Posts tagged learning
A Rookie Cut
Over the past year, I have noticed a young man attending the barbershop I frequent. A tall and well-dressed adolescent who bared some resemblance to my barber, he initially started off with the scut work: sweeping the floor, greeting the customers, and watching. Always watching intently as my barber trimmed my hair.
Slowly, over time, he had begun to learn the tools of the trade - the different scissors and the brushes; the straight razor and the strop - and began to practice on the dummy heads.
Today, I went to the barbershop to find him cutting what must be his first set of heads full of hair. All the while, he was receiving pointers and tips from my barber, his father.
His eyes were focused, his body was tense, as he trimmed the weight from the man’s temple. Snip. Snip. As the locks fell to the floor, he re-examined his work. Was it too little? Was it too much?
“Remember to angle your brush up. It’ll give you more room to work with,” his father would say, and he would oblige and try again, with more angling of his left wrist. In the end, the older man seemed satisfied with the young man’s work. A sizeable tip came the trainee’s way, to which he hurriedly returned to the man.
“The cut is free. I’m still practicing.”
“You’re always going to be practicing. Besides, you’ve earned it. Keep the change.” The customer gathered himself and took his cane as he thanked the barber in training yet again. The young man was pleased.
“Next?” Of all the people waiting in the barbershop, no one took a second glance.
“Does your son know what he’s doing? I mean it’s a rookie cut,” came one snappy customer. No one moved. They wanted the expert, the experienced barber, the man who knew every bump under every patch of hair on their heads. They wanted his father. The brilliance of the man’s eyes that a moment ago seemed so alive, dulled. He put down the gown and reached for the broom.
“Sure, I’ll go,” I said, taking up his offer. He gave me a smile and motioned me to the chair. “Have a seat.”
I understood his plight. We were all in the same boat together. As learners, we depend on the good will of the people we see for us to gain experience, to be better, to become professionals. The process must start somewhere. It was time I returned this favour to another student.
“Caesar trim. Sides short. Front long,” his father called out.
“Hey.”
“Hello.”
“Thanks for giving me the opportunity.”
“No problem. We all have to start somewhere.”
The Zebra
“Tom, come take a look at this,” the attending beckons excitedly. I get up from the charting station and walk over to his computer.
A CT scan fills his screen with a very large, obvious abnormality. “This is one of the biggest I have seen in my career,” he says. The patient had developed not only a large mass but a rare one, causing all sorts of systemic anomalies. Given the extent, it would be inoperable.
As we proceed to the patient’s room, the doctor explains the clinical presentation of mass effect on the body. His eyes are wide and flicker with a fiery excitement. He can barely control the rate of his words as he gushes about the various pieces of the unique clinical puzzle in front of him.
“Are you excited?” he asks after he finishes. I reply that it is “interesting,” much to his displeasure. “How could you not be excited? You might not see this ever again in your life.”
But all I could think about was how this mass, this zebra on a CT scan would soon bring our patient to their untimely death.
Within, I watched the attending as he spoke to the patient and their family about the situation. He explained things with such professionalism, clarity and assurance that I could see no better way it could have gone.
Yet it continued to disturb me, his excitement in it all.
Joseph Addison, a poet said: “Everything that is new or uncommon raises a pleasure in the imagination, because it fills the soul with an agreeable surprise, gratifies its curiosity, and gives it an idea of which it was not before possessed.”
For my attending, who may have seen thousands upon thousands of patients with very similar presentations, this zebra case must have stirred up a renewed sense of adventure, a break from an otherwise regular routine of patients.
Perhaps, it is that hot flush of novelty, that infectious high of our peers that perpetuate our own behaviour.
Too often our fascinations show outwardly as our primary intent. In the process, we forget that the patient has a name, has a right to be treated with dignity, has an illness that still needs to be treated. In the process, we forget that the condition does not define the patient any more than he defines the condition.
It is a strange situation we find ourselves in, to be excited and captivated by our morbid curiosity; on some level, we must in order to learn and improve as clinicians; at the end of the day however, it must come at the expense of someone else’s health. For that, I must always consider the fine line that separates respectful and disrespectful learning.
“Pretty neat findings, eh?” He nudges me. I take a look back at the patient’s room. I watch as the family huddle in an emotional embrace as they come to terms with our news.
“Yeah. It is really interesting,” I mutter bleakly.
I remember one of the first students I was training here. He was a journalist. Was a journalist for nearly thirty years. He well could have been my father at his age!
But he was still learning.
This is a profession where even the old dogs learn new tricks, where the learning does not stop until the day you stop working.
The Only Correct Way...
- Dr. A: This is the way you should do this procedure for your final assessment. It is how it is written in your notes.
- Dr. B: Do not go by what is in your book. That is the classic method. There are better ways to do it.
- Dr. C: Why are you doing it that way? This is the best way to do it according to studies.
- Dr. D: I see you picked up some bad habits. And by "bad habits" I mean "not the way I do it." While you are with me do it this way.
- Dr. E: I ran into trouble before with the way you are doing it so I do not do that anymore.
- Dr. F: Do it however you like.
- Me: Brain cannot compute.
Vertebral Vasculature.
I once saw a patient come in with lower back pain without a history of recent traumas or injuries. The patient’s background history showed a continuing history of IV drug use. More recently, the patient had started injecting in his legs.
As would later be explained to me by the doctor, this clinical picture raises some red flags. The Batson venous plexus is a network of valveless veins connecting the deep pelvic veins and the thoracic veins to the internal vertebral venous plexus. Because of its valveless quality, the flow of blood through the plexus is slow and predisposes to cancer metastasis and bacterial seeding.
With IV drug use, the main worry is an epidural abscess related to a dirty needle. The patient presents with progressive back pain or radicular pain, fever and eventual neurological deficits in the affected spinal levels. The eventual complication that we are worried about is osteomyelitis or the erosion of the vertebrae themselves.
Countered
- Dr. A: You did great. These are the basic tests you should know for the knee exam. Now, tell me what other special tests can we do for the knee. Do you know any?
- Student: Um...I believe they mentioned you could possibly do a Dial test. Is that one you often do?
- Dr. A: A Dial test...What is that?
- Student: They said it could be used to assess for posterolateral instability? *While gesturing the technique*
- Dr. A: Hm...excuse me for a moment.
- Dr. A leaves the room and calls out for Dr. B.
- Dr. A: Dr. B! Do you know what a Dial test is?!
Multiple Myeloma makes you CRABby
The clinical features of multiple myeloma include:
- Hyper Calcemia
- Renal insufficiency
- Anemia
- Bony disease/lesions
Autoimmune Hemolytic Anemia
When erythrocyte membrane is coated with antibodies or complement proteins, an immune-mediated hemolysis can occur. These can generally be classified into two types, a warm antibody-mediated response by immunoglobulin G (IgG) or a cold antibody-mediated response by immunoglobulin (IgM), which operate optimally at different temperatures.
An IgG-mediated immune hemolysis is the classic autoimmune hemolytic anemia. The warm-type hemolysis can be due to lymphoproliferative disorders, drugs, idiopathic or associated with other autoimmune diseases. The patients will present as jaundiced, acutely anemic, fatigued, pale, and with possible splenomegaly. On blood smears, there can be a presence of increased reticulocytes, immature red blood cells as a result of compensation, and also spherocytes, brittle spherical erythrocytes as a result of decreased surface area of the red blood cell when IgG-sensitized portions of the membrane are removed by macrophages.
Spherocytes.
A cold-type IgM immune hemolysis is usually post infectious. These can include Epstein-Barr virus and Mycoplasma pneumoniae. As the name suggests, these antibodies bind maximally at colder temperatures and so present most often peripherally in the fingers and toes, enabling the binding of complement. As the blood circulates to the core and to warmer temperatures, the IgM dissociates, leaving complement attached. This is usually a self-limited and rarely severe enough to warrant more than supportive therapy.
The two types can be differentiated via a Coombs test, showing either the presence of human IgG or complement on the patient’s erythrocytes.
TAILS of Microcytic Anemia
A low mean corpuscular volume is a sign of microcytosis. When coupled with signs of reduced blood point to a microcytic anemia. Potential causes include:
- Thalassemia
- Anemia of chronic disease
- Iron deficiency
- Lead poisoning
- Sideroblastic anemia
Public Question: Techniques for Improving Focus
An anonymous reader asks:
Are there any proven techniques/methods to help increase concentration and focus? More particularly on schoolwork?
From my experience and my talks with a lot of my classmates, my feeling is that there is no one method that works for everyone. It really is a matter of trial and error finding what works best for you. I have had to change the way I study a number of times before I settled with what I do now. Everyone else I know studies differently as well be it flow charts, diagrams, or cue cards; to studying alone or in groups; to working with music or without music.
I have not heard of any technique that has a 100% proven track record to improving concentration and efficiency of studying but if someone does, feel free to comment below.
Other responses after the break…
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