Hello

Hi. As I am nearly out of time, I am taking a short writing break for the next week or two. I do have two more posts planned, but my focus will be on studying for the big quiz. For those who have finished taking it, congratulations! To my other classmates still crossing days off the calendar, best of luck. And to any other wayward readers, I give you my regards.

By Candlelight

(You have to click on this to see the whole animation)

I encourage you to support http://www.earthhour.org/ (if the main website doesn't load, go to http://www.earthhourus.org).

First image is publicly available at earthhour.org. I took the second image in the Duomo in Florence, 2004.

Wyeth

Andrew Wyeth. (American, born 1917). Christina's World. 1948. Tempera on gessoed panel.

Gallery label text at the MoMA:
The woman crawling through the tawny grass was the artist's neighbor in Maine, who, crippled by polio, "was limited physically but by no means spiritually." Wyeth further explained, "The challenge to me was to do justice to her extraordinary conquest of a life which most people would consider hopeless." He recorded the arid landscape, rural house, and shacks with great detail, painting minute blades of grass, individual strands of hair, and nuances of light and shadow. In this style of painting, known as magic realism, everyday scenes are imbued with poetic mystery.

Boards III

The number of resources out there for Step 1 is ridiculous. I had no idea this test got people so riled up. I did a quick Google search and was floored by the amount of time and money people put into this thing. From hundreds of posts about which question bank to use to underground copies of lectures to formulations of the perfect study schedule, you can spend ages on the internet without actually getting any studying done. It's crazy.

But the utility of these things is iffy. What people post on forums is opinion, hearsay. Their data has an n of 1. When people suggest "don't study embryo, I only got 1 question" or "make sure you know your neuroleptic agents, all my pharm was antipsychotics", listening to that is simply bad science (or emotions running amok). People post their super high yield study schedules. What? Why would you want to study based on someone else's schedule? It just seems so bizarre to me.

That's the other crazy scary thing. All these schedules start two, three, four months before the test date. I'm less than two weeks away and have yet to read First Aid or BRS Path (books people "swear by"). I went through BRS Physiology yesterday and discovered something amusing. They include figures in there from another review book. What's even crazier - that review book (which I looked over earlier) includes figures from BRS Physiology. What? There's also this weird phenomenon where the same author will write two review books on the same subject and the text will be pretty much identical (it's remarkably apparent with Fadem's Behavioral Science books). What's up with that? (It's cause each publisher wants to have a complete set). There are a lot of mediocre review books out there. Most of them also have mistakes. But they sell well cause the target audience is medical students studying for an exam.

And then there's the heavy hitters. Kaplan offers thousand-dollar review courses. There's a whole audio pathology Goljan lecture series, but I gave up on that when I found him more offensive than memorable (some people really like his obnoxious sarcasm though). There's also an interesting dynamic with the question banks that everyone subscribes to. It benefits the company to write questions that are harder than actual questions because then when you do better on the real test than you did on practice tests, the company looks good.

This test would be much better pass/fail.

Boards II

I'm going to write about some problems I have with the USMLE, but this is actually not meant to be a rant (I apologize if that's what it turns out to be). There are a number of intrinsic problems with standardized tests as methods of evaluation of whether someone is qualified to be a physician. The questions have to be written such that there is one "best answer," but clearly, this is not the case in real life. On the test, a sickle cell person with osteomyelitis always has Salmonella. My reaction as a test taker is immediate; where's the bubble to fill in? But in real life, there's a 20% chance it's another bug. That's going to get someone someday.

I recently did a question with a stem: "A 40 year old man with recent contact with commercial sex workers presents with..." What? The first few words out of real life patients usually isn't, "I courted a prostitute last night" (though I may be wrong). This question doesn't seem realistic. And certainly, the person could very well have something completely unrelated to his sexual encounters. But on an exam, I've already narrowed down my choices to the STIs.

Certain diseases are overrepresented. How many doctors have actually seen a pheochromocytoma or diphtheria or prostitute's pupils (tertiary syphilis)? Yet those are exam-perfect diseases; I've seen all three multiple times.

Real life differential diagnosis involves a list of possible causes for the patient's symptoms, some more likely than others. A test question involves one right answer and four wrong answers. As a result, test questions rely heavily on buzz-words and key phrases. Lyme disease never presents without a target rash. Chagas disease only happens to immigrants from South America. A malar rash in someone on a new drug regimen? Has to be procainamide or hydralazine. An old man can't pee? It's BPH.

Is this medicine?

It'll apparently get you a license, and a good residency too. I know I probably come across as harsh and/or bitter, but I don't think there are any alternatives. And it's actually not bad; pedagogically, we have to start with black-and-white facts (all heart attacks present with crushing left-sided chest pain radiating to neck and back) before we can deal with the gray of real life.

Here's something else. Consider this: an old man with uncontrolled hypertension and polycystic kidney disease comes in with the "worst headache of his life." A CT is normal. What's the next step? It's a lumbar puncture. This is mandatory. Everyone with a suspected subarachnoid hemorrhage and normal CT gets an LP. On a standardized exam though, there could be test-takers who pass who got this question wrong. On an exam, they can pass if they do well on the other questions. In real life, this question cannot be missed.

I don't care if my doctor knows whether herpesvirus is a DNA or an RNA virus (it's DNA), but I do care if my doctor knows I get an LP to rule out subarachnoid hemorrhage (or at least, my lawyers will care after I'm dead). Sorry, I think I overplayed the drama with that one.

There's really no way around it; these are simply the shortcomings of an exam format that tries to assess whether people are ready to make critical decisions about patients' health and lives. These are the intrinsic problems to the USMLE. I'll write (rant) about the extrinsic problems in the next post.

Boards I

I have been avoiding writing about Boards, mostly because I had a lot of other things to babble about. But here it is. After finishing school, we have about a month off to prepare for Step 1, a licensing exam which covers all the basic science we've learned in the first two years. Most people have been looking at stuff before then, but the three weeks or so before the exam really comprises the intense cramming.

I spent one week up in San Francisco, mostly using the library reserve resources there. I built myself a little fort of textbooks and realized how much anatomy (especially neuroanatomy) I had forgotten. I think the strengths of the curriculum focus on physiology and pathophysiology (alas, we're not so good at pathology) as well as micro. Our curriculum isn't particularly "Boards-focused" which prompts a lot of student anxiety, but I think the systems-based block format really helps in approaching multidisciplinary problems. We're notably weak on certain aspects like biochemistry (they gave us a list of diseases that we didn't cover in class but may appear on the test) and musculoskeletal stuff (I think in the last two years, we might have had only two hours on skin). We're oddly strong at random fuzzy stuff (behavioral sciences, epidemiology), and I think embryology should be okay since we just had it. Pharmacology is scary, and I don't know how it'll be (it is really easy in our curriculum because it is spread throughout so that for each exam, we only have to memorize a handful of drugs). I think as a whole, we do fine but not spectacularly. Our scores are buoyed by the fervent gunners in our class.

Rotations II

For the first half of next year, I'll be moving around quite a bit. Family medicine is in Santa Rosa. I'm happy with that. While I prefer East Bay or South Bay (I have lots of friends in the Berkeley and Stanford areas), North Bay will be a change. It's a little over an hour away from San Francisco and as a rotation, it is rated pretty highly. While Family Medicine in the city involves many different sites, the Santa Rosa experience is a single community based setting.

My second rotation is Psychiatry/Neurology in San Francisco General Hospital. This one has lots of good and bad points. Most people have been trying to trade away SFGH Neuro/Psych because it has awful hours. I think Neuro has the classic 5am rounds everyone dreads. That's a major downside. On the other hand, it's my only rotation at SFGH and I really wanted one because it's a busy exciting county hospital.

I really didn't want Surgery at Fresno, as neither the location nor the teaching is really desirable. Alas, luck of the draw. I guess the upsides are that I'm not super interested in surgery, Fresno may have more hands-on experiences, it's a trauma center, and it's a new setting.

My last three rotations are in the main academic teaching center at Parnassus. Location is fantastic; it's only 5 minutes from where I live. I'm really happy with that. I'm still thinking about whether I want to end up in an academic center, and this will help. It'll be nice having continuity in one setting. The teaching will be great, and I'll get to see more exciting "zebra" cases.

My schedule is missing practice settings like Kaiser, but that's okay. Although it would have been nice to get a wide spectrum of experience in my third year, I have a decent amount of diversity in practice setting and location.

Rotations I

At last, a blog about my third year schedule.

Block 1: 2 weeks of surgical subspecialties (SF) then 6 weeks of family and community medicine (Santa Rosa)
Block 2: 4 weeks of psychiatry and 4 weeks of neurology (SFGH)
Block 3: 8 weeks of surgery (Fresno)
Block 4: 8 weeks of medicine (Parnassus)
Block 5: 6 weeks of obstetrics and gynecology (Parnassus and Mt. Zion)
Block 6: 2 weeks of anesthesia (SF) then 6 weeks of pediatrics (Parnassus)

I really like the order. I start off with a light rotation, family medicine. This will allow me to ease into the swing of things, figure out how to do a good H&P, present a patient, do a write-up. Family medicine is pretty general and should set a good foundation for me in thinking about common illnesses. While some people wanted to start with something serious (medicine) first and save family medicine for the end when burn-out is an issue, I'm okay with having it early. I'll get to pair it with surgical subspecialties and hopefully learn to do a good eye or musculoskeletal exam which will serve me well.

The second block is psychiatry and neurology, and I'm happy with that. Block 2 is when the new residents come in, so I didn't want to do something too procedural or critical for my training. As I'm not interested in either for a career, it will still give me opportunity to learn without too much pressure. Block 3 surgery is okay. I don't think I really care when my surgery rotation is. Non-surgeons tend to cluster their surgery rotations as a first block or a last block, but it's fine.

I'm glad I have medicine fourth; I feel like I'll have had enough experience before then to do well on that rotation. I didn't want to do it too late as I wanted to get a sense of it in thinking about residencies. There's a possibility of burnout (especially after neuro/psych and surgery), but hopefully that doesn't become a problem. My last two blocks are ob/gyn and pediatrics, and I'm happy with that. I'm not thinking too much about those rotations for a career, so it's fine that they come near the end, and I think I'll enjoy them.

Last Day of Classes

The last day of classes went not with a bang, but with a whisper. We had an ethics small group and a patient interview with a woman who was key in starting Medicare. There was a wrap-up session which was nice; the deans gave quick speeches about this transition in our lives, moving from a classroom and lecture based learning to experiential patient-centered education. I think this transition crept up on me and I haven't really come to terms with what it means.

But really, things finished in a trickle. People hurried out to continue their studying. Some people stuck around and chatted a bit, but the atmosphere was not one of celebration, but rather one of stress.

It is an interesting moment though, finishing my second year of medical school. As always and as expected, it has gone by amazingly quickly, especially this year which is only comprised of two quarters. But I think the learning has been tremendous. For example, at the beginning of last year, we learned to do the patient presentation in a specific order. Whenever I deviated, my preceptor would always remind me about information that should have been included in the history of present illness or to include medications after past medical history and not at the end. I didn't really understand it. Now, when listening or reading a history and forming a differential diagnosis, I get thrown off when I hear things out of order. I've somehow been indoctrinated into this culture of thinking.

It's been a rough and tumble two years. The volume of information is overwhelming. It's way more than I can master. I've also started developing patient-doctor skills, but they won't be honed to perfection by the time I get to wards. The first two years haven't been easy, but I've gotten a lot out of them. Am I ready to move onto the wards? The administration say I am, and I have to defer to their experience because I really can't say for sure.

Life Cycles and Epilogue

It seems like a long time ago, but I figure I should write a post about the last block of our core curriculum. Although I was pretty iffy about it at first, I really liked it. I thought it was great how they weaved in many different disciplines: we covered anatomy of the pelvis and perineum, endocrinology of bone metabolism and the reproductive system, organ physiology by discussing changes in pregnancy and childhood, histology of the reproductive tract, and more. We also touched on a few new fields like urology and neonatalogy. Although at first it seemed like a hodgepodge of topics, it helped me think about the big picture and realize how much I have learned since a year and a half ago. We had some awesome patient interviews, and I think as a whole, the block was pretty well organized.

Epilogue review sessions every Friday were fairly good. Some lecturers were awesome, reviewing really difficult concepts and focusing on diseases we are likely to see next year and on the exam. We had an exercise in the lab where we covered 35 cases looking at pathology or microbiology specimens. There were a few small group activities with adequately difficult questions and an autopsy case where we came up with a diagnosis based on gross and histologic pathology. I'm not sure how efficient the reviews were from a USMLE prep perspective, but I do think they were well designed, fun, and educational. Good integration and consolidation.

Quick Late Friday Night Post

I love dancing to live music.

Sorry

I couldn't help it. This came with my daily medical news feed.

Career Fair

We had a career fair to help us navigate the overwhelming number of specialties in medicine. It was more useful than last year when I really had no idea what I was interested in. There were numerous tables with faculty and fourth years to answer questions about the specialty and application process. There were also ten-minute talks about each field.

Here are the specialties I'm considering at the end of second year, when I really know nothing about the clinical aspects of any of these fields (though I presumably know something about the basic science).
1. Anesthesia -> Critical Care
2. Emergency Medicine
3. Internal Medicine -> Cardiology / ID / Hematology
4. Pediatrics -> Cardiology. This is a new one to make it to my list. I just found congenital heart defects to be really really interesting. It's the one thing I liked about embryology.

Final FPC Session

For our final Foundations of Patient Care class, our facilitators took us out to dinner at rnm at 598 Haight. It was quite a good restaurant. While I didn't find the service impressive, the food was really good (grilled hearts of romaine with fuji apples, saint agur, toasted hazelnuts, champagne vinagrette; dungeness crab risotto with baby artichokes, meyer lemon, goat cheese, and tarragon; a fabulous selection of desserts) and the location was fairly good for a group meeting. It was a wrap up session to talk about how we were going to apply classroom concepts to actual patient care next year. It was an odd feeling, knowing that this would be the last time for a while that we would all be gathered together; for the last year and a half, we've had an FPC small group session nearly every week. I've really gotten to know my other five peers and the two facilitators well, and I really love our group. We each have our different strengths and bring a wide diversity to the table. While at first, I wasn't sure about FPC because it seemed so soft and fuzzy, I think the cohesiveness of the group reeled me in. I'm going to miss working, ranting, brainstorming, teaching, and learning with these people. I've had a lot of fun in these sessions, and I really think that I've grown in many ways from interacting with this small group.

ICU

I have talked to two friends recently who've had scary and unfortunate experiences with family members in the ICU. It's a sobering conversation. The experiences of patients and their families in the ICU are rarely positive. It's a stressful time in an unfamiliar sterile environment with rules that don't seem to make sense. The thought of pain, suffering, and death take a toll on the caretakers. The vastness of the unknown coupled with the drought of overt compassion make this a period of intensity without reprieve.

In both cases, I felt almost obligated to apologize on behalf of my future profession for the unpleasant experiences of the ICU. The ICU is a place where the science of medicine really trumps the art of medicine; clinicians have adapted emotionally to the constancy of death and rarely realize that for every new patient and family member walking in, it is a really tough experience. I think as someone interested in critical care, I hope to remember these things and stimulate change. We cannot be complacent as we settle into roles already laid out for us. We need to constantly think about how things can and should be improved.

March

It's March. Back in November, I told myself I'd start in December. Come December, I figured I'd relax over winter break and start in January. Then January and I began a half-hearted effort. February meandered along and the unopened books began piling. Now it is March and I have no more excuses.

This blog is going to go down to four days a week (Su, T, Th, Sa) which will be fine as less is going on these days but I do have topics I would like to eventually write about.

Image is from my friend Julia Hu.

Aging

Aging is a fascinating topic. The changes in physiology and the human body as people get older are diverse, variable, and important to medicine. Diseases of accelerated aging or progerias are especially interesting. What can we learn from these rare genetic diseases where teenagers look like they're in their 70s or 80s? How can a simple mutation cause so many changes?

This is the Turquoise killifish (Nothobranchius furzeri) from Monzambique and Zimbabwe which has one of the shortest life spans of a vertebrate: 3-6 months. It lives out its entire life cycle in seasonal puddles after it rains.

This is the Rougheye rockfish (Sebastes aleutianus) which, on the other hand, lives 205 years.

Images are taken from lecture powerpoint.

LGBT

We had a session on lesbian, gay, bisexual, and transgender (LGBT) health care. It's pretty surprising to me how much disparity there exists in our system. There is no federal legal protection for sexual orientation or gender identity. Insurance and employers differ in whether they cover domestic partnerships. Bias, discrimination, and harassment limit both access and quality of health care for LGBT patients, whether related to sexual practices or not. This is really unacceptable. Physicians have a responsibility not only to advocate for their patients, but also to advocate for those populations which in the past or in other aspects of society may be marginalized. Medicine is really at the forefront of so many arenas - international health, child abuse, homeless populations - that it is shocking that medicine itself could be perpetrators in discrimination against LGBT patients. This is changing, which is good. But it is always important that, no matter what our personal views or opinions are on these issues, we are first and foremost patient advocates and our judgments have no place in determining whether someone gets care.

Nearing the End

Amazingly enough, we're nearing the end of second year. In many ways, it's been ending not with a bang, but with a whimper. I think Boards has scared other students into hiding. I feel a little bad that our attendance at lectures has plummeted though I praise all the people who still do make it to 8AM classes. I think the lecturers really have a lot to offer, and it's unfortunate that they ended up teaching at a point in the curriculum where people's attention is directed elsewhere. I have a lot of issues with how hyped up Boards has become, and this is one of them.

The image was taken by my friend Julia Hu.

Intimate Partner Violence

We had a lecture last week on an incredibly important topic, intimate partner violence (or domestic violence). I was shocked by the prevalence; IPV involves 13-30% of women (85% of cases involve women). It can encompass physical, sexual, psychological, emotional, or economic abuse. Often, perpetrators use threat of harm to maintain dominance over their intimate partners through fear. Abusive relationships only get worse over time. The effect on health is profound; not only does it involve acute injuries, but also chronic pain and mental health disorders. The scary thing, I think, is that IPV is self-perpetuating. Children who witness or experience abuse often grow up to become perpetrators or victims. It is also incredibly hard for victims to get out of abusive relationships.

This was made apparent by two very brave women who came to talk to our class about their experience in abusive relationships. I can't share any details about their stories, but what struck me was how entrenched victims become in these situations. Their husbands controlled everything - credit cards, gasoline, jobs, even whether they could talk to neighbors. For decades, these women had been told that they were worthless and dependent; for decades, they had been threatened and their children had been threatened. Only over a long period of time were they able to set up the necessary interventions to get out of those abusive relationships. I really have a lot of respect for that.