Off-White Coat

New format

2008-08-13T23:22:00.003-04:00

On the advice of a friend, I just ported my blog over to Wordpress. It's much more customizable; the themes are prettier; and I just plain like it.

I'll keep this site up, but why not mosey on over and see what I've been up to lately.

[Update: You'll be automatically redirected. Just FYI. This message will self-destruct in 6 seconds.]

This is just to say...

2008-08-13T11:35:00.002-04:00

...that Montana is awesome.

I spent 10 days hiking around Glacier National Park, Yellowstone, and the Grand Tetons.

Highlights included:
-Climbing to the very top of a snow-laden trail. (Snow! In August!)
-Elk grazing on the front lawn of our hotel.
-Being chased by an enraged mother bison. Those things can move.
-Old Faithful. The lady behind me asked a ranger if the 'stremely accurate timing was "controlled by someone."
-Huckleberry ice cream, which has replaced Canadian Maple Walnut as my Flavor of the Month.
-"Caulk your wagons and float" down the Snake River. Ah, the postmodern pastiche of comparing a real-life experience to a twenty-year-old computer game.
-Generating all the Vitamin D I'll need to tide me over for another year of living in the library. (Almost literally! The second-year classroom is on the fourth floor of said library, and my room is across the street. Hey, at least the commute is non-existent.)

Last day of work

2008-08-01T16:10:00.004-04:00

Tick-tock, tick-tock.

It's a slow day here. Kind of sad to think it's my last one. Although I'm glad my only major project for this week, a presentation on vaccines for substance abuse, went off without a hitch. I am nervous about public speaking, but when one of the other interns tried to steal my thunder with a question that turned into a soliloquy on political ideology, I stole it right back, got everyone back on track, and finished with a bang. (Thunderclap? This analogy is dead.)

Putting together the presentation was pretty cool, though. Basically, antibodies "soak up" the cocaine/nicotine/meth and keep it from crossing the blood-brain barrier. Result: no high. It was all fMRIs and mouse studies and made me realize how absolutely awesome neuro is. It was probably the best class of first year. Even if I did fall asleep during the last exam.

But the absolute coolest part about putting together this presentation was doing the handout, for which I had to haul out the scissors for some old-school cutting and pasting. (Well, taping, but you know what I mean.) I've never done real life cut-and-paste before. You have to think about orientation and spacing! You can't just resize images! It was ... surreal.

So much drama on C-SPAN!

2008-07-30T16:24:00.004-04:00

On a bill to give the FDA regulatory authority over tobacco, especially to ban flavored cigarettes (kids' favorites).

Rep. Boehner (R-OH): This is a boneheaded piece of legislation. *handwaving and rant about big government*
Rep. Dingell (D-MI): I yield myself 15 seconds of time to respond to my beloved friend. Mr. Boehner, tobacco kills. And you will be the next to die.
Entire AAP Office: Whoaaaaaa!

(I wish I were making this up.)

Textbook time!

2008-07-28T14:13:00.002-04:00

Late last week, one of my class reps sent out a survey from the class of 2010 (well, a third of the class of 2010) about second-year textbooks. Exciting! I definitely bought way too many books for first year, though, so I'm trying to hold off this time. The top-rated books for pathophysiology are subject-specific (Lilly's Pathophysiology of Heart Disease, Despommier's Parasitic Diseases), but I'm debating about supplementing with a general pathology book. Robbins, perhaps? Or BRS?)

Truly, though, I'm nerd enough to be looking forward to the start of second year. I went ice skating this weekend with some high school friends, one of whom is now a pharm tech. He was lecturing pharm to everyone who would listen -- basically, me. So exciting to think that in a year, I'll know everything he was talking about! :)

I mean, second year will probably be scary. More volume, more detail. That pesky little board exam in June. Building on previously learned material. Which I have pretty much completely forgotten. (Bones of the wrist? What? I only vaguely remember our rotund little professor with the sweat issues, standing in front of a slide of a giant hand and telling us a dirty mnemonic about Tillie's pants.) But also really cool! I mean, parasites! What could possibly be more interesting than that!

2008-07-21T15:14:00.003-04:00

I've spent most of the last few weeks at work on the phone, trying to scheduling meetings on Capitol Hill but mostly getting transferred from voicemail to voicemail. An awful lot of Congressional staffers are away from their desks, all the time. I have this vision of them wandering the Halls of Power, like zombies in a a 1950s scifi flick, searching for the Mother Ship.

Big news today: the leaked HHS proposal that seeks to redefine "abortion" to include contraception. (Ummm... Griswold v. Connecticut, anyone?) The so-called "conscience" clauses grant financial (and possibly legal) immunity to those who deny services based on religious beliefs. What I can't seem to find is the HHS definition of contraception. Is this just Plan B, which prevents implantation of a fertilized embryo? Or shall we include barrier contraception, which prevents fertilization? What about hormonal contraception, which prevents ovulation itself? (Apologies if I got any of this wrong. I went to a school district that had abstinence-only sex ed, and despite passing both Human Development and Endocrinology/Reproduction in med school, never had a lecture about pregnancy.) If women and men don't have access to basic contraception, and education about its use, abortion rates ("real" abortion, that is) will just climb.

What I find especially interesting (disturbing?) is that the proposal cites a NEJM study that found that 86% of physicians feel they should present all available options to a patient (and 71% would refer the patient to another physician in the case of religious/moral conflict), yet promptly rejects that overwhelming professional opinion in favor of a 2001 Zogby poll that found that 49% of respondents believed "abortion destroys a human life and is manslaughter." Dunno how the Zogby people feel about contraception, but given that 40% of American women use hormonal birth control, I think I can guess.

As a future physician, I'm aware that my personal beliefs may, at times, conflict with those of my hypothetical patients. But, like 86% of physicians, I think that patient need is superior to provider religion. Hey, HHS? What's your definition of paternalism?

The objections of the President of the United States to the contrary notwithstanding

2008-07-15T21:46:00.002-04:00

Raise your hand if you thought "Congressional action" was an oxymoron.

Yeah, me too. The system was, of course, designed to move as sloooooowly as possible. Between committee referrals and hearings and filibusters, it's a procrastinator's dream come true up there on Capitol Hill.

Which makes today's events all the more surprising. After just 4 of his allotted 10 days of consideration, Bush vetoed the Medicare bill this morning. After lunch, the AARP held a rally on the West Lawn of the Capitol. Two hours later, the House voted to override the veto; the Senate vote took place about two hours after that. This is the equivalent of hyperspeed for Congress! Good for them! (Even more surprising: more people voted to override the veto than voted in favor of the bill in the first place. Buh?)

My other task today was attending a Global Health and Poverty luncheon. Irony is eating ham and havarti on rye and drinking raspberry white tea while copying down statistics on how many sub-Saharan African children suffer from malnutrition.

High drama on the Senate floor!

2008-07-11T15:44:00.003-04:00

While I was in New York, stressing over where I'm going to live next year, the Senate was tackling a sliiiiightly more important issue: the Medicare vote.

Act I: The Exposition, or Let's Screw Doctors
For those of you who didn't hear, Medicare was set to have a 10.6% reimbursement cut, effective July 1. CMS, which handles claims, said they'd put a hold on processing claims for two weeks until Congress decided whether to delay the cuts, as they have done every year since Time Immemorial. (I learned today that CMS doesn't process claims for 14 days anyway, so the hold was more semantic than real.)

Act II: The Rising Action, or Let's Put on a Band-Aid (TM)
The House rushed through a bill on June 24 to delay the cuts. (355-59; definitely veto-proof; See how your guy/gal voted.) Following the procedures outlined in Schoolhouse Rock (and, you know, the Constitution), the bill went to the Senate. Given the time crunch, Sen. Reid of Nevada moved to invoke cloture, which meant that the Senate would skip committee, debate, amendment, and the inevitable compromise-with-the-House quagmire and pass or reject the bill in its House form. That motion fell 2 votes short of passage. Not voting were Sens. Kennedy of Massachussetts (understandably) and McCain of Arizona (not so understandably). Here's the roll call.

Intermission
Then Congress went on a ten-day picnic and the American Medical Association went beserk.

Act III: The Climax, or Let's Applaud for Two Minutes
On Wednesday, more than a week after the cuts were scheduled to go into effect, the Senate reconsidered cloture. In possibly the most dramatic moment in Senate history since Preston Brooks caned Charles Sumner, Sen. Kennedy arrived, specifically to vote in favor of cloture. He flew back to MA for more chemo directly afterwards. But thanks to his appearance, the hard work of the AMA and AARP, and plenty of grassroots pushing, the motion passed, 69-30. Again, a veto-proof majority. Again, Sen. McCain did not vote.

Act IV: ?, or What You Will
Bush has repeatedly threatened to veto the bill. Schoolhouse Rock (I mean, the Constitution!) says the president can sit on the bill for 10 business days before deciding what to do. Probably he will veto it after all, so the veto-proof majority in both houses is an important fact. So important that I spent most of the day today writing to my senators to thank them for their votes in favor of cloture and urging them to continue to support access to care. You should too! There's a cool new online system accessible at [lastname].senate.gov, so you don't even have to spend on stamps! And you get automated replies:

Senator Warner is snuggly
Thank you for your email. It is my goal to reply in a timely fashion to every email that I directly receive from a fellow Virginian. I appreciate your views and look forward to responding to you.

Senator Webb is not
Your comments have been submitted.

In any case, it's all very restorative in the Power of Democracy: Congress CAN do things, grassroots letter-writing and phone calls DO make a difference, legislation DOES affect you, me, and that old guy who sits outside the Metro station and plays the pan pipes.

I think I'll go home now and watch Mr. Smith Goes to Washington. Sappy enough for you?

2008-06-30T22:02:00.003-04:00

We have summer reading! Again! As BH, who is in math grad school (taking classes like "topological algebra" and "partial semi-differential hand-waving") said when I told her: "Buh?"

Last year's summer reading was on The Spirit Catches You and You Fall Down, a rather sad story of cultural clashes. It frustrated me no end, which I suppose was the point. We were supposed to discuss in small group but never actually got around to it, so my understanding of cultural competence, $60k later, is not really much better than what it was around this time last year. (I do, however, have a much better understanding of rotation of the gut, for what it's worth. Everyone has situs inversus.)

This year's summer reading is Mountain Beyond Mountains, Tracy Kidder's biography of Paul Farmer. I'm holding off judgment until I actually receive it (could be a while, given the Fourth of July shipping delays), but it should be an interesting read, if nothing else. I'd like to do international work eventually, and Dr. Farmer's kind of a Big Deal in the global health arena. It is gratifying to see that idealism can actually work.

Slow day at work?

2008-06-26T09:49:00.003-04:00

I've settled into a bit of a summer routine by now. Up at 6:30, out of the house by 7:15. I carpool with my parents, who drop me off outside their office and I walk across to my own. I usually get there well before the office opens, so I duck into a Borders across the street and read till 9. (Currently working on Kate Atkinson's Behind the Scenes at the Museum; highly recommended to anyone who liked Middlesex.)

I go to a lot of Congressional hearings. They are becoming a commonplace now, but when I stop and think about them, it's really a remarkable experience. I always seem to arrive just after a tour group of obese Midwesterners; that's summer in DC for you. After I shuffle out of the oppressive humidity (the city retains the atmosphere of its swampy origins) through metal detectors, I head up a marble circular staircase to whatever committee room the hearing will be in. There's usually a long line for the public; often I have to stand in the back or along the sides. The committee sits at a large dais, Democrats and Republicans on either side of the chairman's throne. Witnesses sit facing the committee at a long table, with microphones and water glasses. After opening statements by committee members and testimony by witnesses, the fun part -- the questioning -- begins. I've seen committee members rip into witnesses, and you can really tell when someone loses their cool or has been "rehearsed." The whole thing takes an hour or six. Then I go back to the office and write up a summary for whoever is in charge of that issue.

What has struck me most about these hearings is the almost total lack of clinical representation. Since these are mostly Health subcommittee hearings, the witness panel usually includes a physician, but generally a researcher rather than a clinician. Lots of MPHs, lots of PhDs. It's a little surprising, given that members of Congress appear to respond better to "clinical vignettes" about anonymized children than statistics about disease prevalence. So why not bring in the people who actually care for these kids? Demands of the profession? Less experience with law? 'Tis unfortunate, because it means that Congress is dictating from on high with very little input from the people who would actually be affected by this legislation.

Grassroots stuff -- letter-writing and phone calls and petitioning -- can work, but there's nothing as effective as sitting in front of ten or fifteen Senators arguing your case.

2008-06-04T20:33:00.002-04:00

Today for work, I went to scope out the "Green Our Vaccines" autism awareness rally on the steps of the Capitol. A little background: In spite of repeated scientific evidence disproving the purported link between autism and vaccinations, many parents still blame the vaccines for the devastating condition their family has to live with. Thimerosal, a mercury-containing preservative in MMR and other vaccines, has been targeted in the past. Thimerosal was removed as of 2001; autism incidence rates continued to rise. (Now it appears that aluminum is the fashionable suspect, but that's another story entirely.) As I am interning at the American Academy of Pediatrics, they asked me to go over and see just what was going on.

I expected a lot of rhetoric and a lot of emotion at this rally; that was kind of the point, after all. The speeches took a two-pronged approach: "We are not anti-vaccines, we just want to spread them out more" and "There is a big government cover-up."

The cover-up allegation was really not so surprising -- as the saying goes, you can't spit in DC without hitting either a lobbyist or a conspiracy theorist -- but what really struck me was that they had expanded their conspiracy net to include Big Pharma, the media, and physicians.

Here's the clincher: Robert Kennedy, Jr. stepped up the microphone and rehashed a Salon.com article of his, in which he completely misrepresents a CDC conference in 2000. Skeptico does a solid analysis of the article. In his speech today, RFK Jr went over the same old points: that everyone is sleeping with everyone else and the pillow talk is all about how best to screw over the American public. He then "quoted" from the transcript of the CDC conference with one of the participants, whose name I didn't catch, saying "There is no way to massage the data to eliminate the link [between vaccination and autism]."

Whoa! I thought. That's some damn serious accusation, Senator. That's fraud. So when I got back to the office, I did what any self-respecting scientist would do: went back to the source. In this case, the transcript of the Simpsonwood conference. It's massively long, so after the first ten or so pages, I took advantage of the Handy-Dandy Finder in Adobe Reader and looked for "massage."

No hits. So how's that for fraud?

What just happened?

2008-05-21T11:39:00.002-04:00

I am DONE with first year! It really doesn't feel like summer yet -- for one thing, it's freezing -- but it's Very Nice Indeed to take a break from studying. I went out to dinner with med school friends on Monday (the day of our last exam), and last night I finished off the leftovers in my defrosting minifridge while watching Bleak House on DVD -- guilt-free! It's awesome.

One really good thing about being done -- I get to spend more time with my friends who aren't in med school.

2008-05-17T09:37:00.004-04:00

You know those anxiety dreams where you go to take an exam and as soon as you get the paper you blank out? That was me and the neuroanatomy exam yesterday. I was exhausted from a marathon study session the day before, and apparently I actually fell asleep during the exam. The parts where I was awake weren't much better.

Oh well! The other exams were alright, and I really am not stressed about anything. (Sleep-deprived, yes, but not stressed.) I took yesterday night off to recuperate and eat applesauce and watch a melodramatic costume drama on DVD. Good times. There's one more to go, and then I am done.

It's really shocking to think that the year is almost over. In a lot of ways, I feel like we just got here. I'm moving back home on Thursday; starting work the day after Memorial Day. Perhaps I should have looked into something international -- I'm very interested in global health as a possible career, and I'm exceedingly jealous of my friends who are going abroad (postcards, please!) -- but I think the job will be interesting, and I'm not going to deny that it'll be nice to be home and taken care of for a few months. (I'm grown up, really!)

----------------
Now playing: Virginia Hullabahoos - Your Song
via FoxyTunes

Not that I loved trees less, but that I loved passing more

2008-05-11T13:02:00.002-04:00

Yesterday I printed:

-a 22 page review guide for epidemiology
-a 14 page review guide for psych
-a 124 page review guide for neuro
-a 54 page review guide for endocrine

Also miscellaneous practice exams, one-off review sheets, etc. The goal for today is to quit slacking and get through at least the epi and psych.

Poor rainforest.

Anatomy

2008-05-08T18:43:00.000-04:00

The anatomy memorial service was this afternoon. As far I could tell, there were no families there -- I don't know if that's a common occurrence or just because the date got switched around a lot this year. Several of my classmates read poems or short essays. One theme that came up over and over in the student readings was the difficulty of knowing the body so intimately and the person not at all. I understand the need for privacy, and knowing too much, especially at the beginning of the course, would have made it even harder to do what we had to do. Over the course of the year, as we got to know each other, we got to know her as well: she had severe scoliosis, blue eyes, pierced ears. Something of her past medical/surgical history as well: a hole in her skull for trepanning, a stent in her inferior vena cava, no gallbladder. But knowing the little things would have provided a little closure. What was her occupation? Did she have children? Grandchildren? How old was she? What language(s) did she speak? Did she live alone? What did she like to do in the evenings? I don't mean to sound sentimental, but the relationship with the cadaver is such a unique one -- intimate strangerhood -- that I can't help but compare her to my grandfather, who was a donor as well. Presumably, she had a family as well.

Looking back, I don't really know how I got through anatomy. I detested lab; dissection never came naturally to me, and the phenol made me tired and cranky. I still can't recall the goalpost labs without wanting to throw something at a wall. There were good moments, though. My group was perfectly amazing, and those friendships are the best thing to come out of lab -- better even than my actual knowledge of anatomy, which is tenuous at best.

Amazing! Things are happening here

2008-04-25T22:17:00.003-04:00

Ever since I read Panda Bear's post about the futility of student governance in med school, I've been dying to write a rebuttal. I graduated from a university where student self-governance was practically a founding principle, like liberty in the Declaration of Independence. I had plenty of examples of students effecting change in undergrad, but med school's a very different system, so I decided to hold off until I had a more concrete success than "They modify lectures based on student feedback after each block."

You see, since about January, there have been rumblings of eliminating Honors from the second-year grading scheme. (We are pass/fail for first year, H/P/F for second, and actual grades for third and fourth.) We all felt honors was a carrot of competition they held in front of us, creating extra short-term stress with little long-term yield -- "everyone knows" residency directors don't really care about grades in the pre-clinical years. Anecdotally, there's also a lot of faculty support for the change. There is a big curriculum reorganization in the offing, and the Big People already decided to make the preclinical months honors-free. So why not for us?

A couple of weeks ago, we had a curriculum survey of the entire first year. On the question of honors, almost 80% of the class voted to remove it and go to a straight P/F system. In light of that result, we had an open meeting with the dean of students and the curriculum committee chair. It was remarkably well-attended, much better than lectures for sure. I got the impression that Dr. D, the chair of the curriculum committee and kind of an old-school guy, was very pro-honors and that he would be the one we'd have to win over if we wanted this change to occur.

After the meeting and question/answer session, we took another survey, which revealed that 86% of the class wanted to remove honors from the system. The results were presented at the curriculum committee meeting this morning, after which we received an email informing us that second-year, like first, would now be pass/fail.

So you see, the administration, at least at this august institution, can and does listen to student input.

Now, if we can just convince them to waive our tuition....

MSE

2008-04-06T11:56:00.002-04:00

I've been back for a week now. Without anatomy (I passed!), I have copious amounts of free time, which I fill by watching videos on youtube and strolling around the city. It's wonderful.

We started psych med on Tuesday and have thus far learned about the Mental Status Exam. The examples given in the book are very novelistic ("She seductively sweeps her bangs away from her face....") and so I present for your amusement a quick game of Guess the Patient.

Patient X is a student (age debatable), about 5'10 and 160 pounds. His facial appearance is marked by distinct pallor, which contrasts sharply with the inky black of his open doublet and dirty socks that fall around his ankles. He enters the room in a distracted fashion, looking around him as though afraid of being followed. The knocking of his knees also suggests fear. As the interviewer rose to greet him, Patient X drews his right hand slowly to his forehead, then extended it in a flowing motion to meet the interviewer's outstretched hand. He then sank into a chair, where he remained for the duration of the interview.

The patient answers all the interviewer's questions readily. His speech pattern alternates between slow, monotonous responses and garrulous outbursts. When asked about his mood, he says that he is "very like a whale." On being asked to explain, he winked at the interviewer but did not elaborate.

He has a full range of affect, although occasionally a question about his family causes a shadow to pass over his face and shuts down his emotional response. This is brief, however. Thought process is circumstantial and tangential; long digression of the death of an older man who played with him as a child and appears to have been a surrogate father figure. Some loosening of associations. Thought content is obsessive, centering on the recent death of his father and his mother's subsequent remarriage. Grandiose delusions of his "destiny" as the savior of his family and friends. His girlfriend recently broke up with him, an event he attributes to the influence of her father, a friend of his stepfather.

Some evidence of visual and auditory hallucinations, primarily of his father. These hallucinations command him to avenge his father's death. Admits to passive suicidal ideations (longing for the "sleep of death") but has not made a plan due to fear of the afterlife he believes to exist. He also shows evidence of homicidal ideation against his mother, stepfather, and girlfriend's father.

Cognition: fair. Alert and oriented to self; described interviewer as "fishmonger." Recalls 3/3 objects in two minutes. Digit span 7 forward, 5 reverse. Does not know own age or age of father at death. Frequently confused two childhood friends. Fund of knowledge good on current events, somewhat shaky on chronology and dates of the past. Above average intelligence, reflected in sophisticated vocabulary. Occasionally invents words.

Poor insight. Patient is aware that his friends and family are "concerned" about his recent behavior. He insists that he is "but mad north by northwest."

Judgment: Patient does not appear to understand the need for treatment. Recommend hospitalization for suicidal and homicidal ideations.

On break!

2008-03-26T11:57:00.004-04:00

I love being on Spring Break. I'm just chilling at my parents' house -- sleeping, reading novels, watching movies. It's absolutely what I needed after March block.

Our grades still aren't up yet, but unlike during Winter Break, I'm not so worried this time. Not to say that this block was any easier (it wasn't), but even if I didn't pass anatomy, I'd just have to retake that exam in May, as opposed to spending the summer retaking the entire course. Also, I am personally satisfied with my level of knowledge of the head, neck, and upper extremity.

A few days ago, a friend from high school asked me for medical advice, for a friend of hers. I've been getting this on and off for a while. It's different when it's family though; I have no qualms telling my parents that I know nothing and that they should go see an Actual Doctor. Which is what I told my friend, too, but I felt bad about it. I did have some ideas, and if this were small group, I'd have been fine discussing them. It's somehow different with a real person, though, especially someone I've never met. (Small group cases are drawn from what our preceptors have seen, but since there is an official diagnosis -- a correct answer -- they might as well be hypothetical.)

But you know what? It's break. I'm not going to think about medicine any more until next Monday.

2008-03-18T23:18:00.002-04:00

Exams continue to dominate my life, but Thursday is Match Day, when fourth-years find out where they are going to be training. Even the Times has taken notice.

The run-up to the last anatomy exam.

2008-03-16T21:04:00.003-04:00

A good family friend, now in his fourth year of med school, was studying for Step 1 some years ago. I was incredulous at what he said his study schedule was: essentially study hardcore for 5 hours, take an hour break for lunch and some TV, and then back to the books for another 5 until dinner. I thought he was exaggerating, counting "study time" when he was actually online.

Now, I'm incredulous at the memory of my own naivete. To recap the weekend: on Friday I took a 3 hour exam on GI and spent the afternoon (from 12:30 PM to 1 AM, with a half-hour dinner break) studying either in the library or in the lab. Saturday, I went hardcore from 10 AM to 1:30 AM. Today, I took a practice practical at 11 AM and went to the study lounge in my dorm directly after. Study breaks limited to trips to the vending machine, water fountain, and bathroom. And all this for one measly exam.

The strange thing is, I don't feel tired at all. In college, this sort of schedule would have left me exhausted and murderous. Now, I don't really mind it so much. Yeah, it sucks, but I don't feel as mentally blank as I would have even a year ago. Maybe I'm building up some of that magical stamina that is supposed to get residents through their 80-hour weeks. (Or third-years through their unregulated work hour weeks.)

Life is going to be weird after anatomy. I expect it will be rather like after I gave my undergrad thesis to the bindery. It's consumed my life since the end of August. I really don't know what I'm going to do with myself.

It's that time of the month again

2008-03-11T09:13:00.005-04:00

Exams start on Friday and continue through next Thursday. March Block is acknowledged by all to be absolute hell, but I'm trying to stay positive. In less than a week, anatomy will be over forever! And then we have Spring Break. I'm planning to go home and pass out on my parents' couch for at least three days.

I've always thought of our class as very cohesive and cool and not at all competitive. But atlases have started disappearing from the anatomy lab, which puzzled me until I saw some people wrapping them in the red biohazard bags and stashing them in their lockers. Seriously? Maybe I just missed out on all this in college, because I avoided the regular premed classes as much as possible (I took the Chemistry for Chem Majors sequence, AP'ed out of bio and calculus; baby physics was the only "premed" class I took), but I thought we were cooler than that.

This year is P/F, but second year they throw honors into the mix. We are trying to convince the administration to change that.

On autism

2008-03-03T19:13:00.003-05:00

Parents "shun" inoculation for their children.

This makes me sad, because while you don't have to vaccinate everyone (herd immunity's a wonderful thing), the threshold is always somewhere in the high 80%s. Also, the link between vaccines and autism is completely unsupported by scientific evidence. In fact, we had an entire small group session devoted to debunking it. I should've taken notes on the "miracles" required for the link to be true.

Moreover, after the Wakefield paper was published in the Lancet (and subsequently reported all over the popular press), there was a scare in Britain where parents refused to consent to vaccinating their kids. Result: increased incidence of measles and mumps, with two kids suffering measles encephalitis (read: permanent brain damage). Similar effect in Ireland: 1500 cases and 3 deaths. It's all nicely outlined, with citations, on Wikipedia.

Now, autism is an illness that hits very close to home -- one of my family members has been diagnosed with autism. It's a frightening label to put on your kid, because although there are various therapies, there is no cure. I completely understand why parents would want to avoid anything that might cause it. (Current evidence suggests it's genetic, but obviously very complex and non-Mendelian.) But also frightening: encephalitis. Death. You'd think parents would want to avoid these, too.

On a slightly related note: there are ads in the subway for some medical malpractice firm. In large and glitzy letters, they proclaim that you can win $1.5 million suing for autism. Who do you sue for a complex genetic trait, anyway? The worst part is the testimonial from a "satisfied customer" who notes how pleased she is that her child's incurable neurological condition has netted her some bling. I wish I were kidding.

2008-02-27T23:39:00.006-05:00

Today, in clerkship, my preceptor, a peds gastroenterologist, was running behind, so he threw a chart at me and told me to go in there and talk to the patient. The chart was completely empty except for a photocopy of their insurance card.

So I did my first Real Medical Interview today. For about half an hour. Completely unrealistic to have that kind of time, I know, but I got a ridiculously detailed history involving a rather dramatic family dynamic playing into the medical condition. Really, it was almost novelistic.

It was a little frightening, I admit. With less than a year of medical school under my belt, I have no clue what sorts of questions I need to ask. "So, what brings you here?" was my opening gambit. We rehashed the same topics over and over as I racked my brains for the best thing to say. At one point, the mother asked me, point-blank, for a diagnosis.

"Well," I demurred, "I'm just a medical student, so I can't tell you much."

"Oh." The corners of her mouth turned down. I felt terrible for not having an answer.

So I said, "I just learned about how sometimes, there might be a sort of block between the colon and the brain. Like the nerve cells in your intestine don't work properly, so your brain can't sense when to go to the bathroom. That might be something you could ask the doctor about when he comes in."

Very confident, as you can see.

Then I felt even worse, because I had no clue what I was talking about. All I know about GI, after three weeks in the block, are celiac sprue, Hirschsprung's, and cholera. Oh, and situs inversus. Everyone has situs inversus.

Luckily for me, the doc arrived; I fumbled my way through the presentation (first presentation as well!); and when he went in, his explanation also involved damage to the vagus nerve. So I didn't completely mislead the mother.

In short, my faith and interest in medicine are renewed once again. Thank God for clerkship.

Overtired and undermotivated.

2008-02-22T18:08:00.005-05:00

I feel like I'm in over my head again and kind of want to shut the world out. Or at least the med school part of it. I just want to flit from one social engagement to another -- tonight I'm going to a play, tomorrow to a dance -- instead of being holed up in my room or the library wondering why, exactly, apical ENaC channels are so important. And because my heart isn't really in it, my studying is very unproductive. I stare at the wall a lot.

It snowed today, you see. Snowfall is always beautiful, but in New York the beauty is fleeting. Already, the streets have turned to brownish slush. I really wanted to make it down to Central Park to take pictures, but, like I said. Studying. Death.

Sometimes, I wonder if I'm missing out on life. I am living in the greatest city in the world, and I feel like I can't enjoy it because I have to study. And I know that these demands on my time will only get bigger as I move through the ranks of medicine.

*deep breath*

I am reading Jerome Groopman's How Doctors Think at bedtime, and it's wonderful. I wish that this, rather than The Spirit Catches You, had been our summer reading. The cultural dynamics of Spirit were fascinating and obviously relevant, but Groopman's book is more immediately applicable, I feel. Also better-written. Like Oliver Sacks, he revives the case study as a narrative form. Although it's billed as "how to avoid misdiagnosis," it's really just about listening to the patient and the patient's body. And zebras.

2008-02-18T19:39:00.003-05:00

It's been a good week or so. The formal and afterparty were a lot of fun, just what I needed after exams. And my mother was visiting this weekend, so she and I had a good time exploring New York. We saw Curtains, a murder mystery musical about a theater troupe, set in the later 1950s. Think Kiss Me, Kate meets Radioland Murders.

Last week I went to a talk on the Science of Meditation, partly because there was food and partly because it seemed an interesting topic. The speaker, an alum of my med school, presented a bunch of data on melatonin as a contributer to tissue regeneration, which was intriguing. But then he started talking about the pineal gland being the "third eye" they talk about in Vedic scriptures (uh, did you ever think that might be a ... metaphor?), and yoga as promoting vagal maneuvers. Something about how standing on your head makes your diaphragm go slack? Didn't make a lot of sense to me, either. I'm cool with herbalism as a potential source of drug development, but this business of chakras and reiki and acupuncture is uncomfortably vague. Not to mention Orientalist. It is "Eastern," therefore it brings wisdom to the spiritually-deficient West. I am very, very tired of East-West Othering.

I know yoga and meditation are now trendy, stress-reducing ways for yuppies to achieve nirvana, but because of my background, they are very much a religious activity for me. And therefore intensely personal. And not scientific at all. Take yoga, for instance. It's not supposed to be about flexibility. It means "union," and it is supposed to be a way of moving past materialism and illusion into a spiritual plane in order to commune with God. I'm glad that people have some way of keeping fit and healthy, but it just seems, well, odd to me.

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No more exams!

2008-02-08T15:41:00.000-05:00

Well, for a month, anyway.

It wasn't such a bad block, since we didn't have anatomy. I can't wait for after Spring Break, when anatomy is Over For Good.

And now we have the med school formal tonight, which will be excellent. I love being all girly and getting dressed up for things -- don't get much chance for that these days.

Proof that med school takes over your life:
(3:40:04 PM) Laura: i was just painting my right hand
(3:40:15 PM) Laura: and im very unsteady with my left holding the brush
(3:40:34 PM) Me: uh oh
(3:40:39 PM) Laura: and the first thought to pop into my head is "gee i wonder if being ambidextrous makes you a better surgeon"

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2008-02-06T14:45:00.000-05:00

Surgeon's Blog has an excellent post on all that health economics/politics stuff that keeps coming up in connection with the election.

I would contribute actual content, but I'm tired, and sick, and studying for exams (just genetics to go!). My headaches have been getting more regular and more severe, which is really no fun. I consulted the wise and wonderful WebMD yesterday, which told me that I might have a subarachnoid hemorrhage. I love the internet.

2008-02-03T13:13:00.000-05:00

First, my big news: I got the summer internship I applied for at the American Academy of Pediatrics! It's mainly child health advocacy stuff, things like insurance and immunization, and apparently involves going to Congressional hearings. Woot! It's such a relief to have my summer taken care of, so I can start planning a short vacation. (Last summer? *sigh*)

Three exams next week, but no anatomy. So I'm sitting here twiddling my thumbs, wondering what more I can do. I've gone over my notes, taken ten exams from previous years (overkill? but they reuse questions like mad); I've even made flashcards for things that they specifically told us won't be on the exam.

Anatomy is just such a time drain for me -- it's not intuitive at all, and the exams test ridiculous (and often incorrect) detail from a book whose last edition was printed when I was in elementary school. Even after five months, I still find cadaveric dissection emotionally challenging. (Unfortunately, I appear to be a sap. Damn.) So usually, anatomy dominates my study time to the point where I fall behind in everything else. I know that's what's going to happen in March, when we have our last anatomy exam.

Interestingly, the last time we had an exam block that did not include anatomy, I felt the same way -- like I had adequate time to prepare for the other classes. The difficulty of classes, at least at this school, is all over the map. On one hand, you have Anatomy of Doom; on the other, human development, which is the biggest joke in the world. (If you show up to take the exam, you pass. I know someone last block who bubbled in C for every answer. And passed.) Most of our other courses fall somewhere in the middle.

Is this what life after anatomy will be like? Free time?

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Forsooth and ods bodikins!

2008-01-29T22:29:00.000-05:00

From JAMA's "100 years ago" section:

Probably no more forcible reductio ad absurdum of the currentview, to which we have adverted elsewhere, as to what inherentlyconstitutes the practice of medicine, could be conceived bythe witlessness of man than House Bill No. 704, now before theGeneral Assembly of the State of Ohio, entitled "A Bill to Regulatethe Practice of Non-Medical Healing in the State of Ohio." Non-medicalhealing, forsooth! Why not a bill to authorize the non-juridicalpractice of law, or to establish non-sanitary boards of publichealth? Why not establish in the curricula of our state schoolsand universities courses for the teaching of non-theologicaldivinity, of the non-biologic study of life, or the non-linguisticstudy of languages? We can hardly imagine that any legislaturewill so far stultify itself as not to resent the insult caston its common intelligence by the very title of such a bill.If a bill of this nature must be presented, let it at leastbe correctly described as what it is—a bill to authorizethe practice of healing without requiring proof of acquaintancewith those basic truths and principles on which the safe applicationof any healing measure whatsoever must for all time inseparablydepend.

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.

In which I whine

2008-01-27T19:42:00.000-05:00

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.

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Everyone' s a little bit ...?

2008-01-22T20:03:00.000-05:00

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.]

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2008-01-19T20:29:00.000-05:00

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.

Career development?

2008-01-16T20:20:00.000-05:00

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.

Neuro is awesome

2008-01-12T21:07:00.000-05:00

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.

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Thoughts on economic theory

2008-01-09T21:03:00.001-05:00

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.

ED Shadowing

2008-01-07T19:34:00.000-05:00

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.

Stepford Wives

2008-01-06T22:44:00.000-05:00

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.

2008-01-02T21:46:00.001-05:00

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

Happy New Year

2008-01-01T22:24:00.000-05:00

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.

Apoptosis tongue-twister

2007-12-17T20:54:00.001-05:00

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.

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If anything deserves an interrobang, it's this

2007-12-16T22:52:00.000-05:00

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?!

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2007-12-12T16:23:00.001-05:00

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.

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2007-12-11T22:35:00.001-05:00

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.

Stare into the (economic) abyss

2007-12-10T20:41:00.001-05:00

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.

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Last clerkship

2007-12-05T18:04:00.000-05:00

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.

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Now playing: Benzos - Teach Me
via FoxyTunes

Anatomy syllabus

2007-12-03T14:56:00.000-05:00

"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.

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

Tom, Dick, ANd Harry

2007-11-29T20:54:00.001-05:00

Do you know what's pretty cool? When you pull on the extensor hallucis longus, the big toe actually moves. Visibly. My entire anatomy group freaked out.

It was probably the highlight of anatomy lab thus far. Aside from the Halloween factor, it was the first moment since we opened the left ventricle that anatomy actually made sense.

Fear not, sweet Reader

2007-11-26T22:45:00.000-05:00

I'm still here, albeit swamped with work. I decided to take a real break for Thanksgiving -- studied a bit on the bus ride home but spent four days being a mental vegetable on the sofa -- so I'm now playing catch-up.

I realized the other day that in 3.5 years (give or take a couple months) I'll be finished with my 21 years of continuous schooling ... and earning less per hour than I did the summer I was 17. That's slightly depressing. To quote Scarlett O'Hara, I'll think about that tomorrow.

Perspective

2007-11-14T17:58:00.001-05:00

I was going to complain about my day-long fast (too busy to grab anything to eat between 8 and 6), but then I checked my email and learned that someone I know -- the most upbeat guy I've ever met -- has cancer. We knew he was sick because he had been away for a few weeks, but then he returned, bald and as jovial as ever, so I assumed that whatever was wrong had been fixed.

I guess you can't fix all the people, all the time.

2007-11-11T09:23:00.000-05:00

This is how we socialize nowadays:

(9:08:14 AM) Rebecca: i need to go shower but i wil talk to you later!!
(9:08:18 AM) Rebecca: where are you studying today?
(9:08:31 AM) Me: probably [the library]
(9:08:37 AM) Me: lower level

I really dislike Monday exams, because it means we don't get weekends. The weekend before is spent cramming (see above) and the weekend after is spent catching up with all the classes you ignored in the pre- and post-exam madness.

2007-11-08T08:45:00.000-05:00

Yesterday, I interviewed two real, live patients all on my own.

And when I say "on my own," I mean of course, with an interpreter. My Spanish, though adequate, is not up to snuff when dealing with illness or numbers, which can make it difficult for all concerned. English-speaking patients are a rarity.

Anyway, I ended up filling out the Social Work Assessment on both these patients, one of whom was pretty stable and ready to be discharged, and the other of whom was in a bad state about her cancer diagnosis. She spoke really fast -- the interpreter had to ask her to slow down -- and she kept jerking her head around like a hunted animal. I felt really terrible for her.

And the worst part was, I couldn't sit down with her and help her feel better. Partially there was the language barrier, but more than that, what does one even say to a person whose chronic back pain turned out to be advanced lymphoma?

After returning from the hospital, I went to a reading on gendered illness and women's experiences with illness. I'm still not convinced that there is a distinctly feminine component to the experience of illness. To be honest, the biggest connection I can see is the loss of power/autonomy/agency that often accompanies illness and the loss of power/autonomy/agency that often accompanies the traditional barriers against women. Pretty weak.

Still, the reading was interesting and moving, and it emphasized the use of narrative as a weapon against isolation and marginalization. And there was food.

In which our heroine goes to OR

2007-11-04T18:04:00.000-05:00

I was in the OR today, shadowing anesthesiology residents. (Cheesy title, I know.) It was really fantastic -- one showed me how to put in an IV and another let me watch him give a thoracic epidural for a double lung transplant (!) and afterwards explained the differences between thoracic and lumbar epidurals -- what to watch out for, etc. That was particularly exciting because we just did the vertebral column and spinal cord in anatomy. Who would have thought that all those spinal ligaments are actually clinically relevant? I can tell you that I remember them a lot better now. After weeks in the classroom, it's always really exciting to see Medicine in Action.

And then I helped the anesthesiologist set up for an operation and stayed until the pt went under. I thought I wouldn't really like the OR, but it's actually a cool place. There is definitely a vibe of Go Go Gadget O2 Sat! Still leaning towards the medicine side of the med-surg division, though. We do 15 weeks of surgery rotations here (5 gen surg, 10 surg subspecialties), so I'm sure I'll get all the exposure I need in 3rd year. But it's nice to get a little flavor early.

Mostly, I was impressed at how willing the residents were to have me and my classmate there. I'm sure they must be exhausted and everything, and we were these two happy, well-rested first-years bouncing in and being all naive. They all had great things to say about the program, too. It's gratifying to know that not all residencies have malignant "beat you and eat you" mindsets.

Transection

2007-11-01T17:17:00.000-04:00

I didn't really have much of an emotional problem in anatomy lab, until today. Today we were told to transect our cadavers just below the rib cage and prop their lower bodies up on goalposts. The rationale for this was so that we could have a good view of the perineal area.

Bullshit.

Gynecologists can get a good view of the perineal area without needing to saw their patients in half. (Yes. We had to use saws to get through the vertebral column.) Ever heard of stirrups? They aren't comfortable, but they are a damn sight better than what we had to do today.

I am extremely upset about this whole situation. Even the first day, when we uncovered the shrouds and looked at our cadaver's face, was not quite so bad. We could say to each other, It's ok -- she donated her body. We'll learn from her." That belief helped us with our first cuts.

If this were the only way to learn, I would rationalize it. But it's not.

Today, there was no pedagogical reason for what we did in the name of "learning." I feel physically dirty for having violated a human body. I feel like a medieval medical student, grave-robbing cadavers, knowing what I am doing goes against every fiber of decency in myself -- and doing it anyway.

Transections seems so innocuous on paper. And yet, looking around the room and seeing red-bagged feet dangling in the air -- it was like something from Dante's Inferno. It was disrespectful, had no academic value, and I am disgusted at myself for having taken part.

New Block Resolutions

2007-10-29T12:20:00.000-04:00

Well, exams were fair-to-middling. I passed (at least the ones whose grades have been put up), but only marginally in anatomy.

We started a new block today -- essentially, starting afresh. So here are my Block 3 Resolutions.

I will:

Spend 1 hour per lecture prereading the night before.
Spend 1 hour per lecture reviewing, the same afternoon.
Spend 2 hours in anatomy lab every Sunday, reviewing the structures for the previous week.

I will not:

Fritter away my study time on YouTube. (Diagnosis Wenckebach can conceivably be a "study aid", but the temptation to watch SEVERAL HOURS of French and Saunders is just too great.)
Study only in the hellhole that we call a library.

This is what I did first block, and it worked. It also kind of sucked, balance-wise. Second block, I swung too far the other way -- making free time at the expense of my studies. Maybe this time I'll find the happy medium.

(That sounds like a Lifetime Original show, doesn't it? "The Happy Medium." Seances and crystal meth.)

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Now playing: Yo-Yo Ma, Mark O'Connor & Edgar Meyer - Caprice For Three
via FoxyTunes

Balance

2007-10-23T22:25:00.000-04:00

For the first time, I feel reasonably prepared for a test in med school. Of course, they haven't provided us with any practice questions for this class, so that might have something to do with it. Heh. Syllabi are incredibly high-yield, though. My school doesn't officially provide syllabi anymore, but there are old ones floating around; they cover exactly what the lecturer emphasized and are much easier to understand than the Powerpoints. I heartily approve.

(For non-med students out there: med school syllabi aren't just a list of topics to be covered. Rather, they are extensive, multi-page lecture notes. The anatomy syllabus, for instance, is 650 pages long, excluding the index, errata, and learning objectives appendices.)

I've been a lot better about balance this exam block. For instance, I take about half an hour every evening before bed to read White Teeth, a novel of Awesome by one Zadie Smith. It helps to pull myself out of STRESS mode and remember the power of literature.

Speaking of which, I got the teaching job I applied for and have been teaching 7th graders every other Saturday for the past few weeks. It's a lot of fun, and coming up with lesson plans is not as terrifying as I thought it would be. (There are two other advisors, who are full-time, so that helps.) I'll be teaching solo in December when I do my elective; I know what I want to teach but am holding off on the actual planning until post-exams.

It's going to be so relaxing to have a real weekend this time. I wonder what I'll do.

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Now playing: Mozart - Elvira Madigan Piano C
via FoxyTunes

365 Days Ago

2007-10-16T22:02:00.000-04:00

A year ago today, I got a fat envelope from the med school associated with my undergrad university. I pretty much jumped up and down, right there in the mailroom, called my mom, and went around for the rest of the week grinning like the Cheshire Cat.

The rest of the application cycle brought luck but also heartache. Around November, I had a serious crisis (precipitated by love for my thesis) wherein I was just an email away from withdrawing my applications everywhere and applying to English MA programs.

Crazy, I know.

What was I afraid of? Partly the work (and there's no denying that it's rough; I study about 4 hours a day and more during the week before exams). Mostly the culture of medicine. You know, those people who insist that medicine is supreme, more important than family or sanity or outside interests. It may be heresy, but I applied to medical school because I like stories. And medicine is pretty much the only profession (besides Starving Writer) in which narrative is supreme. I was afraid that "they" would find out that I secretly love stories more than duodenums (duodena?) and that "they" would summarily kick me out of med school, leaving me disgraced and jobless.

In my mind, "they" were pretty much Nazis.

In the end, I decided to stick with medicine because I met a physician who showed me that I was not strange or somehow demented for seeing disease in the framework of a story. That there would be opportunities in medical school to pursue stories. That becoming a physician might actually improve my own stories. I honestly think that that woman is the reason why I am where I am today.

And how do I like it here? Bloody awesome. School is very school-like -- lectures from 10-12 daily, anatomy lab twice a week from 1-5, nightly studying until 9:30 or 10. I'm working much harder than I ever did in undergrad, and failure is a very real possibility (albeit with shadowy, ill-defined consequences).

But I still find time to cook, to read; I even get up an hour early every morning to write. There are many other writers and artists here as well -- we have book clubs and musical performances and writers' workshops -- and I think that's contributed a lot to my rapid adjustment and general joy. It's almost a frightening sort of happiness, as though some Greek god were about to strike me with the plague, just to even things out.

So that's why when Dr. B. asked this morning if med school was all we imagined it to be, I thought, "No ... it's much better."

Lather, rinse, repeat

2007-10-14T23:36:00.000-04:00

Although it seems like just yesterday that we got our exam scores for block 1, our second exam block is coming up faster than you can say "Off to the library!" This time, rather than 2 three-hour exams on a day, we have 3 three-hour exams spread out over the week, with study days in between. A little like college final week, if you will.

Still waiting for the adrenaline to kick in, so I can get studying hardcore. I've been keeping up with 2-4 hours a day, so I'm pretty comfortable with broad concepts, but now's the time to go back and find the niggling details. For instance, two of the genes that influence neural crest derivation are Phox2 and Sox10. I can't help thinking of Green Eggs and Ham.

There's some surprise on SDN that I'm able to live quite comfortably in New York City on 1k/month. Mostly that's thanks to my subsidized dorm room, but here's a breakdown of September's expenses, in case you're curious:

$660 -- Dorm
$150 -- Textbooks
$65 -- Transportation (including a $55 trip home)
$50 -- Food (both groceries and eating out)
$55 -- Entertainment
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$980

I guess my food category seems incredibly low, but you have to remember that this is med school. They practically throw free food at us. Most weeks, I can get 5 or 6 meals by going to various lunch and dinner meetings.

So there you have it. How to live in New York City on a student's budget.

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Now playing: Elton John - Honky Cat
via FoxyTunes

2007-10-10T17:44:00.000-04:00

Today, I came across this line in a patient's chart, dated from the early hours of the morning:

Family remains at bedside.

That resonated with me. The image of a son and daughter sitting by their father's hospital bed, waiting to hear what the physician has to say.

Cliché? Perhaps. But then we went into the room, and the cliché came true.

Though I didn't know about clerkship when I decided to come here, it has rapidly become the best part of my week. I see patients under the supervision of either a social worker or a resident, help gather a history, and generally am a witness to the unique experience that is the Clinical Encounter. In just three sessions, I've seen fear, worry, joy, denial, assertion -- in short, all those pieces of humanity that made me want to become a doctor in the first place.

I don't know pharmacology yet, and I can't differentially diagnose your lower back pain, but I feel so privileged just to be allowed to be with people who are experiencing some of the most intense emotions of the human condition.

It more than makes up for confusing lectures on deciphering an EKG.

P = MD

2007-10-06T20:23:00.000-04:00

I passed my exams!

We're on a P/F schedule, which is God's gift to medical students. You simply can't imagine how fantastic it is to not worry about GPA anymore.

To celebrate, my college roommate (who is visiting this weekend) and I picnicked in Union Square Park with Greenmarket produce -- bread and cheese and the strangest-shaped plums you ever did see -- and went to the Strand, an amazing bookstore. I think this will have to be my post-exam relaxation every block.

This is the weekend of no studying. One needs it from time to time. Hobbies are good.

Exams

2007-10-02T16:45:00.000-04:00

Why's the blog so pink? Well, October is Breast Cancer Awareness Month. My family's had a scare with breast cancer some years ago -- everything turned out fine for us, but so many men and women are not so lucky. So even though I detest the color pink as a rule, I decided to go Pink for October to try to raise awareness.

Ladies, self-exams are good. I admit that I don't always remember, myself, but we had a lecture a few weeks ago about breast cancer and mastectomies, and the post-op pictures were so frighteningly raw and bloody. If I can get a link to one of those "click and we'll donate a mammogram" things, I'll put it up here as well. Breast cancer may not be preventable, but it is certainly treatable if detected early.

*descends from soapbox*

My exams were not so hot. I am notoriously bad at predicting my own performance, though, so perhaps I did better than I thought. And many of my classmates felt the same way, so perhaps there will be a curve. Or something.

Honestly, I was just thrown by the level of complexity of many of the questions. I've taken tough exams in undergrad, but they were almost all short answer or essay. The few multiple choice exams were mainly focused on recognition of the right answer, rather than a logical thinking process of connecting Random Fact A to Seemingly Trivial Minutia B. This is good to know, because we have 6 more exam blocks to get through by the end of the year.

It does help, though, to know that our exams are Pass/Fail only in first year. That is, I think I passed. Removes a lot of the stress. As for competition/cooperation, I have to say that I haven't seen much of that going around. We get a ton of help from the second-years here (they run special workshops the week before the exam to review all the major concepts). But intraclass cooperation seems to be mainly based on study groups; I don't think anyone sent out study guides they'd made. (I did want to upload mine to the class website, but I couldn't figure out how to get the silly thing to work.) I think, though, that we are all still in premed mode, and that will change as the year goes on.

I took some much needed time post-exam to chill, buy groceries, go to the library -- it was delightful. My friend A invited a bunch of people to have dinner at her apartment on the UWS, and it was so wonderful to sit around talking with friends for the first time in weeks. L brought champagne, so we toasted to "finding balance." The past week has been very rough, academically and personally (I kept having to hang up on my mom so that I could study, and I hated that). Hopefully, we'll all find a way to pass but still retain some semblance of a normal social life.

Sucked that we had a full day of classes today. I skipped out on the second lecture to go to an interview for a Saturday school enrichment program I'd like to get involved in. Hopefully that will come through, because I truly want to get more involved in the community here than I was in my undergrad. I should be hearing back from the program director sometime tomorrow. As a good friend from elementary school used to say, "Cross your fingers and hold your nose!"

God complexes and entitlement

2007-09-29T07:43:00.000-04:00

So, I took a practice practical and practice written for anatomy yesterday. (The former was organized by the second years, the latter was in Gray's). Barely passed the practical and solidly flunked the written. Methinks today I will memorize the syllabus, which apparently is the key to success is anatomy.

My anatomy prof is a bit of a jerk -- ok, a serious jerk. In lab, there are a few professors who wander around helping us find structures. One of them, as he was digging out the sympathetic chain ganglia for us, gave us a beautiful explanation of the nervous system, which our actual professor can't teach for a million bucks. We asked if he could give a NS lecture to the class, and apparently Dr. Jerk won't let him because "students shouldn't have to seek outside help."

Going along with that, one of my classmates bumped into the doctor who did our radiology lectures, who was surprised to learn that there would be a radiology component to the anatomy exam. She offered to hold office hours Sunday morning for student questions. As I got dressed after the practice practical, I heard some of the other women in my class bitching that Dr. R. was having Sunday office hours. "Sunday morning. I want to sleep."

Well, so do I. I'm sure Dr. R. would rather sleep, or be with her family, or whatever. As far as I can tell, office hours are totally optional for professors here. Unlike in college, where they are required to hold a certain number of office hours (which they are paid for), here they do it on their own time. And so even though I value my rest, I also am incredibly grateful to any lecturer who is willing to reteach the material so that we understand it.

Most of my class is pretty cool. And I know we're all stressed and tired and cranky about these upcoming exams. But ingratitude like that just smacks of entitlement.

2007-09-21T21:05:00.000-04:00

First exams are in about ten days. My study group met for the first time this afternoon and we tried to cover three weeks' worth of material in just a few hours. It was rough, but I think it was worthwhile. Much easier to study when there are others to talk through the slides with.

Tomorrow, we are going into the anatomy lab to look at various cadavers and aberrancies. Our anatomy exam is only on the thorax, but it's frightening to think how much material is contained in just that segment.

We start clerkships next week. It's not anything like 3rd year rotations: we just learn to interview patients under the guidance of a clinical care provider. We had a practice session today with patient-actors, and it was incredibly difficult.... Perhaps I was concentrating too hard on my body language, because I had trouble coming up with things to say. Whereas I'm sure that if I met this woman (or character, whatever) in a regular social context, without the white coat, I would find it much easier to establish rapport, etc.

On the fun side of things, I went to a wine tasting last night and learned all about Italian wines. It was sort of my last free night before I buckle down and study.

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Now playing: Josh Groban - Cinema Paradiso (Se)
via FoxyTunes

Radiographic Anatomy

2007-09-10T20:12:00.001-04:00

Here's what I did in lecture today: an artistic representation of a transverse section of the heart screaming, "Help, I'm trapped in the mediastinum!"

Radiology is not hard per se -- all you do is look at films all day -- but they are kind of throwing us into things without any real context. When Dr. R. pointed to haze and said "This is clearly the aortic arch," we all sort of giggled nervously. Even histo's clearer than this.

Other than difficulty with the chest X-rays and CT scans, life and classes are going well. I just got back from a weekend in the Catskills, chaperoning low-income city kids for an enrichment program run out of the children's hospital here. They learned team-building and I re-learned how much I enjoy working with kids and helping them understand the world around them. Around the campfire, I told them all about the stars -- they'd never seen stars before -- and Cassopeia and Orion and slaves running north with only the Big Dipper to guide them. They were fascinated, and I got an incredible rush from telling them something new and exciting. I think I'm going to get more involved with the program as the school year goes on.

Reflections on the first week

2007-09-01T22:10:00.000-04:00

Now that my first official week of med school is over, let's look back at my courses.

For 2 hours every morning, we have an integrated basic science class, which thus far is basically one-week crash courses in biochem (last week) and cell bio (this week). I'm very very thankful that I've seen the material before, because it allows me to concentrate on ....

... Anatomy! Our first lecture, on Tuesday, was three hours long. No breaks to speak of. (I think we had five minutes while he was figuring out how to change powerpoints.) Lots of vocabulary. Thursday's lecture was a little better, because it was (1) coherent and (2) intellectually interesting. However, then we went into lab, which was a little rough. Although several of my older family members have died, I'd never seen a body that close up. Ours doesn't have a first name on her wristband, which means she was probably unclaimed. It's tough to console yourself with thoughts of honoring a person's dying wish, when you know that they are only there on the table by accident. Also, my grandfather, who died just over a year ago, donated his body to the medical school where he used to teach. My reaction to "Alba" (what I have named my group's cadaver) made me wonder about his body. Still, a friend later reminded me of Sydney Carton's last words -- "It is a far, far better thing I do than I have ever done." -- and I felt a bit better. This unknown person might be my most intimate teacher in medical school -- and that reminded me of Eklavya and Dronacharya.

On Thursday, a patient of one of our professors came in to talk to our entire class about her chronic illness, which was very touching. She's been through a great deal of pain and suffering -- it was difficult for her to hold the microphone up -- and yet she was in remarkable spirits. She even joked about some of the doctors who misdiagnosed her and told us that her inner strength comes from her hope that life will be better for the next generation of those with this horribly painful disease. I find that remarkably selfless, and it certainly puts into perspective my whining about having to study.

On Friday, we spent most of the day in our small groups, learning about what to do if someone collapses on the street. The basic gist was "don't do anything, but if you really want to, pretend to be MacGyver and improvise a splint out of the New York Times." It was kind of fun and pretty interactive -- and I did learn a lot about trauma cases -- but I'm not sure how useful it would be "in the field." Still, it wasn't a bad way to spend a Friday.

So far, at least, med school isn't THAT bad. Sure, I have to study 4-5 hours a day, every day, but it's intellectually interesting stuff, which makes all the difference in my opinion. I am also a nerd who doesn't ever go to bars. :) I'm sure it will get tougher as time goes on, but I still think it's the right decision.

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Now playing: Ambros Seelos - Spanish Flamenco Matadors
via FoxyTunes

First day!

2007-08-27T19:31:00.000-04:00

As first days go, this was among the best.

I woke up early with an adrenaline rush and watched the sun rise (or rather, the reflection of the sunrise; my room faces west). Made myself a proper breakfast and spent the morning running last-minute errands: getting my name pin fixed, picking up my anatomy book and white coat, things like that.

We only had class from 10-12 today, with a five-minute break between the lectures. It wasn't too difficult; they are starting off with college-level biochemistry, which I majored in. Aside from a very few numerical details, I had seen the material before. I guess that's why they say college biochem helps in med school. Granted, in one hour we covered about two weeks' worth of college material, but the familiarity helps get things settled.

In the afternoon I went grocery shopping to a new store. Had to hike through Harlem to get there, through an area that looked like the Jets and the Sharks were just around the corner, snapping their fingers and dancing like the extremely fey gang members they are. Definitely wouldn't want to go there at night, but the selection and cost was worth it.

I also cooked today! I'm very proud of myself, even if it was just and pasta. Cooking makes a nice break from studying. I think I'll be doing a lot of it.

And I just watched a beautiful crimson sunset over the Hudson as lights shone on the George Washington Bridge and a canoe paddled downriver. God, I love this place.

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Now playing: Mark O'Connor - Butterfly's Day Out
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Orientation Week

2007-08-24T08:53:00.000-04:00

As Orientation winds down, I finally have a moment to stop and reflect on the past week. Since I moved in on Sunday, I've had a wonderful time. Can hardly believe I was afraid of this place, because the last week confirms that I did, in fact, make the right decision.

Mostly they've kept us busy exploring the city -- I've been to MoMA and The Lion King, both of which were fantastic -- and they've talked at us a great deal. We had a curriculum overview and an administrative overview and a safety overview and a financial aid overview and just about every other overview you could possibly think of. Also lots of free stuff -- mugs and pens and food. That last is most important, because we have neither a dining hall nor a kitchen.

Yesterday we broke into small groups and discussed the Hippocratic Oath. The version we'll be reading later today at our White Coat Ceremony was revised in 1928, so it's certainly more modern than swearing by Apollo, but it paints a very idealistic picture. (I guess that's kind of the point of the Hippocratic Oath....) The fourth-years who led the discussions told us a little about the reality of seeing patients and how the Oath can be ambiguous.

Some people in my class had trouble with the implication that we as future physicians are held to a higher moral standard than the rest of society. The Oath says, "my holding myself aloof from wrong, from corruption, from the tempting of others to vice," and one guy called it a "holier-than-thou" attitude. I don't think that's the case. Coming from the University, where Honor is queen (and Jefferson is king), I think that the Oath is just reminding us -- everyone -- that we should live ethically and honorably.

On a lighter note, a bunch of us were playing Taboo last night, and the clue was "When you pee, it comes out of this." My friend L immediately guessed "urethra." The word was "bladder," but we're such nerds.

I think I'm going to like it here.

Pre-moving jitters

2007-07-23T22:16:00.000-04:00

A good friend of mine from high school got married this past weekend. At the reception, I met people I haven't talked to since high school graduation (and one guy I went to elementary school with). As recent college graduates, we all asked each other the same question.

"What are your plans for next year?"

I told everyone that I'm moving to New York in mid-August to start medical school and that I was very excited. I mean, it's New York City. It's on every tourist's must-see list; it has all these songs written about it; it's an absolutely unique place to be. No other city has more theaters, publishing houses, and academic institutions, not to mention an amazingly complex subway system that will ferry you hither and thither for just two bucks a ride. I want to be a part of all that. I want to be a New Yorker.

And at the same time, I'm terrified of the City.

I've never lived anywhere but a suburb and a college town. What if I can't stand city life? What if I get mugged? I don't know anyone in New York; what if I get lonely? What if I can't handle being so far from home? What if I fail anatomy, or worse still, realize that doctoring isn't for me? (*mentally adds "hobo" to list of backup plans*)

You know, once I write all those fears down, they seem kind of silly. I'll be ok. It's just a little bit frightening to go through all the stuff in my room -- the books and papers and clothes and trinkets of 22 years -- and decide what I'm taking with me and what stays behind. Except for a week's vacation at Christmas, I won't really be coming back here again. I think that's what scares me the most.

Going off to college was not such a big deal; it was just two hours away and I never really moved out. But towards the end (fourth year, especially), "home" stopped being my parents' lovely house in suburbia and became my little 11 x 13 room with the high ceiling and the two windows. The one night I spent in New York, at a second look weekend, I became incredibly homesick -- for my dorm.

I do insist that I made the right choice. The school where I'll be matriculating in less than a month (ahhh!) was the only place with which I really fell in love. My future classmates seem chill. It'll just be ... different. As Richard Curtis wrote in The Vicar of Dibley, there's good change, and there's bad change. ("There's the Changing of the Guard ... and then there's prawn-flavored crisps!")

I think the moral here is when in doubt, watch something written by Richard Curtis. Truly, the man's a genius.

Agency

2007-07-19T13:30:00.000-04:00

Yesterday I read Better: A Surgeon's Notes on Performance, by Atul Gawande. It was an excellent book, especially after The Spirit Catches You and You Fall Down. Both address problems in healthcare, but whereas Spirit is anecdotal and a little touchy-feely, Better provides facts to back up its claims. Most importantly, Better focuses on how doctors and nurses can improve things. Mainly, it seems, by giving themselves agency.

Agency is a funny sort of word. I first heard it in my first semester of college, in a class about Shakespearean comedies. I think it was the lecture about Much Ado about Nothing (great play, fantastic movie starring Kenneth Branagh, Emma Thompson, and Denzel Washington). It refers to the power to effect change. So, Hero ("Leonato's short daughter") has no agency in the events of the play. Instead of, say, Merchant's Portia, who does things like cross-dress as a lawyer, Hero allows things to be done to her.

Literary digressions are fun!

But the main point is that agency, and a belief in one's own agency, is important. It underlies the ethical principle of autonomy. There's a lot of energy focused on the patient's autonomy, as there should be. For example, the Lees in Spirit lost autonomy in part because of their inability to communicate with the physicians. In many ways, the book is as much about their struggle to be subjects as it is about Lia's battle with epilepsy.

But there is also the autonomy of the physician. This seems to be gaining ground nowadays, with physician discontent with the insurance system in this country and with government/administrator involvement in how their practices are to be run. Better's kind of unique in that it addresses the autonomy of physicians, surgeons, and nurses to make choices about their practice of medicine. One chapter, which I personally found the most fascinating, deals with medical practitioners assisting in lethal execution, and their ethical and personal dilemmas about how far to go.

It's a great book, even better than Complications, his first. Go read it.

More on The Spirit Catches You

2007-07-14T19:22:00.000-04:00

I finished reading The Spirit Catches You and You Fall Down a few days ago. First off, I mistakenly called the family Cambodian in my earlier post; they are Hmong. I didn't really know a whole lot about the Hmong before reading this book, and I still don't know a lot about them. Interspersed within the medical narrative were histories of the Hmong, who have faced persecution just about everywhere because of their refusal (stubborn or courageous, depending on your point of view) to assimilate into the mainstream culture. Anne Fadiman characterizes them as "scrappy."

But I begin to see why people on SDN are so frustrated with the way the parents behaved. They took the epilepsy meds and pretty much made up their own medication regimen, without informing the doctors. The kid kept seizing, and the result was painful.

What I don't understand is this: why did the parents, who were very mistrustful of Western-style evidence-based medicine, keep bringing Lia back to the doctors? In general, it seemed as though they loved the kid to distraction, but they were so ambivalent about her treatment: medicating her whenever they felt like it, skipping days, overdosing her. For a long time, this was not communicated to the doctors, either willfully or because of faulty (or non-existent) interpretation.

Some bleeding hearts might say it's politically incorrect to suggest that the parents purposely withheld information. But no. Politically (and factually) incorrect would be saying something like "All Hmong are dirty liars," which is just ludicrous. Don't confuse personal accountability with group stereotypes. In fact, the only criticism I have of this book is that Fadiman treats the Hmong like porcelain figurines. The doctors are very realistic -- some efficient and some effusive -- but the Hmong are long-suffering victims to the last man; no criticisms allowed. Although she devotes a lot of time to what the doctors could have done to facilitate communication, she seems almost afraid to point out that compromise is a two-way street and that the parents' confused stubbornness is just as much to blame as the physician's insistence on a biomedical treatment.

In the end, I found myself sympathizing with the parents but empathizing with the doctors. Lack of compromise can have terrible results.

The Scrivener's Guide to Applications

2007-07-10T14:15:00.000-04:00

(or, how to retain some semblance of sanity and financial solvency)

Let's get one thing clear: the medical school admissions process is designed to encourage neuroses. If you subject a group of intelligent, hardworking people to a process shrouded in secrecy and with terrible odds (half of those who apply will be rejected from all schools), you're bound to incur some paranoia.

That being said, you, too, can get into medical school if you follow these easy tips. What makes me qualified to give you advice? I applied to 12 allopathic schools for Fall 2007 (including one Canadian school), got 9 interviews, and ended up with 7 acceptances. All told, applications cost me about $2000 (3000 if you include the MCAT fee, my two suits, and Second Look weekends). Plus, I just like giving away free advice. This particular post comes via a suggestion from my friend K, who is applying for Fall 2008. As I told him, if you know what you're doing, this process is not a crapshoot.

Tip #1 is to be normal. I really can't stress this enough. A friend of mine had a stellar academic record, but she was so obsessed with getting into med school that she ended up shooting herself in the foot and not doing as well as one would have thought. Myself, I was so nervous at my first interview that I babbled and gushed about how great medicine was and ended up waitlisted and then rejected. Maintain an interest in something outside academics/work and applications, because otherwise, sure as the sun rises in the east, you will go crazy. Watch some TV; read a book; hike a mountain—anything.

Tip #2 Let it go. Three days after I took the MCAT, I woke up in a cold sweat because I suddenly remembered that I had confused the Lyman and Paschen series in the physical sciences section. This was a bad idea. Once the proctors call “time,” once you mail off your secondary (with sizable check), once you shake your interviewer's hand and walk out, it's over. There isn't a lot more you can do, short of sending a letter of intent (which is legally binding, so think carefully before you write it). Move on with your life. Hike that mountain I mentioned in Tip #1.

After those two rather philosophical tips, #3 is a bit more practical. Get a copy of the MSAR. The Medical School Admissions Requirements book is a must-have when you start the application process. I don't recommend buying—you'll only use it for a week or two, and since an updated one comes out every year, the resale value is almost nil—but borrow from an older friend or check it out from the library. The MSAR is basically an alphabetical listing of all the medical schools in the US and Canada, with a page-long description of each along with average GPA and MCAT. The rule of thumb is GPA*10 + MCAT; your score should be within one point of the school's score. That means you're a good match numerically, but doesn't take into account your state residency, minority status (Native American, black, or Hispanic; sorry, Asians!), or other personal circumstances. Once you have a list from the MSAR, go to individual schools' websites to narrow it down to 15 or so.

Interlude for personal gripe! AMCAS really sucks. The centralized application service is very poorly-designed. For instance, you have to painstakingly enter each college course (including high school APs and IBs) exactly as listed on your transcript. Not in a table; no, that would be too easy. Nope, each course has an individual HTML form, and once you hit “add course,” it's almost impossible to go back and fix mistakes. And then you send them an official transcript so that they can verify all the information you told them, a process that can take several weeks (see below). AMCAS may be streamlined for the schools, but for applicants, it's an exercise in following directions.

Tip #4: Apply early. SDN would have you believe that several thousand premeds hit “submit” on AMCAS at midnight on June 1, the day the whole thing opens. Like most things on SDN, that's an exaggeration, but do try to get your AMCAS in by the end of June. Verification gets more and more backlogged as the summer goes on, and since most schools have rolling admissions, it's best to be at the front of the pack. Turn your secondaries around fast, too; two or three weeks is the norm. If you're still in college, try to get them all in before classes start. Nothing sucks more than having to write a convincing essay (show, don't tell!) about how empathic and diverse you are after taking a three-hour biochem exam.

Tip #5: Don't splurge on a suit. Before buying from Ann Taylor or Jos. A. Bank, go to outlet stores and mid-range department stores. Look for lightweight wool in conservative colors (dark blue, brown, dark gray—avoid black if you can). Try things on. Women, get a three-piece wardrober (jacket, pants, and skirt). Keep an eye out for sales. No one really knows or cares that you are wearing last season's lapels. You shouldn't have to spend more than $75 on a good-quality suit. And get really comfortable shoes. At one school, the girl next to me was wearing those pointy-toed witch shoes. She slipped them off while she was waiting for her interviewer, and her feet had actually molded to squeeze into that unnatural shape. No fashion is worth that price.

Tip #6: Interviews are fun! I know this seems counter-intuitive, since they are so subjective and all, but the vast majority of my interviews were low-key and conversational. At one, we talked for about fifteen minutes about Harry Potter. But be prepared to explain any weakness in your file: a low semester GPA, a red flag in a letter of recommendation. Interviews are also cool because you get to check out the school and the area in person. My opinion of several schools changed a lot after the interview.

Tip #7: Don't take rejection personally, and don't get cocky over an acceptance. Like I said, this process, while certainly difficult, isn't a crapshoot. That's why rejections hurt so much—some school thought that your best wasn't good enough. Take a deep breath and follow Tip #2. (Keeping a stash of chocolate on hand is highly recommended.) Sometimes, the school is willing to look over your file again and tell you what went wrong so you can fix it. No matter what, don't let a rejection affect your performance at other schools. Similarly, celebrate your acceptance, but don't get arrogant about it. All it means is that you managed to convince someone that you might make a good doctor. The real work is still ahead of you.

There you go; the Scrivener's seven certified tips for getting into med school. Apply away!

By way of belated introduction

2007-07-08T23:39:00.000-04:00

(This shoulda been post #1, but you can't win 'em all.)

I'm a soon-to-be medical student at a school in New York. My parents are both Indian immigrants who showed up in the States to do some programming in the early 1980s and ended up staying for the jobs and later, for the schools. After a fairly typical suburban childhood, I ended up at my state university, where I double-majored in biochemistry (aka premed, in more ways than one) and comparative literature (aka pure joy). I had a great time there, especially in my third and fourth years, but alas! in May they handed me a piece of fake-parchment and evicted me from my idyllic residential college room. So I'm back at home with my parents for the summer, writing, reading, and trying to get myself organized before school starts.

Bored yet? Me too.

Seriously, the best way to know me is to read my blog. I'll be writing about all things medical -- the application process (which, frankly, sucks), classes, issues in medical ethics or policy, international healthcare, and my pet project: medical fiction. I promise to keep the personal stuff to a minimum, because no one wants to read about how Mom hates me and doesn't understand me and . You can get enough of that weepy stuff on Lifetime.

Well, that's it, really. I hope you enjoy.

2007-07-08T21:17:00.000-04:00

Truth be told, I don’t really know that I deserve a blog. I don’t write as well as some of the medical bloggers out there, and I’m sure many of you already know what medical school is like. I don’t even start until August.

But I’ve already begun collecting paraphenalia, like a Netter’s Atlas. It’s sitting upstairs in its shrink-wrap; the thought of opening it is mildly frightening, like an acknowledgment that I’m actually going to med school.

We have a summer reading assignment (how very middle school) — The Spirit Catches You and You Fall Down, by Anne Fadiman. It’s frequently discussed on the SDN boards, where the fashionable position appears to be Cynical Pro-Establishment. One person, who shall remain nameless in the interests of anonymity (and because my memory kind of sucks), stated that as the Cambodian refugees sought out American medical care for their daughter, they should agree to do everything the Western way. I wrote my undergraduate thesis on power struggles in medicine, and so I am loathe to suggest that the balance of power in the physician-patient relationship be so fully given to either party. That seems like less of a solution to culture clashes, and more of a Tarzan-esque chest-beating competition. (”My medicine’s better than your medicine!” “Oh, yeah? Sez who?” “Sez me!”)

That’s not to say that I’m some kind of crazy hippie throwback. I happen to think that magnetic bracelets are in the same category as, say, Chinese tattoos, but I also think it’s foolish to discount centuries-old cultural practices just because they might be unusual. Case in point: Indians have used turmeric for years as a standard home remedy for everything from stomachaches to bruises. Somewhere along the line, the West wised up to this unassuming yellow powder, and a PubMed search for “turmeric” returns 499 papers in 2006 alone, examining everything from cancer to neurodegenerative disorders. Kind of impressive, eh? The moral of the story is: don’t ignore traditional remedies. Sometimes, just sometimes, the uneducated natives get it right.

Er. That was a bit heavy for a first post. I promise I’m not so serious all the time.