Anyone who teaches medical students lately knows that they are constantly instructed and reviewed on their medical ethics. At the end, or even in the middle, of medical rotations the attending physician must fill out a form rating the student on the "Six Competencies" which are (to quote from the ACGME, the Accreditation Council for Graduate Medical Education):

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

These also apply to residents and fellows. In fact, the ACGME is actually the accrediting body for the residents and fellows, not for the medical students. But most medical student programs also borrow this framework.

Now let us turn to a real ethical case. Our medical student had just finished her first spinal tap and the resident was congratulating her on her success. After we had left the patient's room, the resident recalled a recent incident at another hospital in which she had helped a different medical student complete his first spinal tap. He also succeeded and the resident also said "Congratulations! You've done your first spinal tap." Unexpectedly, the patient became angry and upset. "You lied to me" said the patient. "You told me that you had done many of them."

I thought that this was a good opportunity to discuss a point of medical ethics. I asked our current student what she thought of the story about the other student. The current student, by the way, did not lie to the patient. When asked a similar question she said (more or less) "I have never actually done an entire tap myself, but I have participated in them." What did this mean? She had watched someone else do one the previous day and in pediatrics she had seen several performed on babies. She had also tried to do one on an artificial model. She said she was the only student in her group who failed to do it correctly (she didn't tell that to the patient). Fortunately, the patient did not probe her answer further.

When I opened the discussion, I thought our student would condemn lying to patients. After all, she had gotten a lot of recent ethical teaching in her classes and honesty is one of the things emphasized. Instead, she stated that she thought that what the other student did was probably OK and possibly necessary under the circumstances. Her reasoning was that if you don't lie to patients sometimes, you probably cannot do the things you need to do. I asked her if she felt that the ends justified the means. She answered that they probably do in such cases. We were a small group (myself, the resident and the student). So when one of the internal medical teams dropped by to ask a question about a case that had consulted us about, I put the issue to them. Their consensus seemed to be that lying to the patient was not really right, but it was one of those small wrongs that is often justified, especially if you need to do your first spinal tap or arterial line.
 
I do not claim that I have made a scientifically valid survey, but I found our discussion to be interesting. If I had asked the students and residents "Do you think the head of surgery should make his operative statistics totally available to his patients?" they probably would have answered "Of course." In fact, I have asked that question of students and I almost always get the answer that physicians must be totally honest. But possibly the head of surgery might point out that we are in a referral center. We get the difficult cases, so such statistics are not meaningful unless they are put in a certain framework. In other words, we need to manipulate the data a little bit so that the patient will form the correct opinion, i.e. the opinion that it is OK for the surgeon to do the operation. And, in a way, that's really all the students are saying. In other words, they are saying "I know that it sounds bad to have a spinal tap done by someone who has never done one, but it really isn't bad. I know that but you, the patient, don't know that because you do not know how the system works and I don't have time to fully explain it. So it is OK for me to change the statistics a little (i.e. from "none" to "some" "a few" "many" "lots" "all the time" whatever)  so that you form the right conclusion in your mind, i.e. the conclusion that I can do one on you." I think there is a huge element of self interest in how we interpret ethical guidelines. But we are all human.

I know that very few people read this blog at present, but if anyone would like to comment they can use the "guest book" on this page. I have not yet set up a forum or other more sophisticated feedback mechanism.

This isn't a technology site, but I was intrigued by a product I heard about on public radiio. It is called Evernote. I have not yet tried it. It appears to be a free software that allow one to enter all sorts of notes, pictures, doodles, text messages and whatever through a variety of interfaces. Then it uses something that works sort of like human memory to retrieve them for you.  The main hook to my interest was the idea that perhaps this works something like human memory. Could a simple interface for this be used to help patients in early stages (or even later stages) of dementia? Maybe someone could try this out and let me know how this product works. The link is at http://www.evernote.com/about/what_is_en/  (maybe Dr. Joseph Kim could evaluate on one of his medical technology sites, such as Mobile Health Computing listed on my blogroll).

Sorry I didn't give an online real time view of the meeting while I was there. But now that I have gotten back and have time to review my notes, I am going to post some new developments.

For a large number of migraine sufferers (myself included) and neurologists (again, myself included) the development of the triptans for acute migraine was something of a miracle.  But there are some migraines (and some migraineurs) that are not helped by these wonder drugs. That's why it is so encouraging that there are some fundamentally different medications coming down the pipeline.

Just to review, the triptans work by stimulating the 5-HT 1B/1D receptors.  Sumatriptan (imitrex) was the first one developed.  I use rizatriptan (Maxalt) for my own migraines.  Others include zolmitriptan (Zomig) (I prescribe this a lot at my VA hospital because it is the only triptan pill on the formulary), frovatriptan (Frova),  naratriptan (Amerge),  almotriptan (Axert), and eletriptan (Relpax).

Here are some new treatment mechanisms that are getting close to the stage at which actual drugs may soon be approved (say in a year or two):

CGRP (calcitonin gene-related peptide) Antagonists.  One of these, telcagepant, is actually in phase III trials right now.  That means it is very close to the end of the testing process (again, a year or two).

Vanilloid receptor antagonists. Some of the vanilloid receptors are located on the same neurons as are the CGRP receptors.  The vanilloid receptor antagonists seem to be less well studied and thus further from clinical readiness.

I do not have an in depth understanding of the mechanisms of either the CGRP or the Vanilloid receptors,  but, apparently, blocking either the CGRP or the vanilloid receptors antagonizes the dilation of blood vessels located on the dura (a membrane surrounding the brain) by interfering with the action of capsacin (which is independently known to be a pain inducing substance). So this seems to make sense. The extra good part of both the CGRP and the Vanilloid story is that neither of these appear to induce vasoconstriction, which is sometimes a problem with the triptans (but it seems to me that blocking dilation of the dural blood vessels is somewhat akin to vasoconstriction, but I guess it is not direct vasoconstriction).

There is also a new type of serotonin agonist being studied.  The new type activates the 1F receptors rather than the 1B and/or 1D receptors. The first prototype studied had too many side effects and was abandoned. But other such compounds are being developed.

Finally,  some scientists are working on drugs that block nitric oxide synthase. But work on these is not as far along as work on the others.  Frankly, I would think this could be dangerous because nitric oxide synthase is very beneficial. It is one of the good guys in helping to relieve cardiovascular and cerebrovascular constriction. I would be scared to block my nitric oxide synthase. But perhaps some smart person will find a safe way of doing it.

Here's a great educational site that I just found, the "Neurology4MRCP Teaching Website".  It's  put together by a British neurologist to help doctors review for the MRCP (Member of the Royal College of Physicians) examination in neurology. But it should also be quite useful for American physicians and those of other nations. The web address is http://neurology4mrcp.com/. You can find it under "General Neurology" in my list of links on the sidebar.

The medical blog whose link I had just recently posted, Ultramobile Health, by Dr. Joseph Kim, has been renamed. It is now called Mobile Health Computing. It has a somewhat spiffyer (spiffier?) format as well. But it is still about the same thing as before---various nifty little medically related gadgets that one can carry around.

I treat a lot of Veterans at the VA, and I have been struck by the remarkable number of them who are returning from Iraq and Afghanistan with headaches. In most cases these are headaches that they never had before deployment. In the patients I commonly see, the cause seems to be exposure to a blast. The blast rarely involves being hit in the head with an object and it is unusual for the patient to have lost consciousness.  Usually the source of the blast is an IED, an improvised explosive device, though it can be a bomb shot from a military weapon or some other type of explosion. I even thought of writing up some of the individual cases because some of them have very classic migraines that one rarely sees begin later in life.  For example, I commonly see 50 year old patients who never had a problem with headaches. Then they were merely exposed to blast at quite a distance (sometimes more than the length of a football field), shaken a bit, but not knocked unconcious or otherwise visibly affected by the explosion. And then they they started having headaches which are often very similar to those of established migraineurs who have had migraines starting in childhood and extending throughout their whole adult lives. 

This impression of mine has now been strongly supported by a presention at the AAN. Brett J Theeler, M.D., of the Madigan Army Medical Center and his co-workers studied the case histories of 1000 returning soldiers. They found that 98% of soldiers who had suffered any type of blast injury, including the mild ones that I mentioned above. developed some type of headache problem. Many were migraines. Others seemed more like chronic tension headaches.  

There is a lot more to be learned about the problems associated with traumatic brain injury, even the type that initially appears to be extremely mild. From my perspective, however, there is a bit of good news. I have found that most of these headaches are quite treatable. I have gotten good results with standard headache medications in most of the patients.  In some cases the underlying headache problem appears to be getting milder over time allowing me to taper down the levels of medication.