How Rosemary’s Baby Could Make us Better Medical Educators Jeffrey Holt MD TCMC

1. How Rosemary’s Baby Could Make us Better Medical Educators Jeffrey Holt MD TCMC Alex Holt Columbia University Jennifer Joyce MD TCMC

2. Medical Cases are Commonly Used For Active Learning Premise: Many medical cases initially have multiple possibilities until a single finding establishes diagnosis Although lay culture believes diagnosis made by single X-ray or definitive lab test, usually a synthesis of multiple findings: unlike usual medical cases Possible Solution: Build cases which require synthesis Screenwriters excel at this- we can learn from them

3. Typical medical case style: A 24-year-old married woman moves to new apartment building with strange neighbors. She becomes pregnant and has strange dreams. Release: Gives birth to child with horns and devil tail Roman Polanski style Shifting perception is key Events may be viewed in two or more ways Dreamlike sequences

4. Worked Example: Headache • Case Objectives: • Emphasize importance of social factors in diagnosis • Rely on information from patients and not just tests • Importance of open-ended questions • Diagnosis: Headache from hunger • Social Cause: Woman feeding children and herself from grandmother’s social security payments until grandmother dies • Some specifics: • headache began gradually over last few weeks • History: weight loss, stomach ache, cant concentrate, lack of strength or energy • Exam: sympathetic findings (shaking, sweating, palpitations), fruity breath, thin, muscle weakness, fatigue • Lab: urinary ketones, low serum glucose • Let’s add a misleading image (low predictive value)

5. Worked Example: Headache A 34-year-old woman presents with a headache. When asked “where does it hurt” she points to the back of her head on the left. She says that she has them frequently beginning about 2 months ago but they are getting worse. She is sometimes nauseous during the headache. A neurologist diagnosis her with migraine headache and prescribes sumatriptan. An MRI is read as “white matter abnormality consistent with migraine headache”. First release: She returns two weeks later and still has headache. She says she couldn’t afford the sumitriptan. A more detailed history learns she has stomach aches, can’t concentrate and has lost 10 pounds. Exam: thin, shaking, sweating, rapid pulse, muscle weakness. Lab: low serum glucose and urine ketones. Given sumatriptan sample pills.

6. Worked Example: Headache Second release: Medical student and social worker make home visit to patient as part of a community health initiative. She lives in a small apartment with trash and weeds outside complex and teenagers hanging around outside. She has two children who are thin, a mattress in the living room, belongings neat but sparse. Medical students asks her “why do you think you have headaches?” She answers that there has been less food since her grandmother died and the social security checks stopped. Student goes to nearby store and brings back food. Her headache goes away.

7. Ready for Group Work Divide into Groups Write cases with multiple releases

8. First Group Case: Dysarthric paraplegic with vomiting • Case Objectives: • Emphasize importance of social factors in diagnosis • Physical disability is not necessarily intellectual disability • Active listening is important in medical assessment • Diagnosis: Gastroenteritis • Social Problem: Physically disabled people often misperceived as mentally retarded. Just because we don’t understand them doesn’t mean they don’t understand and cant express themselves • Some specifics: • patient in wheelchair with dysarthria (difficulty speaking) • History: Ate with a group at fast food place 24 hours ago and several developed nausea and vomiting. Graduate student with spastic paralysis of legs and speech stammers and difficult but not impossible to understand • Exam: low blood pressure and dehydration by exam. • Lab: Metabolic alkalosis with low chloride

9. Second Group Case: Child sexual abuse (incest) • Case Objectives: • Emphasize importance of social factors in diagnosis • Active listening is important in medical assessment • High index of suspicion for domestic violence (sexual abuse) • Diagnosis: Child sexual abuse • Social Problem: Abused people must feel safe. Rarely confide on first interaction, particularly to the unperceptive. • Some specifics: • Father is anesthesiologist at hospital • Teenage girl reluctant to go to hospital; very anxious there • History: Injured at school and taken to hospital ER (unrelated to sexual abuse). Father comes to see girl immediately and she becomes quiet. Father says social worker is unnecessary as he can get her the help she needs. When she leaves with him she seems anxious • may need multiple releases in case for several visits by social worker. In actual case the patient eventually reported the sex with her uncle while her father photographs (reported to social worker)