*In my Sophia Petrillo from the TV show Golden Girls’ voice* “Picture it, Brooklyn, 2001 a young bright-eyed and bushy-tailed PA student born in Panama but raised in Brooklyn is about to start his first rotation, which happens to be surgery. He is excited to be finally out of the classroom with no windows and the grueling hours and hours (and hours) of lectures and endless torture (I mean examinations). He is also excited about the prospect of seeing all of the diseases he read about in the fables of Lange and Harrison’s. He is also petrified because he feels as if he is not quite prepared to be “out there" yet, so he calls on the powers of his senior class that is about to graduate to figure out what life vests he will need not to drown in the surgery sea. His senior tells him to buy the book “Surgical Recall" because he will be drilled by the surgeons and the more he answers right, the more he gets to participate in the operating room besides the dreaded retraction. He sprints to Barnes and Nobles to pick up the book Surgical Recall. To prepare for his first big case, he reads the OR schedule and finds out his preceptor is going to do a laparoscopic cholecystectomy. He wants in on the case, so he quickly pulls out surgical recall and learns all about the anatomy and procedure. The players of the surgical rounds consisted of him, 2 other PA students from another school on their 5th rotation, 3 medical students, 1 resident and the attending/preceptor. Anyone who has done surgery rotations know it can sometimes be the equivalent of army boot camp, so the “Surgeon General" begins to spit out questions about cholecystitis and the procedures and we are all trying to answer frantically to get into his good graces. They all give about an equal amount of right answers, all trying to get the “one up" on each other. The Surgeon general then tells the team the patient has a history of sarcoidosis and what is the management for it. Everyone was kind of stumped. As you can probably tell by now the bright-eyed bushy-tailed student was I. I remembered a mnemonic I used in didactic year to remember that the “S for sarcoid stands for steroids". I blurted out the answer “Corticosteroids", brimming with pride that the lowly PA student on his first rotation had the “one up" on the other PA students, the resident and the medical students. It was like the heavenly angels were singing a melodic chorus, the birds were chirping and cherubims were playing violins. This symphony came quickly to a screeching decrescendo when the attending turns to me and asks me “How do they work in Sarcoidosis?" I remembered the buzzwords but I didn’t remember how or why corticosteroids worked. Instead of complimenting me for being the only one who knew the right answer, the surgeon general yelled at me, the poor private PA student in front of everyone for 5 minutes (which felt like 5 lifetimes) saying “It makes no sense knowing something if you don’t understand it…etc etc" there were other expletives used (anyone who has ever gotten a verbal lashing during their surgical rotation will know exactly how that convo went). Sitting in the operating room retracting, it gave me a lot of time to decide that I never wanted to be yelled at again and I needed to learn how to understand the things I had learned better. There in the operating room gave birth to the concept of PATIENT-CENTERED LEARNING.
In the didactic year, most students survive by making up useful mnemonics, and cramming the information just to pass they myriad of exams that come at you like tidal waves while you are trying to swim out of the whirlpool of all day lectures. They cram, memorize and regurgitate the information and move onto the next test. They make it through the didactic year but then the clinical year poses a new, daunting challenge. Not only do you have to recall the information of the didactic year but also you have to now apply it clinically. This is where most PA students (often even the brightest ones in the class) have difficulties. Think of our brains as a computer and it will make total sense and then I will go into the PATIENT CENTERED LEARNING technique.
You don’t have to be a computer whizz to understand defragmentation, RAM and ROM
RAM: is our short-term memory, where information is crammed, stored temporarily and regurgitated. Most of us put the things we learn here. The problem with that is that although easier to access, the memory stored here is loss after the computer is turned off (meaning an after the exam or after that course).
ROM: is our long-term memory, where information is stored and retained. Ideally this is where we want most of the material to go because it leads to greater retention. This stays even after our computer is turned off (after an exam). What is not lost in RAM is then placed in ROM in many fragments and unrelated bits.
“DEFRAGGING OUR BRAIN". A computer has to go through the process of defragmentation to work faster and more efficiently. The process of “defragging" your computer physically organizes the massive amounts of information into smaller regions of knowledge blocks (fragmentations), arranging them in a sequence for faster access to the information. It “fine tunes" and reorganizes it. A lot of what we learn in the didactic year is learned in these fragments but then are stored all over the place.
To make it real for you, we learn hypertension in cardiac lectures, we learn about pulmonary hypertension in pulmonary, causes of secondary hypertension (such as Cushing’s syndrome, hyperaldosteronism and pheochromocytoma) in endocrinology. We learn about hypertensive emergencies in emergency medicine lectures, preeclampsia in OB/Gyn etc. But these are not learned at the same time, so we store them as individual fragments when we learn them, often not connecting the dots. Faced with this unique problem of having to reorganize the information for the clinical year, I had to figure out: how can I learn this information so I don’t have to receive any verbal lashings, pass the end of rotation exams, pass the PANCE, be able to an efficient practitioner and be able to explain the diseases to the patients so they feel more knowledgeable about their own diseases and retain as much information over the long haul. My technique “Patient-centered learning" combines all of that into one process so it’s an efficient way to learn. If these diseases are difficult for us to learn despite having the extensive training we went through, imagine how much harder it is for our patients to comprehend their diseases. I can’t tell you how many times in the emergency room I tell patients they have a fracture and then they make a sigh of relief and say to me ‘Ok. At least its not broken" and then when I tell them it is broken, their mouths drop until I explain to them it’s the same. So to help you and our patients, I will explain to you the patient centered learning concept in 3 easy steps:
PATIENT-CENTERED LEARNING 3 GOLDEN RULES:
- BREAK DOWN the disease first by explaining the disease (including the pathophysiology) IN YOUR OWN WORDS in one (maximum 2) sentences whenever possible. The sentence should be constructed as if you were explaining it to your patient for them to understand the disease. By breaking it down in your own words you are processing the information and relating it to your previous baseline of knowledge, which promotes retention. Make sure with this step that you understand the basic anatomy and physiology and pathophysiology pertaining to the disease as this is critical for this concept to work or else it is more memorization and less understanding. Remember that you want to limit rote memory and clogging up your RAM to more understanding to store it in your ROM.
- EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions of the medications pertaining to the diseases. Relate each of those things back to the sentence in rule 1. Relating it back one reinforces the sentence, your understanding and the connections between all the things about the disease to each other.
- CONNECT if possible to other disease with similar processes or the exact processes for comparison and contrast to allow the fragments to be grouped for easier access. Thus also helps you to understand medicine in a broader perspective and over a broad range of topics.
Now that you have the three golden rules I will give you two examples to drive the point home.
Example: Gastroesophageal reflux disease:
STEP 1: BREAK DOWN the disease first by explaining the disease (including the pathophysiology) IN YOUR OWN WORDS in one (maximum 2) sentences whenever possible.
If you have my book Pance Prep Pearls then I have pretty much already done the first step for most of the diseases in the book but if you don’t have the book, fear not. I can easily show you how to do it
Gastroesophageal reflux disease (GERD): decreased lower esophageal sphincter pressure due to relaxation, leading to reflux of the acidic contents of the stomach into the esophagus.
STEP 2: EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions pertaining to the diseases relating it back to the sentence in rule 1.
- heart burn (pyrosis) hallmark: burning sensation in the chest or upper abdomen due to reflux of acidic contents into the esophagus.
- Regurgitation & water brash: due to reflux of acidic contents into the mouth
- Cough especially worse at night: reflux of acid into the esophagus and mouth with aspiration of acidic contents stimulating the cough irritant receptors. This also explains the development of possible aspiration pneumonia and asthma-like symptoms (bronchospasms also limits further damage from acidic contents).
- Hoarseness: due to reflux of acidic contents causing inflammation of the vocal cords
- Esophagitis: due to reflux of the acidic contents into the esophagus, leading to inflammation.
- Esophageal stricture: the damage from the refluxed acid and chronic inflammation can lead to narrowing of the esophagus
- Barrett’s esophagus: the esophagus tries to compensate for the chronic exposure by the migration of gastric cells proximal esophagus. This chronic exposure can lead to metaplasia and eventually esophageal cancer.
- Adenocarcinoma of the esophagus: (see Barrett’s).
- Clinical diagnosis
- Endoscopy: used to evaluate persistent symptoms, look for complications listed above
- Esophageal manometry: used to see if lower esophageal pressure is present.
- Ambulatory pH monitoring: used to see if the pH lowers throughout the day (acid has a low pH). Currently the gold standard. Note all the diagnostic studies are still related to the original sentence you created.
- Lifestyle modifications: all used to reduce reflux and speed up GI transit (ex. elevation of the head of the bed, avoiding recumbency for 3 hours after eating, eating small meals, decrease fat and alcohol intake etc).
- H2 receptor blockers: reduces acid production by blocking histamine-induced gastric acid production
- Proton pump inhibitors: reduces acid secretion by blocking proton hydrogen ion release
- Nissen fundoplication: surgical procedure to reinforce the closing function of the lower esophageal sphincter.
Again note all the management is still related to the original statement.
For step 3, you can tie the information to Peptic Ulcer disease, another disease that may present with epigastric pain and that H2 blockers and proton pump inhibitors are used in that disease as well.
Now you see that with the one (or two) original sentences, the basics of GERD can be remembered easier because you tie it all to one or two sentences. Your brain can package and organize the information so that you can do less memorization/regurgitation and more retention because you tie all the details to a bigger picture as opposed to small tidbits of information.
Now let’s try one more to make sure you have the concept. Asthma
PATIENT CENTERED LEARNING 3 GOLDEN RULES:
STEP 1: BREAK DOWN the disease first by explaining the disease.
Asthma: reversible (1) hyperirritability of the airways, leading to (2) airway narrowing (bronchoconstriction) & (3) airway inflammation obstructing the movement of air out of the lungs.
STEP 2: EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions pertaining to the diseases relating back to the sentence in rule 1.
- Dyspnea: shortness of breath due to airway narrowing and inflammation increasing the work of breathing.
- Wheezing: sounds made as air moves through the narrowed airways. Also explains the chest tightness
- Cough: hyperirritability of the airways stimulates the cough irritant receptors.
- Peak flow meter: assesses the level of obstruction of the movement of air out of the lungs. Most objective noninvasive way to assess severity.
- Pulse oximetry: measures oxygenation and level of obstruction of airflow
- Metacholine challenge test: a test done to cause bronchoconstriction (you have to remember from basic physiology that acetylcholine/parasympathetic stimulation leads to bronchoconstriction and sympathetic stimulation leads to bronchodilation). This concept will also be helpful in understanding the medications. Metacholine is an acetylcholine-like drug.
- Pulmonary function test: gold standard to look for reversible
Remember the 3 components of the disease from the stem sentence:
Bronchodilators (addresses the bronchoconstriction)
- Beta 2 agonists (Ex albuterol): Beta-2 activation stimulates the sympathetic system, leading to bronchodilation of the lungs, increasing airflow. Side effects are due to sympathetic stimulation (including the beta 1 receptor of the heart) leading to palpitations tachycardia CNS stimulation.
- Anticholinergics (ipratropium/Atrovent): central acting bronchodilator that blocks acetylcholine-mediated bronchoconstriction. Acetylcholine activation causes increase bronchoconstriction, salivation, lacrimation, urination, digestion and pupillary constriction. Side effects are the opposite of those including: dry mouth, urinary retention, dry mouth, and exacerbation of glaucoma.
- Theophylline: bronchodilation
- IV magnesium: Magnesium antagonizes calcium-induced contraction of the muscles in the airway leading to bronchodilation.
Anti-inflammatories: addresses the inflammation and hyperirritability:
- Corticosteroids, mast cell inhibitors, leukotriene modifiers: inhibit inflammation at different levels
STEP 3: CONNECT if possible to other disease with similar processes. There are many connections that can be made from this but to give you an example:
Anticholinergic atrovent sounds like atropine (an anticholinergic used to increase the heart rate in bradycardia.
You can even connect it to glaucoma by remembering acute glaucoma can be exacerbated pupillary dilation, which is why anticholinergic drugs (that cause pupillary dilation) can exacerbate glaucoma and why cholinergic drugs (such as pilocarpine) can be used to treat glaucoma and Sjrogen’s syndrome (by increasing salivation).
You can also connect it to benign prostatic hypertrophy by realizing that anticholinergic can promote urinary retention in patients with BPH and can exacerbate the symptoms.
You can also connect anticholinergics to why they work in urge incontinence by decreasing bladder detrusor muscle contractions, improving the symptoms as well as why tricyclic antidepressants m ay also be used (due to their anticholinergic effects).
You can connect the magnesium sulfate used in asthma by remembering it is used in seizures, to treat torsades de pointes, ventricular tachycardia, and for tocolysis (anti-contraction to prevent premature birth). Why the same drug for these very different diseases??
Asthma: Magnesium antagonizes calcium-induced contraction of the muscles in the airway leading to bronchodilation.
Torsades de pointes and ventricular arrhythmias: antagonizes calcium-induced heart muscle contractions and blocks neurotransmission of cardiac neuromuscular impulses, prolonging conduction times and stabilizing cardiac membranes.
Eclampsia: blocks neuromuscular transmission producing anticonvulsant effects reducing the seizure potential as well.
Tocolytic: antagonizes calcium-induced uterine contractions, decreasing labor contractions, preventing premature labor.
Laxative: promotes osmotic retention of fluid in the colon, causing distention, leading to increased peristalsis and bowel evacuation.
Now you have tied that drug and how it works to cardiac, pulmonary, obstetrics, gynecology, neurology and gastrointestinal. So your brain can now make those stronger, more lasting connections.
You can use this technique for almost all medical diseases and the more you start to do it the faster that you will become at doing it. It takes a little while to get used to doing it this way but you will find that when you review it this way, you will retain more each time you review it. It is also helpful to use that one-liner (sometimes simplified) to explain the nature of the condition to your patient, why they develop certain side effects and symptoms. Which symptoms to look out for that are considered “alarm" symptoms. Why they are taking the medications you prescribe to them and some side effects they should look out for. This will make the patient feel empowered because they know more about their condition and things they can do to improve it and why they are doing it. You become a better clinician, you will pass your PANCE/PANRE, you will become more effective at communicating with your patients and increase their understanding and you will do less memorizing and more understanding and retention of the material. A win-win for all!!!
All my best
Dwayne A Williams