Tuesday, June 15, 2010

I'm going to be a dentist.

After completing my rotation in child psychiatry, I spent the next two weeks a the Free Clinic on a family medicine elective. For those of you not from Cleveland, the Free Clinic is one of the oldest free clinics in the country. Given the tremendous poverty in Cleveland, especially on the east side, this clinic is a huge asset to the community. The elective was recommended to me because it forces students to essentially get thrown into a room with a patient and manage them with minimal oversight. The autonomy was apparent from day 1.

I remember walking into the clinic, undergoing a quick 5 minute orientation, signing some papers, then being thrown into a room with a patient.

I walk in: "Hi, my name is Kavi and I've never done this before. Today I'm going to play doctor as I waltz around in my white coat pretending to know what I'm doing when I really don't. What brings you in today?"

Of course I didn't say that, but it's pretty much how I felt. After making my way through the history, doing a brief physical and coming up with an assessment/plan that the patient was cool with, I walked out back into the provider area and met with one of the attendings to discuss my patient. The preceptor was either a family medicine/internal medicine doc or a family med nurse practitioner depending on the day of the week. They would check over my notes, sign out the meds or any labs that I we agreed the patient needed. After taking care of labs and meds, we would both go into the room, chat with the patient for 2 mins. The preceptor would discuss the meds, hand over the actual pills, and wish the patient well. Regarding the meds, the free clinic has it's own pharmacy in house where patients can get meds. Pretty cool.

Basically, the preceptor was there to make sure you're not doing anything stupid. Otherwise, students were essentially in the driver's seat making most of the decisions. The first time seeing a patient and presenting was a tad nerve-wrecking, but the preceptors were very supportive. They asked questions (known as pimping), but they subscribed to the theory of gentle pimpology. Overtime I became pretty confident seeing patients and presenting. Most of the patients were chronic care patients. I'm going to break it down into a simple equation:

Primay Care = HTN + HPL + DM2 +/- MDD/BPD/Anxiety

There you have it. That's the majority of primary care in a nutshell. For those not medically inclined, HTN is hypertension aka high blood pressure. HPL is hyperlipedima aka high cholesterol (think of the dude in the lipitor commercials during the world cup). DM2 is diabetes type 2. Pretty much everyone in chronic care clinic had at least 2/3 of those diagnoses. There was quite a high prevalence of emotional issues as well including MDD (Major Depressive Disorder), BPD (Bipolar Disorder) and Generalized Anxiety Disorder. Once in a while a patient would present with some other condition top of the aforementioned trifecta of HTN + HPL + DM2. Some random conditions included arrythmias, thyroid problems, iron deficiency, plus others.

Needless to say, I became comfortable taking care of these patients. Some might find managing the same conditions boring, but it was pretty cool to flip through the notes and see that a patient with messed up blood pressure is doing quite well now. Or to see that someone's bad cholesterol has plummeted. Even better, someone struggling with smoking has quit. You don't know how many times I said, "quitting smoking is the most important thing you could do for your health." That's pretty much all I said for 2 weeks.

What was most amazing, though, was seeing patients make strides in their health given their socioeconomic status. Just eyeballing the demographic page each patient would fill out, I'd venture to say that the average household income of all the patients I treated was somewhere around 10-20k/year. Most were unemployed or underemployed and did not qualify for Medicaid or Medicare. Sometimes I felt bad telling a patient they need to try cutting salt from their diet, when pretty much all they can afford is salt.

However, there were times too where I really questioned the priorities of some people. For instance, there was the one 45 year old lady who told me she couldn't afford healthy foods and some of the meds we prescribed her that were unfortunately not available in our pharmacy (but cost 4 bucks at any drug store). Literally two minutes after she told me that, she interrupted me and whipped out her iphone to answer a call. I've gotten a lot better at not judging people, especially people I don't know well, but that just made me think to myself for a minute...hmm. The kicker, she can't afford her meds, but she smokes 2 packs a day. Frustrating. I'll give her the benefit of the doubt...it's tough though. I just have to put on my smile, keep on with the motivational interviewing and hope she is ready to one day turn the corner. Pretty much the best I can do.

Chronic care generally lasted from 10-6pm each day. Some days I got out early, other days I stayed a bit later. Once each week there was an acute-care clinic from 5-8pm. Basically acute-care in this setting=STD. Here's a great story-slightly disturbing, so skip this part if you want. What follows is pretty much what took place, verbatim.

Me: "what brings you in today?"

[Imagine a 5 foot 9 African American Male, looks and sounds just like Ludacris. Picture provided for reference.]

Patient: "Man, I tell you 'bout these girls dude. Damn. I'm here for that STD check if you know what I mean."

Me: "Could you tell me more about what happened?"

Patient: "It's like this. I was at the bus station on the corner of St. Clair and 105th wearing this huge fur coat. This girl walks up and looks at me. I'm like, dayumn! So next thing you know she steps inside my fur coat and I stick my finger in her and lick it. Then we got on the bus and I haven't seen her since. My throat kind of hurts now. I need to be checked out pronto dude."

Me: "I see your concern..."

That's pretty much what STD clinic was like. And by the way, the last I checked, the guy didn't have an STD. I counseled him to think before he does something like that again. Otherwise we had a great conversation about Cleveland sports and he told me some jokes (really dirty jokes)-he's an aspiring comedian--an impulsive one apparently. And to my female readership, please for the love of god, AVOID THE RTA.

The last aspect of the rotation included Fridays. Yes, Fridays. The day of female well visit exams. Shoot me now. I never want to do pelvic exams ever again. I can tell you right now, I've crossed out OB-GYN as a possible career path. It's just not happening. I mean, nothing bad happened on the two Fridays during my rotation, other than seeing some gross stuff where the sun don't shine. Not just females. I've done a fair share of rectals during the rotation too. Maybe urology needs to be crossed out too. No thanks. Not for me.

Well, my free clinic rotation is over now and I have moved on to the VA where I am currently on a 2 week cardiology rotation. This elective will be my last before I transition over to my core rotations starting with Internal Medicine at University Hospitals. I've only been on the service for 2 days and I can tell you already that it's quite a shock to the system especially after being on child psychiatry and family medicine which was pretty much all outpatient with very nice warm fuzzy attendings who care about your well-being and future. It's not that the cardiology staff are mean (they're not at all), they're just not radiating as much enthusiasm as some of the attendings/fellows/residents in the outpatient setting. There is a lot more cynicism, back-handed comments and grumpiness that goes on. Pretty much par for the course in any hospital, or at least what I would suspect. Of course this seems to vary depending on the individual.

The rotation is kind of weird in that it tailored to the interests of each student. I told the cardiology chief to help me a plan a rotation that would give me a taste of what cardiology is like...like a broad overview. My schedule has me rotating through different areas such as echo, cath lab, electrophysiology, cardiac critical care, stress lab and outpatient clinic. So far, I've learned a great amount of stuff. I spent Monday with fellows and attendings learning how to read echocardiograms. It's amazing to see how proficient they are at picking out insufficient valves on the fly. I was supposed to spend Monday morning in the outpatient clinic, and I did for about 45 minutes. As soon as I walked in, the fellow staffing the clinic that day told me, "dude, I got nothing to teach you today. Clinic sucks balls. It's just med management like primary care. Go bother the fellow in echo. It's so much cooler and he'll teach you stuff." And he was right, I did learn stuff. It's just too bad some docs don't like talking to their patients at all. It turns out this guy is going on to an interventional fellowship, so he has a different mindset/interests-fair enough I suppose.

Overall, cardiology seems kind of cool. I can see why it's so popular among med students and internal med residents. It's a field with lots of toys, lots of procedures and outcomes that can be good. The procedures/treatments make sense since everything can be traced back to basic cardiovascular physiology principles, there are new advancements all the time especially regarding diagnostics, the field is in high demand, and the pay is good (though is due for 30% reductions in diagnostic procedures with the new healthcare bill).

Today I got a taste of what internal medicine might be like. I got a chance to sit in on the cardiac critical care unit rounds and follow the attending, fellow and 4 medicine residents around several floors as they check up on patients. Today I was supposed to pick up a new admission and follow that patient and be ready to present on rounds tomorrow. The resident who was on call today sent me home after 3 pm because no new admissions showed up by then. He gave me an old patient to present. So now I have to get to the hospital by 7 AM tomorrow, do a quick pre-round session then be ready present by 8. No big deal really, just a tad bit annoyed that no new patients showed up! It seems like my day was a waste, but the resident was one of the nicest people I've met in the hospital thus far. For one, he was kind enough to actually introduce himself and the rest of the team to me (I've grown accustomed, after yesterday especially, to go out of my way to introduce myself). He was very interested in teaching and we went over management of acute coronary syndrome and atrial fibrillation. He did give me some advice though. He told me to go into radiology or dermatology if I can. I was kind of surprised to hear him say that because he actually looked like he enjoyed what he was doing. He himself is planning on going into cardiology, but he said it's a really long road and the lifestyle sucks. I got the same advice from the two fellows planning on doing interventional cards. I kind of wonder why they are doing interventional if they're worried about lifestyle...

One final note, I'm tired of everyone asking me what my "interests" are or what I plan on "doing" after med school. It's not that it's a bad question, but I'm not going to lie to you all. I am at times ashamed to tell people my true interests. I know it's just a fact that everyone in the medical field pisses on their colleagues in other fields. Surgeons hate internists, primary care docs hate specialists etc. I get such a negative reaction when I tell people psychiatry (and by people I mean attending physicians, residents, fellows, patients, hell even other friends in medical school). I get responses ranging from "only crazy people do psychiatry, and you're not crazy..." to "you're to smart for that" to "it's not real medicine," to "ah, interesting..." Among certain physicians it's no problem. I have no shame telling a psychiatrist (obviously), neurologist or primary care physician that I'm interested in psychiatry. In the hospital though, it's a different beast. I was about to just tell the cardio fellow Monday morning "I think I'm interested in psychiatry," until he started cussing to himself about this bipolar patient we had and how it's such a pain dealing with psych issues in clinic. I even remember telling an attending once on a clinical immersion I'm interested in, and after I said psych he was reluctant to show me some aspects of his practice because "oh it's stuff you'll never do as a psychiatrist, don't worry about it." So I've started hedging the question saying, "undecided at this point." Or saying "I'll see what third year throws at me." Or, "we'll see." Or even, "I'm going to be a dentist." I think I'm going to stick with that.

Monday, May 17, 2010

Mood Disorder NOS

It's 3PM, May 13 2010. I'm in a medical examination room inside an outpatient pediatric office located on the East Side Suburbs of Cleveland sitting across from my attending psychiatrist, Dr. Mike, thinking about a couple of things. First, I'm hungry. I'm always hungry. Second, this is so much cooler than studying. Third, in a two incredibly short years, I'll have similar responsibilities as the guy on the other side of the table. As I begin to daydream Dr. Mike asks me, "what's your differential?" Without even thinking I respond, "ADHD combined type and Mood Disorder NOS."

Two very short years of pre-clinical training brought me here to my first ever clinical rotation. The last time I posted an entry was December of 2008. At that time, I was a first year medical student. Everything was new to me. 18 months has transpired since that time and I still feel like everything is new to me. Only this time, I'm not so concerned about anatomy, IQ groups or taking tests. Now, I actually get to deal with real patients, their families, physicians, and other health professionals. It's pretty cool.

Here's a run down of everything that has transpired since my last post:
  • Completed Block 3: biochemistry and GI (I thought it was fun)
  • Completed Block 4: cardiovascular, pulmonary, renal systems and general pharmacology (I thought this was fun too)
  • Completed Block 5: microbiology and other stuff (total hell)
  • Completed Block 6: neurology and psychiatry (most fun I've had in med school)
  • Officially graduated with my Masters in Public Health in January 2010
  • Spent 5 weeks studying like mad
  • Ditched studying for 3 days to hang out with my friends in Houston
  • Took a 7 hour test in a little booth under closed circuit surveilance.
  • Reaped the rewards of 5 weeks of studying like mad
  • Flew to Cambridge University in England to present a poster
  • Drove to Philadelphia to present another poster
  • Walked across the street from the med school to present another poster, and won $100 for the poster.
  • First author of a paper pertaining to off-label uses of psychotropic medications (I know, no one cares)
  • Mourned the deaths of two good people
  • Celebrated a few births (in the extended family)
  • Flew to India to visit my relatives after a 6 year hiatus
  • Switched from a Blackberry to iPhone
  • Played 30 rounds of golf at about 25 different courses in 4 different states (Ohio, Alabama, California and Florida)
  • Witnessed another Cleveland sports disappointment
  • Began my first clinical rotation

After finishing up Block 6 in March, I took 5 weeks to study for Step 1 of the USMLE. For those who don't know what that is, it's a big bad exam that all med students freak out about. Most go into hiding for a certain time period, then re-emerge once the exam is over. Most usually pass and life goes on. High scores generally help when it comes time to applying to residencies. I achieved a score that was higher than what I was expecting, so no complaints here. Glad that it is over. To celebrate completion of boards, I spent 3 days golfing in Alabama with one of my friends. Upon returning from my golf trip I did absolutely nothing the next 10 days. And by nothing, I organized my room, cleaned my car, went hiking with my dogs until they were sick of me, worked out 3 hours a day, played more golf, caught up on research work, read more journal articles, yelled at the TV as the Cavaliers showed no effort or desire, and finally booked my trips to New Orleans (this weekend for American Psychiatric Association Annual Meeting) and Las Vegas (no fancy conference here, just hanging out with some good friends from Rice).

At Case SOM, third year consists of three core rotations (called Core 1, Core 2, and Core 3) and a 4 month research block, affectionately known as vacation-unless you take your research seriously. I placed out of the research block since I spent a substantial time during my first two years finishing up my MPH, which included a scholarly project that took more time than the allotted 4 months for the med school research block. After boards, I'm scheduled to be on 2 months of my research block, followed by core 1, followed by the remaining 2 months of research, followed by Core 3 in January, and Core 2 in March. Since research block does not exist for me, I can theoretically do whatever I want during this time. Having Obsessive Compulsive Personality Disorder, I'm on top of my game. I have decided to use this time to take clinical electives that can be used towards med school graduation credits. This way, I can either defer my four months of vacation to the end of fourth year, or I can decide to use that time later for research since I like research and will probably engage in some other scholarly activity before I graduate (next year's APA conference is in Hawaii...).

So I am officially starting off third year with three 2 week rotations: child psychiatry, family medicine at the free clinic and cardiology consults at the VA. My idea is to pick fields that I find interesting and to work my way towards a more intense inpatient experience that will get me ready to hit the ground running for Core 1 in July, which consists of internal medicine and surgery.

I chose child psychiatry because of all the psychiatry didactics we had in Block 6, I found the child stuff to be the most fascinating. Furthermore, the faculty were really supportive. It also helps to have a father who is a child and adolsecent psychiatrist. So far, I think I made a great choice. Some might think I'm interested in psychiatry because my dad is a psychiatrist. My dad's a smart guy, but not the best test taker in the world. The only reason he's a psychaitrist is because it was the only field he could into. Good for him because he absolutely loves what he does. Part of me wants to see what the hype is about, but honestly I'm interested in psychiatry because I am fascinated by behavior. Child psychiatry makes sense to me because it is a perfect opportunity to intervene early on when psychopathology begins to manifest in individuals predisposed to mental illness. It kind of fits with the public health side of me in that sense. Furthermore, psychiatry as a whole interests me because not much is known about it. Epidemiology is key to research into phenomenology and treatment. While not a whole lot is known about psych compared to other fields of medicine, child psychiatry is basically in its infancy. There are a ton of questions out there waiting to be answered. This kind of fits with the research side of me. Definitely not a bad way to start third year.

So far the elective has been great. It's mostly observational, but I do get a few minutes during each patient interaction to ask the patient (the kid) and his/her parents questions. The attendings are very supportive and go out of their way during the patient interview to highlight key areas in the patient presentation/history that they feel are good learning points. The patients I've come across are amazing. Kids in my opinion are so much more fun to work with than adults. The challenge though are the parents. Not always, but sometimes. The apple doesn't fall too far away from the tree, as they say. Sometimes it's tough to fix the kid when it is the parent with the serious psychopathology. It's so interesting seeing the type of personality disorders the parents have. I never thought I would see so many cluster B personalities (people with relationship problems generally). Lots of narciscism, lots of borderline behavior.

A common misconception in child and adolescent psychiatry is that a given practice consists of all ADHD, and all psychiatrist do is just push pills. ADHD does consist of a decent proportion of the patient population, but you'd be surprised to see how much substance abuse and mood disorders are present. Lots of kids have bipolar. Since not much is known about pediatric bipolar, and since psychiatrists don't like to give kids labels, especially so young in life, pretty much every patient is slapped with the disorder "Mood Disorder NOS." The NOS stands for Not Otherwise Specified. A tip for those of you ever rotating in child psych: if you want to score points on your differential, just blurt out Mood Disorder NOS. And about the pill pushing: in a 30 minute follow-up evaluation, 5 minutes is spent managing the medication while the other 25 is generally spent counseling the patient and his/her parents.

What's amazing is seeing the improvements that kids make. Having spent time in the past working in adult outpatient and adult inpatient psychiatry, I've kind of grown accustomed to taking solace in small victories. Unlike adults, many kids go from manifesting serious problems to doing well at school, and meeting developmental milestones. Early intervention can literally change the course of a kid's life. There is nothing better than seeing a kid who was failing school and getting into all sorts of trouble come back to the office with a huge smile on his face reporting that school is going well, they are making friends and things at home are going well. It's not glamorous like surgery, and it doesn't provide an adrenaline rush like dealing with trauma in the ER, but if that isn't saving a life, then I don't know what is.

The job does come with its challenges. First, you have to be willing to deal with uncertainty. Psychiatry is vague, ambiguous and is not rooted in strict biomedical science (not yet that is). It really is more of an art than a precise science. Psychiatrists have done a great job in the past of observing behavior and categorizing those behaviors that are perhaps problematic into sets of "disorders." In order to help treat psychopathology there are two main tools available: drugs and talking. The arsenal drugs at a child and adolsescent psychiatrist's disposal include anti-depressants, anti-psychotics, mood-stabilizing agents and stimulants. Equally as important is talk therapy (psychotherapy, CBT etc.). No one knows why these things work, but they do. Everyday new research is coming out to fill in the blanks. The biggest explosion of medical knowledge over the next 50 years will be in the neurosciences and in particular, mental health. If you don't like the fact that ADHD can't be explained as simply as lobar pneumonia can, then this isn't your field. Second, you have to have patience...a lot. Parents can be demanding, and often rightfully so because they have to put up with their children all the time whereas you the physician deal with them for fifteen minutes. You have to be calm, and reassuring. Third, your job does not start and end with medical science. There are times where I wish I can just order a lab test, or look at an image. And yes, it is frustrating at times. In the end though, you treat the whole patient. This includes talking with teachers, counselors and parents to see how the patient is functioning in all aspects of their lives. Medical school doesn't teach you this. Life does. Being a good caring person goes a long way.

The other day, a 8 year old girl came into the office with her mom. Poor thing was suffering from some bad OCD. She came into the office and told me everything that was wrong with her in the past. She wasn't able to touch doors, shake hands, or even open her school desk. Kids at school were making fun of her, she had no friends. Life sucked. Six months of SSRI treatment and counseling 3x week resulted in dramatic improvements. She loves school, she has friends, things are good. Before she left, she gave me a gift:

I still have a long ways to go before I decide on a field, let alone a subspecialty. I'm going to wait until I experience everything third year throws at me before I make up my mind, but I can say that child and adolescent psychiatry is something I can definitely see myself doing in the future. I can see why dad loves his job.

Thursday, December 11, 2008

The Resurrection of a Blog

It's been some time, guys. I probably lost my audience now because intermission lasted for about 3 months. A lot has gone on in that time. I'll do a quick summary and get you guys up to date on what's new and what's good.

When I last wrote, we were in the midst of Block 2, which focused on genetics, development, reproduction, endocrinology and oncology. The block was kind of grueling and took a lot out of me, especially towards the end. Going through the block was kind of frustrating since it seemed like all the topics in the block were random and didn't really connect. My opinion of the block changed towards the end when everything just seemed to click. Going through clinical immersion in the week towards the end was kind of cool because I got to see some of the principles I learned put into practice in gynecologic oncology.

Block 2 officially ended on Halloween night. Exam week consisted of three tests: a 4 hour essay exam with 5 questions (each with 3-5 parts), a structure test considering of an anatomy practical with prosections and a 30 min histology test with virtual slides, and a mock Step 1 test. Five weeks later, (this past week), I received my report card. As far as I'm concerned, I still get to keep my allowance. I love going to a school that's pass-fail with no ranking. Apparently I "met expectations" and I did well on the structure exam (anatomy practical + histology). The NBME (practice step 1 test) went well too. I was a bit disappointed though because my lowest sub-scores were in epi/biostats and pharmacology, which is totally messed up since I'm an MPH student and I love pharm.

Speaking of MPH, one of my MPH classes which I thought would be cool (and was kind of cool), turned out to be a complete time-sink. When I saw that mental health epidemiology was being offered this past semester, I thought-cool! Well, it turned out it had less to do with epidemiology and more to do with community based research, research ethics and law. All in all, I ended up writing about a grand total of 30 single-spaced pages for this class, as well as reading two 250 page textbooks. Here's the cherry to top the cake: I was the only person in the class. Oh, and it wasn't any other class--it was a 3-hour discussion-based class.

My other MPH class, a 1.5 hour seminar classs ended up being another time-sink. I'm sorry, but any class that requires you to write 4, 2 page single-spaced papers, and one 5 page single-spaced paper, along with putting together a website, should not be a 1.5 credit hour class. I'm glad it's over. By the way, here's a link to my website if you're curious.

Currently we are in Block 3 which is titled "Food To Fuel." Unlike Block 2, Block 3 is very focused and more predictable than Block 2. Namely, half the block is spent on biochemistry and the other half on GI. We just finished the biochem part and are moving on the GI stuff. So far, so good. My IQ group is solid, and things have been ok for the most part. Biochem has mostly been review from my Rice days. GI is somewhat time consuming but is pretty doable.

For some reason, I feel like things in Block 3 are more clinically relevant than they were in block 2. I shadowed an internal medicine resident a couple weeks ago and I got to see some Block 3 work put into practice when we saw a patient with liver cirrhosis. It was kind of cool to study the liver in biochem and then see what you learned present in the clinic as a real-live patient.

I'm starting to get a taste for what internal medicine has to offer. I like to think through problems and use my basic science knowledge to figure out what's going on. I knew all along that I was definitely more into the medicine side of things than the surgical side of things, but I think Block 3 has only supported my initial feelings. It's obviously too early to tell exactly what works for me and what doesn't, seeing as I haven't really seen any patients on my own yet, but you can get an idea of what you like judging from the subjects that interest you. For instance, I despire pretty much anything relating to anatomy or histology and I liked endocrine and biochem. The dial is definitely leaning towards medicine as opposed to surgery, radiology, etc. (you know...all the fields that can make you rich).

Speaking of anatomy, this block we started dissections. Here at Case we have 4 students to a cadaver and we do dissections in two hour sessions about 6 times the entire block. Our cadaver is named Burt. He's a pretty cool guy, except for the fact that he's ridiculously skinny and finding structures such as vessels in him is a pain since they're so tiny and I lack the fine motor skills (and anatamoical knowlege) to identify and tease things apart.

Let's see...what else...the election season was also kind of intense. This was the first time I have ever been active in the political process and it was rewarding. It's crazy how politics can be so polarizing. The political season was draining. In the end, I think we elected the right guy, but only time will tell.

We had a nice week long Thanksgiving break. I turned another year older. The Cavs season started. Anyone who knows me knows that the only thing that gets me through the dreaded winter is watching the Cavs. What's great is that they are awesome this year. I'm finally getting to go to my first game of the season tomorrow. Lower bowl seats...I'm pumped!

Also, recently Case Med put on their Doc Opera show. Doc Opera is a variety show where students get to display their talents through live songs and filmed skits. If you want to get a taste for some of the work done in Doc Opera, go to youtube and type in "doc opera." For the show, I worked with my Block 1 IQ group (the best group ever) to produce a 4 minute skit based off of the TV show "Survivor." It took some time editing the film, but man was it worth it. I'm looking forward to next year already!

To wrap up, we have a week left before we get out for Winter Break. It'll be a good time to catch up on videogames (err...I mean work...) and relax. Seriously though, I'll be sticking around school for a bit to make some more progress on my MPH resarch capstone. I'll also need to work on a research proposal for the summer. It looks like my research mentor from Cincinnati will help to set me up with someone to work with over the summer, but I'll need to do some work to figure out exactly what I want to study over 8 weeks. I have a bunch of ideas in mind...I'll have to figure out what I can get done that will still leave me a decent amout of time to golf and sleep.

I'll update this blog periodically on random events and things that are going on. This entry was kind of bland, I know. I'll mix it up to keep things interesting. Adios.

Friday, September 12, 2008

Hurricanes and Hormones

Hello, world. It's been sometime since I've updated this blog. It's funny because I've had about 12 different people ask me when I'm going to update this thing. Your wish has been granted.

I was going to put this off until tomorrow since it's past my bed time, but I can't sleep tonight. Well, first of all my big dog Yogi is barking at the neighbors who are hanging out by their deck, but more importantly there is this crazy hurricane spinning around in the Gulf about to ravage Southeast Texas. Normally hurricanes don't affect me since I'm about 1400 miles north of the gulf, but this one is about to hit Houston where I lived for about 3 years. I have some good friends in Houston and I'm kind of worried. For those of you hunkered down in H-town reading this: be safe and I hope to talk to you on the flip-side. For some comedic relief here's a clip of Geraldo Rivera getting rocked:

So you might be wondering how med school is going. I have the perfect analogy for you. Med school is like a hurricane. It moves you around a bit, gives you a breather when the eye passes over, then rocks you again before it leaves. The only difference between a real hurricane and med school: med school doesn't pass over and move inland; instead, it comes back and hits you hard again. Week in and week out. Imagine a hurricane on a pendulum.

Sorry, the political season has got me exaggerating a bit. It's not really like a hurricane, but it's close. Honestly, school is busy. There is a ton of work and reading to stay up on. Just when you think you have a break (Saturdays and Sundays), you quickly realize that there is material you should be covering instead of watching that Browns game, or golfing with your buddy who is still on summer break since he goes to a school on a quarter system (damn you OSU).

Block 2 has been somewhat frustrating due to the nature of the material being covered. Somehow we are supposed to be learning about genetics, but somehow endocrine and reproduction is thrown in there for good measure. At times it's kind of challenging trying to see the rationale in some of the material being thrown at us. How is thyroid function related to the "human blueprint"? I can probably make some hand-waving argument as to why we learn some crazy endocrine during this block, but it's a stretch. Apparently, block 2 is the only block where there is a ton of material kind mixed and jumbled without a clear purpose.

So far of the subjects being covered in this block, embryology has probably been the most frustrating since it requires to most rote memorization. Embryo has been presented to us via lectures and these study guide packets. I think there is enough material presented to us to learn what we need to learn, but it's time consuming to take it all in. Sometimes I feel like I'm trying to memorize the dictionary.

IQs have been pretty solid for the most part. My group is productive and we cover all our objectives. Also, the topics covered so far in IQ involve endocrine which I don't mind. It's becoming apparent that pharmacology is turning out to be one of my favorite parts of med school. Sometimes when I'm going over my case objectives and doing research, I tend to get lost in the mechanisms of action of the drugs and how they work chemically. Someone in my IQ group asked how thyroperoxidase works chemically and I was about to jump up to the board and draw an electron pushing mechanism, but I had to ask myself "is this clinically relevant?" and go on to restrain myself and suggest that the group move on to the other objectives.

Really, that's been the theme of how I've been managing my time so far during the preclinical years. I constantly ask myself two questions: (1) "is this clinically relevant?" and (2) "what's the take home message?". Frankly, I think these are two important questions that med students need to ask themselves when they're studying, especially in open-ended curricula like ours. I'm coming to terms with the fact that I am not going to be solely a scientist, but a clinician interested in advancing medical science. I don't need to know everything. I don't need to memorize everything. Working out in the mornings and reading a good book at night to maintain my sanity is more valuable for my long-term health than memorizing some minutiae from Robbins Pathology, board scores be damned (or so I say that now...)

You may be reading this and thinking "duh" but this is a big deal for me. I definitely suffer from a DSM-IV Axis II disorder: Obsessive Compulsive Personality Disorder. I tend to get somewhat worried and flustered when I feel I should be studying more. Learning to let go of the books and seek a balance in life has been one of my biggest goals for med school, especially as I get older and transition into the next phase of my life. I think so far I've been good at it, but it's tough. Especially when you're around a bunch of smart, motivated individuals and you realize how much more you could learn. The guilt felt when you don't attend a Thursday morning review session, or when you can't make that weekend study session...it's somewhat painful.

Even when you are not studying as much as you could, it's tough to maintain perspective and realize what the "big picture" is. I was reminded of this "big picture" this past weekend when I had my OB-GYN RAMP. RAMP, another acronym, is a glorified shadowing program where first years shadow different physicians. Two weeks ago I went to a hospice to learn more about end-of-life care. This past Wednesday, I had a chance to see the opposite end of the spectrum and spend time on the OB-GYN wards at University Hospitals.

I'm not sure how you all feel, but in-patient settings scare me. Yes, I am scared of hospitals (you might be wonder why I want to be a doctor). As I entered the ward I was given a key-card to get some scrubs to change into. First, I spent about 15 minutes trying to figure out how the damn scrub machine worked. The whole time about 3 different doctors and a couple nurses walked by and giggled. I felt like such a dumbass, and I still do.

So I put on the scrubs and I went to the desk at the center of the ward to find a "house-officer." I'm going to throw this out there: going to the desk in the middle of an in-patient ward is like walking up to a liquor store in the inner city (yes I've been to a liquor store before, but not for Cavasier...but directions). It's kind of scary. Nurses sit around the outside of the desk like gangsters. They kind of just hang out and look tough while you walk by. You ask them where the house officers are and they give you a funny look as if you were lost. Eventually they nod over to a couple docs sitting on the other side of the desk.

The docs for the most part are pretty nice. They're like the store owners. Pretty much accommodating and easy going. And no I am not implying that nurses are mean people. They are actually pretty awesome and serve an integral role in our healthcare system. I just think I have somewhat of an inferiority complex right now.

To make a long story short, I was invited to see a C-section delivery in the wards. I stood against the wall as I saw the delivery take place. Two things: (1) C-section deliveries require a very aggressive approach from the OB-GYN. Imagine cutting a hole in a pregnant woman and yanking a baby out. Literally. (2) Anesthesiology seems more appealing to me than it first did. I was surprised seeing the anesthesiologist comfort and talk to the mother while she is undergoing the delivery. The anesthesiologist doc also spoke with the father trying to reassure him as he was kind of freaking out as the baby was coming out. Furthermore, these guys know their pharm real well. The field definitely seems more appealing than it once did. Still, all that responsibility scares me.

Oh ya, I forgot, a baby was brought into this world. Good times, indeed. It was honestly pretty amazing. But it's funny how the OB-GYN acts when the baby delivered. She kind of yanked the baby out and put him on a back table, then went back to the mother to close up shop. It seemed very "business-like." Frankly, that's how the OR is, and I don't know if I like it. It just seems too technical and formal for my liking. I guess I'll learn more during my rotations.

In closing, I promised to make this blog more interactive. I'm going to pose a series of questions and I want to get your thoughts. With elections coming up, I know there's been a lot of crap being spewed by both sides, but unfortunately there has been very little discussion of what I feel to be the most important issue: healthcare. I understand that we all have different opinions and viewpoints. Furthermore, I don't really care if you're republican, democrat, independent or apolitical. I just want your opinion. First, check out this article, which is a good view of both healthcare plans. Second, respond to the following questions: (1) can private markets be utilized to lower healthcare costs and improve healthcare coverage, or is government intervention necessary? (2) What can politicians do to help contain healthcare costs? (3) What if anything should physicians do to help contain costs?

Friday, August 29, 2008

Week 2 Update

I think this past week, which was the 2nd week of our 2nd block, pretty much gave me a glimpse of what med school from here up until February of 2010 will be like: pretty crazy. Yes, it is kind of like you're drinking from a fire hose, but it's not as terrible as some people make it out to be. Basically, every Monday, Wednesday and Friday, we have our small group IQs from 8 to 10 followed by two hour long lectures (or interactive medium sized groups) until noon. On Tuesday we usually do some combination of gross lab and histopathology until noon. On Thursdays we have optional review sessions which are videostreamed online.

The theme of this week is "Sweet life." I like how the administration tries being cute about things by coming up with random themes for the weeks. Basically "sweet life" entails endocrinology with an IQ case emphasis on diabetes.

On Monday I got to meet my new IQ group. Group 20 is pretty solid. We tend to work very efficiently. Our facilitator is in his final year of MSTP studies (year number 7 or 8 or something absolutely insane like that). He's a pretty cool guy. Our two cases this week involved type 1 and type 2 diabetes respectively. We learned a bunch about the pathophysiology, diagnosis and treatment of these diseases. After IQ, instead of having lectures, we had a 2-hour long medium sized interactive group discussion regarding a problem set involving intracellular signalling pathways. These small groups consist of about 12 students and a facilitator. I definitely learn a lot from the groups and I seem to stay awake seeing as participation is mandatory.

Tuesdays suck. The reason I dislike Tuesdays is because my two least favorite subjects are covered during these days: anatomy and the dreaded histopathology, which I'm sure you already know about. I didn't mind anatomy in block 1...perhaps because I didn't realize how ridiculous it would become. During the first couple blocks of our program, we are introduced to anatomy solely through prosections. Don't worry, I didn't know what the hell that meant until I got here. Basically, instead of spending all day in lab cutting up bodies and screwing up body parts (dissection), they are already cut up for us. So we rotate through several stations while the professors point all the relevant parts to us. I kind of feel like this is a waste of time...perhaps because I'm not so good at keeping up with the reading ahead of time. Part of the reason why I don't keep up so well with my anatomy reading is because it's so damn boring. Anatomy, while not all memorization, is mostly memorization. I HATE rote memorization. Seriously, we have names for all these random ass things in the body. Who the hell cares? I sure don't, though I should and believe me I will be this Labor day weekend! Honestly, the only cool thing about memorizing some crazy anatomical names is that it makes you sound smart. I have mad respect for all my colleagues doing the masters in applied anatomy. You guys are crazy.

Now Wednesday was interesting. I was 20 minutes late to IQ group. I left home at 7:15 and I got to school at 8:20. Apparently there was some ridiculous accident on the highway and I had to literally ride a 25 mph road all the way into town. My IQ group wasn't really hard on me for being late, but I felt ridiculously bad. I brought bagels for them today, so hopefully I made amends.

What was really cool about Wednesday was that I got to go visit a hospice for a program we have called RAMP. Yes, another god-forsaken, unnecessary acronym which stands for Rotating Apprenticeship in Medical Practice? (I think?). These are basically glorified shadowing sessions where small groups of students are sent out to hospital and community practices to shadow different types of physicians. I was placed in a group to go check out palliative/end-of-life care. Honestly, I wasn't too thrilled about the placement. Seeing people die sure doesn't sound appealing, does it? It turned to actually be pretty cool. We got to talk to a couple of patients in the hospice about their experiences. The one was this sweet old lady dying of what seemed to be lung disease. The other was this middle aged guy dying of Lou Gehrig's. It was kind of cool to see how at peace they were. The actual hospice was really nice inside. It had a nice home-like feel to it, which was a stark contrast to the drab appearance of the outside. The hospice is right next to the lake, so some of the residents have an amazing view. One cool thing I learned was that Medicare pays for the cost of hospice care provided that your prognosis is that you will die in 6 months or less.

Thursday was pretty much a review day...nothing too exciting school wise. A couple cool things though. First, I got to eat dinner with an old friend from high school whom I haven't seen since. He actually sought me out and got in touch with me, which was awesome. It's great to see people you haven't seen in so long, especially old friends!

Another cool thing was Barrack Obama's nomination acceptance speech. I don't want to make this too political because arguing politics is kind of futile and time is at a premium for me now days, but I'd like to add the disclaimer that I am a local campaign volunteer and I have decided to support Obama. I don't agree with everything he says , but I love his vision and passion. I'm an independent voter, relatively moderate with a slight left bias, and I actually admire John McCain. To cut to the chase, Obama's speech Thursday night, which was well past my bed time thanks to the whole stupid mountain time zone thing, literally blew me away. If you don't feel a little inspired after this speech, then I don't know what to say. If you have some free time this weekend, and you haven't seen the speech I encourage you to put aside your political biases for a bit, take some time out and see it. You can check the speech out here.

If you haven't thought about the election yet, check out the candidates' websites and read up on their policies. I also encourage you to play nice and be respectful of others' opinions. As much as the media may focus on pointless issues like Obama's religion or McCain's 7 houses, I think that on a whole Americans have two good nominees.

Have a safe and happy Labor Day Weekend!

Tuesday, August 19, 2008

Real Science

Block 1, "Becoming a Doctor," ended last Friday after our 5 hour-long Summative Synthesis Essay Questions (SSEQs). Basically this is a flashy way of saying we had a long ass test consisting of four essays. Overall I thought the test well. I wrote too much for many of the essays and I think my answers were kind of verbose and perhaps somewhat peripheral to the questions. We had one question asking us to describe how the poverty-gap, which is worse in the US than other developed nations, affects the health of the poor. Granted the question was politically charged to begin with, I ended up writting about supply-side economics and how public health funding is affected by fiscal policy. I am in medical school, right? I think it's safe to say we all passed, but we won't know for sure until tomorrow when we receive our feedback.

This week is when med school, in the traditional sense, really begins. Block 2 is called "The Human Blueprint." During this 11 week block we learn primarily about genetics and development. I think genetics is interesting, but I can honestly tell you that the material is out of my comfort zone. I am comfortable with molecular genetics, to an extent, especially with regards to pharmacology and biochemistry. There is still a bunch of other stuff that I am not comfortable with including patterns of inhertience, karyotypes and all the "big picture" genetic issues. Show me a nucleotide structure and I will feel at home. Talk about chromosomal abnormalities and I will freak out.

I might just be overreacting a bit because frankly, I am kind of overwhelmed right now. Every day we seem to have a ton of reading and things we need to go over. It's easy to get lost in detail and lose focus of clinically relevant concepts. I probably know more about genetics than what I give myself credit for, or so I hope.

Speaking of being overwhelemed, this week really is brutal: Instead of having our normal IQ groups, we have a ton of lecture, since this is the first week of the block and we're supposed to be getting acclimated to the new material. For once, I kind of don't mind the lectures since it's nice to have all random details focused into core concepts, but I can see it getting old real fast. I am looking forward to IQ and getting underway with new cases next week. Also during this block, we begin to learn about performing a routine physical exam. We get to practice on each other and standardized patients. It should be good times.

I know it's only been two days, but this basic science is kind of killing me. For one, I am in the small minority that misses public health. Luckily for me I'm taking an MPH class (and seminar, and working on my capstone-albeit at a snails pace) starting this Monday. The class is on mental health epidemiology and it should be interesting. Second, ever since I got to intubate that mannequin, I am really itching to get back to some EMS fun. I was contemplating signing up for one elective to spend 2 hours each week at Metro ER to shadow a doc and learn some procedures. I'm probably going to hold off on this for a bit and see how my schedule falls into place first. It's too easy to commit to activities around here.

In other news, the weather up here in Cleveland has been awesome lately. I came back home from school at around 8:30 pm today and it was actually kind of crisp outside-it feels like fall. I like the fall because it means 1.) football and 2.) greens fees at golf courses will go down soon. It's too bad the best weather of the year has to be when school starts up and I start to get swamped. Oh well.

Tuesday, August 12, 2008

Exam Week

This week is weird. It kind of feels almost like what finals week would feel like back at Rice, the only difference is I'm not pulling all-nighters culminating with breakfast at Taco Cabana at 5 AM. To all my Rice people: you don't know how much I miss TC. It's probably a good thing I came back home for school though, since I end up eating home cooked meals which are quite healthy, not to mention delicious.

The first thing I noticed this week was how short our IQ case was. This week we're discussing medical errors. Tomorrow our group reconvenes and discusses the learning objectives we formulated on Monday. Somehow I doubt we'll spend the entire two hours talking about medical errors.

Today was especially strange since it felt like public health classes all over again, just a bit angrier. Yes, I said angrier: I'll explain. Just to summarize for my friends out there scattered throughout the world, basically, the entire medical school class is split into 20 different IQ groups. While we discuss cases in our IQ groups, during this first block we also worked on a population health descriptive statistics project where we were assigned to learn more about health indicators in a specific Cleveland neighborhood. Today, each IQ group presented their findings in medium group settings of 4 IQ groups/room.

When I walked in my group's assigned room this morning, my day become about 50x better since I saw my MPH program advisor and capstone chair sitting in the front. For those of you who don't know him, Mendel (professionally referred to as Dr. Singer, but he'd rather be called Mendel) is awesome. He's this goofy and nerdy orthodox Jewish guy with this crazy beard. He has 8 kids! He pretty much taught me everything I ever need to know about biostats and most recently cost-effectiveness analysis. I also learned a lot about medicine from him..ok maybe not. But if you go into his office sometime, he has a little game called "med school in a box." Check it out-you'll find it hilarious. Also, don't be offended if he makes fun of you for being a med-student. As a Ph.D statistics/policy-type person, he considers himself a "real-doc." Whatever.

Our presentation went well, and I thiought the other presentations were good too. Afterwards, was when all the fun started.

I think what makes Mendel such a great teacher is his willingness to ask for student feedback and use that to continuously improve his teaching. After our presentations were over he asked for feedback regarding the project. To be blunt, shit hit the fan.

I think it was pretty unanimous that most people were unhappy with the project. Basically it was an exercise in descriptive statistics which many people found ambigous, without sufficient context, and of little clinical relevance. Part of Mendel's job I guess, is to take all this feedback and give it to our block leader, who came up with the project idea (who is a great guy, albeit opinionated, controversial and somewhat disorganized which is unfortunately leading to his continued unpopularity among students).

Personally, I wasn' too thrilled with the project. First of all, I was frustrated that I had to mess with NEOCANDO data when I have my own database of research info that I need to manipulate for my MPH capstone (in fact I shouldn't be writing this blog right now, I need to be working on MPH stuff...). Second, the ultimate goals and expectations of the project were not made clear, and I think that is what also contributed to a lot of frustration. Finally, even after we get all these population health trends, we have to ask our-selves: as future physicians what can we do to change things? As we talk about macroscopic determinants of health I continue to question the physician's role in society. There is so much more I want to read/write/discuss about with regards to health policy, politics and ethics. I won't bore you with these posts now, but I will later. In fact, one of my friends (Gabriel Valle) and I are thinking of setting up another blog to consdier some of these issues to help spur a bit more dialouge.

The session after our presentations regarded our behavioral health projects, where each member of the class was challenged to meet the goal of walking 10,000 steps/day. There was also a lot of interesting feedback regarding this challenge which I will touch on in later posts. I easily get 10,000 steps a day. Actually, that's a lie. I really only take about 2000 steps a day, but if you consider my early morning workouts and converted the exercise into steps, then I'd easily cross 10,000. The only problem is when I'm so committed to my workouts already, the last thing I remember is to convert the numbers into steps and enter them online. Oops. Needless to say, I didn't win any prizes today.

In the afternoon we had buddy lunch. Basically each first year student is matched with a second year student as a mentor. My buddy is awesome. He gave me a lot of good heads-up info for the block to come. He's even letting me use one of his textbooks from last year. Hopefully I'm not sufficiently jaded and overworked to be a friendly buddy for some (un)lucky MS1 next year.

After an hour or so studying some epidemiology a couple friends and I went over to an activities fair where a bunch of extra-curricular clubs set up tables to talk a bit more about their respective groups. In the end I signed up for four interest groups. Psychiatry interest group: duh, it's kind of sad though only about 4 people signed up. Neurology interest group: neuroscience is cool. Emergency Medicine interest group: I kind of miss EMS, so why not? Anesthesiology interest group: wtf? Ya, to be honest I'm really not that interested in anesthesiology (to be fair, right now I'm not interested in it). Something about prepping people for surgery and pretty much being their lifeline while some guy cuts them open just scares me. Nevertheless, I still felt compelled to join. You see, they had this mannequin out on the table. As I walked by I saw a 4th year trying to explain to one of my first year classmates how to intubate. I immediately thought back to Rice EMS and the fun we had doing speed intubations on mannequins. I jumped in and played around for about 5 minutes, intubating the damn thing about a dozen different times. I think the 4th year kind of looked at me the whole time and thought I was crazy. It was therapeutic. Don't ask.

I spent the rest of the afternoon/early evening studying for the exam. I came home, mowed the lawn, played with the dogs, and here I am rambling away. Good times. I'll need to focus a bit harder tomorrow and make sure I have my material down cold. I'll write again after the exam.