Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of 17th November 2016 (#69)
University
of Notre Dame Australia (Fremantle Campus)
Occasional Editorial Comment
The practice of medicine has moved into the molecular
biological, pathophysiological, Nano technological, genetic, and immunological
era. Unless both medical students and their
teachers are well informed of current advances in these areas, medical schools
will graduate “bare foot” doctors without the scientific basis necessary to understand
abnormal symptoms and signs, order the appropriate investigations, and develop
the correct diagnosis(es) and management plan.
When you read the CPC in today’s journal involving the
management of a patient with metastatic oesophageal cancer, you will see where
“personalized medicine” is heading and why it is imperative to have a
scientifically broad-based knowledge in medicine to remain current.
It is essential that students actively focus a
significant amount of their time and to understanding these scientific areas
during the first two years of medical school and to foster an intellectual
curiosity to continue learning into the future. Clearly, most medical students
engage as early as possible in medical school in areas they believe to be much
more important in becoming a doctor, such as history taking and physical
examination, frequently at the expense of their scientific training. Most
medical schools have embarked on an integrated teaching curriculum (generally
organ based) in which teaching revolves around a particular system e.g. cardiovascular.
This teaching involves areas such as anatomy, physiology, biochemistry, cell
biology, and immunology as well as specific diagnostic skills and history
taking related to the particular organ system.
This system leads to learning history taking and physical examination
from early in the first year, often at the expense of significant scientific
learning.
I believe the assessment process during the first two years
should be heavily weighted towards the basic sciences in order for students to appreciate
how important this area is in enjoying the practice of clinical medicine and
understanding the scientific basis of specific questions and clinical signs
when treating the patient.
In today’s recommendations, there are three articles (Editorial, Original article and Perspective)
involving the biology of cyclins and cyclin-dependent kinases (cdk) and the use
of a cdk inhibitor (palbociclib) in conjunction with letrazole in treating
postmenopausal women with advanced ER-positive, HER-2 negative breast cancer.
Students must understand the cell cycle – division cycle (mitosis) completely. These are reviewed well in the Perspective
and Wikipedia (mitosis). The first paragraph of the Perspective states:
Orally available drugs that potently and
specifically inhibit the activities of the cyclin D–dependent kinases CDK4 and
CDK6 represent paradigm-shifting antineoplastic agents. Unlike
traditional cytotoxic drugs, which kill dividing cells by interfering with DNA
replication (S phase) or mitosis (M phase) during the cell-division cycle,
CDK4–CDK6 inhibitors arrest progression through the G1 phase, promoting
transient cell-cycle withdrawal into a quiescent state (G0) or, possibly,
permanent proliferative arrest. Although
cell-lineage identity and collateral signaling pathways may shape these
different outcomes, either quiescence or senescence could avert tumor
progression and help extend cancer-progression–free survival.
Another area of concern is the time in the medical
school curriculum devoted to credentialing of procedures and having our
graduated students “intern functional” on day one of their internship. Do we require first year medical students to
pass their first year exams after their first week of medical school? The
reason for this requirement is the lack in the number of resident staff
available to closely monitor and train new interns. It is in essence a mechanism of passing on to
medical schools the state cutback in public hospital funding. If medical
schools do not remain vigilant, public teaching hospitals, and soon private
hospitals, will be demanding increased remuneration from universities for their
resident and consultant teaching time of medical students. This situation will
result in fraying of the fabric between the teacher (senior residents and
consultants) and the student. The apprenticeship model and goodwill now appear
to be on the wane.
Must Read Articles
Perspective
FOCUS ON RESEARCH
A
New Cell-Cycle Target in Cancer — Inhibiting Cyclin D–Dependent Kinases 4 and 6
Unlike
traditional cytotoxic drugs, CDK4–CDK6 inhibitors arrest progression through
the G1 phase, promoting transient cell-cycle withdrawal into a quiescent state
or, possibly, permanent proliferative arrest (senescence), either of which
could avert tumour progression.
REVIEW ARTICLE
Acute
Pancreatitis
This
review summarizes recent changes in the management of acute pancreatitis,
encompassing fluid resuscitation, antibiotic use, nutritional support, and
treatment of necrosis, and also addresses common misunderstandings and areas of
controversy.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
35-2016 — a 62-Year-Old Man with Dysphagia
A
62-year-old man presented with metastatic oesophageal adenocarcinoma. Two
months earlier, imaging revealed a distal oesophageal mass and enlarged lymph
nodes; biopsy revealed adenocarcinoma that had metastasized to the lymph nodes.
Management decisions were made.
This is an excellent discussion of the management of extensive
metastatic oesophageal cancer, in particular the use of genetic analysis after
failed primary and secondary chemotherapy protocols and radiotherapy. Demonstration of two abnormal genes
associated with the malignancy, especially MET amplification, led to the use of
a MET tyrosine kinase inhibitor (crizotinib) and freedom from clinically
apparent disease after four years! This is a classic example of “personalised
medicine” and a glance into the future of clinical practice.
Articles Recommended for Medical Students
Perspective
Adding
Value by Talking More
In
many situations, having physicians and other clinical personnel talk more with
patients and each other can be the least expensive and most effective approach
for delivering better patient care, and new payment models provide incentives
for such discussions.
IMAGES IN CLINICAL MEDICINE
Tabes
Dorsalis and Argyll Robertson Pupils
A
47-year-old man with HIV infection had shooting pains in his legs, progressive
difficulty in walking, tinnitus, and incontinence. Examination showed Argyll
Robertson pupils, which are nonreactive to bright light but constrict when
focused on a near object. A video is available at NEJM.org.
Great Argyll Robertson pupils, but is the examiner’s
attire professionally appropriate?
IMAGES IN CLINICAL MEDICINE
Heterotopic
Pregnancy
A
34-year-old woman with a history of appendectomy presented to the ED with acute
abdominal pain. An intrauterine pregnancy had been diagnosed by her gynaecologist.
Transvaginal ultrasonography revealed a 4-cm right adnexal mass and free fluid
in the peritoneal cavity.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other Articles which should interest medical students
ORIGINAL ARTICLE
Effect
of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion
In
a pragmatic trial, more than 30,000 patients requiring blood transfusion were
randomly assigned to receive blood after short-term storage or long-term
storage. In-hospital mortality did not differ significantly between the two
groups.
New Pharmacological Therapies
EDITORIAL
CDK4
and CDK6 Inhibition in Breast Cancer — A New Standard
ORIGINAL ARTICLE
Palbociclib
and Letrozole in Advanced Breast Cancer
Among
women with previously untreated hormone-receptor–positive advanced breast
cancer, the addition of the cyclin-dependent kinase inhibitor palbociclib to
letrozole therapy resulted in longer progression-free survival than that with
letrozole alone.
This article is a game-changer.
Other articles which may be of interest to certain students
None
