Unexpected

I didn't realize I'd be so busy or get home so exhausted.

Splints and Casts

I start out with 2 weeks on Sports Medicine with an Orthopedic Surgeon. Today, we had the usual orientation, a pre-test, and a lecture on topics important to all physicians: fractures, avascular necrosis, compartment syndrome. But more excitingly, we learned to put on splints and casts. We practiced putting a plaster volar splint and a short arm fiberglass cast on each other. It was really cool, though I'm not very proficient; my partner could still wiggle his wrist. In any case, the scariest part was using the saw to cut off the cast. It's a vibrating saw that is not supposed to cut skin, but it's really loud and it rips through the cast with heat and a shower of dust. It's worsened by the fact that you can't move your arm (because of the cast) and the knowledge that it's the first time your partner is doing it. Anyway, a picture is shown above.

Image is in the public domain, taken from Wikipedia.

Apprehensive

I'm a little apprehensive right now. I feel unprepared, tired, overwhelmed, and worried. I usually don't feel this way before "back-to-school" days.

A Change of Pace

All the hand-holding and coddling is over. Out of the frying pan into the fire. I've been treating the last few weeks like I was still on vacation - going out, having fun, not doing much reading. That's all going to change on Monday when rotations begin.

I don't really know what to expect. They've told us, warned us, but I don't feel entirely prepared. It'll be a big adjustment figuring out how to deal with patients rather than classrooms, attendings rather than professors. There is a sense of apprehension and excitement. This is what we came to medical school for. But is it what we're ready to do?

Right now, it's hard to predict how much time I will have to blog. I will try to keep this updated and timely, but it's not at the top of my list of priorities. I'm attempting to change a few things. I want to write one poem or story excerpt a week. I will try to document what I'm doing, interesting happenings, and unique patients (as complies with privacy laws). I'll also attempt to reflect on personal changes (and hopefully growth) during these clinical rotations.

Nurses and Doctors

I learned something today. Physicians are the only ones who write orders for medications but they aren't allowed to touch the drugs. Only nurses are allowed to administer medications. It's a form of checks and balances. I'm not sure how exactly it works, but it's interesting.

On the Wards

I'm actually really grateful that we have this transitional clerkship to learn the ropes and make mistakes. There is so much nitty gritty stuff to figure out. I still feel a little out of place on the wards, working with the nurses and clerks, figuring out the computer system, navigating my way through a chart. The paper charts are ridiculous. Most of it is illegible and I'm not even sure how to make sense of it. The computer interface at SFGH isn't the most intuitive either; the data is poorly organized. This was surprisingly disappointing; I know medicine is slow to adapt to technological innovation, but the charts and the computer program really feel at least a decade old. However, it's been a good exercise to practice writing notes; now that we realize it's an important responsibility, we're really learning hard how to write a good note. While I feel comfortable with oral presentations, the practice and feedback we're getting is good preparation for when we will actually be evaluated. I think, though, it's been good to be in the environment just to get a feel of how an inpatient ward runs, who everyone is, where the resources are, etc.

Logistics

Much of this transitional clerkship involves tedious but necessary logistical lectures: what to do in a fire, how to deal with discrimination in the workplace, professionalism. But I can't feel too sorry for myself; imagine what it would be like to give these presentations as your job.

Procedures

I had a great day today. We had a half-day procedures lab which was really fun. The first station was IV placement and blood draws. We practiced on model arms which were amusing. Like real people, all the mannequins differed in the ease of their veins, the color of their skin, and the location of the vessels. At first, it was fairly complicated; I would forget when to take off the tourniquet or have trouble advancing the catheter. But it was a decent simulation in a low-stakes environment. We then had a station on arterial sticks, which I found to be easier. Since the mannequins didn't have pulses, we would just aim at the puncture sites of all the previous sticks. We also practiced lidocaine wheals on each other (pretty much the same as a PPD).

There was a basic life support CPR session. The guidelines for CPR have changed recently (rescue breaths are no longer in the guidelines; you can do continuous chest compressions now) and I learned that the best places to have a cardiac arrest are airports (lots of AEDs) and casinos (lots of AEDs and cameras). It was good review. Lastly, we had a station on suturing, which I really enjoyed. I practiced mostly simple interrupted throws on a pig's leg. I felt a lot better about it than last year when I was fumbling with even holding a needle driver. I'm not very proficient with it yet, but I think suturing is a lot of fun.

As a whole, it was a fun, interactive, hands-on day where I got more confidence in a lot of procedural stuff I felt hesitant about. Hopefully its enough of a foundation to help me when I really need to put these skills into use.

Medical Students

Medical students are very particular. I've been thinking lately about the types of people who self-select into this profession. We're detail-oriented, hard-working, commitment-comfortable (that is professional, not necessarily relationship-wise) people. We pay attention to things that others might dismiss, we picked a path that takes a substantial investment. Medical students often have a bit of obsessive-compulsive personality trait. I'm not sure why. I have some that may help my studying, but most of my obsessions and compulsions really don't seem to be that adaptive to medical school. Most of us like security and are risk-averse. We don't usually take chances, and this is probably a good thing for our patients.

Medical students aren't brilliant. Most of us aren't going to hold patents to world-changing inventions or write symphonies or make unprecedented discoveries. Our skill set isn't built around that (this is why I have such great respect for my peers who are pursuing PhD's, MPHs, even MFA's). We're not spontaneous. We don't set off on great adventures backpacking across Europe with empty pockets. We don't play hedge fund gambling.

Obviously, all the things mentioned here are generalizations.

Reality TV

A friend and I were discussing what it would be like to have a medical student reality TV show. Every episode, the least prepared pre-rounder (medical term for checking up on your patients early in the morning) gets eliminated with a caustic reprimand by the attending. The prize? Honors on the rotation, of course. Oh, but it's not that easy, there are different challenges each week. One week everyone might be assigned a patient who doesn't speak English. Or maybe the student has to do a pelvic exam. Or perhaps contestants aren't allowed to sleep (oh wait, that's just real life). Who will win? The gunner who gets there at 3 in the morning every day but gets on everyone's nerve? The MD/PhD who recites the latest journal articles? The one who sleeps with the intern? (oops, that might be a different show).

Transitional Clerkship

We have a week and a half of transitional clerkship, a bridge from the basic science years to the clinical years. The intention is to shore up any weaknesses before we start rotations. We have four days of inpatient preceptorship to practice the H&P as well as write-up and presentation skills (which are greatly lacking). It also gives us a chance to learn the logistics of the hospital: where charts are, how to access the computer medical record. We have a few lectures on this and that: evaluations and the longitudinal care experience and professionalism. It's supposed to be somewhat low key, and in many ways it is - we're not worried about grades or whatever - but it's also jarring to realize we're going to be in the hospital with a modicum of responsibility.

The Aloha Spirit

I had a fantastic time in Hawai'i (O'ahu and Maui) catching up with old friends, swimming in the ocean, hiking in the mountains, eating pancakes with macadamia nut syrup, learning about Hawaiian history and culture, visiting the 'Iolani palace, wading the tidepools, shopping Waikiki, and reveling in general debauchery. I took this picture of a sea turtle we saw, which was absolutely amazing. Mahalo to my friends who went out of their way to make this trip particularly memorable.

The Art of Pimping

This is a classic article from JAMA. 1989 Jul 7;262(1):89-90 entitled "The Art of Pimping" by Frederick L. Brancati, Dept. of Medicine, U of Pittsburgh.

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It's hard work becoming a revered attending physician in a university hospital. The task daunts the newly appointed junior attending as he strides down the corridor of his first ward with his first team. Oh, he's made some changes in anticipation of his new position. He's wearing a long coat now, an all-cotton coat with razor-sharp creases and knit buttons. The stained, shrunken polyester white pants and tennis shoes have given way to gray, light wool slacks with a cuff and polished loafers. Framed certificates bear testimony to his intelligence and determination. He should be ready to take the helm of his ward team, but he's not. Something's missing, something important, something closer to art than to science. When physicians talk about the "art of medicine" they usually mean healing, or coping with uncertainty, or calculating their federal income taxes. But there's one art this new attending needs to learn before all others: the art of pimping.

Pimping occurs whenever an attending poses a series of very difficult questions to an intern or student. The earliest reference to pimping is attributed to Harvey in London in 1628. He laments his students' lack of enthusiasm for learning the circulation of the blood: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!"

In 1889, Koch recorded a series of "Puempfrage" or "pimp questions" he would later use on his rounds in Heidelberg. Unpublished notes made by Abraham Flexner on his visit to Johns Hopkins in 1916 yield the first American reference: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.' Delightful."

On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Furthermore, after being pimped, he is drained of the desire to ask new questions — questions that his attending may be unable to answer. In the heat of the pimp, the young intern is hammered and wrought into the framework of the ward team. Pimping welds the hierarchy of academics in place, so the edifice of medicine may be erected securely, generation upon generation. Of course, being hammered, wrought, and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning.

Despite its long history and crucial importance in training, pimping as a medical art has received little attention from the educational establishment. A recent survey reveals that fewer than 1 in 20 attending physicians have had any formal training in pimping. In most American medical schools, pimping is covered haphazardly during the third-year medical clerkship or is relegated to a fourth-year elective. In a 1985 poll, over 95% of program directors admitted that the pimping skills of their trainees were "seriously inadequate." It comes as no surprise, then, that the newly appointed attending must teach himself how to pimp. It is to this most junior of attendings, therefore, that I offer the following brief guide to the art of pimping.

Pimp questions should come in rapid succession and should be essentially unanswerable. They may be grouped into five categories:

1. Arcane points of history. These facts are not taught in medical school and are irrelevant to patient care — perfect for pimping. For example, who performed the first lumbar puncture? Or, how was syphilis named?

2. Teleology and metaphysics. These questions lie outside the realm of conventional scientific inquiry and have traditionally been addressed only by medieval philosophers and the editors of the National Enquirer. For instance, why are some organs paired?

3. Exceedingly broad questions. For example, what role do prostaglandins play in homeostasis? Or, what is the differential diagnosis of a fever of unknown origin? Even if the intern begins making good points, after 4 or 5 minutes he can be cut off and criticized for missing points he was about to mention. These questions are ideally posed in the final minutes of rounds while the team is charging down a noisy stairwell.

4. Eponyms. These questions are favored by many oldtimers who have assiduously avoided learning any new developments in medicine since the germ theory. For instance, where does one find the semilunar space of Traube? Or, whose name is given to the dancing uvula of aortic regurgitation?

5. Technical points of laboratory research. Even when general medical practice has become a dim and distant memory, the attending physician-investigator still knows the details of his research inside and out. For instance, how active are leukocyte-activated killer cells with or without interleukin 2 against sarcoma in the mouse model? Or, what base sequence does the restriction endonuclease EcoRI recognize?

Such pimping should do for the third-year student what the Senate hearings did for Robert Bork. The intern, in contrast, is a seasoned veteran and not so easily rattled. Years of relentless pimping have taught him two defenses: the dodge and the bluff.

Dodging avoids the question, wasting time as well as a valuable pimp question. The two most common forms of dodging are (1) to answer the question with a question and (2) to answer a different question. For example, the intern is asked to explain the pathophysiology of thrombosis secondary to the lupus anticoagulant. He first recites the clotting cascade, then recalls the details of a lupus case he admitted last month, and closes by asking whether pulse-dose steroids are indicated for lupus nephritis. The experienced attending immediately diagnoses this outpouring as a dodge, grabs the intern by the scruff of the neck, and rubs his nose back in the original pimp.

A bluff, unfortunately, is much more damaging than a dodge. Allowed to stand, a bluff promulgates a lie while undermining the academic hierarchy by suggesting that the intern has nothing more to learn from his attending. Bluffs weaken the very fabric of American medicine, threatening our livelihood and our way of life. Like outlaws in a Clint Eastwood movie, bluffs must be shot on sight — no due process, no Miranda Act, no starry-eyed liberal notions of openness or dialogue — just righteous retribution.

Bluffs fall into three readily discernible categories:

1. Hand waving. These bluffs are stock phrases that refer to hot topics in biomedicine without supplying detail or explanation. For example, "It's a membrane transport phenomenon" or "The effect is mediated by prostaglandins." In many institutions, they may evolve directly from the replies of Grand Rounds speakers to questions from the audience.

2. Feigned erudition. The intern's answer, though without substance, suggests an intimate understanding of the literature and a cautiousness born of experience. "Hmmm . . . to my knowledge, that question has not been examined in a prospective controlled fashion" is a common form. Frequently, the bluff is accompanied by three automatisms: clearing of the throat, rapid fluttering of the eyelids and tongue, and chewing on the temples of the eyeglasses. This triad, when full-blown, will make the intern bear a sudden resemblance to William Buckley and is virtually pathognomonic.

3. Higher authority. The intern attributes his answer to the teaching of a particular superior. When the answer is refuted, the blame of ignorance comes to rest on the higher authority, not on the obedient, accepting intern. The strength of the bluff depends on just whom is quoted. An intern quoting a junior resident about pathophysiology is every bit as cogent as Colonel Qaddafi quoting Ayatollah Khomeini about international law. An intern from an Ivy League medical school quoting the "training" he received on his medical clerkship goes over like Dan Quayle explaining the Bill of Rights at an ACLU convention. The shrewd intern, however, will quote his Chairman of Medicine or at least a division chief, pushing the nontenured attending to the brink of political calamity. Did the chairman actually say that? The attending is powerless to refute the statement until he is certain.

Indeed, a good bluff is hard to handle. Sometimes the intern's bluff sounds better to the ward team than the attending's correct answer. Sometimes it sounds better to the attending himself. Ultimately, the cunning intern is best discouraged from bluffing by aversive training. Specifically, each time he bluffs successfully, the attending should counter by inducing Sudden Intern Disgrace (SID). SID is induced in two ways:

1. Question the intern's ability to take a history. This technique depends on the phenomenon of historical drift. That is, a patient's story will reliably undergo a significant change in the 8- or 16-hour interval between admission and attending rounds. The attending need only go to the bedside and ask the same questions the intern did the night before. Now the entire case is seen in a light different than that cast by the intern's assessment. Yesterday's right upper quadrant cramping becomes right-sided pleuritic chest pain. Yesterday's ill-defined midepigastric "burning" becomes crushing substernal heaviness radiating to the arm and jaw. Suddenly, the intern is disgraced. He will never bluff again.

2. Question the intern's compulsiveness. In less rigorous programs, this is easy. Did the intern examine the peripheral blood smear and the urine sediment himself? If the intern does routinely examine body fluids, a more methodical approach is required. In this case, results of the following tests, procedures, and examinations may be requested in rapid succession: Hemoccult slide test, urine electrolytes, bedside cold agglutinins and serum viscosity, slit-lamp examination, Schiotz' tonometry, Gram's stain of the buffy coat, transtracheal aspiration, anoscopy, rigid sigmoidoscopy, and indirect laryngoscopy. Once the attending discovers a test or examination left unperformed, he asks the intern why this obviously crucial point was neglected. (The tension may be heightened at this point by frequent use of the word "cavalier.") The intern's response will generally revolve around time constraints and priorities in diagnostic evaluation. The attending's rejoinder: did the intern ea t, sleep, or void last night? The scrupulous intern at once infers that he has placed his own needs before the needs of his patient. Suddenly, he is disgraced. He will never bluff again.

Clearly, pimping — good pimping — is an art. There are styles, approaches, and a few loose rules to guide the novice, but pimping is learned in practice, not theory. Despite its long and glorious history, pimping is in danger of becoming a lost art. Increased specialization, the rise of the HMO, and DRG-based financing are probably to blame, as they are for most problems. The burgeoning budget deficit, the changing demographic profile of the United States, the Carter Administration, inefficiency at the Pentagon, and intense competition from Japan have each played a role, though less directly. Against this mighty array of historical forces stands the beleaguered junior attending armed only with training, wit, and the determination to pimp. It won't be easy to turn back the clock and restore the art of pimping to its former grandeur. I only hope my guide will help.

Vacation

I'm taking a quick vacation to Hawaii with some friends from undergrad. I'll be back Wednesday (I'm flying in red-eye and heading straight to class). Work hard, play hard, (and don't sleep).

I took this picture in March of 2005.

The Anatomist

I heard a talk from Bill Hayes, the author of The Anatomist. The book chronicles the life of Henry Gray and the original illustrator of Gray's Anatomy, Henry Vandyke Carter. Though I don't read a lot of historical narrative, I got really interested in this book after hearing some excerpts. Bill Hayes, a San Francisco freelance writer, got interested in this topic when he realized there were no biographies of Henry Gray. He called UCSF's general Q&A line with an odd request: whether he could meet with some anatomists to help him plan this book. After talking with some of the anatomy faculty (all of whom we know as students), he was invited to attend one or two anatomy labs. He ended up sticking around for a year and half, taking classes with dental, nursing, physical therapy, and medical students. The Anatomist weaves in the author's personal experiences at UCSF's anatomy labs with the biography of the author and illustrator of the original Gray's Anatomy.

I've worked with Bill Hayes in creative writing workshop for the last quarter, and he's awesome. I think it's fascinating that he doesn't have a medical or science background yet all his books focus on topics like the history of blood and insomnia. He has a lot of insight into writing and offers great perspective for us in workshop. Although I have not yet read The Anatomist, it is the next book on my list and I expect it to be completely worthwhile. Bill Hayes' other books include Sleep Demons and Five Quarts.

Image shown under fair use, from Amazon.

USMLE Step 1

I ought to write something about Step 1, though obviously I can't give any specifics. In the last few days before the test, I finished reading First Aid and going over some notes. I didn't have time to do as many problems as I wanted and kept cramming to the end (I learned the P450 inhibitors/inducers the day of). I've always been a study sprinter, which doesn't lend itself to these marathon-like tests, but it's not too bad.

The test itself went fine, though its emphases were slightly different than what I had expected or prepared for. Two things helped me a lot more than I expected. The first is a research background. I had a number of problems that involved interpretation of basic science experiments or data. The problems were purposely written to be intimidating in its nomenclature, format, and length, but the problems weren't actually hard. I feel like fluidity with experimental setups and data helped me stick with questions I may otherwise have skipped. The second is active learning of material outside of school: http://content.nejm.org/misc/eicm.shtml and http://caseoftheday.blogspot.com/.

Cupid's Disease

In a flight of fancy, I decided to learn about syphilis. This is what Wikipedia had to say:

The name "syphilis" was coined by the Italian physician and poet Girolamo Fracastoro in his epic noted poem, written in Latin, entitled Syphilis sive morbus gallicus (Latin for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a shepherd named Syphilus (perhaps a variant spelling of Sipylus, a character in Ovid's Metamorphoses). Syphilus is presented as the first man to contract the disease, sent by the god Apollo as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text De Contagionibus ("On Contagious Diseases").^[1]

Until that time, as Fracastoro notes, syphilis had been called the "French disease" in Italy and Germany, and the "Italian disease" in France. In addition, the Dutch called it the "Spanish disease", the Russians called it the "Polish disease", the Turks called it the "Christian disease" or "Frank disease" (frengi) and the Tahitians called it the "British disease". These 'national' names are due to the disease often being present among invading armies or sea crews, due to the high instance of unprotected sexual contact with prostitutes.

Lost?

This image is from shirt.woot.com and is designed by Jack Anderson.

April Fools 2008

This was the article I wrote for this year's Synapse paper.

Why is Synapse so sexy?

A recent study found preliminary results that UCSF Synapse Editors are 3.6 units sexier than counterpart non-Editor students. Conducted by an anonymous research team in the Synapse masthead, this was a double blind randomized controlled trial with nearly two score participants, a baker's dozen of whom were randomly assigned the role "UCSF Synapse Editor." While legend has it that selection of candidates for these coveted positions falls under great scrutiny, a new insider source suggests that the Editors were actually chosen by a random process in which "Golden Toothpicks" were inserted into free Synapse Thursday meeting sandwiches in the style of the ploy formerly known as Charlie and the Chocolate Factory. Critics of this study claim that Synapse editors were unfairly biased to having voracious appetites.

The assessment of attractiveness was conducted in a double blind fashion where sight-impaired members of the community were invited to score participants. We can only hope that participants' acne did not spell out haikus of love in Braille. Preliminary results indicate an increased attractiveness of Synapse Editors of 3.6 units (standardized to the sexiness of Harrison Ford as he appears in the upcoming Indiana Jones). No statistical analysis was reported; it seems that Synapse Editors failed to pass the Student's t-test. They attribute this to their dedication to this flagship of publication which leads the scientific community with groundbreaking articles such as this one.

A Synapse Editor and blogger who wishes to remain anonymous lest she get mobbed by her hometown (Arcadia) or paraded around by her undergraduate institution (Harvard) said, "Nothing screams 'sexy' more than a healthcare professional who has a way with words. It's no small wonder that Synapse editors may be some of the sexiest creatures on the planet." Rumors abound that the Discovery Channel may pick this up as a reality documentary animal TV show next season.

Although the study was funded by Synapse, the newspaper claims that the same independent oversight committee that assures the quality of these articles also judged the study to be valid. This evidence was sufficient to quell even the harshest responses by critics.

April Fools 2007

I wrote this for the school newspaper Synapse last year.

Free Oto-ophthalmoscopes for Next Year’s Medical Students

Last week, a benefactor under the promise of anonymity announced a donation of $20,000 for the White Coat Ceremony of the School of Medicine Class of 2011. “I was caller number 94 for one of those radio contests and won a car, but because of severe Paget’s disease, I am unable to drive it. I auctioned it off over the Internet over the past few months and decided to take much of the money I made, less the transaction costs, and donate it to next year’s incoming medical class.”

When asked why the medical class, the donor replied, “I had an osteotomy done here at UCSF which greatly relieved the pain in my knees. However, the charm of the anesthesiologist made my experience particularly memorable. Thus, I hope that this gift will inculcate in future doctors a desire to be kind, respectful, and charming.”

The Committee on the 2007 White Coat Ceremony (C07WCC) is currently discussing how to allocate the $20,000. Proposals that have been struck down by vote include moving the ceremony to the top of the Bank of America building, on board a ship circling the bay, or to the historic operating rooms at San Francisco General Hospital. The meeting minutes for March 16, 2007 indicate, “We really hope to use the money on a lasting investment rather than a spiffy location.”

Currently the C07WCC is considering a proposal of purchasing oto-ophthalmoscopes for each member of the Class of 2011. Oto-ophthalmoscopes run several hundred dollars and are used to examine the eyes and ears. Curriculum leaders for Foundations of Patient Care (FPC) hope that this investment would emphasize the importance of “looking at, listening to, and examining patients.” Recently, the white coat gift has been criticized for symbolizing the separation between patient and physician. Instead, an oto-ophthalmoscope would represent a link between the two.

There have been rumors circulating that this proposal is heavily backed by curriculum leaders for Brain, Mind, and Behavior (BMB). One first-year medical student commented, “Dan Lowenstein would do anything to get word out about BMB as early as possible.”

Critics of this proposal say that incoming students would not even know how to spell oto-ophthalmoscope, let alone know how to use one.

Paget’s disease of the bone, also known as osteitis deformans, is caused by an accelerated rate of bone turnover. Clinically, it can present with pain, skeletal deformities, fractures, bone tumors, or neurologic complications.