A friend of mine recently asked me about my stance regarding the use of cognitive enhancers (neuroenhancers) to improve job performance. The motivation behind neuroenhancement use lies in the hope that they help increase productivity through heightened concentration. The caveat is that these drugs are intended to treat attention-deficit disorder (ADHD), narcolepsy, and other medical illnesses. The New Yorker has a thorough overview of the topic, and Slashdot has a colorful thread expounding the opinions of the geek community.

Amphetamine (Adderall; Barr Labs) and methylphenidate (Ritalin; Novartis) are two of the drugs frequently mentioned in neuroenhancement. The physiologic properties of these medications have an interesting history. In ophthalmology, amphetamine is classically used for localization of Horner’s syndrome. When present in the synaptic junction of two neurons, amphetamine induces release of neurotransmitters, effectively activating the circuit. Interestingly enough, cocaine (stimulant), also acts in the synaptic junction by preventing reuptake of the neurotransmitters; this effectively prolongs the effect of neurotransmission.

In theory, increased neurotransmission may translate into improved concentration, as those with ADHD require to function. Its effect on a high-functioning Ivy-league economics major who has an essay to finish is more debatable. While individuals have reported increased productivity through stimulant use, we suspect that there may be a graded response depending on the initial amount of neurotransmitter present. Simply put, if you were high-functioning to begin with, these medications may not work for you. Furthermore, these medications indirectly result in activation of your neurotransmitter receptors to increase conduction. Long-term use may result in tachyphylaxis, due to the desensitization of the receptors. You may need more drug to achieve the same affect for subsequent uses.

Anjan Chatterjee, a neurologist a UPenn, has written about both the clinical outcomes and ethical ramifications of “cosmetic neurology”. His recent paper in Psychopharmacology detailed a study on the impact of Adderall on creativity. The preliminary data is inconclusive, although he suspects that the baseline capabilities of the individual clearly influences the efficacy (or detriment) of the medication on cognitive function.

The side-effect profile of these drugs consists of a grab bag of systemic involvement that includes the cardiovascular,  neurological, and most other body systems. While the majority of its users experience little to no side effects, the fact that we cannot control which neurons are affected by the drug is quite disturbing. Given that neurotransmission is enhanced, stereotyped actions such as tics and blepharospasms are potentially accentuated. Assuming that the target audience of cosmetic neurology are high-strung overachievers who may already suffer from tics when under stress, this combination does not bode well.

With all medical issues aside, the ethical use of neurostimulants is questionable. Some have argued that these medicines are akin to private tutoring–they enable us to achieve our potential. Are anabolic steroids equivalent to weight training? I hope not. This is doping. At best, they “might” enable us to retrieve information we already have in our brains through alternate (not necessarily faster) means. Neuroenhancement cannot be banned either; it would be technically impossible. As Margaret Talbot quotes in her article, “[it's hard to imagine a university administration that would require students to pee in a cup before they get their blue books]“. More data is needed to evaluate the classes and efficacy of neurostimulants before we can make a ruling.

Until then, you may do just as well trying absinthe to spur your creativity.

medicine medicine, pharma

Occasionally I dabble on the piano. One of my ambitions is to advance my limited piano abilities, although over the past few years (and next decade) it’s become difficult to fit the piano in my schedule. Those of you who are musicians will probably agree that after a certain level, the time commitment required to improve becomes exponential (unless you’re a wunderkind). Today I recorded the theme to Schubert’s Impromptu in Bb, Opus 142, No. 3. The work is written in a theme and variation format. It is a melodic piece with limited/no virtuoso runs, suitable for my digital piano. Recorded on a Casio CDP-100 using a pass-through cable to my IBM Thinkpad T42 laptop. Software recording with Audacity, and mp3 encoded using LAME. No editing involved.

misc hobbies, life

I went to the local botanical gardens over the weekend. Overall, it was an impressive array of plant and animal life. I did see a rustic feeding pond populated with ugly catfish:

As all catfish are, these were ravenous. I remember that Bear Grylls once caught a 50 lb catfish in the Everglades by simply putting his arm in the water (The catfish tried to eat him). These fish, however, were not nearly as big but similarly intimidating in the algae-infested pond. Some kids were feeding them Goldfish crackers. Oh the irony…

misc humor, life

I’ve seen many hilarious signs, but this is the first wet floor sign I’ve seen with a stickman having fingers but no toes or feet. He has FIVE fingers, mind you (not the usual four in cartoons).

misc humor, life

Several months ago, I posted Alfred Padilla’s Venn Diagram as a fool-proof means for medical students to decide upon a specialty. I remember how difficult for me to decide upon a specialty–it took me years. It’s been yet another match day cycle and graduation year with newly annointed M.D.’s. Despite the joyous faces of the new grads, I can’t stop wondering how many of us actually made informed decisions in our careers. Given the structure of most medical schools, the majority of our decisions are based on limited exposure to a field. Some medical schools condense the preclinical curriculum to one year (Duke) or 18 months (Baylor), but the majority of them remain at two years.

Two years of textbook education is absolutely unnecessary for medicine. We need early exposure to the hospital with a breadth of specialists. Many of us have no exposure to the surgical subspecialities (urology, otolaryngology, ophthalmology, orthopedics, neurosurgery,anesthesiology) or even medical subspecialties (dermatology, cardiology…etc) before we decide on 4th year electives. The even more obscure fields are shunned (nuclear medicine, rehab, radiation oncology).

If we receive so little exposure to these fields, how do we ultimately decide on them? My theory is that we already have preconceived notions of the field long before medical school. Some of us worked on medical projects in college, and simply decided to pursue a career in that field.

“Chuck wanted to be a neurosurgeon when he applied for medical school because he liked brains.”

“Tony wanted to be a doctor, but he didn’t like to work hard. He chose specialties that he thought had a good lifestyle and/or residency.” Ophthalmology? He’ll be in for a BIG surprise. Dermatology? Tony never knew that dermatology clinic had 40 patients a day (vs 10 for his internal medicine counterparts).

Tony may end up being a miserable doctor. If he had known about Rehabilitation medicine, he may have chosen it. This is an extreme example, but the consequence of choosing a specialty unsuited to you can be disastrous. If Chuck hated neurosurgery after 6 months into residency, he still has 6.5 years to go. He could quit, and his department will hate him forever because now they will have to find a replacement.

The solution? It’s already in the works. Many medical schools like UCSF have preceptorships during the preclinical years to expose students to professional offices. For those of you without formal preceptorships, you can always contact community physicians for help. Your dean’s office will likely have a list of alumni in the area who may be interested in having a student around. Use your hospital. Volunteer for transplant surgery trips. You will be pleasantly surprised what you find.

For those of you who are too lazy or meek to seek (bad pun) out your career path, you can still use my Venn diagram. It is amazing.

medicine humor, medicine