December 26, 2007

A Man of Principles

Perhaps it is because of the intersection of my free time, my "expertise" in the health field and my selection of friends, but I had multiple encounters with the charged topic of politics today.

#1) I was in a chatroom with some friends on AIM and someone linked to a blog entry discussing Christmas. In it, the author (a friend of my friends) said "if I were rich, I'd like to take in lonely people and feed them to let them know that not every rich person is a cold-hearted bastard" (or something to that effect.

One of my friends replied (with some degree of underlying hostility, probably fanning the flames of some old argument) and quoted the author's position on universal healthcare and said "no wonder there are depressed and lonely people; they don't have access to mental health services! rich people prefer to buy them dinners to feel better about themselves rather than pay taxes to help them." Whoa!

#2) While I read this exchange, my mom knocked on my door and said "your brother wants to talk with you about healthcare and tell him why Hillary has a good plan (and Rudy doesn't.) Obviously she doesn't have an opinion on the issue. :-\ I'm completely incompetent on this issue, so I talked about basic principles of governing with my brother to feel out his position on capitalism, its values, the role of government in serving its people, what society should do to support itself and the questions he should be asking.

A few things emerged from these conversations.
I boiled it down to two questions:
"If you had money and power, who would you help?"
and the follow-up question: "who is 'not deserving' of this help?"

What I look for in a leader is someone of principles. What does that mean? To me, it means someone who can tell me what their philosophy of governance is and is consistent with my own views. Someone who would answer question 1 with "Everyone!" and #2 with "I don't know."

I'm going to go out on a huge limb here and tell you my idealistic, blazing future for America that fixes all of our woes as I know them, in my completely zany worldview.

First of all, I think that capitalism plays up the wrong traits for a functional society. It breeds smart, cutthroat people who care about success and sneak by with as much as they can get away with. People who don't buy into this philosophy don't rise to power, whereas a true democracy would speak out for the rights of the impoverished and disadvantaged over those of the rich and powerful. Everyone deserves a chance at an equal footing and in this day and age, that applies to healthcare!

Secondly, I think we've got the priority of our National Budget all wrong. A large chunk of our spending goes towards "Defense" when it could be better spent on Education, Health Care and Science/Research, in that order, with defense and everything else following that. Having a core of healthy, well-educated individuals would go far. What would we do with our military that would suddenly be out of a job? I'd make them part of our new Peace Corps. They'd be "invading" other countries with education, like missionaries without the religious agenda. It'd be a share-the-wealth-and-spread-the-goodwill-agenda. Building up relations, networking and if necessary, make a few bucks here and there.

Immigration policy would be relaxed because I'd like to have people cycle through to become trained. They might even be inspired to become a part of the Peace Corps so they can return home and better serve their friends and family back home.

Social security is a difficult subject ethically because the better that our health care gets, the more of a burden we develop with this. I don't think we should ignore senior citizens and delegate them to the "useless waste of money" category. They have proven their worth to our society and they can still provide value! We just need to find more ways to keep them connected with society so we don't see them as a burden on our tax dollars.


I've got more insane ideas. They need to be better honed, because I feel like I'm starting to spout off garbage already...

December 22, 2007

Goo-ey game

This game sort of reminds me of an amoeba battle. It makes sense, since that's the name of one of the skins the goo can wear.



If I had any programming skills, I'd make a game that mirrors the microscopic environment. It'd be cool to play a game based on immunology for example... it has all the classic elements! You've got your alien invaders (bacteria) that you have to detect (via antibodies and the complement cascade), and destroy (via lytic enzymes and free radicals released by neutrophils and macrophages.)

Besides, the more elements of immunology you add in, the more realistic and educational the system would be.

I'm not sure what the controls would be though. It's a completely autonomous system within our bodies (despite whatever Airborne or other immune-boosting products claim)... aside from the simple factors of nutrition, rest and stress. Perhaps the whole point could be to construct a reliable immune system that can fight off a variety of immunologic stimuli without getting any autoimmune diseases. Ooh! There'd be special levels for TB and HIV for sure. Maybe a few penalties if you accidentally induce lupud following an EBV infection.

Yeah, I'm a total dork. Gamers are dorks too... maybe it'd give a pre-med an excuse to kick it and play Immunology! for a few hours every day to unwind.

Stumbled upon through:
http://www.kloonigames.com/blog/
(home of the awesome crayon game!)

December 14, 2007

Hypnotic Wasp turns Cockroach into a Zombie

As an undergrad, I worked in a bug lab working on gene sequencing of very rare moths, indigenous to Hawaii (found no where else.) In my searches for press releases on one of our projects announcing the discovery of a carnivorous caterpillar, Hyposmocoma molluscivora, I stumbled across the wealth of science information found on blogs like Pharyngula (the top hit for H. molluscivora) and The Loom. Carl Zimmer posts about nifty parasites and I always felt that this story takes the cake.

December 12, 2007

Stedman28 review

My parents got me an early xmas present ... a new phone/PDA! I'm thrilled about it; it has a camera and email and all that jazz my original nokia block phone did not have. It also means new programs! I'm shopping aroung to find medical software for my Windows mobile and I noticed a lack of critical reviews on a lot of things. Reading reviews like "THX SO MUCH OMG" and "I love this program! Keep up the great work!" are nice and all... but very uninformative.

I thought I'd do my blogger duty and contribute my opinions to the all-powerful google cache.

---------------------------------

My first review is on my most-used program on my old PDA... Stedman28. It is the 28th edition of Stedman's dictionary and I purchased a cool combo of hardcover book, PDA software and accompanying spellchecker last year. I don't remember the price, but it was WELL-WORTH it. Just having the spellchecker makes you seem more intelligent; spelling out words like chondrocalcinosis or progressive multifocal leukoencephalopathy with autocorrect is beautiful.

The nice thing about Stedman28 is the simplicity of use. Just write out the word and it flips through the index until it finds the one you're looking for! The definitions usually match up with those from the electronic Stedman's Medical Dictionary for the Health Professions and Nursing 1.0... so the hardcover book had a few more details (and pictures!) of items not included in the e-version.

Now for the critique.
Stedman28 takes too long to use. Here's the steps I have to go through to get my definitions:
Since my 1 year subscription expired, I get a message that says:

"Stedman expiry status: your subscription expired on 06/27/2007. Please renew
now for continued access to product updates and Skyscape support.

I have to click a red x to move through that alert message. I don't like the renewal model... when I buy a textbook, the first page I open up to doesn't say "sorry, you've owned this book for more than a year, please buy our new version"... why should it be any different with an e-book?!? I don't want my programs to harass me.
Then I have to select the correct word list index. As you can see from the above graphic, the menu is split between the A-L and the M-Z list. If you are in the wrong index, i.e. searching for the word "neuron" in the A-L section, it chirps at you a bunch of times as it scrolls all the way to the end of "L."
If I search for a word like "NANC neuron" or "motor neuron," it takes me to the broader definition of "neuron" and then I have to scroll down the list until I find the correct word. Sometimes this can take a long time because of the number of words clustered in the list.

I give this program an B+. I have never had any technical difficulties and the word list is impressive. There are a few eponyms that it misses, but those are easily caught by the Eponym program (review to come.)

December 10, 2007

All done!

After a few months of grueling studying (and a week of being completely BURNED OUT and neglecting studying), I finally finished my week-long set of exams.

The tests were challenging and fair... in the sense that we were given advance warning about the material we would be tested on (unlike the year before us who found our mere weeks before their final that the first 10 chapters of Robbins was going to be on the exam.) I got high marks in all sections, which pleased me. Apparently taking a few days off to just veg out right before the exams didn't hurt me as much as I feared... in fact, it probably reinforced my knowledge-base. I didn't dig out my notes or learn new materials during the past week. Instead, I kept reviewing the things I already knew. It was a good feeling to be so prepared; even though the written essay exam threw a bunch of curveball material that I had to struggle to recall to get partial credit on.

So, where do I find myself during the first weekday of my three-week long freedom?

At school, of course!

Gah. It's not as bad, nor as shameful as it may seem. I have put a research project on hiatus during my finals studying and the lab assistant who was helping me out recently left the lab. I've got to pick up my old project again! How horrible. ;)

Today we had a seminar by a visiting professor on Alzheimer disease, focusing on beta-amyloid proteins effects on neurons. The cruz of the matter is that people with Alzheimers get these plaques of junk (aka beta-amyloid) that cruds up in our brains and messes up with the connections. The professor made the argument that beta-amyloid had a normal neuro-modulatory function in the brain and cautioned against treatments that would reduce levels of beta-amyloid.

This was a big surprise to me. I don't know much about the molecular pathology of Alzheimers... but I thought that amyloid was a waste product, an abnormal process. beta-secretase function predominates over alpha-secretase function for the dysregulation of neurotransmitters in AD!

I asked him a question about the normal function of alpha-secretase and he said that the protein produced is much smaller and it doesn't have any effect. To me, that seems to imply that the normal brain doesn't use amyloid-precursor protein for any positive function, but hey. I'm not a researcher in his field and I didn't want to say "huh? why do you think it has normal physiological functions then?"

I'd like to poke around and do some research on this, but judging by the crazy slides of graphs and his talk about knockout mice missing different nicotinic receptors having strange dose-response curves... I'm not sure I could follow that level of technicality.

One of the things I've learned through my research experience is that I enjoy asking the big questions. Research is something I admire, but I don't really have the lab skills and temperament to enjoy it on a long term basis. Still, I'll be coming in this week to summarize my lab results thus far and start finishing up my experiment. Wet labs are fun, but my goodness! They are SO stressful too! I had an experiment get pushed back a full MONTH because of difficulties with malaria parasites and blood and the lab equipment... it felt like the whole chain of protocol was breaking down piece by piece and we chased after it until everything died and we had to start all over again.

Sorry about the long post. It's been a while since I last wrote and I have a lot to say. I've got more thoughtful things on queue, but these are the things that have been on my mind.

November 19, 2007

PLoS Medicine: How Drug Reps Make Friends and Influence Doctors

Clinical Cases and Images shares a refreshing insight into the manipulative drug rep mentality from the POV of an ex-drug rep.

This article reminded me a lot of a book a friend loaned to me about the way physicians are "bought out" to sell drugs. Unfortunately, I cannot remember the name of that book now... but it made some good points that made me wary of drug reps before I entered medical school.The thrust of the book was that it is unethical to accept gifts from drug reps because they would unconsciously influence prescription writing in their favor. Doctors are not as objective as they would like to think.

However, I was met with an uncomfortable scenario as early as my third day of orientation week in medical school. We had a recruitment fair and some organizations gave out "free stuff" with pharmaceutical names stamped all over them. I wanted free stuff. I didn't want to turn my Ethical Upbringing into a big deal. As a result, I came up with this reluctant compromise... I would be OK accepting small gifts (pens, pads of paper, etc.) as long as I erased the name from their free products.

I bought some acetone that afternoon and scrubbed the names off of those products. I can tune out the names pretty well... but I do feel conflicted if I learn about a new drug in school and I go "hey, that's just like the name on those sticker tabs!" I'd like to come up with a better solution for dealing with drug reps when it really counts.

November 16, 2007

Saccular aneurysms

A quick and dirty way to remember the risk factors for developing berry (saccular) aneurysms

MEN HAS sac(cular aneurysms)
Marfan's
Ehler-Danlos
NF-1
HTN
ADPKD
Smoking

Berry aneurysms are outpouching of blood vessels that exploit developmental defects hidden in the lining. They occur within the Circle of Willis, a series of connected arteries at the base of your brain that provide collateral blood flow just in case something fails. These puffy red berries can burst and bleed out into the brain causing a hemorrhagic stroke.

November 15, 2007

The Big update

I've been pretty busy lately. I have exams coming up next month (11/3-6, 3 3 hr long essay/multiple choice/lab exams, 2 4 hr long NBME neuroscience, neurobehavior exams), but I had to put some time aside to prepare for the Medical Student Mentorship Program's (MSMP)1st Annual Ethics Workshop.

The idea was proposed by one of our senior officers and I immediately jumped at the opportunity to help organize it. I made a shortlived effort to start up an Ethics club last year; I realized that I didn't have the time and energy to commit myself to another club since I'm already an officer for MSMP and the Family Medicine Interest Group (FMIG). We put together a Problem-based learning case on ethics. I found this great case about Andrea, a "locked-in" patient from an article in the Discover Magazine's Vital Signs column. "Andrea Beauchamp" helped the students talk through such difficult topics as advanced directives, access to medicine, universal health care, and physician assisted suicide.

The Ethics Workshop was a great success; a local MD/JD came out to give a primer on medical ethics and opened the room up for questions. At first, no one really asked anything, but then a few brave people started asking some really good and insightful questions. I was impressed! We split up into small groups to work on the cases.

I hesitate to post the case here online... most of the text is taken verbatim from the Vital Signs column. I will email the case to anyone who is interested. We put in some tutor prompts and background information and it is a good ethics case for anyone from pre-med to doctorhood, IMO.

--------------
On a completely different note, I got the results for our practice NBME exam last week. It's the big exam that we take at the end of the second year to qualify for medical licensure. I got a 66/100 (a weighted score), which translates to a 190/300 (185 is a passing score, anything above 220 is considered competitive, I believe.) So... without any formal Board studying, I passed!

Woo hoo! :) The only downside of that is the ego boost and dangerous overconfidence that comes with hubris. crap.

Branches of the ECA & ICA

Branches of the External Carotid Artery (ECA)
STAPLe OF PAM ST
Superior Thyroid
Ascending Pharyngeal
Lingual
Occipital
Facial
Posterior Auricular
Maxillary
Superficial Temporal

Branches of the Internal Carotid Artery (ICA)
OPAAM
Ophthalmic
Posterior Communicating
AChor
ACA
MCA


References
Moores Clinical Anatomy
Blumenfeld's Neuroanatomy through Clinical Cases

October 17, 2007

House MD predictions

I like this show. It has bad medicine. It features a doctor who is the antithesis of good medicine. He regularly commands underlings to break and enter peoples' homes to search for clues about their current disease. He says very rude and insensitive things to patients and their families. He's done outright illegal and unethical acts in the name of saving his patient. Well, I suppose its the thought that counts. He does care, after all.

I get my House fix over at Polite Dissent. There wasn't a new episode of House this week (much to my disappointment when I sat down to watch TV at 8pm) but Scott did put out a challenge to his readers: guess what diagnoses are going to be featured in future episodes!

Most of my studying is out of a hefty tome called "Robbin's Pathologic Basis of Disease." A lot of the random names that fly about in House episodes come straight from this book, so I'm glad to say that after just a year and a half of med school training, I can ID nearly 90% of the lingo from the show.

House has made it easier to remember some of these bizarre entities and ridiculous diseases because I can put a face and a story to many of them now. It's greatly added to the appeal of the show for me. I haven't ever nailed a diagnosis, but maybe someday I will.

Here's my list of predictions. I'll report back week after week about how I'm doing.
1) Bronchogenic carcinoma (some sort of paraneoplastic syndrome, myasthenia gravis, Trousseau)
2) Small cell carcinoma (w/ ACTH or SIADH) … just because I like the ddx of paraneoplastic syndromes, I wanted to toss this in
3) Neurofibromatosis -> acoustic neuroma
4) Cryptococcus infection (c’mon now. A disease you get from pigeons? They’ll use this at some point.)
5) Strep mutans -> subacute endocarditis -> weird stroke syndromes, etc. (i picked this because they’d get use the line “s/he died just from brushing his/her teeth!”)
6) McCune-Albright polyostostic fibrous dysplasia (w/ endocrinopathies GH, TSH, ACTH… might show up in #2’s ddx or vice versa w/ cafe au lait spots)
7) Lyme disease -> Neuroborreliosis (maybe concealed by something like psoriatic arthritis)
8) AVM (maybe concealed w/ something like a traumatic brain injury in a soldier from Iraq… shrapnel would prevent them from running an MRI, House’s favorite diagnostic test)
9) Systemic Progressive Sclerosis (the clinic case of the day of Peyronie’s disease could be the eureka moment for House’s diagnosis)
10) Syphilis -> neuro, cardio etc.

October 13, 2007

OLD AGE is bad for Gout


O besity & HTN
L ead poisoning --> saturnine gout (hits the knee preferentially)
D rugs (i.e. thiazides, furosemide, low dose ASA)
 
A ge
G enetics (partial HGPRT deficiency, etc.)
E tOH (beer > liquor > wine)
 
Gout is a disease of imbalanced production & excretion of a substance called uric acid.  Humans are unusual animals in that we do not break down our purine DNA metabolites beyond uric acid (into substances like allatoin.)  When uric acid accumulates in joints, it can spontaneously form into sharp needle-like crystals that cause inflammation and extreme pain, most commonly in the big toe (podagra.)
 
It can be avoided by reducing OLD AGE risk factors, especially through an appropriate diet of no alcohol and low-purine foods.  That means no beer, seafood or organ meats.
 

References/Resources

Lippincott's Biochem 2nd edition

Harrison's Internal Medicine

Robbins Pathologic Basis of Disease

Poor, G. Saturnine Gout. Baillieres Clin Rheumatol. 1989 Apr;3(1):51-61. I just used the abstract to figure out what made Pb-induced gout different.

Choi, Hyon. Pathogenesis of Gout. Ann Intern Med. 2005;143:499-516.

Golan's Principles of Pharmacology

October 12, 2007

On Loss

My Healer's Art class assignment for the week is to write an antry on loss or disappointment. Here's what I came up with. It has a lot of personal details that I didn't feel like stripping away. This is my life. This is who I am and what I think.

This story takes us back about two and a half years in time. I just finished my last round of interviews at medical schools and I was waiting to hear back from them. My classes were fairly easy; I was taking a music and an acting class to finish off my reqs for graduation and a microbio and embryo class to prep for med school. This waiting time was a big moment in my life... I knew that a good chunk of my life would be altered by the decisions of anonymous others.

One idle night, I was on Myspace and I stumbled across the profile of someone who had captured my interest. She had a picture of herself with a quirky smile and turtles in the background at sea life park. I messaged her, telling her that I felt 'compelled to contact her because I thought she had the coolest pic ever' and 'I wanted to get to know her better.' She messaged me back almost instantly; she was online at the same time. We ended up sending messages back and forth several times a day for a week. Our conversation shifted to instant messaging and then to the phone. We met each other for the first time two weeks later.

It was an exciting time for me. We shared some strange similarities. We both used to play the trombone. We both went to Portland, Oregon for a year of undergrad and loved it there. We clicked so well that I was rarely nervous and I felt as though I could talk about anything with her. I often did. Our best times together always involved just talking. We'd have a picnic in the park together and talk. We'd walk through Waikiki in swim trunks at midnight and talk. We'd go camping and stroll on the moonlit beach and talk. This was a new form of communication for me, to share what I was feeling fearlessly with someone. I'd even say I became addicted to it.

This was a time filled with some uncertainty. Would I have to choose between a love and a life of medicine? I didn't know what would happen in a few months, as the letters came in. Rejection. Rejection. On the waitlist. Rejection. Waitlisted. One night, we were at the park, tossing a frisbee around together and my parents called me.
"Your letter from the University of Hawaii came in! Should I open it?"
"Sure," I said somewhat disappointed. "It says something already that it's a letter and not a packet..."
*sounds of a tearing envelope*
"'Dear Clinton, we regret to inform you that the University of Hawaii will not be accepting your application at this time. We have had a record number of extremely talented and qualified applicants such as yourself...' Oh, I'm sorry, son. Are you Ok?"

To be honest, I don't think I was ever so happy to hear bad news in my life! Getting rejected from medical school was a blessing. It gave me the time to get to know this new and wonderful woman, who was genuine and goofy and adventurous and positive and communicative.

Two months later, we went on a road trip together for close to 8 weeks, up and down the West Coast. We started off in LA, went down to San Diego and Tijuana and then all the way up to Vancouver, B.C. We spent most of our time in Oregon, where we had both gone to undergrad. It was a strange and risky thing to do. After all, we had only known each other for 4 months or so and we were basically homeless, living together for 2 months in a trailer van! It was a great way to do what I loved most... just talking with her.

I tell you all of this to explain my love, so it in turn illustrates the depth of my loss. She is a woman I love with my heart and soul. I would have proposed to her a long time ago if she could have ever uttered three little words that meant so much to me -- "I love you."

She did, you know. It was evident by her joy being around me. However, she wanted to save those words for someone that she wanted to spend the rest of her life with. Someone that wasn't me.

The freedom I felt with her was a failing as well. As easily as I could share my joy with her, I shared my wrath. I was an angry person back then. Angry with myself, mostly. A lot of that sort of mulling self-hatred drove me to improve as I beat myself up mentally. My insecurities, my competitiveness, my self-hatred, all of these things came out because I was totally open with her. She might have liked it that I was so honest and open with her, but she did not like my flare-ups. It also made for a sometimes dysfunctional relationship when I had trouble accepting when I was wrong and she was right. She never rubbed in my face when this was the case. She never gloated. She never did anything passive-aggressive when it was the other way around. It took me a long time to realize that she was incapable of doing any of these sorts of hurtful things. I'm a sensitive guy. She definitely brought this out of me, intentionally or not. I don't really know if being sensitive is something I'd like to change about myself.

The ANGER though... that was her major turn-off. Eventually, it grew worse as our relationship grew longer. She got accepted to the JET program and she was planning on going to Japan. I got accepted to medical school and I was planning on staying in Hawaii. Bitterness grew as I realized more and more that her philosophy of anti-long-distance relationships would apply to us. And there wasn't anything I could do to change that. The helplessness I felt tainted our time together. It came out in bursts of depressive despair and grouchiness that left me wondering... why doesn't she just break up with me already? Why is she drawing this out for as long as possible? Those feelings would pass, swiftly forgotten in my fickle mind... but they would build in her like steam. She didn't like that feeling and often told me that I was too much of a rollercoaster for her.

I knew our relationship was terminal when she would start saying things like "someday, you'll meet someone who will make you very happy" during my bouts of despair. Of course, I was thinking to myself that I already HAD met the person of my dreams... what were the chances of finding that again? Especially if it meant letting her go?

My white-coat ceremony was a bittersweet affair. She was flying off to Japan to teach English the day after I would set foot on the path of medicine. We parted on good terms and the promise to always remain good friends.

For a long time, I was filled with regret. Of all the relationships I've had, this breakup was the hardest by far. I was selfish. I didn't understand how someone couldn't love the oh-so-perfect-Me. I definitely made the relationship strained towards the end because of my unwillingness to accept failure. Looking back, it was always so childish and so ridiculous. I am embarrassed that I acted so terribly on a few occasions with the person who I cared about the most... and even worse, I chased her away because of it.

I visited her in Japan a few times since then. More and more, I've changed to the point where I don't think she'd recognize me. She only knows the old, flashpan angry clinton. After a long discussion with her recently, she sent me a clip from an audio file she was recording to help a student for a English Speech festival. It was particularly pertinent to our talk.
One day, someone came into my life and changed my thinking. He is someone very special. He said "do you think people grow more when they meet someone or when they say goodbye? Saying goodbye can be hard, but we realize the good things about them. At the same time, we start to feel regretful. By remembering those regreful moments, we're able to stop making the same mistakes and start improving ourselves. Saying goodbye gives us a chance to grow.

The big loss I speak of here is not so much the loss of my love, since she still swoops into my life from time to time. It's a loss of a part of me. That is a loss that I can celebrate now, thanks to her kind lesson. :) Thank you, Y!

October 11, 2007

Midterms and Midnight

So I took my midterm on Tuesday.

I had a close friend come to visit from Japan and I wanted to spend as much time with her as possible before she left, so I had to really schedule my study time out in advance. I like having these sorts of "planned distractions" because they really make me focus.

Ok, you've got to quit fooling around and get to work! I tell myself. And it's a good thing too -- the midterm was challenging, but I felt prepared for it. There were only a few questions I was thrown by... and they were the "duh, you should know this already" type of questions. Talking with my fellow classmates, I got the sense that a lot of people were flooded with anxiety after the exam.

What, me worry? I did good enough. That's the WORST possible feeling to have after a midterm, I feel. In some ways, I should have studied less so I'd feel worse about the test and that would motivate me to study even HARDER for the final.

This brings up the pressing point of the night.
I slacked off yesterday. I decided to watch House on TV, take two naps and then go to sleep early.

Because of that ill-advised decision, I had to stay up until *checks watch* 4:15am today!!! It turns out that the limbic system is very confusing and difficult to understand. Hopefully I have a good enough grasp on it tomorrow to be able to present it in a clearer manner than I received it.

At least I have my motivation back. I also had some good lazy naptimes. Now it's back to business!

October 05, 2007

Chatting with a friend

This is something that I'd like to come back to later on. The AIM names have been changed to protect the innocent. ;-)
NotMySecondOpinion (11:34:22 PM): are you going to join the air force?
religiousfriend (11:34:37 PM): I'm not sure
religiousfriend (11:34:43 PM): they need leaders in the air force
religiousfriend (11:34:50 PM): I don't have much leadership experience
NotMySecondOpinion (11:36:27 PM): i think it would be good for you to join, but at the same time, i wouldn't want you to go
religiousfriend (11:36:37 PM): ah
religiousfriend (11:36:40 PM): why do you think so?
NotMySecondOpinion (11:37:16 PM): the military would give you discipline and direction
religiousfriend (11:37:27 PM): that's true
religiousfriend (11:37:36 PM): I don't know about direction
NotMySecondOpinion (11:37:38 PM): but its dangerous, even in the air force
religiousfriend (11:37:40 PM): but discipline, yes
NotMySecondOpinion (11:37:55 PM): and you'd become a part of the military culture, which i dislike
religiousfriend (11:39:29 PM): I don't care for military culture
religiousfriend (11:39:45 PM): I don't want to become a further drain on taxpayer resources
religiousfriend (11:39:56 PM): besides which, the AF is scaling down its officer corps
NotMySecondOpinion (11:42:37 PM): what do your other plans comprise of?
religiousfriend (11:43:27 PM): I'm thinking of entering a monastery
religiousfriend (11:43:40 PM): other than that, law school/grad school
NotMySecondOpinion (11:45:04 PM): is there any incident you can think of that prompted your religiosity?
religiousfriend (11:45:20 PM): a realization of my own finitude
NotMySecondOpinion (11:46:12 PM): thats rather abstract.
religiousfriend (11:46:23 PM): When I was ten, I remember thinknig
NotMySecondOpinion (11:46:31 PM): was it from reading something or doing something?
religiousfriend (11:46:31 PM): "ah, I've lived through one eighth of my life"
religiousfriend (11:46:49 PM): I've read a lot of things
religiousfriend (11:46:54 PM): I've done a lot of things
religiousfriend (11:47:18 PM): but faith is something from God. You can't get it by your own efforts
NotMySecondOpinion (12:02:28 AM): how do you define faith?
religiousfriend (12:02:41 AM): I'm still working on that one
religiousfriend (12:02:54 AM): But ultimately Faith is personal
NotMySecondOpinion (12:04:05 AM): i'm just wondering why you think it comes from God
religiousfriend (12:04:37 AM): Well, from the Materialist side people could say it comes from all kinds of chemical reactions
religiousfriend (12:05:27 AM): but at any rate, I don't have enough faith to faithfully answer your question
NotMySecondOpinion (12:06:18 AM): I disagree with the statement that it comes from all kinds of chemicals
NotMySecondOpinion (12:08:09 AM): I think Faith comes from a strong desire/belief in the connections you make with others and the world around you. Those connections are immaterial, but they might be represented by chemical reactions that take place concordantly or disconcordantly, depending on whether or not your Faith is misplaced
religiousfriend (12:10:54 AM): that's a bit over my head
NotMySecondOpinion (12:14:43 AM): i didn't know what faith meant until i loved someone. i could never really know if they loved me back. that's when i had to decide whether or not I could step back and relinquish control of ... almost everything and just have faith.
religiousfriend (12:15:36 AM): I think you're getting close
religiousfriend (12:15:56 AM): but I don't have much faith, so what can I say
NotMySecondOpinion (12:16:02 AM): yeah, i don't know where God fits in there.
NotMySecondOpinion (12:16:20 AM): thats what i was hoping you could help me with
religiousfriend (12:16:35 AM): mmm, it's hard for me to give what I don't really have
religiousfriend (12:16:42 AM): It's important to be humble, first of all
religiousfriend (12:17:06 AM): Hell is full of people who think they're too good for Heaven
NotMySecondOpinion (12:18:31 AM): what does that mean?
religiousfriend (12:19:16 AM): Well, according to the Faith, Hell and Heaven are the same place
religiousfriend (12:19:34 AM): Think of Gollum
religiousfriend (12:19:44 AM): and how he hated the Lembas bread
religiousfriend (12:20:04 AM): and other elvish things
religiousfriend (12:20:39 AM): Those "in Hell" experience the glory of God in the same manner
religiousfriend (12:20:57 AM): because their hearts are too prideful
NotMySecondOpinion (12:21:31 AM): we make our own heaven, then.
religiousfriend (12:21:57 AM): We don't really "make" it
religiousfriend (12:22:00 AM): we accept it
religiousfriend (12:22:12 AM): but yes, ultimately Faith is a matter of the heart
religiousfriend (12:26:40 AM): http://fatherstephen.wordpress.com/ anyway, this site is much more articulate than me in expressing this sort of thing
religiousfriend (12:26:51 AM): I suggest you add it to your google reader
religiousfriend (12:28:09 AM): http://fatherstephen.wordpress.com/christianity-in-a-one-storey-universe/ this might be of interest to you
NotMySecondOpinion (12:29:20 AM): he spells story weird
religiousfriend (12:30:48 AM): that's to distinguish storey as in a building with story as in a book
NotMySecondOpinion (12:35:07 AM): ah
NotMySecondOpinion (12:52:59 AM): i'll definitely have to read more of that later
NotMySecondOpinion (12:53:10 AM): for now, i'm off to do more work. ttyl!

September 29, 2007

Discover's "Vital Signs" Podcast

One of my favorite sections of the Discover Magazine has always been "Vital Signs," in which a medical mystery was presented and solved in an articulate article. It's House, MD without the attitude.

I recently found the podcast version of these articles!

September 26, 2007

Healer's Art Part 1

I signed up for an elective course this semester on "Healers Art." I was really excited about it because I thought it would be the perfect opportunity to talk about my feelings on medicine and hear what other peoples' thought. Unfortunately, I found out that I was one of two people who had signed up for the course, which dramatically changed the group dynamic idea I had in mind.

I attempted to start up an ethics club last year with the same idea in mind, but there was a similar lack of interest from my fellow classmates.

The course was created by Rachel Naomi Remen and uses her book, Kitchen Table Wisdom, as the text.

We had our first session last week and I really liked it. I'm glad that I had an outlet (with people, face to face, unlike here) with whom I could share my thoughts on medicine. We talked about:
IDing, strengthening & cultivating the human dimensions of the practice of medicine
Recognize the commonality of personal concerns among peers
Discovering and nurturing our Wholeness
It sounds like real Chicken Soup for the Soul type of stuff... and I guess it is. I'm taking it with an open mind.

We drew pictures about what we wanted to change about ourselves by the time we graduate from medical school. It was very open-ended, but I didn't want to get too personal with the thing that I want to change most about myself (which is an attitude shift of reacting to negative things with anger --> reacting w/ constructive actions.)

Here's my pic:

It's about stories. More on that later.

September 25, 2007

Medicine is a man-whore

For you aspiring pre-meds out there, heed this advice:
-get the training over with while you're young; don't take breaks (or alternatively, wait until you're a bit older)

-keep it in perspective. You are not a saint because you are a doctor (don't be arrogant and think more highly of yourself than you should). It is not a calling. See it as a stable, respectable, secure, job. Your work is valuable, but not more valuable than yourself, or your family.

-know the drawbacks, and balance those with the benefits of becoming a doctor today.

-the money *does* matter (both the student loans, and the eventual salary).

-don't sacrifice having children, visiting aging parents, or other significant life events in lieu of becoming a doctor. It will not be worth that sacrifice.

-Choose your specialty with care. Chose based on your personality...not based on what is most prestigious, what other people want you to do. Your specialty will determine your potential work environments, your pay, your lifestyle, and the number of years you spend 'training.'

-Finally, don't work too many hours. If you do, you'll be more tired, less healthy, and more likely to experience dissatisfaction and fatigue.
EM Physician makes some really good points with a healthy dose of good humor. I'm worried about a few of these things myself... I've been more aware of maintaining balance recently and I am so much happier for it. However, I have been rather dependent on my student loans for sustenance and I'm sure that this will come back to bite me. :-\

It's an interesting point to say that you should treat medicine as a man-whore. A seductive, back-stabbing, all-consuming vacuum. Don't fall in love with it or it will hurt you.

I'll do my best to keep that in mind.

September 22, 2007

Kava drinking increases liver GGT levels

The Honolulu Advertiser had an article in the paper this morning about how Kava drinking creates a "liver anomaly."
"There's some evidence of something happening in the liver," said Dr. Janet Onopa, an assistant professor of medicine at the John A. Burns School of Medicine who analyzed the data and reviewed the lab reports. "But it doesn't seem like anything catastrophic."
....
The blood work revealed elevated levels of the liver enzyme GGT — or gamma-glutamyl transpeptidase — in 65 percent of the kava drinkers. The levels of GGT increased with increased kava consumption.
In the control group, high GGT levels were only seen in 26 percent of the non-drinkers.
"We don't know exactly what a high GGT in and of itself means," Onopa said. "It's possible that kava just induced that enzyme without doing any liver damage."


Kava is a traditional drink of Samoa and Fiji. The active ingredient, kavalactone, comes from the root of the plant Piper methysticum. It causes numbing of the lips and tongue when consumed and a mild intoxication of calming quality. Some ill-prepared concoctions still contain parts of the leaves and stem of the plant and this can cause severe liver damage and hepatotoxicity.

I've scoffed at Kava drinking before, but I had some last spring break as a part of a Hawaiian cultural experience. Despite its dirty brown yellow watery appearance and its strange numbing effect, it's not that bad. It's nothing that I would choose to drink, but I can see why many Polynesians drink it.

As for the effects of GGT, gamma-glutamyltransferase is a liver enzyme used like alkaline phosphatase (ALP) as a marker of liver damage. In conjunction with elevation in other liver enzymes like ALT and AST, an assessment of liver health is made.

I think it is irresponsible to imply that the elevated GGT levels signify something other than liver damage. If these enzymes that are normally in biliary liver cells are released into the blood stream in large amounts... to me, it means that they are dying off in larger amounts.

At least they end the article this way:
Even with the high GGT enzyme results of the UH study, the men said they aren't about to change their kava-drinking habits.

But Brown, the lead author of the study, said heavy kava drinkers might consider getting their liver functions tested.

"You want your liver profile to be normal," she said. "If something is causing that to be abnormal, then you should discuss it with your doctor and have your doctor run a liver profile. Then take your doctor's advice."




References:
Honolulu Advertiser, 9/22/07. "Hawaii kava study finds liver anomaly" http://the.honoluluadvertiser.com/article/2007/Sep/22/ln/hawaii709220345.html
Samoan Sensation. http://www.samoa.co.uk/drink.html
Wikipedia, “Kava.” 20067 http://en.wikipedia.org/wiki/Kava

September 20, 2007

Something I noticed

I summarized the slides of a long-winded & technical professor and I made this observation:
 
Research faculty are interested in rare and novel things, while clinical faculty are more interested in impact and applicability.  It makes sense after all... the sorts of people who are attracted to research are the ones who seek out unknown things and attempt to answer questions, while doctors are interested in how they can diagnose and treat a specific disease.
 
This certainly has an effect on how they approach their lecture teaching styles.  I've noticed myself sliding into the clinical role more and more.  When I'm faced with a fact, I have to make the brutal decision -- is this something important enough that I need to try and memorize it?  How will I use this fact in the future?  No longer is there the simple joy of learning something new... there's too many new and exciting things to learn!  I have to prioritize.
 
I'd like it if our professors could understand this and help us out with this process to spare us some of the pain-staking process of going to lecture, getting next to nothing from it, doing independent reading, synthesizing our knowledge, summarize it, share it with others and HOPE TO GODS that it is the right stuff we're focusing on.

September 15, 2007

Family Medicine Interest Group T-shirts

We've got a Family Medicine Interest Group t-shirt competition and I thought I'd try my hand at some art. Our president came up with a great idea for a shirt; the back has a bunch of organ systems with our name in the middle. His original design for the front was an "evolution" of man from baby to geezer. It reminded me of an old riddle:
What walks on four legs in the dawn, two legs at noon and three legs at dusk?
Answer: Man. (Or Family Medicine. ;)


I modified his design by removing the intermediary figures and tossing in a sun and a moon. I like it a lot. So inspired, I tried to come up with some other ideas.
I searched through a bunch of clip art pictures on OpenClipArt.org for something that I could utilize and I came up with the funny idea for this one. I doubt our advisor would approve. :)


My last idea is still undeveloped. I wanted to try something Hawaiian, so I thought I'd go with the word "Ohana" to substitute for Family. My initial thought was to do something with Stitch from Lilo and Stitch. I kept trying to quell that. I thought about what Ohana meant... Here's what wikipedia had to say:

ʻohana means family in an extended sense of the term including both blood-related or extended. It emphasizes that family and friends are bound together and members must cooperate and remember one another.
... The root word "ʻohā" refers to the root or corm of the kalo, or taro plant (the staple "staff of life" in Hawaii), which Kanaka Maoli consider to be their cosmological ancestor.


Well, that flopped. I still have to figure out how to incorporate the idea of taro into Family. And Medicine. Hrm.

September 14, 2007

Don't sacrifice personality for character.

This is just an bit of advice I've formulated today.


I'm probably over-analyzing this, but if there's any place to share it, I figure that this is the best.

What does that mean?
I think of Personality as those cute little quirks that make you uniquely you. They are the things that people do to imitate each other.

Character is the sort of thing that Calvin's dad would always evoke as a way of getting Calvin to do hard work. "Shoveling snow builds character." "Aww... I wanna play with Hobbes!" Character is the ideals of what you want to become.

Why am I bringing this up?
I feel as though I've traded out part of my Personality for Character. When I came to school today, I got multiple comments about my appearance. It wasn't any particularly special day for me; I was just dressed in an aloha shirt and some slacks for Project HOME in the evening. Even at HOME, where everyone was wearing aloha-formal-attire, they were impressed.

"You look like a doctor!" A classmate remarked. "You could march around and people would say 'Hey doc, we need you to save this patient!'" Really? That's cool. I've captured the respectable & conservative aura so soon. I'll admit, it's been the main reason why I'd never get a tattoo or a piercing. I'd lose that sort of asian doc credibility.

So what's the problem?
I only play Doctor at school. It's just a Character I slip into. It's all about professionalism, respect, integrity, compassion and humanity. However, school has taken over my life, slowly and surely. It's hard for me to make a distinction about when I need to behave and when I can relax and be myself again. Can I screw around and study at school after hours? I do sometimes, but I think the impression that a lot of people get is that I'm all work, no play. School is school, to me.

Sure, it's easy to say "be yourself all the time," but I don't really want to get into trouble all the time. It's easier to channel just parts of myself... but it makes me more bland.

I've been hanging out with a new group of people at school recently and I really like their company. They are doing research, so they are as dorky as my med school friends. I went out to out to eat and sing Karaoke with them on friday. How surprising it must have been for them to see me as a funny/wacky karaoker, singing myself hoarse. How unusually fun-loving.

Another thing that reminded me of this recently is that my friends like to do imitations of our classmates. I've wondered if they do one of me... but I think that they don't. It's as though I've washed out those characteristics right out. A few nights ago, we had an executive officer meeting, but I wasn't invited. It was as though I were totally forgotten on the invite list! (BTW, if lynn reads this, she'd feel totally guilty. that's not my intent here.) it was funny to me, because i wondered -- am I that forgettable?

Gods, I hope not.

Thinking back, this is not a new conflict for me. I will always be struggling to maintain balance between my school life and personal life, my Character and Personality. Who I am and who I want to become.

September 06, 2007

Reflection on a reflection

I wrote an email out to the med school classes to recruit for a mentorship program. It was interesting, because I wrote as if you, my blog readers, were my main audience and apparently it was well-received. When I came to school today, two of my classmates came up to me and said "I read your email last night!"

They seemed excited about that for some reason. "Yeah, it was like a bedtime story for me..." one woman said. Whoa! Bedside tales by Yours Truly. "It was inspirational," said another. I was flattered. I didn't really expect that it would recruit more people to join the club; I just wanted to share my reasons for why I joined. I think that is my approach to a lot of things in life.

I thought I'd share it with you as well.

I had my first musculoskeletal CSP (clinical skills preceptorship) today and I was just thinking about what it means to be a preceptor. These doctors take time out of their busy schedules to help train us to become great doctors! They probably remember bumbling through the questions in the history and getting confused during the physical exam. All in all, having access to helpful preceptors so early in
our careers helps to ease us into our roles as confident providers.

Teaching is a great skill to have! You don't have to wait until you get your M.D. degree to make a difference in the training of future doctors. Mentoring is a skill that the Medical Student Mentorship Program fosters. With that in mind, I just wanted to remind you about MSMP's upcoming Mingler! This event will be taking place this Friday 9/7/07 at My University's Center 5:30-8pm. If you are curious, please come on down.

Your parking passes are valid on campus after 4pm!
If you need a ride, I'd be more than happy to take you there. Check out our website for contact info.

Mingler details: First we will meet in the meeting rooms on the third floor for some icebreakers to introduce the mentors to the potential mentees. Then we will adjourn to the Gameroom on the lowest floor for some pizza, salad and billiards/games.
Please RSVP if you are interested in attending. Also, we would like you to submit an
online MENTOR application by Saturday, 9/8/07 so we can have the mentor/mentee
matchups finished by Sunday.

Cheers,
Not My Second Opinion, MS-II, MSMP board



P.S. I know that this has been "club week" at school and there has been a lot of activity. You might be wondering why you should join yet another club. MSMP is unique among the interest groups because it extends beyond the medical school community and it is worthwhile! After all, it made a difference for me, since I'm a med student today. :-)

August 30, 2007

On oops disclosures

Dr. Michael Wilkes's Second Opinion on KCRW on disclosure.

I've commented with my thoughts on disclosure of a cancer diagnosis to a Japanese patient before in "Shh! He doesn't know!" Culturally, it is acceptable for the family to request that this information be withheld from the patient -- something that I found ethically repugnant a year ago.

If a patient asks "why am I getting this treatment", is the family asking us to lie for them? How far is this betrayal of trust expected to go?

However, my recent visit to Japan made me reconsider this. There is a trend in Japan towards more Western values and practices in Medicine (among other things) and cancer disclosure is still a contentious topic there. I asked a few doctors (one was a cardiologist, the other, a resident training in GI) how they approach the subject.

The resident told me point blank that he followed the family's wishes and didn't tell the patient. He echoed the sentiment "a lot of patients cannot handle a diagnosis of cancer." I was surprised to hear this. Cancer isn't the death sentence that it used to be. The elder cardiologist agreed with me and told me that he tells his patients regardless of what the family wants. "It's their right to know," he said. Of course, he did have training in the U.S., so that might have affected his cultural judgement.

I'm not sure how I feel about the situation mentioned by Dr. Wilkes. If I were the surgeon, what would I do?

*deep inhalation*

I'd like to think that I could do the right thing and respect the family's wishes while still fulfilling my role as a doctor. Before the diagnosis is even made, I would like to approach the patient and tell him/her "now, one of the things we are testing for is cancer. If it turns out to be cancer, how would you like this to be handled?"

This gives the patient an opportunity to "opt-out" and puts patient decision-making in the hands of the family. I think this is culturally sensitive for both parties and it has the advantage of forewarning the patient of their potential diagnosis. If they are keen, they probably suspected cancer all along. Perhaps it's just reassuring for some patients to know that they are being taken care of as best as possible without having to worry about the prognosis.

August 29, 2007

Ankle Sprain

Monday was my first day back at school and I've jumped headfirst into learning!

There was a case presentation on someone who fell down and broke their leg. Just a few hours after that, I was running around and I slipped off a stair and rolled my ankle. It was already weak to begin with because I had injured it before. Musculoskeletal problems and rehabilitation all of a sudden became more interesting to me. :-)

I applied the RICE treatment for my ankle on the first two days to control the swelling and pain.
R = Rest as much as possible
I = Ice, for 15 min, twice a day
C = Compression, with ACE wrap, wrapping twice around the foot first to secure it, then alternating in figure-8s around the foot, overlapping by at least 1/3
E = Elevation assists with drainage

My biggest question now is: what can I do to prevent this from happening in the future?

Here are some of the exercises I am supposed to do twice a day as 3 sets. (Whoa! That's a lot more rehab than I expected.)
  • Sit on a firm chair or stand up. Loop one end of surgical tubing around the ball of the foot with the injured ankle. Hold the other end of the tubing in your hand. Put your heel on the floor. Stretch the tubing by pushing down with your foot, the way you push on the gas pedal of a car.
  • Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by pulling up with your foot (lifting up your foot), using your ankle, as if you were trying to pull the table toward you. (This motion is the opposite of trying to "step on the gas.")
  • Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot out to the side, away from the leg of the table.
  • Sit on a firm chair or stand up. Loop one end of the tube around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot to the middle, toward your good ankle.

Exercises and advice by "How to Care for Your Ankle Sprain" 10/1/2002. American Family Physician.

August 23, 2007

Curves of Paget's Disease

Paget's disease, aka osteitis deformans, is a "hot" disease of bone, where your bones are first degraded faster than they are built, then they recover, but in a strange and brittle way. Normally, your body is in a constant state of flux that remains relatively balanced -- unless you're vitamin D deficient (leads to rickets or osteomalacia), estrogen deficient (postmenopausal osteoporosis), etc.

August 19, 2007

A year has passed...

I've completed a full year of medical training and the biggest lesson that I've learned is that I don't know much.

The first patient that I saw with a group of my peers was last year, about this time -- we had just finished learning how to ask a patient about their past medical history and their background information. Our interview with an 80 year old woman turned into a recounting of her personal story, how she came to the state, worked in the fields, raised three children, survived two heart attacks and pneumonia last year. Other parts of her story came out in more subtle ways. She was able to recall details of her past perfectly -- but more recent memories from last week's procedures that brought her to the ICU were more fuzzy. It turned out that she had been diagnosed with Alzheimer's... our preceptor commented how it was therapeutic for her to reflect on her past with us.

This theme stuck with me as I learned more and more how the greatest gift I could give a patient, here and now, is my time and understanding. A lot of doctors are stressed out and they are only given a 15 minute window to see patients! As a "non-essential" part of the medical team, I have the luxury to spend more time with the patient.

I have volunteered at a homeless shelter providing free medical care and we recently expanded our services to another shelter. Time and time again, I have been drawn into a patient's story that went beyond their chief complaint to their underlying condition... how they lost the security of a warm bed and home to call their own. One man came in because of bedbug bites. He used to be a prize-winning chef, but he screwed it all up selling drugs. He was caught and went to prison for a little while, but when he got out, he found out that no one would hire him because of his prior conviction. In his despair, he confessed to me that he had a child on the way and if he was missing from the shelter in a few weeks, it's because he's back on the streets dealing drugs. I asked him about what was important in his life... he said that it was his girlfriend and their new child. I told him to think about the life that child would have and how much more difficult it would be if he were a drug dealer. He ranted on for a while and the visit went on for close to an hour. He said that he felt better afterward. I was glad that I listened to him... and I hoped that he listened to me. I saw him a few weeks later still at the shelter, but he has a black eye and the white of his eye had turned blood red. I hope beyond all hopes that he hasn't resorted to crime and drugs again.

Recently, I saw a series of patients in the clinic that really made me realize how much my volunteer work at the shelter has changed my outlook.

- difficult man

- emotional, obese woman w/ recent dx of DM

- possibly drunk & pregnant woman w/ a painful boil on her thigh - worried about baby!

August 17, 2007

What makes a good doctor?

When you find the answers to this question, you will have found yourself.

One of the most touching parting gifts from my ex-girlfriend before she left for Japan and I went to medical school was a simple project: she gave me a red ribbon and a bunch of colored construction paper squares with slits cut into them so they could be threaded on. The quote above was written on the front with the query "What makes a good doctor?" and the assignment was one that I took to heart.

Now, when I came across something difficult in my journey, something that I found worthwhile enough to blog about, I also try to summarize it on a colored square to hang on the red ribbon. This art project is a constant reminder to me of the important lessons I have learned. This entry will be my electronic file of my ponderings as I journey to find myself.

  1. Being Proactive: I drew blood during my first week of medical school! The act of being proactive is not about being aggressive or stubborn, it is about being open and willing.
  2. "Yes-And": Stephen Colbert's commencement address on improvisation, silliness and refusal to become a cynic
  3. Competence: Strive to be your best, but don't fret about your inadequacies!
  4. Motivation: a nephrologist preceptor told me "95% of being a good doc is how badly you want to be good."
  5. Sacrifice: Make the most of your spent time and energy - make it meaningful
  6. Ask an unscripted question
  7. Resist complaining, stay positive
  8. Count something
  9. Write something
  10. Change

August 13, 2007

Fwd: FW: New Medical Student Org

I was sent this in the mail today and I thought I'd pass it along. I am quite hesitant about "hanging up my shingle" so to speak, because of the intimidating business logistics involved. How much time would I actually spend with patients? Should I join a physician group so I don't have to worry about starting from square one and hiring all the staff? Should I set out on my own so I can be completely independent? Would I be happy with that?

I have no idea what problems lie ahead on this path to primary care. And I'm glad that a student organization has set out to tackle some of these worrisome issues.
You came to medical school to acquire the knowledge and technical skills necessary to make your mark in the world of medicine – but when you leave, will you be equipped with the right tools to make the important career decisions in your near future? Given the increasing financial pressures on the practice of medicine and the growing medical student debt load, today's medical graduates are navigating a more complex terrain than ever before. We owe it to ourselves and to our future patients to make informed decisions about how we choose to practice medicine.

The Business of Medicine (BOM) is a student-run, non-profit organization that was founded in 2006 by medical students at Georgetown University. BOM's mission is to increase medical student awareness of financial challenges and opportunities impacting the practice of medicine. Simply put, we recruit thought leaders and experts to speak at medical schools. Topics covered include Financial Planning, Residency Selection, Post-Residency Career Paths (private practice, hospital-based medicine, academic medicine, etc), Reimbursement, Health Insurance, Medicare/Medicaid, Physician Income and many more.

BOM also maintains a website with links to the most high yield resources on Debt Management, Insurance/Policy, Malpractice, and Career Development. Each link posted has been screened by medical students to provide the most concise, relevant, and accurate information available on the topic. We invite you to explore our website at: http://www.businessofmedicine.org/ and hope that it will help save you time in the future. We welcome your comments and suggestions for improvement as we continue to develop and keep our site up-to-date. It is truly a site for medical students by medical students!

You've invested valuable time, energy, and financial resources into the process of becoming a physician. We invite you to join us in our mission to bring BOM to medical students nationwide and to empower yourself by learning how to best protect this investment.

For more information about how you can get involved, please contact us at bom@businessofmedicine.org. We look forward to hearing from you!

August 11, 2007

Time-tested science

A publication for every fact, a life for every arrow.


This is just something I've been pondering for a while... all throughout my studies, I come across piles and piles of research which must be quickly "triaged" into a read, file, or discard category. So much research goes into each simple little fact in a textbook, demonstrating a link from A->B. Someone could devote their entire life towards this modest goal, because there are so many different methods of experimentation!


My embryology teacher in undergrad put it best as "show it, block it, move it."


  1. Show it: First things first. You need to run epidemiological studies, immunofluorescence studies, etc. to show that a certain gene/enzyme/disease/factor is present in association with whatever you're studying. And you need to do assays, dig through piles of charts, or run huge randomized polls of selected populations...

  2. Block it: Then, you can stop it. This can be tricky in some cases. You need to demonstrate that a disease/condition/observation disappears in the absence of the variable you're tweaking.

  3. Move it: Then, you can move it. Can you create the disease/condition/gene product with the modest introduction of your tweak somewhere else? This is the most ethically questionable of the three principle study designs, since you cannot induce diseases in humans and expect to get away with it. Often, animal studies are performed with the hope that it can apply to other models as well.

Three simple concepts. Yet the execution of them can take trial after trial, assay after assay, tons of paperwork to get funding and support and recognition.


I'm surprised sometimes that scientific progress hasn't halted altogether, given the amount of work, time and money it requires. I have a great appreciation for the unsung heroes of the laboratory whose obscure brilliance might only be recognized by a super-select few. (Few? Can I even use that as a noun? It sounds okay to me.)

August 09, 2007

Writing a Personal Statement

This is the most difficult part of any application -- the free and creative portion in which you distill your essence into something that falls within the 5300 character limit.

How do you do this? I've talked about my own personal statement in the past.

TheReporter has some other tips and thoughts on writing a personal statement:
Humility and honesty that must come out in your essay.
A successful personal statement FOR MEDICAL SCHOOL is about the patients, and their perceptions/feeling, more than anything else. Try this before you do your next draft: describe a patient's experience/thoughts, from the first person viewpoint, from the time they first suspect they are ill to the time they see a doctor.
This goes beyond a mere essay to get into medical school. We're talking about a philosophy on how to approach patients. How a doctor ought to use the Golden Rule. This is a life-long concept... and what TheReporter is really doing is asking -- are you the type of person who has enough social intelligence that you can put yourself in someone else's shoes? How did that make you feel?

Writing a personal statement is not about echoing the tired cliche of "I want to help people" or "I want to be like Dr. X and Y because they changed my life." A personal statement should be a personal revelation with emotional content that makes people tilt their heads and go "hm..." Find your personal character flashback moment.

Strive for insight, but don't push the boundaries and make bolder claims than you can support. Practice expressing yourself. Take chances and open up with a patient when you reach a point of awkward silence when they wonder why you're in the exam room. Smile. Laugh. Ask questions. Creating experiences will inevitably lead you down a road that you can look back on and say "wow, I've got a lot of material I can draw on for a personal statement."

Healthcare Blogger Code of Ethics

I just came across this concept through Nick Gene's Pre-Rounds Interview with Dr. Lei of Eye on DNA.
Med Blogger Code of Ethics:
1. Clear representation of perspective - readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the professional perspective from which they are blogging.
2. Confidentiality - Bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients’ identity cannot be inferred.
3. Commercial Disclosure - the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.
4. Reliability of Information - citing sources when appropriate and changing inaccuracies when they are pointed out
5. Courtesy - Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.

I agree with these ideas, especially those about Reliability of Information. There's so much garbage out on the internet that obscures the truth... it's important for health professionals to ensure that they are providing a refuge from this refuse!

August 08, 2007

The New News (Google Comments & my own)

A story recently came out about Baby Einstein in the newspapers. They cited the "Journal of Pediatrics" for publishing a story on the paradoxical effect of educational DVDs with children under 24 months. These infants understood fewers words than children of parents who read to them, according to Clinical Cases and Images. CCaI went on to claim that many official news sources failed to link their online articles to the original study and in fact, the Archives of Pediatrics & Adolescent Medicine was the publisher.

However, when I read the article that CCaI posted, it did not coincide with the information suggested in the original articles. It proves CCaI's point though... check your sources! ;-)


In related news, google news is adding the ability to comment on news -- if you are a part of the news story. This has the potential to provide rebuttals (as seen by McDonald's in response to astudy that kids find carrots and veggies wrapped in McD packaging tastier). It has the potential to provide further information DIRECTLY FROM THE SOURCE (as seen in the FDA approval for a new HIV-drug Selzentry.)

I think that the internet will revolutionize how we receive our news. After all, I learned about all of these stories through Clinical Cases and Images... a blog targetted to educating IM residents in the Cleveland Clinic. Unless traditional newspapers can adapt, adopt and become adept with new technology, they will swiftly find themselves outstripped by other alternative news sources.


[edit] Hm... Medgadget provides a little more info from the original Times article, confirming CCaI's reference.
Led by Frederick Zimmerman and Dr. Dimitri Christakis, both at the University of Washington, the research team found that with every hour per day spent watching baby DVDs and videos, infants learned six to eight fewer new vocabulary words than babies who never watched the videos. These products had the strongest detrimental effect on babies 8 to 16 months old, the age at which language skills are starting to form. "The more videos they watched, the fewer words they knew," says Christakis. "These babies scored about 10% lower on language skills than infants who had not watched these videos."

However, the article does not make the bold claims that the authors suggested... or maybe I'm reading it wrong.

Television and DVD/Video Viewing in Children Younger Than 2 Years
Frederick J. Zimmerman, PhD; Dimitri A. Christakis, MD, MPH; Andrew N. Meltzoff, PhD
Arch Pediatr Adolesc Med. 2007;161:473-479.Time Magazine reports on the findings that the popular Baby Einstein video series, meant for infants, lacks scientific merit when it comes to spoken word, and seems to actually do harm.

July 22, 2007

Drinking

My other post on alcohol has proven to be very popular... it's on the second page of Google if you type in "Alcohol allergy!"  :)
 
Here's some other facts about alcohol that you probably should know:
 
12-ounce bottle of beer = a 5-ounce glass of wine = a 1.5-ounce shot of 80-proof liquor = 11-14 grams of alcohol.
 
>60 grams per day for ~2-4 weeks leads to fatty liver (steatosis)
>80 g/d for ~2-4 weeks leads to alcoholic hepatitis
>160 g/d for ~2-4 weeks leads to cirrhosis
 
Drinking a six pack of beer a day can turn your liver from an efficient energy producing machine into a fatty sludge.
 
A beer gut might just be a superficial symptom of underlying pathology.  While steatosis is reversible, cirrhosis is not.  When your liver starts building up scar tissue, blood that normally comes from your gut is shunted to other places.  Blood waste products build up in your blood stream and you might turn a sickly shade of yellow (jaundice) or start having mental difficulties (hepatic encephalopathy.)  You might bleed into your stomach and start vomiting up a lot of blood (hematemesis due to esophageal varices.)  You might get hemorrhoids and you bleed out of your rectum.
 
Not pleasant.
The lesson -- if you decide to drink, drink in moderation.

July 12, 2007

Gupta v Moore on "Sicko"

Michael Moore has a new movie out, entitled "Sicko." It speaks out about the current situation of our health care system in the U.S. My class is having a summer outing to go and see the movie tomorrow, but I won't be able to make it. However, the movie is not far from my mind. I'm currently volunteering at two homeless clinics and I'm reminded almost daily how difficult it is for these people to get good, reliable health care. Having universal health care would be a great step in the right direction. In some ways, they sort of have this already, in the form of ER visits. Our country does not turn anyone away from the emergency room... but I sometimes wonder what happens in other countries with socialized medicine. Are they rejected at the door if they aren't a citizen that pays taxes? Why do a lot of companies provide health insurance supplemental to that provided by the government?

Dr. Gupta wrote a story for CNN about how Michael Moore "fudged" some of his facts. They played his piece right before inviting Moore to respond and he went OFF.


Moore is a very passionate person. He's great with theatrics too, accusing CNN of failing to do it's job in fair reporting, trashing Fahrenheit 9/11 and now his new movie, when they both will be shown to be right on the dot... he was even pushing to get them to apologize to the American public for pandering. I don't think he ever means to be deceitful and if there's anything that will rile him up... it's lies. Accusing him of lying is probably the worst button you could push. I think he speaks the truth on his facts. I also agree with an assertion by Dr. Gupta made a few days after the initial report that Moore "cherry-picks" his data. Michael Moore is a movie-maker and documentarian..ist? He is not a scientist... he doesn't spend his time publishing factual journal articles. What he has proven to be very good at though... is simply getting people to talk about important issues. :)

Dr. Gupta's reply can be read here: http://www.cnn.com/HEALTH/blogs/paging.dr.gupta/2007/07/my-conversation-with-michael-moore.html
He made an admission that he misspoke on Sicko's claim of Cuba's health care cost per person as $25... when in fact, the movie said it was $251, the same value that he quoted.

One of the things I found most interesting was reading the replies on Dr. Gupta's blog.
If you admire this man, then why were you nit picking his movie? It seems to me that you should try to make his data better.

As a former overweight American, I think Michael Moore should follow the path I took and lose some weight. Obesity is the best example of preventative medicine. I appreciate Mr. Moore doing a film on our healthcare system, and agree we need an overhaul of the system. That being said, it is ridicule that Mr. Moore constantly assails the government yet thinks they are capable of running a healthcare system.

...But the most important thing is that people in those countries can buy private healthcare for a fraction of what American people do. The reason is that there is not an oligopoly as there is in the US. Another thing is that in all these countries to study to be a physician is basically free for the student.


Whoa, really? I'd like to have free healthcare and FREE HEALTHCARE EDUCATION. Now, that would be a truly rewarding public service!

June 30, 2007

Ecylse, the "Zorse"



What the heck is going on with this horse? It's part zebra, apparently.

while most zebra-horse crossbreeds sport stripes across their entire body, Eclyse only has two such patches, on its face and rear.

The one-year-old zorse was the accidental product of a holiday romance when her mother, Eclipse, was taken from her German safari park home to a ranch in Italy for a brief spell.

There she was able to roam freely with other horses and a number of zebras, including one called Ulysses who took a fancy to her.

When Eclipse returned home, she surprised her keepers by giving birth to the baby zorse whose mixed markings betray her colourful parentage.

Via DailyMail

At first, I thought that this would be a good example of mosaicism, but upon further research, I found out that this would require a mutation. I guess I was thinking something more like X-inactivation, seen in the colorful coat coloring of a calico cat.

In any case, I thought that this was a striking example of genetics in action. Yay weird science!

June 01, 2007

"Flea" Bite

A while ago, I started to read the posts of "Flea," a pediatrician blogger so named by snarky surgeons who call pediatricians "fleas."

He took to his pseudonym well, offering biting commentary in the medical field, often offering harsher truths than I thought appropriate, as evidenced in my response to his entry on Lavender Essence and vaccines. A doctor has a position of high responsibility and respect and it requires a certain amount of professionalism... which apparently, extends to blogs. You cannot let your guard down, even when you use a blog as an outlet for something as frustrating as a malpractice lawsuit.

Flea's posts became irregular and more and more of them cited an ongoing court case he was involved in. I thought that this was a risky thing to do and as many speculated when his blog was completely erased -- it did not bode well for the outcome of his trial.

Indeed, he was featured on the FRONT PAGE of the Boston Globe just a few days ago! That's crazy scary. I would not want something like that to happen to me.

Worried about how a blog might affect your career and your reputation if you should be discovered? Clinical Cases and Images offers a few pieces of advice: write as if your patients and your boss reads your blog everyday. Conform to HIPPA. I added a disclaimer to my sidebar, but I don't have the traffic/notoriety/fame that Flea, Respectful Insolence or Dr. Dimov have to warrant full disclosure.

Kevin, M.D. offers his own comments and summarizes the responses in the blogosphere.
Eric Turkewitz, personal injury lawyer provides some links to the ongoing story.

May 31, 2007

TSH effects: hyperTRICEPS

Since I'm on the topic of hyperthyroid, I thought I'd share a little mnemonic I just made about the steps of thyroid hormone synthesis that are affected by TSH stimulation.

HYPER TRICEPS
HYPERplasia of the follicle cells
Trapping
tRansport
Iodination
Conjugation
Endocytosis
Proteolysis
Secretion

Autoimmune hyperthyroid, aka Grave's Disease, creates antibodies that resemble TSH and trigger all of these steps willy-nilly without any regulation! This makes your follicular cells very hungry for iodine and they start sucking out all of their stored colloid and dumping the hormones out into the system.

I'm not going to bore you with all of the nitty gritty details. For that, you can go to Boron & Boulpaep or my favorite, Guyton and Hall.

PHASED up hyperthyroid

I've talked about the exopthalmos you see in Grave's disease before.

Here's a way to remember a few of the signs of Hyperthyroid!
PHASED up thyroid
Palpitations
Heat intolerance
Appetite
Sweaty
Emotions/energy lvl/Eyes
Diarrhea

Patients who have hyperthyroid might be noticed by their weird-looking appearance. They have bulging eyes, a strange lumpy neck and they are always anxious. This disease is usually caused by an autoimmune disease that attacks and activates the thyroid gland located in the neck. Increased levels of thyroxine (T4) and T3 hormone lead to a high energy state, which can cause weight loss, muscle weakness, and the increased basal metabolic rate makes them feel hot and sweaty.

I know someone who had this. She told me about her diagnosis and I looked up a few of the symptoms and asked her about them. I remember thinking that she did look a little bit weird, but I couldn't quite place my finger on it. In retrospect, she did have an enlarged thyroid, she was very thin and her eyes were a little bit buggy. Now that she has had treatment (not sure if it was selectively radioactive iodine or medication)... she looks a lot better. I'm sure she feels a lot better too.

May 30, 2007

Portable ePaper

I'm waiting for the day that they invent ePaper. I'd like to be able to take notes on something thats flexible and portable, something that I could read hundreds of books on with the flip of a page, that requires very little power, and it has wireless access to the internet.

I think that having a device like this would greatly improve my own speed and productivity and more importantly, it would be TOTALLY RAD. A lot of docs these days have palm pilots or Treo phones with mini keypads and stuff like that, but they are so tiny! I rarely use my palm pilot because it makes a highpitched electronic sound that gives me a headache.

My tutorial group was talking about our proposed electronic purchases yesterday. One girl was displeased with her old Treo. Someone else commented on about getting a tablet PC.

And then, I saw this today on Geekologie.
Holy cow, this laptop is thinner than a penny is wide! It's almost as thin as the new Razr phones! And it uses flash memory (the same stuff that comes on jumpdrives and in digicams) so the battery life is >12 hours.

Whoa. I can't wait to buy this, jewelry and purse-looking straps be damned! It is a sweet device.

May 23, 2007

*stressed*

I've been staying up very late these past few weeks studying. I've been worried about the upcoming exams on gastroenterology (mouth to butt), endocrinology (hormones and such) and hematology (blood and immune cells). Our exams will cover our knowledge of common procedures and practices involved in the most common diagnoses of these fields, anatomy, histology (microscopic anatomy), pathology (Dana Scully autopsy work!), physiology, genetics, biochemistry, etc.

Whew. It's a chore just to try and list the topics that we are supposed to know about. I feel pretty confident about the most recent material since I've kicked my butt into high gear... but I'm VERY stressed out about older material.

Our ex-Secretary of Defense said it best:
The Unknown
As we know,
There are known knowns.
There are things we know we know.
We also know
There are known unknowns.
That is to say
We know there are some things
We do not know.
But there are also unknown unknowns,
The ones we don't know
We don't know.

—Feb. 12, 2002, Department of Defense news briefing


I'm at that stage where I don't really know what it is that I don't know. There's something different about feeling confident with material that doesn't quite cut it when you're faced with a blank page and you're told to "write the mechanism for diarrhea caused by E. coli."

The best way to face this stress is to study, I suppose. And the best way to prove to myself that I've been learning more material than I've been forgetting it is to apply it and start grinding away at mechanisms on scratch paper.

I noticed that I've stopped writing here in lieu of studying, when in fact, this is my best outlet for expressing myself, educating myself and conveying my thoughts in a coherent way that will pay off in the future. I plan on picking this blog up again. I'll use it less as an opportunity to teach and more as a way to figure out what the heck I'm going to do from where I am! :)