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.

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.

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!

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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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.

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!

From JAMA's "100 years ago" section:

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

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

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

In which I whine

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

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

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

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Everyone' s a little bit ...?

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

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

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

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

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

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

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

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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.