Monday, December 17, 2007

Apoptosis tongue-twister

From the transcript for this lecture:

There are other members of this family that are pro-death factors: three examples are bak, bax, and bim. In a normal healthy cell, bak and bax are normally present; however bak is bound by bcl-2, which neutralizes it, and bax is in the cytoplasm, where it can't do much in terms of mitochondria. Bim is present in low levels. When a cell gets a signal to cause death, bim levels go up, bax and bim move into the mitochondrion, and bim binds to bcl-2, displacing bak and neutralizing bcl-2. And now bak binds to bax, when bax and bak bind to one another they form a pore and this pore permits the release of cytochrome c from the mitochondrion. This then binds to APAF1, which binds to caspase 9, which then activates caspase 2, causing death.

Now playing: Newsies - King of New York
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Sunday, December 16, 2007

If anything deserves an interrobang, it's this

Haha, so unprepared for tomorrow, it's not really funny but I cannot force myself to care anymore.

So close, so close to being done with one-eighth of my medical education HOW DID THAT HAPPEN?!

Now playing: Wolfgang Amadeus Mozart - Piano Concerto in A, K. 488, I
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Wednesday, December 12, 2007

You see this? Imagine it in black and white and about half the size, and you'll get an idea of the pictures in my anatomy syllabus-textbook-thingy, written by the course director during the Nixon Administration and apparently illustrated by a three year old with no sense of proportion or relationships.

I mean, the big orange thing in the middle is, I think, supposed to be a uterus, but why does it have a zipper up the middle? Why are the ovary and uterine tube popping out of the fundus, like the spinning thing on a beanie, totally unsupported by mesometrium?

There is also a small plastic earring back (or maybe a cigarette) impaled in the bladder-like thing, and the bizarrely transected rectum appears to be receiving arterial supply and venous drainage directly from the sacrum.

Thank goodness for Netter.

Now playing: Ragtime - Prologue: Ragtime
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Tuesday, December 11, 2007

The more I study, the more my lack of knowledge becomes apparent. It's frightening.

Also, I do not understand why we have the longest anatomy course in the country (August through March), yet I'm still always cramming. Either other schools learn less or I am just not getting it

I can't wait for next Friday, when I'll bubble in my last exam and then have a whole ten days off. Gosh, I don't know what I'll do with myself. The last time we had days off with genuinely nothing to study was a weekend after our October exam week.

Monday, December 10, 2007

Stare into the (economic) abyss

Last Friday, I went to a lunch talk, run by my advisor, who always invites guest speakers to her biweekly shindigs. I attend religiously, partly for the free food (starving med student here) and partly for the opportunity to learn a little more about this crazy crazy world I belong to now.

Friday's speaker was a health administrator from a major hospital system out in the 'burbs. She was very well-prepared -- even had a massive long powerpoint handout -- and spoke quite articulately about what drew her into health administration.

I have to say, though, the content of her talk frightened me. Her job is essentially to track the physicians employed by [Major Hospital System Out In The 'Burbs] and call out the ones that are too expensive. I paraphrase: "Dr. Jones, as you can see in the spreadsheet on page 6, represents a net loss to hospital of $6,000 a month. This is because he treats Medicare patients like private payers."

Now, having spent hours on the phone with Medicaid my clerkship, I'm well aware that Medicaid is terrible insurance that pays for hardly anything. (I wasn't aware, till that talk, that Medicaid pays the hospital a lump-sum per patient/diagnosis rather than a per diem.) But the idea that one should treat Medicaid patients differently -- that is, employ a different, presumably lower, standard of care -- is morally repulsive to me. If the quality differential between antibiotic A and B does not make up for the fact that B is twice as expensive, then we should be prescribing A to both the illegal immigrant in 285-2 and Bill Gates over in the fancy-pants wing.

One other way that the administrator suggested lowering costs was by setting up follow-up appointments for whatever "other" (i.e. non-emergent) tests need to be run. Fair enough, but as one of my classmates pointed out, "What if the patient has a history of not showing up?" There's really no good answer to that, at least from the save-a-dime perspective.*

The rationale for all this cost-cutting is that the hospital can invest in better technology, etc. Great. I just don't see why the poor patients have to get shafted while the private ones sit in rooms fancier than most hotels. (I saw that on the tour at one of the schools I interviewed at. Kind of a shock, to see full-length mahogany mirrors and a window-seat/pullout bed for guests, and a wardrobe in a hospital room.)

This reminds me of a modern definition of chivalry I heard at some point. Treat all men as gentlemen, and all women as ladies.

Unfortunately, I'm not idealistic enough to believe (though I hope) that the system of health care in this country is going to change overnight, or even by the time I graduate. I don't even know if universal health care is a panacea -- probably not. Either way, it's going to be a long slough through politics and government (which are not the same thing, as Yes Minister taught me). But it's something that I fervently believe that everyone in medicine does need to think about, and hopefully do something about.

*I'd just like to point out that I'm probably one of the most frugal people I know. I detest waste of any sort (monetary, mental, or recyclables). I once went into Filene's and was shocked at the shoe prices; that's how frugal I am. But I also happen to think that the dude at the bagel cart deserves the same quality of care as the dude at the White House. Yeah, yeah, filthy pinko commie.

Now playing: Alexander Scriabin - Etude in G sharp minor, Op. 8, No. 9
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Wednesday, December 5, 2007

Last clerkship

Part of the requirements for first-year medical students at my school is a weekly clerkship, where you interview patients under the supervision of a health care provider (usually a physician, but sometimes an NP, nutritionist, etc -- mine was a social worker). Today was the last day of fall clerkship and hence the last day until February where I get to go to the hospital, sit down with a patient, and just chat.

I met lots of different people during my clerkship -- mostly older adults who needed some sort of post-hospital care, such as home attendants, hospice, etc. I certainly feel a lot more comfortable interviewing now than I did in August, but at the same time I'm very aware that clerkship is unique and not much like the Real Practice of Medicine. For instance, today I spoke with a patient for almost an hour. That kind of thing doesn't happen in clinic.

There was one thing, though. Some time ago, I spoke with a woman who had been diagnosed with a particularly aggressive cancer, hence the SW referral. As I asked her about family, she seemed kind of vague and forgetful of her kids' names, etc. Jerking her head around, not really tracking, very edgy. I mentioned this to the SW and the resident following her case. Today, the SW told me that the doctors had said she was fine (that's relative, I guess), sent her home, and a few days later her daughter-in-law brought her back in, saying she had been forgetting to take her meds. Several tests later, they decided that cancer traveled up to her brain.

As I was sitting there stunned and depressed and remembering my grandfather's struggle with cancer that ended up in his brain, the SW congratulated me on my "insight." Huh?

I guess finding something the teachers missed is every student's dream, but my inclinations that way always leaned more towards "Discovering that some basic mathematical theorem is wrong and watching the entire structure of mathematics come crashing down." (What can I say, I hate math.)

When the "thing" that people missed involves life/death/pain, congratulations are just not in order. I'm glad they caught it and all, but I can't help feeling depressed on behalf of the family, and on behalf of my childhood self.

Now playing: Benzos - Teach Me
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Monday, December 3, 2007

Anatomy syllabus

"This complex movement involves rotation in the suprameniscal compartment about a transverse axis through the femoral condyles and a concomitant anterior gliding movement in the inframeniscal compartment as that transverse axis moves anteriorly."

Why, anatomy? Why must you be so ... vocabularied? And lacking in pictures?

On the plus side, between the snow yesterday and the date -- December already! -- I've started playing Christmas music.

Now playing: Danny Elfman - Jack's Lament (from the Nightmare Before Christmas)
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