Tuesday, January 29, 2008

Forsooth and ods bodikins!

From JAMA's "100 years ago" section:

Probably no more forcible reductio ad absurdum of the current view, to which we have adverted elsewhere, as to what inherently constitutes the practice of medicine, could be conceived by the witlessness of man than House Bill No. 704, now before the General Assembly of the State of Ohio, entitled "A Bill to Regulate the Practice of Non-Medical Healing in the State of Ohio." Non-medical healing, forsooth! Why not a bill to authorize the non-juridical practice of law, or to establish non-sanitary boards of public health? Why not establish in the curricula of our state schools and universities courses for the teaching of non-theological divinity, of the non-biologic study of life, or the non-linguistic study of languages? We can hardly imagine that any legislature will so far stultify itself as not to resent the insult cast on its common intelligence by the very title of such a bill. If a bill of this nature must be presented, let it at least be correctly described as what it is—a bill to authorize the practice of healing without requiring proof of acquaintance with those basic truths and principles on which the safe application of any healing measure whatsoever must for all time inseparably depend.

I must say, I love the overly rhetorical style of Edwardian correspondence. Kind of a pity that we no longer speak like this. "And lo! the Huntington chorea is caused by a gene, which is to say, a series of nucleotide pairs that in their entirety encode proteins deficit in the caudate of these poor unfortunate patients, and thusly results in a myriad of most fearsome symptoms."

Exams next week! I must go underground for a bit.

Sunday, January 27, 2008

In which I whine

Life's kind of crazy right now. We have exams Feb 4-8, and somehow next week turned into class/meetings every day from 9 AM to 9:30 or 10 PM. And then I have to come home and study. Bleargh.

Yesterday, after teaching from 9-3, I was at study group from 3:30-6, when they kicked us out of the library. I was in the anatomy lab from 10-12 this morning, and then in the library from 2-7:30. Um, death much?

So now I think I deserve a short break to eat leftovers, clean, and watch Mansfield Park on PBS. I admit to being an Austen lover, but I don't have particularly high hopes for this one. Fanny Price is a bit meh for my tastes.

Now playing: Lynette Perry, Steven Sutcliffe, Mike O'Carroll, & Conrad McLaren - The Crime Of The Century
via FoxyTunes

Tuesday, January 22, 2008

Everyone' s a little bit ...?

As part of my student membership in the AMA (because I like to maintain some semblance of political understanding), I get a free four-year subscription to JAMA. I don't often read it, because I have enough to read, and I can never really understand all the drug trials and whatnot anyway. All that doctor-y stuff seems so far away.

But today, as I was idly flipping through it on Google Reader, I came across this article, which echoes many of the sentiments I've felt in the past. As the American-born child of Indian immigrants, I've had to deal with back-handed "compliments" like "Wherever did you learn to speak English so well?" "Um... Northern Virginia." (I was tempted to add "What about you?", but as it was my supervisor at a summer job, I thought it unwise.) The worst that's happened to me, I think, was profiling by the police at Times Square on New Year's Eve.

Usually, it's older people who say things like this, but I'm not sure that's such a great excuse. After all, by "older" I mean people in their 40s and 50s, the generation that grew up during the civil rights marches. And sometimes, even from my peers. (One of my classmates once said, laughingly, that she was the only American in our group of 2 Canadians, 1 Chinese girl, 1 Colombian, her, and me. "Hey," I responded with a smile, "I'm just as American as you!") There was even a time -- and I'm ashamed to admit this now -- that the frequency of these comments made me wish to be Caucasian, just so that people would accept me as the nationality I am.

There is a lot of talk about the melting pot (I believe the new PC metaphor is the "salad bowl") but when it comes down to it, this country -- or certain segments of it -- unfortunately say or do things that are xenophobic. Not even xenophobic, because as I say, I'm not foreign-born, and immigrants of European ancestry, as the article points out, usually never encounter these problems. Come on, come on, let's use the word: racist.

The author of the article is, I think, a little overgenerous in her dismissal of the racist comments she's encountered. A diagnosis of a serious illness is certainly overwhelming, but it doesn't give you a free pass to be an ass. She also argues that her own "profiling" of physician-colleagues encourages patient discrimination, but again, that doesn't excuse the patient at all. Each of us is responsible for our own actions and thoughts.

Which begs the question: how to deal with patients who make openly racist or discriminatory comments? I'm sure I'll encounter some. Is there any sort of recourse for physicians who are discriminated against by the people we are supposed to be helping? Does professionalism really demand that one ignore these issues? At what point will I be confident enough in myself to say -- both in my professional and my personal life, "Excuse me, I find your comments to be unacceptable."

[Edit: I think I should point out that I wouldn't withhold care as "revenge," though I suppose I would ask that another physician take over the case. But really, that's just running away from the issue.]

Now playing: Ragtime - Prologue: Ragtime
via FoxyTunes

Saturday, January 19, 2008

I just got back from the psychoanalysis conference. It was pretty fascinating, and it was wonderful to meet other students who are interested in psychiatry. (We had a day-long student session, followed by a general talk about the history of psychoanalysis.)

What I liked most about psych (-iatry? -oanalysis?) was its focus on story and narrative. As a literature major in college, I've been searching for something that gives me the same sort of thrill I got when immersed in a character or a plot. Some of the speakers shared stories from their own practices (properly disguised, of course) that really brought me back to that place. The focus on the past and the iceberg of the Unconscious -- really just the concept that a person's motivation is deep rather than superficial -- are also appealing, as is the interdisciplinary synthesis that informs much of psychoanalysis. But most of all, I really enjoy the prospect of getting to help make sense of this crazy arena we call Life. As one of the speakers put it, psychoanalysts "help people create cohesive narratives of their lives."

Unfortunately, psychoanalysis is an additional four years of training after a psychiatry residency. Although the traning is part-time, the opportunity cost is high: you could be seeing and helping your own patients in that time. Also the elitism aspect of it, the notion that psychoanalysis is for neurotic rich housewives on the Upper East Side. One of the speakers said he uses a sliding scale, but I'm not sure I like that idea (although it's better than shutting the poor out entirely).

And lastly, my god, did they adore Freud. I was surprised, because Freud's theories, while obviously influential in creating the field, are a century old by now. I know, from my literature training, that a lot more work has been done in psychoanalytic theory -- there's Lacan, and Derrida, and a whole slew of feminist psychoanalysts -- that were just trampled on in the rush to worship at Freud's altar. To analyze the analysts a moment: it's almost as though they are using the approbation of a dead master to cover the disrespect that psychoanalysis gets from just about every other field.

Honestly, though, if psychoanalysis is discredited as "not real science," it is at least partially their own fault. I'm not talking about the historical lack of evidence-based studies that psychoanalysis actually helps -- those are coming out recently, with support from neuroscience, fMRI, etc -- but rather the apparent disowning of any attempts at progress in the field. Can you imagine medicine practiced as it was circa 1905? "Here you go, Farmer Jones, have a poultice for your infected boil, and we'll have to amputate next week. If you're still alive, that is." So why is psychoanalysis so adamant that Freud Got It All? That's practically dogma.

I think that psychiatry is just about the most fantastic thing I've considered right now, and especially in minority communities, where psychiatric disorders carry a stigma that "regular" medical problems do not. And one can certainly use psychodynamic thinking and "talk therapy" in regular psychiatric practice (i.e. it's not just about Xanax and Zoloft). Although psychoanalysis is kinda cool, I'm not convinced that the extra time and training are worth it.

Wednesday, January 16, 2008

Career development?

I just attended a talk about trauma surgery. It was less about what it's actually like being a trauma surgeon (though he addressed that during the Q/A at the end) and more "This is what you need to do to pass your surgery boards."

He also had a ton of frightening pictures of people with mangled body parts and poles sticking through them and whatnot. It was not a pleasant sight. Trauma surgery certainly sounds kind of cool, and I'm sure it's incredibly rewarding, but I'm not exactly thrilled at the thought of gashes across faces.

There were several pictures of failed suicide attempts (slit wrists, one throat cut so deeply that they were able to intubate directly through the wound, etc.) which just reminded me of something a friend of mine, who used to work with a crisis hotline, told me. They got several calls about suicidal ideations, and once they established that it wasn't an imminent danger and that the person really just needed to be talked out of it, they would "de-glamorize" suicide by talking about what would happen if it went wrong. Such as, "If you slit your wrists, you could end up with necrosis or sepsis in your fingers and would have to have them amputated." Apparently it worked quite well.

What interests me more than the immediate surgical intervention is the longer-term psychiatric implications that would lead someone to suicide. As a matter of fact, I am going to the student section of a psychoanalysts' conference on Saturday. Although of course I don't know that I want to become an analyst, or even that I like psych that much (though on paper it sounds fascinating), I figure it can't hurt to explore a little before third year. Also, this is New York City, where even analysts have analysts. It should be a good program.

Saturday, January 12, 2008

Neuro is awesome

So, as I was sitting here with Dr. Kandel's massive Principles of Neural Science (excellent text, by the way; he does for neuro what Costanzo does for physio), I thought:

"Hey! I actually understand why GABA channels are inhibitory and glutamate receptors are excitatory! And therefore how barbituates work!"

You must forgive me for the exclamation points. These moments of total clarity are far between in med school, where I usually feel like I'm about ten steps behind where I need to be.

Back when I was a starry-eyed undergrad having crises about med school vs. grad school, several people explained to me that the difference between the two was that med school is all about memorization, and grad school is all about integrative thinking. Although there is a great deal of memorization in med school (especially for anatomy), it's mostly in terms of learning a new vocabulary. Kind of like having to memorize all those axioms for geometry in middle school. Once you have the basics down, things actually do start to make sense. Sometimes.

Now playing: Stephen Sondheim - The Worst Pies in London
via FoxyTunes

Wednesday, January 9, 2008

Thoughts on economic theory

Thanks to recent lectures, I've been thinking a lot recently about the role that economics plays in our health care system hodge-podge. I've found that economists tend to have an extremely narrow worldview. For them, it's all about the money. To some degree, this is pervasive in our country. Measures of success or failure are, almost entirely, monetary.

I disagree. Sure, money is important, but it is by no means the most important factor in health care, even in a country where costs are spiraling out of control. Money's useful as a means to an end, but as Kaufman and Hart so hilariously reminded us in the 1930s, you can't take it with you. Monetary measures of success make even less sense in a health care context, where so many people are driven by intellectual curiosity and a desire to be useful. As newbies on SDN are regularly advised, medicine provides some job security, but if you're in it for the money, get out now.

Here's the thing. Beyond a certain personally-determined point (say, 30k, 50k, 80k -- whatever), income doesn't really matter any more. Obviously, everyone's balance point is different and depends on things like educational background, career choice, personal goals, family situation, etc. My own limit, based on my educational debt and the fact that I'm not going to have a real job until about 10 years after many of my peers, is somewhere in the region of 50k; much less than that and I might consider leaving medicine (and doing what else? writing?) Once your basic needs are met, the rest is just fluff.

I took a fantastic literary theory class in college, which made me by turns a structuralist, a psychoanalyst, a deconstructionist, and a Marxist. (I remember when I told my parents that one.) Literary Marxism, which is quite different from its economic cousin, is the view that money and class are the most important motivators. I suppose that I am therefore now an anti-Marxist. (Theory-wise, I'd peg myself for a deconstructionist at the moment. The reader brings more to the text than many other theories allow for. But that's a story for another blog.)

To recap: economics isn't everything. In fact, it may well have been an over-reliance on economic theories that got our health care system in the current mess. As Lange's excellent Understanding Health Policy states, health care is not a good in the same way that DVD players are a good -- it's too unpredictable, for one. Economics has been the driving ideology of health care at least since the turn of the last century, when charitable almshouses began consolidating into hospitals. Perhaps the debate on universal health care should turn to a different model, one that addresses both the motivations of physicians and the needs of patients.

Monday, January 7, 2008

ED Shadowing

Today I spent four hours shadowing in the peds ED, an opportunity set up by the peds interest group here. I love being in the hospital and seeing patients, even if as a first-year med student I don't get to do much. (Though I examined a fifteen-month-old today!) I'm also impressed by how much the attendings, residents, and even third year med students, seem to enjoy teaching. Every five minutes, someone came up to me and was like "Wanna see a lupus case?"

There were mostly what the attending called bread-and-butter cases, the sorts of things that could and should really be seen by a generalist. But a couple of True Emergencies, brought in on stretchers by paramedics. So... a nice mix, I suppose.

The atmosphere fairly crackled with adrenaline pretty much the whole time I was there, even during the slow moments. Emergency certainly attracted a particular crowd, I can say that. After just 4 hours, I'm not quite sure if it's my style, but I like the thinking-on-your-feet aspect of it. We'll see.

Sunday, January 6, 2008

Stepford Wives

So, as I was making dinner (whole wheat pasta: delicious and nutritious, and most importantly, cheap) in the common kitchen attached to the dorm lounge, one of my classmates came up and started cooking. She boiled some water on the other burner, and pulled several vegetables out of her plastic bags, along with a tupperware full of grilled chicken, and began a-chopping.

"Smells delicious," I commented after a few minutes. "What are you making?"

"Chicken noodle soup, but I'm cheating."

At which point she showed me a package of noodles shaped like roosters. (They were exceedingly cute.) Then she dumped them in her boiling water and proceeded to add all the fresh vegetables, chicken, etc.

How is this cheating? Would not-cheating have been making the noodles by hand, like Lucy and Ethel in the Pioneers episode of I Love Lucy?

More to the point, are there actually people out there who cook things from scratch? One of my friends made homemade icing for our post-exam party, and just this evening, someone else was making and baking five dozen cookies, from scratch. I get the impression that mixes and shortcuts are frowned upon, only to be used by Evil Mommies Who Love Their Jobs More Than Their Kids. It's like living in the 1950s, except this is 2008 and we are med students and we have negative free time. (Though I did go skating at Bryant Park today. And afterwards I studied in the New York Public Library. Because I am a med student.)

I know a few basic recipes, mostly so that I can avoid living entirely on Ramen. (I did that for a semester in college. I saved tons of money, but it was terrible.) And I love to cook, but I also love to pass my exams. So when it comes to Betty Crocker cake mix or Goya's flan thing, I'm totally there.

Wednesday, January 2, 2008

From Moore's Clinically Oriented Anatomy, 5/e, 937

Tuesday, January 1, 2008

Happy New Year

2007 was a crazy year for me, what with getting into the med school I attend, writing my thesis, graduating college, moving very far away from home, learning 10,000 new facts (according to our Dean of Students), struggling with the emotional aspects of dissection, making new friends, and just generally stretching myself in ways I would never had thought possible on January 1, 2007.

Huh, I wasn't going to recap the past year, but I suppose I already did. =)

I hope to post here a little more frequently this year. Once a week, at least.

Classes start again tomorrow. I resolved no more than 2 cups of coffee a day; we'll see how long that one lasts.