that patients should be trigger-happy in filing suits against their doctors anytime everything does not go as expected. The article reinforces this notion with quotes like:

"The first question everyone I know asks is, 'Are you suing?'" says Christine. "My mother, my sister-law-law, my husband. My husband is on a rampage -- he's on the lawsuit bandwagon."
Christine, who's a physician herself and didn't want her last name used, was reluctant to sue. She didn't want a black mark against her doctor. "He's such a nice guy. He delivered my children," she says.

The thing that really gets me is that this patient is a physician herself! She should know better than anyone else the risks involved with the procedure and whether or not her doctor was truly negligent. "Christine" even states:

Christine says her doctor explained what he thought went wrong: When he was using a cauterizing tool, he must have nicked the ureter, the duct that carries urine from the kidneys to the bladder. "He really owned up to it," Christine says.

So, Christine believes the doctor took responsibility and then treated her appropriately. Then why the hell is she suing??? This just makes no sense. If doctors are going to sue other doctors, then what hope do physicians have from avoiding frivolous lawsuits from lay patients? The article does go on to note that in other countries, there are general compensation funds which assist patients who have had complications recover their costs without assigning culpability to physicians in cases where the mistakes are not due to negligence. We really should have a system like that here, but somehow a "social" solution in the US seems unlikely. Gasp! Social medicine! Perish the thought!

The Health Hazards of Blogging

Blogging is safe for your health, right? Well, apparently the stresses of blogging can lead to myocardial infarction. While GigaOm clearly has a lot more traffic than this humble little blog, should I be concerned? Oh my god, what if I don't post about what happened on rounds today??? Okay... breathe slowly... just breathe.... whew, that was scary.

Hm, I shouldn't make fun of a blogger's MI, but c'mon, it's a blog. If one is so panicked about not breaking some tech story that they're addicted to their inbox, and also smoking like a chimneystack, then perhaps they should write about a less stressful topic, like gardening or yoga or something. Just a thought...

Pimping On The Wards

Pimping on the wards is a common experience for most any medical student. I forget what I initially wanted to write this post about, but I was reminded of the contrived haphazard nature of pimping recently. My attending, who was well-intentioned I believe, was aware that I am taking USMLE Step 1 soon. At our previous meeting, he told me I should bring whatever book I was studying from as he wanted to glance at it (he's a foreign medical grad, I believe), so I obliged. After I had shadowed him, we went back to his office. I assumed he'd just ask me a few questions about how the day went and send me on my way. What I got instead was 30+ minutes of him flipping through First Aid for the USMLE Step 1 and asking me random questions while two other students looked on.

Thirty.

Straight.

Minutes.

Now, luckily I've been studying for a while and had a pretty good familiarity with First Aid, so I got most of the q's right (or at least, made some reasonable sounding comment). And, sure, I need to review and study. But... man, I can't imagine what would have happened if he had tried to do that 4 weeks ago. This episode (among others) leads me to wonder the real motivations behind pimping. Sure, people say it's for educational purposes. I agree that when done in a systematic, relevant manner, pimping serves this purpose. However, someone flipping through a book asking random q's is not that. Heck, the attending even said at the end that the session was like Jeopardy, which was a fairly apt description. So, here are what I think the 5 real reasons are:

5. Showing off - Just because someone has 10+ more years of education more than you and more than enough accolades doesn't mean they don't want you to know how much they know.

4. Schadenfreude - Trust the Germans to have a word like Schadenfreude. Part of me can't help but believe that some attendings experience a bit of joy at our squirming.

3. Insecurity - To be honest, I haven't had this be the case at all, but as this post and this NYTimes article note, it can be one reason why attendings pimp in some cases.

2. Tradition - They got pimped, so they feel "obligated" to pass along the "fun." Thanks. No really, thank you sir, may I have another?

1. Because they can - 'Nuff said.

Hm, I guess I sound more bitter than I really am. For the most part, I haven't had that many bad experiences being pimped, but I guess I just fail to see the point most times and would rather enage in an open discussion and have someone ask questions in a non-"put me on the spot" way and then explain concepts vs. just firing q's at me. Anyone have their own outrageous attending pimping experiences? Let's hear 'em!

Worried about being pimped on the wards? Check out:

Updated 2015-12-07

The Falling-Down Professions

As a recent piece in the NYTimes discussed, medicine is a falling-down profession, which I take to mean a profession that has seen better days. As the article notes:

As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had.

In a typical complaint, Dr. Yul Ejnes, 47, a general internist in Cranston, R.I., said he was recently forced by Medicare to fill out requisition forms for a wheelchair-bound patient who needed to replace balding tires. “I’m a doctor,” he said, “not Mr. Goodwrench.”

Sad, but true. As the brand of 'doctor' has been devalued over time, so has the morale within the profession. One thing that the article fails to mention though is the length of time needed to become a practicing MD. Any time people make a decision, especially a purchasing one, they are implicitly consider their 'return on investment,' or ROI. As students, we are purchasers of professional education, be it law or medical or business school. I don't know all the figures, but let's assume for the sake of argument that med school is $40k per year, law school $50k, and business school $60k. Now, to simplify this further, assume that people only consider the ROI as their first 5 years of employment. A lawyer invests $150k over 3 years, and typically will find a job starting around $100k, which translates into a ROI of roughly 233%. The b-school student invests $120k, probably gets about $100k coming out, for a ROI of roughly 316% over 5 years.

The med student? Pays out $160k, earns $40k per year for an avg of 5 years of residency. ROI? 25%.

25%!

Terrible when compared to 233% and 316%, no? Of course, these are averages of numbers I pulled out of the air and have no real application in reality. Still, they illustrate the general point. The morale in medicine will not improve until the ROI improves, no matter how benevolent we imagine ourselves to be.

The Consumer's Favorite Doctors?

Consumers visit "doctors" all the time while shopping. A funny post over on mental_floss discusses the medical backgrounds of these doctors, specifically Dr. Brown, Dr. Scholl, Dr. Martens and Dr Pepper. As one thinks about this type of branding, it reflects how America's attitudes towards physicians have changed over the past 100 years. At the turn of the century, doctors were seen as respectable members of society who were authorities on a wide range of subjects. The title 'doctor' had influence. The logic of marketing dictates that manufacturers would not have branded something "Doctor X's Tonic" or whatever unless the label "Doctor" added some value. Would you buy a drink called "Sergeant Pepper" (heh)? A shoe insert named "Commodore Scholl's"? I think not.

However, society today views physicians differently. Popular media shows physicians as on edge, as we often are. Or, perhaps worse, as being ditzes and sex-starved (um, as we often are?) People are skeptical of their doctor's advice, and often turn to the internet or other non-traditional sources for advice. Why the change?

It seems that the seeds of medicine's demise were sown in medicine's success. As one of my attendings on surgery mentioned, the advent of modern medicine changed people's expectations. His father had been a pediatrician prior to the days of vaccines. Many children would be stricken by diseases such as polio. Parents were fearful, and physicans often provided a calming presence, even if they could not provide any solutions. In some sad cases, patients would even die, but no one would blame the pediatrician, but rather in fact would sing his praises at the funeral.

Then, vaccines arrived. Over time, parents stopped seeing the crippling effects of diseases like polio, and rather were left to deal with crying babies and sore arms. Instead of seeing the physician as an authority, people (especially the kids) came to see the pediatrician as someone unduly inflicting pain. Over the decades, this has led to people even questioning the rationale behind vaccines. Of course, vaccines are not necessarily 100% safe, and physicians and parents should remain vigilant. However, this is not tantamount to rolling back decades of progress against diseases by arguing that vacccines are harmful.

Of course, the story is anecdotal, and only one part of the issue. The "evolution" of the American healthcare system, dramatic shifts in the structure of society, and increased consumer awareness have all served to tear down the pedestal upon which doctors once stood. While it may be beneficial for sodas and shoe inserts to have "doctors" tied their brand, physicians should be mindful of their own 'brand' and how it is perceived in the marketplace of society.

Jim Breuer Explains Alcohol and Its Effect on the Body

Everyone knows alcohol has many effects on the body. The short term effects of alcohol intoxication include poor judgment and coordination. Long term effects include liver damage, pancreatitis, and Wernicke-Korsakoff syndrome. However, learning all those metabolic pathways is painful. Where does NADH form? What does thiamine have to do with this? Are these Man Laws? It's all too much to take in.

However, now, thanks to the miracle of the interweb, SNL alum "Professor" Jim Breuer explains it all about alcohol:

If only this was all I had to know about alcoholism for medical school... if only...

Why I Am Scared of Ob/Gyn

I am scared of my Ob/Gyn rotation. I'll admit my view is not well-informed and based mostly on hearsay. However, everyone seems to work long hours, and be on edge. Several people have independently mentioned bad experiences they've had with particular residents. I'm not saying everything about Ob/Gyn is bad, but.... well, there's a reason why I scheduled it for after residency applications have been submitted.

Still, sometimes I ponder whether I was not giving Ob/Gyn a fair shake. I'm not sure I could ever be interested in gynecology, but there was a time that I toyed with the idea of obstetrics (chalk it up to one too many episodes of "The Cosby Show"...). However, the final nail in the coffin was this clip from "Knocked Up" (NSFW):

Okay, so I shouldn't take my career decision cues from Knocked Up, but the fact that this scene even works as humor must mean it has some basis in reality? Anyway, shalom!

Updated 2015-12-07

Vikas Bhushan and Tao Le, Cont.

In a previous post, the crack investigative team over here at Scrub Notes looked into the seedy underbelly of the First Aid machine. Finding not very much, we moved on to more fertile fields. However, as a commenter has noted, the bios in First Aid itself do shed some light on the goings-on of the duo. In the interest of full disclosure, here is the entire bio for Dr. Bhushan from the 2006 edition of First Aid [my comments in this color and links added]:

Vikas is an author, editor, entrepreneur, and roaming teleradiologist [heh, seems like he lists the occupations in order of importance to him!] who divides his days between Los Angeles [!], Maui [!!], and balmy remote locales [!!! oo, more mystery] with abundant bandwidth. In 1992 he conceived and authored the original First Aid for the USMLE Step 1, and in 1998 he originated and coauthored the Underground Clinical Vignettes series [shameless plug; also why are the vignettes 'underground'? More air of mystery, I guess]. His entrepreneurial adventures include a successful software company; a medical publishing enterprise (S2S); an e-learning company (Medsn); and, most recently, an ER teleradiology venture (24/7 radiology) [what company has this man not formed?]. His electic interests include medical informatics [is this really an 'interest'? especially compared with the rest?], independent film, humanism [Reeeally? Humanism? Isn't that kind of broad?], Urdu poetry, world music, South Asian diasporic culture, and avoiding a day job [Sigh, I can make all the comments I want, but this last bit is pretty frickin' cool]. He has also coproduced a music documentary on qawwali; coproduced and edited Shabash 2.0: The Hip Guide to All Things South Asian in North America (available at www.artwallah.org/shabash) [Shouldn't this be called First Aid for the Unhip South Asian?]; and is now completing a CD/book project on Sufi poetry translated into 4 languages. Vikas completed a bachelor's degree in biochemistry from the University of California, Berkeley; an MD with thesis from the University of California, San Francisco; and a radiology residency from the University of California, Los Angeles.

My commentary aside, it's clear that this man is living the high life. He sounds like that guy on those commercials:

Stay thirsty, my friends... Stay thirsty. Oh, Dr. Le's bio is there too, but I'll spare you. He's written some books, went to Yale, does research on asthma education at University of Louisville. Perhaps he's also a man of "eclectic" tastes, but we may never know...

Updated 2020-02-28

Robot Dating and STDs

Robot dating probably doesn't make too much sense on a med student blog, but as I was reading this post, I saw this clip from Futurama which showed a futuristic version of a health-ed video:

Haha, that clip just reminded me of those awkward sex-ed videos they used to show back in middle school. I guess I included it on this blog just because of the STD reference at the end ("Electro-gonorrhea: The Noisy Killer"). Don't buy that? Well, just keep in mind that I'm studying for the step, so... yea, this is part of my integrative studying. Um, yea, that's it.

Sadly though, if you think about it a little bit, roboprostitutes (prostitrons? call grids?) could become vectors for STDs. Oh, to remember the days when the only robot one had to worry about was the robotic Richard Simmons! Also, if this is the future, why are they still using VHS? Maybe it's just some inside joke on Futurama that I don't get... anyone know why?

Of Phimosis and France

I was reading a random Top 10 list about movies that were saved by historical inaccuracies, when I came across a little tidibt about King Louis XVI (the monarch who immediately preceded the French Revolution):

One of the conflicts in the film centers around Marie and Louis' (Jason Schwartzman) difficulty in producing an heir. In the movie, Louis is afraid of sex. In reality, Louis had phimosis, a condition in which the foreskin of the penis cannot be fully retracted. This was later fixed with an operation, and the couple did in fact conceive.

Ah, phimosis. One of those conditions that causes people of sound mind sadly to snicker just a little (hello, priapism). Having read a little history and been in a med school for a few years but never having heard of this, I decided to do a little investigating. However, being the lazy guy that I am, I entrusted my research to the good folks at Wikipedia. I thought the phimosis theory was strange enough, but the Wikipedia posits an even more outlandish theory:

The true cause of the couple's infertility is revealed in a letter written by Marie-Antoinette's brother, Joseph II, to another brother, Leopold II. Joseph in April 1777 visited Louis and Marie-Antoinette in France, and had a frank talk with both of them regarding sexual matters; from this, he discovered that the King slept with his wife for duty rather than pleasure. There was no problem with the King's sexual organs: Joseph wrote, "he has strong perfectly satisfactory erections", and "he sometimes has night-time emissions"; the problem was that when the King and Queen slept together, "he introduces the member, stays there without moving for about two minutes, withdraws without ejaculating but still erect, and bids goodnight...when he is inside and going at it...[ejaculation] never happens." In the Emperor's opinion, the pair were "two complete blunderers", who had nothing wrong with them aside from lack of sexual knowledge and desire (Lassonne had already opined in 1773 that the lack of consummation was down to "clumsiness and ignorance").^[11]

Joseph, it would appear, remedied the couple's ignorance during his 'talks' with the pair; by August, the marriage was finally consummated, and the pair had thanked him for his advice, to which they attributed the consummation.^[12]

So, Wikipedia, you're telling me this guy... not just any guy, but the KING OF FRANCE... had n idea how to use his... um... "royal sceptre" for over 5 years??? I couldn't believe it, so I decided to go to another source, the all-knowing PubMed. But, again, being lazy, I am just going to link to the first abstract I found. But, yea, this does not really answer anything, as I did not have access to the article, and the article is in French. Since I am too lazy to continue this investigation further, I will simply conclude that King Louis XVI had phimosis *AND* had no idea what to do with his phimotic (?) phallus. Mystery solved.

Dwarf Gigantism

I'm busy studying for the Step, which I'll be taking in February. As interesting as studying all day can be, I tend to take (frequent) study breaks. Here's a video I came across during one of those breaks:

Heh, a lil rough around the edges, but a funny idea. Poor dwarf giant... loved by no one, scorned by all. Sometimes I bet NBA guards feel that way. In real life, they're taller than almost everyone else (giants), yet on the court, they're the shortest people out there (dwarfs).

Teachers Vs. Professors

Med schools should hire actual teachers with actual training in how to teach. For that matter, colleges should too. It makes no sense to simply assume because someone is proficient in their field that they would necessarily be good at conveying that knowledge to other people, especially if they have received no formal training in how to teach. Maybe if professors were required to go through some basic training, they would be okay, but in many instances, I would prefer someone who knew less but was better able to convey that knowledge to me, instead of someone who knows a whole lot, but has no clue on how to communicate those ideas effectively. For more, let's turn check out some point/counterpoint action:

Teachers use instructional aids to guide learning and help students who learn through different modalities.
Professors put together 100+ slide powerpoints with 9-point font that they flip through at warpspeed with the assumption that if it was displayed, it was taught.

Teachers take the time to ensure that students understand key concepts, and explain the underlying mechanism in clear, concise ways.
Professors believe in the "Say it once, show it once, never mention it again til it shows up on 5 questions on the test" view.

Teachers add in interesting tidbits to make the lectures come alive, and also to aid students in remembering key facts.
Professors add in boring tidbits about their pet research projects to keep the class asleep, and also to torture students when these tidbits again show up on the test.

Teachers realize that if students are not understanding a concept, they should reconsider how it is being taught.
Professors believe that if students are not understanding a concept, then the students clearly have not being studying enough, and they should question the students' work ethic (true story).

Am I bitter? Perhaps a little bit. I guess I've just found that while studying at times, I'll come across a concept explained in a concise, easy-to-understand way, and I'll actually feel like a lot of things coming together, which is nice. However, it makes me wonder what I am paying the medical school for exactly, especially during the basic sciences. Perhaps I would have been better off investing in review books and studying those instead of wasting my time in lectures. Grr, stupid powerpoints.

Vikas Bhushan and Tao Le: Who Are The Authors Of First Aid For USMLE Step 1?

Given what I found out about Dale Dubin, I have started to become more curious about these people who write these 'amazing' review books. What makes them so qualified to tell me what to study and what not to? Who are they? What do they have to hide? Okay, fine, so most of them are just residents and physicians, but it's interesting to note that while some are leaders in their fields, others are just known solely due to their review books. I guess they just took really good notes back in med school.

At any rate, nearly everyone who takes Step I ends up using First Aid for the USMLE Step 1, and with good reason. The book is a concise, yet fairly thorough, review of most of the concepts covered on the test. We all read the book, but who wrote it? I have the 2006 edition, which lists 4 authors, but I'm most curious about the first two: Vikas Bhushan and Tao Le.

According to McGraw-Hill Australia:

Vikas Bhushan, MD is a practicing diagnostic radiologist based in Los Angeles, California. Tao T. Le, MD is Assistant Professor of Pediatrics, Division of Allergy and Clinical Immunology, Department of Pediatrics at University of Louisville; and Assistant Professor in Medicine, Division of Allergy and Clinical Immunology, Department of Medicine at Johns Hopkins University.

So, Dr. Bhushan is a radiologist. Cool. But really, is that the whole story? According to this pdf, Dr. Bhushan is also a "world-renowned author, publisher, [and] entrepreneur."

Vikas Bhushan, MD, is chief executive officer and cofounder of Medschool.com. Dr Bhushan is a worldrenowned author, publisher, entrepreneur, and board-certified diagnostic radiologist who resides in Los Angeles. Dr Bhushan conceived and authored the original First Aid for the US Medical Licensing Examination Step 1 in 1992, which, after 10 consecutive editions, has become the most popular medical review book in the world. Following this, he coauthored 3 additional First Aid books and led the development of the highly acclaimed 17-title Underground Clinical Vignettes series. He was an active researcher in medical informatics and digital radiology and completed his training in diagnostic radiology at the University of California. Over the course of his career, he has worked directly with dozens of medical school faculty members, colleagues, and consultants and corresponded with more than a thousand medical students from around the world. Dr. Bhushan earned his bachelor’s degree in biochemistry from the University of California, Berkeley, and his MD with thesis from the University of California, San Francisco.

Is it just me, or is every physician you ever hear about "world-renowned" in some way? But, I should give him props: apparently he has 200,000 books in print and has raised millions for in venture capital for his start-up companies. So, yea, props, Dr. B. Anyway, what about Dr. Le?

Apparently, he co-wrote First Aid while a resident at Yale. What is up with Yale being the place to go if you want your notes turned into review books? Shoo, if I were there, I'd just take meticulous notes for everything and then try to pimp them out to publishers. Get me on that med review book gravy train.

Alright, I guess I should be taking meticulous notees anyway, and I suppose this wasn't as interesting as an expose on Dale Dubin. I still have my doubts though. Obviously these guys have done well for themselves, but did they actually do well on the Step exams? Is this like the 270+ Club? C'mon, release your scores! The public demands it!

Updated 2015-12-07