Following Lasagna

The saddest rounds

2011-04-04T18:12:00.000-07:00

Today's rounds were the saddest I've ever been a part of.

Mrs. R has tracheal cancer. It is metastatic and terminal. She's received treatment already- a trach tube, chemotherapy- and there is no more that we can offer her. She can't speak, so she writes, whenever there is something more complicated than can be communicated with a nod or a gesture. Her level of education is low, and she writes in all capital letters, and mis-spells words- which somehow makes thing even more poignant. Something about those few words in large capital letters, a few letters swapped here and there, seems very urgent, very desperate. We ask her how she's doing, and she shakes her head.
"What is it, Mrs. R? What's wrong?"
I push over the pen and paper, and lower the table so she can write to us.
I CALL AND NO ONE COME 4 HOURS
"You tried to call your nurse? You needed something?"
6-10 LAST NIGHT
We apologize, we try to reassure Mrs. R that we will do everything we can to make sure she's comfortable. She had had trouble breathing last night, and nursing reports this morning were of liquid tube feedings oozing out around her trach site-- not a good sign, and not something you'd want to happen to a woman receiving "comfort care". Suffocating on your food is far from comfortable. In fact, we discuss in the hall, what may be best for Mrs. R's comfort right now is to stop the tube feeds altogether. Which is a dismal thought, but indeed perhaps better than a death due to choking on liquid feeding formula.

From there we go upstairs to visit Mr. M. Mr. M has bladder cancer that obstructs his urinary tract, and for which the only treatment is surgery. Which he cannot have, because his heart is not strong enough to survive it. He has been on our service for weeks, first while we negotiated with the surgery team whether there wasn't some way to get Mr. M the only surgery that would save his life- and then, when that failed, to arrange for hospice placement. Today we have good news: there is a bed for him at a small facility run by nuns, that the social worker assures us is lovely.

When we walk in the room, a chaplain is sitting on the edge of Mr. M's bed, and I can tell by his body language that they have gotten to know each other well over the last few weeks. We tell Mr. M the good news. It's hard to hear his response because he speaks softly and has no teeth, so we are all leaning forward. The resident is about to answer the question he thinks was asked, which is, "How long do I have to live?" when the chaplain corrects him.

"No, he said, 'how long will the rehabilitation be?'"

We look at each other, a little panicked. The resident wants to be straightforward, to convey to the patient what everyone else in the room understands and accepts, because it is not our life's end that we are discussing, and it is much easier to avoid denial when it is someone else's death. But he also does not want to be blunt and heartless; he wants to maintain good rapport with his patient. And so he dances around his words a little. Not enough to seem dishonest; but enough to seem a little uncomfortable, which to me is reassuring: seamlessness when discussing the end of a patient's life betrays overconfidence, or something worse.

"Mr. M, what we want you to understand is that this cancer that you have, we think it's the thing that... that will ultimately be the cause of your death."

More questions from Mr. M., increasingly desperate: Why can't I have the operation? Why didn't they find my cancer sooner? Why can't you just take the tubes out and let me be?

"Mr. M," the resident continues, still trying to find the right mix of straightforward and comforting, "you need to understand that if we take those tubes out, you'll... you'll pass away in the next few days."

Mr. M is struck silent, finally tells us that he wants to be alone, and we walk out. We talk about the difficulty in accepting an approach that does not have cure as its objective, and the necessity of explaining the same thing several times over, of not assuming the patient is at the same stage of acceptance that you are. We write our orders and move on to the next patient, because there's no time in the middle of rounds to linger on sadness.

On case presentations

2010-12-01T19:55:00.000-08:00

The attending's advice:

"Tell it to me like you're trying to sell me a car.

...But, you know, tell the truth too."

Revelation of the Day

2010-09-13T18:49:00.001-07:00

Uncanny similarities....

On surgeons and being nice

2010-07-07T16:34:00.000-07:00

"Nice doctors kill people," the surgeon told me, apropos of a question I'd directed elsewhere.

He explained: when doctors spare their patients pain by skipping tests or aspects of the physical exam that are uncomfortable, they end up harming the very people they'd set out to help. And he has a point: If you don't palpate an abdomen because your patient has belly pain, you could miss a surgical abdomen, and your patient could die (this resembles something that happened recently on the pedi ward, although I don't think that death was preventable; but that was the version of events that happened in the responsible resident's head).

But I wondered: can't you be nice and competent at the same time?

Sometimes I think, yes, of course, the best doctors are those who are nice and who listen and explain things clearly and give an encouraging smile before leaving the room. With something as complex as health, in which the power of the mind is startling and patients' outcomes have more than a little to do with their attitudes, being nice may actually heal.

But, I do understand his point. And the more I work with surgeons, the more I get it: being nice doesn't take you very far if it means you skip more tests or spend less time learning about more effective treatments and procedures or pay less attention to the detailed nature of your daily tasks. There's only so much time for learning and teaching in one day. If you're the average patient, you don't want a doctor who will scream at you, but you really don't want a doctor who doesn't know enough to perform procedures well.

So, while you can always be nice, and there's no justification for flat-out aggression, there probably is some trade-off between niceness and competence.

And it might just be that I've spent the last two weeks walking amongst them, but I'm feeling more like an asshole surgeon every day. What do I need to know before walking into the OR-- the name of the patient, or the name of the procedure? Well, it would be nice to know the patient's name, but as a surgical student, what's more important is the procedure. And I kinda like working with assholes: at least you know where you stand, and you know you can push back and have that be perceived as strong rather than pushy.

This probably has a lot to do with my background of being a nice person with a focus on the more behavioro-psycho-social aspects of medicine. Coming from a place in which surgeon is a dirty word (a figurative place, that is; wouldn't want to implicate of my previous places of learning), I can only be pleasantly surprised by the surgeon's perspective as I learn to adopt it. Competence, after all, is what any patient wants more than anything else that his or her physician might offer.

So, another realization in the road to medical knowledge, and another goal: to find the right balance between competent and nice.

Eulogy for EN

2010-02-08T22:28:00.000-08:00

My assignment was to write a reflection on the experience of having, or not having, a longitudinal geriatric patient. I wrote this. It's probably not what my teacher wants.

My patient, EN, was overall a very healthy 81 year-old at our first meeting in April of 2008. She had also recently been diagnosed with SCLC in January of that year, as an incidental finding on CXR taken when she was in the ER for a pulmonary embolism. When I first spoke to her, she seemed to understand what that diagnosis implied, but was resigned to everything her future had in store – especially in light of having been a “heavy smoker” in her youth and middle age. However, she was quite upbeat throughout the interview, joking about family members and friends in the residence in which she and my preceptor lived. I was also able to create a good rapport with her because she was friendly and welcoming, and because we shared a love of travel – hers evident in the world photographs on the walls of her apartment. For a few moments after the H&P was over, we had a chance to talk about Africa, where I had spent two years as a Peace Corps volunteer and a few months as a researcher. She had been to South Africa recently, saying that after Apartheid ended, she “just had to go”. And that people in her generation never thought they would “see a free South Africa”.

EN clearly valued family and spoke fondly of her daughters, but was too independent to follow them to the cities in which they lived. Instead, she spoke of traveling with them. At our third visit, EN told me she and her three children had traveled over the Christmas holiday to the home in which she grew up in Connecticut. It was something she had long hoped to do; I got the sense that having accomplished that visit, EN felt that much closer to a peaceful death.

My visits with EN were not free of awkwardness. Knowing something about the prognosis for SCLC, I never knew exactly how to ask about EN’s plans for how she would maintain her health, which was necessarily unsteady. I said goodbye not knowing if I would be able to greet her again. On our third visit, EN was hooked up to an oxygen tank, which was out of sight in her room as we talked in the living room. The cannula snaked around the coffee table and back through the doorway. I tried to appreciate the freedom that the device allowed, rather than concentrate on the loss of function that it signified.

My preceptor wrote me that EN died a few months after it happened. He told me he’d spoken at her memorial service, and told everyone that she had insisted on following up with the medical students whom she’d begun to see despite its increasing difficulty. I appreciated this, and, strangely, didn’t feel sadness, exactly. I felt the loss of a strong and unique person, and I imagined the photographs being taken down from her apartment by her children and the oxygen tank returned to the hospital or medical supply unit. But it occurred to me that sadness is a syrupy emotion, provoked by displays of pathos. EN, never wishing to be anyone’s victim, never projected that. She resisted portraying herself as weak and incapable, choosing instead to relate to others on the basis of shared interests and ideas. She will be missed, but never whimpered over.

Sympathy for the factitious patient

2009-12-09T11:22:00.000-08:00

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.

It comes from all sides

2009-11-17T16:32:00.000-08:00

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

Patient: "Study incessantly."

Jumping off the hedonistic treadmill

2009-11-11T22:27:00.000-08:00

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.

Only in Berkeley event of the day

2009-10-27T16:52:00.000-07:00

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.

Narratives

2009-10-25T23:02:00.000-07:00

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?"

Counting Down the Hours

2009-09-13T13:37:00.000-07:00

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"

Insight and humanity

2009-09-09T16:42:00.001-07:00

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.

O.I.B.

2009-08-29T16:27:00.000-07:00

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.

HIV in the porn industry: time for regulation

2009-06-16T22:58:00.001-07:00

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.)

F*@# the AMA

2009-06-11T11:22:00.000-07:00

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.

Ah, the internet

2009-05-18T21:50:00.000-07:00

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.

Disconnected

2009-05-04T18:37:00.000-07:00

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.

Finding your Box

2009-03-02T20:31:00.000-08:00

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.)

Snide comments from the Doc

2009-02-25T19:36:00.001-08:00

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."

Lucky

2009-02-24T18:11:00.000-08:00

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.

Baby Love

2009-02-18T18:35:00.001-08:00

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...

2009-02-18T18:14:00.001-08:00

... 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.

Coffee: is there anything it can't do?

2009-01-31T20:28:00.000-08:00

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.

Inked by science

2009-01-25T14:55:00.000-08:00

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.

Un-gagged!

2009-01-23T20:26:00.000-08:00

This just made my day.

The Vanishing Point

2009-01-21T23:55:00.000-08:00

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.

What it means to be a biology nerd

2009-01-17T22:11:00.000-08:00

"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.

Truth and its delivery

2009-01-15T22:21:00.000-08:00

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.

Check me out

2009-01-14T00:13:00.000-08:00

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.

food, choice, and the brain

2008-12-05T09:46:00.000-08:00

I just discovered WNYC's Radiolab, which I can't believe I've never heard before. It is now tied for my favorite podcast with the BBC World Have Your Say, which I adore also. Podcasts: little joys of the world.

So the episode I caught was about choice, and how our brain manages to give us enough information to let us get through every day -- especially the cereal aisle. My friends know that choice is an especially sore spot with me. The whole episode is fascinating and provides enough interesting thought points for the next five or so dinner parties you might attend.

All of it is interesting, but the part I really love discusses the work of Baba Shiv, a professor at the Stanford School of Business (natch), who gave participants in a study either 2 or 7 digits to memorize. They were then instructed to walk down the hall, but were stopped before they got to the supposed second part of the experiment by someone offering them compensation for their participation -- either a slice of cake or a bowl of fruit. So, turned out that, consistently, the people with seven digits in their head took the cake. Those with two took the fruit. The reason, Shiv thinks, is that with the reasoning side of the brain occupied, people chose what looked tastiest to the emotional brain. Those with some extra space in their rational brains used it to make the healthier decision.

So now I know why I gain anywhere from 2-5 pounds during finals.

Answers (or: Zen and the Art of Medical School)

2008-12-03T14:02:00.000-08:00

For better or worse, I took a personality assessment last year, as a participant in a study that another student in my program is doing. The test told me I'm an INTJ, which I like to refer to as the "evil mastermind phenotype." The description tells me that I look to put the world into logical frameworks (and am not so great on the personal relationship side of life -- oh well).

While, yes, this lends itself to scientific thought and exploration, it also produces some problems within the study of medicine. Because medical problem solving is all about finding the logic behind the mysery -- but when push comes to shove, something is still unexplained. I would much rather be the person writing the textbook than reading it, because the authors have the liberty to pick what they know and gloss over what they don't.

Scientific study continues with an aim towards explaining the unexplained, but there's also a point of complacency -- a point at which physicians seem content to know that a symptom is caused by a certain disease, and know which treatment works. How exactly the symptom occurs may never be explained, and may never need to be explained, practically speaking.

But for the med student, particularly one who craves answers, this is a continual source of frustration. The structural framework for explaining the disease is almost complete, but is missing a few blocks in one corner. You can drive yourself crazy looking for answers that you'll never find, or trying to reconcile contradictory theories.

So, apparently, there's an additional skill you need to learn in med school: learning when to give up. When to accept that the answers aren't there, and be at peace with the ambiguity. The first battle is with the material, and the second with the frustrated brain. For an INTJ, the second may be harder to win.

History and the Emergency Room

2008-11-05T22:08:00.000-08:00

Someday my grandchildren will ask me what I was doing on the historic night when the United States elected its first African American president, and I will tell them I was sitting in the Alta Bates emergency room.

Here's what happened:

Yesterday evening, I was staffing our student-run medical clinic, run out of a local church. We keep our medications in two big hardware carts. The drawers are labeled and the meds always have some degree of organization, but the staff rotates and the clinic is always chaotic, so there's often a bit of a scramble to find what's needed and see if it's within the expiration date and functional. Near the end of our clinic session -- when the election had already been called and the streets of Berkeley were erupting with celebration! -- a client with risk factors and possible symptoms of diabetes came in. We rifled around in the drawers and tried to find the equipment to take his blood sugar. I picked up a device that looked promising, started to open it to load it with a lancet... and felt a twinge of pain as the already-loaded lancet stuck me in the left index finger.

There's a strange moment when your mind moves from the mundane -- does this gadget work? Which strips do we use with it? -- to the profound, which, in this case, was, "have I just done something that could endanger my life?" Dumbstruck for a few minutes, I then picked up my bag and walked to the ER.

Where I waited for about 1.5 hours until the doctor saw me, asked questions about the needle and the exposure, and finally decided I was so low-risk I didn't need any post-exposure prophyllaxis. But they did take my blood for testing now and instruct me to come back for follow-up in a few months. Overall I was calmed, glad for the experience to be on the other side of the door, and totally grateful to my two classmates who stayed there with me until midnight. If you're going to spend a historic night sitting in an ER, it's best to have company.

Call it

2008-10-04T21:47:00.000-07:00

I saw my first patient pronounced dead today. He probably came into the ER dead already, so I might not have witnessed him die. But I did get a very unsteady feeling as I heard the resident who'd been giving orders say the words, "Time of death: 2:31 PM." The resident was impressively poised and calm as he shouted tasks to the group of students, interns, and nurses (the attending was in the room but remaining hands-off). But even he was visibly shaken as he had to pronounce a human being dead, and, as I stuck around to listen, call the coroner.

Earlier in the day, the patient's son had taken him out from his residence for a hamburger. It turned out that the patient was on a puree-only diet, and the hamburger directly precipitated his death.

"Wow," one of the nurses commented, "that son is sure gonna feel guilty."

Or, I wondered, did he know exactly what he was doing? Did he and his father talk about the emptiness of a life of institutions and puree? Did they decide a hamburger would be the perfect way to go?

Doctors don't get to know the answers to these questions.

Shared Histories, National Cultures

2008-09-21T17:18:00.001-07:00

I've been really fascinated by the idea of shared cultural heritage for awhile. Culture is, of course, always interesting, but culture in general more often connotes an age-old (albeit changing) model of thinking and acting. The idea that I keep turning over in my head is personal history and how that shapes regional culture.

For example, my close college friends, all Californians, and I, an East Coaster, have had several conversations about the '89 earthquake. They can all name where they were and what they were doing when it hit, and their feelings and fears that loved ones might be affected. I can vaguely remember hearing about a big earthquake and thinking it had something to do with the World Series that year, but it didn't play a big role in my childhood.

Or, there's this cartoon:

I know I will always remember the moment when I learned what had been done to the World Trade Center and the people within them, and how the world changed for me after that. But a whole generation of younger people is growing up without that moment in its history; and it is probably wondering what the big deal is.

I was comparing Peace Corps experiences last week with someone who had served in Armenia. He was telling me that Armenians are a chronically depressed people, and when I asked him about it, said he thought it had to do with the post-Soviet economic downturn associated with being instantly cut off from Moscow's support and resources. The country to this day hasn't recovered, leading to a national sadness and a difficult service for an optimistic American volunteer.

I spoke about Mozambique, about how although the people there are shockingly poor, they manage to stay happy. I told Mr. Armenia that I thought this was because of the disasters -- man-made and natural -- that Mozambicans are constantly having to deal with. If they don't figure out how to pick their lives up and go on, they won't survive. So they've developed an incredible resiliency that, to the casual observer who doesn't prod about civil war or cyclone stories, seems like a happy-go-lucky attitude towards life.

So it occurred to me that most of the conflicts in the world arise because of differences in shared histories. And they continue because of our inability, or unwillingness, to see things from another perspective. Israelis, for example, are often portrayed by the American Left (I love you Left, don't get me wrong; but you'd be even better without the blinders) as cold and heartless. I agree that Israelis are tough, sometimes intimidatingly so; but they're tough because they have to be. They've witnessed suicide bombings near their neighborhood grocery stores; they've heard stories about gruesome murders on their local news stations; and they send their kids off to school on buses that could be hijacked. If they want to keep living day-to-day, they have to toughen up.

Palestinians, too, have personal histories which include having their rights stripped, hearing stories from their parents and grandparents about being driven from their land, and seeing walls put up to keep them out of economic and social opportunities.

It's not really fair to end this post just encouraging each side to see the others' perspective. That's a really difficult thing to do, when everything in your memory and everyone in your social sphere tells you otherwise. Maybe what I'm encouraging is that the rest of the world, those who would be mediating conflicts or sending aid, try to understand personal histories and the difficulties that can accompany them. Before we label Armenians as sad-sacks, Mozambicans as stupidly happy, Israelis as bellicose or Palestinians as uppity, we need to try to incorporate into our thoughts a sort of international empathy.

Triage

2008-09-07T19:52:00.001-07:00

One of my favorite aspects of getting a medical education is how medical concepts and images seep into everyday thought and parlance. So, for example, exposed wiring at the base of a telephone poll begins to look like the brachial plexus. Or the sites of complicated road intersections can only be described as anastomoses.

My current imported concept is triage, which is mostly about prioritization, but connotes a sense of urgency, of impending disaster if not executed correctly.

Triage is becoming my mantra because I have a sense that the world could implode very soon. As faceless stormtroopers crush protests at the RNC and journalists are crushed to the ground screaming, our possible next vice president seems to be fond of burning books, and Roe v. Wade seems more threatened with every passing moment, choosing how to spend one's time is of the utmost importance.

In that vein, today I took an hour to phonebank for Obama. There are countless ways to spend your time, many of them worthwhile and productive. But to me, this is what is urgent now. If this election is lost -- the patient's death, by my analogy -- I don't want to know that I didn't do everything I could to save it.

Dessert with no dinner

2008-08-11T22:54:00.001-07:00

The way HIV/AIDS-related programs are executed in Mozambique often reminds me of the episode of M*A*S*H in which Major Winchester donates gourmet chocolate to the Korean orphanage, only to learn that the head of the orphanage has traded the stuff on the black market for food staples like rice and beans. "Forgive me," he says, when he's realized his mistake. "I have given dessert to children who have had no dinner."

You'll see what I mean when you read this. When the magnitude of the HIV/AIDS epidemic became known, the international community flocked to the aid of affected countries, pouring money into programs for prevention, treatment, and impact mitigation. This is most definitely a good thing: helping sick people, and preventing people from getting sick, is a valid goal, particularly in the case of AIDS, which affects people of the age who otherwise would be earning money for their families and taking care of children.

But whether it's because of these ties to economic development; or because of the threat of AIDS spreading from Africa to our own safe and cozy homelands; or because of the ability of this disease to capture the imaginations and hearts of donors, AIDS has unfairly taken top priority on the international aid agenda. It's not uncommon to visit a hospital in which the beautiful, new areas dedicated to AIDS care sit beside the other wards, which are overcrowded, crumbling, and understaffed. Or, teenagers' curricula on STIs and sexual health, often NGO-run, are fine-tuned based on international best-practices -- but the students have had no adequate preparation in areas like the germ theory of disease or population biology, which are essential to their understanding HIV's transmission and spread through populations.

Or, like in the article linked to above, people with inadequate nutritional intake are given expensive and potent medications to treat their illness. I work in HIV/AIDS research, and I believe that it is indeed an international emergency. But we in the international development, research, and health communities need to ensure that dinner is provided before dessert.

Validation; or, The Next Level

2008-08-08T09:55:00.000-07:00

It might be that it's Friday night, and that I get to hang out with some old Peace Corps friends later, and that I get to spend some lazy, pampered days in New York soon, but I'm happy right now.

I had an extremely validating conference call this afternoon. For the past two weeks or so I've been poking away at my computer, forcing myself to generate code that might work to turn out numbers that might be vaguely relevant or useful or correct. If this sounds like the wrong way to do research, welcome to data triangulation. We look at lots of numbers and try to pull out something meaningful from them.

Problem is, I've never been trained in triangulation -- I'd never even heard the word in this context before my first meeting with my thesis advisor. I figured someone would clearly explain to me how the process works in time for me to present the findings of said triangulation to a high-level group of researchers here.

So far nothing has become a whole lot clearer, and I'm on my own for the presentation, which is next week. The main higher-up on the project, though, R, always seems to have something in his head. He's said several times that we'll need to "take it to The Next Level" with the help of analysts at UCSF, which drives me crazy because this project, as my master's thesis, should mostly be done by me. Which is why it was so nice to speak to said analysts today, in a call that R missed, and learn that "The Next Level" appears to be a nebulous area existing only in R's head. The first few minutes of the call went something like this:

UCSF: "So, did you and R get a chance to talk on Wednesday?"
Me: "Yeah, we went over some scheduling issues and he gave me some tips for the presentation, but I was hoping he'd be on this call. He wants your help in taking it to the Next Level."
UCSF: "Yeah, so about that Next Level... do you have any idea what he's taking about? Because, the level you're at now... that's about the level we can work at."

Which is so great to hear. Because after 2 weeks of battling it out with Stata (and constantly checking friends' blogs and celebrity blogs), it seems that maybe I do have good instincts in this whole data analysis thing. Not that a trained professional couldn't do it 10 times faster, but I think I'm coming out with about the same results that an MPH on the project might, via the same logical routes that my thoughts have been taking over the past 2 weeks. I may not have the organization or confidence or refinement of a seasoned professional, but at least I feel that I could someday.

So I'll let you know when I've reached The Next Level, but for now I'm happy on this one.

Procrastination, the brain, and celebrity fluff

2008-08-07T05:01:00.000-07:00

So it's down to the wire in my time spent working in Mozambique, and all I can do is watch bad romantic comedies and compulsively update my useless celebrity expertise on perezhilton.com. What I should be doing, and what I can press myself to do for vast, uh, minutes on end, is analyzing the 9 datasets that make up the material of the triangulation project. But it seems that my brain has become overwhelmed. With each passing day spent staring at the computer screen, my fingers are getting clumsier, my mind slower, and my capacity for concentration shorter.

I put a romantic comedy on as I fell asleep last night, because my brain's craving for them is like a late-night ice cream craving. There was a moment when I drifted off to sleep and was only conscious of a stream of numbers.... 40.0, 11.1, 12.5 -- of the type I'd been endlessly keying into an excel spreadsheet earlier that day. The number streams seem to be causing stress on my neuronal connections, causing these poor cells to beg for Jennifer Aniston and her sister's wedding. I've even started watching the second-rate American shows that a Brazilian channel here broadcasts; shows I had never heard of and would never watch in the States, but which make it here maybe because of low syndication fees, because they give my mind the idiocy fix it needs.

I've never had such severe concentration problems, but then again I've never required such heavy, numbers-oriented concentration before. Another problem may be that I'm on my own with the work here, and I'm never sure if what I'm doing is productive or even correct. So there's probably some fear of failure mixed in with the cognitive overload, conspiring to put my mental output at about zero. I don't know whether to push on or give in and raid my roommate's DVD collection.

Onde está a coração

2008-07-28T09:48:00.000-07:00

Yesterday I went to another home -- I think I've probably blogged about at least two other "homes" by now. This home is where I stayed during my two month-long Peace Corps training: a cozy, woman-headed household in a little town about 45 minutes outside of Maputo.

It's remarkable how much it did feel like home: the kids ran out to greet me, my mom scolded me for not keeping in better touch and told me I should get married soon, and I was fed a big, greasy plate of spaghetti. I had brought a lot of toys for the kids, so we all played in the yard after lunch and got our hands covered in the red dirt that characterizes the village. I let the kids take some pictures with my camera, which they couldn't get enough of. They were too excited and impatient to learn the rules well, so there are a lot of pictures of torsos with no heads and ground with no figures, but there are a few that are surprisingly poignant. Here are 3 of mine followed by 2 of theirs.

In case you were trying to figure it out, frisbees, Silly Putty, and harmonicas all make great gifts for rural African kids. Trust me on this.

Mozambican girl plays frisbee: the dream realized!

+ Jovem!

2008-07-19T01:37:00.000-07:00

A colleague at the National AIDS Council invited me to his TV show, a talk show for youth, because this week's show would be about multiple concurrent partnerships -- the topic of my current research. Fantastic! I thought -- though I made sure he meant *in the audience* and not *as a guest speaker* before I accepted. Him being what I thought was your average beaurocrat, I assumed "+ Jovem" was a toned-down, government-run show. I was envisioning Charlie Rose set in Mozambique and focused on HIV/AIDS, with a live audience who would get the chance to ask some questions.

Well. So last night we arrived at the studio, I and a colleague from UNAIDS whom I had invited. The guard waved us in the front door, past a long line of young people; VIP treatment! A few other production aids walked us through the halls to the set, where we climbed onto the risers where the audience was seated. The youth started rolling in, raucus and excited, many dressed to the nines for their opportunity to be seen on TV. Jorge, the National AIDS council beaurocrat/TV host, started describing to all of us how the show would go. The special invited guests were the second-in-command at the National AIDS Council, and a representative from N'weti, an HIV/AIDS communication-oriented organization. There was also a woman from the Ministry of Health who would make a plug for a good hygiene campaign that was to start the following week. And, a DJ and a rap group... and two groups of Marrabenta singers... and another duo of scantily-clad female singers... and there would be T-shirts given out, and there was a large display of "Klin" detergent and two girls wearing Klin t-shirts which would have some camera time as a sponsorship deal. So, as with all things Mozambican, there were surprises, there was chaos, there were things happening which it was better to just take in and not question.

The show started with Jorge and a group of guys wearing sparkly blue vests doing a little choreographed dance, which completely cracked me up. Imagine yourself meeting a work colleague to discuss contacts and resources useful to your project. Then imagine that same colleague, a few days later, breakin' it down with a posse of sparkly-vested dancers. Classic.

The HIV-related conversation wasn't fantastic, especially because of the straight-laced, academic tack taken by the interviewees. The kids in the audience were more concerned with gossiping with each other and sending text messages. But they did have a chance to share their thoughts about multiple partnerships -- always poorly defined, but in their context meaning having more than one boy- or girlfriend at once -- and they seemed to be getting into it. I hoped the youth watching at home would have similar conversations with their families and friends.

One of Jorge's assistant approached my UNAIDS colleague, Katia, and I, and told us we would be asked questions. Despite our impassioned protests to not have to speak on national TV, Jorge insisted. Katia almost forgot the name of the special guest, but pulled it together to make a point about how we are trying to bring what have been private conversations into a public debate in order to confront the HIV emergency in Mozambique. Then the question came to me, as a foreigner, what were my impressions of what was going on here with all of these multiple partnerships?

Putting the question like that, there was really one answer I could give: Well, this isn't just Mozambique, and it isn't just Africa. It happens everywhere in the world, and it's a problem that the global community will have to tackle together. Despite this being the in-vogue theory as to why AIDS has taken such a hold on Africa (previous theories being unsafe blood supply and high rates of STDs), I do believe it happens everywhere, and, moreover, I believe it creates a culture of inferiority when the debate is framed as, "what is wrong with these Africans?" I've already met a sort of cultural defeatism when, as a Peace Corps volunteer, I told people that I had friends who were virgins at 23 because of their strongly-held beliefs. The answer I got was, "Well, maybe in America you can do that. Here, among us Mozambicans, it's not possible."

So, that's the story of my 15 minutes of fame in Mozambique. A statement about global unity on + Jovem, and I think the Portuguese grammatical errors were minimal!

I was a lonely teenage broncin' buck....

2008-07-15T22:47:00.001-07:00

These were anonymously left at my doorstep last night... Thing is, there are three women living in my house, and none of us has any idea who they might be from. At least it provides us with some entertainment.

Points if you can sing the line following the title!

Update: spontanous cure!

2008-07-10T13:54:00.000-07:00

Good news: As of this morning, my phone is demonstrating complete, spontaneous cure! All the names are coming back. Phew. Old age will be put off for awhile yet. No word as to what triggered it, but perhaps it was the certainty of knowing its diagnosis. :)

And, just to make sure I haven't offended anyone, this wasn't meant to trivialize dementia, which is no doubt an extremely difficult thing to deal with for patients and their families and loved ones. It was more to demonstrate how warped a med student's view of the world is, when she looks at a phone and thinks neurology.

Diagnosing

2008-07-09T11:09:00.000-07:00

I guess you know you're a med student when it's all about the diagnosis. Lately I've been trying to diagnose everything: I diagnosed my roommate's ear pain (bacterial otitis media resulting from URI), my cold (mostly URI symptoms with some GI -- I think it was a coronavirus), my everlasting psychological angst (still up in the air).

Today I found myself diagnosing my phone. I guess the case presentation would go something like this:

7 y.o. phone presents with lack of memory recall. Symptoms appearing gradually over the last week, easily noticeable to owner. No significant past medical history, aside from some possibly damaging drops on the ground. Family history unknown (any registered problems with basic Nokias?). Memory recall impaired only when calls or messages appear, in which case number is correct but appropriate name not matched. Name appears without problems in stored list.

Diagnosis: phone seems to be experiencing declining memory consistent with dementia. Oh, my poor phone.

Development ideals and master's theses

2008-07-04T11:53:00.000-07:00

Earlier this week on a conference call, my co-investigator on the project we're working on shocked me into embarassment. He spoke of the importance of involving the National AIDS Council in all steps of our project, adding that we should avoid conference calls from Americans to Americans -- calls like, well, the one that was taking place right then.

The reason this embarassed me so much was that I had been totally preoccupied with fighting for my own place in this project. As a student, it's hard to have one's voice heard against those with more experience, more letters after their names, and more publications under their belts. I never wanted to carry out a project on my own, because, let's face it, those letters and publications do mean something, and whatever project I worked on singlehandedly would be bound for disaster.

But I didn't want to end up anyone's research assistant, either. With so many high-profile scientists on the project, I could picture myself relegated to a position as someone's errand-runner, reporting back every day, until my job was done and the real, higher-level analysis fell onto someone else's plate. So I'd begun to assert myself, to think of the project as "mine", to plan out the next steps quickly so that I could retain some control.

The problem was, any project that has as its goal improvements in the health or well-being of a population really should belong to that population, and not to some ambitious master's student. In my determination to make this project "mine", I'd lost sight of the fact that the problem, its study, and its eventual solution, is all theirs. This project belongs to the people of Mozambique, and to claim otherwise is to do the Mozambican people, and the entire ideal of international development, a huge disservice. If any interventions, and the research they are based on, are to be successful, they must come from within.

And so I am learning to be at peace with a master's project that has two levels: one, the research itself, which I am aiding in the execution of; and the other the process of working with individuals within governmental and non-governmental institutions, of understanding people's concerns and interests and finding solutions together. It is both a great challenge to find the time and energy to work with others on their terms, and a relief to know that the burden of this research is not on my shoulders alone. I am learning to love my role as consultant to Mozambique, and whatever happens with the research, I know there will be good stories to tell at the end of the process.

Unbiased reporting?

2008-07-02T23:41:00.000-07:00

Look closely at the pictures of the candidates in this story, published in one of the largest-circulation newspapers in the country, about Obama leading polls in a few key states.

If this were the NY Times, there would be international outcry. Seeing as this is Mozambique, the main implications were my roommates and I laughing about it in our kitchen.

What would grandpa say?

2008-07-02T23:33:00.000-07:00

I couldn't resist this when I saw it in the grocery store.

My grandpa, a connoisseur of Jewish deli corned beef, would roll in his grave.

Five reasons why I appreciate the Peace Corps

2008-06-26T23:53:00.001-07:00

1. Being part of the community
My return to Mozambique as a researcher working on a national level has really brought home how unique the Peace Corps experience is. Living abroad isn't unique -- I meet expatriate foreign service members, aid and humanitarian workers, and some industry folks, every day. But the expatriate existence is nothing like being a community volunteer. As a volunteer, even if living with email and working in an office, you are a part of the community in which you live. Your friends are nationals, your recreation is sitting at the corner bar with your colleagues and sharing one of the 750 ml bottles of beer, or maybe gathering for a party in which all the women bustle about cooking fish stew and corn meal xima while the men sit on plastic chairs and talk. As a born outsider, you may never be able to completely fit in, but as a peace corps volunteer you come pretty close.

2. Experiencing poverty
Every person who is born into privilege should somehow experience poverty. Peace Corps volunteers aren't completely poor, as they have their medical and emergency expenses fully covered, but our salaries are pretty darn low. Below the lowest tax bracket low. And it's a powerful experience to walk down a street and know that most shops aren't accessible to you, and to find yourself making friends with people whose company you don't necessarily enjoy, just because they can provide you with fancy food or rides in their car. It goes a long way to understanding how people without means end up putting themselves in risky situations.

3. Being different
As a white person in rural Africa, I got stared at everywhere I went. Babies sometimes looked at me and began to cry. Children begged and yelled "mulungo", white person, every time I passed. Men gave me endless attention and quite a few marriage proposals. My male friends were always approached by women trying to marry off their daughters. Being so different starts to weigh down on you, and you begin to expect the worst from everyone. I'd never experienced this kind of overt prejudice, nor the hardening of spirit which is produces, living in the States -- although many do.

4. Comraderie
Every time I meet a Returned Peace Corps Volunteer (RPCV), I know we share much in common. Even the volunteers from different continents or working in different sectors can understand my experience, and I theirs. Having been in the Peace Corps is almost like being inducted into a secret society within which there are few rules but much good will. It is an automatic feeling of acceptance when I meet other RPCVs, and the sense that we could talk for a long time, sharing stories from our volunteer days.

5. Self-sufficiency
There is much I'm still learning about, well, everything. But being in a strange place, speaking a strange language, and dealing with completely unforseen ups-and-downs as a volunteer has given me a sense that I can generally handle things. There's a certain "wait-and-see" mantra that volunteers need to adopt if they are to do well at site, which has also served me well back at home and at school. If I don't know how to do something -- well, I'll figure it out. Or, I won't, and I'll see where that brings me.

Sports, pride, and poverty

2008-06-22T10:50:00.000-07:00

Sunday night of a football-filled weekend. Last night was the Russia-Holland match of the Euro Cup, a match which might have slipped by as one of the less important of the tournamet, if it weren't for the strong Dutch expat presence in Maputo. As it were, there was a rowdy, happy gathering of Dutch and others in one of the popular expat bars in the city, which I somehow stumbled onto. I don't watch soccer as a fan, but I do get caught up in the games when I watch with a dedicated crowd. And I have to say, the Dutch in their bright orange shirts won me over, and by the end of the game, an upset loss, I was almost as disappointed as the rest of them. I said almost.

Today, I had the opportunity to see a live game between the Mozambican national team, the Mambas, and the Madagascar team. Again, I had never watched a Mamba game before -- but it was impossible not to get swept up by the thousands of cheering, dancing, heckling, celebrating fans in the stadium. Here are some pictures:

Guys carrying Mozambican flags -- and dressed in Mozambican flags -- watch the band play the national anthem.

Goooool!

Peanuts!

The guards were carrying batons, guns, and gas masks. Good thing everything stayed calm.

The game made me so happy, as it clearly made everyone else so happy, that I got to thinking about sports and their importance in our lives. Sports bring out feelings in us that are basic and universal: pride, competitiveness, and comraderie. Athletes around the world, whether footballers in Mozambique or baseball players in the States, inspire these emotions in their fans.

Money, of course, can confer advantages, like fancy equipment and trainers. But an athlete is an athlete, a game is a game, and a fan is a fan. Sports provide an even playing field, as it were, for civic or national pride, and pride in the athleticism of men and women. In a place, like Mozambique, where it is hard to be carefree -- hard to forget about the difficulties facing life each day -- football provides a pure sense of pride and competition. Becoming enveloped in a game and infected by the enthusiasm of the crowd feels like freedom.

You can't go home again

2008-06-20T07:25:00.000-07:00

(Fine, I'll admit it... this blog is driven 90% by fun titles.)

For the last few days I've been traveling up to Vilankulos, the town in Mozambique which I called home for two years. I was happy to come home to the States after my service ended, but ever since coming back here I've been dying to get back there.

I knew there would be some changes: about 6 months after I left, Vilankulos was hit by a devastating cyclone. The pictures my friends sent me almost drove me to tears, and probably would have, if they weren't accompanied by words representing the characteristic Mozambican attitude of, "Eh, we've been through worse and we'll get over this too". It's easy to underestimate this Mozambican resilience, especially before hearing the stories -- everyone has one -- from the civil war. But that's for another day.

In Vilankulos, there were indeed signs of the cyclone, even more disturbing because it is now a year-and-a-half later. The brand-new marketplace, almost finished when I left and functional for only a few months, was still roofless and empty. The hospital buildings that my organization worked hard to help the Ministry of Health erect also showed signs of enduring damage, and also weren't functioning normally. And, unrelated to the cyclone, the high school was holding classes in tents, because the public university had taken over half of the beautiful, new, World Bank-built structure that was supposed to be Vilankulos's new high school. I wondered, could someone just call the World Bank and let them know that their project was being so misused? Could I? "Hello, uh, World Bank...?"

Good things were apparent, too. A new bank and a cell phone store had sprung up near the center of town. A new market in one of the outer neighborhoods. New paint jobs, mostly the yellows and blues of the two leading cell phone companies, shined in the brutal midday sun of the tropics. But mostly, there was just the sense that people were continuing to live their lives. The buzz of the central market and the shuffle of the feet of women wearing colorful wrap skirts as they carried baskets on their heads and babies on their backs.

And for me, this was the saddest part. Life had moved on past me. My former colleagues greeted me with smiles, and we exchanged pleasantries and enquired about family members, before they moved on to their tasks at hand. Two new volunteers have replaced my sitemate and I, and their house has a familiar Peace-Corps-volunteers-live-here comfort. There are new babies, new relationships made, old ones broken. Life has moved on.

When I left Vilankulos this time around, yesterday, I didn't know if I'd ever return. I love the place. But what was once home no longer is; the home I have in my mind is not a place but a spot in time -- a time now past. I don't think I believed it before now, but you really can't go home again.

Notes on the Underground

2008-06-19T07:24:00.000-07:00

Five hours in London between flights, and I decided to ride The Tube. There really wouldn't be time for anything much beyond that, but wouldn't that make the trip worthwhile? Living the life of a London commuter, minding the gap with the best of them?

It was actually a little bit of fun, even if I did get some funny looks because the quaint voice of the announcer kept making me spontaneously smile. But the experience was also a little worrisome: the smallness of the Underground car couldn't help but make me realize that Londoners too, not just their modes of transportation, are smaller than we are.

Every time I ride the NYC subway, I become worried because of how large we've gotten: large enough that only a small percentage of riders seem to fit within the confines of one seat. Even with my sample size of 2 hours on the tube, it seems clear that Londoners are managing the challenges of life with supersized fast food and little time for exercise better than Americans.

Maybe if we shrink down our public transportation we'll force ourselves to shrink too...?

File under: depression, poetry, the Pacific Northwest

2008-05-13T22:24:00.000-07:00

Patient: It's like it's always cloudy, always raining.
Me: Wow, that's a really poetic way of putting it.
Patient: Yeah, it's like... have you ever lived in Seattle? It's like that.

Finals

2008-05-13T15:38:00.000-07:00

It's finals week, and I'm almost finished with my first year of medical school.

Do I feel any closer to being a physician? Sometimes I think yes: my vocabulary has changed such that I now refer to heart attacks as "MIs" and pulmonary embolisms as "PEs." I even shocked myself by using that last abbreviation in front of a patient, and not catching the mistake until maybe 20 seconds into the blank stare that I got in return.

But most of the time, no. The experience is still providing me with my weight in comedy gold, from all the newby-meets-the-medical-world flubs. Last week, when our suitcase clinic physician asked me to describe a patient's rash, I had several "rashy" words fly through my head -- pruritic! maculopapular! -- before I realized I didn't actually know their definitions and had no idea if they applied to our patient's rash. So I was left with: "Uh, it's red. And dry."

But I think I'm doing ok. Enough of the basis for understanding is there, such that I'm beginning to see how the diffrerential diagnosis process works -- even if I can't use it myself yet. More importantly, I'm still fascinated by it all, something which keeps me wanting to learn every day.

However, that doesn't actually mean I'm motivated to do the work I need to be doing. Finals week is an interesting thing: time ceases to have any meaning, day blends into night which blends into day again, and the real point of anything is totally lost sight of. It's a uniqueley academic thing -- although maybe analogous to armed combat, albeit on much lower level of unpleasantness. I don't think you can get PTSD from finals week, but I'm not positive.

Finals is also unique for its characteristic sine-wave of procrastination, which goes something like this: work hard for 2 hours, get bored and burnt out, waste time for 2 hours, panic that no work is getting done, work for 2 hours, and so on. Easy access to the internet has opened up new worlds of procrastination. Worlds which include emailing, chatting, watching videos, and, yes, blogging. Which reminds me: I really need to get back to work.

YouTube and Reproductive Health

2008-04-29T20:14:00.001-07:00

The crazy world in which we live never ceases to amaze me.

Today in my reproductive health class we debated whether or not women should be granted asylum in the United States to be able to have abortions. It's a really interesting and nuanced question that involves not only issues of human rights and unsafe abortion, but the U.S. asylum process, historical precedents, and U.S. politics and public opinion. It was really a fascinating thing to be a part of.

Also fascinating was a mini-lecture afterwards from an ob-gyn working to expand abortion access. She spoke of two recent and completely mind-blowing initiatives: Women on Waves and Women on Web. Women on waves is a boat of professionals who bring on board women facing unwanted pregnancies in countries in which abortion is illegal -- and then sail into international waters to perform a medical (Mifepristone/Misoprostol) abortion (or to decide to continue the pregnancy after a counseling session). Women on Web is even crazier: women in countries where abortion is illegal can order, over the web, and from an anonymous source, misoprostol/mifepristone doses sufficient to abort the fetus. How do the women know how to use these medications, or when to seek help? Well, there's an instructional YouTube video.

YouTube, to me, is a time-waster, somewhere to go when I'm not thinking about anything serious. The idea that a woman could be relying on YouTube to ensure her health is, well, crazy. But in a crazy world, where all the official rhetoric touts a woman's individuality and the validity of human rights, and yet we get closer to overturning Roe v. Wade everyday, and women in the U.S. military are not allowed abortions, the solutions must be crazy too. People have an endless supply of ingenuity, and will use every resource at their command to address the problems with which they're faced. YouTube included.

Wouldn't it be nice

2008-04-01T18:52:00.000-07:00

Sometimes I wish doctors didn't have to solve problems.

The patients I've had the opportunity to speak with are fascinating people. Really, everyone has interesting things beneath the surface, to be discovered if you ask. In a medical interview, the questions scrape the surface, but only barely. We hear about family and social support, difficult aspects of a life, and daily habits -- but only for a few seconds. Only what's especially relevant, and what there's time for.

Sometimes I would prefer to just sit and chat, without having to worry about getting at the medically relevant information. This is particularly true of the geriatric patients we see: a lifetime of stories, and all we hear is "I eat a balanced diet" and "I had a hard time when my sister died last year." I want to hear about the family, what they did for fun when they were kids in the 1920s and 30s, and which sister he was closest to.

Maybe this means I should consider psychiatry, if what I like about medicine is the sitting and chatting. Or maybe that means I have a naive view of what psychiatry is -- I'm sure the psychiatrists have their own vital data that they need to gather through leading questions. But at least there's more time to sit and talk.

Politics and Heartbreak

2008-03-10T21:00:00.001-07:00

I have midterms to study for, but all I can think about is Eliot Spitzer. When I saw the headline, it felt like hearbreak.

What does it mean to believe in someone you've never met so much that finding out about his moral transgression breaks your heart? For one thing, it means I'm less jaded than I thought I was. Two years of working for the Federal Government and experiencing first-hand the egos, petty power struggles, and hierarchy systems; and another two of working in HIV prevention in Africa, seeing nothing work and hardly anyone notice or care. I thought I was rough enough around the edges. I must've been wrong.

It also says something about electoral politics. It says that through our elected officials, who operate in the public sector on behalf of us, we express our voices. We want to believe in what our representatives are saying and doing because it makes us believe that we can say and do those things. It makes us believe in humanity, and in our ability to come together as a community to build better lives for us and our children. And when one politician who has succeeded so spectacularly in affirming these beliefs falls from grace, it shatters our hopes.

Disillusionment with politics is nothing new. Richard Nixon infamously disillusioned an entire generation of voters. George W. Bush has done it again, more recently. But W. never represented half of the country, the half that voted blue and wore t-shirts with W.'s picture that proclaimed, "Not my President." Spitzer was the voice of the reformer, the underdog, the idealist. The person who believed the world could be different. Now he has let us all down; he has broken our hearts.

Reaching Out

2008-02-26T20:04:00.000-08:00

This past Sunday, I volunteered at a blood pressure screening event organized by the Ethnic Health Institute (EHI), an outreach group associated with Alta Bates Summit Hospital. The first thing I came away with, after a long morning of measuring blood pressures at two large, African-American churches, was a complete love of outreach work. Some people whose pressures I took hadn't been to see a doctor in years. It's not that people aren't concerned about their health; it's just that they don't have the time, don't have the insurance coverage, or don't know the best way of navigating to HMO system to be able to see someone who can respond to their concerns in a respectful manner.

Which is where outreach comes in. In this revolutionary service, the health care providers go to the people, instead of the other way around. People who haven't been able to receive services suddenly find them stepping on their toes.

Outreach services have some added bonuses, which I discovered this weekend. One is that the sites where outreach services is delivered -- churches, in this case -- are much happier places than hospitals. I loved chatting with folks as they came out of church happy, talkative, and full of the music of their choirs. It also allows the providers a glimpse into the worlds of their clients. The biological world has intimate linkages to the psychosocial world, and any deeper understanding a physician can gain into this latter world will help her understand her patients' medical conditions.

Finally, I came away with a little excitement, and maybe some fear, at being looked at as a professional. I hadn't anticipated that, sitting on the other side of the table and wearing a name tag, I would be treated as an expert. People hung on every word I said, clutched the pamphlets I handed them, shook my hand. It made me think more about how I phrased my words and what I emphasized. It's not every day that someone listens to what I'm saying.

I got an A?

2008-02-20T20:27:00.000-08:00

Yesterday, my patient gave me an A. My preceptor (the doc whom I shadow/help/learn from every few weeks) had left the room and given me the chance to interview the patient. On coming back, my preceptor asked the patient, conspiratorially, "So, how'd she do? An A-? B+?"

My patient, a lovely woman, and now one of my favorite people ever, gave me an A. Which, of course, made me really happy. It also has limited value, because I didn't actually have to produce any results -- the patient's treatment didn't depend on me, and the patient wasn't familiar enough with the history-taking process to know what questions I'd forgotten or not followed up on thoroughly enough.

But, I don't think it's meaningless. It says something (albeit small, I know, you don't have to remind me) about how I interact with patients. I actually do think I've gotten better at speaking with and listening to patients, at turning the "patient interview" into a "patient conversation."

But, a few minutes later, as my preceptor and I examined the patient's heart, I completely failed to hear what turned out to be a quite distinguishable heart murmur.

So, the point: medicine contains within it a huge set of skills, and a whole lot of information. It's so different from anything I've studied before because it has a well-defined end-point -- to be able to effectively treat patients -- and yet is so vast. A first-year who has improved in one area is likely miserable in a whole lot of others. And not only is it difficult to learn everything, but it's also hard to know how fast you should be learning. It's as if the "fire hose" that is medical school has created a puddle around you, and you're now trying to figure out if it's best to tread water or drink yourself to dry land. And how much you can drink at once without making yourself sick.

Our faces, ourselves

2008-02-05T22:42:00.000-08:00

We recently had a basic clinical neurology lesson, in which we learned that the human face is among the most captivating objects with which to lure someone's eyes. When a patient is minimally responsive, moving your face from side to side and observing his or her eye movements can give you valuable information about the patient's mental state. Faces are the first objects that capture a baby's attention.

And yet, when I was told that a faculty candidate looked like me, I had no real basis for agreeing or disagreeing. I could objectively say that yes, her hair and skin colors looked like mine, so sure, there might be a chance that she looked like me. But could I really say if there was a "resemblance"? Could I "see it"?

No. Which is often the case with people who are told they look like celebrities or relatives or friends. Somehow, despite having a finely-tuned mechanism for picking out human faces, and telling one face from another, and years of experience with our own faces, it's very hard for us to compare these faces to others'. Is it precisely because of this extensive experience with our own faces that prevents us from seeing it as others do? Or is it a projection of our desired or possessed characteristics onto our physical aspects (as in, "I can't look like her because I'm more youthful-looking than she is")? Or something entirely? What does this mean in terms of our concepts of who we are, and our relationships to our physical appearance?

Pick your battles

2007-12-18T21:57:00.001-08:00

A few weeks ago (yes, I'm a bit behind on the blogaschedule), I attended the American Medical Student Association Region X conference. AMSA is a forum for med student activism, and the conference was titled "Advocacy into Action: Taking responsibility for the future of health care." While being really impressed with the passion and spirit that everyone -- speakers, participants, and organizers -- showed, I walked away a bit disoriented.

My problem was how to choose. The issues at hand were all pressing, important, and easy to get caught up in, especially after hours of impassioned speeches from people who dedicated large pieces of their lives to their issues. Global health, health disparities, health care reform, reproductive health rights, issues of race, gender and sexuality in medicine. These and more were addressed, with a plea to "get involved" behind every speech and presentation.

So how do you decide how much time to dedicate to activism, when learning to be a doctor is already so taxing? How do you pick what the best use of your time is? By the number of people you may be able to help? The profundity of your impact? Or maybe it's about you: you pick the issues you feel closest to; you're drawn by what has touched you in the past.

I care about change on a systemic level -- the idea of being an advocate for women in the developing world is one of the reasons I'm in medical school. But lately I've been feeling that focusing my efforts on people thousands of miles away is irresponsible, and will tear my attention into pieces. So I made a decision to get involved in advocacy around universal health care in the U.S. It's as pressing an issue as any, and only by speaking up will any change ever happen. Look for more posts on this in the future.

Let's be clear that I still haven't come to a conclusion on this. I still don't know how starting an activist career will affect my performance as a student, or overall sanity. And I don't want to ever stop pursuing international women's health issues. But getting involved in issues closer to home makes me feel like I'm serving my future patients, and taking responsibility for mistakes my own government has made, at the expense of its people. And it's exciting: we're planning a lobby day to take place next month. If you're a California voter who believes in expanding health care access, come join me.

The grass is always greener

2007-11-12T01:26:00.000-08:00

In recent conversations with friends, I've told them how trapped I sometimes feel as a student.

I told one working friend that I need more balance in my life, that it seems that all I do is study; she wrote back and told me how she'd been wishing that she could just sit all day in coffeeshops and concentrate on learning. I told a friend in Mozambique how much I wished I were there. She quickly wrote back with a list of reasons she wishes she were here.

Why is it so hard for us to be happy?

Why Medicine Doesn't Make Sense, #1

2007-10-27T12:51:00.001-07:00

How can someone design a drug without knowing how it works?

I keep running across descriptions of drugs that say "mechanism of action unknown". How does this happen? As I get deeper and deeper into the study of medicine, I am more and more amazed by how much what is practiced is a crapshoot.

Maybe medicine is more an art than a science.

On Death and Understanding

2007-10-19T18:05:00.000-07:00

A few days ago, I found myself having a very hard time understanding how an infection can actually kill a person.

I asked this question, specifically about pneumonia, as my professor and I walked out of class. Part of the difficulty, I think, is that it's not a simple event. Intuitively, a massive invasion of foreign organisms doesn't seem like it can be a good thing. But to actually outline the steps until death -- pathophysiology, if you'd like to put a name to it -- is much more difficult. Which organs are most affected? What are the proximal causes that actually make these organs fail?

The professor explained that the inflammatory exudate floods the alveoli to such an extent that breathing becomes labored. But, I insisted, can't you just aspirate out the fluid? If we know what's happening to a person's lungs, can't we just fix it?

The answer, of course, is that it's not that easy, antibiotics aside (and antibiotic resistance is a whole other story). Once the inflammation response is at full strength, the influx of cells, cellular debris, and protein into the lungs results in a complete loss of lung architecture such that the normally air-filled lungs actually take on the consistency of the liver.

I still couldn't wrap my head around it. And it will probably be awhile before I do. Because really, it's not just an intellectual difficulty in understanding the process; it's also a psychological difficulty in really comprehending how a body that functions, sustains a living individual, can become one that is lifeless. Humans know what death is from a young age, and have some exposure to it; but really understanding how a person dies is something that comes much later, and much harder. This, I guess, is where the man is who loses a loved one and says, "one minute she was with me, and the next, she was gone."

I know I'll need to wrestle with it some more. And I probably won't really understand it until I have firsthand experience witnessing the end of a life. And maybe not even then.

Thrilling thought of the week: I love Mondays

2007-10-11T00:38:00.000-07:00

You know you've found the right graduate program when you look forward to Mondays.

I love Mondays because those are the days when we're presented with a new case to read through and drive our learning (see a previous post for more on PBL). Mid-week, when we're plowing through test results, synthesizing information from biochemistry and physiology and clinical manifestations, and sifting through sources that contradict each other, things aren't as much fun.

But Mondays, the sky's the limit. Everything that seems like it might fit -- a disease read about long ago, something someone's cousin once had, anything that sounds mysterious and interesting -- makes it up on the white board. Our new patient has abdominal cramps? Well maybe it's appendicitis. Maybe an STI. We should take her sexual history. How about abuse? Let's figure out her social situation. An exotic infectious disease? Let's get her travel history. Something related to a chronic condition -- does she have diabetes? Let's examine her, and maybe give her a pregnancy test

It's an exercise in medicine, but in the part of medicine that requires lateral thinking. Really, it's an exercise in stretching your mind to the limits of logic, and sometimes past that, just to make sure nothing's missed. With eight people in the room, ideas fly like ping-pong balls. The excitement rises as we exhaust all the possibilities we can think of and flip the page for more clues on our patient's problem. Eventually, most of our list will be crossed out as we learn more about the problem and its characteristics. But for a few minutes on Monday, anything is possible.

AMSA needs to work on its grammar

2007-10-05T08:16:00.000-07:00

I just sent an email to my congresswoman thanking her for voting yes on SCHIP and continuing support for the bill as it goes back to congress after Bush's veto. And of course you should do the same because this bill will expand coverage to children who otherwise would be uninsured, helping more people in this country achieve a higher standard of health. To me, it's that simple; if you feel differently, please do tell.

But for heaven's sake, don't cut-and-paste what AMSA has written as a letter template:
"As a physician-in-training, your support of the SCHIP reauthorization bill was greatly appreciated...."

What? That means that "your support" is a physician-in-training! People, this is basic stuff. Maybe you should lay off the physiology, or even the health advocacy, for a bit and review English grammar. Maybe it doesn't really matter. But it seems to me that if you want your voice heard, you should at least make sure you're speaking correctly.

Blog of Events That Occurred During JMP Late Night Lit Review

2007-09-27T09:59:00.000-07:00

I can't take credit for this....

9/26-9/27/07

11:09 – David has Coca-Cola poisoning. Will has decided to watch family guy and eat Top Dawg. Andie seems to be progressing nicely now that she has a picture of Barry Bonds in front of her. I am very . . . very . . . . upset about this lit review.

11:10 – David is laughing at me. Looks like I’ll be the only one to be contributing to this blog.

11:24 – I saw David put his head in his hands.

11:25 – Will is living in a state of ignorant bliss, still watching Family Guy without an inkling of consequences.

11:26 – David hit his funny bone – it wasn’t very funny. Group seems to be turning on Andie – she has too many resources.

11:28 – David: “I have no idea how to do this. What am I doing.” Will tells Matt that he is spending more time on the blog than on the lit review.

11:41 – Matt considers buying another cup of coffee for the second time in a half hour.

11:48 – Guy Micco shows up and said, “This is sick.” He asks us what we are doing here. We ask him the same. e gives us figs.

11:49 – Discussion of the movie “The Ring.”

11:54 – Discussion of getting McDonald’s breakfast in a few hours. Good discussion.
MIDNIGHT
12:11 – Will is asleep on the couch. Will thinks he’s better than us – he is wrong.

12:20 – Will has reverted to referring to himself in the third person like Bob Dole.

12:33 – Andie denies just hitting her funny bone.

12:34 – Realizations all around about how hepatitis, a disease of the liver, is aptly prefaced with the prefix “hepat”.

12:46 – Fantasies about large fans being installed in the Fun Room commence.

1:05 – Will is missing.

1:11 – Will is still missing. David states time, followed by Matt making a rule that there is no more mentioning of time.

1:14 – Will is back.

1:55 – Group decides to address the problem of the Fun Room having a hell-like temperature by putting the fan in front of the open refrigerator temporarily.

1:56 – David is hungry, and proceeds to have moral dilemma over whether or not to steal yogurt from the Fun Room fridge. He ends up taking it.

1:59 – Discussion of erections – strangely not awkward.

2:37 – Jason is discussed as character in a martial arts movie – he would be a wise and uniting influence.

2:39 – We discuss the highlights of JMPers zoning out; focus on Nicole.

3:06 – Matt loses it – lashes out at Will.

3:07 – Will loses it – barricades himself with pieces of paper.

3:08 – Nicole loses it – yells “I can’t take it!” bangs her hands on the table, and then makes an odd screeching noise.

3:25 – Group discovers levers on left side of chair – great fun!

3:36 – Another unjustified lashing against Will. Matt feels bad, but will not tell Will. Will retaliates by threatening to shave half of Matt’s head.

4:38 – Discussion topic: is the word “sequalae” in vogue? If so, why?

4:51 – Nicole is taking a nap on the couch.

4:59 – David is done.

5:09 – Will is taking a nap on the couch.

5:28 – Will is up.

5:52 – Matt leaves.

Coffee Shop Sociology

2007-09-23T23:09:00.000-07:00

I'm extremely unfocused when I'm at home. Too many distractions are too tempting: a kitchen full of food, an internet connection to play around on, a room that always needs straightening. So I often pick up and go to a coffee shop, where $1.50 for a small coffee also buys me a few hours of relatively focused study time.

And usually at some point during the coffee shop outing, I'll have to make a bathroom run. Who wants to pack up all those papers, books, pencils, and sometimes computer, only to lay them all back out again a couple minutes later (and feel guilty about sitting down without having bought anything new)? Not me. So I usually turn to the person next to me and ask, "Will you watch my stuff for a minute?" And every once in awhile, the same will be asked of me; I'll always comply.

So I got to musing: this is a weird phenomenon. I don't know the person sitting next to me any more than I know the prospective thief of my stuff. Why would I trust him or her with my stuff? I guess there's the factor of sameness -- because that person is a coffee shop-goer just like me, I feel a kinship with him/her. But probably not trust. Moreover, why do people agree to watch others' stuff, and comply while those people are away from their seats? They can't have built a friendship while sitting nearby sufficient to really care if that person's stuff is stolen or not. The best I can come up with is that people avoid conflict whenever possible. They don't want to make a scene out of refusing to watch someone's things for just a few minutes, nor do they want to deal with the resulting scene if a person returns to find his/her stuff missing. Hm.

I tried googling "watch my stuff", really the only permutation of this request, and got this video made god-knows-why by some Columbia business students. It's not really that funny, but it is appropriate.

Bike accident, one week later

2007-09-20T17:04:00.000-07:00

Most of the injuries are healing just fine, and I'm back on my bike, very cautiously this time around. One interesting aspect, though, is that I now have two red bruises on my arm that just appeared there yesterday. As in, eight days after the accident. And I don't even think there was direct impact to the site where one of these has shown up. Is this weird? Anyone out there have experience with delayed bruising? According to my classmates, I either have leukemia or hemophilia. Thanks, guys.

What situations like this make me realize, though, is how happy I am to be in a problem-based learning curriculum. It's not just that I have two funky bruises on my arm; it's "huh, I have two funky bruises on my arm. I wonder if I can find more information on that which could tell me how weird that really is." It's a sometimes tortuous process that means you're always looking for more information, but it has the excitement of a detective chase. I'll try to post more on PBL in the future, which probably won't be hard, as it dominates my life these days.

Doctor, heal thyself

2007-09-12T22:50:00.000-07:00

I'm really going to kick myself for taking that title so early in the blog's life; I'm sure I'll need it later.

But it is appropriate here. The story goes:

Yesterday was our first day of preceptorships, a sort of guided clinical rotation series, in which we're paired with real live physicians who give us an introduction to patient interviews and exams. We know nothing. We're all nervous. I manage to run a little late as I leave the house and get on my bike, speeding down streets I don't know so well.

At an intersection, with typical "biker's arrogance" (I just made that up, but you know what I mean, don't you?), I edge under a red light -- and am hit from the side by a car in the far right turning lane, who hadn't seen me coming and is taking off as the light turns green. My bike and I are knocked down, and I land on my side, my helmet the last thing to hit the pavement.

And, I'm fine. I'm a bit scraped up, and am paying $90 for a new back wheel and for fixing the front inner tube, but mostly I'm thankful that I got off so easy. I even made it to the preceptorship in time for a really fascinating morning. It could easily have been much worse: according to the Harborview Injury Prevention and Research Center at the University of Washington, over 500,000 people in the U.S. end up the ER every year because of bicycle accidents. The lesson here for doctors, doctors-in-training, and everyone else: nothing is so important that you should speed through a red light. Have some perspective, and think about your health and safety.

And, tonight is the first night of Rosh Hashana. Happy New Year, and remember to wear a helmet.

Anatomy backblog #2

2007-09-09T22:13:00.000-07:00

There's always something funny about struggling through a new situation. It's the teetering on the edge of panic that, if you have enough perspective, can be hilarious. This feeling is magnified if you're a first-year medical student trying to get a grasp on your first experience with a human body.

Don't get me wrong -- there are plenty of sobering, reflective moments too, when you're working with cadavers. But there's a certain humor in the oh-my-god-why-did-they-let-me-do-this-when-clearly-I'm-a-bumbling-idiot feeling of being handed the responsibility of cutting into the body of what was once a living, breathing, human being.

"Stay calm," I would try to tell myself, scissors in hand, not sure whether to laugh or burst into tears, but pretty sure neither of those would be useful, "she's already dead. There really isn't much you can do now to change that." It probably helped a little. But I still managed to cut off a few arteries that should have been kept on, create a knotted mess of the small intestines, and put the liver in backwards in front of my instructor. Not my crowning achievement.

Or, during a pre-exam study session, when we were all a little more on edge than usual. We were grouped around the thigh, trying to find the sartorius muscle, which, because the deep dissection was already done, had been cut and pulled back to who-knew-where. We picked up candidate muscles: "hm. No -- rectus femoris." One of my classmates picked up a testicle. Looked at it for a second, hopefully. A voice from behind her: "Uh, that is not sartorius."

We eventually found it, I think. And we did eventually get our bearings on the cadavers, at least enough to lessen the panic a little.

I don't mean to be callous, here. All of us were entirely grateful to be given the opportunity to explore on our own the complex, wondrous bodies we worked with in anatomy lab. Excitement, anxiety, fear, humor: all part of the experience.

Anatomy backblog #1

2007-09-09T22:10:00.000-07:00

We took anatomy over the summer, in a very sink-or-swim start to med school. Fine, they threw us a lot of life jackets. But the water was still cold. Anyway, here are some posts from the summer.

Anatomy is all about mnemonics. There’s so much to remember that without them, you’re lost in a sea of nerves and muscles. A few are actually found in the textbooks: SCALP, for the layers of the (yes) scalp, Randy Travis Drinks Cold Beer, for the brachial plexus, or Some Lovers Try Positions That They Can’t Handle for the names of the carpals. These are generally useful, and sometimes surprisingly dirty. I guess every mnemonic needs something to make it memorable.

Then there are the mnemonics that we make up ourselves. Some have already taken their places in history among my classmates. For the pronunciation of the acetabulum, many of us – probably due to those agonizing years of studying chemistry – wanted to pronounce it with an accent on the second syllable, when really the accent goes on the third. How to remember this? Said one of my classmates: “I just remember that Tab tastes like ass.” Or, how to remember that the visceral layer is always deep to the parietal layer? Another classmate: “I think about VIPs: they’re never on the outside. They’re always on the inside, coming out. But never on the outside trying to get in.” Or, to remember that the Great Vein and the Left Anterior Descending artery of the heart run together? In a Scottish accent: “The Great LAD.”

Often, though, mnemonics take on a personal slant. They work for whoever made them up, because they fit within the organizational wiring of that person’s mind. I’ve had classmates try to describe to me their own brilliant mnemonics, in explanations that are more complicated than the anatomy itself. No wonder that each of our presentations usually includes a tip on how to remember things – if it works for you. We all learn differently, and each person knows his or her mind best. Well enough to know if he’s looking at lovers or just lunates.

Med School Blog, take I

2007-09-02T21:36:00.000-07:00

I threatened to create a med school blog awhile back, but a few things kept me back. There were finals, yes, but mostly it was lack of the perfect blog title. Finally, I found one. The home of my electronic ramblings will heretofore be named for the late Dr. Louis Lasagna, author of the revision of the Hippocratic Oath that I am to take this Friday. The oath is full of compassion and wisdom -- characteristics that any medical student must aspire to.

Well, it's either that or the delicious, layered Italian pasta dish of the same name. Take your pick.