Pun

The workup of chronic pelvic pain is multidisciplinary. A gastroenterologist might start with a colonoscopy, in contrast to a radiologist who might start with a KUB.

OSCE

This past weekend, we had a 4 hour final exam for our Foundations of Patient Care class, the Objective Structured Clinical Examination (OSCE). Its goal was to assess our readiness to begin clinical activities of third year, assessing us on such criteria as communication, physical examination, clinical reasoning, and writing skills. We had six stations with a 20 minute patient interaction, a short writing exercise, and a feedback session on our performance. The stations had both patient actors and real patients (with their physician). It was grueling yet it went fast; it kind of gives us a sense of what third year might be like seeing patient after patient. I can't write too much about the specifics of the exam, but I did a cardiac exam on a real patient with findings, a few H&P's (history and physicals) on standardized actors depicting a wide range of chief concerns, a delivery of bad news (new diagnosis for someone not expecting it), and an interview of a patient with a "hidden agenda" (his chief complaint was not what he came in for). The standardized patients individually had different "personalities" and we had to adapt to them. If I dare say it, it was a fairly fun (for a Sunday final at least) experience and it actually helped build more confidence in my limited clinical abilities.

Lottery Preferences

After all the hubbub and consternation yesterday, this is what I ended up doing. I ranked my preferences by rotation such that I would lock in a rotation each round. I ranked internal medicine the highest, preferring blocks 3-5; then Ob/Gyn, preferring 3-6; then Surgery, preferring 1, 5, 6; then family medicine, preferring 1, 4, 5; then Pediatrics (preferring 1) and Neurology/Psychiatry (preferring 2). I put in some Salinas and Fresno rotations at the bottom to make sure I didn't bottom out of my list.

It's fairly complicated to explain why I ranked rotations when I did. Basically, I preferred not to start my third year with Medicine (important) or Ob/Gyn (too intense); I'd rather ease in with an "easier" block like Pediatrics. Looking at dates, block 2 is when new residents start and so I preferred not to do procedural specialties Ob/Gyn and Surgery or really important ones to me like Medicine. Lastly, I didn't want to do Medicine block 6 because I felt that it was too late in the year. I sort of wanted to do a 6-week block late in the rotations (such as Ob/Gyn 5) in order to allow me to do a 2-week anesthesia rotation at that time.

Tomorrow, we'll be back to normal blogging.

Addendum

I wanted to post this in case anyone is using this blog as a strategy for how to play the rotation lottery (which I highly do not suggest). After talking to my friend Emily again, I may be changing my strategy.

In the previous strategies, I was trying to "lock in" a block for each round of the lottery. For example, I was listing things by block: Block 1, Rotation A then B, C, D, E; Block 2, Rotation B, then A, C, D, E.

However, I think I have been slightly convinced that I should instead "lock in" a rotation for each round of the lottery. In this case, I would list by rotation: Rotation A, Block 3, 4, 5, 6, 2, 1; Rotation B, Block 4, 5, 3, 2, 1, 6; etc.

This does not allow "relational" preferences (ie. block A before B) but is probably what I'm going to do.

Math Consult

I just realized that the lottery for rotations is happening tomorrow. As I was thinking about it, I found it to be both more interesting and more complicated than I originally anticipated. I got a math consult from my friend Emily. This is a simplified version of what I wrote:

Third year is made up of 6 blocks of time (1-6) in which we are assigned 6 different rotations (A-F) at different sites (less important). Students will be assigned to rotations through a lottery process and each student will get one rotation at one site for each of the 6 blocks. The rotations can be done in any order.

The way the lottery works is that each student submits a preference list. This is an ordered list of choices for 3 things: block, rotation, and site. The list can be any length. The computer will randomize all students. Starting with the first student, it will start at the beginning of that student's list and assign the student to the first choice that has an available spot (which would be the first choice on the list). It then moves to the next student and goes down that student's list until it finds a choice with an open spot, etc. After it goes through all the students once (a "round" which has assigned each student to one rotation), the computer randomizes students again and does the same thing: it assigns someone to the first choice on the list with an open spot that does not conflict with what the student already has. After 6 rounds, everyone is assigned to 6 different rotations for the 6 different blocks. (I suppose if your list is too short and runs out, you get assigned randomly).

So my list might look like:
1. Block 3, Rotation C, Site a
2. Block 3, Rotation C, Site b
3. Block 3, Rotation C, Site c
4. Block 3, Rotation D, Site a
5. Block 4, Rotation C, Site a

If Block 3, Rotation C, Site a is filled but b is not, then I will be assigned choice 2. If I've already been assigned to a Rotation C, I will be assigned choice 4. If I've already been assigned to Block 3, I will be assigned choice 5. Sites are not mutually exclusive; even if I've been assigned site b, I can still be assigned choice 2.

My question is: is there a way to optimize my list?

These two ideas occurred to me. I could try something like this:
1. Block 3, Rotation C, then A, B, D, E, F
2. Block 4, Rotation A, then B, C, D, E, F
3. Block 5, Rotation B, then A, C, D, E, F
etc. - this makes it so that at each "round" in the lottery, I am assigned something in block 3, then 4, then 5.

Another idea is this:
1. Block 3, Rotation C
2. Block 4, Rotation B, then C
3. Block 5, Rotation A, then B, then C
4. Block 6, Rotation D, then A, then B, then C
My reasoning is that if I don't get my first choice for block 3, I don't want to exclude my first choice for block 4 (which would happen in the first scheme).

Interesting stuff.

After talking to Emily for a bit, we realized that these two schemes emphasize different preferences. If one has relational preferences such as wanting to do B before C before D, then the first scheme (or variation of it) may accomplish that. It will preserve relationships between rotations over absolute blocking of rotations. Emily points out that if I wanted to do all my favorite rotations first (or least favorite, or whatever), this would be the optimal way to do it.

On the other hand, if one has absolute preferences such as wanting to do rotation B in block 3, then the second scheme may accomplish that more readily. It seems as though if your first choice is filled, then the first scheme will allow a frameshift while the second scheme allows switches (point mutations?).

That's our hunch. It's actually a bit mindboggling to think about, so it might not be completely correct or there may be a more optimal scheme. I'm not sure yet how I will rank things, but as I have to decide tonight, I will probably remark on it tomorrow.

Home Stretch

We've entered the very last part of the curriculum; there's only one exam left. Aptly, the very end of the Life Cycles block encompasses aging. For these last three weeks, we're discussing topics such as menopause, osteoporosis, gynecologic problems, benign prostatic hypertrophy, and progerias (very interesting diseases of accelerated aging). Class attendance and academic enthusiasm has sort of trickled off as the unspoken threat of Boards picks people off. But with the aging population, such topics are more and more important to the foundation of good medicine.

No Second Troy

"No Second Troy"
W.B. Yeats

Why should I blame her that she filled my days
With misery, or that she would of late
Have taught to ignorant men most violent ways,
Or hurled the little streets upon the great,
Had they but courage equal to desire?
What could have made her peaceful with a mind
That nobleness made simple as a fire,
With beauty like a tightened bow, a kind
That is not natural in an age like this,
Being high and solitary and most stern?
Why, what could she have done being what she is?
Was there another Troy for her to burn?

Photograph taken by Stan Hu of a media luna which I believe is similar to a rond de jambe a terre (but someone with actual knowledge of ballet may correct me).

Abortion

I've been reluctant to write about this topic, but I think I should. We had a great lecture on medical and surgical abortion earlier this week. Abortion is a hotly contested topic, but I am not an expert and this is not a forum for political controversy. Instead, I want to write about what I learned. Nearly half of pregnancies are unintended, and in the majority of those, some form of birth control was used. Abortions are the most common surgery in the U.S. for women of reproductive age, and nearly a third of women will have had an abortion by age 45. Those statistics were fairly surprising to me.

It is also important to know that most (~90%) of abortions are first trimester abortions, not the second trimester abortions that are often the heat of debate. First trimester abortions are far safer than giving birth. The lecture also covered reasons why women get abortions (including why they get second trimester abortions). We learned about the different medicines and surgical maneuvers used in abortion.

I think all physicians need to know about this. So many patients consider it, undergo it, have questions about it, etc. that a physician would be derelict in his duty if he did not learn the medical side of abortion. But a physician should not be required to perform one if it is against his conscience. Indeed, I'm not sure how I would feel about performing an abortion (especially a second trimester one). But I did learn a lot from the lecture this week.

400

There's a total lunar eclipse tonight. It should be awesome. Hopefully it doesn't rain. Opening on the Quad!

Undifferentiated

Parents always tell their children that they can become whatever they want to be when they grow up. Over the last few days, I've been thinking. If that were the case, knowing what I know now, what would I want to be? If I were completely undifferentiated and if I had the capacity to pursue any study, what would I want to do?

I decided that I would love to study the philosophy of physics. It's just so cool. I took a class in it once as an undergrad and absolutely loved it. I think it's so amazing because it gets at the fundamental nature of the universe in two different ways: empirical science and theoretical philosophy. Physics (along with mathematics) has this beautiful elegance to it that mirrors formal logic. In this way, it can be scrutinized with the same criteria that analytical philosophy approaches arguments. Because both physics and metaphysics try to get at the laws that govern how matter and energy interact, the implications of such theories have a large bearing on different aspects of our lives. Like philosophy of science, we should study the assumptions, foundations, implications, and applications of modern physical principles.

I'm especially fascinated by philosophy of quantum mechanics. The strength of quantum mechanics lies in its ability to elucidate empirical observations that previous theories could not explain. But its philosophical implications are huge. It seems to undermine determinism by allowing stochastic phenomena (which some libertarians claim is sufficient for free will). Furthermore, it invokes curiosities like the effect of measurement on physical systems. If no measurements are occurring, states of physical systems follow unitary dynamics of a time-dependent Schrodinger equation (linear, continuous, deterministic). But upon measurement, a system's wave function may collapse into one of its eigenstates whose probability is determined by Born's rule (discontinuous, random, nonlinear). When John von Neumann described this in 1932, he left open the interpretation. That's where a lot of the philosophy kicked in. The physics may make sense, but what does it mean?

Someday, if I run out of topics, I might discuss a really cool idea called quantum suicide and how it may prove DeWitt's Many Worlds interpretation of Everett's relative state formulation. Very very cool stuff. If I were actually smart enough, I would do philosophy of qunatum mechanics. Right now, it's just a hobby.

"I fully agree with you about the significance and educational value of methodology as well as history and philosophy of science. So many people today - and even professional scientists - seem to me like somebody who has seen thousands of trees but has never seen a forest. A knowledge of the historic and philosophical background gives that kind of independence from prejudices of his generation from which most scientists are suffering. This independence created by philosophical insight is - in my opinion - the mark of distinction between a mere artisan or specialist and a real seeker after truth." -Einstein.

Alternative Careers

There's an interesting interview question I got asked as I was going around to different medical schools: "What would you do if you did not get in anywhere?" Presumably the right answer is to polish my file, then apply again (a sign of commitment).

But it's an interesting thought. What would I do if I weren't in medical school? I think I'd still be doing some sort of school for various reasons. I don't have (m)any marketable skills. But here are some things I'd think about. I would love to do a creative writing program like an MFA or (in a dream world) a Stegner fellowship. Someday I'll apply, though it will be a while before my manuscripts become good enough. I lean towards short story writing, but oddly enough, I'm happier with the poetry I produce than the fiction. For a long time, I was iffy about how important an MFA was; it's neither necessary nor sufficient for being a good (publishable?) writer. And it doesn't seem like you can teach creative writing in the same sense that you teach mathematics or even English literature. But one of my friends did a poetry MFA at BU and her poems markedly improved. I think a year or two of intense devoted study to a craft does make a difference.

I'd also be very happy doing an MA ("coterm" in Stanford's lingo) in philosophy. Philosophy is one of those intensely interesting subjects that you cannot study (at least to any great depth) on your own. It requires a lot of guidance. I could see myself sitting down with a biochemistry or history or political science textbook and getting something out of it, but I can't see myself doing that with Kant or Leibniz (praise be his name) or Heidegger. Even with a bare bones background in philosophy, I find the level of abstraction and dependence on historical context so complicated that I need a formal curriculum to help me work my way through the texts. So even though I would have no idea what I'd do with a masters in philosophy, I'd be completely content in pursuing one.

The other possibilities are more practical but less exciting. I could pursue an MS or PhD in biology if I could find a good mentor and driving question. I could see myself working in lab for a bit, probably directed towards some sort of graduate education. I don't really know if I could see myself working; obviously, it's something most people do after undergrad, but I'm not sure if that would really suit me. But I am happy where I am and I don't think any of those alternatives would be as good for me long term as medical school.

Regrets II

Herein lies the rub. I picked a track that has a singular focused goal: to become a doctor. The cost of that decision involves the restrictions on time, activities, energy, etc. at a point in my life when I wish to keep my varied interests and cultivate the few talents I have. Jeff's reply to my post yesterday pointed out several good points. No matter what my situation, I wouldn't be able to pursue everything I want to do; my imagination is too wide. Nobody has enough time to try everything, and in attempting to do so, I would be sacrificing depth for breadth which may be admirable, but may also be foolish. I should also keep in perspective that my goal (or perhaps duty) is to be a functioning contributing member of society. While I need not be completely end-directed, I should be tracing out a path that will allow me fulfill my societal obligation; hence, medical school rather than a hodgepodge of hobbies and unkempt curiosities.

In thinking about this, I also realize the great benefits of having a structured program. Without this overarching goal in mind, I could easily find myself lost, nibbling on something here, dabbling in something there, the unfortunate sense of moving without any motion. At least now, I will have some measure of assurance that some years from now, I shall be closer to reaching an end-point that I shall be happy with. Knowing myself, I would not fare too well if I completely lacked direction.

Regrets

For this three day weekend, I'm going to ramble to this prompt: Do I have any regrets about the decision to attend medical school?

There are some interesting aspects about my personality. I rarely regret things; for some reason, I just don't get that feeling very much. In some ways it's rational (you can't change the past, so it's an unproductive emotion), but that's not sufficient to explain everything since rarely are emotions reined by reason. In any case, I seldom think about decisions and wished I had chosen otherwise (despite my obsession with free will). Yet I spend an inordinate amount of time reflecting on things I do, which may be an odd complement to the lack of regret.

Do I have regrets about medical school? In broad strokes, no; I'm fairly certain I'd choose to retrace my steps given the opportunity to consider alternatives. But I think of other things I could have done and where I would be in those cases. I did not realize this when I entered, but medical school involves a significant sacrifice on the part of the student. We make a substantial investment of time and energy to acquire the skills of the trade; while we are in school, we give up the luxury of time, geographic mobility, youth, outside interests. Like cells, as we become more and more differentiated, we pick up exciting CD markers but lose others.

The first of these that I can remember is orchestra. I love playing the viola. I was in an orchestra ever since the fourth grade. I wrote college essays about music, I traveled to play concerts, I really felt it was an integral part of my life. But as a college sophomore, I found myself at a branch point where I felt I couldn't keep doing everything I wanted. Perhaps regretfully yet probably prudently, I gave up orchestra to focus on other studies. Now, looking back on my atrophied skills (I used to be able to transpose alto to treble with ease, now I don't think I can do it), there is some degree of remorse.

What I've realized recently is that my friends who have liberated themselves from academic obligations have found themselves embowered with the enviable chance to explore new avenues of learning, enjoyment, talent. I wish I were in the same position. True, such wonders are not outside my grasp, and I've been growing in many aspects outside of curricular teaching, but I find myself reading fewer non-medical books, writing less, thinking less about issues of philosophical and practical importance. After all, I had to wait for a three day weekend after an exam to beginning exploring these thoughts on this blog.

Indeed, some of my friends have put together this email chat-list called "Keisaku" (Zen Buddhism; a flat wooden stick used during periods of meditation to remedy sleepiness or lapses of concentration) where we send out random thoughts and ideas to stimulate discussion of interesting topics. We've talked about the feasibility of co-operative kitchens in cities, what consciousness means, how to improve internet chatting, nutrition, online gaming communities, deep sea creatures...it's ridiculous and lovely. How surprising, all the things in this world that don't involve chief complaints and stethoscopes.

I think that is one reservation I have about my decision to go to medical school. I would love to learn Argentine tango, write a decent villanelle, have late-night conversations about free will, try photography, practice viola, bake, or read something that doesn't have to do with the USMLE Step 1. Maybe tonight I'll start.

Adolescent Patient Interview

We had a fantastic patient interview with a seventeen-year-old high school senior who has cerebral palsy and spastic quadriplegia. It was a real pleasure to have her speak; she was funny, engaging, educational, and poignant. She talked a bit about what it was like to be the first person in a wheelchair at her high school, how she had to work with teachers to meet her educational goals, and the impact of the disease on her life. But as she talked, she became incredibly inspiring; despite her disability, she skis, swims, plays soccer, uses facebook, hangs out with friends, has two college acceptances. She faces the same issues that all teenagers face: crushes, cliques, obsession with fashion, the increasing workload of high school. There were many funny points in the presentation, when the powerpoint stalled and she filled in by saying "So this one time, at band camp..." or when she referred to one of her pictures as the "braces and acne stage." She showed us pictures of her with friends, hanging out with the fire department, at a junior prom. The whole point of the presentation, I think, was to emphasize that teenagers with chronic diseases are first and foremost teenagers. They go through the same problems and situations as do we all. Patients with disabilities we cannot even imagine having are able to achieve an incredible and inspiring amount.

Happy Valentine's Day

I took this picture at a banquet in 2001.

Adolescence

We've moved on from childhood into adolescence. For some reason, I don't find this stuff as interesting, but I do think it's important. Adolescence should be a time of optimal health; after all, the teens and twenties are the prime of life after the vulnerability of childhood and before the onset of chronic diseases. As would be expected, morbidity and mortality is not due to biologic disease per se, but more from motor vehicle accidents, suicide, and homicide. As a result, the adolescent assessment focuses a lot on psychosocial aspects of health (HEADSSS) as well as puberty and contraception. Although it's not as interesting to me (it's very fuzzy), I'm enjoying it more than expected.

Eponyms

Here's the challenge (thought up by Alex Penn) - What's a differential diagnosis for dyspnea...using only eponyms? Here's what a few of us thought up:

Lambert-Eaton Myasthenic Syndrome
Guillain-Barre
Austin-Flint (I think this one's iffy, it's a sign not a syndrome)
Eisenmenger's syndrome
Ebstein's anomaly
Tetralogy of Fallot
Fanconi anemia
Pancoast tumor
Marfan's syndrome leading to pneumothorax
Klinefelter's syndrome leading to pneumothorax
Factor V Leiden -> DVT -> PE
I think we're starting to stretch it.

Child Abuse

I've been putting off this serious but important post on child abuse. We had a lecture on "non-accidental injury" last week by one of the experts on the subject. I was quite taken by the topic. Child neglect and abuse (physical, emotional, and sexual) play an unfortunately prominent role in child morbidity and mortality. It's really shocking to me. As such, it is the responsibility of all physicians (not just pediatricians) to assess patients for these injuries. What really struck me is how difficult it is to identify child abuse. While certain pathologies (types of bruising, various fractures) highly suggest abuse as an etiology, this is confounded by diseases like hemophilia and osteogenesis imperfecta. For every suspected case of abuse, there can be a biologic explanation. On the other hand, injuries that may be explainable could end up being abuse. This puts physicians in a tough position since child abuse is something that we really need 100% sensitivity and specificity for identifying. No one wants to miss a case, and the consequences of a false case could be potentially devastating. This whole issue is an interdisciplinary one, involving social workers and child protective services and the police. I found the talk poignant and educational.

A Night in Vienna

Images for this post and the last post taken by my friend Chris.

"For all the times you stayed up late to get it right...we applaud you." - The quote that changed my life.

Pediatrics

We've been learning about pediatrics the past few weeks. I really enjoy it; kids are fun, they're cute, and the whole development aspect is interesting. A lot of the physiology is really fascinating: jaundice in neonates, congenital heart defects, vesicoureteral reflux. We've watched a lot of videos about pediatrics: the neonatal resuscitation, the sequence of normal development, the infant neurologic exam. I think what I love about kids is their innocence. They learn and grow so quickly, playing and being silly, it's wonderful.

We also had some families come talk to us about having kids with a chronic condition. Yesterday, a mother came and talked about her adopted son who was developmentally delayed and how much they had to work to get the resources they needed to help him develop. Today, a family of an eight year old with Down's syndrome came to talk to us. They were incredibly open with the stages of grief they went through when they found out (the prenatal AFP screen gave a false negative). Now, you can tell they absolutely love their eight year old. She talked a bit to us and was incredibly cute (but shy). Afterwards, a few of us went up to talk to her in person. The greatest thing happened. One of our classmates Jackie went to the same elementary school that she goes to, and upon discovering this fact, they sang their elementary school song together. It made my day.

Preceptorship

We had a single preceptorship session for learning about the "Care of the Critically Ill Patient." I was assigned to the Highland Hospital Emergency Department, the main trauma center for Oakland (others were assigned to chaplains, hospitalists, palliative care physicians, oncologists). I had a great experience. The preceptor was a UCSF residency graduate, super receptive to us coming and gave us a fabulous introduction to emergency medicine and tour of the department. We then split up and saw several different patients. The first patient I saw was fascinating and challenging and is described here. I then saw a classic presentation of an MI (left sided chest pain radiating up left neck and down left arm, diaphoresis, weakness, past history of heart disease, etc.). Although it would seem like a great case for learning about the "critically ill patient," the guy was comfortable and chatting to me pretty easily. The last patient I saw was a strange one. A mother, high on pot, brought in her four year old daughter because she was "tweaking." I didn't know what that word meant. It turned out the child was acting very strangely, with something that looked like absence seizures along with nystagmus and decreased awareness. They thought that she had accidentally ingested some sort of medication, and luckily, the child is fine now. I really enjoyed my experience there, seeing a good variety of patients, learning more about emergency medicine, and discussing how doctors deal with cases of great severity.

NEJM Image Challenge

This is a pretty cool website:
http://image-challenge.nejm.org/default.aspx?mode=js#
It is an image challenge from the New England Journal of Medicine. Intended for practicing physicians (ie. not medical students or for USMLE review), it features a (usually very cool) clinical image and a question. Interestingly, you can see what the general public chose, which is often not the correct answer (wisdom of the masses fails here). I think this site is fantastic and fun.

Transience

One thing that strikes me about being in school is that everything seems to be somewhat transient. My schedule changes every day. I meet new professors, learn different subject matter, chat with various friends all the time. I don't know where I am going to be in a few years; in fact, I'm not sure where I'll be in a few months. Rotations are two weeks to two months long. I'm constantly learning to adapt to new circumstances, find my way around novel problems, engage exciting challenges. I honestly have no idea what "the real world" or "work" is like, but I imagine it may not have such freshness, such variability. The ephemeral nature of things - it's wonderful in some senses, trying new things, accomplishing tasks I didn't think I could brave, developing a breadth of skills. But it's also oddly constraining, not having many constants in my life, letting things go when I can no longer support them, juggling priorities. I like it, but I'm not sure I'm willing to give up things I love because I don't think I can do them anymore.