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.

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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

The hospital can be disorientating, to both the patients and its workers. We commonly witness ICU psychosis, a form of delirium that the elderly frequently spiral into while being in the intensive care unit. Several factors contribute to this state, with sensory deprivation being a common culprit. Sensory overload from the multitude of pumps, monitors, and alarms also lend to the confusion.

Unfortunately psychosis isn’t limited to the elderly. Patients of all ages “misbehave”, especially at night. Combine some pathology with an Axis II diagnosis, and you will have a perfect combination of pain. Last evening, I was called to reason with a young woman with lupus who was admitted for renal failure (likely nephritis). She had just undergone a renal biopsy earlier in the day, and we were also slugging her with steroids. She demanded to be discharged. She also had a record of noncompliance with medical advice. When I saw her, it was obvious that she lacked insight to her disease. She had already signed a hospital waiver stating that she understood that she may die if she left the hospital. I attempted to review the consequences of premature departure from the hospital, which included death. She nodded to me, and walked out. Por qué los pacientes castigarme?

Soon afterward, a patient going through alcoholic withdrawal demanded to leave, citing noise. I convinced him to stay by transferring him to a private room and giving him earplugs. Two hours later, he became combative and required sedation.

We have every reason to be confused in the hospital. After a handful of encounters with crazy patients and staff, I became disoriented as well. With GOMERS screeching on 6A (elderly care unit), fluorescent lighting, and wall clocks that permanently read “9:25″, we have every reason to be confused. Every time I walked by the frozen clocks, I had to glance at my pager to reassure myself that time had not stopped. I made every effort to glance out an unshaded window every few hours, even only to gaze at the starlight to reorient myself.

When I step back into the shoes of a layperson, I am always amazed at the tolerance of physicians. After a decade of training and torture in a caste system, perhaps doctors do deserve a fancy house or a fast car. The irony? When I walk out into the parking lot, it’s the nursing staff who have the Beamers, Infiniti’s, and big SUV’s. The physician’s lot is populated with an occasional splurge, but the majority of them are station wagons with car seats, Hondas, Camry’s, and family cars.

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Unless you’ve been hiding in a bubble over the last few years, you’ve probably heard of Electronic Medical Records (EMR), or Electronic Health Records (EHR). Some of you may even have experience working with these systems. Dozens of companies have invested millions into computerizing health records with the notion that digital information will remedy the healthcare system’s multitude of problems. These software frontends have evolved into impressively complex applications, ranging from Visual EMRs to BrainLab’s Digital Lightbox touchscreen interfaces.

One of the concerns with electronic data of any form is security. When the security of health information is involved, we cringe–there is an intangible queasiness to having your health records disseminated to the world. The feeling is worse than having your credit card information stolen. No matter the number of bits we throw into our encryption schemes, health policy pundits will always claim that our data can be hacked.

Well, how secure are paper records? If a file room goes up in flame, that’s the end of it. No backup. No recovery. What about theft? That simply involves old-fashioned robbery. No fancy hacking required. The irony is that paper records ARE secure, because of their inherent flaw that EMRs are designed to eliminate–penmanship.

Physicians have horrible penmanship. There are always exceptions, but the stereotype holds true in most cases. I recently spent 2 weeks at a primary care physician’s office. Making any sense of the chart records was simply impossible to an outsider. Lab results? If they’re not correctly placed under the “LABWORK” tab, good luck finding it. Progress notes? I barely advanced past the date. I was able to interpret a few of the cryptic scribble, like “RRR” (heart exam reveals regular rate and rhythm), but only because I am familiar with the jargon.

Take the image above. To a layperson, the scribble writes, “AFTER…”? To a medical professional, that looks like a medication dosing. Ceftriaxone? Ceftin? Ceftibuten? Who knows. To the skilled medical professional, we can work backwards to guess which medication we usually dose at “1 gram IV”.

Poor penmanship is the security system for paper records. Good luck reading any of the record. In fact, we might not even have a record for our VIPs. The data is all in our heads. Your health information is safe with your doctor. That is, until your doctor becomes senile.

computing, medicine humor, medicine, tech

The U.S. experienced two influenza pandemics prior to the current scare–one in 1918, and another in 1976. All three of these were of the same strain, H1N1. The avian flu that hit Asia a few years ago was of type H5N1. Influenza kills thousands yearly, mostly targeting the very young and old. This can be described as a U-shaped mortality curve. Why, then, are we concerned about this swine flu if the run-of-the-mill flu kills thousands anyway?

The mortality curve of this swine flu is shaped more like a “W”. Young adults appear to be targeted as well. Why not hammer out a swine flu vaccine and immunize everyone? Well, one is being developed, with hopes of also being incorporated in the influenza vaccine in the fall. There is also historical concern for mass vaccination.

In 1976, the death of an army soldier in Fort Dix, NJ from swine flu triggered panic. Gerald Ford issued a mass immunization program, and 40 million people were immunized by the end of the season. The problem? One in every thousand people innoculated with the swine vaccine developed Guillian-Barre Syndrome (GBS), a neuropathy that is typically defined by ascending paralysis. About thirty people died from GBS related to vaccination. There was only one recorded fatality from the 1976 swine flu. The lesson learned? While in retropect the vaccination program may have been more harmful than helpful, it’s unclear whether this overreaction actually staved off a potential epidemic.

So far, it appears that the swine flu has been less virulent than we anticipated, but we will have to see…

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