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CONTEXTUAL LEARNING FOR PREMEDICAL : ,;.'..,. r· " . ;tI;o. .. :_eivc,~.e~n~~tEe;fi,t~~"· rii;~~: for the AI. Th . .~ STUDENTS : . /~:"· ,.,',. ,. Penny J . Gilmer Alison Grogan and Susan Siegel Florida Stale ,University INTRODUCTION F l" ~ r , { : Contextual learning for premedical students was created to provide learning opportunities not normally available to undergraduate students. Premedical students often search for ways to gain experience in the medical field prior to entering medical school. The contextual study of systemic lupus erythematosus has given the students the opportunity to study a disease in many of its aspects. Sources of information for the study ranged from literature to patients and physicians. The multitude of sources provided knowledge not only of lupus, but of the medical profession as well. The contextual study of systemic lupus erythematosus began with a conversation between the senior author and a former middle school science teacher. The teacher remembered the author's research interest in the response of the immune system to cancer cells. She mentioned the surprisingly high number of cases of lupus in her home town, the rural community of Monticello, Florida. At the Monticello Family Medicine clinic, there was a reported ten cases out of a population between 6,0008,000 people. The authors eventually discovered from 79 Gilmer, Grogan & Siegel Selected Conference Papers 81 80 th incidence was within range numerous sources that e rce but is around 14.6(which vanes from source tod:,u ndi~g on the population 50.8 cases/lOO,OOO people, pe 'ded a challenge that I 'ty of lupus provi possibilities. Sources ranged tested). The comp eXI would incorpora~e numero~sl . and use of the Internet to Journal •artlC es, I'VV , and the physicians who treat from tex t"~'ks , speaking with lupus patients these patients. SYSTEMIC LUPUS ERYTHEMATOSUS to s is an autoimmune Systemic lupus erythema su ·th the disease form disease with no. known ~ause. P~:: w~ normal antibody antibodies agamst their own . the body and forms recognizes foreign substance.~ m ed from the body. I hich are remov immune comp exes w bod ~ rms immune complexes With lupus, though, the d ~ 0 es thus attacking and with its own org~s an ssuolC::ules are known as I . These Immune m destroy mg. . . (ANA) because they attack nuc ear antinuclear anubodl~s ells The formation of the components of their own \ ~welling and scarring of immune complexes results I . and discomfort associated tissues. These effects cause pam with lupus. . complaint of many lupus Joint problems are. a major imilar to rheumatoid patients. Swelling r.esultsdm Plrob~e,md~:y problems when the .' Many pauents eve op \U I 'ng and eventual rena arthnUs. immune complexes lead . to I ~ "butterfly" rash on the failure. Other sympt~ms mcdu e' fluctuations. With the d presSIOn an wei ght · f ' . often difficult to diagnose. A face, augue, e myriad of symptoms, lupus IS ANA test that is specific for positive immunofluorescence . . the antinuclear antibodies is in the diagnOSIs. Lupus, as with most other autoimmune disorders, is more prevalent in women than in men . Women are 10-15 times more likely to develop lUpus. Black women are at greatest risk, with Asian and white women following. There is a possible link between high estrogen level and lupus. Interestingly, men with lupus typically exhibit a higher estrogen:testosterone level than men without lUpus. Men with lupus usually have the discoid form of the disease. Discoid lupus appears as a red, raised rash which is often coin-shaped (hence, the name). This rash is often large and scarring. Women are more susceptible to systemic lupus which affect~ organ systems of the body. A third form of the disease is drug-induced. Drug-induced lupus is caused by some prescription drugs for hypertension aod irregular heartbeats. The lupus symptoms subside once the medication is discontinued. Treatment of the disease is as complex as the disease itself. The variety of drugs needed to treat the multiple symptoms all have some potential damage. Corticosteroids are commonly prescribed for treating internal changes caused by lupus by decreasing inflammation. Cytotoxic drugs are used in extreme cases when the patient fails to respond to corticosteroids. Rest and avoidance of sun are also highly recommended for patients. CONTEXTUAL LEARNING In the contextual study of lupus, many sources were used in gathering information, including books, journals, and patient files. With patient files, the issue of ethics in medicine and patient-physician confidentiality was pursued. Gilmer, Grogan & Siegel Selected Conference Papers 82 . . e above interviews were conducted .to h)\Iowmg th . ' f the study began WIth ontain additional data. ThIs phasetl'tI~oner at the Monticello . . ·th a general prac . f th a dIscussIon WI .' us an overvIew 0 e for on patient charts. He Family Medicine. chOlc. He disease and explamed what to tI'ents had to go to . ed that most lupus pa . . also explam . t rns Another phySICIan specialisL~ .fo~ some of th~: ::~: to ~ne of his p~tien~. at the chnlc mtroduced d ted with speciahsts \0 Interviews were also co:n~c chiatry, as well as with rheumatology, nephrology, FI ';?'da State University. an immunology professor at 0 great benefit to the study. Patient involvement was a . . and verbal .' . questionnaIres Written commu~lcatlOn .vla 'ded insights into the communication 10 mte~lews ~~~ lupus is not a visible . '~~I • personaI aspects of the dIsease., . ·&..... ~tions are 10..... . be many of Its manl....... . th dIsease, cause. . ·th s about havlOg e Patients shared theIr feehngs WI u f:: disease. I ttended LupuS Foundation of The authors a so a .th people there At the ( sand met WI . . Amenca local mee 109 . Is spoke about lupus-related meetings, health p~ofess\O~a pecialty We had a chance to to ics based on theIr area 0 s .. m~t patients and to hear their questIons. THE PAPER SOURCES books Much has been written about lUpus. ~any ~<nH:ts .d . f r mation about the vanouS ~r and journals pr~vl ~ 1O.0 Talbot, 1993), epidemiology of lUpus, inc1udlOg Its hl~ory ~ O'Dell 1995' Pollak and ~d ~athoge~esis ~~tzl~~), sympt~ms (S~hU~, 1993): PlraOl, .1993, W , Hahn, 1993; Quismono, 1993, diagnOSIs and treatment ( I 1993) as well as the Wallace, 1993; Wallace et. a., ' 83 pathology of the disea.~ (Dieppe et. aI., 1986) and its many manifestations within the body. All sources agree that lupus is mysterious and unpredictable. No two people have exactly the same form of lupus. It cannot be determined prior to diagnosis which body systems will be affected. Only involvement of the kidney can possibly be ruled out. After diagnosis, if kidney involvement has not occurred within the first six months, the patient is unlikely to develop symptoms of renal failure. A firm background of the disease was developed from written sources. Pictures in these books brought the images of rashes, scarring of organ systems, and joint inflammation (Dieppe et. aI., 1986). Views within the body allowed us to "see" lupus as not possible from the outside. The Internet was also a great source of information. The Lupus Home Page (1996) provided an overview of lupus, and a number of other web sites led to further learning. The Lupus Home Page revealed basics of the . disease, including types and symptoms of lupus. It also identified the prevalence of the disease in women and associated disease "flare-ups" with menstruation. The home page was optimistic about the prognosis of the disease. Only in extreme cases was it identified as fatal, and new research continues to provide information for treatment and coping with the illness. Patient files at the Monticello Family Medicine clinic were reviewed, and measures were taken to insure confidentiality. The importance of ethics in medicine became apparent and the relationship between doctor and patient were respected. Nine available patient files were examined--all females--which provided the first glimpse of . bow differently lupus affects people. The authors traced the disease from symptoms to f'dUl~:>Sis in each patient. The course of treatment provided Gilmer, Grogan & Siegel Selected Conference Papers 84 for each patient was followed through the doctors' notes and the laboratory data. Each individual patient had a different pathway of symptoms and treatments. Often, months and years passed before an official diagnosis of lupus was made. PHYSICIAN SOURCES From the paper sources came sufficient information to form an intelligent basis for discussion with others, namely three specialty physicians. Each physician provided a background of the disease manifestation in the particular organ system. The doctors explained diagnosis and treatment of conditions. One of the three, a rheumatologist in Tallahassee, had a number of lupus patients. He gave us a brief history of lupus and explained that it does not usually occur vertically within families; i.e., a child and her aunt may have the disease rather than a child and her mother, although the latter is possible. Joint involvement in lupus most often leads to symmetric polyarthritis of the small joints (hands and feet). Pain is caused by inflammation due to formation of the immune complexes in the joint area. Over-the-counter medications such as asplfln are recommended in mild cases, while corticosteroids are prescribed in more severe cases. A second physician, 11 rheumatologist and expert in lupus from the University of Florida, gave a seminar at Florida State University at which he spoke about a particular antinuclear antibody specific for DNA. This antiDNA antibody is found in patients with kidney involvement. He described an immunofluorescence test on kidney tissue, in which every nucleus fluoresced, indicating 85 the ~resence of the antinuclear antibodies. The formation of the Immune complexes causes extensive scarring and can lead to renal failure. . ". nephrologist in Tallahassee provided additional mfor~tJon abo~t kidney involvement in lupus patients. He explamed ~at kl~ey involvement is rare in patients over ~5-40. A bIOpsy aIds in the diagnosis of the severity of the t1lness. Se~ere kidney involvement leads to renal failure when .scarnng damages the microscopic glomulerli, which are kidney filters needed to make proper urine. When filtering capability is decreased, substances essential to the ~y such as amino acids and glucose are lost in the urine whtle w~ products are retained in the body. Dialysis is often u~ m ~ases of renal failure to increase the amount of q~ahty unne excreted from the patient. He further exp.lamed that kidney ~ansplants were occasionally an option. ImmunosuppressIve drugs are given to the patient to help prevent rejection of the transplanted organ. Lupus does not often reoccur to damage a transplanted kidney. A Psyc~iatrist in Tallahassee spoke to the authors . about ~e emotional aspects of dealing with lUpus. Althougb lupus IS not always fatal, it is hardly curable. Symptoms ~y vary fro~ day to day, and the pain can be tremendous. ~?, uncertamty, and fatigue often lead to depression. He indlca~ that most lupus-related depression sufferers have no hl~ry of depression. Antidepressants are often prescnbed to control depression. . PATIENT SOURCES Communication with lupus patients was initially .b.and~ed .through a ~uesti~nnaire. The answers provided information about dIagnOSIs and manifestations of lUpus. Selected Conference Papers 86 Two of the patients indicated that they were willing to meet with two of the authors about their experiences with lUpus. All communication between the authors and the patient was through the physician. Two female patients in their 50's were interviewed at the Monticello Clinic. Both were well educated about their condition. Self-awareness is touted to be important in coping with the disease, and these women demonstrated it. Each had years of symptoms before her diagnosis. The symptoms differed in each case, but both had multiple symptoms. Both agreed that stress worsened their symptoms. Speaking with patients gave lupus a face. Seeing how patients coped with lupus provided insight into how it feels to have lupus. One of the patients introduced the authors to a book entitled "Living with Lupus" (Blau, 1993). Another guide for patients is by Wallace (Wallace, et. aI., 1993). Understanding patients needs and feelings appears to be an enormous factor in caring for them. Gilmer, Grogan & Siegel other and by recogn " r living with lupus. Izmg lterature SOurces dealing with CONCLUSIONS . The study of lupus led throu h mterweaving of SOurces bU'Jt g many pathways. The disease as the authors tt I upon the complexity of the it--as we learned more a e"Tted to analyze and understand to others. The sourc~s w~u:;f~ beaer able ~o explain it another. A patient described p as one thing lead to her doctor and the tr tm a symptom and told us about ~mptom and the treat:ente:;d· the doctor e~plained the JOurnal led to further reti suggested a Journal... the knowledge and ~rences ... which led to more doctors. more quest/ons for the patients and the Interest grows with th Everything expands and in th. e wealth of knowledge. one relative point, I~pus. IS case, It all goes back to LUPUS FOUNDATION OF AMERICA The Lupus Foundation of America (LFA) has chapters which provide support services to individuals with lupus and for their families. LFA is a volunteer-driven nonprofit organization. In Tallahassee, it meets once a month from January to September. Guest speakers at the meetings discuss different aspects of lupus and effects of treatment, both good and bad. In October, which is lupus awareness month, the Tallahassee-Big Bend chapter conducts a large meeting with numerous speakers. LFA provides encouragement to patients by supporting each 87 REFERENCES Blau, S. (1993). living with Lu . Med to help yourself. R d' pus. All the knowledge you . ea 109, MA: Addison-Wesley. Diewe, P. A., Bacon P A B ... (1986). Atlas of Cli~cai amIJI, A. N., and Watt, I. Medical Publishing, pp. 8.4 9W;:U9010gy. London: Bower , " .3, & 9.6. I I I I Rk I Selected Conference Papers 88 Hahn, B. H. (1993) Management of Systemic Lupus Erythematosis. In W.N. Kelley, E.D: Harris, Jr., S. Ruddy .. & C.B. Sledge (Eds.), TextbookojRheum(J(ology, 4th Edition, Volume \I (pp. 1045-1055). Philadelphia: W. B. Saunders. Gilmer, Grogan & Siegel 89 Wallace, D. J. (1993) An' . Wallace & B. H.' Ha:::alanal therapies. In D. J. Erythemarosis. 4th &fti (Eds.), Dubois Lupus & Febiger. I on (pp. 563-564). Philadelphia: Lea Kotzin, B. L, & O'Dell, I. R. (1995) Systemic Lupus Erythematosis. In M. Frank, F. Austen, H. Clamall, & E. Uranul (Eds.), Samtt'r's Immunologic Disease (pp. 667692). Boston: Little Brown. Wallace. D. J., Hahn B H . A patient's guide to Lup~s E~ QUlsm~rio, F., Jr. (1993). & B. H. Hahn (EdS) Dubo' ematosls. In D. J. Wallace Edition (pp. 542-552).' IS Lupus Erythemarosis. 4th Lupus Home Page. (1996). Author (on line). Available: < http://www.iesd.auc.dkrIupus/index.html> Pollak, V. E., & Pirani, C. L. (1993). Lupus Nephritis: Pathology, pathogenesis, clinicopathologic correlations and prognosis. In D. J. Wallace & B. H. Hahn (Eds.), Dubois Lupus Erythematosis. 4th Edition (p. 533). Philadelphia: Lea & Fellinger. Quismorio, F., Jr. (1993). Systemic corticosteroid therapy in Systemic Lupus Erythematosis. In D. J. Wallace & B. H. Hahn (Eds.), Dubois Lupus Erythemarosis. 4th Edition (p. 533). Philadelphia: Lea & Febinger. Woods, V. L. Jr. (1993) Patho . Erythematosis. In W. N.· Kelle genesIs of Systemic Lupus Ruddy , & C ' B . Sledge (Eds) Toy, bE. D. Harris ' Ir ., S . 4th edition, Volume II " ext OokojRheumarology. B. Saunders. (pp. 999-1015). Philadelphia: W. I I I I I I Schur, P. H. (1993). Clinical features of SLE. In W. N. Kelley, E. D. Harris, Jr" S. Ruddy, & C. B. Sledge (Eds.), Textbook (?f Rheumatology. 4th edition, Volume II (pp. 1017-1039). Philadelphia: W. B. Saunders. Talllot, I. H. (1993). Historical Ilackground of Discoid and Systemic Lupus Erythematosis. In D. I. Wallace & B. H. Hahn (Eds.), Duhois Lupus Erythematosis. 4th Edition (p. 4). Philadelphia: Lea & Felliger. I I I