I am sitting in one of the most beautiful architectural marvels I have ever seen: the iconic Rose Main Reading Room of the New York Public Library. A thoughtless turn of the head while stretching my neck and I catch a glimpse of centuries of knowledge in their primordial form — first edition journals and volumes neatly displayed in stacks of thousands. I could look up and be mesmerized by a scene that is reminiscent of a trip I once took to the Sistine Chapel in Rome, with a ceiling inlaid by golden frames sculpted around angels and flowers that adorn portraits of rose-colored clouds.

But I do not. I am instead studying for my boards and repetitively reading about Bacteroides fragilis and glycogen storage disorders. A headache builds as I enter my seventh hour of studying that day, and even then I wave the headache away as I try to recall the mechanism of how amitriptyline reduces chronic pain from tension headaches. My sandpaper eyes are forced to stay open as my ciliary muscles try to accommodate my struggle.

Indeed, studying is a struggle.

quote: "I greet the sun and see past its farewell each day with my study guide in hand. Flashcards accompany my meals and walks have functionally become DVT prophylaxis rather than enjoyable excursions."As medical students, we are no strangers to studying. To get into medical school, we must first do relatively well in undergraduate classes and receive an acceptable score on the Medical College Admission Test, or MCAT. Afterward, we continue to take exams during our preclinical and clinical years in medical school, with boards and licensing exams to follow for the rest of our careers. Indeed, between the time we enter medical school to when we emerge as attending physicians, we will have taken well over 30 exams. But my current adversary is considered one of the most important exams we take as future physicians. The first national board medical exam, Step 1, is the equivalent of the SAT to high school students. It is a strong determining factor for medical residencies and serves as one of two major quantitative measures of a candidate’s appeal — the other being clinical grades.

And so I study. I greet the sun and see past its farewell each day with my study guide in hand. Flashcards accompany my meals and walks have functionally become DVT prophylaxis rather than enjoyable excursions. I try my best to remain focused and keep what I learned three weeks ago from falling through the seemingly ever-expanding sieve that is my brain. But this is what I’m supposed to do. I’m supposed to study so I can take this test. But even as I repeat this mantra, something is off.

When I decided to come to medical school, I did so because of two broad reasons: I wanted to help others and I loved learning medicine. Just two years ago, I would gleefully read the latest articles on neuroscience or immunology in my spare time and marvel at the complexity of our bodies. I took joy in understanding how much there was to learn and loved the challenge of learning. In my mind, every opportunity to learn was a chance to become a better doctor. But while those patterns continued in medical school, my enthusiasm slowly began to temper as I found myself reading more out of obligation than enjoyment. And it was through this insidious slope that I found myself, here today in this beautiful library, woefully anticipating how much there is to still learn. Even as these thoughts continue to percolate, I remember there was once a time when I would have taken a brief pause after every new fact and whistled in appreciation.

So I stop.

I try to whistle, at least metaphorically.

quote: "I think about the extraocular muscles I just used, the atelectasis my sigh just prevented, and the prefrontal cortex that helped me synthesize these thoughts. And I cannot help but smile."I crank my head up and force these tired eyes to appreciate this library. The ceiling is truly beautiful. I turn to the history engraved to my left. Colors of aged red, mysterious blue and forest green sharpen into focus. And then, as I slowly move my field of vision back to my books, I take a deep breath. I strive to look beyond bullet points of information and recapture some of the wonder I once had. I think about the extraocular muscles I just used, the atelectasis my sigh just prevented, and the prefrontal cortex that helped me synthesize these thoughts.

Studying will always be a part of medicine. The onus is on us for why we study. There are exams, of course, and these milestones can be as much a measure of our fatigue as they are of our professional progression. But we can choose to appreciate what we learn as a privilege. We can eagerly study in anticipation of being better physicians and scientists, all while marveling in the wonderment of it all.

All we need is a reminder to take a moment and look up.


Related Content

3 Comments

About the Author

John Choi

John Choi is a lactose intolerant medical student who believes in the power of sharing stories and regretfully loves cheese.

The oral exam. The candidacy exam. The comprehensive exam. There are many names for it, but all pre-doctoral graduate students come to fear it. At different universities, this pivotal exam happens at different points in your Ph.D. At Johns Hopkins, most students will take their candidacy exam after their main courses are finished, but before they have completed the majority of their thesis work.

Tired student studyingThis is usually somewhere between the end of the first and second year of graduate school. The examiners are a committee made up of faculty members, who prepare questions on both general aspects of the student’s field of study and specific topics pertaining to the student’s thesis in order to assess their readiness to continue the bulk of their thesis research.

I am currently a third-year student in the human genetics pre-doctoral training program. For students in my program, the oral exam takes place at the end of our second year, when we have finished most of our classes. We prepare a ten-minute talk on a topic of our choice (usually our thesis work), which is followed by two hours of questions from our committee members. I took the exam last year, and it was a harrowing, but valuable, experience.

Here are some tips that helped me while I was studying:

  1. Set aside dedicated time to study. You might be thinking, “But I just can’t take time off from my lab!” You need to prioritize, and your oral exam is of the utmost importance. You can’t continue on in your Ph.D. program, or in your thesis lab, without passing this exam. You might be thinking that you don’t need to study very much, but it’s likely that you haven’t realized how much you don’t know or may have forgotten since your coursework. It wasn’t until I sat down to make my study guide that I became overwhelmed by the sheer amount of information I was expected to master. Don’t be afraid to take time away from your lab work in order to thoroughly prepare; most advisors have also served on many exam committees and are usually very supportive about the process.
  1. Rehearse explaining the specifics of your lab’s specialty. Because you may be starting off your exam with a short talk or written proposal regarding your work, you will need to know the details about relevant methods and hypotheses. Usually, you are working with this material on a daily basis. Even so, make sure to practice explaining the complicated intricacies of your project that you might not talk about every day. Since most members of your lab know these areas already, it can be easy to forget that they are not common knowledge to researchers outside of your specific field.
  1. Try to familiarize yourself with the basics on most, if not every, topic from your classes. Your examining committee will have their own set of expertise. They might ask you questions from subjects of their specialty or content from lectures they gave during your courses. The professors will not expect you to be an expert on every subject, but you should at least be able to explain major ideas, broad concepts and a range of methods.
  1. Set aside dedicated time to relax. This might be the most important tip! Especially if you are highly motivated, don’t forget to take a break. Your brain needs time to let new concepts sink in. This way, you can incorporate new facts with what you have already studied. Taking a nap, eating healthy food and meeting up with friends can all help to take your mind off the stress of the oral exam. Find what works best for you.
  1. Ask for help! Other students have gone through this as well. They can help give you tips on what to study or where to go on campus for a quiet environment. You might also want to have older students ask you questions in exam format, so you can practice answering out loud. If you start feeling overwhelmed, don’t be afraid to ask your program coordinator, your advisor, or your lab mates for help! They might be able to set you up with a tutor for difficult topics, give you more time away from lab, or help you with time-sensitive experiments while you are out of the lab studying.

Your candidacy exam will be hard, but it’s supposed to be! Your committee will push the boundaries of what you know. Just remember that this trial brings you one step closer to completing your Ph.D.


Related Content

  • How to Relieve Stress: A 5-Step Plan to Feeling Good
  • Effective Communication: How Do Johns Hopkins Scientists Learn to Speak? Read more.
  • Stress eating?  Researchers have shown that eating or drinking delicious food can involve parts of the brain that are important for evoking stress-related responses.

1 Comment

About the Author

Sarah Robbins

Sarah Robbins is a human genetics Ph.D. student. Her skill at reading recipes has made her able to translate her talents from pies to PCR.

Imagine going to the doctor to be tested for HIV in sub-Saharan Africa. You will likely have to travel a long distance to get to a clinic, and, once you arrive, your blood will be drawn and sent to a central testing laboratory for analysis. You will then have to wait for the results to be delivered to the clinic and return to the clinic for your diagnosis. In Zambia, it takes approximately 92 days for this process to be completed. When you are an HIV-positive mother waiting to find out if your newborn child needs antiretroviral therapy, each of those 92 days can mean the difference between life and death for your baby.

Management of infectious diseases such as HIV in sub-Saharan Africa has been a major part of the career of William Moss, M.D., a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health. He works closely with the Johns Hopkins research field site in Macha, Zambia, to study the epidemiology behind infectious diseases that devastate Africa.

Mobile phones help get an earlier HIV diagnosis

Click to enlarge

New work from Moss and his group focuses on finding ways to shorten the 92-day wait for HIV test results. Capitalizing on the increasing amount of technology available in rural Zambia, Moss and colleagues conducted a study using text messaging to deliver HIV test results directly from the central testing lab to mothers or rural health clinics. The results, published in the April issue of BMC Pediatrics, found that by sending a text message directly to the mother, they could reduce the time from sample collection to receipt of diagnosis to just 18 days.

Unfortunately, the use of mobile phones is still not widespread; only 30 percent of mothers in the study had ever used one. Luckily, the local clinics do have mobile phones, so delivering results via text can still decrease the time to diagnosis, to approximately 36 days. By cutting 56 days off the wait for diagnosis, HIV-positive children can receive antiretroviral therapy nearly two months earlier. Reducing the time to treatment significantly ameliorates the clinical symptoms of HIV infection and prevents the progression to AIDS, vastly improving their quality of live and longevity.

As noted by Moss, implementation of the mobile phone messaging system for test result delivery was by no means trivial. It required the hiring and training of new staff as well as the purchase of mobile phones and “talk time” for the phones. Other major obstacles for mobile phone messaging systems include unreliable network coverage throughout rural areas, lack of digital literacy and skills, and the large gender gap: Men are much more likely to have mobile phones, while women are responsible for the children’s health. Additionally, villagers were often skeptical of the benefits of using a mobile phone when they had relied on their traditional system for years. However, with the right funding and infrastructure, the utilization of technology throughout Africa has the power to have significant and widespread impacts on health care. Studies such as this highlight the great potential of available technology to encourage governments and private investors to take note and get involved. Someday soon, nationwide mobile phone messaging systems may become common place, drastically cutting the time to diagnosis and improving each individual’s access to care and treatment.


Related Content
More amazing things that mobile phones are doing for public health:

About the Author

Rebecca Tweedell

Rebecca Tweedell is a fifth-year Ph.D. student in the Cellular and Molecular Medicine program with a strong passion for infectious disease research. In addition to loving anything and everything nerdy and generally uncool, she is an avid runner, rower and random sport participant. Her dream job is to be a Disney princess, singing and performing by day, while writing scientific manuscripts by night.

Over 3,000 years old, Judaism is one of the oldest monotheistic religions. Calling oneself a Jew draws on a rich history and a continually growing set of religious texts; it is a link to a culture of resilience and a peoplehood that have withstood incredible persecution and social restriction, immigration and assimilation. Thus, for many, being Jewish is much more than having a certain faith tradition.

a group of friends celebrating Hanukkah

Image courtesy Eric Weaver

In the early 1900s, Jewish students filled almost half of medical school spots in America. Although the religious composition of medical students has since shifted, there remain strong sentiments in the Jewish religion that encourage careers in medicine. Judaism defines the human body as sacred; learning how to heal it is viewed as tantamount to “doing God’s work” by preserving another human’s life. Ilan Caplan, a second-year medical student, described how his faith compels him to one day become a family physician: “[The body] is the vessel that God has given souls to walk around in.  Therefore, to try to keep the body as healthy as possible is itself a holy act.”

Being a Jewish practitioner in medicine can also confer a responsibility towards social justice. A large part of how Zackary Berger, M.D., Ph.D., conceives his work as a physician is through advocacy and political work. “There is a prophetic ethical tradition of trying to improve the world,” he notes. For example, in Exodus (one of the books of the Torah), the prophet Moses writes of how God says, “I will bring you [the Jews] out from under the yoke of the Egyptians. I will free you from being slaves to them.” The theme of freedom from slavery underlies Passover, one of the major Jewish holidays.

quote: [The body] is the vessel that God has given souls to walk around in. Therefore, to try to keep the body as healthy as possible is itself a holy act.This responsibility toward the other similarly motivates Maya Siegel, a third-year medical student. When asked about how her religious beliefs influence her decision to pursue a career in medicine, Siegel responded, “Social medicine and systems of injustice affect our patients... I am also motivated by Tikkun Olam, the concept that the world was created imperfect, and we as humans are required to work to make the world better.” Compelled by the importance of tradition, ritual and community in the lives of her Jewish peers, Siegel is active in the Jewish Students Association at the Johns Hopkins University School of Medicine as well as in the local Jewish community in Baltimore.

Eric Weaver, a second-year medical student, also feels a deep connection with the rituals and traditions of Judaism; however, his personal practices have more recently been influenced by an affinity with Buddhism, and especially the practice of meditation.  Rather than being unable to reconcile the two religions, Weaver points to the rare openness that Judaism has toward other ideas and beliefs. In fact, it is important to note that calling oneself Jewish doesn’t necessitate a belief in the existence of God or the divine; rather, Judaism is, in general, more interested in the “practice” of religion (e.g. rituals, tradition). Weaver finds that his current identity lies in a delicate interweaving of the anchoring and focus of Buddhism, the culture and traditions of Judaism, and the value placed on kindness and love in both.

With regards to incorporating his faith in his medical practice, Berger chuckles when he shares that wearing his yarmulke (a cap that sits on the crown of the head) is often a conversation starter for patients to ask questions about his religious identity.  In general, he urges us to see religion not as an outlandish practice but as common and important to the lives of others. “Understanding a patient’s religion is understanding their spiritual needs. It is an important part of interacting with every patient.”

About this series:

Although medicine is often seen as a field that is distinct from religion, religious beliefs have a significant impact on the way physicians and medical students approach their training, interactions with patients, and understandings of disease and death. Biomedical Odyssey bloggers Rabia Karani and Stephanie Zuo have created a short blog series on faith and medicine to give you a glimpse into the worlds of Johns Hopkins students who have been influenced strongly by and/or are actively practicing their faiths. 

We hope that you come away with a deeper understanding of the profound impact and immense strength that arises when peoples of faith seek to do good work in the medical field with all their hearts, minds and souls.


Related Content

About the Author

Stephanie Zuo

Stephanie Zuo is a fourth-year medical student who believes in the healing power of a listening ear.

The contagious yawn is a well-known component of the communal human experience that transcends languages and cultures. We joke about it in offices and dedicate Mythbusters episodes to understanding its frequency, and researchers have even shown its ability to pass between species (try yawning in front of your dog or cat and see how long it takes them to follow suit). But there are other contagious behaviors as well: for example, cringing at someone else’s pain, as well as itching and scratching. The mere mention of lice can send hands directly to hair, and observing somebody scratching their head vastly increases your likelihood to do the same. These actions are not in response to any direct itching stimulus, but simply due to verbal or observable suggestion.

dog yawning at a catBecause these contagious behaviors are so ubiquitous, we often don’t realize what strange phenomena they are. If I were to throw a ball at you, you would instinctively flinch and cover your face, but a person standing near you would not flinch as well. Contagious itch, in contrast, occurs because visual signals from nearby peers engage numerous brain regions that then modulate connections usually reserved for direct, reflexive signaling. The root of these actions is generally attributed to “mirror neurons,” a distinct population of cells that fire both when an animal performs a specific behavior, and while observing another animal perform the same behavior. The evolutionary functions of these mirror neurons are still vigorously debated, and they have been implicated in a wide variety of socio-cognitive behaviors including imitation-learning, perception-action coding, and even empathy in humans. However, because thus far these neurons have only been identified in primates, the tools for studying them in a lab are limited.

To more directly examine the roots of contagious behaviors, researchers sought a behavior they could induce and observe in mice, which would allow them to take advantage of the rich genetic toolbox available for this model organism). By exposing wild-type mice exhibiting normal scratching behavior to chronically scratching mice, they demonstrated a strong imitative itch response that had not been previously shown. Importantly, these mice still itched even when they only saw a video of another mouse scratching (something I’m sure we can all empathize with, having yawned or scratched in imitation of a character on TV).  In these “imitating” mice, the authors found gastrin-releasing peptide (GRP) positive cells in a region of the brain called the suprachiasmatic nucleus (SCN) were more active during the itching behavior. Although the SCN is most often studied in the context of its role in pace-making in the circadian rhythm, these cells also receive direct visual input, and the authors hypothesized they may be acting as a relay station between visual information and behavioral response.

quote: this research suggests these reactions are more reflexive and autonomous in nature, and likely evolved within our ancestors well before humans could appreciate the humor of a 3 p.m. yawn traveling throughout the entire officeThe authors went on to apply cell-type specific targeting, which allowed them to activate and inactivate GRP+ cells using a variety of advanced molecular biology techniques. By working with mice genetically engineered to express either a light-inducible or light-repressible protein only in GRP+ neurons, the authors were able to specifically activate or inactivate only the GRP+ neurons by exposing them to a specific wavelength of light (called optogenetic manipulation). They then showed that specific activation of these neurons resulted in a significantly increased scratch response when the animal was viewing another scratching mouse, while optogenetic silencing or ablation of GRP+ neurons resulted in a significant decrease in this imitative behavior. By demonstrating both positive and negative control of this behavior through GRP+ neurons, their role is shown to be integral to contagious itch in mice.

These findings point in an interesting direction by demonstrating a hard-coded, biological signal for mammalian contagious behaviors. Often, yawning after someone, or “feeling someone’s pain,”  considered an empathetic reaction, involving higher cognitive functions.  But this research suggests these reactions are more reflexive and autonomous in nature, and likely evolved within our ancestors well before humans could appreciate the humor of a 3 p.m. yawn traveling throughout the entire office as if carried on the wind.


Related Content

1 Comment

About the Author

Benjamin Bell

Benjamin Bell studies sleep and circadian rhythms in mice and flies, and is fortunate the mice understand his semi-nocturnal work schedule. When not actively in the lab, you can find him thinking about research and science-writing on his motorcycle, on the hiking trails, or at any local concert venue.

As the population of elderly people in our country grows, and as air travel becomes more accessible, medical professionals will be increasingly faced with emergencies in the air. During medical school, students are given some preparation for these situations should they arise: for example on my third-year ob/gyn rotation, we received a lecture on how to deliver a baby on an airplane, and during our fourth year, a lecture on handling medical emergencies in the air. However, as I learned when recently confronted with a medical emergency during a flight, it is really the ability to think quickly and adapt to the resources at hand that allows you to best deal with such situations. As providers, it is sometimes easy to forget to take a step back and appreciate medicine as a profession founded on the basic principle of helping those in need, and these situations often serve as reminders of this concept.

plane flying over the sunsetI had never felt less prepared to talk to a patient in my life. I was running on two hours of sleep and had been out of my clinical rotations for almost 10 months; however, when someone called out for a doctor and no one moved, I stood up, knowing that a little knowledge and experience are better than none. When I reached the patient, he was completely unresponsive to the screams of his terrified wife. His head was tilted back, his jaw was slack and his eyes were rolled back into his head. Almost thirty seconds after I reached him, his eyes re-focused, and he regained consciousness, with no memory of the event. His wife explained that he had done the same thing two minutes before, which had prompted her initial cries for help.

Completely on my own to care for the patient, I performed a quick exam, took a history, managed to collect his vital signs and calmed down his terrified family and the panicked flight attendants. The flight attendants kept asking me whether they should land the plane, an enormous decision to make as a medical student, but thankfully one I did not have to make alone, due to the arrival of a family practice physician who had been at the front of the plane and had not heard what was happening. Together, we tended to the family for nearly an hour, and for the remainder of the flight, everyone from passengers to the captain thanked me, ending the flight by clapping for “the medical student.”

quote: The most important piece of any clinical interaction is the doctor-patient relationship ... speaking with the family and keeping them involved was the most valuable asset I was able to provide.

This experience brought me back to the basics of medicine. In a situation with very limited resources, I revisited what patients really expect from their medical provider. The most important piece of any clinical interaction is the doctor-patient relationship, and on this flight, speaking with the family and keeping them involved was the most valuable asset I was able to provide. By maintaining a calm presence, and simply being there for the patient and his family, I was able to offer them some peace of mind until the flight touched the ground. This experience was one that truly humbled me, because it was yet another reminder of how fulfilling medicine can be. In the face of difficulty, you can offer people a shred of hope as a provider, and in the face of fear, you can offer them a soothing smile, a calm voice and the presence of someone who is there in a time of need.


Related Content

1 Comment

About the Author

Rabia Karani

Rabia Karani just completed her M.P.H., and is now finishing up her last year of medical school. She is passionate about any topic regarding patient care and public health. An anthropologist at heart, she is an avid reader, a Harry Potter enthusiast, and she hopes to use her love for writing to inspire understanding between different groups of people.

As an undergraduate, I frequently shadowed physicians and remember vividly many moments and anecdotes from those experiences, many of which would go on to shape my future career aspirations. One of my close mentors, a veteran vascular surgeon at the end of his career, once reminisced about his surgical training at The Johns Hopkins Hospital in the early 1960s, telling me half-jokingly, “During my intern year, I walked into the hospital on the morning of the First of July and didn’t leave its doors for the next year.” He went on to say, “They called us House Staff for a reason. When you’re a resident, the hospital is home.”

Of course, a lot has changed since then. Resident work hours are now regulated by the Accreditation Council for Graduate Medical Education (ACGME), which first instituted work hour restrictions in 2003 after a series of lawsuits, research studies and reports revealed how sleep deprivation and long hours can lead to breaches in patient safety, preventable mistakes, and trainee depression.

Since 2003, these regulations have been critically examined and periodically modified, the subject of an interminable and fervent debate among medical trainees, doctors, politicians and the general public. In 2011, the ACGME revised duty restrictions, banning 30-hour shifts and placing a 16-hour cap on shifts worked by first-year residents. On March 10th, the ACGME Task Force released another revised set of work hour restrictions, which will go into effect on July 1. The new rules increase the maximum shift that interns can work from 16 to 24 hours, plus four hours to ensure safe patient handoffs and allow residents to participate in non-direct patient care educational activities, while maintaining the 80-hour work week limit. Importantly, second- and third-year residents can already work a maximum of 24 hours per shift under the previous rules.

The 2015 Medscape survey results reflect the highest burnout rates among critical care (53%) and emergency medicine (52%), and with half of all family physicians, internists, and general surgeons reporting burnout.

click to enlarge

In its announcement of the change, the ACGME noted that “the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized … and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and effectiveness of care delivery of the team as a whole.”

Learning Effective Leadership vs. Resident Burnout

Proponents of the change argue that the longer shifts reduce handoffs between physicians, a key source of medical errors); maintain continuity of care in critical situations, such as during a surgery or immediately following a new admission; and give residents and educators more flexibility to optimize their training. The change also gives interns more opportunity to observe and follow patients throughout the natural course of an illness, especially on the night of admission.

When asked about the goals of the revisions, Dr. Jessica Bienstock, Johns Hopkins Associate Dean for Graduate Medical Education and member of the ACGME Task Force, stated “The Common Program Requirements encourage training programs to teach new physicians how they can be effective participants and leaders of team-based patient care that is the standard of healthcare today … and allow residents to benefit from the personal and professional satisfaction and sense of accomplishment, indeed the meaning and joy, that comes with professional commitment to one’s patients when you care for them in a longitudinal manner.”

Opponents of the change, including Public Citizen consumer group and the American Medical Student Association, argue that sleep-deprived residents are at greater risk of car accidents, needle-stick injuries and depression, and that the vast majority of patients oppose loosening of duty hour restrictions. With increasing awareness of the high rate of burnout, depression and suicide in the medical profession, this rule change has some worried that wellness among medical trainees is still not a top priority.

There is no simple answer. Optimizing duty hour restrictions depends on many competing factors, and it is clearly hard to reach a consensus about what is best for patients and residents. The relationship between duty hours and burnout is a complicated one, as burnout is a multifaceted and complex problem. Research has not always demonstrated a clear correlation between duty hours and burnout. Despite the contentious nature and strong emotions that often overshadow work hour regulations, in the end. patients, residents and medical educators are all united by the same priorities: a desire for high quality and safe medical care, effective and efficient training, and happy, healthy medical trainees.


Related Content

About the Author

Benjamin Ostrander

Benjamin Ostrander is a third-year medical student who strives to keep life infinitely interesting through creativity with words, food, music, medicine and more.

Diet—what and how people eat—is becoming a powerful potential intervention for a variety of debilitating neurological diseases. The ketogenic diet, in particular, has been a well-established treatment for epilepsy for the past century. Yet, even now, physician-scientists are discovering new indications for the ketogenic diet.

Ketogenic diet as a promising treatment for severe intractable epilepsy

The Atkins diet was all the rage in the early 2000s. Now, a diet with a low-carbohydrate emphasis similar to that of the Atkins diet has proven beneficial to an unexpected group of people—patients with intractable epilepsy.

The ketogenic diet is based on a low-carbohydrate, high-fat and adequate-protein composition. Through this diet, the body is forced to burn fats as fuel instead of carbohydrates. The liver converts fats into fatty acids and ketone bodies, which travel to the brain to be used as an energy resource and through the bloodstream, inducing a state called ketosis. Ketosis has been shown to contribute to a reduction in the frequency of seizures.

Ketogenic diet consists of 75% healthy fats, like avocado, 20% proteins and 5% carbs. The CDC recommends the diet as a treatment for epilepsy.

Since the 1920s, the ketogenic diet has been a mainstay in the treatment of pediatric epilepsy, but Johns Hopkins researchers have found that the diet can also be helpful in treating the rare, super-refractory status epilepticus (SRSE). SRSE is a very severe form of epilepsy, characterized by lengthy periods of seizure that necessitate medically induced coma as intervention. There are currently no set practice guidelines for what medications physicians should administer after 24 hours of SRSE.

According to Dr. Mackenzie Cevenka of the Adult Epilepsy Diet Center at The Johns Hopkins Hospital, “ … the ketogenic diet is effective in [treating] one-third of adults with epilepsy who are resistant to traditional anti-seizure drugs.” In a study of fifteen patients hospitalized with SRSE, doctors started the ketogenic diet over the course of 72 hours while patients remained in medically induced comas (1). If patients awoke and had improved conditions, they could eventually change to a modified Atkins diet, which is easier to follow, as a long-term treatment option. Overall, eleven patients (79 percent) were successfully treated with the ketogenic diet, with eight recovering within a week after the onset of SRSE.

Variations of the ketogenic diet exist for patients with epilepsy. The other common nutrition plan, the modified Atkins diet, has been administered to mostly adult patients since its inception at Johns Hopkins in 2002. The modified Atkins diet results in lower rates of seizures in half of patients within a few months of starting the diet.

Overall, diet therapy for various forms of epilepsy for patients of all ages is safe and efficacious. Careful supervision by a neurologist and dietitian, who are well-versed in the implementation and adjustment of the ketogenic diet, is necessary for good patient care, especially for those suffering from severe forms of epilepsy.

References

  1. Ketogenic Diet Shown Safe and Effective Option For Some with Rare and Severest Form of Epilepsy

Related Content

Visit the Adult Epilepsy Diet Center at Johns Hopkins Medicine to learn more about how we're using the ketogenic diet as a treatment regime in children with epilepsy.

About the Author

Adela Wu

Adela Wu is passionate about making connections between ideas and people, and seeing how her interests in literature, creative writing and medicine play out in that theme. In addition, she also enjoys river and sea kayaking, having recently whitewater kayaked the Shenandoah River rapids.

As a fourth-year medical student at Johns Hopkins, I have had the privilege of working with attending physicians in a number of outpatient clinics. My roles in the clinic have varied. In most clinics, I see the patient independently, take a history, and perform a physical exam. I then describe the course of the illness, medical history and physical exam to the attending physician, as well as share my assessment and plan for the patient. The attending and I then go and see the patient together. Other times, I am less involved in the clinic, perhaps only taking the history independently or shadowing. There are opportunities to write patient notes, ask questions and receive feedback, but the amount and quality of teaching vary between clinics.

students in an ongoing discussion with a professorIn 2015, a group of Johns Hopkins medical students began investigating the factors that contribute to a successful outpatient educational experience for students in the neurology clerkship. They presented their findings at the American Academy of Neurology meeting last year. In collaboration with the neurology clerkship directors, they surveyed 67 students who took the neurology clerkship between 2014 and 2015. They found that students were significantly more likely to perceive a clinic session as an “effective educational experience” for each additional patient they interviewed, presented, and documented. In other words, students felt that they learn more when they are actively involved and have greater responsibilities.

In addition, the group also explored how students impact the clinical productivity of the attending physicians. This information is critical because of the widespread perception that medical students hinder clinical productivity, as attendings must juggle supervisory and teaching roles with patient care. Therefore, the group catalogued relative value units (RVUs), a metric for assigning value to clinical activities and a measure of clinical productivity, per clinic session with and without a student for 43 attending physicians.

study findings: Surprisingly, the majority of physicians (74 percent; n=32) had 42 percent more RVUs per clinic session when a medical student was in clinic, compared to the same clinic without a medical student. Surprisingly, the majority of physicians (74 percent; n=32) had 42 percent more RVUs per clinic session when a medical student was in clinic, compared to the same clinic without a medical student. This increase is most likely because in the time that the student sees the patient, attending physicians can simultaneously see a second patient or finish patient notes. Furthermore, the RVUs per clinic session significantly increased as the number of patients that students interviewed, presented and documented increased.

This study suggests that medical students can be actively incorporated in outpatient clinics in a way that is mutually beneficial for both the student and the attending physician. Students feel that they receive a greater educational experience when they are actively involved, and they can also increase the productivity of the preceptor.

One limitation in this study is that only neurology clinics at Johns Hopkins Hospital were surveyed. This work is still under review, but the next phase is to examine the generalizability of the conclusions across medical specialties and institutions. Currently, I am working together with Stephanie Zuo, another Biomedical Odyssey blogger, to extend this study to the pediatrics and women’s health clerkships at Johns Hopkins. Our hope is that this project can improve the outpatient educational experience for future medical students, as well as encourage attending physicians to participate in medical education.

1 Comment

About the Author

Alisa Mo

Alisa Mo is an M.D./Ph.D. student who's passionate about the intersection of neuroscience, genomic medicine and society. She’s also a pianist and enjoys cooking.

Seven medical students shuffle through the narrow doorway. One of my classmates steps forward and addresses the patient. “Hello, Mr. M. How are you doing this morning?”
Mr. M. does not respond.
“Mr. M.? Mr. M.?” The student shakes the patient’s shoulder vigorously. The student feels for a pulse. “I have a pulse, and I see chest rise.” We all release half a breath: The patient is not in cardiac arrest. But why can’t Mr. M. respond?

Patient and doctors in the emergency roomFortunately, Mr. M. is not in any danger because Mr. M. is a mannequin. But this is no mere plastic simulacrum. Mr. M. really does have a pulse. He has lungs that inflate to lift his chest. He can be shocked, intubated and examined for neurological deficits. Mr. M. is a $100,000 machine built for simulating emergency medicine. And he is also a forgiving instructor to green second-year medical students just learning to translate textbook medicine to the hospital bedside.

Medical school is traditionally divided between two years of classroom-based instruction in physiology and the mechanism of disease, and two years of hospital-based training. On the wards, medical students rotate through each of the core specialties for several weeks at a time: internal medicine, surgery, pediatrics, obstetrics/gynecology, neurology and psychiatry. The transition between these two phases of medical education is, unsurprisingly, associated with significant intellectual and emotional shock. Students are no longer full-time learners solely responsible for expanding their own knowledge. In the hospital, they become active participants on the medical care team, accountable to patients and professional colleagues as well as to their own learning.

quote: At this stage of education, it’s all about introducing and drilling in the basics. Mnemonics are (literally) lifesaving tools used to bridge the gap between learning a medical principle and internalizing it. To better prepare soon-to-be third-year students for the rigors of hospital medicine, the Johns Hopkins faculty developed the Transition to Wards course. The three-week class concentrates its efforts on common early stumbling blocks faced by medical students. Students review the interpretation of frequently used diagnostic tests, revisit the principles of biomedical ethics, train in basic procedural skills and learn the steps for initial management of an acutely ill patient.

At this stage of education, it’s all about introducing and drilling in the basics. Mnemonics are (literally) lifesaving tools used to bridge the gap between learning a medical principle and internalizing it. One classic for acute care: “When a patient is sick, say ‘OMI!’—oxygen, monitoring and IV access.” The transition course provides room for mistakes without human consequence during the steepest part of the learning curve.

Why can’t Mr. M. respond? Oxygen and monitors are hooked up, and the IV is open. He is not in cardiac arrest. Heart rate, respiratory rate and blood oxygenation look good, but his blood pressure is concerning at 144/80. Two years of pathophysiology kicks in. My teammates call out potential causes for unconsciousness, and side conversations instantly spring up, each pair or trio debating a different diagnosis. Another classmate, silent until now, suggests in a clear, crisp voice that we check a finger stick blood glucose.

I want to high-five her for her insight: Low blood sugar is one of the most common causes of nonresponsiveness — obvious in retrospect, but it’s astonishing how few concepts are obvious to a medical student struggling to diagnose an active problem. We check the blood sugar; it’s a third of what it should be. We give glucose, and slowly, Mr. M. comes to.
A small victory, perhaps. Hypoglycemia is not a difficult or complex diagnosis. But a team of my classmates examined, diagnosed and treated a simulated patient for a potentially lethal condition. My classmates saved a life. That’s enough to put a spring in my step.


Related Content

About the Author

Carson Woodbury

Carson Woodbury relishes a good detective story. Drawing early inspiration from Scooby-Doo’s Mystery gang, he fell in love with the natural world and all its enigmas — from Herodotus to developmental genetics. He is a second-year medical student, an aspiring mountaineer and an avid reader of The Baltimore Sun. His dream job is chief medical officer of a starship.