Medical School of Hard Knocks

Website Design

2011-05-02T07:28:00.000-07:00

If you or someone you know is interested in having a simple website designed, leave a message in the comments section. When you have $200,000 in student loan debt you become very motivated to reduce it.

Doctor Mortgage

2011-04-11T14:01:00.000-07:00

I have learned way more in the past few days about mortgages than I wanted. In the past, medical students who were under contract at a residency program could get a mortgage for 0% down, 0 mortgage insurance, no prepayment penalty, and at current market rates.

Unfortunately, this exact mortgage is all but extinct with the ongoing financial downturn. The cashier at McDonald's who said his salary was $100,000 ruined it for all of us. That said, there are a few options for those of us with huge medical student loans and little-to-no money down. Here are the current options:

1. Huntington Bank As long as they have a branch where you want to move you are set. They will give you a loan exactly as stated above, given you have a decent credit score. Two notable exceptions: Chicago and Miami, where they do not have banks. This was the company that I went the furthest with, unfortunately I am moving to Chicago.

2. Suntrust Bank Same as above as far as I can tell. Only works if you are moving to a state in the southeast.

3. Other Banks Several other banks have physician mortgage programs that do not count deferrable student loans against you and have some other perks. Unfortunately, most/all require a standard down payment 3.5% for FHA, 5% for conventional loans. Most do not require mortgage insurance, but instead they charge an inflated interest rate (by 0.5% typically). An example of a bank that does this is 5/3rd bank and Bank of America.

Mortgage Brokers Be careful using mortgage brokers as they will either want a set amount money at closing (in exchange for them referring you to a bank) or the bank will significantly raise your rates.

A couple of other considerations: compare packages from multiple banks--you may find that a standard loan will result in reduced monthly payments. Best of luck!

Waiting for Superman

2011-03-30T10:21:00.000-07:00

In "Waiting for Superman," they mention that 1 in 57 doctors will have their medical license revoked, but only 1 in 2500 teachers have their license taken away. Either there are too many doctors being punished, or there are barriers in this country to getting rid of poor teachers.

Failed education has to be one of the saddest aspects of American society today. Without the teachers that I had I would not be where I am today, a few months from graduating medical school. I was one of the lucky ones. They taught me what I needed to know to move on. More than that they motivated and inspired me. They made learning fun.

Here is to all the great teachers of this country. And here's to one of the saddest but most moving documentaries I've seen.

Vertical Gardens, Grown on Walls - NYTimes.com

2011-03-29T13:15:00.000-07:00

“In the rain forest, I realized that plants didn’t need to grow in pots with labels...”

Vertical Gardens, Grown on Walls - NYTimes.com

Some Funny Videos From Wayne State's Graduating Class

2011-03-29T12:54:00.000-07:00

The Ten People You Meet in Medical School (Part 1)

2011-03-28T13:58:00.000-07:00

1. The Questionable Admission

Eighty-four percent of medical students are not in the medical school honor society known as Alpha Omega Alpha. Most medical students work extremely hard while still recognizing the need to relax, spend time with family, etc. Yet even by average medical student standards some people seem to stand out, and not for a good reason.

They pronounce "cation" as CAY-shun. They include alcoholic pancreatitis in differential diagnoses of children. They put on masks when seeing Alzheimer's patients to "keep from getting it." In the operating room they think that a hemostat is for when you need blood in a hurry.

In general, they make you wonder how they ever were able to demonstrate some basic medical knowledge to an interviewer or pass the MCAT--that is until you realize that they have the same last name as the auditorium that you are sitting in.

2. The Gunner

The best known medical student type. They knew from the time they were 3 that they wanted to be a dermatologist and had presented before the American Dermatological Association by the age of 10. They are the students that send emails about how unfair it is that the library is closed from 2-6am. Although they know every inch of the hospital by heart, if you need to know where the nearest movie theater is you're on your own.

3. The Health Fanatic

He works at GNC in his spare time just to keep up on all of the latest supplements and vitamins. He somehow finds time to work out 5 times a week before rotations, even if it meant getting up at 3am while on Surgery. He carries around a gallon jug of water and drinks through it twice a day. He is the definition of physical fitness and looks like he might blow a vein in his neck at any minute.

4. The Grandpa
Who knows what motivates a 55 year old with 6 adult children to enter medical school. Maybe he got sick of his job, maybe he wanted a reason to get away from his daily routine. But seriously, did he ever think about how he's going to be most of the way to 70 by the time he finishes residency. Not only that, but he'll end up paying hundreds of thousands of dollars while only having a few years to make it back, and who wants to be working that hard at that age anyways. When I'm 60 I want to be sitting on a warm beach, not spending 80 hours a week disimpacting my peers.

5. The Guy Who is Just Doing This for the Heck of It
Similar in many ways to the grandpa, the Guy Who Just Does This for the Heck of It is generally older. Through some combination of a fulfilling career/rich parents/well-off wife he was able to amass large sums of money (some of which he likely donated to the school) and plenty of free time. He sits in the back of the room and pesters the lecturers on any point he deems controversial. In the end, all they really want is to be able to stick an MD at the end of their name so that they can attract the opposite sex or endlessly pat themselves on the back, or both.

Problems with the Current NRMP Match

2011-03-28T09:18:00.000-07:00

Fifty years ago the medical community was faced with a worsening problem. In many specialties, the competition for the best and brightest medical students was at an all time high. Medical students were forced to commit to residency programs while still years from graduating, or risk doing residency at undesirable programs. Hospitals were forced to play the game or risk losing out on top applicants. Then the National Resident Matching Program (NRMP) arrived on the scene.

Established in 1952, the NRMP created a new process for residency programs to find medical students. Now programs and students would "rank" each other, then submit their respective lists to the NRMP (first on paper and now electronically. A computer algorithm match medical students to programs, and order was restored to the world. Or at least that is what they want you to believe. From their website:

"The National Resident Matching Program (NRMP) is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education (GME). It is governed by its Board of Directors. Five medical/medical education organizations, one program director organization, and three medical student organizations nominate candidates for election to the Board: the American Board of Medical Specialties (ABMS), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), the American Hospital Association (AHA), the Council of Medical Specialty Societies (CMSS), the Organization of Program Director Associations (OPDA), the AAMC Organization of Student Representatives, the American Medical Student Association (AMSA), and the AMA Medical Student Section. The Board also selects one program director, three resident physicians, and one public member from at-large nominations. Each year, the NRMP conducts a Main Residency Match that is designed to optimize the rank-ordered choices of applicants and program directors. In the third week of March, the results of the Match are announced.

The NRMP is not an application processing service; rather, it provides an impartial venue for matching applicants' and programs' preferences for each other consistently. Each year, approximately 16,000 U.S. medical school students participate in the Main Residency Match. In addition, another 20,000 "independent" applicants compete for the approximately 25,000 available residency positions. Independent applicants include former graduates of U.S. medical schools, U.S. osteopathic students and graduates, Canadian students and graduates, and students and graduates of international medical schools."

Unfortunately, things are not quite as perfect as they would like you to believe. First, the match is expensive. Both medical students and residency programs pay a significant amount of money each year to the NRMP for them to do three things: ensure that medical students are eligible to participate, maintain a website allowing for list entry, and running the lists through a basic computer algorithm. For this they collect roughly seven million dollars per year.

But more than just a financially, there are several problems that arise when one considers the actual mechanics of the match. If you are not familiar with the process, it can be found here. The most simple way of thinking about it is that medical students are guaranteed to match at their top choice if the program ranks them within as many open spots as they will have. For instance if the University of Chicago has 5 spots in their orthopedic residency, then any medical student in their top 5 ranks--who ranks them first--will match there.

As you can see from the description, the match really favors residency programs. No matter how much they try to tell medical students that they have the advantage because their list is "looked at" first by the computer, program directors really have the final say. I could want to get into a plastic surgery residency at the Mayo clinic, but unless I am ranked in their top few spots, it is not going to happen. In less competitive specialties students lists are emphasized to a greater extent, but the power still resides with the programs. I do not necessarily have a problem with programs being favored, my problem is more with the deception that medical students have the power to determine their destination.

A related problem is that "the Match" does not actually create the best possible matches. Using the same line of thought as above, a program may match a medical student that ranked them 15th, while not matching a medical student who ranked them first. Although the program may be happy that they got someone from the top of their list, in actuality they are getting a future resident that didn't really want to be there. This seems like a prescription for losing residents who drop out or refuse to sign a contract.

Those that do match did so through a program that is unlike anything else in society. When does one apply for jobs and expect to wait 4 months to find out where they matched. "Well I ranked Subway over Burger King but I'd really be happy going anywhere in my top three..." Intentionally or not, the match has created a system that restricts concrete thinking about where one would best fit in. And because of how closely guarded the data is, it is difficult to determine just how poorly the match performs.

Which brings up another problem. The match is trying to do all things for all people. As mentioned before, the match seems to work best for specialties that are not very competitive such as family medicine. When a program has to rank 300 applicants to fill 20 spots, there is a greater emphasis on where a medical student would like to end up. As described above, this works less well for competitive specialties. Because of this and the lack of information provided by the NRMP, several specialties have formed their own matches.

Those that do not match must either wait another year or take part in something called "the Scramble." During this time, medical students that did not match contact programs that did not fill all of their spots. It is impossible to describe the chaos of trying to contact the a dozen programs that have hundreds of medical students calling at the same time. Because of this many programs that have spots open are filled through back room deals via channels of communication within the specialty.

Having just gone through the match process I can say unequivocally that the system is flawed and in dire need of modernizing. It is expensive and stressful and often does perform its one task well, to best match medical students to programs.

As always, feel free to put any thoughts on the Match in the comments.

The Medical School Forum is Here

2011-03-28T07:07:00.000-07:00

We now have a forum up for asking and answering questions related to medical school and medicine in general. It can be found here. It's like other forums just more intuitive and better looking. Also humble.

A Tongue in Cheek Look at Sites Like Orthogate

2011-03-25T10:21:00.000-07:00

Orthogate is a site where people post "advice" for medical students applying for orthopedic residencies (among other things). In general the posts are mostly self-serving opportunities to tell everyone how great you are, and the advice is usually generic and/or meaningless. This was a lighthearted, wholly made up post that I put together on a page for people to discuss how "the Match" went for them. I've copied this mostly for posterity as it isn't as funny without the context.

"I'm not going to put any of my grades here, because needless to say they are awesome, as is everything else about me. Here are my thoughts on programs broken down into needlessly confusing tiers. By the way, I second what the last guy said about big name programs being overrated, I just liked them the best.

Tier AAA:
HSS: Awesome. Fellows. Awesome. Program director is competent in orthopedics.
Mayo: Awesome. Middle of nowhere. Awesome. Chairman had firm handshake. Mentorship.
HJD: Also in New York. Awesome. Expensive. Nice brunch.
Harvard: Fellows I met told me that they added to the experience. Boston. Awesome.
Iowa/Utah/UCSD/Carolinas: Awesome place that isn't in a huge city. Less awesome when more people find out about it. Great for hipsters.
Pitt : You want second opinion? You ask Freddy Foo twice.

Tier A1AA:
Campbell Clinic : Not affiliated with the soup manufacturers. Beautiful new orthopedic hospital: The Bruce Pearl Center for Orthopedics.
Duke : Had one or more trauma attendings if I remember correctly. Anti-Arizona bias noted.
Colorado : Create your own unsubstantiated rumors here (especially if you are an MS1 and you heard this from your friend who is an Ob/Gyn).
Washington : Harborview ER. Rainy. Historically, many residents find fellowships.
Grand Rapids : Rotate through trauma and sports during residency.
Tier 1AA (Residency Championship Subdivision)
UCSF : Residents smiled frequently on interview day.
Yale : Cumbersome application requirements. Maine is beautiful in summer.
Beaumont : Family and dog friendly, but not both.
WashU : Best free weights of any program south of Wisconsin.
Miami/LSU : Receptive to sexual favors.
Dartmouth/Hopkins/Columbia/Brown : Patients will have no idea that your training was no better than at Henry Ford.
U of South Alabama : Guaranteed to catch a whiff of James Andrews cologne at least once during residency.
Minnesota : In alternate years prefer either non-rotators or rotators, please consult website to determine value of doing rotation.
Med Coll of Wisc : Those lacking ovaries need not apply.
Wisconsin: Those with ovaries need not apply.
USC : Those lacking ethnic diversity need not apply.
Detroit Medical Center : Will interview anyone.

I'm losing focus here as I only did a 4 hour workout today. Maybe I'll add to this after hanging with the brahs. Oh and I matched at a SUPER PRESTIGIOUS SECRET PLACE that is not EVEN ON THIS LIST. Hope this is helpful!!!"

The original thread is found here.

Match Day

2011-03-07T04:20:00.000-08:00

Match Day is fast approaching! Only 10 days until everyone knows where they will be spending the next 3-7 years!

2010-12-09T08:11:00.001-08:00

On the road to Dartmouth for the 4th interview this week and 5th overall. Very tiring. Trying to write down thoughts on programs before I forget.

2010-11-20T18:40:00.001-08:00

Lots of questions asking "why did you apply here." Never answered "rather be here than Witchita" which would've been closer to the truth.

2010-11-20T18:13:00.001-08:00

Kicked off the interview season today. What an awkward/interesting process. 5 interviews in 5 hours, with 60 students for 4 positions. Good to have one done.

Orthopedic Pimp Questions

2010-07-17T23:32:00.000-07:00

Here is a list of questions that I'll add to from time to time of ortho pimp questions I have been asked/heard people asked.

What is the innervation of the three muscles that insert as the pes anseurinus?

What are all the muscles that insert on the scapula?

What is the muscle belly of the iliotibial band?

What is worse regarding ROM lost, a subtalar or talonavicular fusion? (TN)

What composes the nucleus pulposis and annulus fibrosis--in detail?

In the OR:

What nerve is in danger with this incision?

What is the innervation of this muscle? As mentioned before, much more rarely are questions re: origin and insertion asked-- don't waste your time knowing the 3 main arteries to the knee if you don't know the innervation of the tensor fascia lata.

What muscle is this?

Why can't I use the cautery on the Mayo stand? (Only patient is grounded)

What are the layers that I will be cutting through? More commonly asked in gen surg than ortho

As always, feel free to add other questions you have been asked in the comments.

Secrets to Orthopedic Away Rotations

2010-07-17T23:19:00.000-07:00

Here is a quick rundown of what I've learned and been told about how to thrive while on an orthopedic away rotation.

First and foremost, as I'm sure you already know this is a tryout. It's a chance for you to try a program on for size, but moreso it is a chance for them to see what kind of resident you might be in their program. It's easy to slip into the mindset that just because you graced them with your presence for a month that they are going to think better of you. Not so. In fact that is why on average it is a lot easier to hurt your chances of getting into a program by doing an away than it is to help your chances. The all encompassing first rule of away rotations is: always work hard.

What are some of the ways you can shine? You can prepare the notes before the resident's arrive in the morning. Perhaps it is just where I am at, but unlike general surgery, it seems that the residents do not care (and may even prefer otherwise) if you see a patient in the morning before they get there. They seem more concerned that the actual rounding process is streamlined. Regarding the OR and pimping, the most important thing to know is anatomy. Most commonly you'll be asked questions such as "What nerve is in danger with this incision," "What muscle is this," etc. Expect more nerve-muscle questions than insertion, origin and action questions.

When in the operating room, assume that once you are given a role once, they expect you to fill it from that time onward. For instance, some common tasks are adjusting the lights, sponging up blood in the field, and using the suction. Additionally, one should be familiar with deep tissue, subcutaneous, and skin closure so that when the attending asks if you are comfortable doing so you don't respond by saying something like "we'll I only saw it once..." Another thing to mention: when the resident or attending moves towards where you are standing, you should move to the other side of the table, they won't always take time to say "Hey can you switch positions with me."

Another OR tip: when retracting don't worry about them repositioning the retractor frequently. It is likely nothing but them wanting it in a specific place and not a commentary on how you are doing. You'll likely notice them doing the same thing with the residents.

The biggest thing that programs are looking for is hardworking, teachable medical students that appear to be engaged in the case or lecture, with whom they can get along with on a day-to-day basis. Most of the time they would rather have the above student as a resident than one that is just the best at answering all of their pimping questions.

Hiking Mt. Olympus

2010-07-17T22:07:00.000-07:00

After hiking Mt. Olympus (Utah) today and nearly requiring LifeFlight to get me off of the mountain, I thought I might share a few thoughts that you will not easily find on SummitPost or other similar sites that dramatically oversimplify some of the challenges that you will face. But before I get ahead of myself, here is the rundown of what happened and the mistakes I made.

Starting out around noon (aka the "Hottest Time of the Day"), I parked just down the street from the trailhead, along Wasatch Blvd. I had read on a few pieces on climbing Olympus that there were more cars broken into in the parking lot that there were windows shattered along the street--a rumor that was denied by several people that I met on the trail. But going back to the start time, if you are from a humid state such as the southeast or midwest you will be unpleasantly surprised at how hot it is. The temperatures were in the mid-90s, but because it is so dry here it felt like high-70s and I thought nothing of it.

After starting out at a decent grade out of the parking lot, you enter a series of open switchbacks with low vegetation and great views of the valley. There are a few spots with minimal exposure, but for the most part the trail is extremely safe. In my mind the trail has four segments: the first segment contains mostly scrub brush and grasses.

In the second segment, you enter an area of low trees mixed with increasing amounts of rock that you have to navigate as you climb. In the middle of the summer, this segment also contains your only source of water on the hike in the form of a small stream. Many other sites talk about how it is a steep hike that is only 3ish miles each way, but you would be surprised how fast you go through water, especially if you have not fully acclimated to the altitude.

The third segment of the trail has higher trees, steep grades and significant amounts of rocks in the trail that will slow you down. Many times you are walking in a tunnel of foliage with increased humidity.

The final segment is what I found to be the most grossly underdescribed in other websites. This is the segment of the hike above "the Saddle," a flat segment of ridge that gives great views to the east.

First of all, if this is grade 3 climbing then it's 3.9. The last 45mins or so of the climb is a lot closer to grade 4 climbing than it is grade 3. When I think of grade three climbing, I think of the kind of climbing that is necessary near the summit of many Colorado peaks where you are going up and over some low boulders but would not fall/roll more than 20ft in a worst case scenario. The last bit of climbing on Olympus has significant exposure in several spots and requires at least minimal vertical climbing skill, more than your average mountain hiker may be comfortable with, especially considering many hikers on Olympus are lugging decent sized packs up, which significantly alters one's center of gravity. Never mind my biggest pet peeve about this segment.

Utah. I get it. You are all about the "go for it, and if something goes wrong, maybe we'll be able to help you before it is too late." I also understand the massive amount of wilderness in Utah. But this is probably the second most popular hike in the SLC area! This is a trail that has 12 year olds and 70 year olds on it. And yet there are zero markings as to the trail above the saddle! Not only is this incredibly dangerous, but it also means that you waste large amounts of energy coming back down as nearly everyone takes different paths and has to double back when they hit a 10 foot drop off. In other words it's manageable on the way up but can be disastrous on the way down.

I got in a situation where I was so low on energy that I had to continue down despite the fact that it was much much more dangerous and exposed than the path that I went up on. There were times where a slip backwards would have almost certainly meant broken bones and likely worse. Not only is the trail marked at all, but there is a grand total of two cairns to help one navigate down, and one of them is next to the mailbox at the summit! It's no surprise that in the past few years a number of people have died.

To wrap up my meandering story, although I brought plenty of water I quickly dried up the available calories in my body and became so nauseated that I could not get a dry granola bar to go down--so I called for help. Luckily as the trail is mostly on the valley side, you should be able to get help if needed. I had become so weak that I was afraid of falling down the trail, even though I was back in the 3rd and slightly less steep stage. I had to just sit and wait until my friends could help me by bringing some zofran (anti-nausea) and some liquid energy.

Was much of this my fault for leaving on a hot day at the hottest time of day? Yes. Should I have brought more calories with me? Yes. Are there dangers inherent to climbing Mt. Olympus that are not described on other sites? Yes. I hope that if you are like me and searching out info about the climb that you be sure to start early, budget extra time, and take extreme caution above the Saddle area if you plan on summiting. Multiple people die here every year, if you are like me you may underestimate how difficult the grade is, especially if you are used to the typical Colorado 14er which rises a mile in 7 or more miles walked. Feel free to share your Olympus stories in the comments section.

PS these images are my own, please do not copy them onto other websites without permission as they are protected.

Last Objective Medical School Ranking

2010-06-28T17:32:00.000-07:00

Here is the last time that the NIH compiled statistics regrading research dollars to specific medical schools. Harvard ranked 26th... I'm sure they have a great personality.

Medical School Rankings / Top Medical Schools

2010-06-28T16:39:00.000-07:00

Every year US News and World Reports ranks medical schools based on a complicated process of assigning varying values to different criteria. For instance, how much research is performed at a given institute is put on a scale of 1-10. Quite frankly, this is a very asinine way of going about things.

What they really did was determine what schools would be considered the consensus top 5 schools based upon reputation alone (Harvard, Hopkins etc.) and then devised a system where these schools ended up on top and the rest of the medical schools fell into place somewhere behind.

Does anyone look at these from year to year? Oh look! Harvard is back in first this year! Hopkins sure had a good run going! How ridiculous! But they can do one better!

Now the braintrust over at US News has created a ranking system even more backwards. Did your 2 years of advanced chemistry during undergrad foster an interest in Geriatrics? Better find the best school for preparing you for your future career! Never mind that 99.999% of students either change what specialty they were interested in or seriously consider other options.

And how would you rank medical schools for how they prepare you for a career in geriatrics. Do some medical schools have especially old cadavers? Is the average age of the faculty >65?

Here are my thoughts: talk to medical students, talk to doctors--evaluate the advice they give you and see if it applies to you. At the end of the day it really doesn't matter where you end up. Got into Hopkins, Penn or Harvard. Congratulations! Now whenever you introduce yourself people are going to think that you are either grandpa gave a sizable donation to build a new library, or that you sold yourself as some oppressed Eskimo-Latino who grew up as the son of toilet assembler only to survive mean streets of Malibu and USC.

In other words, you are probably better off going where you know nothing is going to be handed to you. Newsflash: in California they won't know the difference between Wright State and Wayne State, so you better spend your time in med school wisely, e.g. study hard for Step 1 and get some research done during your four years.

Your thoughts?

A Funny thing Happened on the Way to the Cadaver Lab: An Open Thread of Interesting Hospital Occurrences

2010-06-28T16:25:00.001-07:00

I've mentioned a few stories that have stood out to me in my four years of medical school. Now it's your turn--through the years hopefully we'll come up with some good ones. Other health-care workers feel free to share your funny stories.

Saving Money In Medical School

2010-06-27T06:05:00.000-07:00

In medical school one is given large loan "disbursements" at two times every year. Because very few people have any other source of income, you can minimize the amount of debt that you end up with by following several rules. I'll list them from most-to-least insightful:

1. Invest Extra Loan Money

At every disbursement, transfer 50% or so of the money into a brokerage account. This helps in many ways. First, since the money is no longer in your bank account, there will be a psychological effect of thinking that there is less money for you to spend. In effect, even if you aren't one to make a paper budget, we all still spend with an idea of how far we need to stretch out our money.

The second benefit is that many of these brokerages, such as TD Ameritrade (which I use), will give you 5 free trades. What this means is that you can transfer your money into a short term CD, safe stocks, or a mutual fund without paying $10 to put your money in and take it out.

Of course, they hope that you fashion yourself Gordon Gekko and move your money in and out of different stocks, thereby making 6+ trades and giving them money. You are smarter than that. Additionally, if all you do is move 50% of your money into the account at the start of the year, you will get close to 1% in interest, which is better than you would get from a bank's savings account.

In short, if you can put the money into a CD or mutual fund you may even be making money on the loans (depending on the interest rate), which is much better than losing 4-6% as the interest piles up in a checking account.

Feel free to compare TD Ameritrade to other sites, I like them and they are not giving me anything to push their site over any other.

Not a good idea with loan money:

2. Make a "Per Day" Budget

Take all of your monthly expenses: rent, car payments, gasoline, groceries, cell phone bills, etc. and put them in an excel spreadsheet. Then divide them by 4.3 (or whatever Google tells you is the number of weeks in a month) to show how much each thing costs per week. Then break that down into per-day expenditures.

Not only will this give you a rough idea of how much discretionary money you have on a day-to-day basis, but it may also give you insight into areas where you can save. For instance, my wife and I found that we could save close to $3,000 if we were able to pay off our car loan early.

You may find that you are saving more, if only to see the amount that you could be saving per day increase. In other words, it can become a game where you are rewarded for saving, by picturing what you could do with that money, e.g. spring break trip or new bike.

Hope these are helpful, they have both helped me tremendously, feel free to post other tips in the comments section.

Can I Get Into Medical School? An Open Thread

2010-06-25T06:24:00.000-07:00

I thought I'd make an open thread for prospective medical students to ask questions and I'll do my best to answer them a-la Dear Abby. Feel free to post other experiences/frustrations you have had in trying to get into medical school.

If Shelf Exams Actually Were Representative of What You Saw in the Wards

2010-03-17T14:57:00.000-07:00

Pediatrics
1. A 7 year old female presents to the clinic with a three week history of looking "not quite right." This is her third visit in the past four days. The patient's mother is on disability due to cologne exposure at work, and the patient is uninsured. Her mother states that she has been having fevers as high as 37.2 (99) degrees and has been having early morning awakenings, e.g. 8am. Physical exam, family history, and past medical history are benign, but limited due to the patients use of her Nintendo DS during the exam. Her mother states that she had a cousin who was sick with HIV that felt better after receiving antibiotics. What tactic might keep the patient from returning to the office in the next 24 hours.
a. Give gentamicin, hope for an adverse effect that requires a ENT consult
b. Tell the patient the office will be closed for the next week
c. Give the mother a prescription for Valium
d. Put them in the waiting room for 4 hours before telling them their rapid strep was negative

Surgery, Medicine, Neurology, Family Medicine:

2. A 46 year old male presents to the clinic with unbearable pain. He leapt unto the exam table like a Russian gymnast when no one was looking but now winces and moans in pain when the stethescope is placed on his chest, despite the fact that he complains of knee pain. All radiographic studies have been negative. He begins the interview by offering that he "isn't looking for pain meds or anything." In fact, he's never been better--in order to keep feeling better he just needs a few more vicodin to get him over the hump. When you ask how much he would need for a month he says "I don't know man!" When you write a prescription for sixty 5/500s he goes ballistic and accuses you of not "understanding" how much pain he is in. His unkempt wife sits in the corner shaking her head scoldingly. What is the next step.

a. Keep the patient from getting between you and the door

b. Refer to chiropractic care

c. Give daily cortisone shots for a week

d. Recommend physical therapy

to be continued...

Amazon Seller's Account (or The World's Worst Customer Service)

2010-02-02T17:26:00.000-08:00

Being a medical student, you go through a lot of books. From the first day of school when you are told to purchase a dissection guide, Grey's Anatomy, Netter's, and a book of pictures of dissections, we collect lots of books that are nice to have for the 4 months of the course but have little value otherwise.

I thought I would be forever condemned to keep bookshelves full of useless materials--then I found the Amazon Seller's Account, but first a little background.

I've been buying books off Amazon for years. I'd estimate that I've spent a couple thousand dollars, both on books for myself and medical books that I've needed for courses. So you can imagine how excited I was to find a seemingly easy way to resell the books.

So within a few minutes I had opened an account and listed all of the old books that I wanted to get rid of. Keep in mind I had never opened an account before. Imagine my surprise when I received this email from Amazon within 6 hours of opening an account.

Hello from Amazon.com.

We are writing to let you know that we have blocked your selling account. Your open listings have been canceled and you may no longer sell on our site. Any subsequent selling accounts that are opened will be closed as well.

We took this action because it has come to our attention this account is related to an account which has been previously blocked for performance issues or violations of our policies. While we do not provide detailed information on how we link related accounts, we have significant evidence that this account is related to a previously blocked account.

While we appreciate your interest, please understand that the closure of an account is a permanent action. Thank you for your understanding with our decision.

Regards,

Seller Performance Team
Amazon.com

First off, who's idea was it to send out form emails like this to valuable customers, especially if there was a chance they could do it in error. For someone who puts value in their word in commitments they enter into, it was very offensive to hear these baseless acusations.

Clearly Amazon had made a mistake as I had never opened an account in the past. I expected that a quick email would be all it would take for them to correct what must have been a clerical error--how wrong I was. Here's the next email that I received in response.

Greetings from Amazon.com

I have verified that your account has been blocked by our Seller Performance team on January 30, 2010. Please e-mail them at seller-performance@amazon.com regarding the status of your account. You may also reply to the block notice in the Notification page of the Customer Metrics section in your selling account

For more information, see our Help page on Appeals for Suspended or Blocked Accounts:
http://www.amazon.com/gp/help/customer/display.html?nodeId=200370580

Questions about your funds should be directed to our Payments team at payments-funds@amazon.com.

These departments do not offer telephone support. However, they will respond to your e-mail as soon as possible.

For more information on your Seller Performance ratings, please visit:
http://www.amazon.com/gp/help/customer/display.html?nodeId=12880481

Thanks for being part of the Amazon.com online community. I do hope this message finds you well and I wish you all the best in all of your future online sales.

Best regards,

Carlos V.
Amazon.com Seller Support

Clearly this was another form email--Amazon may not have any problem accusing people of wrongs they haven't done, but I guess they have difficulty actually responding to emails sent in response.

In my final email I stated that because my issues were in no way addressed I would be canceling my Amazon credit card and never purchasing from them again. Here was their response (note: in my email I never mentioned being "singled out" this must've been their email they send out to people who don't just give up and allow their name to be dragged through the mud..

Hello from Amazon.com.

We apologize that you feel singled out by our actions, but want to assure you that is not our intention. Be assured that our policies apply to all sellers.

We regret we are unable to provide further information on this situation. Further correspondence regarding the closure of your selling account will not be answered.

The closure of this account is a permanent action. Any subsequent accounts that are opened will be closed as well.

Best regards,

Seller Performance Team

Needless to say, if others are dealing with this problem, Amazon is going to have some PR difficulties in the future.

Update: This is the 5th ranked site in Google when one types "Amazon Seller's Account"! Which is great! I feel like in some small way I am "sticking it" to "the man," for how despicably they treat their customers. If reading this and having a similar problem, please share your story in the comments section so as to help get the word out.

Young Hearts and Lauren Hill

2010-01-09T17:37:00.001-08:00

Yesterday we had a review of EKGs. When discussing EKGs the cardiologist mentioned that "Young hearts may demonstrate U waves." All I could think about was asking him if young hearts beat free tonight.

A week ago a woman named Lauren Hill came to the hospital to teach as about diversity. I wanted to ask her if she was familiar with the fact that: girl you know you better watch out, some guys, some guys are only about. That thing, that thing, that thiiiing.

I'm easily distracted.

The Ambiguous Psychiatrist Sound

2010-01-09T17:22:00.000-08:00

What do you do when your goal is to elicit as much information as possible from a patient while neither supporting nor condemning their thoughts/actions? The answer is the ambiguous psychiatrist sound.

It's somewhat hard to describe if you have never heard it firsthand, but I'll do my best.

It somewhere between "Mmmm" and "Hmmm" but it isn't just the combining of the two sounds "Mmmmhmmm" because if you aren't careful "Mmmhmm" can come off as sounding condescending or disbelieving.

Instead it is almost an impossible fusion between the two sounds. As if you could be saying both Mmm and Hmm in the very same instant. It's best used with a gutteral, breathy not to disguise any possible inferences that a patient could possibly derive from the sound. Additionally, the best psychiatrists can include an almost imperceptible rise in pitch at the end of the sound to further confuse the patient as to whether it was questioning or affirming.

It's like saying "I respectfully want to inform you that I'm listening but I want you to clarify, if you are able" but with the simplicity of one syllable. In short, it is the perfect sound in the hands of a skilled practitioner and it can work wonders on the psych ward.

Health Care Reform: Medicine vs Surgery

2009-11-19T09:04:00.001-08:00

Lost within the political debate over healthcare reform, is a battle currently going on within medicine itself. Although most if not all doctors agree that there needs to be significant changes to the health care system, there is significant debate as to what exacty this should entail. Before I get too far ahead of myself, let's go back to the opening salvos...

In response to this statement the American College of Surgeons released the following letter, which goes on to decry the gross exaggeration of what a surgeon makes on a given operation. In addition it states that misinformation regarding healthcare does nothing to further the debate, adn that the surgeon patient relationship could be damaged as a result. Also, interesting is the many surgical subspecialties that signed on to the letter. This was not just the American College of Surgeons (ACS), but it also included everything from the American College of Obstetricians and Gynecologists to most if not all of the surgical specialties (Urology, Orthopedics, ENT etc.).

More recently the American Medical Association (AMA) has come out in support of the current legislation that passed in the house relating to health care reform. In a letter to Speaker Pelosi, the AMA applauded many of the proposed changes that the bill would enact--specifically they stated that the bill would expand coverage, reform the insurance industry, and protect patient-physician decision making.

Not long afterwards the ACS shot back with this letter to the senate, cosigned by 21 other specialty organizations. It rebutted several of the points made by the AMA and focused on several key issues that it had with the bill.

Additionally they reaffirmed the need for Tort reform in this statement:

CHICAGO: The American College of Surgeons applauds Democrats – led by House Majority Leader Steny Hoyer (D-MD) – for recognizing the need for Congress to address medical liability reform as part of the overall health care reform bill currently under consideration. Over the past few weeks, we have been encouraged to have heard Democrats and Republicans across the country talking with constituents at town hall meetings about the need to address this important bipartisan issue.

The current climate in this country is one in which surgeons and other physicians are forced to practice in an environment of defensive medicine, sometimes ordering additional and possibly unnecessary tests in order to avoid lawsuits. Addressing medical liability reform as part of the overall health care reform bill will help to stem the tide of rising health care costs.

The American College of Surgeons urges President Obama to make medical liability reform a more central component of his call for overall health care reform. Further, we urge the leadership of both the House of Representatives and the Senate to include this important issue in the bills that they will take up in the coming weeks.

Here is President Obama speaking to the AMA regarding Tort reform.

Recently, the ACS has released a side by side chart of the House and Senate bills, along with what they view as some of the drawbacks.

The battle lines seem to have been drawn, with the AMA standing with the president and the majority of the Democrats (except Tort reform), while the ACS and most Republicans stand in opposition (although both groups support repealing the Sustainable Growth Rate provision--something opposed be most Republicans and some Democrats). It's interesting to me how this has happened, I wonder if the average surgeon would describe themselves as being right-leaning politically and the average medicine doctor would say they are left-leaning, or whether this is just how the chips fell in this one instance.

Surgery - The Start of Third Year (Part 1)

2009-11-16T08:25:00.000-08:00

After two days of ortientation both to the hospital and the surgury rotation in general we were finally able to start getting our hands dirty learning the basics of general surgery. I was both extremely nervous and very excited, nervous that I would make some glaring mistake, nervous that I would ask stupid questions and be thought of as a student not deserving of the trust that was placed in me, nervous that I would not be able handle the long hours associated with the surgical rotation, but most of all just nervous that maybe I was not going to be able to cut it as a clinical medical student. At the same time I was also very...

Excited. Excited that I never again would spend days on end studying for a (mostly worthless) biochemistry test. Elated that I was now going to be working with real patients. Overjoyed that I was going to play some small role on a team that was working to help heal patients. Needless to say it was a time marked by dramatic mood swings.

Before I get too far, I should give a little more background.

The surgical rotation that I am on does mostly common general surgical procedures, for instance gall bladder removals, appendectomies, thyroid and parathyroid surgeries, some melanoma removal and emergent surgical cases.

The service that I am on is specifically a trauma service, so over the course of the next 6 weeks I'll be helping to take care of a lot of patients who have been in a car accident, or fallen and broken bones, or patients that require an emergency appendectomy or other urgent procedure.

I found all this out during the first two days of orientation, but nothing that they tell you during orientation could prepare you for the experiences and emotions that you will feel as you walk into the hospital on your first day of work.

Immediately I met the chief of the service--for the unindoctrinated, the chief of the service is a doctor who is in the final year of their residency, in general surgery this means that they have been out of medical school for 5 years. In my situation the chief resident had been a doctor for 6 years as she had taken a year to do a fellowship in critical care.

Also on the trauma team was a first year resident, aka an intern. At many hospitals, about half of the interns are on a track to become general surgeons while the other half are either in a year-long "preliminary surgery" program or are in a "transition year". For the most part, those in those in the "preliminary surgery" program are either US or international students that didn't match into the surgical specialty they wanted to (ortho, ENT, general surgery, etc). Students in a transition year have already been accepted into other programs, but as part of their training they rotate through different specialties for their first year. For the first month we had a transition year student who was accepted into the Radiation Oncology program, and the second month we had a Preliminary Surgery resident.

I was very fortunate in that I was on a relatively small team for my surgery rotation. In other hospitals, 4 medical students would be assigned to teams of 10 residents. The major difference between our 3 person team and the larger teams seen at other hospitals was the lack of mid-level residents on our team. In other words the 10 person team would have a number of 2nd, 3rd, and 4th year residents sharing the workload. The downside to a small team is that when there are 40 patients on the rounding list for a Saturday you only have the three of you to see them all. The upside is that many times in the OR it was just me, the attending and the chief resident doing a case. Which for me was the most interesting.

Start of a New Chapter

2009-07-11T06:10:00.000-07:00

A week ago I started a new chapter in my medical life; 3rd year rotations. It has been a huge adjustment, but a very fulfilling one at the same time. No more speding days on end with my nose buried in a book. From now on the majority of my learning will be hands on.

When I have the time I'm going to be writing about the experiences that I have while on rotations so that I can someday look back and remember what it felt like to be just starting out.

For my first two months I am rotating through surgery (which I first saw as a curse but am now really enjoying) at one of the busiest surgical centers in the country (in terms of # of surgeries at this hospitals three sites).

How to Stop Sunburn Itch

2009-06-23T14:51:00.000-07:00

My life was almost cut short by a terminal case of surburn itch this afternoon. In my desperate state I couldn't find a good source on the internet regarding how to stop sunburn itch. Because of this (and its remote connection to the medical nature of this blog) I decided to describe my own experience and create a "comment forum" on how to possibly remedy the condition.

Before I continue, let me clarify something: this is regarding the pain-from-getting-burned-just-stopped sunburn itch, not the my-skin-is-peeling sunburn itch.

Here is the backstory:

After spending some time near the equator, I developed a whopper of a sunburn. For a few days I had some difficulty sleeping secondary to the pain the I experienced any time that I moved. Lathering up my back with aloe and other mosturizers, by Sunburn Day 3 the pain was starting to abate and I figured that I was just about out of the wood. Then the unthinkable happened.

I was minding my own business (standing on the street corner when these two guys started to make trouble...wait that's another story), sitting by the computer when out of the blue my back starts to itch.

So naturally I reach around and scratch it. And would you believe it, that didn't seem to help. I keep scraching, but I'm quickly realizing that I need something bigger as I can't scratch my entire back at once, so I run into the bathroom and start frantically grinding my back up against one of the towels that we had hanging up. All this seemed to do was create a kind of itch/pain wherever I last scratched.

This seemed to help for a few minutes, but I was quickly leaving the this-is-mildly-annoying part and entering the I'm-at-risk-for-losing-my-mind phase.

I then tried laying face up in bed and moving up and down, but of course that didn't work. Then I tried arching my back as much as possible (is that decorticate or cerebrate?) as if I was going to do a backwards cartwheel, then curling up into the fetal position--zero help whatsoever.

All the while the itchiness was coming in ever greater waves. My heart was racing and my entire body began to pulsate with each heartbeat. You may think I am exaggerating, but until you have suffered through a good case of sunburn itch, you'll never understand. There were times where I actually considered going into the emergency room, I was that concerned that something serious might be going on.

So here was the one thing that helped: put about an inch of aloe vera gel on your back. I'm assuming it is your back that got burned because, unless your a nudist, chances are you went to the beach with skin white enough to make the Amish proud and decided to spend most of the day face down. Here's the important part: lie completely still, facedown on the bed. I'm sure that after a lot of itching you will be having some involuntary back spasms with how bad the pain is, but the only way to feel better is to keep from moving the burned part.

At first, putting gel on your back is only going to make the itching worse, and you'll still have some lingering itchiness, but it will pale in comparison to how miserable you were beforehand.

Addendum: My wife couldn't believe that I was in as much agony as I was letting on--feel free to point to the comments section of this post when your friend/parent/significant doesn't believe you. Also, feel free to leave comments in the forum if you would prefer. Thanks to everyone who has posted their own stories in the comments section, they always bring a smile to my face.

If you have a second, please click on a link. Every little bit counts when you have 200k in student loans.

Drag Me to USMLE Step 1

2009-06-05T10:26:00.001-07:00

I'm stuck in a never-ending Step 1 studying, phase of life, I'll post some more once I emerge.

Secrets of Happiness

2009-05-12T14:56:00.000-07:00

A Harvard study of which has been running from the 1960s to the present found that there were seven characteristics common to the happiest of the men studied. The characteristics were: mature adaptations (chosing altruism, humor etc in response to difficult situations), education, stable marriage, not smoking, not abusing alcohol, some exercise, and healthy weight.

The complete article can be found here.

Here is an exerpt from the article taken from The Atlantic:

What happened to you?

You grew up in a kind of fairy tale, in a big-city brownstone with 11 rooms and three baths. Your father practiced medicine and made a mint. When you were a college sophomore, you described him as thoughtful, funny, and patient. “Once in awhile his children get his goat,” you wrote, “but he never gets sore without a cause.” Your mother painted and served on prominent boards. You called her “artistic” and civic-minded.

As a child, you played all the sports, were good to your two sisters, and loved church. You and some other boys from Sunday school—it met at your house—used to study the families in your neighborhood, choosing one every year to present with Christmas baskets. When the garbageman’s wife found out you had polio, she cried. But you recovered fully, that was your way. “I could discover no problems of importance,” the study’s social worker concluded after seeing your family. “The atmosphere of the home is one of happiness and harmony.”

At Harvard, you continued to shine. “Perhaps more than any other boy who has been in the Grant Study,” the staff noted about you, “the following participant exemplifies the qualities of a superior personality: stability, intelligence, good judgment, health, high purpose, and ideals.” Basically, they were in a swoon. They described you as especially likely to achieve “both external and internal satisfactions.” And you seemed well on your way. After a stint in the Air Force—“the whole thing was like a game,” you said—you studied for work in a helping profession. “Our lives are like the talents in the parable of the three stewards,” you wrote. “It is something that has been given to us for the time being and we have the opportunity and privilege of doing our best with this precious gift.”

And then what happened? You married, and took a posting overseas. You started smoking and drinking. In 1951—you were 31—you wrote, “I think the most important element that has emerged in my own psychic picture is a fuller realization of my own hostilities. In early years I used to pride myself on not having any. This was probably because they were too deeply buried and I unwilling and afraid to face them.” By your mid-30s, you had basically dropped out of sight. You stopped returning questionnaires. “Please, please … let us hear from you,” Dr. Vaillant wrote you in 1967. You wrote to say you’d come see him in Cambridge, and that you’d return the last survey, but the next thing the study heard of you, you had died of a sudden disease.

Dr. Vaillant tracked down your therapist. You seemed unable to grow up, the therapist said. You had an affair with a girl he considered psychotic. You looked steadily more disheveled. You had come to see your father as overpowering and distant, your mother as overbearing. She made you feel like a black sheep in your illustrious family. Your parents had split up, it turns out.

In your last days, you “could not settle down,” a friend told Dr. Vaillant. You “just sort of wandered,” sometimes offering ad hoc therapy groups, often sitting in peace protests. You broke out spontaneously into Greek and Latin poetry. You lived on a houseboat. You smoked dope. But you still had a beautiful sense of humor. “One of the most perplexing and charming people I have ever met in my life,” your friend said. Your obituary made you sound like a hell of a man—a war hero, a peace activist, a baseball fan.

Don’t!

2009-05-11T09:38:00.000-07:00

Here's an interesting article on delayed gratification, something I'm sure most medical and pre-med students are all too aware of:

Dept. of Science: Don’t!: Reporting & Essays: The New Yorker

Valuable Orthopedic Websites

2009-05-07T16:50:00.000-07:00

Here are a couple of valuable websites that I've looked at:

Orthopedic basics from the AAOS:
http://orthoinfo.aaos.org/topic.cfm?topic=A00274&return_link=0

A listing of all orthopedic programs in the US:
http://www.orthosurg.net/orthopedic-residency/programs.asp

A site of everything otheropedics, that I haven't used much myself but that other's have recommended:
http://www.orthogate.org/

Questions to Ask While Interviewing for Orthopedic Residencies

2009-05-07T16:38:00.000-07:00

A little preparation can go a long way to showing your interest, this was provided by one of the fourth year students:

General Questions
What is the structure of didactic curriculum?
Is there time allotted for electives?
Do the residents have a high operative volume?
How busy is the ER? Level 1 trauma center? What types of trauma?
Do residents attend national conferences? Is it funded?
Where do the graduating residents go?

Questions for Residents
What are the strengths/weaknesses?
Did you ever consider leaving the program?
How many facilities do you cover? How do you like that? A lot of driving? Any required rotations in different cities?
Do fellows take away from learning experience?
What is call schedule like? How are the call rooms? Do you sleep while on call?
Do you have ample time to read?
How is the balance between autonomy and supervision?
How is ancillary staff? Are they helpful and pleasant to work with?
Is there a lot of scut work?
How is your relationship with the staff?
How do the residents get along? Do you hang-out outside of work? Are there any sports teams that you play on?
Do the residents get along with other residents in the hospital?
How do you like the city?
How are the benefits? Parking? Meals paid for?
Do you have moonlighting opportunities?

Questions for Chairman/PD/Attendings
What are your plans for the future?
How do you see the program changing in size or structure over the next five years?
How long have you been here? Do you plan on staying at this program for the next 5 years?
What is the status of the programs accreditation?
How highly do you emphasize resident education?
How do you feel the relationship is between the staff and the residents?
What are the research opportunities like? Is it required? How is it funded?
How are the residents evaluated?
How do the residents perform on OITE? Boards?
What do you look for in a candidate? How many people do you rank?

Some Tips From the 4th Year Students on Getting Into Orthopedics

2009-05-07T16:32:00.001-07:00

Some notes from our 4th year panel last night:

1) Ways to get around your school's limits on away rotations
a) Do a “research” month somewhere you want to go
b) Use weeks off to get a feel for the program, just contact the people at the program beforehand

2) Get a blackberry, iPhone or other smartphone. When it comes time for interviews, hospitals will send out an email to 100 students, the first 80 students to schedule an email will be interviewed the rest won’t

3) How do you have a chance to match out west/east etc (a region where you aren't in medical school)?
a) Rotate in the region
b) Better chances if you are from out there
c) “I like the weather” is a bad answer if they ask why you want to come here

4) Be prepared for crazy questions on interviews
a) Tell us a joke
b) Do puzzles while answering questions

7) Letters of recommendation
a) Most places only want to look at ortho letters

8) Step 1 advice
a) Average nationwide is 231 for those who matched
b) People from have matched with a 217 on Step 1…and a 250 on Step 2, can use the Step 2 to make up for a low Step 1
c) Vastly different views on how to prepare, do what’s best for you
One just read = 256
One did all questions = 255
d) Once you get an interview, all the scores go out the window and everyone is on an even playing field

9) Interview trail
a) Rank all programs that you would rather go to than sit around for a year if you don’t match
b) Don’t rank multiple specialties unless you would be happy doing either, there are lot’s of miserable radiologists that really only wanted to do ortho
c) Be ready to answer the question, “What would you do if you didn’t match this year?”

10) Your school's alumni
a) Contact people for free places to stay, i.e. many doctors will put you up for a month in another town for free during your rotations, the school has a directory

Med School Videos From the School of Hard Knocks

2009-05-02T08:59:00.000-07:00

...warning, some use of profanity...

Book Review: Hot Lights, Cold Steel

2009-05-02T07:48:00.000-07:00

Although I've mentioned this book in prior posts, I thought it only fitting that one of my all time favorite medical books is given a post all to itself. First I'll include a summary, followed by my review and a link to where you can buy it off of Amazon.

Hot Lights, Cold Steel: Life, Death, and Sleepless Nights in a Surgeon's First Years
by Dr. Michael J Collins

"If he didn't feel overwhelmed before the Mayo Clinic senior orthopedic surgery resident lobbed a beeper at him with the nonchalant order, "Cover for me," 29-year-old ex-cabdriver, ex-construction worker, and, at the time, brand-new resident Collins certainly did then. It was his first day on the job, and
instantly he began fielding calls from staff nurses requesting orders for patients he hadn't laid eyes on. If it hadn't been for his innate sense of humor--brilliantly demonstrated in this memoir of his Mayo residency--and a sense of perspective derived from that experience, he might have failed. He didn't, and here he honors those who helped him along the way and those whom he helped. As a man who recognizes that he, too, makes his living with his hands, Collins anguishes over the options available to a carpenter who had severed four fingers. After assisting at a young cancer patient's leg amputation, only to learn later that she had died within months, anyway, he agonizes over what drew him to his profession in the first place and what could possibly keep him on course. "I wanted to be the guy who confronted the arbitrariness of life and strangled the unfairness out of it." Instead, while honing his craft, he learned from a Vietnam vet that the main thing patients deserve is compassion. If Collins' scalpel is as sharp as his pen, his patients are in capable hands, indeed."

Hot Lights, Cold Steele is a firsthand account of what it is like to be an orthopedic resident at one of the busiest and best hospitals in the nation. For the unindoctrinated, the Mayo Clinic is generally thought of as the best program to get into in terms of the training experience for orthopedic residents. I've heard that getting in is so difficult, that medical students who scored below a 240 on the USMLE need not apply because they will not even look at your application (a 240 and above includes only the upper 4% of test takers or so). In other words, aside from being a very interesting story in its own right, it shows what it is like at the best orthopedic training hospital in the country.

Interwoven through Dr. Collins story is the theme of choices. The story opens with a dilema as to whether he should try to save the arm of a boy who nearly had it ripped from his body when it became intangled in a combine, or amputate the arm immediately. The choice to moonlight at another hospital, or get some extra sleep. The choice to go to church with his family, or use that extra time to relax.

At once both lighthearted and introspective, Hot Lights, Cold Steel challenges the reader the reader to put themselves in the shoes of an orthopedic surgeon (which is why I loved it). It tells the story of one of the most loved patients he saw, a patient who all the nurses talked about and kept tabs on once she left the hospital, and you can't help but experience the hurt when he later finds out that she died a few months later.

During the lighter times, I found myself laughing at the similarities to my own life. When he talks about going from one clunker to the next, I'm reminded of my own experiences with cars (I've been getting in the passenger door and climbing over for the past 10 months). When he talks about making choices between medicine and family or medicine and faith, I think of all the similar choices I've had to make.

In summary, this is a book that will make you laugh and make you cry, and I don't think that you have to be a medical student, or a budding orthopedic surgeon to love it.

Discussion on Orthopedics and What it Takes to Get Into an Orthopedic Residency

2009-05-01T12:53:00.001-07:00

Here's a video discussion about orthopedics in general and what it takes to get into an orthopedic residency program.

How To Do Well in Your 3rd Year Surgical Clerkship

2009-05-01T12:20:00.000-07:00

Here is a form on the internet from Vanderbilt University detailing how students
are scored on their surgical clerkship.

My Lecture May Be Awful, But At Least I Have Travel Pictures To Show

2009-05-01T09:18:00.001-07:00

Have you ever noticed that some of the dryest presenters put pictures of all their travels in their presentation. It always seems to be the dermatology people--it's like they want to rub it in your face that they have tons of free time and are making money hand-over-fist.

Advice on Getting An Orthopedic Residency

2009-04-29T04:53:00.000-07:00

Here's a bit of advice I got from an Orthopedic Surgeon on what are the important things to consider when trying to get into an orthopedic residency, it's valuable because it speaks to things other than just the typical "get good Step 1 scores, do lots of research etc.":

"I would tell you that scores on tests are important, but that they would a given, that I would expect excellent scores. There is no doubt that a recommendation by a friend known to me would count highly, but a rotation at the program would count the most. That has always been the case. So, if you spend a month at a program and are knowledgeable, tireless, eager, nice but not an obvious brown nose, competent at procedures, first to arrive and the last to leave, can quote articles from JBJS, you will be a shoo-in."

First Year Haiku

2009-04-24T05:13:00.001-07:00

Anatomy
Welcome to Med School!
Did you buy your scalpel yet?
Dead bodies are here

Clinical Medicine
Your first real patients
Except they are just actors
They think they're great

Tests
Gauge how good you'll be
Life is multiple choices
Oh wait that's not right

Specialty Choices
Most are rational
Except the bug-eyed, creepy guy
Loves pediatrics

Email Listservs
Some department fights
Are best disseminated
To all four classes

Biochemistry
You won't need this again
Continue the illusion
Undergrad mattered

Physiology
How many times can we
Tell students about GFR
Before they go crazy

Pretending to be Interested in OB/GYN To Get Free Food (or An IUD at an OB/GYN Party)

2009-04-24T04:33:00.000-07:00

Sorry about the dearth of posts in the past few months, second year is much more time consuming than first year, especially once you get closer to Step 1 season. (This is going to be a very "rusty" post)

A couple of days ago I received an email saying that there was going to be an OB/GYN interest group meeting and that there would be some free food involved. I was starving, so I decided to see if people interested in OB/GYN were actually human.

I walked down to the conference room where the meeting was being held, and the first thing that I noticed was that there was one of the staff members guarding the door to make sure that nobody came in, grabbed food, and left. Clearly they knew that there wasn't going to be a lot of interest in OB/GYN today.

So I put on my best "I can't wait to deliver babies for the rest of my life" face and confidently walked past the food police to sit down at the conference table, as if I didn't even come for the free food. And it must have worked because all of the other OB/GYNites seemed to accept me as one of their own.

As I began to look around at what kind of people would actually want to go into OB/GYN, I was struck by the fact that they seemed normal, on the outside at least. (I was also struck by the fact that they didn't have any food). Clearly, I was the only second year student at the meeting, but I did my best to act like a first year while deftly avoiding their conversations about the neuroanatomy test that they had coming up.

The food finally arrived (baked potatoes, chili and broccoli--not great but better than going hungry) and I took as many of the chocolate chip cookies that I could reasonably fit on my plate, which didn't seem to bother any of the other 8 obstetrics lovers, their stock was rising.

So what kind of people go to an OB/GYN meeting? One was a mother, the other women couldn't wait to be, and the two guys that were there seemed to be a little to excited to be around this many women (as evidenced by their laughing at anything that was said). Needless to say, the topic of conversation was babies--which I love, but I don't need to spend lunchtime for the rest of my life discussing every bit of infant minutia.

When the doctor finally arrived who was heading up the meeting, everyone quieted down and waited for him to begin. But before I continue, a brief quiz:

Which of the following is a group of OB/GYNs and which is a group of orthopedists?

A)

(don't let their smiles fool you, they're miserable on the inside)

B)

Back to the story, so the OB/GYN doctor talks about his life in medicine, how he came to be doing what he's currently doing etc. There really wasn't anything especially interesting or unique to his story, aside from the fact that he mentioned he worked in rural Arkansas for a few years after finishing his residency, and though I hate to admit it, he actually seemed pretty normal.

Then came the questions, someone asked, "I heard that OB/GYN is awful and getting worse" or something to that effect.

To which he responded that things weren't necessarily getting worse, but that those who had spent a lot of time in practice were noticing that OB/GYN had changed dramatically from what it was when they started as doctors; less individuals, more groups, doctors who were more concerned about lifestyle than just seeing a lot of patients.

Someone else asked a question about malpractice (OB/GYN's have to pay for malpractice insurance 18 years after they're done practicing!), and then a few questions later and it was over.

As I walked out, I was struck by the fact that those interested in OB/GYN are actually quite normal, as long as by normal you mean that they enjoy the thought of putting thousands of dollars towards paying malpractice and talking about children and women's reproductive organs 24/7.

How Hard is Medical School (Made to Sound as Depressing as Possible)

2008-11-21T12:43:00.000-08:00

Medical School is extremely hard.

First, you arrive at medical school. A bright, cheery MSI.

And you are really, really excited to be here. I mean, possibly more excited that you will ever be for anything thus far in your life (unless you're already married, had a child etc.) You recognize that it is going to be hard but at the same time you think to yourself, "Well I got in, didn't I, hopefully the administration didn't make some huge mistake." Have I mentioned that you are excited. Tens of thousands of people didn't get in to medical school this year, but you did.

Then you get done with the lazy week of orientation, which you probably skipped half of anyway, and you arrive at your first class.

ANATOMY- Day One

Welcome to Medical School here at the Medical College of the United States. Blah. Blah. Study a little every day. Blah. Blah. This is going to be the most challenging thing that you have ever done. Blah Blah. This is the axilla. Blah blah.

Video begins:

"This is how to disect a human body..."

Professor: Ok class now we are going to go downstairs and begin disecting, there will be 6 people per cadaver.

You (thinking to yourself): This is great! I'm finally doing something that is interesting. No more boring stuff like General Chemistry for me!

And that first night you study better than you ever have in your life, because if you know one thing, it's that you don't want to be one of those 5 or so people that drop out (and you definitely don't want to Modify, which means that you end up taking 5 years to complete medical school instead of the usual 4.). And you keep studying every night for the next month, and on some levels it's actually fun (or at the very least tolerable).

Then the first test arrives.

And you pass! Not only that, but you do pretty well--not honors by any means, but since your main concern was just getting through, finding out that you are an "average" medical student is actually not all that bad.

So you keep studying, and studying, and studying, every night for the next few months. Not only for anatomy, but also for embryology and histology which are taken concurrently. And very gradually this sense of newness begins to wear off.

(to be continued...)

The Depths of Memory

2008-11-21T12:14:00.000-08:00

Isn't it funny how a word, a place, or a stage of life can have so many associated feelings.

When we think of childhood, our mind doesn't immediately think of a top-down summary of how good or bad our childhood was, no, instead we immediately pick a single memory, a moment in time. The night when dad let us Trick-or-Treat until the wee hours of the morning, no matter how tired he was. The time that we went sledding down a 20ft high hill that seemed like Everest to us. Humans seem to have a knack for taking something that is irreducibly complex and forming a few overarching memories.

Equally surprising is that we can have a negative memory of a place where we had countless days of pleasure. But whenevere someone calls that place to mind, our first thought is that of sadness.

For me that place is Ludington.

Growing up, we would often travel up to Ludington to visit with my grandparents and other family members. A town of about 60,000 or so, Ludington is at once both beatiful and quaint. It has a turn-of-the-century downtown area, great beaches, and large swaths of natural forests.

When I was younger we would play wiffleball outside for hours on end, or go out for ice cream at the nearby dairy queen. Other times I would ride my grandpa's old 8-speed bicycle down a winding dirt path through the forest, a path the bike was definitely not made for. For me, Ludington was the place our family always went to.

Yet for some reason whenever I am reminded of Ludington, I picture it in the middle of winter; overcast and empty. But why? Why is it that a place that has been the site of so much enjoyment in my life become a place that I remember with such a sense of sadness and melancholy.

The more I thought of it, I realized that I have come to associate Ludington with death. The memories that I had of Ludington with both my parents are now tainted with the pain of divorce. The memories that I had with my granparents now are associated with the realization that they won't be around forever. Memories of riding grandpa's bike make me think of a time where I will no longer be able to talk to him whenever I want to.

But why is it that our brain puts that all into one feeling, one image. Maybe it's just easier. Maybe we don't really want to think off the hurt, so our brain puts out an imposing image to scare us off. I think it's one of the more interesting defense mechanisms that we have.

Once my grandparents leave Ludington, I don't think I'll ever go back there (alone at least). It's one of the most beautiful towns in Michigan, but for some reason I can't get passed the dark image I have of it.

Learning vs. Studying

2008-09-09T06:20:00.001-07:00

Are learning and studying the same?

Most people that are in medical school have probably had a conversation that goes something like this.

Non-Medical Student: "You're in medical school! You must love school, I could never put up with four more years of it"

You (or Me): "Well I don't know, I don't really think that I love schooling all that much..."

If you are anything like me, you probably find it really hard to give someone a satisfying answer to that question. I've thought about my own motivations a lot, and this is what I've been able to come up with.

I love learning. I love finding out something new that I think is applicable to my life (or to my future life). I love when I finally understand something, when I spend time trying to wrap my mind around something and then I finally "get it."

I hate studying. I hate being told to read 200 pages of notes and commit it to memory. I hate sitting down in a lecture hall for 5 hours of lectures followed by 3 hours of lab. For me at least, there is nothing fun about that.

I'd love to learn another language, or how to play a musical instrument--or even another sport--but the medical school curiculum is so constrained that there is no time for that. So what you end up with is a bunch of people who are (on some levels) miserable for the better part of two years with one test after another hanging over their heads.

I agree that much of the information learned in medical school is very valuable, but I think that there are much more efficient (and less costly) ways of training our future doctors.

So how would I change medical school to make it better.

The biggest change I would make is to switch to a 3 year preceptorship, broken down like this:

First year: anatomy, histology, physiology (6 months) pathology, pharmacology, microbiology (6 months)

Second-Third Year: 6 months of family practice at 2 different sites, 4 months of internal medicine, 4 months of general surgery. 1 month of Emergency Medicine, OB/GYN, Psychiatry, etc.

Fourth year: 8 months of required electives, 4 months for interviewing etc.

In this system you would have to expand the "shelf" tests to account for longer periods in each rotation, but I feel like this would be a better situation for everyone.

Current doctors can feel like they are having a greater influence on future doctors. Medical students will absorb much more information when facts are associated with real life situations. Patients will have better trained doctors, and hospitals can hire a few less MAs and save some money. In my mind, it seems like medical education is stuck in the dark ages--where medical students are still being taught to memorize side effects for 100s of drugs, even though that information is now only a PDA click away.

Wouldn't that time be better served learning how to be a better doctor instead of a fact-spitter-outer. How many times have you heard from doctors that many of their colleagues in medical school who were great students have made terrible doctors--isn't that a sign that something needs fixing?

Time to Start Throwing the Baby Out with the Bathwater, Studies Show

2008-09-09T06:19:00.001-07:00

It’s common knowledge that young children are nothing more than freeloading ner-do-wells, but could they also be making you sick? That’s the question researchers from the University of Alberta wanted to find out.

“We were all sitting around the lunchroom one day when out of nowhere John starts coughing,” said Todd Maste, a doctor of homeopathic medicine. “And I said to him: ‘Hey didn’t you say your kid was coughing last week?’ And he was like, ‘Yeah he was.’ All the sudden it hit him. His kid was making him sick.”

But mere anecdotal evidence was not enough for this modern day Sherlocke and Homes. They sought a degree of certainty only attainable via a double-blind, randomized study.

“We took, uh, 20 kids who were sick, uh, and within two weeks 12 of [their] parents got sick too. Clear cut kid to parent transmission of disease.”

Armed with this knowledge, Maste and his colleagues sought out the manufacturing giant Pharmista, makers of Hydroxyfatburnercooker™ and Schlonger™ to see if there were any marketing possibilities for a new over-the-counter drug. Matt Barnes a marketing executive explains:

“The information that Dr. Maste had come up with was so groundbreakingly earthshattering, that I thought ‘We’ve got to take this and run with it.’” Barnes later added, “All the way to the bank.”

Sir, Do Helicopters Eat Their Young?

2008-09-08T07:54:00.000-07:00

Be careful how you respond to this question if you find yourself looking up from a hospital bed--the wrong answer will get you admitted for Stage 3 alcohol withdrawl. Either that or the alcoholics just know something we don't.

Words That Draw People to This Blog

2008-09-08T07:18:00.000-07:00

In looking at the demographic information about who actually reads my blog I found that there's been a gradual change from "people who accidentally find it because they typed in a google image search" to "people who accidentally find it because they were searching for something else."

Just for the fun of it here are the most common searches that lead people to my blog (in the past year):

How hard is medical school 20ppl 6.08%
medical hierarchy 16ppl 4.86%
Medical school is hard 13ppl 3.95%
medical school quotes 10ppl 3.04%
how hard is medical school? 6ppl 1.82%
med school quotes 4ppl 1.22%
is medical school hard 4ppl 1.22%
hierarchy of medicine 4ppl 1.22%
school of hard knocks baseball 3ppl 0.91%
hierarchy in medicine 3ppl 0.91%

I guess there are a lot of people out there concerned with how hard medical school is--maybe if those people got together with the "medical school is hard" people then they wouldn't have to search anymore.

Mostly for my own curiosity (and to record it for posterity) here is the geographic breakdown.

United States 713 67.90%
Netherlands 129 12.29%
Canada 40 3.81%
United Kingdom 38 3.62%
Australia 15 1.43%
Mexico 14 1.33%
France 8 0.76%
Italy 8 0.76%
New Zealand 7 0.67%
Spain 6 0.57%

In order to maximize the number of people to read my blog, I think I'll title my next entry: "Is Medical School Hard in the United States? Yes, Medical School is Hard in the United States." And then I'll throw the word "hierarchy" in there for good measure.

Addendum: I am now the number two hit on google if you were (for some unknown reason) to type "medical school of hard knocks." And I've got a message for someone out there, you'd better watch your back 'guy-who-once-wrote-an-article-for-TheOnion-using-the-words-medical-school-of-hard-knocks' or your going to lose your number one status.

My First Surgery

2008-09-08T06:50:00.000-07:00

A week ago today I saw my first surgery. It was a sigmoidectomy. The patient has cancer that was occluding most of his/her sigmoid colon and as a result (s)he was unable to eat normally.

I was there was due to my working on some research involving tumor detection.

Specifically, the project that I am working on is trying to differentiate between tumor and non-tumor using a laproscopic probe and a special kind of laser (and a database of scanned regular tissue and different tumors). Put simply, the goal of the research is to be able to tell whether something is cancerous or not in a much shorter time than it takes to get results back from pathology, and the doctor doing today's surgery thought that we might be able to glean something valuable if we saw a tumor resection.

Back to the surgery, the patient also had secondary metastatic tumors in the liver, but these did not spread any further, thus making her a candidate for surgical removal of the primary tumor. (S)he previously had been undergoing chemotherapy, but from what I understood this has not been successful.

Before I entered the operating room I had the slightest bit of nervousness that I wouldn't be able to stand the sights and sounds of an operation without getting squeamish. I was afraid that (even though it was laproscopic) I wouldn't be able to handle seeing the blood or the inside of someone's abdomen, but luckily there was very little smell, and I tolerated the blood just fine. I think the key was not really taking the time to think about it, it's a bit sad but it seems like the best way to get through the first few times is to not think of the person as a human being--whether you're in the anatomy lab or watching a surgery.

The surgery went on for a few hours without anything especially exciting happing, but I was extremely excited to be there. To see someone performing a surgery made me feel like I could someday be doing it--which isn't to say that it wasn't an incredibly complex process, I just felt that it was something that I could learn.

The other thing that I was struck with was how advanced the tools are that the surgeon used, especially the staplers. I had seen/heard about cauteries before, but to see how a miniature stapler seals off both ends of the colon, and how they pull it out through a gel "hand port" to resect it--it really is a feat of engineering and antiseptic technique.

Altogether it was a very exciting 2 hours, but I definitely need more comfortable shoes if I'm going to be standing up for that long ever again.

An Argument for Detroit

2008-09-07T22:00:00.000-07:00

If someone tries to start an argument with you while on a Detroit bus, think twice before saying something incindiary. Oh, and watch out for snakes.

Charts

2008-05-22T08:07:00.001-07:00

My summer work involves helping an orthopedic surgeon with some chart research. Here are couple of things that I thought were funny.

"patient appears to be significantly older than she claims"

I love how every patient seems to be described as pleasant. For instance, "Jane Smith is a pleasant young lady who presents to my service with..."

Referencing a 50+ year old: "The patient is here with her parents."

On a surgical note there always has to be a diagnosis. So commonly you would see something like "Diagnosis: left distal comminuted fracture of the radius." But because you need a 'diagnosis' for every procedure, when someone is just having surgery to remove plates and screws the diagnosis reads "Retained Hardware." As if some patients' hardware magically disappears when they no longer need it, while others have to come back for surgical removal.

For some reason it seems that doctors need to go over the top in thanking referring doctors. Many read like this, "Dr. Smith kindly/graciously/generously refered patient X to me to treat her..."

Objective Structured Clinical Examination

2008-05-08T16:23:00.000-07:00

Today I took the first of many examinations involving standardized patients. It's called the OSCE, but to call it anything more than a checkpoint that 99.9% of med students pass with flying colors is giving it more credit than it deserves.

Here's how it goes at the best medical school in the country:

You arrive at a floor of an old hospital and stand around and wait for a few minutes with a bunch of other medical school students that are just as nervous as you are even though you all know there is nothing to be afraid of.

You have some idea that this is going to be a pretty straightforward case ("my elbow hurts"), but the med students who just finished joke that they "never expected that the patient was going to be playing the part of a deranged psychopath," as they walk past.

Next your herded like cattle into a room where you are given some basic instructions, but all the while the proctor is talking, students are frantically scribbling notes of all the questions that they want to ask while they are in the room--only to find out that you had a few minutes to write after the instructor finishes talking.

Overhead you hear a mechanical sounding voice say, "Three minutes remaining! Three minutes!" Which is a warning to the students who are currently interviewing patients in rooms 1-10.

All the while I'm thinking to myself, "What if I seize up in there and forget to do things in the right order, or I ask all of the questions in too mechanical of a way." Or, "What if my patient is a total jerk like the guy that I had to interview during one of our small group practice sessions."

Then time was called, all of the medical students in the waiting room exit and find the room to which they are assigned (mine was room 5).

As I'm standing there, my mind is going a million miles a minute. "Should I knock, or shouldn't I--or I could just see what everyone else does--but what if no one knocks and we were supposed to."

Everyone knocked, so I did. Then I walked into the room and handed the grader (there is a patient and a grader in the room) a sticker with my name on it--from then on you are expected to completely ignore the grader.

Here's a synopsis of how the interview went (I lucked out and got a really nice patient):

-----------

Me: Hi Mrs. Samples, I'm a medical student at Wayne State--What brings you in today?

Mrs. Samples: Well I've been having this stomach pain for the past few days.

Me: When did it start, what makes it better or worse, how severe is the pain, what kind of pain etc. (waiting in between questions for her to answer)

Mrs S.: 2weeks ago, worse with spicy foods, 5-6, burning

Me (because I knew we were being graded on transitions): So in order to delve a little deeper, I'm going to ask you some questions about your Past Medical History.

(and so on, until I got to social history when I asked her about whether she was sexually active with a partner--which is how they want you to phrase it)

Mrs. S: A PARTNER, I am with my HUSBAND if that's what you mean (she said it jokingly, but her volume took me aback)!

Me: I see. (mumbles something else)

(next up was alcohol--I thought that we were supposed to ask specific questions if someone said they drank anything at all)

Me: So Mrs. S do you drink at all? Alcohol, that is.

Mrs. S: Well I like to have a couple of imported beers every few weekends.

Me: Have you ever felt like you should cut back.

Mrs. S: TWO BEERS, have I ever felt like I should CUT BACK from having TWO BEERS a week. No I haven't

Me: (tentatively) Has anyone ever been annoyed by your drinking?

Mrs. S: ANNOYED BECAUSE I HAD TWO BEERS!?

Me: (not getting that I probably don't have to ask these questions) So I take it you've never felt Guilty about your drinking or had an Eye opener?

Mrs. S: NEVER

Me: Okay, I think it's time we take your blood pressure (which I think I got a little low, by then I just wanted to get out of here--I finished in 12 minutes but most everyone else took less time)

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

Then we were sent off to a room to write a SOAP note before we were free to leave. One of my friends had a doctor in the room who asked him if there was "anything else he wanted to ask about the patients past medical history," which worried him because he thought he had already asked all of the questions. I'm just glad I got a trained grader instead of a doctor.

Locus Motivatius

2008-04-29T10:36:00.001-07:00

Recently scientists have discovered a new region of the brain found in primates and higher species that has been named the locus motivatius.

Functional MRI studies have shown that this area at intersection of the occipital, temporal and parietal lobes is chronically underdeveloped in the interlopers, the malcontents and the miscreants of the world. But perhaps more interesting is the transient loss of function recently seen by researchers in the United States.

Recently, it has been demonstrated that accute, short term lesions of the locus motivatius are a common occurence around the months of April and May in students of all ages. Symptoms include: lethargy, time wasting, tv watching, and blog posting.

There are no known treatments, but often times symtoms spontaneously resolve with the onset of "warmer weather" or the conclusion of all required classwork for the year.

When Good Anticipation Goes Bad

2008-04-28T20:32:00.000-07:00

Played in my first softball game of the season tonight which we won 16-14. Unfortunately all of the planning and anticipation in the world couldn't help me this game. Anticipation without execution was worthless, and I made a couple of errors in the field--fun night though. It's good to be playing on a team.

Here's what I looked like:

Baseball

2008-04-27T18:10:00.000-07:00

Very few people appreciate baseball. Most people think that it is just a bunch of standing around swinging a bat as hard as you can. But there is so much to baseball that Joe Smith Fan doesn't even notice.

Baseball is about moving a step to the left because you know that the batter likes to pull the ball. Baseball is stealing on an 0-2 count because the pitcher is likely to throw a breaking ball.

I'll admit it, 99% of baseball is anticipation, and I understand that anticipation isn't that interesting to watch.

But for those who have the willpower to struggle through learning how to hit an unpredictably-moving ball the payoff is enormous. Sure it's satisfying to score a basket in basketball, but you could score 40 points in a quarter and still lose. In baseball, I would argue that there is the highest buildup and importance on any single play--on par with a goal scored in soccer.

Perhaps you might even say that the reason there is an ever decreasing number of baseball fans in this country (and children who learn to play it growing up) is because the way our society is being restructured. We want to be entertained now, not 10 minutes from now, this very instant. And heaven forbid, we have 10 minutes during the day where we aren't on the internet (guilty) or listening to our Ipods, or watching TV.

Where has all the time for contemplation gone, where is the anticipation in life anymore. We want instant gratification and nothing else.

Is it any wonder that there is an increasing number of kids who come down with ADD? Rather than teach our children to appreciate simple things such as a family walk through the woods, we sit them down in front of the TV so we can have some peace and quiet.

Bill Bryson the author of books such as A Walk in the Woods, once wrote:

“To an American the whole purpose of living, the one constant confirmation of continued existence, is to cram as much sensual pleasure as possible into one's mouth more or less continually. Gratification, instant and lavish, is a birthright.”

Take the time to appreciate the anticipation of life.

Red Wings

2008-04-24T10:01:00.000-07:00

A few Hockeytown brawls and hits before the big Wings-Avs series starts tonight.

Sleep

2008-04-23T15:47:00.000-07:00

Sleep. Most people sleep for about 1/3rd of their life, but rarely do people even think about what is going on when we sleep. For most people sleep is just a required part of living--but few people realize that sleep is essential to life.

When I was at the greatest college on earth I had a friend that purposely went without sleep for as long as he could. After about three days, when he could no longer consciously force himself to stay awake (despite any additional caffeine) his body forced him to drift off to sleep--on the floor where he was sitting.

When I was talking to him a few days later he reported that he began to experience hallucinations after staying awake for ~60 hours straight. After about 70 hours without sleep his body overrode his willpower and forced him to enter the sleep cycle. Without this he would have eventually died.

Of all the things that I've learned this year, probably the most interesting is that those who are physically unable to sleep will eventually die, usually within 9 days of the last time they slept. Although, for people who are able to voluntarily stay awake it has been shown that people can go upwards of 11 days without sleep, as described below.

One of the most common causes of death by insomnia is called Familial Fatal Insomnia. An exceedingly rare condition, FFI is an autosomally dominant condition that has been identified in only 28 families worldwide (according to wikipedia). It was first reported in the 1970s in Italy when two women from the same family died from an insomnia-causing disease, but the actual mutation is thought to have occured in an Italian doctor living in the 17th century.

The cause FFI is somewhat similar to diseases such as variant Crutzfeld-Jacob disease or Kuru inasmuch as it is a disease that results in a buildup of misfolded proteins in the brain (prions). In FFI, a mutation in the genetic code causes the improper translation of genetic material to proteins which causes the protein to improperly fold and aggregate with other misfolded proteins. In FFI, these proteins collect in the sleep regulating region of the thalamus, causing insomnia.

Once the first symptoms appear (usually when the patient is in their 50s), patients have around 7-36 months to live. There is a definitive course of progression for those with FFI.

First patients experience panic attacks, then hallucinations, then weight loss and insomnia, and subsequently dementia and death. At the end of its course, FFI causes patients to forever be stuck in a semi-sleep state which appears much like sleepwalking to observers. Any attempt at drug therapy such as sleeping pills only resulted in a faster spiral into dementia and death.

Equally interesting is the study of forced total sleep deprivation and its affects. In 1964, a 17 year old named Randy Gardner stayed awake for a record-12 days. What follows is the account from wikipedia.

"It is often claimed that Gardner's experiment demonstrated that extreme sleep deprivation has little effect, other than the mood changes associated with tiredness (mood swings, short temper, loss of concentration).[5] This is primarily due to a report by researcher William Dement, who stated that on the tenth day of the experiment, Gardner had been, among other things, able to beat Dement at pinball.

However, Lt. Cmdr. John J. Ross who monitored his health reported serious cognitive and behavioral changes. These included moodiness, problems with concentration and short term memory, paranoia, and hallucinations. On the fourth day he had a delusion that he was Paul Lowe winning the Rose Bowl, and that a street sign was a person. On the eleventh day, when he was asked to subtract seven repeatedly, starting with 100, he stopped at 65. When asked why he had stopped, he replied that he had forgotten what he was doing.[6]

On his final day without sleep, Gardner presided over a press conference where he spoke without slurring or stumbling his words and in general appeared to be in excellent health. "I wanted to prove that bad things didn't happen if you went without sleep," said Gardner. "I thought, 'I can break that (Peter Tripp's 1959) record and I don't think it would be a negative experience."

Getting Along

2008-04-20T10:08:00.000-07:00

For those not familiar with The Screwtape Letters (as I was not until I read it recently), CS Lewis wrote The Screwtape Letters from the perspective of the a demon writing to his nephew.

“When two humans have lived together for many years it usually happens that each has tones of voice and expressions...that are almost unendurably irritating to the other. Work on that. Bring fully into the consciousness of your patient (the human that is targeted) that particular lift of his mother’s eyebrows that he learned to dislike in the nursery. Let him assume that she knows how annoying It is and does it to annoy - if you know your job he will not notice the immense improbability of this assumption. And never let him suspect that he has tones and looks which similarly annoy her.”

-C.S. Lewis The Screwtape Letters

Many medical blogs that I have read seem to be filled with primarily angry criticism leveled at the health care system or patients.

And it's easy to do. Although I tried to write my last post as rationally, and un-emotionally as possible, I'm sure there was a bit of frustration throughout it.

So why are there so many angry people in healthcare? I would argue that it is undeniable that were working in an imperfect system. For everything that is wrong with the US health care system, the poorest person in the states receives health care 100 times better than many of the poor throughout the world. So how do we try to we form a productive critique of something, be it health care or otherwise.

I think that part of it is fighting the constant battle against complaint for complaint's sake. I think that it's important to think through whether what you are doing serves any positive purpose or whether it's merely blowing off steam (which isn't to say that there may not be a place for venting--but one should consider if complaints are always best aired amongst other doctors or medical students).

CS Lewis, the British writer who penned the Chronicles of Narnia series, seems to masterfully capture a nuance of our daily living. When we are faced with the same thing day after day, it is human nature to find things to dislike about it. This holds true in relationships ("She always clogs the toilet and leaves me to fix it...") and I think it also is true of medicine.

Just by the by working in close proximity with the same individuals, I think we can find (and perhaps sometimes invent) things to dislike. Medical school has taught me more than medicine, it's taught me to complain. "This is crazy that we are paying X number of dollars when Ph.D student are getting paid 1200 a month."

"I can't believe the questions they asked on that test."

"Professor X has no idea what he is doing."

And the funny thing is, who really cares? The truth is, I'm as guilty as the next person, and that type of complaining does nothing.

When I began medical school I had some idea that life in medicine wasn't going to be a breeze. Although I was a bit wet-behind-the-ears I knew that relying on being a doctor to bring me 100% of my happiness was not realistic. But is this overwhelming flood of complaint part of the problem behind why so many medical students finish their 4th year with little or no hope of enjoying the rest of their professional lives.

Pragmatic, thought-out criticism is vital to continually trying to refine the health care system that many of us will be working in, but I think it's important that we all try to cut out a healthy chunk of the pointless whining we take part in, especially myself.

Is There a Doctor in the House?

2008-04-17T09:34:00.000-07:00

Recently I read something about the new program that has begun in nursing where a nurse practicioner has the opportunity to become a doctor.

What? A nurse who is also a doctor? How could this be?

I'll tell you. Nurse Practicioners in some areas now have the opportunity to pursue a degree known as a Doctor of Nurse Practicioning.

Maybe some of you are thinking: This is great! Another possible option for nurses to pursue. No longer are they forced to adhere to the constraints of what it means to be a traditional nurse, e.g. being involved in every aspect of patient care.

I'm not of that opinion. And here's why:

Here's a blurb from the University of Tennesse, Memphis:

"The DNP curriculum is Web-mediated including opportunities for synchronous and asynchronous learning. Students are only required to be on campus 4 times a year (July, December, January, & April) for 5 to 7 days each session. With faculty approval, clinical courses can be completed in the student's state of residence."

What is this, the University of Phoenix? Other reports I've heard have stated that nurses need only complete 1000 hours in order to complete the program. It's absolutely ridiculous on a number of fronts.

First, the amount of experience that a medical doctor gets is at least ten-fold higher the experience that a DNP candidate would have to gain.

Second, what does it mean to be a nurse anyway. What is so wrong about being called a nurse. Personally I think that nursing is one of the most selfless, noble professions that one can pursue. Why is it suddenly necessary that we need nurses proscribing medications and being addressed as doctors.

Third, there was such a righteous fervor over the inventer of the artificial heart (Jarvik) who is a Ph.D "doctor" that was supporting a certain medication on the internet. Where is the fervor now. We're going to see a day where someone with 1000 hours of experience is seeing a patient that has no idea about the difference between a DNP and an MD "doctor." It's disgusting, and I think the biggest reason is because the current doctors of America couldn't care less.

Where were the doctors when malpractice lawsuits have got out of control? Where were doctors when people saw the subtle signs that medicine in the US was going downhill? Where are the doctors now when an exer increasing number of "physician extenders" encroach on what it means to be a doctor? Sadly, the pay is still good, the hours aren't terrible--so the majority of doctors could care less what state the health care system is in when it is handed off to the next generation.

Instead they'd rather complain about duty-hour restrictions, and how medical student today "just aren't as driven as they used to be."

Edmund Burke once said, "The only thing necessary for the triumph [of evil] is for good men to do nothing."

Is what is going on in the medical system evil? I don't think so. But the only thing necessary for it to continue in its downhill trend is for enough of today's doctors to do nothing.

The debate over the validity of having Doctors of Nurse Practicion is sadly going to become a debate over whether the still male dominated doctors are just trying to keep the female dominated nurses down. And at its root I think many people will view it as a gender equality issue. But it isn't. The question is not whether a nurse could be as knowledgeable/valuable as an MD doctor, because I can tell you right now, there are some nurses that are smarter/more adept than some doctors. The question is what would be best for patients

The root of the question is this: What does it mean to be a doctor, and what does it mean to be a nurse? Are there roles that a doctor should fill that a someone trained as a nurse shouldn't be filling? In the same token, are there roles that are better filled by a nurse? I think that the answer to the last two questions are both yes. But if the DNP program (among others) continues, we'll continue to dilute the respect that the average person has for someone who is known as a "doctor" until we're all just "health professionals," despite our vastly different training.

4/48/04 Update: Today in class we had a family of acondroplastic dwarfs come and speak to our class as part of a genetics patient panel. Here is a phrase that the father used, I'll try to reproduce it verbatim.

"When we were at this conference in Dearborn one of the nurse practicioners / doctors got up to tell everyone a story..."

The person he was referencing turned out to be a nurse practicioner and not a doctor. I don't for one second think that John Smith patient has any idea what the difference between a nurse practicioner and a doctor is, and I think they would know even less about what the difference between someone who has NP-C and MD on their coat (if they even looked).

It's misleading to patients and those who keep pushing to expand the role of nurses are exploiting it.

Shadowing

2008-04-16T06:08:00.000-07:00

The past two days I have been shadowing a family practice doctor per the requirements of the medical school for completion of the first year, and I was struck with a number of things.

1. I'd like to think of myself as a pretty good communicator, and I don't mean that in a self-aggrandizing kind of way--just ask my fiancee, I'm not always the best at remembering things--but there is something of an art form to medicine. The doctor that I was shadowing absolutely has it down. He know's the "character" that he needs to play during the medical interview process. At times he pretends to be the aloof, almost clown-like character to put people at ease or to get a laugh.

But he also knows that there are times when he has to play the role of counselor, or father, or disciplinarian. There is so much more that goes into medicine than words and formats: he never strictly follows OPQRSTAA (Onset, Provocative/Palliative etc.) when talking about a condition, but he does have his own schpeel that he gives to parents of children under the age of one, e.g. "I like to remind parents to use a lot of sunscreen even if the baby is going to be under an umbrella..."

Moreover, you realize that there are a lot of patients who come in, that he could probably diagnose in a matter of seconds, but still he takes about 5 minutes to talk to the patient about their concerns. For instance, one of the patients who came in clearly was describing a simple pulled muscle, but he still took about 10mins to talk to her about it, before he even began to examine her. Part of it was a desire to rule anything out, but part of it was making sure that the patient felt like she was being heard by someone who cared to listen.

2. The Power of Human Touch. I've heard this a few times throughout medical school but it's important for doctors to touch their patients. Sadly, in this day and age, the first thing that many people would think if you said that was, "Doctor's touching their patients--there should be less of that." Perhaps because of the stigma of the few doctors who touch their patients innappropriately or perhaps due to our Politically Correct/lawsuit happy culture, I fear many doctors may keep their patients at arms length--which is truly sad.

Many patients that come off the streets may have been physically abused or mistreated for their whole lives, and the chance to touch someone in a loving way--e.g. rest one's hand on their shoulder, or even hold the stethescope so that one's fingers rest on their back--is often lost.

3. There's so much pain in this world. One of the women who came into the office had been put on large doses of inhaled steroids to treat a very bad asthma attack that she had had. Her face was the slightest bit edematous and perhaps a bit moon shaped (as is common with high glucocorticoids). And a few minutes into their discussion she said, "My face is so fat...I feel like a freak." And she began to cry. My heart just broke for her.

Maybe because I could empathize or maybe because it is just human nature, but I couldn't help but well up with emotion for her. I wonder if you need to remember how to respond to the patient, while not letting it affect you. Or maybe you just let it affect you and move on, I don't know.

More to come

Good Quotes and Writer's Block

2008-04-05T07:43:00.000-07:00

“Eventually, all histories must be formally structured, but much can be learned by letting the patient ramble a little. Discrepancies and omissions in the history are often due as much to overstructuring and leading questions as to the unreliability of the patient. The enthusiastic novice asks leading questions; the cooperative patient gives the answer that seems to be wanted; and the interview concludes on a note of mutual satisfaction with the wrong answer thus developed.”
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

“Moderate pain is made agonizing by fear and anxiety. Reassurance of a sort calculated to restore the patient's confidence in the care being given is often a more effective analgesic than an injection of morphine.”
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

"The details of the past history may illuminate obscure areas of the present illness. It has been said that people who are well are almost never sick, and people who are sick are almost never well. It is true that a patient with a long and complicated history of diseases and injuries is likely to be a much poorer risk than even a very old patient experiencing a major surgical illness for the first time."
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

"All patients are sensitive and somewhat embarrassed at being examined. It is both courteous and clinically useful to put the patient at ease. The examining room and table should be comfortable, and drapes should be used if the patient is required to strip for the examination. Most patients will relax if they are allowed to talk a bit during the examination, which is another reason for taking the past history while the examination is being done."
Current Surgery J. Englebert Dunphy, MD, & Lawrence W. Way, MD

Saccadic Eye Movements

2008-03-27T17:21:00.000-07:00

Put one finger about arms length in front of you. Now slowly sweep your finger from the far left of your visual field to the far right, while tracking your finger with your eyes. Notice how you can "see" the blurry background even if you are focused on your finger.

Now place the finger of one hand at arm's length near the border of your peripheral vision on the left and the finger of your right hand at about arm's length near the rightmost border of your peripheral vision on your right. Now quickly switch from focusing on one finger to focusing on the other finger.

By now you are probably thinking, "This is supposed to be interesting, it seems pretty routine to me." But dig a little deeper. In order for you to switch your focus from one finger to the other, your eyes "saw" everything in between. But did you experience a sweeping image, or did you see one image "jump" to the next image.

If our brain merely interprets the information from our eyes as is, you should see a fast, blurry sweep as you shift your gaze. But you don't! Somehow your brain blocks out almost all of the input from the time you decide to shift from one finger to the next. It's almost as if all that exists between one focus and the other is a timeless vacuum. The movement of focus from one object to the next is called Saccadic Eye Movement.

And where does the time go? When you looked from one eye to the other, did you perceive any delay? I don't think that I do. Although the time between looking at something on one end of your vision and the other end is only a matter of tenths of milliseconds, imagine all the times that you switch focus during a year--it must be on the order of minutes when all added together. Not to make this stray into the realm of science fiction, but where does all the time go? It seems as if your brain tells you that the time never existed.

We know so much about the human body but we know so little, and it's things like this that keep us coming back for more--despite the drudgery.

Where Do We Get Off

2008-03-26T05:41:00.000-07:00

Where do we get off. When did medical students start thinking that they run the show? Has disrespectful behavior always been a problem at schools of graduate education? Is it because we all have a bachelor's degree in something and we think that qualifies us to complain nonstop?

One of the most disturbing trends that I have witnessed while at medical school is the drastic increase in the amount of complaining and improper conduct towards professors. During the class time, a student once raised his hand to ask a professor a question, here's how it went:

Student: Doesn't that enzyme do the opposite in the presence of insulin

Professor: Well, I don't think that is correct

Student: No, that is correct

Since when is this considered acceptable behavior? Since when have we decided that that is appropriate for future professionals?

I think it goes back to how many in my generation were raised. A lot of people have mentioned that our generation was the first "you can do anything!" generation. What I mean by that is that most of my generation had parents that told them they could do anything. Never mind that they have no singing ability, you are the worst parent in the world if you don't make them feel like they are the next Pavaratti.

I've always thought my parents did it well. When I was a kid, I wanted to play professional basketball. Rather than just say, "Sure you will someday, you can do anything you set your mind to," he was very pragmatic about it. He said things like, "If that is something that you want to do, than you will have to make big sacrifices to get better at the sport." And I did, for awhile--but then my friends wanted to play with GI Joes, or there was a new movie out at the theater, and I gradually realized that professional basketball wasn't in my future.

I think the best thing that parents can do is encourage their children that many things in life are attainable through hard work, but without having certain innante physical or mental gifts, not everything is possible. If I am 4'7" I'm probably not going to play center for the Piston's someday. If I don't have anything resembling a singing voice, I probably won't be a world famous singer. This doesn't mean that I shouldn't work hard, but I should have parents who can see the gifts that I have and steer me in the right direction.

Another reason that I think that there is so much trouble with respect and discipline is the Political Correctness wave of the 90s-2000s. Don't get me wrong, there are aspects of PC that seem reasonable, such as eliminating the terminology of phrases such as "you people," e.g. "you people are all the same... But one of the downsides of the PC movement is the idea that there is nothing that is right or wrong.

Heaven forbid a teacher uses red ink to grade a paper! Who knows what might result from that! The child's fragile psyche could be forever damaged as a result from the 70% that they got on a test. It's pure ridiculousness and I think that it has contributed to the mentality that many of my peers have that they are always right. Not to mention the fact that they are probably angered that medical school grades are on a strict curve, and that 2/3rds of the students don't get scores above 90% anymore.

In summary, it's very frustrating to be surrounded with so many smart yet rude medical students, especially when the few obnoxiously vocal will be thought of as representative of the entire class.

Top Ten Pistons Buzzer Beaters

2008-03-24T13:39:00.000-07:00

I was wasting time on YouTube when I stumbled across this clip--my dad and I were at the game where Stack hits the game winner (#9). Also, if you look close you can see Alvin Gentry and Doug Collins--two former Piston coaches.

Here's one by Rasheed

The Allure of the Mountains

2008-03-24T10:30:00.000-07:00

What is it about mountains that draw so many people to them? Second only to living on the water, people seem to have an almost magnetic draw to living at higher elevations (or at least near them). So sacrificing the rich, sea-level air millions of people either hike, climb or live among the mountains.

In my experience with some of my family members, you can never explain the allure of the mountains to someone that does not have an innate draw to them. So if you have never dreamt of what it might be like to stand atop a mountain, you may not resonate with any of this. I can explain to my parents what an awesome experience it was to climb Horn Peak (see above and right), but they just don't get it. Maybe it is because they are from a time where there wasn't alot of free time to pursue interests such as hiking or mountain climbing, or maybe it is just because they have no inner "call of the wild," but for some reason, I can try to explain my motives until I'm blue in the face but they never seem to "get it."

To me the mountains represent the unknown. Every step upward is a step into a world that very few get to experience. A world of mountain meadows, evergreen forests, and snow capped peaks. The time I've spent in the mountains has been an opportunity to spend a day in another world. In an age of urban sprawl and suburban developments, mountains represent one of the last natural frontiers onto which the spoiling hands of humanity haven't yet reached.

Mountains also offer one a measuring stick. A test of willpower and overcoming the screaming pain in your legs with mental toughness. They allow you an unparelled test of endurance, as many climbs last hours to days.

Mountains are the place where world class athletes and a run-of-the-mill healthy individual are brought to similar levels. Many people falsely think that anyone who climbs mountains, does it so that they can inflate their ego by saying that they summitted Mountain X. Perhaps due to the huge numbers of people who attempt to climb Everest with little previous experience, often resulting in unnecessary deaths, many people have it in their minds that the only reason you would want to climb is so that you will have one more trophy for the mantel. But for me, climbing was much more than just reaching the top.

It was the stream that we found halfway up, with hundreds of small waterfalls as the snow melt made its way down the valley. It was the 10 of us, encouraging one another to keep going. It was the last 100 yards that couldn't be covered more than 5 yards at a time. It was the 10 of us encouraging each other to keep going. It was the knee deep snow we had to tromp through. All of these things came together to make for a once in a lifetime experience.

In a world of entertainment with increasing television watching and increasing obesity, mountains offer the opportunity to step into a world that few others will ever enter. A world of reality, where goals their accomplishment are crystal clear. An opportunity to see the world around you in a way like never before. A chance to get away from the constant noise of modern society and think clearly for the first time in a long time.

Simple NCAA Tournament Picking Rules

2008-03-21T09:16:00.000-07:00

Here is the backbone of my rules for picking teams in the NCAA Tournament.

1. Always choose the #1 Seeds in the first 2 rounds, almost always in the third round.

1a. The following rules should be disregarded in the final four. Then you are on your own.

2. Never pick a team whose name is "X State" unless it is Michigan State (Kansas St. got me this year, but it almost always holds true).

3. Never pick the underdog that everyone else is picking--George Mason proved this point.

4. Pick the Big Ten teams to beat any other team not in the ACC--even then think about picking the Big Ten team. See point 14 for a clarification.

5. Pick West Virginia to win unless they are seeded worse than 11.

6. Pick Syracuse to win at least two games any time they make the tournament.

7. Don't pick teams that got in because they have done well in the past, e.g. Arizona (I almost pick AZ because of Kevin O'Neill--the former Detroit Piston's assistant, but luckily I realized that would have almost violated rule 15).

8. Pick any team with the word "Texas" in it until you would be forced to violate one of the other rules.

9. Never pick 16 seeds over 1 seeds or 15's over 2's, nice try though Belmont.

10. If all else fails pick teams that you want to root for, it will at least make the games more interesting.

11. If you are going to pick a big upset, pick a team that is "hot" coming into the tournament. If George had beaten Xavier like it looked like they would, that would have shown this to be true.

12. Never pick Duke to go far if they are a 2-6 seed. For that matter, ACC teams that get seeds between 2-6 don't usually do that well.

13. Michigan State will either be eliminated in the first round or make it to the final four, in most years.

14. Never pick low seeded Big Ten teams, the probably suck and only got in because of the "strength of the conference."

15. Don't pick a team that lost its coach midseason. This could be called the Indiana 08 rule.

16. Never pick against a Tom Izzo disciple (this is one of my Cardinal rules). This applies to Tom Crean at Marquette and wherever Kelvin Sampson ends up. I never picked against Oklahoma when Sampson was there and I wouldn't have picked against Sampson at Indiana. In the case of a head to head pick Izzo over Crean and Crean over Sampson.

17. When rules contradict use your judgement.

18. Bo Ryan at Wisconsin is one of the 5 best coaches in college basketball, pick against him at your own risk.

Why Medical School is Awesome (Opening Black Boxes)

2008-03-19T10:37:00.000-07:00

We live in a world of black boxes. Most of us go through the day fairly oblivious to why things are the way they are. We know that a spark ignites a mist of gasoline to power our car. But can we explain the process of the internal combustion engine much further than that? I know that I can't.

The same is true for our bodies. Which isn't to say that the average person is completely ignorant of biomechanical processes, I've known since high school biology that when one puts their hand on a hot stove a reflex arc is triggered that causes you to quickly remove your hand before you are even consciously "aware" of it. But with that level of knowledge, you sometimes don't even know what you don't know.

But one of the best aspects of medical school is that you are constantly confronted with aspects of medicine that most of the world views as a black box. For instance, the subject matter for today was the anatomical basis for pain. To me, pain has always been more of an idea than something concrete. Pain is what happens when you try to open a package with a sharp knife and it slips and cuts into your finger. But in medical school you get the opportunity to dive deeper.

You can understand the basis for why you rub your arm after bumping it on the table. You can understand why people with spinal cord damage have very little return of functionality below the damage, but even better you have a whole new set of deeper questions you can explore.

Somewhere within the difficulty of medical school are the things that keep us coming back, things like opening up black boxes.

An Out of Context Quote

2008-03-19T10:09:00.000-07:00

"So if you wanted your orgy to go well you went to Bachhus"
-My Pastor

The Free Clinic (The Importance of Speaking a Patient's Language)

2008-03-18T06:03:00.000-07:00

(the details of this story have been altered)

Yesterday at the Clinic that I volunteer at periodically there was a man who came in who is a missionary to Detroit. Yes, that's right he has been sent from his home country of Venezuela to be a missionary to the Spanish speaking population of Southeastern Michigan--perhaps a sad commentary on the work that the local churches were doing to minister to those of the inner city.

So I went out into the waiting room and called Mr. Hernandez back into one of the rooms of the clinic. As we were walking, I asked him if he spoke any English, to which he responded in the negative.

I did my best to stumble through some of the basic spanish that I still remembered from undergrad combined with a few of the medical terms that I had picked up while working at a clinic whose patient population is 50% hispanic. Most of the sentances sounded something like, "Uh...necessito tocar...uh...su......pression." But as is the case most of the time, he was more than happpy to pretend like he understood every word I was saying rather than appear rude.

This guy had really high blood pressure, and I mean really high. 196/120 high, and I noticed from his chart that he had somewhat poorly controlled hyperlipidemia (high levels of "bad" cholesterol etc.). Once I had taken all of his vitals I told him that I would be right back with the "doctor," who is actually a nurse practitioner--but I didn't know how to say "nurse practicioner" in Spanish, and even if I did, I doubt that he would have any idea what the difference was between that and a doctor.

The next time we went back into the room, we brought one of the medical technologists from the clinic who was fluent in both Spanish and English. Here's how it went.

Sandra
"Ask him if he has been taking his medication"

Translator
"Yada yada yada (for the next minute)"

Patient
(Talks to the translator for around 45 secs)

Translator
"He says that he always takes his medication"

Really. That's all that he said in 30 seconds of talking? I take my medication. Tocarlo. It seems like he could have said that in a word or two, what did he use the other 40 seconds to talk about? And what were you saying the whole time? Neither me nor the LPN said anything (and I'm not sure if she even thought about it, but for me it was a bit of a disconcerting experience).

I realized then why the other doctor wanted me to do as much as I could without using a translator--especially when the only translators that we have available have very little background in medicine. A couple more examples:

Later on the translator kept saying that if he came back and talked to the nurse who specializes in diabetes, they could give him a meter for checking his blood sugar. But when the translator repeated the phrase in spanish she said we would give him a machina para pression (basically, a machine for checking his blood pressure).

I really knew that the message wasn't getting across when the translator didn't know the English word "testosterone," when she was explaining what the patient said to her.

So much of the medical interview can hinge on a single word. Did the patient say he checks his blood sugar occasionally or often. Has he had high blood pressure for 5 years or 14 years. What is the nature of the pain in his chest, is it stabbing or is it like someone is sitting on top of him. These difficulties are increased when you get a translator that fancies herself as a doctor and feels that what gets asked during the medical interview is her business.

The best translators that I have seen are those that take one sentance the doctor says in their native tongue and translates it into one sentance in the patients language. When the patient responds, the translator should stop the patient every sentance or so in order to translate back to the doctor. But in a larger sense, this experience has reminded me how important it is to learn as much as I can of Spanish, as it would be one of the most valuable foreign languages to learn as a future doctor in the United States.

Very Old Posts--Take Three.

2008-03-16T23:03:00.000-07:00

Here's the only post I ever wrote about medicine until I started this blog, it's funny how I have to learn this lesson over an over again.

Saturday, February 12, 2005

Someone said something that I really should take to heart the other day. At the meeting for pre-med students, I asked what sacrifices the three-doctor panel had to make in med school as well as during their residency, and one of the doctors said something really thoughtful. She said to enjoy the stage of your life you're in. That seemed so true to me because we, as humans, spend so much time wanting to be older when we're young and wanting to be younger when we're old. Not only that, but often times we fall into the trap of thinking that the next stage in life is going to somehow be easier. If I can just get through college then I can start living life and it'll be so much easier... But in reality life really doesn't get any easier. So why not make the most of the life that you're living right now, no matter how bad it may seem.

Second Thoughts on Information Sharing

2008-03-13T07:46:00.000-07:00

After being very opinionated about how I would never share information relating to study material here, I found out something interesting about myself.

I received an email informing me of a new program that is just beginning this summer for students in between their first and second years of medical school. As far as I know, this email only went to me, and only because I had applied for a similar program that they decided to discontinue. At the bottom of the email they asked if I might be able to spread the word as they wanted to have 9-10 students take part in the externship this summer.

So what did I do. Without even thinking twice I put together an email that made this program sound like it was the best internship ever, and sent it out to the entire class. For a moment I thought about not sending out the email because the more people that applied, the more competetion I would face, but a second later I decided to send it out anyway. I guess it just goes to show you that someone can support healthy academic competition while still believing that competition doesn't have to extend to all parts of life.

Another Bit of Medical Information (Psychiatrists Take Note)

2008-03-11T18:50:00.000-07:00

In The Know: Is The Government Spying On Paranoid Schizophrenics Enough?

Information Sharing in a School With Relative Grades

2008-03-11T17:05:00.000-07:00

I'd like to think of myself as a pretty friendly, open person.

In the past I have played on team sports, I would hope that those people on my team would say that I am a "team player."

But if I knew of a website that I thought could help students to do better on a test, I would in no way feel morally bound to inform my entire class via an email.

First, for the unindoctrinated, this is what I mean when I say relative grades. The basis for grading in medical school is done by standardizing how you did on a test with how everyone else did. Therefore if you scored lower than average on one test, your standardized score would reflect that--even if your raw score was 98 out of 100 possible, if everyone else got 99% you would have an unimpressive looking relative score. In the opposite scenario, if the average score on a test was 50% and you got a score of 65% correct, you would probably honor.

ALL medical schools must quantify how students rank within their class. Before one of the two people who read this write an angry comment, read on. You may say, but my school doesn't have grades. Generally people that say that follow up by saying "all we have is Fail, Pass, and Honors." I've got news for you, when you fill out an application for residency you medical school must provide some way of distinguishing your Pass from the other 100 students, if I'm not mistaken this is given on a scale of 16 with the middle of the bell curve set at 8, and with a 16 representing the top 1% of students or so. Although I have not confirmed this personally, I've heard people say that the only time they are graded is in 3rd and 4th year--I find that hard to believe, but I'll take their word for it.

By way of example (hopefully I'm not belaboring the point), at Wayne State we have a system of Z scores where the average on any given test is set to equal a Z score of 500. For instance, if I scored 75% and the average was 75% then my Z score was 500. If I scored an 85% my score would be near 600 (considered "Honors"). A score of 65% would be on the border of failing. Unfortunately, as mentioned above, you can have a very high raw score and a relatively low Z score (once I scored 92% with a z score of 460).

Getting back to the topic, one of the questions someone told me to ask the interviewer when I interviewed for medical school was, "How competitive are the students at the medical school?" In other words, is there a sense of teamwork at the medical school or is it everyone for themselves. To which, most would answer that there is a sense of comraderie in medical school. And there is. But can there be comraderie among people that are competing. I think that there can be, and I don't buy that competition is a bad thing.

Like it or not, we live in the era of American Idol and banning red pens. Perhaps in a reaction to how they were treated as children, there is a whole generation of parents that thought they should lie to their children about their children's abilities. "Sure Johnny, you can be a professional singer, you've got a great voice!" "Of course you can play in the NBA, who cares that you can't make it in the basket." At the same time we tell our teachers. "Don't use red pen to correct homework--it hurts students feelings." Luckily my parents always told me I could do anything I set my mind to, provided that I had some degree of God-given giftedness (I could practice basketball 'til I was blue in the face, but there isn't much need for undersized guys who can't jump).

I hope that our generation treats our children the way that my parents treated me. So that we don't have shocked children who are told for the first time that they can't sing by American Idol. And who realize that to become a doctor/engineer/teacher, you have to outwork a lot of people and that maybe it takes a C or D to realize that.

I've come to the point where I can admit that having a life is going to cost me getting an "Honors" in medical school--it just isn't worth losing all social interaction in the name of grades. Because of competition, I am driven to study many times when I'd rather relax. Because of competition I am able to set realistic goals. Because of competition we have highly educated doctors. Because of competion, I won't send out a mass email. Now if I can just figure out where to find all the information I want to keep to myself.

“Life doesn't imitate art, it imitates bad television.”

-Woody Allen

RHS

2008-03-08T13:19:00.000-08:00

Here's a condition that all aspiring doctors should familiarize themselves with.

Medical Hierarchy

2008-03-07T12:19:00.000-08:00

Everyone in the medical field knows that there is a hierarchy in medicine. Those who are outside of the field of medicine may or may not have any idea. This is evidenced by experiences in the emergency room. When I was a kid and went to the ER, I had know idea that the guy in the white coat might have been fresh out of medical school, but not everyone is as blissfully ignorant as I was--I've heard many patients immediately ask for the "real doctor" (They must be frequent visitors to the ER).

But for those in the medical profession, there are countless points at which you are forced to realize exactly where you are on the totem pole. There are obvious things such as the ability or lack thereof of signing off a note on a patients chart. For medical students this means writing out what you think is a good note, then finding a doctor who will check it and sign at the bottom.

Aside from the more obvious things, there are a litany of lesser things by which people are kept in check. I would argue that whether they are intentional or not, they serve as an important check in keeping one from becoming too full of themselves or feeling that they had "arrived" and no longer needed to study.

One of the more commonly referenced is coat length. For those not indoctrinated, the white coat of a medical student only goes to the waist (if that), while the coat of an actual doctor (resident or attending physician) goes all the way to the knee. But I think that the hierarchy can be much more subtle, and even though it is not always recognized as such, those that step outside of it are punished in just as subtle of ways.

For the gunners, although people may tolerate them to their face, I would be surprised if anyone would go out of their way to help them. Say for instance someone knew of a chance to meet with several higher ups in the surgical world, I don't think that the first thing you would do is call them up to let them know about it. If someone wants to be a gunner to the point that everyone can see they're looking out for number 1, people will consciously or unconsciously punish them for it.

Although I personally can't speak to this, I've heard that the same principles apply to medical students on rotations. Don't make the residents look bad. It seems pretty straightforward, but I guess some people were never properly trained in the social graces. (bunny trail: a lot of people say things like "I just need to get past the basic science and start clinical rotations, then I'll really shine"--we can't all be right can we). I wouldn't have said a word when was at the Morbidity and Mortality conference, I don't care if they pointed at me and asked what my name was, I would have hoped someone else would have answered. Real or imagined, I've got a healthy (I think) fear of being blackballed.

Lastly I think there is an even more subtle component. Next time you are in a room, look at the seating arrangement. Say for instance you are in a room with a chair a couch and hardwood floors. I would venture to say that 9 out of 10 times, the most senior doctor will be in the chair, the three residents will be on the couch, and the medical student will be on the floor.

Signs You May Be At a Clinic That Reuses Medical Supplies

2008-03-06T07:42:00.000-08:00

1. Patients are informed before their appointment that the need to "bring their own betadine."

2. While other health care providers are switching to computerized medical records, this clinic is trying out the whole "no records" thing.

3. Any box that once had now has

4. The insulin about to be injected is a deep shade of red.

5. You notice from his diploma that your "doctor" actually only has a Ph. D in economics.

6. Patients requiring surgery must bring someone with the same blood type for on site transfusions.

7. Bills can be paid in 10 easy payments of 11.99

8. Upon entering, patients take a number from a deli-style machine.

9. Before the doctor will see you, patients are fill out a questionaire asking, "What did WebMD say you have?"

10. Hand sanitizer is coin operated.

Very Old Posts--Take Two

2008-03-05T10:01:00.000-08:00

Another blast from the past. Note: I never actually read this book--this was during the whole "people may actually care to know what you are reading phase." I was trying to be clever.

Tuesday, June 21, 2005

Currently Watching
Go Paddle - Beginning to Intermediate Kayak and sit-on-top
see related

Open Water 2: Terror on Lamberton Lake (a true, albeit exaggerated, story)

Scene 1
The scene opens with our protagonist (yours truly), calmly paddling in his kayak across a serene, sunlit lake. (foreboding music) When all of the sudden the protagonist thinks to himself (zoom in on face) "This kayak seems pretty stable, but you know what they say about kayaks..." (Flashback to mother's warning) "If you were to tip over in the middle of the lake, that would be a nightmare. Nightmare...nightmare...nightmare (fade out and snap back to reality...uhh-ope there goes gravity [bunny trail]) Zoom in on protagonist face again. "I wonder how much it would take to tip this over...I'm sure it would take an awful lot..."

Scene 2
Scene opens with our protagonist gently rocking the kayak back and forth. "See it is hard to tip over!" When all of the sudden a trickle of water drips over the side. Quickly the drip of water becomes a stream. And then a torent, engulfing the right half of the kayak. The once proud Old Town kayak is now listing heavily to the right, but she wasn't about to give up without a fight. Lurching back to the left, the kayak struggles against the rushing water with all her might, but it was too late. With a gasp she rolled over, like Rasheed Wallace in the playoffs.

Scene 3
(Quick shots of our protagonist swimming next to his disabled kayak, a look of sheer horror on his face) Alone and adrift in the middle of gi-normous Lamberton Lake our protagonist looks around for any sign of help coming. Nothing. He realizes that he must either sink or swim...literally. After a few failed attempts at flipping the kayak over in the middle of the lake, our protagonist realizes that he must swim to shore, all the while pulling his kayak behind him! (fade out with protagonist swimming toward shore)

Scene 4 The Earth Shattering Conclusion
After laboring for hours, trying to get back to shore, our protagonist finally crawls onto shore. Exhausted and relieved, he kisses the ground, before beginning his long walk back to the docks. Just when it seems he is out of danger, he slips, severly lacerating his right foot, blood jetting upwards. But he's already been through so much that day that he continues on, his resolve only further hardened. When at long last he arrives at home, to a grateful country... (roll credits)

The Protagonist.........Myself
The Kayak...............Old Town Kayak
Burt Reynolds...........As himself

a ©stew production

Cheers for Fears

2008-03-05T08:32:00.000-08:00

Hey med students, please stop signing off letters with "cheers," we're not from England and were not in a 90s sitcom. And last time I checked, I don't have a glass of anything in my hand.

On Greed and Medicine

2008-03-04T09:30:00.000-08:00

"Clark County prosecutors said they were investigating a medical clinic accused of shoddy injection practices that exposed patients to potentially deadly infections."

What's going on in the world of medicine of late? I realize that every time the media catches wind of a story about (actual) medical malpractice it immediately becomes headline news--if not nationally, at least regionally. Also, I think that as professions go, doctors are the most ethically minded. But why does this ever happen? How can someone make such sacrifices to get through medical school and residency (supposedly to help their fellow man) and then become an utterly different person after they become full doctors? How does a doctor snap, or have "angel of death" doctors already snapped before medical school, and are simply good actors?

For those that don't want to spend a lot of time reading about the long and short of it, I'll summarize for you.

Within the past few days a story has broken in Las Vegas that a small practice in the city (Endoscopy Center of Southern Nevada) has been reusing syringes in order to save a buck or two. Workers at the clinic reportedly were told by the doctor in charge of the center to reuse supplies and medications in order to save money.

Here's an example: say I come in to have some procedure done that requires intravenous anesthesia. The nurse (or whomever) walks in and begins an IV by sticking a needle into one of my veins. Little do I know, but a few minutes/days/weeks ago, that very same needle was stuck into a patient who came in for HIV. Many years later, I now have been infected with HIV as a result of almost unbelievable choices by people that I have been indoctrinated to trust.

"This should never happen in contemporary health care organizations."

The one thing I will never understand is how someone can go through a minimum of four years of medical training and still take part in practices like this. Let's say for the sake of argument that the nurses and other staffers were told to reuse medical supplies to save money, and let's say that there were not any incentives given by the doctor relating to number of items reused (which are both accurate assumptions, given the data). How on earth can you, in good conscience, keep silent. Do not get me wrong, the doctor who was in charge deserves the lion share of the blame, I hope this disgusting act of greed puts him in jail for a long, long time. But why didn't anyone say something. It seems a sad commentary on the modern view of responsibility in this country when a handful of people can all go along with something they know for a fact is wrong and endangering patients.

Doctors are consistently ranked as the most respected and trusted of professions. And 99.999% of doctors spend every day earning that trust, but a seemingly increasing number of health professionals are being found out as betrayers of that trust. How will this change medical practice in America. Will patients be less apt to agree to necessary surgical procedures? Will nurses have to remove packaging of medical supplies in from of patients (this wouldn't surprise me if it was required in the near future)?

"Southern Nevada Health District officials said last week they traced six cases of hepatitis C to the clinic, including five people who were infected on the same day."

If this is accurate, then this is unbelievable. I don't know what the chances are of getting Hep C from a needle stick, but I've heard that the chances of getting HIV from a contaminated needle (from a needle stick, which I would assume is less dangerous than the practices described above) are something on the order of 1 in 300, at least among medical professionals who are accidentally stuck. Basically (although I am by no means an expert) this would seem to point to the fact that the needles were used tens, maybe even hundreds of times.

"We need to let them come up with what exactly is the problem. In the meantime, that place is closed."

I'll tell you what the problem is. Greed mixed with zero care for patients well being. There seems to be a spectrum in medicine, a spectrum that goes deeper than statistics like "patients per hour." On one hand you have doctors who are completely absorbed with the pursuit of money. On the other hand you have doctors who can truly say that they are not at all concerned about their income. To the former, I would ask the question, why not go into business, chances are you could make a lot more than in medicine (bunny trail: I think the answer is a formula: middle class/lower class smart student sees 7 years of work = almost guaranteed 100,000 dollars per year for life)

In truth, I think that most doctors fall somewhere in between. I'm on pace to rack up $160,000 of debt and someday I'm going to have a wife and family to support. It's through taking a reasonable look at finances that I am able to say, yes I can stick this out and someday I can pay off my loans and live very comfortably. Does that make me a selfish person--if I drive a new car every five years and live in a million dollar house while many in the world are starving, I think the answer is yes. How do we keep from sliding down the slippery slope into unmitigated greed and waste? If we could answer that question then maybe we could decrease the frequency of outright malpractice.

African Watering Hole Webcam

2008-03-04T08:32:00.000-08:00

Found this site the other day, it is strangely addicting. Generally the video focuses on the watering hole, but lately when I've checked it the operator tends to move the camera around.

A Tribute to RDK

2008-03-02T10:13:00.000-08:00

This post is exceptionally long, I apologize. When I was an undergraduate student at the greatest institution of higher learning in the world. I had a really awesome adviser. Even though I was a biology major, and he was a chemistry professor--I knew from the classes that I had with him that I wanted him to advise me on life/professional decisions. It just reminds you of the huge impact that teachers have on our lives. What follows is an old excerpt from a xanga post I wrote during undergrad, and subsequently, an article I wrote about him for the college newspaper (please excuse the horrendous prose--oh and by way of explaining the title of the article, Calvin's mascot is the Knight).

"Tonight was the best lab ever. I actually understood everything and RDK was on top of his game. He was joking around the entire night, which definitely made it fun. He was like, 'Well if only one student understood the lab tonight then I can be happy... I'm not going to say who that is (points at me).' And I said, 'Oh stop it!' in the most obnoxious voice I could do. To which he laughed, good times."

Arabian Knight shares experiences

By XXX XXX
Guest Writer

Shells whistle overhead. A stray rocket crashes into the balcony of a high rise apartment building. A professor is gunned down in a parking lot by a crazed student. While this may sound like the script from the latest Scorsese film, these were just some of the experiences of one Calvin professor during the Lebanese civil war.

“I got my bachelor’s degree from Calvin in 1965, and then I went to Wisconsin for my graduate work,” said Roger DeKock, professor of chemistry. “But [in the early 1970s] there was a downturn in the chemical industry.”

Forced to work in consecutive post-doctorate programs that took him first to Florida and then to England, professor DeKock was more than ready for a teaching position. “While I was [in England] I got this job offer to go to the American University of Beirut. It was my first job offer, so [my family and I] decided that even though it was further from home, we’d better take this job.”

The first couple of years that DeKock and his family spent in Beirut were relatively calm, but the political climate in Lebanon was about to take a turn for the worse.

“People had been muttering things to me at the university, like, ‘Boy this place (Beirut) is getting to be a powder keg — and it really was a powder keg. From the Palestinians in refugee camps to the way the government was set up, there were so many pressures because of the [tensions between] the Christians, Shiites and Sunnis.

“April 13th, 1975. I still remember the day very well. It was a Sunday; the weather was beautiful; it was spring. I remember hearing late in the day that some fighting had broken out in Beirut.”

News reports would later say that a Palestinian gunman had opened fire on several people leaving a church in a Christian suburb of Beirut. In retaliation, a Christian group detained and then killed 26 Palestinian civilians. The fighting would only intensify.

“From certain parts of the campus you could see [two] high-rise hotels; one was the Holiday Inn and the other one was the Beirut Hilton. Opposing factions took over the hotels, and they started shooting at each other from the tenth story up. I distinctly remember trying to sleep that night and hearing shelling in the distance, and that created a very uneasy feeling — to hear fighting going on when one was trying to sleep.”

As the fighting intensified, DeKock’s need to evacuate his family became increasingly evident. “The airport would close periodically and then we couldn’t possibly leave, but one evening my wife and I were going out to get some food, and we saw an airplane landing. I said to her, ‘we’re going to get you and the two children a ticket and get you out of here.’ They got out of [Beirut] before the worst came.”

The sectarian violence between warring factions almost always resulted in collateral damage. “I heard bullets flying on campus — there would just be stray bullets,” said DeKock.

The apartment complex where DeKock stayed was not any safer. “There was a Lebanese army post right on the Mediterranean about a block from our apartment complex called “Bain Militaire.” The part of town that I lived in was the Muslim side of the city — the Christian side was the East side, and periodically the people running the rockets on the East side would try to take out that officer’s club.

“But they weren’t that good at aiming. If you heard the rockets go over you were safe, because they had overshot and they would probably go into the Mediterranean, but sometimes they would undershoot. We had one that landed on our street. It was at night.

“It was a huge explosion, and I thought, ‘Oh my goodness, what happened?’ But after everything calmed down, there was no shouting or screaming, so we guessed that nobody got killed or injured. We went out in the morning and looked, [and saw] that the rocket had hit on the sixth story balcony across the street and brought down the balcony on some parked cars down below — those cars were totally pancaked under concrete.

“Another thing that I noticed was that people who were normally unstable would really go off the deep end during times of war. That must have happened to one student, because he came onto campus with a gun — this was the spring of ’76. He came and killed two deans; one was the Dean of Student Affairs and the other was the Dean of Engineering.

“We heard on campus that there was some shooting, so we were told to shut our office door and turn our light off because we didn’t know who this person was shooting at. A few hours later we got the all clear and were told it was safe to leave. I went to walk home, and as I was walking by the School of Engineering, I walked by the pool of blood where the Dean of Engineering had been killed in the parking lot. He had tried to outrun the student.”

The atmosphere in the classrooms took on a different type of tension. “[Students] didn’t start talking politics to each other on campus — they knew not to do that. It’s like here at Calvin, if you know that somebody is a Bush supporter and you’re not, you just decide between each other to keep quiet. I think that there was a lot of disagreement among students but they didn’t start getting into shouting matches.”

The effects of the civil war stretched into other areas of civilian life. “I spent a lot of time just trying to get groceries. Something that would’ve taken me 30 minutes a day here, now could take two hours, waiting in lines to get bread, milk or meat.”

As many expatriates fled war-torn Beirut, anything that could not be taken on a plane was left behind. “Several of the people that we knew had pets, and they all left them behind with me. I didn’t want to just turn them loose, because when people started to leave, they just let their pets run loose in the city, and that was a horrible life [for the animals].

“I ended up with all kinds of propane gas cylinders that you would use for cooking. When people left, [all of their unused cylinders] ended up with me. I had 10 propane gas cylinders, and when I left I passed them on to someone else.”

The roughness of war contrasted the beauty of Beirut at peacetime. “When we lived there [before the civil war] people called Beirut the Paris of the Middle East. Arabs from the gulf countries would all come to Lebanon in the summer because the climate was so moderate.”

Because of the proximity to both the mountains and the Mediterranean, Beirut was once a popular tourist destination. “The mountains were about a 30 minute drive [from the Mediterranean]. People used to say that you could go swimming in the morning and skiing in the afternoon,” said DeKock.

In the summer of ’76, DeKock decided enough was enough. “The university would close periodically, the hotels were burning, the downtown — which was about three miles from where I lived — was destroyed while I was there. I left because it was dangerous, I thought, ‘why not get out while I can?’ I didn’t like being away from my family.”

From the mid-‘70s to the ‘90s the civil war in Lebanon continued in one form or another, and although formal warring has ceased, the area remains a hotbed of political strife, as evidenced by the violence between Hezbollah and Israel this past summer.

Professor DeKock had to send his family back to the United States for safety reasons while he spent time in Beirut alone.

Besides seeing war and violence first-hand, the DeKock family had experiences unlike many other young families.

DeKock, a professor of chemistry, lived and taught in a war-torn Beirut, Lebanon, in the 1970s.

Xanga!

2008-03-02T09:35:00.000-08:00

It's funny to look back on what I thought was blog-worthy back in high school. I fairly religiously blogged back then, and I'm glad. Even though they are all pretty awful, it's nice to have a reminder of what was going through my head at that age--which is partly why I started to blog again. And partly because it is a great medium for thinking and refining one's feelings about things in one's life or events in general.

Here's a couple of really "old" entries:

Monday, January 30, 2006
I think that the more I experience life, I've found that there are two types of people in the world. Those who are content to consistently run away from their problems and those that choose to stay and try to make the best of the hand they've been dealt. I find that every day I have to fight being the first person.

Sunday, October 30, 2005
Note to parents: Your son/daughter is no more/less unique because his name is spelled Jaymes or James, also this goes out to all the people who've named their daughter Allison, Allyson, Alison, or however else you can think of spelling it; you aren't doing anyone a favor, just creating a thousand headaches for your son/daughter because no matter how many times your child tells someone, it's always going to be spelled Jason and Allison. Also if your last name is Williams, don't name your son Jason, I think that there are about 1 billion Jason Williams' in the world already. Just to give you an example Jason Williams (NBA players) 1. played for the New Jersey Nets then killed his limo driver (2) Played for Duke and the Bulls until he took a tree on in his motorcyle and destroyed both of his legs and (3) got traded to the Heat from the Mephis Grizzlies. Oh and there's a Jason Williams who plays for the Michigan State football team and also one that scored 3 goals in 16 minutes for the Red Wings. And that's just the first ones that come to mind...

Tuesday, October 04, 2005
Here's a conversation with my dad (on AIM):

stewb1943: Si Senor

baptistsoccer: haha

baptistsoccer: si means if

baptistsoccer : sí means yes

stewb1943 : you're too good, thought I had you there

(later on)

baptistsoccer: love ya dad

stewb1943: me too

Sunday, September 25, 2005
Wasn't it great to be ten and the only decision you had to make was whether you wanted to play tag or wiffleball.

Monday, July 11, 2005
People should start doing crazy things right now...because who knows when you'll need to use the insanity defense.

I won't bore you with anymore. Good times. Well, maybe a couple more. (I think I convinced myself I was a comedic writer in bloom--to Steven Colbert: I'm still waiting.)

Wednesday, July 06, 2005
I wonder if anyone has actually "backed that thang up" in response to "you'z a real fine woman"

Tuesday, May 31, 2005

The other day at work I thought about how bad it would hurt to fall onto the grill. But then I thought, "Well if you did it right... verticle lines are slimming"

Wednesday, May 25, 2005
I was at work the other day and we've got a bag of "Fancy Mixed Nuts" that I sell, the thing is, they're mostly just peanuts. Now how is it that a bag of peanuts can be called "fancy." I mean seriously, is there anything less "fancy" than the peanut. We use it to make a butter for goodness sake. You don't go in the cupboard and reach for Pecan Butter, now there's a fancy nut...

Free Love on The Free Love Freeway (British Office)

2008-03-01T15:52:00.001-08:00

Orthopedics

2008-03-01T12:50:00.000-08:00

"To someone with a hammer, everything looks like a nail."
-I have no idea who first said this, but it's true nonetheless

I came into medical school without having a definite idea of what branch of medicine I wanted to go into, and I can still say that I am not totally sure exactly what I'd like to do. But always in the back of my mind I thought I would go into orthopedics.

It all started when I read a book entitled Hot Lights, Cold Steel, written by an orthopedic surgeon named Michael Collins. I think this is one of the best medical-general interest books that I have ever read--an maybe part of it is that I am the type of person that would be interested in orthopedics.

I played sports in high school (a rather common experience I've read), but I don't think that having played sports is the main reason that I became interested in orthopedics. The reason I feel that way is because if I went into orthopedics and never saw a sports-related patient, I would still consider it to be my first choice.

But when I consider the following reasons, I find it hard to believe that anyone would go into any other specialty, which partially explains why ortho is so popular.

1st (and foremost) Treatment-Effect Relationship: With what little medical knowledge I have, I've realized that I would never want to go into something like internal medicine, where the primary way of caring for a patient is by giving a drug that will fall somewhere on the working-not working spectrum. Orthopedics offers a very definite relationship between the work that you do for the patient (surgical or otherwise) and the results that the patient has, e.g. someone comes in with a broken arm, the orthopedic surgeon reduces the fracture, and a few weeks later the arm is restored to functionality. In orthopedics, problems are can often be completely (or nearly so) fixed, not attenuated to some degree. I've heard a doctor in another branch of medicine joke, "What's a lab test for an orthopedic surgeon? (Pretends to hold vial up to light) Yep, looks blue." Ben Franklin once said that it's better to be thought of as stupid and remain silent, someday I think that I would be perfectly content to be satisfied and thought of as less smart, rather than a miserable neurosurgeon.

2nd Stability through Time: This is one that I've never heard anyone else mention, but it always has stood out to me. I think that 10 years down the road, PAs, nurse practitioners, and supermarket clinics will drastically change the way many specialties will work, esp. family practice doctors (which also is something I considered). But 10 years from now, while the actual techniques and materials that orthopedic surgeons use will have changed, the principles behind the orthopedic treatment of patients will not have changed. Maybe this has some overlap with point one, but what I'm trying to say is this: 10 years ago someone with a bad hip came to an orthopedic surgeon to have it replaced (just like they will 10 years from now). But ten years ago, the treatment for cardiac conditions was largely surgical--now it seems largely medical (from what limited information I've heard). For me this is just another reason to go into a specialty that you can devote your working life to with no fear of having to make big changes somewhere down the road.

3rd Working with My Hands This was never something that consciously led me to consider orthopedics, but rather something that I noticed in hindsight. I enjoy working with my hands--I played baseball in high school, and I have done some woodworking these past two summers and I absolutely love it. Actually, I think it may even go back one level further. I enjoy creating things. I like taking nothing and turning it into something. I like having plywood and 2x4s and turning them into a coffee table. I like in baseball (now softball) that every time the ball is hit to me I have to "create" an out from different circumstances. I like seeing a color that stands out among many different colors and making a photo that I will appreciate for a long time. That's why I think that someday I'll enjoy both the process and the results of orthopedics.

4th Forming Relationships: Perhaps this first part is a biased opinion, it seems that orthopedic surgeons enjoy each others company and that they are generally one of the "happier" doctors that I run into (collectively, I'm sure there are exceptions). The orthopedic practice in my hometown plays as a hockey team in a rec league, and the doctor I shadowed just seemed to be really happy doing what he was doing. Also, I like that there is a component of clinical work in orthopedics. What you are doing isn't strictly surgical and because of this one can take the time to form relationships with his/her patients (although admittedly, there are other specialties which allow for greater relationship-forming). I guess it's the balance that appeals to me. Also, I like that even though orthopedics is demanding time-wise, from what I've heard one can still be a family man/woman--which is very important to me. I got into medicine to help people in a way that is challenging, rewarding, and scientific, not to desert my future wife and use the excuse of a calling. A calling is feeling led towards medicine--so much so that you would spend the prime of your life pouring over books and working through long hours of residency. It's not an excuse to spend 100 hours a week working (post residency) and think that is what's right for your wife/husband and 5 children. So to summarize that mini rant, orthopedics allows one to self limit the time put in so as to have a balanced life.

5th Medical Mission Work (not necessarily ortho-unique): Someday I would like to do medical mission work, and I think that having some surgical skill, be it general orthopedics or otherwise, would allow me to be the most effective at helping the under-served of another country. In other words, having a surgical skill would allow you to perform a greater variety of services to the indigenous population than perhaps an internist would be able to--this is not at all meant to be a knock on other specialties.

6th Condition Diversity Orthopedic surgeons work throughout the body and it seems like it is harder to be pigeon-holed (unless you want to be) than it is in other specialties. Whether it is true or not, I've heard that the majority of the work a general surgeon does is gall bladder removals and appendectomies, and to me at least it seems that orthopedics allows the doctor to decide what they would like to focus on/not focus on.

Cons: Long hours during residency, on the longer end in residency length

This is why I don't know who would want to do anything else, that said, I still have very little practical knowledge about medicine itself and am still open to changing my mind.

In Defense of Gunners

2008-02-27T04:32:00.000-08:00

Gunner. GUN-ner. noun: Considered by most to be the most annoying type of medical student, a gunner is a student that is "gunning" for a residency and willing to do whatever (they think) it takes to get said residency.

I am not a gunner.

If anyone would like to see that my grades bear this out--I'd gladly put my Z scores up here. You would not be impressed, which isn't to say they are abysmal, but enough about me.

Why defend the gunners, you ask. They are probably already busy defending themselves at this very moment to one of their annoyed classmates--why stand up for them?

Here's a confession: I hated gunners. I hated how anytime there was anyone with any clout who spoke to us, the gunner(s) of the classroom would be sure to ask them limitless amounts of questions just so that the would stick out from the class. I hated how I could study most of the time most of the days of the week and I was still just an average student because of the 1/4 of my class does absolutely nothing but study, sleep, and eat (while we're on the topic, I hated that people could openly mention that they studied way less than me and still did better on a test). I hated how obvious gunners would make their "networking" with doctors, other med students, etc. It got to a point that I even nicknamed one of the gunners in my class Verizon Wireless (it's the network).

Here's the one thing that I can say I respect about gunners: they know what they want, and though they probably aren't going about it the best way, they are doing what they think it takes to get what they want.

Here is the type of "gunner" that I can (almost) like: He (or she) is certain that he wants to get into a difficult residency, e.g. derm, plastics, ortho. Because of this he realizes that he definitely can't completely let grades go by the wayside, but at the same time he has friends, a life, and is seen at the medical school on non-test days. Rather than annoying everyone else by monopolizing a speaker's time, or being the first to answer all of the questions in class, he gets to know doctors on their own time, or talks to the speaker after words (although too much of this would be borderline :)

To summarize, actual outright gunning is annoying and is a great way to alienate your friends (that you won't have for long), but those that are simply pursuing what dreams they have I can respect. The difference is true gunners take satisfaction in being thought of as a gunner, while the others would just be content to be in whatever specialty they like when they finish medical school.

"People have got to know whether or not their President is a crook. Well, I'm not a crook. I've earned everything I've got." -Richard Nixon

Verie Inn Secyure MD, MBA, Ph.D, MPH, JD, FACS, CRNA, CPA

2008-02-26T15:29:00.000-08:00

"There is nothing so stupid as the educated man if you get him off the thing he was educated in."

Will Rogers

Does anyone really need multiple graduate degrees?

I always thought it was interesting to analyze the type of people that get into medical school. A few people went to medical school because everyone in their family for the past 4 generations have been doctors. Some go becasue their parents said that they would pay for the education plus living expenses. Still others got into medical school because it was just something to do. While the vast majority of people get into medical school for the right reasons, I think it is the last group that is the most interesting.

Picture this, a smart undergraduate student, who also has considerable foresight, realizes about the end of their sophomore year of college that they are about 9 months from having to know what they want to do. Many students harness this fear to do some serious soul searching and decide upon a career choice such as going into business or becoming an accountant or teaching high school. Then there is the small but definite minority that decides to finish up their undergraduate degree and then decide on some graduate school ad hoc.

But, you might say, medical school has so many hoops that you have to jump through (MCAT, ACGME etc.) . How could someone decide to spontaneously pursue a career in medicine? I think that there are two ways that it is done. First, someone takes classes to get a Masters of Basic Medical Science (read: I couldn't get into medical school the first time I tried). Or you could have someone who takes an extra semester or two in order to squeeze in the requisite year between taking the MCAT and getting into medical school.

The long and short of it is this. A definite percentage of students in medical school are only in it for either the prestige/respect factor, or because they had nothing else to do. Which gets back to my first point: there are very few exceptions where someone could justify the need for multiple degrees.

1. MD/Ph.d: I have asked those who should know on multiple occasions why someone would want to do this. Generally, the response is some mumbled "I just don't know exactly what..." At the very least it means 10 years of combined schooling/residency, and for what? So that you'll be a better researching physician? Why not just take two years during residency and do some research, then you can develop your own goals rather than piggybacking on the work of someone else who probably isn't doing something that you're that interested in. I can almost guarantee that it would be 1000 times more valuable to do research as a resident because you would have much more freedom to do exactly what interests you and because you would have much more experience at that time. By that time you will have a much better idea of what you want to do with your medical life. I just don't get this one--maybe I'm just not smart enough to. The one benefit is that instead of paying for school you get paid ~14k for 7 years, but I wouldn't trade two less years of professional life for 28,000.

2. MD/JD: This is the only one that I can see reasonable people doing. If you want to spend the rest of your life suing doctors, you might as well get an idea as to the innerworkings of the medical machine. Seriously though, if you wanted to devote your life to the service of mankind both medically and legally, e.g. working with the poor, then this would absolutely be a noble calling.

3. MD/MPH: I'll be honest, I really know nothing about an MPH other than it stands for Masters of Public Health. But just the same, I can't imagine that you learn more about public health by sitting around in lecture halls than you would be spending the same amount of time following around those who work in public health.

4. MD/FACS I just found out that FACS stands for Fellow of the American College of Surgeons, this would actually be something I think should be strongly encouraged.

So in summary, I think that multiple graduate degrees are ridiculous and I realize that a CPA is not a graduate degree. I apologize for the rambling nature of this post--but at least I'm the only person that has to read it ;)

Free Clinic Encounter

2008-02-22T10:36:00.000-08:00

So there is this clinic that I like to work at periodically that serves those of Detroit that cannot afford normal health care but that are still either working or trying to find work. And there is this doctor there that seems to like me as a med student, either that or they're just friendly to all med students. I say this because she is very good about making patient encounters a learning experience. But she is this petite woman. So one day this guy comes in dressed in "urban cowboy" apparrel and you just know when people with big leather boots come in that they are just looking for a prescription for some more drugs.

Long story short, the guy was in an accident a few years back (in his defense he did nearly die), but he grossly exaggerates his pain (10 out of 10--everywhere in my body!) in order to try to convince her to give him another prescription for some opiods. And to try to be even more convincing he tried to act completely out of it, I guess because he thought that by acting like he had no mental faculties he would be a better candidate. For instance, even though he had to write his name and the date at the top of the mental coherence test (which he got right), he suddenly thought that it actually was "November" not "February."

But thank goodness the doctor wasn't buying any of it, and before we went back into the room to give him the "bad news" she told me to be ready incase he got hostile in response to what we were about to tell him. So I ran through a few scenarios in my mind in case I (being the only one of us within 70 pounds of this guy) had to defend the both of us. Luckily he took the news pretty well inasmuch as he didn't get violent.

So I sat down on the stool while the doctor explained in detail why he wasn't going to get what he wanted, while he did his best to roll out some answer like, "Well, I just think that when I was on the Oxycontin I was in a good place, a place were I wanted to be." But when she asked him where he wanted to go from here, e.g. pain free or working etc, he didn't have an answer. Even more troubling, his medical records showed that he had tried to kill himself on a couple of occasions by overdosing on pain medication.

As this was going on, I noticed that the doctor kept trying to get my attention for some reason. When we finally made eye contact she motioned towards the door with a look.
So I got up and moved towards the door. When I talked to her later, she said, "I was trying to get your attention forever but you were just sitting there on that stool!" She didn't say it in an angry way, but rather she was more just pretending to ream me out. To conclude she told me, "Never let a potentially angry patient get between you and the door."

Oh and the guy also made some vague references to feeling "homicidal" without his pain medication, his one thinly veiled threat from the encounter.

Medical Records

2008-02-22T10:20:00.001-08:00

Medical records are a funny thing. Search google for "Hospital X Medical Records" and you can very easily get a fax number by which to request the medical records of a patient, with the only requirement being that you send over a faxed copy of the request for the records including the signature of the patient. And if you put something like "the patient is in the office" on the request you can even get them in a matter of a few minutes.

How fun would it be to send a request over to Henry Ford and say that you've got Joel Zumaya in your office and would like to see the MRI of his shoulder; then take a look to see if the injury was really consistent with a "box falling" or a dirt bike accident (assuming I actually knew something about shoulders, MRIs, or medicine in general).

Shakespeare once said that the guilty "protesteth too much," and Zoom-Zoom's preemptive strike with his vehement denials seemed a bit suspicious when not to many people were questioning the validity of his story.

Obviously this would have serious legal and ethical ramifications, so I would never actually even consider it. But it would be interesting none the less.

Morbidity and Mortality

2008-02-20T11:21:00.000-08:00

M&M conferences are one of the more unique things in medicine. I know that I'm not the first person to think this, but when I went to my first one this morning I was struck by the layout.

Not that it was an earthshattering experience, or something that forever changed my life, but rather it was an interesting experience. In what other profession do professionals lay out for all to see--in vivid detail--the mistakes that were made.

Since they have M&M every week, chances are that if you picked a random week you would not hear about someone who accidentaly gave someone 10x the normal dose, instead the most common thing that you hear about is situations where very subtle warning signs were missed, or where a patient died for no clearly defineable reason.

The only people to talk during the M&M conference is the nervous resident who is presenting and the attending physicians who ask the questions. It's not at all like the TV version where people are shouting contentious questions at the presenter, but rather it is a very quiet environment where residents and students can learn from the mistakes and missed signs of those who have proceeded them.

Solitaire

2008-02-19T06:08:00.000-08:00

The difference between perseverance and obstinacy is that one comes from a strong will,

and the other from a strong won't.

~Henry Ward Beecher

I was playing solitaire the other night (to take my mind off of studying for the biochemistry test that I have to take in a couple of hours) when I noticed that I wasn't really playing solitare anymore.

In the solitare game that I have, you don't need to click and drag the cards in order to place them on the stack. In other words, if I wanted to take a 3 of hearts from the deck and place it on one of my piles all I had to do was click on it--which is great inasmuch as it is easier, but it can make it so that you don't actually have to know where you want the card to go, the computer will place it on the correct pile if any moves are available. Pretty soon, rather than actually thinking, I was just clicking on each of the cards to see if any moves were possible.

Which got me thinking. How much of my life and the lives of those around me been shaped by the mentality that all that matters is "winning." Not everyone is motivated to come in first, but I think there are alot of people who have fallen into the trap of just trying to get through things. What I mean is that, for many medical students, all they want to do is survive medical school.

It is an easy trap to fall into--and one that I must say I fell into of late. I have subconsciously made many decisions that directed me down the path of "just getting through." Because I thought it would be easier to get up later and stream the lectures (the lectures are recorded on video) I convinced myself that it was "more efficient" because I could watch the lectures at 2x speed. Yet, instead I found that I was doing less studying than I had been doing when I came to lectures everyday. The time that I was saving I wasted because I had adopted the mentality that medical school = passing grades for 4 years.

So to conclude this rambling post, I think it's important to constantly evaluate the motives we have. Are we just trying to "win" at our solitaire games or are we actually taking the time to experience what we are going through and live our lives to the full--no matter how difficult a situation may be.