Immuno Rage

I cannot quite remember any class that has inspired such rage. It was not the material itself, which I liked, or even the obscure clinical trials, some of which were interesting but mostly boiled down to: oops, this TNF blocker for rheumatoid arthritis gives you cancer (which the FDA didn't spot until after it was approved) or uh-oh, looks like you can get progressive leukoencephalopathy from your psoriasis meds (all of which convinced me to tell everyone I know to stay away from Phase 1 and 2 trials).
I also feel like a good chunk of immunology is guesswork - we know how certain things interact and many of the big players, but ultimately it's an extermely complex system that we're just scratching the surface of. And when we mess with one thing, say nTregs, the consequences are often unexpected and vary widely from model organisms. There are many diseases that people are suffering from today and I do sympathize with the urgency to develop drugs to help them even with incomplete info. I guess that is part of the challenge of medicine: sometimes it means operating on partial info in desperate situations, especially with cancer and painful, chronic diseases.

But anyway, what really got me about this course was the questions! For some reason the way these questions were worded and presented with the material just burned me up! I have not felt this angry at a class before. I can maybe blame the heat, or that I needed on object at which to focus my unspecified rage (Dr. S), but I don't know. After the exam there were the typical discussions about questions and complaints about the course. I managed to distill my issues into two main points:

1. The material was presented poorly from the beginning without a big picture, proper diagrams, or any good interconnection and context. We were expected to straight up memorize random letters and names with little info for how they interacted and that just don't work for me!
2. There were major inconsistencies between the material presented in class, the notes provided and the lack of a real textbook meant we went shopping for various sources (purple book, white book, red book, brown book, HY, wikipedia) many of which gave conflicting info about basic topics (like HLAs that never showed up on the exam btw)

These two factors combined with poorly worded questions made for an extremely frustrating course. When I said this to a few people outside the test, one guy said the following "Those are two great points that, as SGA representatives, we have brought to her attention. She said you will thank me later for teaching you how to learn." Wow, haven't seen such arrogance and idiocy since the days of Bush II. Yet, if I did well and got within the grade range I think I did, I will admit that the trial by fire of having to teach myself the course did at least emphasize that I am a dedicated visual diagram learner. I understood this before, but I suppose now I know it for sure. But let's not be too conciliatory until the grades are out...

Immunology... or how not to teach a class

I am continuously reminded of how much of a visual learner I am and perhaps this is why Dr. S's Immunology course, until this point, has been a struggle. I cannot pay attention at all during lecture and the notes, though thorough, are very text based with few diagrams. I need diagrams!
But on top of that, the order in which the material was presented just did't work for me. Immuno was a course I enjoyed in undergrad and generally found interesting (I even shadowed at an Allergy Clinic) but I found myself starting to hate the course and the professors.
I didn't realize my problem was how the material was presented until I put together T cell activation on my own. I used a combination of Wikipedia (decent article) with a copy of High Yield Immunology. I also referenced the class notes to make sure I had what I needed to know. Then I took it all and drew out a diagram with all the relevant cytokines. And it makes sense. Macrophages are cool again, CD4+ T helper cells rock and I can appreciate how HIV kills.
I've had poorly taught courses before, but never could I say exactly how to make them better. With this course, I think a better integration of cytokines into the Th section along with more and better diagrams, coupled with big picture understanding would go a long ways to improving it. And a coherent lecture would help too.

Evolutionary Medicine

Listening to lectures on sonic foundry can occasionally make me feel like a deranged hermit. I spend days alone at my apartment and venture down to interact with society only for small group discussions, the occasional DES session or a trip to IGA. The atmosphere is distraction free, which I think has made me more efficient and productive this semester (we'll see about that after midterms). The ability to set ones schedule and actually stay awake through lecture has certainly made my med school experience a lot less stressful, but it's not without its frustrations.
Listening to the Immunology lecture just the other day, our Prof. discussed the polymorphism of MHC and the various alleles for each MHC locus within the population. She then asked a simple question: how does this benefit us from an evolutionary perspective. Now, I know Sonic can be misleading but I could hear the crickets. One person ventured a guess but missed the point. Meanwhile, I immediately thought of biodiversity and the lessons I learned from my Evolution class in undergrad - one of those "I'm a biology major, not a pre-med major" classes that I took before deciding to go into medicine. So, I am sitting here screaming duh people, if you don't have a diverse recognition of antigen then a single microbe that goes unrecognized by the entire population can wipe out the whole species! The genetic bottleneck is a big problem in conservation biology. And yes, evolution applies to humans too - even more as we think.

Evolution is often a lost part of medical education. We learn a great deal about the immediate causes of a disease, or even how one can become susceptible, but we are generally not trained in the "why do we get atherosclerosis in the first place?" kind of questions. This piece in Aetiology discusses the med student mentality:

If basic biology and traditional medicine make up the plot of our disease "stories", evolutionary medicine would be somewhat like the moral. My roommate is a medical student and when asked, she can tell you how just about anything in the human body works and what is happening when things go wrong. When asked why things go wrong, her answer will refer to a proximate cause, such as certain foods leading to plaque build up which can lead to heart disease. If the question of why is rephrased, as in why does the disease even exist at all, then she's stumped. This is the question considered by evolutionary medicine. Why aren't our bodies able to repair clogged arteries? Why are we prone to infections? Why are our bodies so good at some things but so inept at others?

The post goes on to discuss the book "Why We Get Sick: The New Science of Evolutionary Medicine". Especially relevant to my fellow immunology students is the following example discussed later in the same post:

So if infections are one evolutionary explanation for disease, what's an example? I recently came across an interesting article about infection and it's relation to premenstrual syndrome. In the article Premenstrual Syndrome: an evolutionary perspective on its causes and treatment, Doyle et al. propose premenstrual syndrome is due to an exacerbation of a set of infectious diseases during cyclic changes of immunosuppression by estrogen and progesterone. While genetics and non-infectious environmental influences have been examined and found largely unable to explain PMS, infectious causes have been overlooked. However, it is know how immune function varies throughout the menstrual cycle in such a way that there could be less effective control of fungi, viruses, and intracellular bacteria, so making the leap to a persistent infection contributing to PMS doesn't seem too difficult. Supporting this hypothesis is a long list of chronic diseases with suspected infectious causes that are exacerbated premenstrually including Crohn's disease with Mycobacterium avium and juvenile onset OCD with Streptococcus pyogenes.

It's a really fascinating interplay between immunology, environment, and genetics. You can also consider the influence of epigenetics for good measure and I'm sure your head will start to spin! The book looks like a good read and hopefully something we'll see in the medical school curriculum of the future. Anyone out there read this book or ones like it?