Neurology, week 7

The theme of the week was psychosis and the PBL case centered on schizophrenia. Schizophrenia literally translated from Greek means “split mind” and is a diagnosis which describes a mental illness characterized by disorganized thought processes, delusions and hallucinations. I’ve simplified it greatly but even from the few symptoms I’ve listed one can see how this might have a significant impact on social behavior. The class was lucky enough to have a speaker come in and talk about their personal experience with schizophrenia and the problems they faced as a long time sufferer. Of the points that she touched on the one that I thought was the most interesting was when she talked about how real the hallucinations and delusions were to her. I have seen this before with other patients – the mind has an incredible ability to rationalize the most irrational idea or thought. So – even though the though processes are disorganized and the individual delusional, on some level the rational brain is still working and seems to be trying to make sense of what is happening.

I find understanding the illness from the patient point of view perhaps one of the most helpful things that I can do at this point in my schooling. The more I am capable of putting myself in a patient’s shoes the better I am able to come up with strategies that will work in their case. Having a speaker attend class that had actually suffered from schizophrenia was a great way for me to gain a better understanding, as is reading case studies or seeing examples of other suffers. One such example that I have come across in other classes is that of Louis Wain and his cat paintings.

The case of Louis Wain is interesting because he was an artist who developed schizophrenia much later in life. The story goes that Louis Wain was a London artist born in 1860 who drew cats initially to amuse his wife while she was sick with cancer. His cat sketches and paintings were quite popular at the time and he apparently published collections of his work as well as illustrated calendars, etc. When Louis was 57 he developed schizophrenia from which he never recovered and was eventually institutionalized for. Supposedly, during the remainder of his life he continued to draw cats but in an increasingly erratic fashion (see pictures above) up until his death in 1939. His drawings are often cited as a way to gain insight into the disease process and the delusional state of Louis Wain’s mind. However, this may or may not be true …

The pictures and the idea that Louis Wain may have illustrated them during his disease may in fact be a myth. In an excellent article on the Mind Hacks blog (found here), the idea is present that the erratic cat pictures may be simply artist experimentation have nothing to do with Wain’s psychosis at all. In fact, later works by Wain were not as abstract and were much more conventional in nature. Regardless, current theories on schizophrenia seem to suggest that there are physical changes to brain prior to the onset of the disease. So in reality Louis Wain may have been painting for many years with the underlying disease present. The question could really be – how long did Wain suffer from schizophrenia before it was actually recognized and what did his work look like during that time? It may not be as dramatic but it could be interesting to see…

For more of Louis Wains art check out the Chris Beetles Gallery (here)

The Model of a Psychopharmacologist

“The Model of a Psychopharmacologist” was created by Stephen M Stahl, MD, PhD, of the Neurosciences Education Institute, who is an adjunct Professor of Psychiatry at the University of California San Diego, and the author of Essential Psychopharmacology. The video seemed fitting for this week as we are officially out of neurology and into psychiatric illness. There is no better way to celebrate than with a little Gilbert and Sullivan…Enjoy!

Neurology, week 6

This week was chronically painful…I mean covered chronic pain. To give the class an idea of what a patient suffering from chronic pain would feel, we were exposed to a PBL session guaranteed to induce a long bout of head banging. It wasn’t all bad – the lectures were, for the most part, pretty good, with the possible exception of the case wrap-up on Friday. It has sapped my strength to write because it’s left me with little positive to say.

One of the lecturers this week said something which summed up medical school:

The time allotted to a topic in medical school is inversely proportional to how often you will actually see it in practice.

The case in point was a 2 hour lecture on headaches and migraines this week…which is apparently all the class time I will get on the topic.

Aside from a pile of homework, I need to rank my choices for the rural practice lottery which closes Sunday. I figure there are two strategies to ranking the choices – one where you go for the true rural experience and the other where you go for practical experience. The “true rural experience” option would hopefully place me in the middle of nowhere with the advantage being that it would give me the most realistic idea of what it would be like to be a rural doctor. As an added bonus there are some pretty cool areas which would be fun to visit, and it could be the more memorable of the two options. The second approach is that I rank my choices according what I feel will give me the most “hands on” experience. In this case, I would rank the locations which are close to primary care centers the highest with the hopes of getting some decent practical experience before third year. I think I am leaning toward the “practical experience option” in order to brush up on some basic skills and gain some confidence for the wards in third year. I should know the results of the rural placement by Friday next week.

Neurology, week 5

Our Sherman’s march through the brain continues as we cover the aspects of consciousness and unconsciousness. Although impossible to ‘define’ consciousness adequately, we did collectively fight the good fight and covered the anatomical components of consciousness as well as the mechanisms that cause unconsciousness. This week also begins our first foray into relating physical brain structure with behavior.

Of course – when one begins to talk about the physical brain and behaviors associated with certain areas, the story pf Phineas Gage is inevitably told. I have heard it a couple of times before in other classes. The story goes, that sometime in 1848, one Phineas P. Gage was working with a construction crew working on the railroad outside of a small town in Vermont. While Phineas was tamping down some gunpowder, the powder exploded and blew the tamping rod through Phineas’ head (see picture). Phineas survived the blast and the massive injury to his head with loss of vision in one eye and some facial paralysis…as well as some facial disfigurement, which I suppose was not completely unexpected (again – if you haven’t already, look at the picture). What was unexpected was the massive change in Phineas’ personality. Where he had been hard-working, responsible and cordial he was now “fitful, irreverent, indulging at times in the grossest profanity“. The doctor examining Phineas during this time noted:

In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage

Supposedly this is the first time there was actual evidence that suggested that damage to the frontal lobes could alter aspects of personality and social behavior. Whether this is true or not, I don’t know but it must have been quite interesting for the early neurologists to be able to relate physical damage in a specific area of the brain to an alteration of outward behavior.

Phineas aside there are a number of school related things that are beginning to gather steam. The first of which is the rural placement, which I have talked about previously (here) and the second is the choosing of the third year rotations. Both of these are “big” medical school choices although truthfully neither really is, as both will be decided by a lottery at the end of the day…at least the illusion of choice is there. I am really looking forward to to the rural placement and clerkship year right now, because the classroom learning is becoming too routine and tedious in its own way. A change would definitely be nice!

Valentine’s Day

Check out the latest from the masters of illustration at Street Anatomy, a true selection of art and treats for your Valentine including these “bleeding heart” cupcakes.

To the two or three people that click on this site on a regular basis, will you be my Valentine?

of coffee and caffeine

Caffeine – good bad, ugly – I don’t know. All I know is that without that cuppa joe or two in the morning I am dysfunctional (see graph). I admit, it is a bit of a guessing game as I try and maximize the level of caffeine while trying to avoid the neurotic jittery feeling that follows an overdose. Luckily the good folks at Developing Intelligence have taken the time to describe how to get optimally wired. A must read if you are a coffee addict gourmand, like myself.

Neurology, week 4

As I sit down to write this I realized that the week passed in a blur. It’s week 5 of 19 in this long semester, and the end of my first PBL group of 2008. I think I’m going to miss the group as it was one of the most laid back, fun to be with groups I have had since the beginning of medical school. The next group has some intense personalities which may or may not be problematic – I guess I’ll see. Unfortunately, it is most often the personalities of either the tutor or your peers that make the PBL process more painful than it needs to be. For example, I remember being in one particular group where there was an individual who wanted to debate whether or not we should bring food on Fridays! Good grief! Food on Fridays is one of the few things I actually look forward to, and usually people are into bring food to share at the Friday sessions. It’s simply one of the few decent social interactions there are in PBL, and this wanker person had (for whatever reason) taken issue with it. Needless to say the rest of the 5 weeks of PBL (that is 3x a week for a total of 15 sessions altogether) went as smooth as sandpaper. I digress here – there’s a new PBL group starting next week, and I hope it’s as good as the one I left.

The material we cover this week involved strokes. It’s interesting stuff and aside from a couple of lectures that were horrible, I thought everything went well. Perhaps one of the highlights was a talk by Dr. Klein and his wife, Bonnie, who had previously suffered a stroke. They covered what it was like to navigate the Canadian medical system when Mrs. Klein first suffered from her stroke and the problems they encountered as they moved from the acute episode to recovery. On numerous occasions if it hadn’t been for Dr. Klein’s advocacy for his wife she most likely would have died, or at the least suffered needlessly. It is truly eye opening to see the power that people possess when it comes to determining their outcome in the medical system, and it is frightening to think that someone who was less connected or less well versed in Canadian medicine could have had a completely different outcome.

At the end of the talk I was left with the question: Was it the system, or the circumstances of Mrs. Klein’s case that lead to difficulties? Even after hearing them speak, I’m still not sure. Mrs. Klein suffered from a stroke which resulted in a “locked in” syndrome, a condition where she was aware and awake, but could not move or communicate due to complete paralysis. It is hard (no doubt) to treat and in her particular case it was only after a experimental type of surgery that she started to show improvement. Her condition even though it was hard to treat, certainly wasn’t helped by the fact that she moved through a number of different hospitals and had to deal with a number of different “experts” which at times hindered her recovery. This is where Dr. Klein helped the most, and in each instance was able to overcome the (sometimes large) obstacles which impeded his wife’s care. The Klein’s were a fantastic way to end the week, and we (as a class) were very privileged to have them speak to us today.

To read more on the circumstances surrounding Dr. Klein and Bonnie, read the article (here) published in the CMAJ (Don’t worry it’s a short article (3 pages) and interesting). If you want more information on Bonnie’s story she published a book about it called: Slow Dance: A story of stroke, love and disability. It’s a good story with a happy ending.

Neurology, week 3

A month has passed since the start of second semester, and it’s hard to believe that time passes so quickly. I am, like the majority of the class (I think), feeling a little behind in my homework and will probably spend the bulk of the weekend trying to catch-up on the various readings, lectures, labs and quizzes. I don’t know exactly what it is about this time of the year but there is a strange feeling that seems to be be pervasive, or at least present in those that I talk to. It could be that people still haven’t quite found the rhythm for the second semester, or perhaps they’re still worn down from the Christmas exams, I don’t know. Whatever the reason, the class seems to be overly stressed with the material, especially given where we are in the semester, but lack the motivation to really buckle down and get things under control. The reason why this is I’ll never know, and truthfully I can’t really begin to capture the mood in the class right now, but what I do know is that it feels a little “off” and different from the first semester.

The material we covered this week involved the brain stem, with the PBL case centering on a patient with Multiple Sclerosis. Interesting stuff, but there is a certain lack of understanding when it comes to the pathophysiology of the disease. Throughout the week our PBL group was prompted to play out scenarios where we informed the patient of her diagnosis, or answered questions as whether or not her life would be “over”. I always find these “playacting” sessions kind of funny. I suppose I shouldn’t, but it is so artificial and so forced that it’s hard to make it sound anything less than ridiculous, especially with something like MS. MS is one of those diseases that is hard for someone like me, who has never been exposed to it, to really understand how hard it will affect a patient’s life.

On a positive note we’re beginning to ramp up to year three. This means that there are information sessions starting next week, which will eventually give way to us choosing our third year rotations as well as rural practice sites. The selection process is more like a lottery, so the appearance of choice is only illusionary. Still it gives me something to look forward to. The book learning (lectures with class) has been wearing me down lately and I am looking forward to the change that the clinical years will bring.