What it means to be a biology nerd

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

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

Truth and its delivery

Photo: Gary Hershorn/Reuters

Two stories from today, which tie together nicely:

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

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

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

It's all in the delivery.

Check me out

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

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

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

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

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

food, choice, and the brain

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)

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

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

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.