The Deathly Hallows

Obviously, I won't give anything away (which makes for a conveniently easy post as it has been a long day), but this book was fantastic. It seems silly to write something about it as the world can almost be divided into two camps - those who have read it already and those who will never read the Harry Potter books. But this last volume is a just bookend to its companions. It introduces some new plot devices but remarkably resolves old questions cleanly. Though it has less charm than its predecessors, it certainly dares to venture into the dramatic, the dangerous, and the terrifying. Treading the line between mystery and elucidation, this book entertains the themes of death, friendship, sacrifice, and resolve. It's masterfully written and really crowns the Harry Potter collection.

Draco Dormiens Nunquam Titillandus

What can I say? This last decade (at least in terms of children's literature) has been defined by Harry Potter. I remember being quite resistant to the craze at first, dismissing them as "kids' books." But bored one day, I picked up Sorcerer's Stone and was instantly mesmerized. I think setting a fantasy coming-of-age story in a school setting was brilliant. Indeed, I was able to associate with the students of Hogwarts and the concerns, desires, and fears that come along with dealing with studies, peers, professors, and the looming mystery of the Dark Lord. The plots of these books are immaculately intricate; the details fit so well that all the clues fall into place like cogs of a pocket watch, making the entire contraption work beautifully. Indeed, subtle events early on play powerful roles in the later books, really giving the sense of the depth and perception of the planning that went into the arcing storyline. They're fun, entertaining, eloquently written, beautifully presented, and magical. Indeed, I have had long nights debating Harry Potter lore with friends who recite passages on demand. There is no better way to take a break from medical school studying.

Summer Thing of the Week

I guess in honor of the recent release of Harry Potter Book 7, this week's theme will be something like things that entertain me. Books, TV shows, comic strips, things that break up the monotony of study.

Puns

Those who know me well know that I love puns. I somehow got the nickname "punster" freshman year.

"It is better to have loved a short person than to never have loved a tall."
"Wear short sleeves; support your right to bare arms."
"The cattle were fast asleep so we had to move them with a bulldozer."
"There's a fine line between fishing and standing on the shore looking like an idiot."
"The other day at the park, I was wondering why frisbees get bigger and bigger as they get closer to you. And then it hit me."

Anyone remember the video game Street Fighter? "They call me Hadoken cause I'm down right fierce."
There is also a great coffee shop in Ireland called "Brewed Awakening." So fantastic.

Me: I've got a really hot date tonight.
Ting: Really?
Me: Yeah, I'm going to microwave a plum.

Revati regarding math: For eigenvectors, I had to relearn the rational roots theorem!
Me: Rational roots...that's when you use the kind of shampoo that makes you smarter.

Morici: So what about our plan?
Arvind: Our plan?
M: To resurrect the dinosaurs.
A (without skipping a beat): You mean, like lazarusaurus?

Okay I think that's enough for now.

Corpus Christi

When I studied a few months at Oxford, I was associated with Corpus Christi College. I loved the place. My time at Oxford was filled with mystery and magic. Indeed, I lived in a house that had 48 residents and 50-some staircases. Nobody could find her way around that place for the first week. There were rumors about secret passageways and shortcuts to the laundry room, the library, the music room. It was such a great place. My bedroom even had a fireplace.

The city itself was enchanting. I visited a pub built in 1242, climbed Carfax tower, and registered with the Bodleian library. It houses every single book published in Britain since the 1600s. In fact, they measure their collection of books in miles. To gain access to the library, we had to take an oath in front of a black-robed judge-like person. Quite the experience.

I took an Oxford tutorial on Philosophy of Religion. Despite only meeting 8 times for 1-2 hour sessions, it challenged me the most of all my philosophy classes. Each week, I read anywhere from 5-15 texts and wrote a paper. At the tutorial, I read my paper aloud and in the style of the Socratic method, I had to defend my arguments from objections by the professor (tutorials only have one student per professor). It was a fantastic way to learn philosophy, and I focused my attention on arguments for and against the existence of a God as well as the relationship between God, language, and meaning.

Ah, I miss England - Sainsbury's, Ben's cookies, pasties, the reduced Shakespeare company, Countdown, High Street, Ahmed's kebab vans... It was fantastic studying in a whole different place; it really felt like an excursion into something mythical. I built some of my best friendships there and developed some of my core philosophical beliefs.

DEFY

One summer in college, I got suckered into volunteering as a camp counselor for a program called Drug Education For Youth (DEFY). A collaboration between a nonprofit and the police department, this was a summer camp for 3rd-6th graders focusing on drug education, character development, positive role model mentoring, and community outreach. The 9-12 year olds chosen for this program need the self-esteem to resist gangs, drugs, and alcohol.

DEFY was located at Camp Pendleton, a major Marine base in San Diego. Most of the other counselors were police officers or Navy personnel; I was the youngest and the only one still in school. I was also in charge of a bus of kids. Before we even left, I caught one kid threatening another with needles while the other was brandishing a glass bottle. I surprised myself by immediately disarming them with a harsh and severe attitude. These were fourth graders, and they had no business wielding sharp objects and threatening each other.

We all slept in a barracks, which was a pretty unique experience. Living on a military base was interesting. I had to make sure my kids were following all the rules: saying "Thank you ma'am" to the lady who served us lunch, removing hats before entering buildings, standing still during colors at dawn. I was amazed at the efficiency of the other counselors; every night, we got over 100 boys into and out of the showers in half an hour. We had classroom time to teach them about drugs, gangs, violence, and alcohol. We worked to build their self-esteem, discipline, and motivation. We rewarded them by demonstrating how K-9 attack dogs are trained, showing them amphibious military vehicles, and letting them go through fun obstacle courses. All in all, a fun time doing stuff that I probably won't ever do again.

Viola

Although I started playing the violin in fourth grade, I switched to the viola in ninth. I was changing music teachers to one who was already teaching my younger brother (we're three years apart). The teacher told me that he didn't want two brothers playing the same instrument because we'd become too competitive. I was devastated; everyone I knew played violin and no one played the viola. Nevertheless, I was persuaded to switch and realized the teacher was right; my brother would have been way better than me on the violin.

I played in orchestras for almost half my life (about 10 years). I remember flying to Sacramento at the end of high school for a music thing. One of my friends was a cellist and had to buy an additional plane ticket for his instrument. The name listed on the plane ticket was "Cello Cello." That flight was soon after 9/11 and I was "randomly" chosen for a check at the gate (they've since stopped doing that). I was forced to open my umbrella and drink from a bottle of water I was carrying. Then they had me open my viola case, take out my viola, and show them that it was hollow inside. I wouldn't have been surprised if they wanted to hear me play something. But since then, I haven't really had any run-ins with airport security.

Things That Annoy Me

Today's post is short as I have many things to work on and a presentation to prepare. During ICU rounds this morning, I realized that one thing that bothers me (which I used to do but have tried to reform my ways) is the addition of "-wise" to organ systems during the quaint tradition doctors call rounds. I've heard so many people say things like "Respiratory-wise, this patient is doing fine; GI-wise, he hasn't been able to eat; neurologically-wise, he is alert and oriented." No! Those aren't real words. In fact, "neurologically, he is alert and oriented" is so much better than "neurologically-wise." Ugh! I inherited this pet peeve from an attending down at Stanford's ICU's.

Telnet

I started playing with the internet around 1996 when I was in 6th grade. We had just upgraded out of Windows 3.1 and AOL was still the unfortunate leader in Internet Service Providers. Within a month, I had already gained access to one of my friend's accounts by guessing his password (it was the name of his girlfriend). The next year, I tricked another friend into thinking I had hacked into his account by employing a discovery I had made regarding the font AOL used (a capital i looked exactly like a lowercase l, allowing nearly indistinguishable account names). But since then, I have an almost computer vigilante approach to these kinds of things so I've never exploited them.

AOL at the time did not allow easy access to the open internet; the interface focused on content housed at AOL. So in early high school, I figured out how to use Telnet, a network protocol to access unix-like servers and simple network devices. Back then, of course no one encrypted anything, so I was able to bore myself by accessing servers of the local community college and play online games and whatnot. Fortunately I had no inclination to do anything malicious (and indeed, this was the golden time before cybercrime - identity theft was unheard of).

For some reason, as the internet matured, I became less interested in deciphering its inner workings. I never really cared much for trends like slashdot, "l33t" speak, or webpage design. I was also pretty late to investigate things like Napster and Facebook. I did however latch onto blogging really early. I began blogging a year after blogger was released and have stuck with it since, avoiding Xanga, Livejournal, and Myspace. I kept a daily blog through much of high school and had a patchy time during college, but now I'm back.

Summer Thing of the Week

So my classmate Emily tagged me in one of those silly pyramid-chain-scheme-blog-virus things and to humor her, I should play along (kind of). I guess this week, I'll blog random things about myself. My life isn't half as interesting as Emily's but I guess this blog tends to be a little impersonal so I'll try to add some color.

Pathology

To round out the possibilities as a doctor, pathology is a unique specialty which does not have its own patient service but rather supports other physicians. Pathologists are consulted to interpret biopsies, tissue samples, urine, blood, sputum, etc. as well as conduct autopsies to propel medical knowledge forward. In general, they have the greatest amount of basic science knowledge using many standard research techniques (cell culture, PCR, antibodies). There is no night call. Anatomic pathology involves autopsies, cytopathology, and surgical pathology whereas clinical pathology includes hematology, microbiology, clinical chemistry, and blood banking. Pathologists often have research and teaching positions. Although they used to make a great deal of compensation, that has been decreasing. Training consists of a clinical year plus a three year clinical or anatomic pathology residency or four year combined residency. Subspecialties include neuropathology (2 years), forensic pathology, dermatopathology, blood banking, chemical pathology, pediatric pathology, hematology, cytopathology, and medical microbiology (1 year).

Ob/Gyn

All third year students have a rotation in obstetrics and gynecology, though I've heard that most who enter this specialty knew very early on that they wanted to. Obstetricians deal with pregnancy while gynecologists deal with infertility and diseases of the female reproductive tract. Most Ob/Gyn's do both. It's considered both a surgical specialty (like urology) and a primary care specialty (like pediatrics, family medicine, or internal medicine). One of the problems with obstetrics is that lawsuits have made malpractice insurance incredibly expensive. This is one reason why fewer and fewer family practice doctors deliver babies. It is a big deterrent against obstetric practices for high-risk pregnancies. Ob/Gyn involves both surgical and non-surgical approaches with time in the office, OR, and delivery room. There can be emergency deliveries and night call. Many more females are going into Ob/Gyn. Training is 4 years, and subspecialties include reproductive endocrinology, gynecologic oncology, maternal-fetal medicine, and urogynecology/reconstructive pelvic surgery.

Neurosurgery

Neurological surgery is usually touted as the toughest and most impressive specialty. Indeed, residency is at least 5 years following a year of general surgery and includes neurology, neuropathology, and neuroradiology. Neurosurgeons manage diseases and disorders of the brain, spinal cord, peripheral nerves, and related structures. It is a high stress high risk job with both incredible and devastating outcomes. There is a wide range of patients. Surgeons often have to take night call; hours are long. However, compensation is very high and there are major advances in the field. There is also the satisfaction of being able to do something few others can.

Emergency Medicine

Emergency Medicine (EM) covers a pretty broad spectrum of acute illnesses in all age groups and takes advantage of both medical and surgical therapies. These doctors often deal with life-threatening conditions. Since it is shift work, it allows time for other interests such as research or having a life. There has been an increase in Emergency Department visits and a resulting shortage in emergency doctors. There is no longitudinal care or long-term patient relationships. Training is 3-4 years for EM and 5 years for combined EM/internal medicine or EM/peds programs. Subspecialties include medical toxicology, pediatric EM, and sports medicine. Sometimes, emergency physicians go into critical care or hyperbaric medicine. Lately, this specialty has become extremely competitive.

Cardiology

Cardiovascular Disease (the formal specialty title) is pretty cool because it relies on both traditional history and physical exam skills as well as fancy technological advances. Invasive cardiologists are subspecialists who perform angiographies and catheterization (angioplasty, valvuloplasty). There is also a subspecialty clinical cardiac electrophysiology which studies arrhythmias. Although generally office-based, cardiologists may also work in hospitals with long hours and night call. The increasing numbers of cardiologists has led to intense competition and a movement to decrease the number of cardiologists. Training is an internal medicine or pediatric residency plus a three year fellowship (which includes research). Further training requires an additional year and also includes nuclear cardiology.

Anesthesiology

Anesthesiology is primarily a hospital based specialty whose domain encompasses the operating rooms, pre-op clinics, intensive care units, and pain clinics. Anesthesiologists give general and regional anesthesia during surgical, obstetric, diagnostic, and therapeutic procedures. The main subspecialties are critical care and pain medicine. So an interesting thought is what is going to happen to anesthesiology with the greater use of nurse anesthetists and minimally invasive surgery. Indeed, anesthesiologists are mostly important to intervene when something drastically wrong happens. They have to respond quickly and confidently to airway issues, cardiovascular collapse, shock, and other emergencies. They manage patients before, during, and after surgeries. Training is an internship year followed by a three year residency. Anesthesiologists do not build long-term patient relationships. They often work in a team. It is a good field for those interested in research; they are also known for having fairly good lifestyles.

Summer Thing of the Week

All the posts this week will be about medical specialties. I feel like the most common question I get asked when people find out I'm a med student is what field I'm going to go into. As a first year, like a freshman in college regarding his major, I can waffle and say I have no idea. And it's probably okay as a second year too. But as increasing numbers of my classmates figure out what they want to do, I feel a greater pressure to at least think about various specialties. After all, residency applications are at the end of third year, and the sooner I have an idea, the better.

Intense Concentration, Intense Compassion

These were the watchwords of BMB and I really like them. Indeed, it was a block with lots of focused studying and learning as well as encounters with passionate patients, poignant diseases, and difficult issues. It was the only block with a cumulative final, and from the beginning with the grueling neuroanatomy, we knew this block meant business. But it was also really fun, inspiring, and motivating. The ensemble of lecturers really got us excited about neuroscience. Many of the course directors went far beyond their call of duty to put together review sessions, moderate the message boards, run our small groups. I was really impressed by the intellectual passion and sort of wish it was matched in our other blocks. In fact, I had so much I wanted to write about, I'm still blogging about BMB weeks after we finished. After the final (what a feeling) we all went down to the park for a picnic. Watching the class play football, lounge in the sun, eat hotdogs, chase after pets, I realize we've become pretty close now, so different than the hodgepodge at the beginning of the year. The sun was out, the drinks were cold, there wasn't a worry on anyone's mind as we relaxed in Golden Gate Park just hours after our final final. I don't think it sunk in for many of us that we were now "MS2's," and I was amused when one of my friends asked, "So what are you?" Confused, I looked back at him before realizing he wanted the answer, "I'm a second year medical student now." Intense concentration, intense compassion.

Case of the Day

Our Brain, Mind, and Behavior block had a case of the day contest, which was incredibly fun. Several times a week, our course director Andy would present a challenging case, usually involving a radiologic image, strange history, or video. We had to figure out the diagnosis. It was very addicting and very fun. I'm not sure why, but I would get obsessed with figuring out the case, spending hours on Google, Wikipedia, and medical resources to identify the disease. Most of them were odd, rare diseases like recognizing the pulvinar sign (bilateral thalamic hyperintensity) on brain MR or locating the lesion of bitemporal hemianopsia. The detective work of these puzzles was kind of thrilling. I feel like I learned a whole lot about how to research signs and symptoms as well as a host of fascinating diseases. Active learning is so much more effective (though time consuming) than passive studying. In any case, case of the day was ridiculously fun, and I would love to keep it alive.

Substance Abuse

"Steer clear of hallucinogenics / To get high I just do calisthenics." (K.Flay - Just Say No).

Our last week of BMB included a few days on substance abuse. Despite being pharmacology heavy, I liked these lectures. Illicit drugs are interesting in that they change from generation to generation; ravers in the 90s "rolled" with ecstasy (they were first distributed in tootsie rolls) but today's kids go "pharming" for prescription drugs. It's actually fascinating to me that drugs have entire cultures and economies built around them; we learned that pacifiers are often seen with "E" users because E can cause your jaw to clench down (it acts on serotonin, the part of the serum that increases muscle tone).

Furthermore, it is important to identify substance abuse and dependence, especially since alcoholism is so prevalent in our society. But drugs are complicated - we have to learn to identify signs of acute overdose, withdrawal, chronic use, and combinations with other drugs.

We also had a poignant speaker talk about the effect of drug use on physicians. Physicians indeed have a higher rate of substance abuse than the general population. This may be related to many things such as ease of access, understanding of mechanism of action, or a lack of societal awareness that doctors can be vulnerable to drug use. Nevertheless, drug use has a huge impact on the physician, affecting not only his personal life but also those of his patients. And only recently has there been a greater awareness and push to find and treat impaired physicians. I think that being a professional with high socioeconomic status in a position of power makes doctors vulnerable to drug use, addiction, and denial. Indeed, it is fundamentally important for us as medical students and future peers to watch out for each other.

Cosmetic Neurology

Cosmetic surgery is performed to improve appearance in otherwise healthy people. These aren't burn or trauma victims; they just want a tummy tuck or a nose job to look better, be more attractive, increase self-confidence. Whatever we think of cosmetic surgery, it's an accepted thing. If someone can pay for it, they can get it.

But what if there were medications or procedures that could improve cognitive capabilities in otherwise healthy people? What if you could take a smart pill to increase intelligence, memory, reflexes, attention, or even personality? Would we have a problem with this? Somehow, I imagine that society would frown upon people who had some surgery to get a perfect score on the SAT. Indeed, synthetic growth hormone isn't given to people with normal height who want it. But on the other hand, a cup of coffee might increase one's alertness and we have no objections with that.

This isn't science fiction. Modafinil ("Provigil") is a drug to treat narcolepsy, but it can be used by anyone to increase alertness despite sleep deprivation. You hear about Ritalin to improve attention in someone without ADHD. These drugs actually enhance the cognitive resources of normal, healthy people.

Ethically, how should we consider cosmetic neurology? It seems hard to argue that cosmetic surgery is intrinsically morally wrong, but there is an incredible urge to label cosmetic neurology as such. It seems abnormal to try to enhance intellectual attributes with medicine for some reason. Our test scores, how smart we are - we would like to think that these things are influenced by how hard we work rather than whether we can afford a pill. And indeed, what a skewed economy we could imagine if dollars could buy your way into medical school (wait, can't they already?) or get your kindergartener into that coveted academy. But why would it seem so repulsive to take a pill to learn more efficiently as opposed to hiring a tutor? On what grounds can we say that cosmetic neurology is morally wrong?

Peachy

I'm back from Georgia where I had a fantastically relaxing time with some friends. We toured Macon, St. Simons Island, and Savannah. Among many things, we practiced Southern accents, swam in the Atlantic, ate peach ice cream, sang Disney songs, and debated Flannery O'Connor. In any case, it really helped make this so-called "last summer ever" seem more summery. I'm getting back into the groove of labwork and blogging about life as a medical student (or something like that). I still have some vacation inertia; all I want to do is kick back with a good read and some dark chocolate (which, according to a recent JAMA randomized control trial, reduces blood pressure and improves formation of nitric oxide as a vasodilator). Right.

Independence Day

I hope everyone has a fun, safe, and relaxing Fourth of July. When you're debating between wood or charcoal for grilling, remember, fire works (sorry). I'm taking a weekend trip to Georgia for a reunion with some folks I went to Oxford with and so the blog will be on hold until Monday.

CC

In a medical write-up, CC often stands for "chief complaint," which is what brought the patient into the hospital (usually in the patient's own words). Being California and all, in our Foundations of Patient Care class, we learned that instead of "chief complaint," CC really stands for "chief concern" because patients do not complain; they are concerned about their health and well-being.

Placebo

Placebos are medications that have no pharmacologic action but somehow exert a beneficial effect. This is actually a multifaceted and complex phenomenon. First, someone might feel better after taking a placebo simply because of the natural course of the disease. For example, if you always take something at the peak of a headache, your headache will get better no matter what you take (since it was at the peak). The effect of your headache getting better could be mistakenly attributed to the medicine rather than how headaches normally progress. Also, medications are favored by a "regression to the mean" effect. That is, when you see a doctor because of chronic low back pain, it's usually because you had an episode of extra severe pain. Well, it's likely that subsequent pain episodes will be average (that is, less painful than the episode that brought you to the doctor). Lastly, the actual placebo effect is an effect based on suggestion and expectation. If you think something will get better, it might be more likely to get better. Indeed, endogenous opiates are released when placebos are administered; your body produces pain-killers simply from the suggestion that you're actually getting pain-killers.

I think this is interesting, especially since placebos are standard in the design of clinical trials. Surprisingly, the very first clinical trial conducted by James Lind in 1747 on citrus fruit and scurvy included a placebo.

Iserson's Getting into a Residency

I'm not really a "gunner," but I did pick up and take a look at Iserson's Getting into a Residency. It's a pretty thick guide on all the steps you have to take and hoops you have to jump through to figure out what residency you want to go to and how to get there. It's pretty detailed, covering even logistical issues, how to dress at interviews, what questions to anticipate, when to submit applications, how to rate different specialties. Unfortunately, it seems that if you did not pick up this book as an undergrad, you're already behind (I think they make a point of scaring applicants). A lot of the things here are pretty obvious to those who've been through the application process for med school, jobs, etc. But it seems comprehensive, which is good. It can also be useful for international medical graduates and osteopathic students. Right now, I'm finding it most useful in looking at the wide range of possible specialties and how to go about distinguishing them. I suggest this book early on in your med school career, but I haven't looked at other "Get into Residency" type guides to say how good this is.