Emergingsea Monster

Emerging into Next Phase

2020-04-12T00:45:00.003-07:00

Breath

2012-03-01T08:28:00.005-08:00

N.B. This post may be considered, um, politically incorrect. Let's just consider it in a clinical context.

I am jewish, well, my mitochondria is. And if I'm right, my oral microbiome, rather, my breath, is as well. I call it "Jew Breath". It resembles mothballs(note: this is not my breath all the time, only occasionally!). I've noticed it a lot at Temple and had it independently confirmed by an old jewish roommate:

"You know what I'm talking about" I said to A. "Jew Breath is real!". A put his face in his hands, smiled, and nodded slowly, admitting the painful truth. I could smell it on him too.

As an SGU'er, with my school's majority Indian population, I also noticed among some a certain "Indian Breath" (or more offensively: Desi Breath). I can't quite put into words what it smells like, but I prefer it to Jew breath. Anyways, a fellow (caucasian/goyim) med student who is dating an Indian women actually had that breath... which means either the smell is not associated with the subcontinent OR she transferred some of her oral flora to him through excessive make out sessions (how long and how many remains a subject for further study).

There is some clinical relevance to this, however. Analyzing the myriad microbiomes of the gastrointestinal tract is a hot research topic,implicated in everything from Chron's disease, type 1 diabetes, failure of anastomeses in surgery (from a grand rounds lecture pre-pub) to development of pancreatic cancer. And it turns out, some research has found a difference in the oral microbiome of different ethnicities.

So maybe there is something to Jew Breath after all...

Maple Syrup

2012-01-29T16:05:00.000-08:00

The tapping of trees for maple syrup was practiced in north america for thousands of years before the arrival of the immigrants. The French adopted its use early on and it's a tradition that has had a noticeable impact on the St. Lawrence River valley. Maple syrup also has a history as one of the earliest examples of socially responsible purchasing. Slavery lords of the south produced much of the sugar in the United States in the early to mid 19th century. For abolitionists, maple syrup became an alternative source of sweetener to divert funds from the economic clout of the slave owners, as were other agricultural products similarly boycotted as part of the Free Produce Movement. Interestingly, the Free Produce Movement began in the 1790's and lasted until the 1850's. Somewhat parallel to today with fair-trade and organic goods, the "Free Produce" products never were able to compete economically with slave labor products. Though, one could say "Free Produce" is finding a more enlightened market in the 21st century, ultimately people have to value their ethics of human rights and environmental responsibility more than saving money...

Round, Cut, Eat, Sleep

2012-01-24T18:06:00.000-08:00

Alarm slap at 4:45, got 20 miutes to get ready. It starts with a cold bike ride through the dark park, and suddenly I have coffee and Ins & outs. The parade of patients then flies by, soon back in the OR and the ritual scrub in begins. Inside the abdomen now, presurized camera port view - like a reverse submarine periscope. Hiding spleen and adherant umbilicus, don't forget the internal hernias. We're out and grabbing an Oxygen tank, wake up - you did well, well your GIT did, now it's up to a duel b/w your WBCs and disturbed microbes. Pass off at PACU, go grab something for $3.26 - surgery makes you hungry. But at the end of the day sometimes, you're more tired than hungry - wake up at midnight wiht the light on, turn it off - rinse and repeat.

Competitive Specialties

2012-01-12T16:38:00.000-08:00

Entering clinicals, I never expected to like the more "procedural" specialties. But ever since I scrubbed into my first C-Section in OBGYN, I've been drawn to the OR. The excitement, the atmosphere, the sense of accomplishment, the work of having a few, long, nice projects to work on for the day and the ability to see a difference in a patient after surgery are all very attractive to me. I can see that much of my pre-clinical work was also project oriented, even if it had little to do with surgery.

If only things were so simple. I decided to take SGU up on there clinical academic advising services (something I made good use of in basic sciences with the great Dr. DB). I sent in my CV, GPA, Step 1 and goals of matching in Surg or OBGYN. I will say Dr. PB (the clinical advisor) gave me some needed advice and gave a great critique of my resume. But he basically said I have less than a coin flip's chance of matching in either specialty. Not a 0 chance, but not great either. It's tough news, but I'm thinking about what I can do to change my chances and think hard about what I like about the OR.

But it got me angry and thinking about WHY certain specialties have cut offs. Does someone need to be that much smarter to go into General Surgery than to go into Family Medicine? Is the academic training of Dermatology really more broad than Primary Care?

From my experience in medicine: No. In fact, general practice is in many ways more challenging intellectually - you really have to know the subtle signs of sickness to catch the deadly diseases early among the sea of worried well. No, there is something else at play, as DJ Shadow once alluded to...

The most competitive specialties pay the best. Lifestyle is a part of this, which is why EM - a midrange compensation - is becoming highly sought after. This is not surprising if one is a cynic, but it's disheartening if one is kinda typical on stats paper but wants to follow their interests and make a difference in a field. We live in a capitalistic society, so I guess I shouldn't expect things to be different - it's just always startling when the brutal reality of it stares you in the face. I just wonder what the distribution of Derm vs. Family vs. Surgery vs. Psych would be if all of them paid the same and had the same hours. And what that would do to the delivery of healthcare in this country. Considering how many physicians I've hear complaining about compensation cuts, I'm guessing it would be a bit different than today :)

F/U post comparing specialty distrubution in other healthcare systems (europe, canada, india) to follow...

Fully formed

2011-09-06T14:06:00.001-07:00

(Paul) Farmer entered Harvard med school in the fall of 84. He was only twenty-four. He told me once, "I was fully formed at twenty three." He meant, I think, that by then he had his philosophy and worldview in order, and he knew he wanted to marry them to action..."
From Mountains Beyond Mountains

How many students enter med school with an independently formed world view?
Sure, many have goals, mainly around specialty, lifestyle, etc. But in many ways the med school admissions process selects more for students who can have the world view of their institution imparted onto the next generation of doctors than for those who have their own ideas about what they want with medicine. Ideas that, in many cases, take time away from the pre-med grind in order to formulate.
I am seeing the validity of my original goals with medicine the more I get into the grey fog of action, indepenence, and socio-politics that is clinical practice. A validity that was much harder to see in the cold facts of mcq memorization that was basic sciences.

This is clinicals

2011-08-25T17:25:00.001-07:00

Have reached the stage of exhaustion where I am a complete neurotic, overly sensitive, giggling monstrosity. I am so toasted yet still oddly wired and excited to get up and go to the hospital and explore brooklyn and i dont even know. This is clinicals.

When Normal is Abnormal

2011-04-29T16:10:00.000-07:00

In the last week of my Introduction to Clinical Medicine course, we had a middle aged women patient with hypothyroidism. She had a bought with Grave's disease and ended up with radioactive iodine therapy which, though it cured her hyperthyroidism, left her with hypothyroidism. She was later put on levothyroxine but ever few years they needed to increase the dose. I remember asking if this was typical to our clinical professor that day, Dr. R, and he said that this is quite common with hypothyroid patients.

--

My friend B also has hypothyroidism. B also developed hypothyroidism as a result of radiation, but this was for her Hodgkin's Lymphoma, which she successfully beat. B initially went undiagnosed until her Oncologist, and the best Doc she's ever had, noticed her sweating too much when she came in once, and immediately ordered a TSH test. Since then she was placed on 50ug of Levothyroxine and her TSH was typically around 1.1 (reference range 0.4 - 5, though there is some debate about this).

Sir Charles Robert Harington, discovered the structure and synthesis of levothyroxine

Over the past year or so, B started to notice her hair falling out. At first she thought it was due to two surgeries she had within a few months of each other (both for unrelated conditions). Her previous Endocrinologist took a job in another city and so she saw a new one at a prestigious university last June. After looking at her TSH (2.2) and examining her rather quickly, she told her "your hair is not going to all fall out" and rather rudely dismissed her concerns.
Dismayed by this for a while, B continued to watch her hair fall out for the next several months and then started to get some painful acne. After this she made an appointment with a Dermatologist in November. Her PCP signed off on the referral, though he didn't have much insight into her hair loss either. The Dermatologist examined her and drew some blood. Before she got any results back she prescribed spironolactone, presumably for its anti-androgenic effects to counter the acne and hair loss. She ran her own tests and noticed she had a slightly elevated aldosterone, called B and told her to take the spironolactone.
The spiro at first stopped the hair loss but didn't induce much regrowth. After a month on it without any complaints, the Derm doubled the dose to induce regrowth. Within a few weeks B started to notice some strange side effects, though not entirely uncommon. She stuck through this (she is a very compliant patient) but then started to just get plain lethargic over the end of winter and into spring. She also stopped working out and couldn't seem to keep her apartment organized. B thought perhaps it was the long, cold winter but then she started to get salt cravings and gain some weight. Again, possibly spiro side effects, at least the salt craving.
Since spiro is a potassium sparing diuretic, one must be careful about potassium intake. One day in March, B ate a bit too much broccoli and appeared to get symptoms of hyperkalemia. It could also have been just bad broc, but after that she was scared off eating anything with a lot of potassium - cutting out some of the fruit staples of her diet such as bananas and juices. After this, she started to feel insatiable hunger and, as a cancer survivor, started to get paranoid about the constellation of symptoms of tired, hunger and generally feeling ill.
Just this past week she had her yearly check up with her Oncologist. After reporting how she felt to the interns and doing some blood work, they came to a rather obvious conclusion: B needed to increase her dose of levothyroxine. It turns out that at this appointment, her TSH had risen to 3.3, while still in the "normal reference range", her oncologist knew her history and that B's typical range for proper thyroid treatment was a TSH of around 1. She prescribed a dose of 75ug and explained that her hair loss, weight gain, and lethargy were all likely due to the hypothyroidism.

--

Looking back on this, there are a few interesting lessons. First, the reference range does not always tell the whole story. References ranges are in fact based on the population mean for a lab value, +/- 2 standard deviations. This helps us see pathological outliers, but it doesn't always tell the most accurate story for an individual. It reminds me of another story where a fellow med student, and former nurse, said someone could have a blood sugar of 40 be not outrageously low (though we're taught <60 is low) because he could just be someone who has low sugar. While I have not had enough clinical experience to appreciate this, it seems to make sense and was certainly analogously true for B.
Also, I know my own personal clinical judgement got warped when trying to help B figure out what was wrong. Makes me wonder how much physicians can really get emotionally vested in their patients before we start to see what we want rather than what is really taking place.
However, the most disturbing aspect of this whole endeavor was the fact that 3 separate, board-certified physicians completely missed what was going on. Not only were her symptoms dismissed (endocrinologist), completely missed (primary care doc) but she was also misdiagnosed and given an unnecessary treatment (dermatologist). A year of distressingly losing hair and the psychological consequences of that, gaining weight, rising blood lipids and also some inflammation on top of it all, could have been avoided if someone had just put together her symptoms with her #1 chronic condition and what is "normal reference range" for her, individually.
It raises many questions about the coordination of care, the role of medical records, and even the attentiveness (perhaps overworked, perhaps not) of the physicians in our US healthcare system. I just wonder how typical such cases truly are... and will certainly do my best to keep this in mind on my clinical rotations later this year.

Science 2.0

2011-04-27T17:29:00.001-07:00

Damn you wikipedia!
I tried to remember what the name of the social networking researchers was called, only to find out there are several competitors that look interesting. ResearchGate was the one I was looking for, but then I found Academia.edu, epernicus, and then SciSpace.com. Now instead of happily signing up for ResearchGate, I want to look into each of these but don't have the time. So I will likely forget about it for another few months and repeat the same process. Unless I can remember this blogpost...
Add these to my neglected accounts on Medpedia and LinkedIn, as well as that whole inspiration exchange thing AMSA has, and we're getting into serious social networking overload here.
Ok back to facebook.

The Unconventionalists

2011-04-24T13:24:00.000-07:00

Nature (the journal) is running a theme this week on the future of the PhD. Some interesting convos going on in the comments over there, and I even found another cool book to read from it.
One blog post at the nature network stuck with me though. This scientist-in-training reflected on her unconventional aspirations and how others would react:

In the cover of my unspoken reality, I dared to be disappointed with my top 5 academic institution, where to entertain creative ideas of a non-traditional career in the sciences was to be exiled from the class of 'serious' scientists. A lullaby for a weaker child of chemistry. Enjoy your dreams of a lesser biology. She couldn't make it in the big leagues, they'd say. So I hide my dreams of translating science, colorful pages lost in a library of dull covers with obscure, impossible-to-pronounce titles. Surface Plasmon Resonance Series - Nanotechnology-based Sensors. Professor, here is my secret: such a library of science begs translation for the curious non-scientists. Thrilling stories of scientific discoveries that will make our fellow non-scientists as curious as we. Put me in coach. The only thing I know better than science, is the art and draw of language.

As someone with a non-traditional trajectory in medicine, I can hear her picturing others thinking "what are you doing here"... and have had others tell me the same thing. It can be frustrating at times, but I love her "Professor, here is my secret" line, it really captures how I feel when people ask my planned specialty or wonder how what I have planned with medicine...and why I persist on reading fiction in the middle of the semester. And then I run across quotes like these and feel a little bit better about it:

I cannot serve as an example for younger scientists to follow. What I teach cannot be learned. I have never been a '100 percent scientist.' My reading has always been shamefully nonprofessional. I do not own an attaché case, and therefore cannot carry it home at night, full of journals and papers to read. I like long vacations, and a catalogue of my activities in general would be a scandal in the ears of the apostles of cost-effectiveness. I do not play the recorder, nor do I like to attend NATO workshops on a Greek island or a Sicilian mountain top; this shows that I am not even a molecular biologist. In fact, the list of what I have not got makes up the American Dream. Readers, if any, will conclude rightly that the Gradus ad Parnassum will have to be learned at somebody else's feet.
-Erwin Chargaff
Heraclitean Fire: Sketches from a Life before Nature

Islands

2011-04-08T22:45:00.000-07:00

Awesome article about how Central Park is an ecological island, human-made in almost every sense, but the laws of nature operate - resulting in an entirely unique species of dwarf centipede,Nannarrup Hoffmani.

Made me think how Hospitals can also be ecological islands, on the microbial scale.

Oh there was also exams this past week. Went well overall. Have some experimental results to share regarding the 10,000 question method for step 1. Apparently, doing just questions for pathophysiology review gave me the same score as doing straight reading/revision type review, but was much more fun to do questions! Not sure what this means for board prep yet though....more later.

Celiac without the Celiac

2011-04-05T17:04:00.000-07:00

Exam week here. Pathophysiology was yesterday, lots of confusing questions about GI and Heme, like patients with celiac that had Iron and B12 deficiency (...??) and nonanisopoikilocytosis (seriously?) but otherwise a doable exam. I did several hundred questions and started to get a sense of how different QBanks have different styles. Exammaster makes it too easy by putting things that have nothing to do with each other for answer options and many first order questions, though they have good explanations. Kaplan QBook does a better job of making the choices more difficult, but still remains pretty straightforward. UWorld is the most dificult, but you're always clear about what they want - just you don't know the answer most of the time.

SGU's style consists of descriptions of conditions associated with the disease you just diagnosed and then about a paragraph full of distractions. So out of a 1/2 page vignette, probably 2 key words that are actually relevant. Anyway, in honor of nonanisopoikilocytosis, here is a link to a neat story about when you can have Celiac without having Celiac.

Patients Lie

2011-03-24T18:06:00.000-07:00

icu has 4 beds for all of Grenada

4 icu beds for 100,000 people

Grenada only has 4 monitors for the patients in the ICU

no one else on the wards has a bp/hr/rr monitor

there is no beep beep beep in any other part of the hospital

i didn't notice this until this week, the 7th time i went.

Dr. g was our instructor for the day

Cuban doc, came to Grenada because his dad is a surgeon here

you do school in Cuba for free, but you owe the govt 6 years of social service

then you can go wherever you want if you pass their test

came to Grenada 2 years ago knowing no english.

There were 3 patients in the ICU

one was the girl we had seen previously in peds, with muscular dystrophy

she was alert but in need of monitoring

the other was an older man with a subarachnoid hemorrhage, apparently unconscious

and another was a middle aged lady also with a cranial hemorrhage

before we saw the tube put in, we were to examine the man with a subarachnoid hemorrhage

as usual, no one in my group is quite awake, yet i am fully caffeinated by this point

so i take the lead to examine

one of the guys in my group says we cannot touch the patients in ICU because

his friend was there before and they weren't allowed

so i am puzzled as to how we can examine this patient without doing anything

i ask Dr. g - he says yes you can examine

so we try to communicate, he does not seem response

he makes some unintelligible muttering sounds

another fellow student suggest we do the Glasgow coma scale to assess this patient

the GCS is the scale used to asses and monitor levels of consciousness

you have 3 sections and get points for each section

conscious awake aware = 15 points

you asses visual stimuli response, verbal stimuli response and touch/pain stimuli response

if you are in a coma and completely nonresponsive, or even if you are dead

you still get 3 points for showing up

So we decide to do the GCS scale

he does not seem responsive to verbal stimuli - we ask him to blink if he hears us

it is just random, and he mutters

he gets 2 points for verbal

after some observation we decided his eyes don't really open to our voice

we think 1 point maybe

however, we need to test his response to painful stimuli

so i decide to poke the patient, but not hard

he moves his arm a bit when i touch

V says no, you really can't assess that

and that that is not a response to your stimuli because you didn't get his consent/understanding

i say we don't need that, but how are we supposed to assess this?

i am told by my colleagues that we don't need to really do it

its just a textbook thing

i say that is absurd, aren't we supposed to be monitoring this every hour?

what do you guys suggest?

they are nonresponsive

Dr. g then brings us over to see a nasogastric tube put in the middle aged lady

they needed to sedate her.

After, we go outside the ward

Dr. g asks us if we have any questions

i remember to always ask a question, i read this somewhere about rotations

so i ask how are we supposed to do the GCS scale and how important is it that we really do it?

Dr. g says

instead of answering

i will tell you a story:

I was given a page to examine a patient with coma

comes in, boy, 10yo, has IV line on each arm, fluids

given oxygen nasal, given nasogastric tube.

i examined the patient - respiration is normal, rr 20 bpm, hr 80bpm, bp 120/76

airway sounds normal, so does heart

something is not right he thinks, intuitively

i does his reflexes - none

i pinched the patient, no response to pain, no response to stimuli.

i calls the nurse over and say

"nurse this patient is dead, he died 5 minutes ago" shocked looks and gasps

"bring me the tools so that i may perform the autopsy"

suddenly the boy cries "no no, i am alive!"

Reboot and Open Access

2011-03-19T22:04:00.000-07:00

My guilty spiral of not posting, and then having things to post but not enough mental energy/time, seemed to be stalled in a perpetual procrastination spiral, but then I ran across a fellow med student blogger - Lex MD - and realized that I don't need to write paragraphs of detail about, well, studying without internet (it really works - thank you silly campus Bradford security restrictions!) in order to keep things going here - or at my other neglected blog with Global Pulse Journal (though I have been keeping up with the twitter account). So even with Step 1 slowly creeping towards me, I hope to have a little more of a social-net presence.

Speaking of journals, I've been loosely following the Open Access debate going on in the scientific journal community. It seems that one of the journals I published at supports the DC Principles for Free Access to Science, purporting to be a middle way between traditional publishers and open access advocates like the Public Library of Science and the NIH. An interesting debate - any thoughts out there in blog land about this?

MS2

2011-01-18T11:24:00.001-08:00

Med school is about not giving up on things.

Med school is about understanding how much time you have and what is possible to do.

Med school is about scheduling.

Med school is about finding time for things that you care about, like your neglected blog, even when you've got a long to do list.

Med school is about stepping back the week before exams and remembering why you have been sitting for 14 hours straight trying to download this book into your brain.

Med school is about understanding work and your duty to get things done, even when you're exhausted.

Med school is about learning how much we know of the human body, and how much (more) we have to learn.

Med school is about understanding what Oscar Romero meant when he said ""We cannot do everything, and there is a sense of liberation in realizing that. This enables us to do something, and to do it very well. It may be incomplete, but it is a beginning, a step along the way."

Brain Off

2010-11-28T10:50:00.000-08:00

I think my brain just turned off. This term is all about perservering and effeciency and not burning out. But when you can only concentrate for 20 minutes and then need 2 hours to recover - well, welcome to term 4.

I have a great big list of things I'd rather be doing, including blogging, listening to music, finding new music, reading more Lovecraft, playing with my Google Reader, watching movies (anything), playing nintendo8.com, working on various personal projects(enviro-med school review), making some of my ideas at Global Pulse become a reality (re: map of archives), write a grant proposal to fund some of these ideas, beg the Dean for funding for another project that is somehow going to come together in 2 weeks while I'm "studying" (re: waiting for term to end). Oh, Term 4.

And there is a lot to write about what transpired over the past few months, but for some reason every time I sat down to do it I would end up passing out and then waking up with my computer asleep and the light on. But, I will update! I need to look back on this when I'm really busy and laugh...I think.

The Dengue

2010-09-28T19:36:00.000-07:00

Dengue has struck Grenada in full force. The week before the Microbiology midterm, Prof. L, who was lecturing on Dengue, got the Dengue. Some classmates got it. Then this week, my lab partner gets it. Dear God, what is going on here!!

Luckily, we have the milder form so there has not been any fatalities (that I'm aware of) and everyone seems to be recovering... fingers crossed. That is not the case for other areas, especially in Asia, where it can be fatal.

If you have the time, send a report of your local Dengue cases to HealthMap and check it out to see the burden of the disease across the tropics.

In school news, I survived midterms and found them difficult but doable. Afterwards I went to the wonderful CUGH (more on this later) conference in Seattle and spent a few days at home in Boston. Looking at people in the field of Global Health and Environmental health in action, presenting on their various projects was certainly motivating and really reminded me why I'm here. The perspective helped clear my head and made me realize hey - there are only 9 weeks or so left of this semester and this time next year I'll be in clinical rotations! It's amazing how one can lose sight of that in this endless August heat.

You wouldn't like me when I'm Angry

2010-09-07T06:48:00.000-07:00

4 weeks into term 4. This semester is going fast... and you really have to spend every minute just to keep up. My little sleep/workout experiment continues - I managed to consistently get up a few minutes before 6 - though exhaustion has keep me in bed until about 6:15am these days...

One thing I've noticed is the work schedule has really shortened everyone's tempers... or at least mine and my friend Ph. I feel like David Banner - especially yesterday as a variety of small nothingness made me furious - from not being allowed off the bus at the security spot, to searching for the mysterious (and non-existent) poster printer and then being late for lab for the first time only to walk in on a pop quiz (luckily did not count for credit). I still managed to pwn the quiz though. I nearly lost it on the Lab Director when he said I should just hand in a hand-drawn version of my concept maps - after I've been using (with great enjoyment) the software they posted on the website! After explaining my issues with printing on campus, Dr. W says: "why don't you just hand draw it?" and that nearly made me turn green and tear my shirt off. I started to say "First of all...you $!%* ^*#@" but realized who I was talking to and managed to switch it up to "First of all, (catch breathe) this has been a great learning tool! And secondly you recommended it" so we managed to patch things up and I can submit electronically.

Today I am in a much better mood and I think it is because I got up at my normal time and worked out. Yesterday, I had no workout and got up kinda late (6:45 - about an hour behind schedule) so the day started off on the wrong foot. But really, the daily exercise has kept me balanced and focused -- I really think it's kept the stress level down this term... of course, we'll see how it pays off on the exams!

Otherwise, term 4 is a massive amount of very interesting and actually real medicine work. I am putting together a lot of things in my head from past experiences and thinking about future research...I love it :D

Term 3: A tale of two terms

2010-08-10T04:13:00.000-07:00

I arrived in Grenada with something less than rampant enthusiasm for class. Starting a term at the end of June just felt too much like summer school - even though it is summer weather here all the time. My concentration wasn't where it needed to be and I slept late, played on facebook, and generally didn't get a lot done (adjustment disorder?).

Given this, I got the grade I deserved on the midterm... :/

Then another deadline crept up on me: my Review paper was due August 1 (more details about this later). For a long time I've wanted to switch to a morning schedule, but have always stayed up until around 12-1 and woken up 8-9, despite knowing my best studying is in the morning.

So I decided to use this to get it done - I started waking up progressively earlier over the course of the week. Putting the alarm clock in the other room helped and leaving the shades open helped with this. Once awake and after exercising, I would then go to campus to write the paper in free AC. This was a tough adjustment at first and I had to force myself to bed initially. For those considering such a switch you have to really plug through the first two weeks and do it gradually.

But by the end of week 1 I was waking around 6:30-7:30 (compared to 9am before). After another two weeks of this I am on a 6am schedule (as evidenced by writing a blogpost at 7:15am). Wake up, workout, make breakfast, pack my lunch and hit the books usually by 7:30 (when not blogging).

Another impetus was that the Term 4 Pathology class lectures will not be recorded online (audio only, no slides) - so going to class is now quasi-mandatory. Combined with the rampant rumors that Path is insanely difficult, that certainly helped.

My second exam was my highest score at SGU. Maybe the material was more interesting or I took it more seriously to avert a GPA disaster... regardless, I study more and feel better from waking up early and exercising. I hope I can keep this going for Term 4 and keep my brain and body tuned through Step 1.

Anyone else have stories of exercise/sleep schedules helping them in med school?

Swing on the Spiral

2010-07-30T17:31:00.000-07:00

Looking forward, while looking back and spinning while standing in place.

Term 2 - Genetics, Parasitology, Community & Preventative Medicine, Neuroscience, Immunology, and Physiology.

Yet, when I think back, I just remember the bright sun. I think this was the first term I really understood it's power down in the Tropics. Living on campus gives one a false sense of the island in many senses. The AC is on everywhere, all the time and since the buildings are relatively clustered, you really don't have to go outside for a long time to traverse around. Even going to IGA (the "supermarket") and the beach was rather restricted in Term 1 (my roommate had a car, so we'd wait until HE wanted to go) and I'd go in the evenings.

But living off campus showed me this other world of Grenada. I talked to more people from the Island, learned about the weather patterns and previous droughts (it was a bad one this time), found a market that has locally produced foods and snacks (local plantain chips!!), and generally started to get a sense of the people here. They are friendly, they like to have fun, and I think, if I were back home, I could pick someone from Grenada out after talking to them for a bit, just certain mannerisms and ways they speak.

You don't get that on campus though - it's essentially a giant resort. No pool though, and you can't go to the beach on campus(2 stars). And the Grenadians play two roles: Security & Maids - which gives a distorted lens of this island as dangerous and poor. Both of which belay the diversity on the island. I know because I felt that way living on campus!

One thing that now rings quite true was when my advisor, Dr. B, said during Anatomy lecture that he walked home after dark almost all the time, and never had a problem or felt unsafe.

Oh yeah, medical school. I wish I used a quantified self tracking tool to chart my feelings towards each course over time. Initially, I thought Neuro was awesome, but then at some point it got annoying, and then fluctuated back to alright with potential for interesting subsets. I was excited about Immunology, and, as previous posts indicate, grew frustrated with how it was taught but still liked the material. Physiology was always alright at first, but then it grew on me. And Dr. H was excellent - one of the best teachers here - even if he does watch Fox & Friends every morning. I've done diabetes research in the past so that was a known interest, but I was surprised to find myself really enjoying the Endocrinology section. Parasitology gave a great global perspective and showed how debilitating certain, entirely preventable, diseases could be. Genetics went by in a flash, I just remember many of the diseases were quite rare (as opposed to parasitology - interesting what society focuses on). Community & Preventative Medicine was not taken seriously by anyone, unfortunately, though I enjoyed it - but felt that the principles of the course needed better integration with the bulk of the material we learn in medical school.

Now Term 3 is coming to a close this week and the much rumored about Term 4 is making its presence known through emails and syllabus/handouts. Term 3 is a funky combination of what I'd say is Public Health with a good chunk of Psychiatry. We learned about Malpractice, the recent health care reform, epidemiology, ethics and evidence based medicine. These things are fresher in my head and deserve their own post - so they'll get one.

While Term 3 has progressed, I've also been writing a Review paper on Electronic Health Records and Health Social Networking. This supposed to be the last part of my Research Fellowship and now I'm struggling with whether to continue with a great boss and interesting research(I'm pretty sure he wants me to stay), or find somewhere else to learn new things. I want to learn about Health Impact Assessments and maybe also about mobile health tracking devices.... nevermind all the other potential opportunities out there I haven't checked out... I don't anticipate much time to do much of these activities this semester, but I am looking at a winter break that is, at this point, open. On top of that, my current position helps me pay my rent ... not something guaranteed with other opportunities...and I've published 1 paper so far, with a second one nearly complete...so will have to do some reflecting on this... any advice appreciated!

That is Medical School Year 1 (MS1) and I'm spinning in place in Term 3 , looking at MS2 and beyond. Sometimes I get sick of being so far away, on a hot little island. But then I saw a former work colleague's IM picture of the old Map Plotter (printer) spewing paper. That made me appreciate my decision to come to Medical School on the Spice Isle.

Facebook Debates: Conservatives on Healthcare

2010-07-14T19:43:00.000-07:00

An acquaintance of mine from undergrad happens to be a Republican rep. in the NH State House. We shared a good discussion on the environment and animal rights (he's an animal loving environmentalist republican!) and have kept in touch via Facebook. He likes to foster debates on topics on his page and while most of his friends are conservative, there is some variety and occasionally a few insightful words are written. Recently, a discussion started up on healthcare that I spent some time participating in and wanted to present it here. It started when ND said that her her replacement hearing aids weren't covered by her insurance. Without further ado:

ND: Tell him to make it a national law that all hearing aids are covered by insurance for all ages in every state.

BL: Judges do not make law, only legislators can do that, however there are judges that seem to forget that thier job is to decide if legislation is constitutional and if the cases before them meet those standards...

ND: Okay! Thanks for letting me know :) I'm leaving my expertise in the science fields to build up on my political knowledge! It costs $6000 for a really good pair of hearing aids. I have had them since I was 3 and have excelled with them. But my 2nd pair (and current) are starting to dwindle. I can't afford a new pair. Technically, you are supposed to receive a new pair every 3 years. I have only had two pairs. I should be on my 6th pair. Insurance companies say they are cosmetic. How is that fair? This is why I'm fighting. They cover eyeglasses, so they should cover hearing aids. I'm pretty sure it violates the Americans with Disabilities Act by not providing coverage for hearing aids.

Me: ‎@Nicole - has your physician helped in any way with this? Have you tried your local Lions Club or Sertoma Clubs, they can sometimes help.

ND: Nope! Lions club = sub-par hearing aids for the elderly that were recycled. I need higher power and better quality because I'm losing hearing as I'm getting older. And I'm still in college, with hopes to go to medical school. But yes, I tried all of my options. Now I'm taking this to a state level because everyone who has hearing loss goes through this problem. Insurance companies think HAs are cosmetic and not really important. Why do people get insurance for eyecare? That's not fair. I don't want Grandpa's hearing aids. I want my own specially fitted to my needs and power level. I can't become a Pediatric Oncologist with mediocre hearing aids. If someone is covered for eyecare, I should be covered for hearing care.

ND: Oh and insurance covers VIAGRA?! But not hearing aids... Totally messed up.

Me: That sucks, as a medical student I am continuously shocked by the behavior of insurance companies and how their actions pervert the motivations of health professionals. The government is not blameless here either, but health care does not operate as a "free market", no matter how many may wish it to - it's a societal responsibility to take care of each other!!
On the bright side, your plight should provide excellent material for medical school essays and interviews ;)
Rep. Bettencourt - are you listening?

TB: ‎"Tell him to make it a national law that all hearing aids are covered by insurance for all ages in every state." = Everything that is wrong with this country.

Skip: You are right, John - it is not a free market - it is HIGHLY distorted by Govt spending AND regulation - both based on politics rather than proper supply / demand signaling.

Sure, we should take care of others - so John, how much are you willing to pull out of your personal pocket, or how much time are you willing to devote to PRIVATELY solve Nicole's problem? Or, like many, are you simply willing to be lazy and outsource YOUR responsibility (after all, you ARE part of society, right?) to politicians and bureacrats? Why is your FIRST response - hey, let Govt solve the problem?

Sorry, dude - THAT's the base problem that GOT us into this problem - expecting that Govt can solve all ills by taking more of what others have earned simply to give to others. Man up, dude

On the other hand, Nicole, if your contract with the insurance company IS what you say, then Govt SHOULD step in (via the courts) and enforce what has legally been agreed to. what does your contract actually say (vs what a bureacrat within the insurance company is telling you)?

Me: I think a little history lesson is in order here. Blue Cross/Blue Shield started as physicians and hospitals realized that their services, due to technological and medical advances, were becoming too expensive for people to pay for out of pocket. So Hospitals contracted with teachers (Blue Cross) and had them pay $6/yr for 21 days of hospital care if needed. By having everyone pay an affordable fee, they avoided a situation where anyone had to pay an unaffordable bill. Blue Shield developed from employers contracting with groups of physicians to provide care for their employees in a similar manner.
As these plans expanded throughout the country and involved more people, a type of rating called "community rating" was used - that is everyone paid the same amount regardless of their utilization. The young businessmen paid $300/yr (even though they use less) and the older coal miner also paid $300/yr. The elderly retired person paid $300/yr as well even though they used more than that... By charging everyone the same the Blue Cross/Shield were able to afford to cover their expenses. Yes the biz guy paid more than he used but by doing so he allowed the elderly to be cared for.

The relevant part of this for our convo is that after WW2, when these plans expanded greatly, the private insurance market (professional insurers, not physicians/hospitals) got involved. Now the private insurance guys see that the businessmen only use a small amount, so they decide to offer them a plan for far less - say $100/yr. At the same time, the private insurance didn't bother with the elderly or the coal miner - they cost too much cause they actually need health services!! Now Blue Cross is stuck with the elderly etc., being more expensive users and having lost their cheaper users, they have to charge more - suddenly the elderly cannot afford health insurance and neither can those at the lower end of the economic ladder.

Hence, the 1960's we have this situation and the govt steps in to provide Medicare and Medicaid to plug the wholes in the "free market" system. This creates distortions, of course, which are then attempted to be fixed by various means, but largely ignored.

So yes, the govt did create distortions, but it was going in to correct distortions that were already present in the system. It seems to me the notion of insurance needs to be reformed - the incentives of insurers need to be fixed to provide the baseline of care for everyone at an affordable price. And the incentives for physicians and hospitals needs to be realigned to providing the best care as well as the best outcomes on a population scale - not the most care to get the most reimbursements as is currently the practice (I need to read more how the recent healthcare reform attempts to fix this - been busy with medical school - but from what I understand it doesn't do much in this regard).

You pay out of your pocket through insurance to cover those in your insurance plan that cannot afford to pay out of pocket for the entire cost of their hearing aid or the entire cost of their Chemotherapy (which can be millions of dollars). Getting donations through your social network could never make up the money needed in catastrophes for the vast majority of people - that is why we have insurance. As a medical student, I donate my time to helping others (since I live off student loans, that is the best I can do currently). Taxes do a similar thing - a community that is facing a flooding disaster could in no way afford to rebuild without assistance from wider society (taxpayers in the state/nation). We enter into the social contract of insurance or taxes in order to provide each other with the means to live healthy lives and be cared for when we need it.

Medical care is not a consumer purchase - you can choose to forgo TV or buying new furniture - with medical care, your choices are sometimes life or death, but more often you are forced into substandard living (as is the case with Nicole and her hearing aid). If someone could explain to me how medical care fits the dynamic of a free market (even if it is to reference me to texts) I am listening.

Me: no responses?? Guess you free market types prefer to outsource your arguments to Rush...

BL: Nicole, just so you know, the NH state legislature has passed a bill that requires private insurance companies to cover hearing aids. But, it does not cover those who are on medicare or medicade. I guess it is ok to require private companies to cover but not the government. If anyone wants to understand why insurance is so expensive it is the government mandating coverage for non emergency or life threatning issues.

Double standard. BTW I wear two hearing aids and have had hearing loss since I was 5. So I understand the issue.

Skip: ‎@John - your example of BC leaves out 1 thing - the voluntary nature of joining at its inception. And remember, because of wage controls instituted by Govt, "bennies" were the only way that companies could attract better workers than their compeition - thus GOVT started this snowball-from-hell down the slippery slope - and NOT the free market. It then got codified into tax law as a right off for companies but not for individuals - skewing the marketplace more and more and really making insurance prohibitively expensive over time. Add to that the politican penchant for adding mandate after mandate after mandate simply because a few people decided they wanted THEIR costs spread over eveyone else. WHY should I have to pay for someone else's treatment for alcohol addiction when I myself am a teetotaler? I have now lost the liberty to choose a plan that suits me and my family - politicians have decided they know better than I what I need or want.

Medicaid was not instituted simply to "plug holes" - review Progressive history stemming from the 1880s Frankfurt school that basically states, in a 180 from our Founders, that Govt SHOULD be in charge of the details of our lives and not we ourselves. Socialized medicine (which Medicaid and Medicare are components thereof) is simply an offshoot of that, and Statists that believe that the State is the premier entity in American life (vs the Individual primacy of the Framers of the Declaration & Constitution) are basically turning the philosophical underpinnings of our society upside down and inside out.
I disagree with your basic premise - healthcare is neither a right nor should it be an entitlement - it is a service for which one should be able to contract freely between providers and consumers. Govt, however, has made this almost impossible with "rent seekers" doing their harm as well.
And as far as "donations through your social network could never make up the money", before Govt became so bit that it crowded out private charity (see Brook's research on the inverse relationship of expanding govt & private help) - that DID happen and happened well (see de Tocqueville, commenting on how people DID take seriously their responsibilities through VOLUNTARY charity (vs what is now FORCED charity via taxes).

Me: ‎@Skip - While it is true the tax environment for benefits helped inflate health costs (something I believe the recently passed HCR bill attempted to address, not sure how that worked out), it was one of many factors - you cannot ignore that as medicine advanced and life expectancy rose the cost of care became greater and is continuing to do so, with the greatest financial burden in the last years of a patients life - again, when they are least able to afford the care (hence, Medicare).

At the heart of your argument is that the rights and freedom of individuals becomes trampled by societal (in this case government at any level) intervention into health care. I would argue that the Founders ideals, as enshrined in the Deceleration of Independence, that everyone has an inalienable right to Life, Liberty and the Pursuit of Happiness has as a pre-requisite in modern industrial society: the right to health care. The burden of poor health destroys liberty, crushes hopes of happiness and, in emergency situations, denies your right to live.

You must remember there was a difference in times between what our society is today and what it was in the time of the Founders and even Tocqueville. Jefferson even said he would rather trust to nature than his physician when he was sick - and for good reason, there wasn't much anything modern about medicine in the 18th century or most of the 19th for that matter (at least the part Tocqueville lived to see) - this was before antibiotics, before vaccines(which provide life-saving benefits to all, when all decide to take them), before modern surgery, anesthetics, before MRI, CT or even XRays! Before the germ theory of disease was accepted - Physicians believed the "four humors" were the foundation of medicine well into the 1800s!!

In todays world medicine gives people the freedom to live productive lives contributing to society. In fact, The Economist recently ran an article describing how a nations intelligence, and thus their economic development, is held back by parasites and pathogens ( http://www.economist.com/node/16479286 ). By not giving everyone the right to accessible, quality health care, we are denying them the ability to live their lives to the fullest - these costs end up coming back to the public through violence, crime, dependency and lack of productivity among other costs. And a part of that right is affordability, not forcing choices between medicine, rent and food.

In terms of charitable giving being inversely related to government tax burden, I would invite you to review the literature (and link me to Brook's research as I could not find his/her specific work) as from what I found through Google Scholar, charitable giving may or may not be elastic regarding taxes - there are many more factors that come into play such as cultural norms, religion, societal structure and stratification, how much people control the means of their sustenance and various other influences. The economics literature, as I see it, is not in the agreement you present. And while Tocqueville certainly had some interesting things to say in his "Memoir on Pauperism" regarding dependent classes of society, his arguments are not based on any empirical observation and are clouded by selection bias as well as his own upbringing as a member of the aristocracy (hence his tendency to think of a benevolent link through charitable giving to the poor and scorn the assistance of the poor through taxation).

Regardless of any relationship, and there may be one, it is irrelevant - the cost of health care is unpredictable and can easily overwhelm any individual and their social support systems ability to cope. This is one reason why we have so many people going bankrupt from medical expenses - there is a general lack of understanding of the intrinsic nature of healthcare in todays world needs to be financed by large groups in order for any one individual to afford access to proper care. The free market system cannot operate in healthcare in a proper manner for this and many other reasons (think about the asymmetry of information between physician and patient!). Also, in a "service" one assumes there is a choice of whether or not to even have the service in the first place - that is fundamentally NOT the case with healthcare ( unless you consider death a choice). Government, as the instrument of the People, has a role to play in this. What role exactly is up for debate, but by shirking our social responsibilities to one another we hold back the potential for all of us to live freer and more productive lives.

DMK: I have been a tool-fool since my first Erector set in 1946. As a retired contractor and Master Electrician, I have many, many tools that allow me to do work that is otherwise impossible, extremely taxing or can only be done in slipshod fashion without a special tool.

Government, too, is a tool of sorts. One that was compacted to provide protection from enemies foreign and domestic ~ to protect us from others who ignore our social contact and resort to violence, deception and fraud. Not from ourselves.

It is a tool of blunt force trauma, itself, and is the only agency we allow to initiate the threat or reality of force to achieve compliance. It has more the nature of a sledge hammer, chainsaw or front-end loader than a scalpel. Only disease itself has killed more people than government in command (and not always on purpose either).

The issue is not that health care is a great and wonderful boon, nor that it becomes more & more expensive as failing bodies require more. No one disputes that sudden but unexpected illness or accident can result in the need for very expensive medical intervention that can bankrupt personal or family finances.

The real question is what tools and postures do we employ to deliver this boon to the individual. It is one of cost, to be sure, but individual choice has a huge role to play as well. One size does NOT fit all. But equal rights under the law requires just that! Not to mention the daemon of lowest common denominators, the "Problem of the Commons" and, of course, the inefficiencies of bureaucracies immune to effective feedback. The sad truth is, health care is not a task for a tool that specializes in coercion. Ask any disabled vet about the VA.
(A personal disclaimer here. I am a vet who has used the VA and have a great respect for the wonderful Nurses and Doctors who helped me. The VA made considerable progress under George Bush, but still had to accomplish its mission with a budget that failed to provide all the needed resources that were routinely available in local hospitals.)

In short, Skip is correct. Free enterprise is the way to go if you are results oriented. History, both here and abroad, makes this plain.

Me: I lean towards evidence based medicine, that is, I like to see peer-reviewed documentation that a procedure or therapy works. Even in allopathic medicine, many things we do are based on past experience of "it works, do it that way" rather than actual hard-evidence of efficacy. For instance we learned about Tube Feeding for dementia patients this morning. Surprisingly, it shows no evidence of prolonging life, decreasing infections or increasing comfort. Evidence shows it may increase discomfort and result in use of restraints. My point is that what we expect from Reasoning about a subject (tube feeding prolongs life) may not be what actually happens in the real world.

Yes, government is a blunt tool of coercion at one level - but in a democracy that tool is - when designed properly - held accountable and can be tweaked as circumstances dictate. In a decentralized state/local oriented system decisions can be adjusted to local circumstances more easily. There must be a balance though of fundamental rights guaranteed to all vs. decisions devolved to the lowest level. With private insurance, our current model, it is difficult to ensure accountability for necessary coverage except through the use of government regulations. But please feel free to present evidence to the contrary.

But the conversation seems to be going into one of cultural philosophy and further away from Outcomes - what works the best to deliver the best care, afforably for all. At my core, I'm a scientist but as a physician in training know that not everything that works is proven, but I'll ask anyway: Can anyone present evidence or examples (peer-reviewed preferable) of free market delivery of accessible, affordable, quality healthcare in a modern day setting?

Me: by the way, this is a fun and enlightening discussion - glad to see it stay civil.

Not Dead Yet

2010-07-11T23:24:00.000-07:00

It has somehow been 2 months (!) since my last post, but I will be picking this up again soon... Term 2 concluded successfully and Term 3 is well under way. Had a busy, productive and fun break too... and plans to think about for the year ahead... more shortly after (or before) midterm on Friday.

The Neuro of Music

2010-05-10T08:08:00.000-07:00

Great post over at the Nature Blog network on the neuroscience of music and pleasure:

"Why do we enjoy music? Well, simply put, research shows that music elicits a number of physiological changes including increased release of dopamine from neurons originating in the ventral tegmental area, a mid-brain structure associated with the emotional reward [1]. This reward for music that we enjoy evokes an autonomic response subjectively referred to as "shivers down the spine." [2]. This is a robust and highly reproducible phenomenon."

I will have to catch up on those papers, but it is really interesting that the "shivers down the spine" you get from really good music is a real, physiological phenomenom. Makes sense. And if you've never felt it, you need to get some better music! Also note the parahippocampus is NOT correlated with pleasure, which makes sense considering it's proximity to the amygdala (fear response center). It also makes me wonder how people with Parkinson's experience music later in the course of their disease considering the lack of dopamine...

I would take issue with the implicit assumption that only "pop music" can produce such a response - although he does put the caveat of "consonant"(will have to read this more in-depth after finals!). I think it is much more tied to the emotional context of the music, state of mind of the listener and familiarity with the music being played. I can get the shivers from anything from Yo-Yo Ma to Tool and a lot in between. Most of the time it is based on my understanding of the music and/or lyrics, but the prerequisite, for me, seems to be quality musicianship.

For those floating around in the blogosphere... what music has given you the shivers?

Physio Testes

2010-05-04T09:24:00.000-07:00

Or how Dr. H made physiology fun through corny jokes:

"We know that increased heat decreases the viabilty and production of sperm. Studies have shown that men sitting crosslegged with their laptop (on laps) the testicle closer to the laptop (hotter) produces less. Another quick way mentioned is to see if the male wears tightie whities. If so, tell him to change to boxers.... now, if you don't believe me consider this: ever seen batman? does batman have children? I rest my case."

Ingrown Toenails and Funny Bones

2010-04-30T17:59:00.000-07:00

Distractable has a great post on the relevance of Physics to clinical practice - it's on old post but a good one and it came back to mind cause a friend got an ingrown toenail. Dr. Rob (distractable) discusses the physics of ingrown toenails and also gives us the following clinical rules (yes, this is on the USMLE):

This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

People step on them – scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
Heavy objects are kicked – careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

I would like to add to this the Ulnar Rule, which is observed by anyone who has taken Anatomy. Once you learn that the Ulnar nerve (or mulnar as some like to call it) is in fact your "funny bone" you are doomed to a life of hitting it at least once a week. What was once an annual event is now a regular part of your life. Thank you Gross Anatomy.

That's all for now - time to get back to Renal.