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Discussion about entry: Diagnosis Life: A Medical Adventure Game
This is discussion about Diagnosis Life: A Medical Adventure Game.
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Your web site is a fantastic one to show to medical students and I will certainly be referring medical students at the Boonshoft School of Medicine, Wright State, Dayton Ohio with two caveats:
1) The medical history and evidence based physical exam is FAR MORE important in making a diagnosis than the pathology lab.
2) You have missed a major cause of pathology of disease that links many diseases together.
The family friend whispered one word to the GRADUATE: "Plastics"
I whisper to you: "Cytokines" - They should be featured front and center as an anchor and as a glue to explain the pathology of a potporri of diseases.
See: December 7, 2002 Lancet article from Hong Kong on the "cytokine storm" as an explanation for human pathology of the H5N1 virus and as a model for "all human pathology"
What happened to the immune system when the reconstituted 1918-1919 influenza virus was used to infect the monkeys at the Level 4 facility? What was the DIRECT cause of their alveoli being flooded with inflammation fluid
And as Louis Pasteur is purported to have said on his deathbed:
"The bug is nothing; the terrain is everything"
where "terrain" = macrophages, pericytes....that have been stimulated to release (and continue to release) those pro-inflammatory cytokines.
What explains the pathology of Bird Flu, SARS, smallpox, hemmorhagic mediastinitis of anthrax, hantavirus, ulcerative colitis, allergic rhinitis, sarcoidosis, many middle ear effusions in children, post-viral chronic coughing....?
So a suggestion: You need to include in your game THE GAME of ACUTE AND CHRONIC INFLAMMATION.
Charles Beauchamp MD, PhD
Associate Professor of Community Health
Boonshoft School of Medicine
Wright State University
Dayton Ohio (First in Future Health)
I very much appreciate Dr. Beauchamp's kind words. And his emphasis on the history and physical diagnosis is central to my own approach to teaching pathology. I suspect he recognized this by playing the game. If the player speaks to the pathologist before a good history is taken, the pathologist replies, "There are a thousand and one lab tests, but the single most helpful is the patient history."
Without spoiling the game, I deliberately chose, for my first scenario, an illness that should be diagnosed and correctly treated at presentation on the basis of the history and physical exam. Routine labs are helpful only to show that the patient is seriously sick. The game will not allow a biopsy to be taken until the history and physical exam are complete. This gives two different ways to arrive at the correct diagnosis in time to save the patient's life, and the final critique will be most favorable.
As an MD who's switched by preference to the osteopathic tradition, I have a special opportunity to emphasize the relationships between structure and function that are the key to good, clinically-oriented pathology teaching. The "whole person" philosophy make students accepting of my constant reminders, "How does what you see under the microscope / in the surgical specimen cause the patient's signs and symptoms?" The pathology team plays a central role in the teaching of physical diagnosis and clinical imaging. Our labs are CPC-based, with 3-5 cases per hour. By the second year, students attempt a diagnosis (or at least a "diff") after the history, another after the physical, a third after the labs and imaging studies, and a final, definitive diagnosis when the tissue studies are shown.
When I was a resident in the 1970's, my chairman told us that the future to understanding disease was in the study of the molecules involved in cell-cell interaction. Dr. Beauchamp is right to remind us of the central role of cytokines in disease. Instruction in this enormously complex realm is handled, at my institution, by the molecular biologists and immunologists. I have chosen, in my own notes, to provide references to the current literature. If gene probes for cytokine expression become an important part of diagnositic pathology practice, I will introduce photos into my pathology notes. If lab assays of cytokine and cytokine-receptor levels, already an important research tool, become central to the diagnosis of particular diseases in the clinic, I will cover them. In the meantime, I felt obligated to limit myself to providing current leads, and of course to describing the impact of cytokine-related therapies, such as those that have revolutionized the treatment (and hence the anatomic pathology) of multiple sclerosis, inflammatory bowel disease, and the immune-based arthritis family of diseases.
The second scenario is almost completed, and once again should be an easy call to any clinician with good skills observing people and taking a history. No one will think of the right lab without a good history. The third scenario won't be spoiled, I hope, by my mentioning that our students are often surprised when they are introduced to the concept of superantigen toxicity, and why it's good that most of the lymphocytes are "fast asleep" most of the time. I appreciate everyone who's enjoyed the games so far. Health and friendship.
I found your posting here extremely helpful, for while I had read your entry and played your game, I (who have no MD) couldn't grasp the fine points you were trying to articulate or have the player come to realize as a result of playing your game. Thus, I wonder whether you might not be wise to include some of those points in the application itself, in place of your more generic comments, so that those who have no MD can quickly grasp your points. (For example, it might make sense to say that the game shows that, "to make a diagnosis, it's essential that the doctor take the history", or some such...)
Best,
Diane
The Changemakers Team
Talc in feminine hygiene products (ovarian cancer), CAD + Depression, asbestosis induced mesothioloma, procelain gallbladder and gallbladder cancer, ulcerative colitis and adenocarcinoma of the bowel, Bowen's Disease, Takayasu's Arteritis.....
Pubmed searches and results:
Cytokine AND pathology ---> 67,673 references
Cytokine AND cancer ---> 74, 665 references
Do you have a cytokine multiplex assay machine?
CB
To stress the importance of the patient history and physical exam in your game, I suggest you extrapolate from the following three texts (no longer published but not out of date) and create game out of conversational, hands on medicine and thinking as a prelude to consulting the laboratory:
Symptom Diagnosis by Yater and Oliver, Fifth Edition, 1961
Guide to Clinical Reasoning by Kraytman, 1981
The Complete Patient History by Kraytman, Second Edition 1991
BYW please excuse my misspellings in prior communications
Charles Beauchamp
Your advice sounds very good. I added what you suggested, and I feel it plays better and will probably be much more satisfying, especially for non-physicians. Although I went to a top-notch medical school, I was not well-prepared for the frightening and confusing world of ward medicine once the classroom phase was over. Although at the school where I now teach the preparation is much better, part of my purpose in creating this game for everyone is to depict just how nightmarish the learning medicine can be. I'm pleased to be able to submit these little adventure games to a group that's dedicated to finding creative solutions to human problems.
I appreciate your advice. I have made change in the game introduction and encounters to reflect this. Although I received an excellent overall medical education during the 1970's, I found myself poorly prepared for the ward experience. It was a frightening and confusing time for me, as it is for so many students even today. Medical student's who've tried my game have found it helpful as an introduction to the system by which physicians decide on diagnosis and treatment. Of course, each scenario (of which I've completed two so far) will also provide a realistic encounter with a patient who does not seem especially sick but who will die if the physician doesn't make a relatively difficult diagnosis while there's still time.
Dr. Tucker, your comments reminded me that my game should have additional value -- simply to show people who are interested in the education of tomorrow's physician just how challenging and often overwhelming it can be to begin seeing patients. Especially when there's almost no guidance and only negative criticism, the beginning student can become frustrated and feel it's hopeless. I've devoted my own life to helping people understand disease, and preparing medical students to deliver patient care that's both kindly and scientifically solid. My adventure games are only a sidelight, but if they help others understand the process of becoming a physician, and think how we can make it better for everyone, they'll be well worth it. Health and friendship.
Dr. Friedlander,
Thanks for your note and your responses. I wonder why you don't put more of this "story" into the application itself. Indeed, there's a category in the application well-suited to house one part of it (namely: "what's the origin of your innovation? tell us your story"). In addition if you view your game as filling a gap that exists as a result of the way doctors are traditionally educated, you should tell us more about that in your application itself, as that's central to the innovation your game constitutes
Best,
Diane
Thank you.
The Changemakers Team
Dr. Friedlander:
I believe your idea is workable and innovative. Even though I am neither a doctor nor a student, a few of my family members are doctors and heard about how difficult it is for medical student and new doctors.
I understand that your idea is to use this game as a learning tool for medical students as a virtual experience to prepare for the ward. Just as training pilots use flight simulators to practice flying, this game should allow the medical students to get acquainted to the various situations.
My concern is with the link between your idea and social change. It is unclear what kind of social problem this idea is going to solve from reading the entry.
Under “What is your vision for how this initiative will affect the world”, it says "more good computer simulations for physicians to enjoy at the end of a hard day." I believe your idea can go beyond that. This idea can be incorporated into the teaching curriculum, and change the way students are taught at the medical school breaking away from the traditional teaching style (social change).
Regards,
Yoko
Hi, Dr. Friedlander,
Just a little note written in the hope of encouraging you to expand your entry a bit -- incorporating some of the points that have commentators have offered, expanding on sections that are more abbreviated than they might be... I know that your entry remains too brief for (and thus, unclear to) some. While the skeleton your entry provides seems a fit one, it would be great if you could provide it a bit more flesh...
Thanks,
Diane
Changemakers