Friday, March 24, 2017

Medical School Seeks To Make Training More Compassionate

After the SUICIDE of a 4th Year Medical Student, a Medical School is seeking to change its training culture

A New York City medical school has embarked on a soul-searching campaign of culture change after a 27-year-old student there jumped to her death last summer from her eighth-floor dorm residence.

“Rocked by waves of anguish, anger and frustration, guilt, fear and profound sadness,” the Icahn School of Medicine at Mount Sinai is trying to forge a kinder, gentler system of training, according to an essay by a dean at the school​in the New England Journal of Medicine.

The school is considering significantly expanding access to mental-health specialists, as well as changing aspects of its grading system. Another idea on the table: creating a hub for activities related to student health and well-being.

“Medical school is a cauldron,” says David Muller, the school’s dean for medical education, and the author of the essay that promises to improve conditions for Sinai’s doctors-in-training, both students and residents. The residents are at the front lines of care, Dr. Muller added in an interview, and “feel very often helpless and hopeless, the machine is intense and churns on relentlessly.”

One morning in August, the fourth-year medical student took her life on Mount Sinai’s campus on New York’s Upper East Side. Several months earlier, a medical resident, also female, committed suicide at the school’s West Side campus.

Jordyn Feingold, a first-year medical student, lived next door to the woman who committed suicide in August. Ms. Feingold had arrived at Sinai only 10 days before the tragedy and recalled how she and her peers were racked by “cognitive dissonance”—excited about starting training but distraught at the tragedy. “It was very weird,” she said.

Ms. Feingold, who is 24 and has a master’s in applied positive psychology, joined a task force Dr. Muller charged with figuring out how to improve Sinai’s academic culture and doctors’ well-being. “We are so focused on taking care of patients, to give quality care, but absent from our education is how we can take care of ourselves,” she said.

In 2014, two other young doctors-in-training at two different New York-area medical schools committed suicide. “We are all in the same very, very, scary boat,” Dr. Muller said.

The deaths underscore a broader problem, researchers say: That young doctors and medical students face grueling academic pressures and are experiencing high rates of burnout, depression and psychological strain.

But it isn’t because individuals drawn to medicine are necessarily more prone to angst. “We found at admission that the kids look fine,” says Liselotte Dyrbye, professor of medicine at Mayo Clinic in Rochester, Minn. “It is as if they go through our training process, and they develop worsening mental health.”

Dr. Dyrbye blames this on an “absurd” medical system: “It is the curriculum, it is the learning environment, it is the type of stuff you do as a [young] physician, and it is not unique to Mayo, it is not unique to Sinai.”

The Mayo researcher, who studies physician well-being, says in addition to mastering vast amounts of information, medical students and residents cope with “complex patient interactions, the suffering, the deaths.” Too often, “it is not a supportive environment—students are set up to compete with each other.”

Arthur Caplan, a bioethicist at the NYU School of Medicine, describes physician burnout as “a kind of epidemic” that can also hurt patients.

“There is trouble for patients in having a work force that is burned out,” he said in a video on the medical-information website Medscape, noting that these physicians may have “compassion fatigue” and could be prone to making medical errors.

It isn’t clear what drove Kathryn Stascavage—the student referred to as “Kathryn” in the New England Journal essay—to suicide, nor what role the pressures of medical school may have played.Through Dr. Muller’s office, the family declined to comment.

Even so, Prameet Singh, vice chair of psychiatry at Mount Sinai’s West Side campus, says the tragedy “gives us a chance to pause and look at what is the matter with our medical system—what do we do to contribute to the stresses and tribulations.”

Dr. Singh, along with about 30 faculty members, medical students, fellows and residents, took part in the task force, and proposed steps to remedy the academic culture. They were split into three areas—mental health, physician well-being and the learning environment.

Dr. Singh’s group, which focused on mental health, grappled with making it easier to consult a therapist. That meant both removing the stigma of psychiatric care, and arranging access to affordable practitioners, since many don’t accept insurance. One proposal calls for making more therapists in the institution available to students. Another idea: identifying 15 to 20 therapists willing to lower their fees for students. The school also would like to ask students to have regular mental-health checkups, with an “opt-out” possibility if they don’t wish to have them.

Jonathan Ripp, an internist on the faculty of the Icahn School who co-chaired the working group on well-being, believes young doctors and trainees are suffering because medicine has changed dramatically.

“There are a lot of new pressures and physicians are being scrutinized more than before,” Dr. Ripp says. An older generation “could spend most of the time looking at the patient and speaking with the patient,” whereas now, “you have 15 minutes to see someone.”

Dr. Ripp’s group suggests dedicating space on campus to a clearinghouse where young doctors and students could avail themselves of a “menu of well-being”—such as finding a psychiatrist or signing up for a mindfulness training session.

His group wants “protected dedicated time” built into the schedules of medical students and trainees, to allow them to take a break, meet with peers, and review stressful incidents such as the death of a patient. “Until now, it was expected you would deal with it,” Dr. Ripp said, “but it is not normal to experience a death and go about your business.”

Dr. Muller is most concerned about the academic culture: “I said to the group, we can have an army of psychiatrists, and have mindfulness and yoga every day, but if we don’t change the fundamental culture of academic medicine, all we will do is produce more burned-out people.”

Sinai tackled one source of angst—a high-stakes grading system marked by quotas for third- and fourth-year students that limited “honors,” a coveted distinction that helps an individual enter residency programs—to 25% of the class. After “honors,” the “high pass” distinction was limited to 25%, while the remaining half of the class would receive a “pass” grade. The system provoked intense rivalry among students, Ms. Feingold says.

The school has rejiggered the distribution to allow one-third of students to receive “honors,” one-third “high pass” and one-third “pass,” Dean Muller said, with an eye to creating a system that will drop the limits altogether.

Dr. Muller is hopeful the tragedy will accelerate change: “The same kind of compassion and humanism we are teaching them to show patients, they should be showing each other and we should be showing them.”

Source:     WSJ

Wednesday, March 22, 2017

Doctors Say: Deadly Spider Venom Could Ward Off Stroke Brain Damage

Ingredient in funnel web spider venom can protect cells from being destroyed by a stroke, even when given hours after the event, study shows

Doctors have stumbled on an unlikely source for a drug to ward off brain damage caused by strokes: the venom of one of the deadliest spiders in the world.

A bite from an Australian funnel web spider can kill a human in 15 minutes, but a harmless ingredient found in the venom of one species can protect brain cells from being destroyed by a stroke, even when given hours after the event, scientists say.

If the compound fares well in human trials, it could become the first drug that doctors have to protect against the devastating loss of neurons that strokes can cause.

Researchers discovered the protective molecule by chance as they sequenced the DNA of toxins in the venom of the Darling Downs funnel web spider (Hadronyche infensa) that lives in Queensland and New South Wales.

Venom from three spiders was gathered for the study after scientists trapped and “milked exhaustively” three spiders on Orchid beach, about 400km north of Brisbane.

The molecule, called Hi1a, stood out because it looked like two copies of another brain cell-protecting chemical stitched together. It was so intriguing that scientists decided to synthesise the compound and test its powers. “It proved to be even more potent,” said Glenn King at the University of Queensland’s centre for pain research.

Strokes occur when blood flow to the brain is interrupted and the brain is starved of oxygen. About 85% of strokes are caused by blockages in blood vessels in the brain, with the rest due to bleeds when vessels rupture. Approximately six million people a year die from stroke, making it the second largest cause of death worldwide after heart attacks.

When a stroke happens, the oxygen level in the brain drops. This forces the brain to burn its primary fuel, glucose, very differently. Instead of oxidising glucose for energy, the brain switches to a process called anaerobic glycolysis. The reaction releases energy to keep the brain working, but it also produces acid, which can cause brain cells to die.

In a series of studies on rats, King showed that a single small dose of the spider venom molecule protected neurons from induced strokes. The compound works by blocking what are called ion channels in cells, specifically those that respond to the onset of acidic conditions in the brain.

Reporting in the journal, Proceedings of the National Academy of Sciences, King describes how administering Hi1a two hours after stroke reduced the extent of brain damage in rats by 80%. But the compound was still effective eight hours after stroke, reducing the amount of brain damage by about 65% when compared with untreated animals.

Rats that had the compound recovered far better than those that went without. “The untreated rats performed very badly after stroke. Their neurological and motor performance were terrible,” said King. But treatment with Hi1a “almost restored these functions to normal,” he added.

The researchers hope to start human trials of the compound in the next two years, but have more experiments to perform first. These will test whether the molecule works in all cases of stroke and is safe to use when blood vessels rupture in the brain, rather than become blocked. In the latest study, the compound was infused directly into the brain, but the scientists have found since that nasal deliver works too.

If trials show that the compound works, it could potentially transform the treatment of stroke patients. There are no drugs on the market that can protect the brain from stroke injuries. The best hospitals can offer are infusions of clot-busting drugs if a clot is to blame, or a surgical procedure called endovascular thrombectomy, which physically pulls the clot from the brain

Before doctors can administer clot-busting drugs, they must confirm with a brain scan that the stroke was caused by a blockage. This is because the treatment thins the blood and could make matters worse if the stroke was caused by a haemorrhage.

If Hi1a is found to be safe for people who have had with brain bleeds, it could be given to patients as soon as they reach a doctor. 

“The drug could be given in the ambulance to most stroke patients before hospital arrival, maximising the number of neurons that can be saved,” said King. “This should diminish the mortality from stroke and provide much better outcomes for those that survive as more brain function will be retained.”
Kate Holmes at the Stroke Association, said it was unknown whether Hi1a could be an effective treatment in humans. “We welcome any treatment that has the potential to reduce the damage caused by stroke, particularly if this can benefit people who are unable to arrive at hospital quickly,” she added. “Current treatments must be given in half this time period and it is too early for us to know if this research can offer an alternative for stroke patients. 

“We urge for stroke to be treated as an emergency. The sooner a person can get to hospital after a stroke, the sooner the right treatment can be received which can improve survival and help recovery,” she said.

Source:     The Guardian

Monday, March 20, 2017

Diagramatic Representation Of Bacterial Infections