Wednesday, December 9, 2009

Sympathy for the factitious patient

I went to the student health center last week for my annual exam. I showed up a few minutes late, and so rushed to fill out the paperwork while in the waiting room, expecting to be frowned at and told I should have arrived on time.

Instead, I was met with smiling faces, as the nurse ushered me in to an examining room, allowing me to drop my bag and jacket, before guiding me to a seat in the hall from where to take my blood pressure and temperature.

"Well, isn't that nice," I thought. "Like having a personal aide who tells you where to be and administers personalized services." Right then, I understood -- well, to some extent -- Munchausen Syndrome patients.

Patients with this disorder manufacture symptoms in themselves, usually through ingestion of toxic substances or inappropriate medications, in order to receive attention from healthcare professionals. While I don't really think I'd ever be capable of that -- Munchausen patients generally have personality disorders or history of abuse, so there's more going on than just a desire for some attention.

But in a very impersonal world, in which you can get through a day, or maybe a week, or maybe more, without any real meaningful human contact, especially if you're perhaps a little introverted or perhaps have a small-feeling job in a cubicle, this kind of attention feels really nice. It's attention not to how much work your team has produced or when you have entered and exited the building, but to you and your well-being. For a few moments, the efforts and thoughts of several professionals are focused just on you, and nowhere else. I don't have a small-feeling cubicle job, and am a student in what is maybe the most attention-intensive medical program in the country. But I can most definitely understand the desire to prolong those moments in the clinic.

Tuesday, November 17, 2009

It comes from all sides

Me: "Do you have any advice for me as a medical student?"

Patient: "Study incessantly."

Wednesday, November 11, 2009

Jumping off the hedonistic treadmill


I really like this entry from Slate's Happiness Project. In it, the author talks about how, after getting a case of conjunctivitis, she had to stop wearing contact lenses. And it was only through this experience that she realized how happy she was to have the convenience of contact lenses -- which, without this deprivation, she took for granted and even sometimes complained about, given how much of a pain it was to put them in and take them out.

The problem is that becoming accustomed to all of our conveniences and privileges creates a "hedonistic treadmill", in which we continue on at a steady pace without appreciating what we have.

Having a fluctuating hearing loss is often frustrating, bothersome, and difficult, but there's this thing: when it bounces back up from its low dips, I get insanely happy. Having five senses that work! Being able to meet new and interesting people! The world is my oyster. Somehow, having this hearing loss has allowed me to jump off the hedonistic treadmill.

Tuesday, October 27, 2009

Only in Berkeley event of the day

I participated in a 12-minute die-in for health care reform today on Sproul Plaza. We had to move a little down the path because of a huge display of bloody fetuses by an anti-abortion group, and the counter-protest by a pro-choice group. As I left, a student was stepping up to a microphone and welcoming everyone to a celebration of Filipino Awareness Month.

Just another Tuesday in Berkeley.

Sunday, October 25, 2009

Narratives

I heard a talk from Rachel Remen last week, whom I found extremely charming and inspiring, even though the talk was projected from a DVD. Apparently some people's charisma comes through even in virutal presence. Anyway, she offered the following anecdote:

Three stonecutters are sitting at their work stations cutting stone. The first is asked, "what are you doing here?" He answers, "I just sit and do the same thing every day, putting the stone through the cutter. It's terribly boring and mindless and I can hardly stay awake."

The second stonecutter is asked the same question and answers, "I am making money to support my family. Because of me my children are growing up healthy and learning about the world, and my whole family is happy."

The third stonecutter is asked, and responds like this: "I am helping to build a cathedral -- the most beautiful, most monumental building and a wonderful accomplishment of human cooperation and ingenuity."

The story tells us about the importance of the narrative. Each stonecutter is doing the exact same thing, but each bestows his own meaning to it. This is, of course, a lesson we can personally all take home as we try to bestow meaning to our own lives.

It's also relevant to my learning as a physician. A patient has his or her own narrative that will always affect the clinical encounter and the outcome of the case. In psychiatry, which I am just beginning to learn about and which for some reason makes me often think of the Jennifer Lopez movie The Cell, how the patient constructs his narrative is everything.

I asked my teacher, "But the idea of 'early life stresses'... doesn't it get blown out of proportion, and lead to blaming everything on the parents?"

But, and as her answer hinted, I don't think this is the right way to think of things. A medical model would tell you, well, stress here (and maybe a genetic predisposition) leads somewhere along the line to illness. But in psychiatry, we're not diagnosing that way. We're listening to what's going on in the patient's inner world, trying to understand how she conceives of her health, thoughts, and relationships to other people and things. It's not so much about what "really happened" but about how the patient has experienced those things.

The approach becomes not, "what is the stonecutter actually doing?" but rather, "How does the stonecutter construct his narrative about what he's doing?"

Sunday, September 13, 2009

Counting Down the Hours

These are lyrics from a band that I'm a little obsessed with. On bad days, this is what I feel like about my hearing.

And I go on
Wondering if I've got a soul and
Counting down the hours 'til it goes

-- Ted Leo and the Pharmacists, "Counting Down the Hours"

Wednesday, September 9, 2009

Insight and humanity

There's a concept in psychiatry that most of us don't consider often. Insight, defined in my intro to clinical psychiatry book as, "the patient's awareness of his or her mental illness and the ability to connect this disturbance to other problems", is not really the most important important aspect of a patient's mental state from a diagnostic perspective.

But what strikes me is that insight is perhaps the most important factor in determining our emotional reaction to the patient. Consider an older patient with dementia, for example. He is losing his mind, forgetting who his children are, giving them gruff and slightly wary welcomes when they come to visit. Maybe we roll our eyes, shake our heads a little as we repeat what we've been telling him for weeks, that his visitors are his family, and he should be nice and sit and talk with them for awhile.

Now consider the same patient, who, in a moment of insight, realizes that his mind is slipping away past his reach. A lifetime of professional accomplishments and personal connections is blurring into an oblivion that he recognizes as the path towards the end. Our patient has now gone from a sweet old nuisance to a tragedy.

Why? What is it about this one feature that evokes such a an empathetic response? I think it's because insight gets at what makes us human. Ants will never have the insight into their situation aside from an instinct to run when they see large objects moving quickly near them. Insight implies a broader realization, a conceptual understanding of illness and one's relationship to it.

Ancient playwrights knew that insight is the stuff tragedy is made of: the entire, horrible events that lead to Oedipus's putting his eyes out happen before the play starts. Things only turn tragic when Oedipus realizes what has occurred -- when he gains insight.

Although embedded within the endless descriptive terminology that psychiatry uses, insight describes more than a symptom of an illness. It describes an expression of humanity.

Saturday, August 29, 2009

O.I.B.

I have an ongoing mental list of "only in Berkeley" occurrences, that I'm now going to start as an electronic list.

1. At the live broadcast of new president Obama's inauguration speech on the Berkeley campus, the mention of "nonbelievers" gets the biggest cheer of the day. OIB.

2. On an afternoon jog up in the Berkeley hills, on a quiet residential street, I run into a group of Code Pink protesters, apparently camped out in front of the house of a Berkeley professor who has been implicated in some sort of Evil. OIB.

3. The squirrel that has come into the Free Speech Cafe on campus wanders around freely for several minutes, gaining only some raised eyebrows and shrugs, even from the cafe staff. I finally chase it out, because I realize no one else will. OIB.

More to come, I'm sure; never a dull day in the Republic of Berkeley.

Tuesday, June 16, 2009

HIV in the porn industry: time for regulation

I know, it seems like a strange cause to take up.

But the fact is, being a porn actor puts one at huge risk for STIs including HIV. I wish I had a good and shocking comparison, along the lines of, "being an average porn star for one year is equivalent to riding a motorcycle on a crowded indie speedway without a helmet for a month without stopping", but I don't have any statistics. (And someone should really look into calculating that risk!)

You get the idea, though; being in pornography with the very limited regulation currently in effect is running a huge health risk, and no one should be required to do that to keep his or her job. The recent revelation that a porn actress had tested positive for HIV and possibly infected a costar and her boyfriend prompted the apparently hushed-up fact that several others in the industry have become infected with HIV in the last 5 years. Thousands have tested positive for Gonorrhea and Chlamydia.

The heterosexual porn industry has rejected suggestions that regulation include mandatory condom use, and actors who demand condom use are often not asked back for further work. (Meanwhile, because HIV is so prevalent in the gay community, gay porn studios generally require condom use.) The current regulation around safety in the industry is that actors must arrive on set with the results of an HIV PCR test. However, HIV testing is not flawless, as a cluster of cases in the porn industry in 2004 showed; further, requiring that actors pay for testing on their own, and dismissing anyone who is HIV-positive, is illegal.

As this article (which you can download for free! I love Plos Medicine!) argues, regulation of the porn industry must involve condoms, which will lower risk of STIs and HIV significantly -- and carry the added bonus of normalizing condom use for viewers. The industry apparently thinks that people will stop watching porn if actors are wearing condoms, something that hasn't played out in the gay porn industry. State regulators need to show some backbone and stand up to the industry in order to protect porn actors and their partners.

(On a side note: is this blog getting too soapboxy? I figured that if there was anyone reading this blog, a good use of it might be to write persuasive arguments about issues arising in medicine and public health... but if no one reads it because it's too preachy, it defeats itself.)

Thursday, June 11, 2009

F*@# the AMA

This is making me so angry I can hardly even think. The American Medical Association has a stated mission "to promote the art and science of medicine and the betterment of public health." How an organization with this mission, composed of supposedly human beings who have taken the Hippocratic Oath (or the Lasagna Oath, which we know I love!) to "do no harm" can oppose a system that would improve health coverage to Americans is beyond me.

They say that having a public insurance provider would "restrict patient choice" by driving out private insurers, a logic I'm not even sure I understand. But let's look at the "patient choice" available right now: how many people, even those lucky few with good private coverage, can say they have the choice they'd like in providers? And as this blogger points out, the private insurers enjoy such hegemony over the industry right now that they can raise premiums as they wish, padding the pockets of their wealthy CEOs, thus often driving individuals and businesses into bankruptcy. (Health care costs are the main cost of individual bankruptcy filings in the U.S.) In a free market system, which the AMA seems to tout as king, supply and demand are in communication -- they aren't mediated by HMOs with price-setting behind closed doors in a mysterious, non-transparent process probably influenced by big Pharma and big Insurance.

I guess the AMA's stance shouldn't surprise anyone, because it seems that it has a long history of opposing plans that help people, including Medicare. I honestly don't think the AMA is an evil cabal of specialists trying to make sure they can easily afford next year's timeshare in the Hamptons, although there's probably some of that too. I think most of it is a subconsious reaction that many Americans have that equates "government-controlled" with "inefficient". What Americans must realize is that health is not a commodity like any other, and that American health and productivity do not benefit when health insurance companies make money. Sure, government can be inefficient; it would be the responsibility of the overseeing agencies to make sure that it is run well and makes use of all the current technologies and strategies for maximizing service output. But the current system of armies of actuarial specialists setting premiums based on risk is far more inefficient. A public system has the potential to make Americans healthier than they've been for decades, at lower costs. Under the current, privatized system, there will always be people slipping through the cracks. Anyone who wants to get as angry as I am should just visit a community free clinic and chat for awhile with its clients.

Physicians for a National Health Program is an organization that advocates for single-payer healthcare -- care provided to all Americans by government agencies, with provision of care managed privately. This is the only way to give Americans real choice in their care, and real coverage for their health problems. Obama's plan doesn't go far enough, but it's a step in the right direction. The AMA's stance is 50 steps back.

Monday, May 18, 2009

Ah, the internet


I'm trying to write up some materials for the project I'm working on, which looks at the role of multiple, concurrent partnerships in the HIV epidemic in Mozambique. I probably should have known better than to Google Image "network concurrent sexual" to find a good illustration of network characteristics when partnerships are concurrent.

Along with some racier stuff (and some things about computer programming...?), I got the picture above, which made me laugh. It's actually from a PSI site, and PSI is one of our main partners on the project. So it really does have to do with what I'm studying. I guess I sympathize with wanting the page to be visually appealing, and yet not having a picture that represents what's being discussed.

But still... this is funny. Some PSI intern is now patting herself on the back for being able to sneak in there a picture of a guy grabbing his lady friend's tuchas.

Monday, May 4, 2009

Disconnected

According to my new ENT, there's a problem with my connexins. These proteins, pictured above, assemble in a pretty flower shape on cell membranes, interacting with connexins on neighboring cells to form gap junctions. Gap junctions turn out to be important to neurochemical signaling. So, specific types of mutations in the genes encoding connexins can lead to deafness and/or hearing loss.

I elected not to have any genetic testing done at this point, because it wouldn't change my treatment, but the doctor said that connexin mutations are the most frequent causes of slowly progressive sensorineural hearing loss -- and that these mutations, autosomal recessive alleles, occur at a higher prevalence among Ashkenazic Jews (who, it turns out, are also susceptible to fat metabolism disorders and GI disorders, probably among other things I haven't learned about yet. All those population bottle-necks, I guess?). So it's likely that this is what's wrong with me.

I guess it's nice to know that. It gives it some closure, and gives me a good idea what might be in store in the future. It's also a little weird, though, being someone with a "rare genetic condition", whom I should be seeing on an evening news story rather than, well, the person who is looking out through my eyes. It took me awhile to get used to being "the girl who wears hearing aids"; now I guess I'm also "the girl with the rare genetic disease." I got used to the hearing aids, though, so I'm sure I'll get used to this -- it'll just take some time.

Monday, March 2, 2009

Finding your Box

Today my STI seminar was led by a guest lecturer, a specialist on the health of transgender people. The information was really fascinating, highlighting the great diversity of sexual identity and expression of people. The session just came to life, though, with the funny, dynamic facilitation skills of our guest, himself a trans person.

In talking about finding one's sexual identity, he spoke about looking at intake forms in clinics, in which there were only two sexes/genders represented. "Where's my box?" He remembered thinking. He identifies as "genderqueer", one of more than a hundred labels that transgender people use.

There was something really familiar about this thought to me, although I've never has a struggle with sexual identity, or even racial identity. What resonated with me was the whole concept of identity search in a broad sense -- finding how you want to express yourself, how you want others to perceive you, with what groups you identify most closely with. Life is all about finding your box.

(For info on trans health, spend some time here: http://transhealth.ucsf.edu. You won't regret it.)

Wednesday, February 25, 2009

Snide comments from the Doc

Sweet young gyn patient being perscribed oral contraceptives: "Will I get fat?"
Darling older Ob-gyn: "You might get fat, but it won't be from the pills.
[Backpedaling...] I mean, er, that's not one of the side effects. These pills won't make you gain weight."

Tuesday, February 24, 2009

Lucky


Today was long: gym, then gyn preceptor, then finishing research and writing on pulmonary hypertension, then reading for my climate change class, then meeting with a classmate to plan out our in-class discussion to take place this Thursday.

But then, out the window, this scene. And later, dinner with friends. Life is full of obligations, deadlines, things to hand in; but when you can take in this much beauty at the end of the day, and appreciate good food with your friends, you're pretty damn lucky.

Wednesday, February 18, 2009

Baby Love

Lately many of my friends have been coming down with Baby Fever. It's just the age all of us are entering, I guess, and maybe the fact that some of our friends and siblings are starting to have their own babies. (A history of exposure to babies, it seems, is the greatest risk factor for the Fever.)

I've mostly been spared from the mindless desire for, as my program director would say, a germ bag. Not that I don't love spending time with my little niece, or appreciate her extreme cuteness or think that she's a genius. It's just that spending time with her doesn't make me want to run home and have my own (or wherever that would be done...).

So today I was a little taken aback when I was hit hard with Baby Love. The offending little one was a two-week-old preemie and maybe the smallest human being I've ever seen. He was so tiny as to be a little alien-like, hands trembling as he raised his skinny arms. But he was "fiesty" -- even his NICU nurses had called him that -- sucking vigorously from his bottle and later tilting his shoulders as if trying to roll over and crawl away.

His young parents were so excited and nervous that they couldn't stop talking; I'm pretty sure I don't want to ever be in a pediatrician's shoes. But their baby had such an earnestness, in an extremely tiny little form, that it made me want to take care of him.

I don't know if it'll develop into a full-blown bout of baby fever, but I'm pretty sure it was love.

You know your pediatric clinic is underfunded when...

... the sports stars in the posters on your walls are from two decades ago.

I walked in today past a Mugsy Bogues height chart. Then in an examining room saw Mark McGwire, Jose Canseco (yes, A's era), and Tim Hardaway. Which was great for me, because these guys are from the time when I paid attention to sports, but I'd guess a little confusing for today's pediatric patients.

Saturday, January 31, 2009

Coffee: is there anything it can't do?


I just caught the author of this book on a Science Friday podcast, and am dying to read it; it sounds like a paradise of intellectual nerd-dom. The book tells the story not only of Joseph Priestley's discovery of oxygen, but also of his role as enlightenment leader (which was controversial enough to get him expelled from England) and his relationships with the American founding fathers.

As a side note, the author offered this:

"It's not an accident that the age of reason accompanies the rise of caffeinated beverages." Apparently, before coffee came to Europe from Africa (it originated in Ethiopia!), the drink of choice for those who could afford it was alcohol. Once coffee became popular, there was no stopping enlightenment leaders, who, wired on caffeine, went on to lay down the foundations for modern science and government.

You can listen to the author here -- or just go to the coffee shop and fuel your own personal enlightenment.

Sunday, January 25, 2009

Inked by science


I really want to get a tattoo, so today I started doing web searches for ideas and tips on what might work well. (I do know what I want to get, but not yet sure where or what the design will look like.) I found this website of scientific tattoos, which is good for at least 3 hours of time wasting. They all fall somewhere on a range of super-dorky to... well, super dorky but also really awesome.
I particularly like the one above, a picture of the phylogenetic family tree of HIV. On the back of a researcher looking into the origins of the virus. It reminds me of my work with rotavirus phylogenies, and a particularly zealous phylogeneticist. There were a lot of days when I'd come in, check my email, and find that this guy had poured hundreds of virus strains into a similar family tree -- because he thought it would be interesting. When he started color-coding, I considered blowing up the tree pictures and wallpapering my room with rotavirus. I never considered painting my skin with them, though.

Wednesday, January 21, 2009

The Vanishing Point


I started reading my grandfather's published papers a few weeks ago, while on at my parents' house on vacation. I never met my grandfather, who died of cancer before I was born. All I knew of him was a portrait, a sparsely-lit photograph, that hung in the hallway of what was once his and my grandmother's apartment. He stood at an angle to the camera, holding a lit cigarette in a cigarette holder, hands gloved; he exuded a cosmopolitan, European elegance.

My grandparents had come to the US just after the Nazi Anschluss -- a close call. Both of my grandparents had been trained as psychiatrists, and my grandfather began practicing as a Freudian psychoanalyst at some point after his arrival in the States. I knew little of his work, but enough about Freudian thought to prepare myself for deep disagreements between my grandfather's ideas and my own. I figured I could place him within historical context and treat the experience as an intellectural curiosity.

I wasn't prepared for two things. One: that not only would the papers he authored about female sexuality (see, for example, this) be outdated and mysogynistic, but that they would carry such bizarre, visually graphic descriptions of female sexuality that I would have to stop reading for fear of never enjoying sex or romance again. It makes for an interesting aside, however, to note the dedications on each of the papers. My grandfather had gathered together copies of all his published work into a boxed collection to give to my grandmother. And each graphic, mysogynistic paper was inscribed affectionately in dainty script to the love of his life. Apparently he was able to separate his love for his wife into one compartment, and his biopsychosocial reading of female sexuality into another.

The other thing I wasn't prepared for: I really liked the paper he wrote about Van Gogh's last works. In it, he discusses the impending suicide of the painter as it is foretold through his paintings. The one shown above, Wheat Field with Crows, is one of his last paintings, if not the last (whatever, Wikipedia). The picture is not only dark in color, but also composition: it is done in reverse perspective, drawing the viewer's gaze in to the foreground instead of out to the horizon. As my grandfather wrote, this means that the vanishing point, where in a normal painting the land disintegrates into the horizon and disappears, is here the painter. With this painting, in my grandfather's Freudian psychoanalytic viewpoint, Van Gogh painted a "visual suicide note."

Wow.

Saturday, January 17, 2009

What it means to be a biology nerd


"I just decided, screw it, you know, I'm gonna let it come out and make the best of it and enjoy it as much as I could and marvel at it. I mean, when you really think about it, it is amazing that an animal can take in your flesh and turn it, using its own genes, into a fly"

-- Evolutionary biologist Jerry Coyne, narrating his experience of having a botfly larva living in his scalp. Go here to listen.

Thursday, January 15, 2009

Truth and its delivery


Photo: Gary Hershorn/Reuters


Two stories from today, which tie together nicely:

1.
I ate dim sum with two friends of my parents. One, a pediatrician, told me of an early experience she had giving bad news to the family of a child who had died of leukemia. The family, she said, had come to the hospital the day after the child's death, asking to see the child. My lunch companion called over the doctor who had been working with the child and family, asking what on earth was happening. It seems that the doctor had explained everything to the family, offering her condolences. But the family's shock produced such a disbelief that the words of the doctor had been completely erased from memory.

My friend went on to talk about other doctors who knew how to relate to families as they gave bad news, one even crying sometimes as he talked with patients' families. Crying was appropriate in these situations, although textbooks from previous generations might say differently, simply because the emotional cues from the doctor provide a way for family members to wrap their heads around what has happened. Simple words without an appropriate response may not allow family members to really understand what is being said. Denial is a powerful thing.

2.
After lunch, I went to the Art of Participation Exhibit at the SF MOMA, which documents artists' attempts, over the last 5 decades, at involving their audience in their art. We walked by one piece, an inkjet printer with a long trail of paper and words. It sprung into action as we walked, printing a story about a commercial plane crashing into the Hudson River. A commercial plane crashing into the Hudson River?? This had to be some sort of trick, a play on the news and our responses to it, a fabricated and ridiculous story. But no; the NYtimes.com reports that it's true. Coming from a printer sitting on a table in an exhibit in the MOMA, I wouldn't believe it.

It's all in the delivery.

Wednesday, January 14, 2009

Check me out

Watch this. I'm the one in the white coat, holding a sign. :)

How does SB840 cut costs? In a few ways. Probably most significantly, it puts everyone into the same "risk pool", eliminating the need for the intense actuarial assessments that are currently done to decide who will be denied care. Also, it allows Californians to access preventive care, thus preventing the need for costly ER services during the final months of people's lives. (As we watched a trauma patient come into the Highland ER a few months ago, my preceptor commented that just being wheeled through the doorway means a bill of $7,000. The team assembled to meet the patient included an ER attending, three ER residents, three nurses, a surgeon, and, I think, an anasthesiologist.)

Finally, from the 1978 Alma-Ata Declaration, which has little to do with SB840 but much to do with why I'm involved in the single payer movement:

"...Health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right...."

The battle might be a long one, but I think the US will, maybe in the next 10 or so years, join every other developed country in providing health care to its citizens.