Starting Clinical School

Semester 8 started and I started attending my Clinical School on Monday 18^th July 2011. Orientation week for my hospital in Melbourne was defined as 18^th July (Monday) - 22^nd July (Friday) 2011.

Orientation week was very busy and I was so tired every day, as it was a complete change from the final 2 or 3 weeks of my holidays where I was basically sleeping, spacing out and attending to my special interests as much as possible. Given that I have insomnia and sleep late at night, I was really exhausted when I had to wake up at 7 AM to get ready to go to my hospital by 8:30 AM, but my anxiety (in relation to “first day of” any event) managed to keep me alert for the rest of Monday.

Throughout the week, there were lectures on different body systems (eg Cardiovascular, Respiratory, Neurology, Urinary etc) and the various Clinical conditions that can occur for them. These lectures were supposedly “introductory”, but I have forgotten so much of my Preclinical knowledge during my Research Year that the lecture contents seemed like gibberish (to me) for the most part. I had very little idea of what they were talking about, so I’ll have to do further research on the discussed topics in Medical textbooks in my own time. Frankly, I imagine that most Medical students would cope better if the Research Year was made optional, so most students would be able to enter the Clinical School with a lot more Preclinical knowledge retained instead of forgetting it during the “1 year holiday”.

Of concern was the introduction lecture to the Hospital System and protocol, and I’ve observed that there’s a lot of bureaucratic red-tape involved, ESPECIALLY from the Hospital Administration who seem to be able to conduct so many reactive “committee meetings” for “Code Grey” or “Code Blue” (emergency hospital codes), performance reviews etc. The number of “committee meetings” that the hospital administration seem to conduct seemed grossly disproportionate in respect to their main job requirements, and from reading the anecdotes of other senior medical students and doctors, this behaviour is rampant in public hospitals across Australia.

My favourite lectures for Orientation Week were the following:

- Clinical School Introduction

- Semester 8 + 9 Overview

- Medical Long Case + Short Case Introduction

- Psychiatry + Psychiatric Issues in Doctors

These were the only lectures that I could understand, as I barely did any Medical studying during the holidays before Clinicals started. Semester 8 + 9 consists of one main subject called “Integrated Clinical Studies”, however the total subject mark is comprised from other components in the following proportions:

OSCE (Sem 8, 10%)

Tutor Mark (Sem 9, 10%)

MCQ Exam (Sem 9, 40%)

OSCE (Sem 9, 20%)

Long Case Presentation (Sem 9, 20%)

The only assessment that’s worth anything in Semester 8 exams is the Semester 8 OSCE, which is a relief. However, this doesn’t mean that I should slack off, because the arrival of the MD students (the new Graduate entry Medical Degree at Melbourne Uni) next year will make it harder for me to access patients, so I might as well see as many patients as I’m comfortable with this Semester (Sem 8) to gain more and more Clinical experience.

For my clinical school, a Long Case (exam style) is a thing where you meet a random patient with a Medical condition that you’ve learnt previously, and you have 1 hour to interview them, perform physical exams, and then create a summary + management style, along with possible Differential diagnoses, and then present your relevant findings in front of 2 Doctor judges via a 12 minute presentation. A short case on the other hand is much less stressful and is quite similar to an OSCE, if not the same.

In the Psychiatry lecture, the lecturer said that a lot of JMOs (Junior Doctors) and medical students have anxiety and/or depression, but they don’t always talk about it with other people for fear of being seen as “weak” or a “failure”. He also said that lots of doctors are burnt out and/or have “closet” alcohol consumption issues, and that female doctors are more likely to be depressed and commit suicide (%age wise) than male doctors. After seeing the hospital environment during Orientation week and Week 1, and from reading the anecdotes of countless other health professionals in the public system, I’m not surprised that this is the case, and I wouldn’t be surprised if I quit the Medical field within 10 years after graduating (assuming I manage to graduate, needs to be elaborated in further detail in future)…

We are expected to attend the hospital from 9 AM - 5 PM (sometimes coming earlier coz of annoying lectures/tutes that start at 8 AM or even 7:30 AM), Monday to Friday. So it’s kinda like a fulltime job, except we’re not getting paid, and we’re supposed to be here to learn. The timetables KEEP ON CHANGING (sometimes it changes every 3 days) and there is barely any routine for lectures and tutes, which is frustrating me so much, as I have a stronger preference for routine and it makes it really hard for me to plan times to see patients on the wards in advance. I also don’t like how my locker is rather small (it’s around 2/3 the size of my locker in high school), has only 1 compartment instead of 2, and I can’t fit my bag in without taking my lunch bag out and placing it on top the main bag.

However, there are also some positive aspects about my Clinical School/Hospital. I don't have to wear a tie in winter at least, as my clothing style is still considered "neat" (hopefully won't have to wear a tie in Spring and Summer either). The toilets are very clean and have a pleasing atmosphere, more so than the toilets at the main Melbourne Uni campus. There are lectures scattered throughout the week that are compulsory to attend, and they serve as ideas on what to do further research on in textbooks. This is supposedly more didactic. Same with the tutes, where we get 2 or 3 a week. There are usually handouts provided in the tutes, and are conducted in smaller groups, so it’s easier to learn things. I like the bedside tutorials, coz I can see how the doctor talks to the patient, so I know which questions and phrases are appropriate and/or polite by Neurotypical standards in that given medical context. I’m also assigned a teacher who I’m supposed to meet once a week, who will teach me “social skills” and supposedly point out my “mistakes” in my interactions with patients, and how to improve on it.

I did get into a lot of trouble during Orientation week, which I won't be able to elaborate for legal reasons, but overall Orientation Week was extremely busy and exciting, and it felt like ages went by, as with Week 1. I can’t believe only 2 weeks of Clinicals have gone by…

My Experience from a Repetitive-Transcranial Magnetic Stimulation (rTMS) Trial (Part 2/2)

In 22^nd and 29^th June 2010, I visited the Alfred Psychiatry Research Centre in preliminary sessions to fill in my personal details and provide my official diagnosis to Dr. Peter Enticott. I also filled in several questionnaires that aimed to primitively gauge my severity on the Autism Spectrum (eg the Autism Spectrum Quotient created by Simon Baron-Cohen) along with answering his questions regarding my condition, what I’m doing in life and how I cope with it etc.

After the interview, I then had to take part in a “social stories” tests (not multiple-choice) where different social scenarios were read out to me, and I had to answer questions regarding the characters’ feelings, in addition to some questions with very obvious answers as they were “controls”. I was able to answer the questions correctly IIRC, but I had to assess it intellectually and not intuitively like how most other NTs do it, I was unable to answer the questions immediately. I also had to watch several videos of these shapes moving around on a computer (laptop) screen, and I had to explain the “story” behind what the shapes were doing. I could explain some of them, based on the speed of movement and the positioning of them (eg “The big triangle is chasing after the small triangle, and the small triangle is trying to hide from the big one”), but there were others where they were just bouncing around the screen in a pattern but with insufficient substance for me to create a “social/story” description. For the pattern-bouncing ones, I just said that they were bouncing along the walls at angles which is uncorrelating to physics in real-life (hitting angle vs bouncing angle), and that I was unable to make up a story regarding them.

For a paper that involved ASD and NT individuals and the “social” comprehension of animated shapes, you can check out this paper: http://brain.oxfordjournals.org/content/125/8/1839.full

Afterwards, a demo rTMS was performed on the area of my motor cortex which controls my hand muscles. The rTMS was done to calculate the minimum (threshold) induced current required to trigger muscle twitching in my hands (more accurately my right index finger IIRC). This minimum induced current would then be used as a reference to personalize the rTMS intensity (frequency is kept the same) of my Anterior Cingulate Cortex. It felt really weird to see my right index finger twitching upon rTMS stimulation without me wanting to move it in the first place!

On 20^th July 2010, I had to undergo an fMRI prior to the rTMS treatment. The fMRI was to assess my brain activity while I performed simple cognitive tasks in the machine, to determine which side of my brain shall receive the rTMS. I was supposed to push a button when I saw a certain action in the video monitor (visible to me via various mirror positionings) such as a hand grabbing a cup, or hands waving about. I think this has something to do with the “Mirror Neuron Theory” of Autism, where there’s a disputable hypothesis that there’s an underactivation of “mirror neurons” in ASD individuals. The fMRI was VERY LOUD, even though I was wearing earplugs.

I was then allocated to the placebo or active treatment group. Either treatment group received rTMS sessions for each weekday in a 2 week period. One rTMS session was supposed to last for 30 “trains”, where one “train” lasts for 10 seconds with 50 rTMS pulses (hence the 5 Hz). There was a 20 second interval after each “train”, therefore each rTMS session was supposed to last for 900 seconds, ie 15 minutes. My rTMS intensity was first initiated at “30%” (of maximum strength), but soon increased to 46% for my remaining sessions.

My initial 2 week period was from Monday 2^nd August to Friday 13^th August 2010. In each rTMS session, I wore a blue cap on my head (same cap for all sessions), with small measuring tape measuring stuck along its mid-sagittal line. The cap was tied to my head in a tight manner and then Dr. Enticott or Ms. Peachey positioned the rTMS “helmet” above my head to target the area of my brain to be stimulated. During the rTMS “trains”, I could hear a clicking noise with each pulse, along with a tapping sensation in my head, and it wasn’t painful. The coils performing the rTMS heat up quickly, so there was an aircon continually operating within the helmet to slow down the heating. I could feel my head being cooled down a bit.

1 month after that 2 week period, I had to fill in the same questionnaires, do the same social stories test, and do the same shape animation analysis as a follow up. I gave similar answers to before, and I didn’t feel that much different in terms of cognition, although I suspected that my eye contact slightly improved, although that could be a placebo effect. It turns out that I received the placebo treatment, and was then offered the REAL “Open Label” rTMS treatment in November 2010 instead. This time, I could feel a bit more pain at the top of my head after each pulse, although I clenched my teeth and beared it.

Below is the record sheet for the REAL “Open Label” rTMS treatment (Click on image for better resolution):

I can definitely confirm that after the real “open label” rTMS treatment, my eye contact has improved dramatically, far more so than the placebo rTMS treatment; it doesn’t hurt at all to look at people in a conversation anymore, I was completely shocked. In the past, I could look at people in the eyes but always felt a piercing intrusive sensation, like they were threatening me even if I knew that they were perfectly harmless (eg old ladies). Now, I can talk at somebody and look straight at their eyes for 15 minutes straight without feeling any pain or threat at all!!! Most notable was one case, where I hated maintaining eye contact with one of my Aunts, even though she was polite and kind to me, but when I saw her several months after the treatment, I could look at her the entire time she spoke to me without flinching or cringing inside!

I find this result bizarre given that the Anterior Cingulate Cortex doesn’t seem to have much relevance to sensory processing (according to my brief literature search at least). I experienced no other improvements/changes in other areas of cognitive, sensory and emotional processing. But certainly for the eye contact, this was a significant change and I have informed Dr. Enticott about this. Having improved eye contact means that I can now spend more time comfortably looking at a Neurotypical’s face in a conversation and attempt to analyze their facial expressions while listening to their speech, even though multi-modal (of communication style) processing is still hard for me and most other ASD individuals. It has given me more motivation to study the facial expressions of these NTs, so I can try to detect subtle cues in case they try to bully me, or manipulate/stab me behind my back.

The rTMS treatment has given me drastically improved eye contact while predominantly preserving my other positive Asperger traits. My other negative Asperger traits still exist, but the removal of one undesired trait (pain in eye contact) is more than excellent for now. This will be an important tool for me to mildly improve my communication with NTs, and to help defend myself from persecution from NTs for the rest of my life. I hope my eye contact status will remain like this without ever waning. I think rTMS for selective symptomatic treatment of specific ASD traits has great potential, and I support further research into rTMS and its effects on consenting ASD adults.

My Experience from a Repetitive-Transcranial Magnetic Stimulation (rTMS) Trial for ASD (Part 1/2)

NOTE: My blog post/s regarding my experiences with Transcranial Magnetic Stimulation (TMS) is/are way overdue, so my apologies to fellow ASD comrades (non-Communism related) and other blog readers for not posting such TMS experiences in November or December 2010. I’ve been busy with work and also procrastinating with other activities during the time since then.

I have just completed my Orientation week at my Clinical School which was very busy and stressful but will write about that in a post after the TMS ones.

(I was doing some Medical Literature search for further details about the Neuroanatomy involved in this trial. I may have made a few errors in the descriptions, so this post may be corrected in the future.)

Last year, I was 1 of 20 people to take part in a Transcranial Magnetic Stimulation trial that was conducted at the Alfred Psychiatry Research Centre that also has connections with Monash University (both located in Melbourne, Australia).

The full project title is called “The use of rTMS to Improve Theory of Mind Among Adults with Autism and Asperger’s Disorder”. I personally would’ve preferred the term “Asperger Syndrome” over “Asperger’s Disorder”, but that was how they named the condition in the title. The principle investigator was Professor Paul Fitzegerald (whom I never met in person), but the major investigators who conducted the trial that I had frequent contact with were Dr. Peter Enticott, Ms. Peachey and Ms. Rhook.

Very brief synopses of this study and others conducted by the same people can be read at www.med.monash.edu.au/spppm/research/devpsych/neuro-tms.html

www.clrsasd.org.au/documents/MAPrcASDResearchUpdateJan2011.pdf

The project aimed to see if stimulation of a certain part of the brain via rTMS (repetitive TMS) would increase the intuitive social awareness, and hence Theory of Mind in individuals on the Autism Spectrum that were verbal (especially HFA/AS people). I dunno the results for the other individuals, so I can’t say if the rTMS trial was overall successful, but I’ll be talking about my own anecdotes/results later on.

TMS is a relatively recent (primitive TMS started in the 1980’s), non-invasive technique to induce weak electrical currents in a conductor (in this case a specific area of the brain). The weak electrical currents in the neurons are created from a rapidly changing magnetic field that is a result of insulated electrical coils that are arranged in a specific style (usually coils), placed near the "conductor" and rapidly change direction in current. The rTMS involves multiple pulses in one go (in my case 50 pulses/10 seconds, ie 5 Hz), as opposed to "normal" TMS which is just single or double pulse per go. rTMS involves far more pulses, and therefore is supposed to create a longer lasting effect.

Unlike Electroconvulsive Therapy, TMS is much more selective by activating a far smaller part of the brain and has a very low chance of triggering seizures in those who don’t have a history of Epilepsy, and is far less likely to trigger memory loss.

The brain area that was targeted in this trial was supposed to be the Anterior Cingulate Cortex (even though the Participation Information states “Medial Prefrontal Cortex” which is located very close to it, I’ll have to ask Dr. Enticott for clarification). The Anterior Cingulate Cortex is located in Brodmann’s Areas 24 and 25 IIRC, and from various studies is partially involved in “empathy”, emotional processing/regulation and Executive Functions.

I chose to take part in this trial because the only other place I was aware of that was also performing rTMS trials for ASD individuals at the time was at the Beth Israel Deaconess Medical Hospital (BIDMC) in Boston, Massachusetts, so this was the perfect opportunity to take part in a potentially life-changing experience. I refuse to be completely “cured” of my Asperger Syndrome as I have numerous positive traits from it (innate drive for honesty and integrity, lack of materialism, non-judgmental towards those with non-harmful differences, strong eye for detail, hyperfocus).

I was very sure that this wouldn’t be a complete cure because I read about the accounts of John Elder Robison (famous person with Asperger Syndrome, author of autobiography titled “Look Me in the Eye”) and his friend who took part in the rTMS trials at BIDMC and reported improved intuitive ability to read facial expressions, eye contact, production of “auto-appropriate” facial expressions in response to others, and slightly improved Executive Functioning, but still retained other ASD traits like having narrower interests, stimming, seeing detail, being non-judgmental, honesty, and still having to learn most other social skills at an intellectual level and not automatically.

I felt that rTMS may offer a potential reduction in some undesired traits that make it harder for me to function in my daily living (such as intuitive difficulty reading facial expressions and body language of Neurotypicals and dislike of eye contact although I could manage it) while preserving my other positive Aspie traits that I value (as mentioned above). I thought that taking part in the rTMS trial would mean that I’d be betraying my “pure” ASD-self and the ASD Community (especially those that are vehemently “Anti-Cure” and “Pro-Neurodiversity”), but it is indeed true that for many Higher Functioning adults on the Autism Spectrum, their condition is a mixture of both beneficial and disabling traits, and that to reduce the severity of the disabling traits while maintaining the beneficial ones *WITH THEIR CONSENT*wouldn’t be immoral or unethical imo. I do acknowledge that some of the disabling traits are more a result of ASD individuals being the minority group in society, but unfortunately we will always be a neurological minority group in the world and will have to conform to a degree : (

I also acknowledge that my strong attention to detail and my hyperfocus ability is actually an indirect result of my partial Executive Dysfunction (having “normal” Executive Functioning results in “higher levels” of information processing, such as seeing the big picture and being able to rapidly switch between tasks, both which I have difficulty with), but I didn’t think that the rTMS would significantly increase my Executive Function to the extent that I wouldn’t be able to strongly see detail anymore.