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Wednesday, April 25, 2012

Done! Maintenance of Certification for the American Board of Internal Medicine

Today I took my boards, for the first time since 1989. It wasn't bad. I can't write anything substantial about the content because I swore on a stack of Harrison's Text Books of Internal Medicine that I would not, "copy, reproduce, adapt, disclose, solicit, use, review, consult or transmit ABIM examinations, in whole or in part, before or after taking my examination, by any means now known or hearafter invented."  Also, I "further acknowledge that disclosure of any other use of ABIM examination content constitutes professional misconduct and may expose me to criminal as well as civil liability." My lips are sealed.

I scheduled the test through the ABIM site on the computer and had to travel about 2 hours to get to a testing office since I don't live near a big city. The test began at 8 AM, and was limited to 6 hours to answer 3 blocks of questions and about an hour and a half of break time that could be taken between these blocks. The office had about 12 cubicle style desks and was quiet and warm enough that I didn't need a jacket. Jackets were discouraged since they were very serious about making sure that we didn't have any electronic devices or notes with us. We even had to remove watches, turn out pockets and show the proctors that we didn't have contraband in our socks. Really. We were videotaped and observed by the proctor as we worked. The testing was done on a computer and a tutorial was available before the test and online from home. The format was not difficult and didn't require any typing skills. It was possible to finish each block of questions well within the allotted time, even though I was pretty sleep deprived. I took both of my breaks, but not for the full amount of time. I brought food, which was a very good idea since getting up early and being nervous makes me really hungry. It was also kosher to look up answers to questions during break, though we weren't allowed to change any answers after leaving the desk. Each block of questions seemed to be similar, no change in themes as far as I could tell. After completing a block we could review and change answers before electronically sealing them in stone.

After the test there was a little survey about what we thought of the whole thing. I pretty much "strongly agreed" with statements about how the testing site was just fine and the staff was helpful, but was unable to strongly agree that the test questions were relevant to practice. I actually did enjoy taking the test and found that the game of multiple choice was as much fun as it ever was, a logic puzzle crossed with a trivia game with obvious questions thrown in for variety. But most of the questions were about hypothetical patients who were very sick but weren't morbidly obese, didn't have more than 2 or 3 chronic medical problems and took a maximum of 5 medications. These are not the very sick patients we see in practice. The other thing that was unrealistic was the fact that we didn't have access to our computers and cell phones which are the way that we make sure we do our jobs right. Good doctors know where to go for the right information and don't depend on their limited cranial capacity to keep track of medication interactions and treatment regimens and  the difference between proximal and distal renal tubular acidosis. I recognize that an open book format would be difficult to incorporate into a standardized testing situation, but that would be a test that would be really useful to prepare for.

I hope I passed. I think I passed but I won't find out for something like 3 months. The human/digital interface works in mysterious ways.

Saturday, April 21, 2012

WHAT?!? (Update in Neurology)

In the year 1986 I loved neurology so much that I arranged to spend 3 months in England watching the most godlike neurologists on earth practice their art at the National Hospital for Neurological Diseases in Queen's Square, London. People came from all over the world to be diagnosed by grand old men (there may have been women but I didn't see them) of nearly magical prowess who also taught medical students. They knew what people had, mostly by talking to them and watching them, doing neurological examinations, and less importantly by doing blood tests and imaging procedures. I was a sponge and would have gone into Neurology as a specialty except that the rest of medicine was also really interesting.

Now I am reading the MKSAP booklet on neurology as I continue to study for my internal medicine board exam, 90 pages of digested and compacted information about the brain in health and disease, treatments, recommendations for evaluation of symptoms, and although I have been practicing medicine and treating all kinds of neurological diseases, or so I thought, the whole field looks nearly entirely unrecognizable. Wow.

Dementia, for instance. I have been treating dementia nearly constantly for the over 20 years I have practiced. I mentally categorized dementia into Alzheimer's disease which comprised most of the elderly and forgetful patients, and strokes, also called multi-infarct dementia, and then "other weird things" which had names like frontotemporal dementia, Huntington's disease, normal pressure hydrocephalus and things I might have to look up, though they definitely weren't treatable. It turns out they still aren't treatable, at least not very effectively, unless the person is forgetful due to some deficiency or something, but now you definitely DO want to get a CT scan or MRI (dogma used to be that imaging was only for cases that looked atypical) and that you don't want to check for neurosyphilis (which we used to do all the time though the tests were never positive, maybe because of where I practiced.)  And the classification is different.  The weird things are still weird, but there is a classification called frontotemporal lobar disease (FTLD) that includes progressive non-fluent aphasia and semantic dementia, both of which involve primarily word finding issues, as well as frontotemporal dementia which involves prominent personality changes and odd behaviors.

Now for headaches. I have treated headaches forever, kept reading about treatments, had them mentally categorized as migraines, cluster headaches, muscle tension headaches and other weird stuff, with the largest category being muscle tension headaches. Wrong, apparently. 90% of significant headaches are considered to be migraine type headaches and the pain can be in the sinuses, the neck, forehead, or one side of the face, which was the default location according to my ancient and now apparently defunct wisdom. They are usually associated with sensitivity to light and sound, can have nausea and have some sort of aura or neurological symptom that precedes the headache (I already knew that.) Cluster headaches are just one of 3 types of headaches that are categorized as Trigeminal Autonomic Cephalgias, which also include Paroxysmal Hemicrania (sharp stabbing brief head pain, 15 times a day or more) and Short Lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT.) I thought that cluster headaches were treated with migraine medicines and prevention with verapimil and sometimes responded to oxygen. That's true, apparently, but they also respond to a course of oral corticosteroids in conjunction with an occipital injection of topical anesthetic and cortisone, which I have only used for what I thought of as occipital neuralgia, which was supposed to be an inflamed nerve in the back of the head, but is disturbingly missing from the syllabus! The weird stuff is reassuringly about the same as it used to be, things like spinal headaches, pseudotumor cerebri, analgesic associated headaches and thunderclap headaches which sometimes presage subarachnoid hemorrhage and need to be aggressively evaluated.

The treatments for migraine have changed a little bit, though I have been following this pretty well because of having to use these medications on my patients in primary care. There are a few surprises, though. Prevention with medications for seizure disorders, especially lamotrigine and topiramate, are familiar to me and is the use of various blood pressure medication. I had heard that the herbal medication feverfew was effective, but the syllabus only mentions butterbur (Petasites Hybridus) in the herbal category, but does so with none of the usual lack of enthusiasm that most herbals get.

Much of this syllabus is no different than what I thought I already knew, but here is a list of the things that I wouldn't have believed as recently as yesterday:
1. Hypothyroidism and celiac disease can cause ataxia. Celiac disease can also cause neuropathy.
2. 10% of patients with frontotemporal dementia will have ALS or the other way around. I always thought patients with ALS had no cognitive problems.
3. CT scan is recommended in anyone with a head injury whose headache lasts longer than 72 hours.
4. Botulinum toxin injections are used for treating benign essential tremor of the head.
5. The vocal cords can spasm causing a person to be unable to speak in certain circumstances and the treatment is botulinum toxin injection into the muscles controlling vocal cord contraction.
6. The most common cause of Guillain-Barre syndrome is an intestinal infection with Campylobacter Jejuni and patients can get dysautonomia including cardiac rhythm disturbances and constipation.

How much of this will I remember, I wonder, and how much of it will be true in another 10 years?

Friday, April 6, 2012

Still studying for the American Board of Internal Medicine Maintenance of Certification Exam: what's wrong with this picture?

Really nothing is wrong with still studying. I'm still enjoying it and absorbing some non-negligible percentage of what I'm reading. There is just a tremendous amount of stuff that has become commonly held truth since I last took this exam.

But as I study, which is still following the general form of reading a multiple choice question from the MKSAP (American College of Physicians Medical Knowledge Self Assessment Program) then reviewing various sources on anything that I don't feel totally confident about, some of the patient vignettes demonstrate a lack of attention to the big picture.

The multiple choice questions are all case presentations, which is good since it keeps me engaged. Here are a few of the more disturbing ones out of the hematology/oncology section which I am working on now, reworded, simplified beyond recognition.

1. A 70 year old severely demented man, living at home with his wife, very thin, presents in bad shape with respiratory failure and pneumonia. He is admitted to the intensive care unit, given antibiotics and IV fluids and supported on a ventilator. He is able to breathe on his own, ventilator is removed, wife decides he should go to a nursing home, he develops bruising and bleeding. The diagnosis? Vitamin K deficiency, not too hard to guess given the lab values and setting. But...pneumonia is "the old man's friend." Why didn't they have a discussion with their primary care doctor before he was put on the ventilator about the prognosis of severe dementia with malnutrition, and then maybe he wouldn't have had to die in a nursing home?

2. A 60 year old woman with a history of a smoldering bone marrow disease has 2 weeks of fatigue and bruising, presents to the emergency room. Her white count is high, platelets low, she has a fever. Her blood smear is shown, myeloblasts with Auer rods, diagnosis is acute myeloid leukemia. She also has some infection, as yet unidentified. But...why is she in the emergency room? She would have to wait hours, probably, surrounded with sick people from whom she could get even more infections, feeling lousy, and then see an ER doctor who didn't take the internal medicine board preparation course, and might potentially even miss the diagnosis. Certainly she has a primary care doctor and an oncologist somewhere who could coordinate her care. ER care is way more expensive than office care but is becoming sort of a standard for dealing with unplanned medical needs.

3. A healthy 59 year old woman without risk factors for a deep venous thrombosis (blood clot in the leg) presents the the ER with a swollen leg, but not terribly swollen and in a pattern that is more suggestive of an injury than a clot. Clearly the big worry is whether she has a blood clot. She could have any of a number of expensive imaging procedures, they suggest, or a relatively simple blood test called the D dimer which, if negative, effectively removes worry that she has a clot in the leg. But...D dimers are often false positive for various reasons, and doing a simple bedside ultrasound, which the ER doctor could do if the ultrasound tech wasn't right there, and could really do it for free since it takes 10 minutes or less, could get her reassured and out of there in next to no time. Most ER doctors don't know how to do this, but it would take them about an hour to learn. It wasn't one of the multiple choice options.

4. A 48 year old man presents with a swollen leg after a long trip somewhere. His ultrasound did show a blood clot, requiring anticoagulation. How long does he need to stay on expensive, injectible anticoagulation before he can transition to pills for 3-6 months? 5 days, of course. That's the way it has been forever, still is, related to how quickly the pills (warfarin is standard) take to actually work to prevent further clotting. But...in the last 6 months there have been 2 articles demonstrating that rivaroxaban (Xarelto), a new oral anticoagulant which works within minutes or hours rather than days, can effectively replace the injectible anticoagulant and the warfarin, which would mean that any but the most disabled or unstable patient could get a prescription and go home. Probably even go back to work, depending on what work was. This drug is expensive, but absolutely nothing compared to a day in the hospital. Plus rivaroxaban requires no blood test monitoring. How long will it take us to change? It will probably be pretty quick since the new drug has powerful Janssen pharmaceuticals as its champion. Maybe a year. Maybe longer.