Learning Medicine

Learning Medicine
The Ultimate Guide to Study Skills in Medical School

Friday, October 8, 2010

We're almost, kinda, sorta geting to do some medicine - Part II

Morning all,

So on to part II - the exciting part of yesterday.

Duke, like its peer institutions, has incorporated a bit of Team-Based Learning (known as PBL at other schools). I believed, and still believe to an extent, that TBL is more of a pedigogical gimmick that some educational experts thought would be a nice diversion from that antiquated mode of teaching called..well, teaching. You know, with lectures, notes, homework, etc.

The people who plan our curriculum are high on TBL, probably as much for its novelty as its efficacy (which remains to be seen). I understand the idea behind TBL. Letting us work in group to try to solve problems will help us integrate the disparate bits of knowledge we've acquired, and it will should help us apply that information in the context of a team, which is the normal setting for the medical scene. All that sounds nice, but in practice, TBL has been more of a nuisance than an aid. It's time consuming, inefficient, and the experience is highly dependent on the quality of your teammates. Nevertheless, despite our initial resistance, I think TBL is beginning to grow on us, and to Duke's credit, I think that has a lot to do with the fact that the instructors have been willing to shape and reshape the TBL time based on our feedback and evaluations. They are responsive to our criticism.

I'm not averse to TBL so long as it stays at its current level of incorporation. What I mean by that is that we only get it for like 2-3 hours 1x a week or once every 2 weeks. That's just enough. Any more than that would be too much and would take away time from our lecture and study time. At some schools - even here at Duke in other programs - TBL has taken over to the point where all activities are team activities, even exams! Those poor DPT students have every exam in group format, so your performance is largely dependent on how prepared and engaged your teammates are. If you've got good teammates, well that's great. But if not, you're helplessly yoked to people you don't want to be yoked to and your performance is then tied to theirs. I hope Duke Med at least never gets the bright idea to do that.

So on to the first really good TBL.

As I mentioned in part I, we've learned about the heart and skin in the last few weeks, and this TBL session worked off of that.

For our group application, we were given some information about a patient. Now, we've only been in med school for eight week, so how should we even begin to diagnose a disease? What the hell do we know? Well, as I learned yesterday, more than we think.

We were given information about the patient.
- She had skin lesions, wooly hair and thick skin on her her palms and heels.
- A histo slide of her skin showed abnormal layers, namely, a separation between the stratum spinosum and granulosom.
- A cross section of her right ventricle showed fat where there wasn't supposed to be fat - in her myocardium.
- We also were given an EKG that had abnormalities such as a right shifted axis and an inverted T wave.

Given this information, we were then tasked with figuring out what her disease was. I'd venture to say that a month ago we wouldn't have the foggiest idea where to start. But today, it all came together. We reason that from the appearance of her skin slide, there was a problem with the junctions - desmosomes to be precise - between the spinosum and granulosom layers. A desmosome defect could likely be a global problem, we surmised, to then we thought, how could this be connected to her heart? The fat in her myocardium suggested that the myocardium was somehow not constructed the right way - it was loose, allowing fat cells to make their way in between the muscle.

Knowing that intercalated discs hold cardiomyocytes together, and also knowing that IDs contain desmosomes, we made the connection. OK, so it's desmosomes and some clinical symptoms. Now what?

Thank God for the internet. My teammates did some quick sleuthing and came up with a disease that exactly matches the symptoms: Arryythmogenic Right Ventricular Displasia.

From Wikipedia:

Arrhythmogenic right ventricular dysplasia (AVRD), also called arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), is an inherited heart disease.

AVRD is caused by genetic defects of the parts of heart muscle (also called myocardium or cardiac muscle) known as desmosomes, areas on the surface of heart muscle cells which link the cells together. The desmosomes are composed of several proteins, and many of those proteins can have harmful mutations.

The disease is a type of nonischemic cardiomyopathy that involves primarily the right ventricle. It is characterized by hypokinetic areas involving the free wall of the right ventricle, with fibrofatty replacement of the right ventricular myocardium, with associated arrhythmias originating in the right ventricle.

AVRD is often found in association with diffuse palmoplantar keratoderma, and woolly hair, because their genes are nearby and often inherited together

This is a pretty wild disease, and for the patients who suffer from it, deadly. Nevertheless, as medical students, we can't help finding things like this super interesting, even if its effects are so bad.

By the end of this TBL I realized what we had done. We were given a few pieces of information about a patient. We went step by step through each piece of data and made conclusions about those data. Then we integrated it all, as a team, and came up with a potential diagnosis. One person went to the lecture notes, another searched the scientific literature, another went to Robbins. We deliberated, disagreed but then convinced each other that we were right. Not bad for eight weeks into med school! Admittedly, the instructors picked something they knew we could figure out, and they gave us lots of information that a clinician might not always have. But still, we kinda, sorta, almost did what doctors do. It was encouraging to say the least and got me more excited to learn what's coming in the remaining 10 months of Duke Med bootcamp.

Anyway, I'm sure I'll have more positive experiences to report in the future, so stay tuned.

This weekend my MSTPers and I will be going on our annual retreat. We'll be staying at a beach resort in Wrightsvill Beach, NC. Good food, free resort, some beaching, mingling, lots of science, good times. Who said medical school was hard? : )

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