A Parable For Our Times

Posted on December 1, 2025 by marylbrandt

Sometime in the early1900s a surgeon performed colectomy for a patient who suffered from schizophrenia. Post-operatively, not only was the patient’s colonic pathology cured, but it appeared that their schizophrenia was as well.

Not too long after, another surgeon noted the same thing… he had operated on a patient with schizophrenia who was less psychotic after removal of part of their colon. These two anecdotes became a theory… which led to a large number of schizophrenic patients undergoing removal of their (healthy) colons.

This doesn’t make sense, right? Except that it turns out that major trauma (like a big operation in the early 1900s!) can lead to a temporary relief of psychosis in some patients with schizophrenia. In other words, it probably would have been just as effective – and just as temporary – to induce a high fever…which was also a form of treatment for schizophrenia in the early 1900s. (Ebaugh et al., 1938)

There’s a parable here, one that helps us navigate dangerous, unproven theories that are proposed by (usually) well-meaning people …

Portrait of Baynard Holmes in 1889, from Wikipedia

In the early 1900s there were many well-respected physicians who thought schizophrenia was caused by “autointoxication”.¹ Baynard Holmes, Professor of Surgical Pathology and Bacteriology at the College of Physicians and Surgeons in Chicago, was one of them. His foray into the surgical treatment of schizophrenia was personal; His son Ralph had his first psychotic break as a second-year medical student. Holmes abandoned his other academic work to concentrate on “curing” schizophrenia. He first published a paper showing that schizophrenic patients had delayed transit in the colon and hypothesized that stool “stuck” in the cecum was therefore the cause of schizophrenia.(Holmes, 1920)

Holmes operated on 22 patients, creating an appendicostomy to flush the stool out of the colon.(Noll, 2006) There was a 10% mortality rate… and one of the 2 patients who died was his son, Ralph.(Davidson, 2016)

Henry A. Cotton, Sr, was another authority who promoted, and took advantage of, the autointoxication theory of schizophrenia. He was a psychiatrist who oversaw, and then performed (!), colectomies on over 200 patients with schizophrenia. He reported a success rate of over 80%…. and a mortality rate of 25-30%.(Davidson, 2016)

In 1923, a group of physicians did what needed to be done from the beginning – a randomized controlled trial. Not surprisingly, there was no difference in outcome between patients treated with surgery and those who did not have surgery.(Kopeloff & Kirby, 1923)

It took a long time for these dangerous operations to stop, despite the proof that they didn’t work. We can only imagine how many hundreds of patients underwent this futile and very dangerous procedure before it was finally abandoned. In today’s world of rapidly available communication it takes 17 years for new evidence to change clinical practice. (Morris et al., 2011) We can assume that in 1924 it took longer than that. In addition, there were physicians (like Henry Cotton) who ignored this new data and continued to remove healthy colons from schizophrenic patients because they personally benefitted from doing the operation, either financially or because of their reputation. (Davidson, 2016)

So what “instructive lesson or principle” does this parable illustrate?

You may add to this list, but I think we can start with these…

We can be blinded by our desire to end suffering (especially if it’s someone we love)
As human beings, our desire to heal can limit our ability to be objective about outcomes… which is why we have clinical trials (and the scientific method).
And finally (and unfortunately), there are charismatic but evil people who take advantage of people who are afraid and/or suffering.

By the way, there are remnants of this theory still with us today in the form of “detoxificaiton” of the body by cleaning out the GI tract with diet, purging, and/or enemas. (It still doesn’t work…) ↩︎

Davidson J. Bayard Holmes (1852–1924) and Henry Cotton (1869–1933): Surgeon–psychiatrists and their tragic quest to cure schizophrenia. J Med Biogr. 2016;24(4):550-559. doi:10.1177/0967772014552746
EBAUGH FG, BARNACLE CH, EWALT JR. PSYCHIATRIC ASPECTS OF ARTIFICIAL FEVER THERAPY. Archives of Neurology & Psychiatry. 1938;39(6):1203-1212. doi:10.1001/archneurpsyc.1938.02270060093003
Holmes B. Dementia Praecox: The Insanity of the Young. Dementia Praecox Studies: A Journal of Psychiatry of Adolescence. 1920;3:105-138.
Kopeloff R, Kirby G. Focal infection and mental disease. Am J Psychiatry. 1923;80:1490191.
Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510-520. doi:10.1258/jrsm.2011.110180
Naumann DN, Marsden MER, Brandt ML, Bowley DM. The Bouffant Hat Debate and the Illusion of Quality Improvement: Annals of Surgery. 2020;271(4):635-636. doi:10.1097/SLA.0000000000003623
Noll R. Infectious insanities, surgical solutions: Bayard Taylor Holmes, dementia praecox and laboratory science in early 20th-century America. Part 2. doi:10.1177/0957154X06059446

Life long learning (for real) … and why AI is only a tool

Posted on November 2, 2025 by marylbrandt

I recently came across the powerful concept of “hourglass learning” in this post by two professors who teach teachers and, not surprisingly, wondered how it might apply to teaching physicians and other healers.

A visual representation of the hourglass learning paradigm, illustrating six stages: Establish a Purpose, Extract Evidence, Make Sense, Form Meaning, Reproduce Knowledge, and Share Knowledge, arranged within an hourglass shape.

That being said, if you love learning (or love someone who is trying to learn), these concepts can be applied at any age to anything – from bird watching to learning math!

Basic Sciences (Medicine taught in a classroom)

For basic sciences, the hourglass paradigm works well, but I added some practical points from the equally powerful SQR3 (Survey, Question, Read, Review, Repeat) system using a typical hour-long lecture and assigned reading as an example.

Survey (Establish a purpose).

It’s easy to forget that you don’t actually study medicine to pass a test… you are learning to heal, to serve those who need you. In that light, the first step – “establish a purpose” – can be thought of in two ways. The first is to set an intention, to remember why you are studying. And then, more specifically, to ask “What is the purpose of this lecture?” That’s where the tool of “surveying” comes in.

This is an exercise in curiosity not “studying”. Skim over everything to get the big picture. Look up words you don’t know (and their roots). Look at how the lecture is organized. Are there obvious sections? Are there lists that look like they will be important? Can you tell what the most important points will be?

Question (Extract evidence)

This is an interactive process that starts with your survey.

Before the lecture: As you are surveying make notes (on the slides, in the margin of the notes, or as a separate list) with what questions the lecture will and, more importantly, won’t answer about the topic.

During the lecture: Listen for and jot down the answers to the questions you wrote down the night before. If there are questions that aren’t answered in the lecture, ask the professor afterwards.

Read (Make sense)

After the lecture but on the same day (don’t wait!), add to your notes to make everything as clear and as organized as possible, look up anything that is missing, and then make a one page “30,000 foot” review of the lecture.

Educational infographic on embryology highlighting gametogenesis and fertilization processes, including key terms and images illustrating the blastocyst development and implantation.

Review (Form meaning).

The 4th step is to return to the “why” by linking the lecture to how the information applies to actual human beings. Even though search engine AI may point you in the right direction, it should never be your sole source as a professional. (That’s in bold for a reason.) As a professional you need to make sure the information you have is vetted (i.e. peer reviewed).Start with PubMed or UpToDate to find a review article on the topic.

Repeat (Reproduce knowledge).

Real learning only happens with repetition, so setting up a schedule to review your notes with progressively longer gaps between reviews is the secret to success. This is where Anki or other similar systems can really help.

Graph illustrating the Ebbinghaus Curve, showing the percentage of data remembered over multiple repetitions. An image of Hermann Ebbinghaus is included beside the graph.

An important note on question banks… You can’t learn medicine from UWorld. (Again, in bold for a reason.) BUT, question banks are an awesome way to confirm you’ve learned the important stuff – and to identify where there might be some gaps. So please use them as an adjunct to, but not core of your studies.

Explain (Reproduce knowledge).

A great way to make sure you have “metabolized” what you are trying to learn is to share it with others. This is where study groups come in. They take as many forms as there are students, but in general, the most effective groups work as “out loud” reviews of the topics after everyone has spent time reading, reviewing, and repeating.

Teach (Share knowledge)

Teaching in the basic sciences is not as easy as in the clinics (other than “teaching” each other in study groups). But having a goal to to teach makes you organize your material in a way that insures you really understand it.

Rotations, Residency, Fellowship, and Practice (Medicine taught in clinic and hospitals)

The same “basic science” style of learning continues in clinical training, but there won’t (usually) be hour-long lectures or assigned reading. Instead, you’ll be seeing patients, attending conferences, and, yes, you will still be taking tests (shelf exams, in training exams , board exams, maintenance of certification tests, etc).

We want to and need to stay current in our field… but how? Here’s the best way I’ve found to do it, a practice that will serve you from starting rotations in medical school until you retire:

Find the most current and thorough textbook for your specialty
Make an Excel spreadsheet of every section/chapter
Set a goal (and make a plan) to cover the entire book in a year (which will look something like covering 12 sections/ week with weeks off for vacation and holidays)
When you read a section, make notes that are good enough that you never have to go back to read it again (see above… the same system as learning the information from a lecture). At the same time, make review cards in Anki (or however you prefer) to prepare for standardized tests.
Repeat every year! (It gets progressively easier after the 1st year since you are editing or adding to your notes)

A table displaying medical topics related to the appendix and colon, including sections on anatomy, treatment, and patients seen during clinical training.

Here’s the good news… Most of the 12 sections for the week (or whatever it works out to be for your textbook) will be chosen based on the patients you are seeing (It makes it a lot more fun…). The bad news is that all textbooks have really boring sections that still need to be learned, so spread them out over the year to make sure you cover them (but not all at once).

Obviously, these notes are just the foundation of studying a specialty. You’ll also be making notes during Grand Round lectures, conferences, from articles, about “pearls” dropped on rounds, etc.

Repeat (Reproduce knowledge). Teaching and explaining on rounds is a built in way to make sure you understand enough to explain it to others. (Plus you look really good). This is where one page summaries and/or mindmaps really help since they make it easy to remember (and teach).

(Share knowledge) In clinical medicine, there are many opportunities to share … rounding, informal teaching for medical students on our rotations, formal lectures, presentations at conferences, handouts, etc, etc. Take advantage of this unique form of “group studying”!

A visual representation of the hourglass learning model, showcasing the stages: Survey, Question, Read, Review, Repeat, Explain, and Teach, each with brief descriptions.

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler

How do you know?

Posted on October 26, 2025 by marylbrandt

The definition of “knowledge” in English is pretty straightforward – To “know” something means being familiar and/or aware of it in a way that lets us understand. I find it fascinating that English has only one word for “knowledge”, where other languages use multiple words to reflect the depth and nuances of the concept. “Once widespread in Germanic, the verb [to know] is now retained there only in English, where it has widespread application, covering meanings that require two or more verbs in other languages (such as German wissen, kennen, erkennen and in part können; French connaître “perceive, understand, recognize,” savoir “have a knowledge of, know how;” etymonoline

How we understand “knowledge” affects how we teach, how we learn, and how we see the world.

The philosophers of Ancient Greece saw acquiring knowledge as an important part of the human quest for wisdom. Enter episteme, techne, phronesis, gnosis, and doxa. These nuanced ways to think about knowledge and wisdom have a lot to offer us as we navigate the misinformation and philosophical chaos of our time. For those in medicine, these nuanced definitions add beautiful complexity and understanding to our work, with special inspiration for those who teach the healing arts.

Episteme: Intellectual knowledge (Root of “epistemology”, the study of knowledge)

This is the information we learn in our classrooms, from books, and from teachers.

A crowded anatomy classroom scene featuring medical professionals in white lab coats surrounding a patient on a table, engaged in discussion and observation. — The Anatomy Lesson of the Irish College of Surgeons, Robert Jackson, 2010

Techne: Technical knowledge (Root of “technology”)

Techne refers to the technical skills of a profession – the grasp of grammar for a writer, pedagogical skills for a teacher, the ability to perform specific procedures for a surgeon.

Two surgeons in surgical attire engaged in a procedure in an operating room, depicted in a stylized manner. — Photo by Mary L. Brandt, MD

Phronesis: Practical wisdom

I recently read this remarkable essay by Sami Sinada in which he states: “Medical school teaches episteme. Residency builds techne. But phronesis? We assume it appears through osmosis. It doesn’t.”

The entire essay is well worth your time to read, but Dr. Sinada makes an important point – Our medical school and residency curricula have gaps when it comes to teaching practical wisdom (which is the core of doctoring). He goes on to argue that we can close that gap with five important pedagogical choices:

Start with uncertainty, not answers.

Prioritize continuity over episodic care.

Use ethical cases as judgement training.

Make expert reasoning audible.

Require reflective writing.

A 19th-century painting depicting a doctor seated next to a sick child lying on a bed, with concerned family members in a dimly lit room, conveying a sense of care and concern.

Doxa: Common belief, popular opinion. (Root of orthodox)

What strikes me about doxa is that it has no moral weight associated with it. Doxa can refer to the deep orthodoxy of thousands of years of tradition in a culture … everything from how we greet each other to what we believe… as well as culturally accepted, politically motivated lies.

An infographic illustrating different greeting customs around the world, showcasing interactions in various countries with visuals and descriptions. — Source

Gnosis: Insight, deep personal knowing

Gnosis is most often associated with gnosticism, a religious and philosophical movement in the 2nd century. But I wonder if the concept of a deep inner knowing (whether or not you view that as divine) isn’t worth refurbishing for our time as an important way to “know”. Contemplation, meditation, prayer can all open spaces that defy our intellectual understanding, leading to a way of “knowing” that, in some ways, we need now more than ever.

A silhouette of a person sitting on a bench, gazing at a glowing, magical tree surrounded by a starry night sky. — Link to the PBS series Wisdom Keepers

Knowledge without transformation is not wisdom. Paulo Coelho

Three astonished faces … followed by grins.

Posted on November 17, 2024 by marylbrandt

This week I told three separate friends about using their phones to create usable text from notes … and all three were astonished and then grateful. I’m sharing this in case this is something you need, too!

Hold the camera (like you are getting ready to take a photo) above any printed or handwritten text (notebook, article, book, screen etc) until you see yellow “corners” appear. In this example I’m using my phone’s camera to look at this CNBC post: Apple’s latest iPhone update lets you copy and paste text from photos — here’s how on my computer screen… which is a little meta.

Next step (after the corners appear) is to touch the icon in the lower right screen (the one with four corners and three lines), which starts the process of choosing your text.

You can use “copy all” or highlight the text you want to save.

You can do this “live” (like in my example) or from a photo you’ve taken and saved.

You’ve copied it to a clipboard on your phone. Open Notes, Google drive, Word… whatever you use on your phone and paste!

p.s. Unfortunately this only works on an iPhone (sorry Android users)

How to Ace Your Clinical Rotations

Posted on January 9, 2024 by marylbrandt

I don’t know many other professions that organize their teaching the way we do in medicine. In medical school, we start off with 18-24 months in a classroom and then send our students out on “rotations”, a month or so at a time in different medical specialties. The number of months (and years) is different, but the concept is the same for all professional medical training. In some ways it’s an old-fashioned apprenticeship – with all the good and bad parts that come with that kind of learning.

No matter how easy or hard your rotations might be, here are four important strategies to help you learn more and enjoy the process while you do it:

Photo credit

1. Be mindful, deliberate and excited about learning.

This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.

Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat. If needed, write it on a piece of paper to keep in your wallet or on your wrist.

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Learn to practice mindfulness. Mindfulness will keep you grounded and decrease your (normal) anxiety. Mindfulness is not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)

Learn to keep “beginner’s mind” (and write about it). The very first time you walk into an operating room it will seem like (almost) magic. It’s astounding, right? We have drugs to induce a painfree unconscious state… there are instruments that can delicately dissect out a nerve… I could go on, but you get the picture. When it’s new, it’s astounding. That sense of discovery can be nurtured even for things that have become more routine. This is a practice (yes, you have to practice this, too!) which will add joy to your learning… which, by the way, means you’ll learn more!

Get an app like Day One, a highly rated app for journaling. Use it for a brief notes to record “firsts” (first drainage of an abscess, first time you see a rare anomaly, etc). Take photos (HIPAA compliant!) to remember the places and events of your day. List at least one thing a day that delights you. (Trust me on this one… it helps!)

2. Understand what you are going to learn (the big picture)

On every rotation, you will be given a list of learning objectives. By all means, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).

You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.

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3. Develop a system for lifelong learning now

Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.

For more details on how to set up your system, check out How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards. Here’s a summary of the key points:

Remember it’s school.
Make a list of all the topics in the textbook.
Breathe deeply. You are not going to read every page in the textbook in addition to your assigned reading.
Create a schedule to SKIM every chapter
TAKE NOTES. All the time.
Figure out how to store your notes so you can find them in the future
Go through your daily notes in the evening and then store them in your system
Review, review, review

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4. Take care of yourself.

Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Be intentional with this, too. If it helps, make a list every day of things you’ll plan to do, things that help you thrive. Review it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.

Don’t forget to take a “Sabbath” every week. True time off is critical for recovery from this stressful work.

If it gets too hard, seek help. It’s a sign of strength, not weakness, and most (if not all) of your fellow students, residents, and attendings have been there.

Being someone who goes to work every day to learn how to heal other people is one of the most amazing jobs on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you are learning to take care of another human life with the goal of relieving their suffering. What could be more important than that?

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Why worrying is a good thing… until it becomes a bad thing.

Posted on October 26, 2023 by marylbrandt

I had the honor of speaking at the American College of Surgeons this week on a panel about stressors clinicians have control over i.e. can modify. I was assigned a topic I had not really thought about before – which meant I learned a lot! After the talk, there were many people who came up to me and asked if they could have my slides… so here they are!

This is a really important concept… worry is an intrusive thought, which means it just pops in your head. And it’s unpleasant, so you worry about worrying!

Another important point here – worrying is always about something in the future (as opposed to rumination, which is always about the past)

These are the two main ways worrying helps us – motivation and emotional buffering. The motivation part is pretty obvious. Emotional buffering is also obvious, but I didn’t have a name for it before. Take for example worrying that you will fail a test. If you end up getting a good grade on the test it is somehow even more exciting… but, if you do poorly your disappointment is somehow buffered.

In terms of emotions, control is the opposite of worrying. Take the test I mentioned above. If you are worried you will fail it, the way to deal with that is to regain a sense of control. For example, using smart notes to optimize learning during your rotations, using this plan to ace your in-servce exam, or this plan to get ready for exams during basic sciences.

This principle holds true for ALL clinicians – no matter how long your have been in practice.

I shared one of my techniques to worry successfully, which is to create an “SOP” for every procedure I perform.

And then I tackled the next question… what to do when worry begins to spiral.

I introduced this validated tool to see if your worrying has crossed the line to problematic or pathologic.

And pointed out that if worry is causing you to suffer, it’s a problem.

The way to deal with problematic worry is to try to return it to the kind of worrying that helps us, which we can do with any action to control what we are worried about. Worried about a test? Make a plan for how and when to study. Worried about a relationship? Plan to meet or pick up the phone to talk. Again – no matter what your are worried about – do something to create a plan to address the worry.

But despite our best efforts, the spiral of worry can land us in a bad place. If you find you have anything on this list (or if you are really suffering), it’s pathologic worry.

It’s super important that you act – quickly. This is your amygdala trying to hijack your brain! (Remember flight-flight-freeze?) If you don’t derail it quickly, it will continue to spiral and land you in a world of anxiety. In other words, follow all the steps for problematic worry – but if it doesn’t work, don’t wait. Get help.

Advice for Graduates

Posted on June 15, 2022 by marylbrandt

The following is a guest post from my father, Professor Floyd Brandt.

At the time I decided to retire, I experienced two thoughts: First, I had been in a footrace for several years between retirement and obsolescence. The second thought was the closing line from Stephen Sondheim’s song Send in the Clowns — “Isn’t it rich, isn’t it queer, losing my timing so late my career.” Given the issue of obsolescence, I declared that my retirement was a trip from doing to being and then discovered that being is as challenging as doing, and often more so—learning to pause, meditate, and seek the joys of solitude requires new thoughts and habits.

Many, if not most, professors are inclined to think about what they would say in their Last Lecture and some even write it for the millions who will never read it and for students who will never remember it. My final lecture to my graduate classes could be divided into the pragmatic and the personal—I have included the pragmatic here:

After graduation, be your own professor. Keep asking questions. The quality of your life and the organizations you inhabit are dependent upon the quality of questions posed and answered.

During the interview with a potential employer, ask as carefully as possible, “What stories can you tell me about the company or organization”. If they have no stories, you may want to consider another company or organization.

As soon as possible, assemble a “Go to hell” fund equal to six months of salary available in case you need to refuse to engage in an unethical, illegal or extremely distasteful activity.

Attempt to locate the leaders in the organization who has real concern about defining the next decade.

Find out and then think about the years your boss was a teenager.

Begin to develop a flexible plan for the future. It is a truism that individuals and organizations that plan, seldom follow their plans, but they tend to perform better than those who do not plan.

Recognize the value of patience and silence. It usually takes a few years to achieve a top position in an organization.

No Time to Teach? Try This.

Posted on April 27, 2022 by marylbrandt

I’ve started a new practice as a medical educator that has been working so well that I thought I should share it.

Once (or twice) a day in every teaching hospital every service makes rounds and, while managing and treating their patients, the attending (and/or senior residents) teach.

https://middlemarch.com/film/making-rounds/

Inevitably, there are unanswered questions that come up as we discuss patients. Many of them are questions I don’t know the answer to, or are related to a hot topic that might have new information just published. Here are some examples of questions that have come up on rounds on our pediatric surgery service:

Are there new recommendations about how to manage gallstone pancreatitis and/or choledocholithiasis in kids?
What is the caloric content of the different formulas we prescribe?
What is the best way to calculate calorie needs for a burn patient?
How and why do you swaddle a baby?
How do you manage supplemental oxygen after you extubate a patient with severe facial burns?
Where does “second line” come from?

Typically in the past, each student and intern would be assigned one or two of these questions to answer. They would be expected to report back to the team the next day – which might or might not happen depending on how busy the day was (and if the attending remembered to ask them). But to be honest, this way of teaching has become harder with time. There is a post-call resident who is not there the next day, the students often have didactic sessions that are required so they aren’t there, and the day can get so busy that there isn’t (perceived) time to teach on rounds.

But it’s our responsibility to teach (the word doctor means teacher!). Teaching is also a powerful antidote for burnout because its so important and so meaningful. It was clear – I had to come up with a way to make this work in spite of the limitations created by our schedules and clinical responsibilities. So here is what I do now in addition to teaching on rounds:

During rounds we come up with one question per person (everyone, not just the students and interns).
Each person is responsible to answer their question via a group email that, as the attending, I start on the first day I’m rounding.
The answers are short and helpful – as though each person is taking notes for themselves. No PowerPoint presentations, no extensive diatribes.
The email answer is due before the next morning… but no one is allowed to stay up late to do this.

Here’s what was sent on our group email to answer the examples I listed above. (Disclaimer – These are unedited. Don’t use these for patient care unless you look things up yourself!):

What is the “board answer” for treatment of gallstone pancreatitis?

Usually mild as the stones pass spontaneously in the majority of patients but can be severe (even life-threatening) although this is rare. This is due both to fluid loss (equivalent of a severe burn) and to SIRS

initial Tx: Fluid resuscitation, pain control, nutritional support (oral when patients are subjectively hungry – low fat diet)
Surgery during the same hospitalization (Munoz, 2022) (Berger, 2020) (Noel, 2018)
ERCP only if there is cholangitis or persistent cholestasis (Schepers, 2020)

What is the “board answer” for treatment of choledocholithiasis.

First step: Is it asymptomatic or symptomatic (i.e. pancreatitis, cholecystitis, cholangitis)?
Emergency ERCP (<24hrs) for cholangitis, cholecystitis and/or pancreatitis with obstruction
Stones must be cleared. There is no benefit to waiting and there is a downside to waiting since there is always a risk of cholangitis or pancreatitis with a stone in place.
Most surgeons use pre-operative ERCP for known choledocholithiais followed by cholecystectomy, but ERCP at the time of cholecystectomy in adults (Rucci, 2018) (Cianci, 2021) and kids (Fishman, 2020) has been shown to be safe – and perhaps better.

Calorie content of available Tube Feed/Supplements:

Two Cal HN – 2 Calories/mL – high protein

Glycerna 1.2 – 1.2 Calories/mL – lower glycemic index

Nepro Carb Steady – 1.8 Calories/mL – high fiber, gluten free, for lactose intolerant

Impact Peptide 1.5 – 1.5 Calories/mL – supposedly decreases risk of enteral infection in surgical/trauma patient with peptide formulation

Vital 1.2 – 1.2 Calories/mL with 1.2g of NutraFlora per 8oz for gut health

Pediasure Peptide 1.5 – 1.5 Calories/mL – designed for those with malabsorption

Ensure Plus – 1.5 Calories/mL with 16g protein

Osmolite 1.5 – 1.5 Calories/mL – fatty acids for different digestive profile

Jevity 1.2 – 1.2 Calories/mL with 4g fiber/8oz and 1.9 NutraFlora for gut health

Kate Farms 1.5 Peptide – 1.5 Calories/mL – supposedly marketing for smaller tubes without needing to be watered down

Nutritional needs for burn patients

Calorie calculator is complex: https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-017-0076-x/tables/1

2.5-4.0 g/kg/day protein for burned children vs 1.5-2.0 g/kg/day for adults

Fat should be less than 15% of total calories

Carbs 7g/kg/day for burned children

Where did swaddling begin and why do we do it? How do you swaddle a baby?

Etymology/History

Swath (a strip in a field or a strip of cloth)
1325 first recorded use in English – Cursor Mundi (Gött.) l. 1343 A new-born child..Bunden wid a suadiling band (OED)
Almost universal in the 18th century, with or without a cradleboard

Benefits of Swaddling (van Sleuwen, 2007)

Infants arouse less and sleep more
Soothes pain in infants
Prevents hypothermia
Decreases excessive crying due to stimulation

Adverse effects of swaddling (van Sleuwen, 2007)

Hyperthermia if not monitored
Increased risk of hip dysplasia
Increased risk of SIDS if prone
Promotes skin infections in hot, humid climates

Video showing three different methods of swaddling

Facial burns and airway management:

*The mortality associated with orofacial burns or smoke inhalation is related to the degree of lung damage, patient’s age, and the extent of the burn; it is not related to the method of upper airway control. Arch Surg. 1976

*In Facial burns, edema of the head and neck, supraglottic, and glottic areas is the most common cause of airway obstruction

Modified Tube for Endotracheal Airway Management of Children with Facial Burns Antonio G. Galvis, MD,

The team from this article designed a particular ETT setup

Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001).

Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Critical Care Medicine. 1991 Mar;19(3):352-355. DOI: 10.1097/00003246-199103000-00012. PMID: 1999096.

What a second line means!

The “second line” refers to the spectators who join or follow the main line (usually the brass band) and contribute to the walking parade. This is what separates a second line from any other New Orleans parade: groups are not only welcome but encouraged to follow along, allowing the second line to grow as it marches. The term “second line” doesn’t only refer to the parade itself, it also speaks to the type of dancing you will find during those parades. “Second lining” is a highly recognizable strutting, chicken-like dance move that many people use to keep pace with the band. So “second line” is a term with many meanings; it applies to a type of parade, a part of the parade, and a dance move used within that parade.

Studying for the In-Training Exam

Posted on January 30, 2021 by marylbrandt

Every year every resident in the United States takes an exam (called the In-Service or In-Training exam) that covers all of their specialty. It’s meant to be a formative exam for residents and their programs, which means it’s supposed to let everyone know which areas need more focus. Unfortunately, because there are numbers associated with this test it has become a higher stress exam than it should be, especially for residents who are applying to competitive sub-specialties.

First a word to Program Directors. When you think about this test there are only three categories for the results

1) Possibly at risk to pass the boards (< 10^th% ile?)

2) Going to do fine (11-79^th %ile)

3) Extraordinary test takers who really know the info (>80%ile)

This is a comprehensive (and long) exam that often has a VERY narrow bell-shaped curve. What that means is an incorrect answer on 2 questions (some years) can drop a resident up to 10%ile points. Doesn’t it seem silly to think that 70^th%ile is somehow “better” than 60^th% or 50th%ile? (I’m looking at you, subspecialty PDs)

Now for my colleagues in training. You stressed about this exam, you “crammed” (yes, we all did it – even those of us who know it’s stupid) and now you are breathing a sigh of relief that it’s over…

Take a good break from studying. For the next two weeks, use all the time you would have been using to study to binge watch something on Netflix, read a few novels you’ve been meaning to read, or do whatever gives you rest and joy. Then….

Put this in perspective. At the end of your residency, you will be launched into the wonderful, scary, amazing world of practice. You want to know that you know enough to do this, right? So back away from the idea of the In-Service exam as a pain in the gluteus, and see if you can think about it as a formative exam. Which leads me to…

Learn About Deliberate Practice. The best way I’ve found to think about deliberate practice is to understand how musicians practice. I wish I could remember where I read this so I could properly attribute it (please let me know if you know!), but here’s the best example I’ve found to understand deliberate practice – Serious amateur musicians and professional musicians practice a similar amount of time… say 2 hours a day (for the sake of this discussion). But how they practice differs. The amateur will play the piece from beginning to end multiple times, occasionally stopping to repeat the stanza that trips them up. The professional will play it once or twice, spend an hour on a stanza that trips them up, then start over. That’s deliberate practice. Taking the things that are hard (or you don’t like) and repeating them until they aren’t hard.

So, putting this all together, here is what I suggest you do to get ready for the In-Training Exam:

Step 1: Make notes.

Take one of the major textbooks in your field and make a spreadsheet of every chapter, topic, and subtopic in the book. Your goal is to make notes on every topic in the book from March 1^st to December 1^st. Start with some simple math… March 1st to December 1st is 39 weeks, so take the total number of topics in your text book and divide by 39 to set your weekly goal.

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But you won’t start with page 1 and work sequentially to page 846. (Yes, for those not in medicine, the books are usually that long). When you are on call, and you admit a patient with pneumonia, read the chapter about pneumonia and make notes to store in Google Drive? EverNote? OneNote? It doesn’t matter as long as they are in the cloud and searchable. If you hand write notes that’s ok, too, just use an app like Scannable to turn them into PDFs and store them on the web (don’t forget the keywords and/or tags so you can search for them when you are reviewing). What should the notes look like? You graduated from college and medical school, so I’m betting you have a system that works for you. But, if you’ve never heard of it, take a look at the SQ3R system for studying. (Spoiler, it really works.)

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A few other words of advice. It is VERY helpful to link your notes to a specific patient. You’ll remember everything much better; I promise. So, mention the patient with COVID pneumonia who always wore their yellow baseball hat… but don’t put any PHI in your notes so you don’t get in HIPPA trouble. Also, don’t limit yourself to notes from the textbook. This system allows you to make and store notes when you read an article, learn a pearl on rounds, create a mind map, use questions banks, or do a presentation…

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Step 2: Deliberate practice. There will be sections of your textbook that thrill you. Parasites? For some reason we are all fascinated by them. Coagulation cascade? Not so much. Recognize that it will always be easier to learn about parasites than the intrinsic and extrinsic pathways. (Unless you are going into blood banking, in which case I apologize). Which means you need to spend more time on the coagulation cascade. Darn. #DeliberatePractice

The fundamental thing that differentiates learning (for your patients) from memorizing (for the test) is repetition. Your goal is to see everything you need to learn at least 5 times, spaced over at least 3 months. If it’s a topic that is difficult for you, it will probably be more times over a longer period of time. #DeliberatePractice

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One of the best ways to learn specific pieces of information you need to know (like the coagulation cascade) is to use an app like Anki or other flashcard apps. The advantage of these apps is they force you into spaced repetition (remember the minimum of 5 times over 3 months?), but if you are more comfortable with the old-fashioned (but effective) analogue system of actual flash cards, go for it!

But – write this down and put it over your desk – You can’t learn to practice medicine from Anki. You may be able to learn the coagulation cascade and the ratios for Massive Transfusion Protocols… but you won’t learn how to care for a patient who is bleeding out. That’s why you read and that’s why you are in residency.

Another great way to learn something is to teach it. Put together a brief presentation and handout for your medical students on the coagulation cascade… and make notes about their questions, who was there (maybe even a team photo?) before storing your handout with your other notes.

Step 3: Review. This system builds in review of everything you learned over the year (by reviewing it at least 5 times over at least 3 months, remember?) but for next year’s In-Training Exam, plan to take a full month before the exam to stop making notes. Spend this month before the exam to go through question banks, review your notes, and memorize the coagulation cascade. 🙂

Amazing Advice for Interns

Posted on October 19, 2019 by marylbrandt

I asked a simple question to my colleagues on Twitter yesterday.

Thanks to all my colleagues for their amazing responses! This list is almost the curriculum for a course on how to do well (and be well) as an intern.

Enjoy…and take notes!