Week 2

I started off this week by meeting with my mentor, Dr. Goodman, for the first time.  We met quickly in her office after she got out of a meeting and before she started seeing patients.  She asked me about my research interests and the work I do up at Cornell.  Unfortunately, she told me that she didn't have any projects that lined up well with my interests but she had a few projects going on that I could look into.  She mentioned that she was working on a project in collaboration with a pathologist at HSS, Dr. DiCarlo, who might have something I could work on. During this meeting, she also mentioned that she would try to arrange for me to go into the OR one day a week with one of her surgeon collaborators.
After this brief chat, I started shadowing Dr. Goodman as she met with patients.  Most were patients with RA who were becoming more symptomatic and needed to have their medications adjusted.  There were also a couple of patients whose pain was becoming so severe that they were becoming depressed.  Dr. Goodman mentioned that they may want to consider anti-depressants or seeing a psychiatrist because the depression can cause the RA symptoms to get or feel worse and it becomes a positive feedback loop of pain and depression.  One patient (patient Z), who is about 80 years old, came in who Dr. Goodman says is always happy and healthy with minimal complaints about his RA.  However, on this visit he needed to be brought into the hospital in a wheelchair because he had terrible neck pain.  This drastic change in symptoms without a clear cause convinced Dr. Goodman that the patient should be admitted to the hospital for future observation and treatment.
After seeing patients, I then shadowed one of the Rheum research assistants who had just been in a TKR surgery.  She had collected samples from the joint that had been replaced and brought them to pathology for sectioning and staining.  The RA told me that they rely on the pathologists to tell them exactly what their samples are.  The pathologist was able to look at the sample and tell us where in the knee joint it was from.  I thought it was interesting that the RA doesn't find this out from the surgeon when they receive the samples. While we were in pathology, the RA introduced me to Dr. DiCarlo and explained that I was looking for a potential research project.  Unfortunately, Dr. DiCarlo was really busy and it seemed as though his mind was elsewhere so I gave him my 30 second elevator pitch but I think it kind of went in one ear and out the other. 
Tuesday morning I attended the Combined Arthritis Program (CAP) conference where a couple of orthopedic surgery fellows presented some patients who had recently undergone surgery.  Most of these patients had good results, however, there was one, a ~30 year old, whose range of motion was worse after the surgery than it was before.  He wasn't in pain anymore, but his knee was very stiff.  The attending surgeons explained that there was really nothing to do for this patient.  No other replacement would work better and his ROM may improve with more time. 
I then went and shadowed Dr. Goodman as she saw patients.  We started by checking in on patient Z.  There was also a spine doctor there to see him as well.  The spine doctor looked at his back and neck and by palpation found that the pain was isolated to some of the soft tissue along the neck and shoulder, but it did not appear to originate in the spine itself.  Both the spine doctor and Dr. Goodman were at a loss for what could be causing his pain, which made patient Z jump and yelp whenever his neck was palpated.  Unfortunately, patient Z has a pacemaker so a MRI could not be performed.  Instead it was decided that an ultrasound should be performed to look at the soft tissue.  Hopefully this ultrasound can shed some light on what is causing patient Z's pain.
I spent the rest of the Tuesday doing some administrative stuff, getting access to the HSS medical library, and getting some training from the librarian.
On Wednesday, I went to Grand Rounds.  At this meeting, a patient was presented who was admitted with some unusual symptoms.  This patient was under the care of Rheum because they were admitted with a red splotchy rash (purpura) but they had also been having some mental ailments (dizziness, confusion, etc).  After running a number of tests and diagnostics, including a kidney biopsy, it was determined that the patient had Henoch-Schonlein purpura, which was not immediately expected because this condition mostly affects children and this patient was middle aged.  What was interesting was that this diagnosis would not have been made if the kidney biopsy had not been performed and analyzed by pathology.  The pathology was the only way to definitely determine the diagnosis.
I spent most of the rest of Wednesday shadowing the Rheum RAs.  They had abstracts for a conference due on Friday so they were frantically trying to put those together.  This also threw me into the world of clinical studies and all of the leg work involved in getting IRB approval, finding and recruiting patients, collecting and analyzing data, and presenting that data to the community.  One of the RAs told me about a spondyloarthritis (SpA) cohort group she was working on and that there had been talk of looking into DXA scan data from these patients.  She said she would talk to Dr. Goodman to see if I could possibly have that be my research project. 
On Thursday I attended adult reconstruction and joint replacement conference.  I saw a video of a TKR surgery.  This was interesting to see because I haven't actually seen any surgeries yet.  But mostly I was just happy that watching the video didn't make me feel sick/dizzy.  I'm still a little concerned that I'll pass out during my first OR visit, but hopefully I won't (fingers crossed).  The surgery video was interesting because it really just focused on the knee, so it was hard to tell that there really was a person there on the table.  I also didn't realize how much they manipulate the joint to put the replacement in.
I next attended the Rheum journal club.  The first article that was presented was on RA and cardiovascular risk, with the main take away being that patients with lower disease (RA) activity levels also having lower cardiovascular risk.  For the doctors this suggested that they should pay close attention to any cardiovascular issues in their patients with higher disease activity levels.  The second article was on the effectiveness of a new drug used to treat melanoma, this new drug was found to be more effective than the old standard drug alone.  It was hard for me to find the connection to Rheum, but I think these drugs are avoided in patients with RA and other autoimmune disorders in fear that they may exacerbate the disease.  The drugs work by activating the immune system in hopes that the immune system may kill cancer cells, but it is a fear that in RA patients, activating the immune system would simply worsen their autoimmune disease.
Later on Thursday, I met with Dr. Goodman to talk about potential research projects.  Unfortunately, she said that the SpA/DXA study would not be possible to do this summer, but I may be able to find another project using the SpA cohort.  She gave me some of the cohort summary data and some background reading to do.  I met with Dr. Goodman again later in the day to discuss my findings and we determined that I might be able to look at comparing disease activity levels and patient functionality in patients with SpA.  She told me to do some more literature searching before we made a decision.
On Friday, I did some more research on SpA in the morning to make sure this area had not already been investigated.  At noon, I attended a "disparities" meeting.  I'm not sure what the official title of this group is, but it is a group of Rheumatology attendings, orthopedic surgeons, biostatistians, and clinical researchers who do research focusing on the disparities in treatment, outcomes, etc between patients of minority groups and patients of majority groups.  They discussed a new study they just got IRB approval for looking at patients who are scheduled to undergo TKR or THR but cancel before the surgery.  They are looking into the demographics of the patients, when they cancel, their reason for cancelling (could be deemed necessary by doctor, could be personal), and other variables.  The initial study will focus on patients who cancelled their surgery on the day of the surgery during the year 2013.  The reason for this focus is that day of cancellations are systematically tracked within the hospital whereas the method for recording cancellations that occur before day of varies depending on the surgeon.  This initial, retrospective study will provide some evidence that will inform what data should be collected for the larger prospective study.  I spoke with Dr. Goodman after this meeting and she suggested that I should work on this project since it is just starting and will wrap up before I leave.  So she put me in contact with the clinical researchers who are running the study, who I will hopefully meet with early next week.  I'm hopeful that this research project will stick.