Green

Coming from Stanford and San Francisco, I've been somewhat attuned to sustainability. We have a fundamental responsibility to preserve intergenerational equity and maintain environmental potential. Yet nearly all of us live in an unsustainable manner. We consume without regard to future generations. The impact on the environment is unjustifiable; not only are we destroying the atmosphere, oceans, freshwater, forests, land, ecosystems, and biodiversity, but we are also causing detrimental effects on human health. I believe our technological, medical, industrial, agricultural, and other advances have allowed us to extend the carrying capacity of our environment but beyond the limit of sustainability. Hence, there are movements for global awareness, sustainable living, renewable energies, responsible food production, green design, etc.

Recently, I've become interested in integrating sustainability and medical facilities. On my clinical rotations, I've realized how many resources are used in an environmentally unconscionable manner. For example, even a simple outpatient surgery uses incredible amounts of disposable materials. I like to focus on towels. After scrubbing - disinfecting my nails, hands, and upper arms before a surgery - the scrub nurse hands me a sterile towel. Carefully, I dry my arms in a prescribed fashion preserving sterility and then throw the towel away. I don't understand why; the towel merely dried off my antimicrobial soap slathered arms. There's no blood, no body fluids, no MRSA bacteria. Why can't they be re-sterilized and reused?

I imagine putting towel reuse bins in every operating room might save a bit, but honestly, it wouldn't put a dent in the amount of waste a hospital generates. To me, this example reflects the unfortunate mentality that pervades the hospital. Until recently, sustainability was not on the radar. People did not think about it. We were above it. After all, we're "saving lives." We have to use what it takes. When you look at the ethical principles of beneficence, doing right for the patient, and justice, providing equal care to all, beneficence wins out. Practitioners rarely think of justice and rarely interpret it as providing equal care to those patients in the far future, when resources may not be as plentiful.

When I was on ob/gyn, one of my attendings told me that in China, doctors can do a hysterectomy with four pieces of suture, the material used in surgical stitches. That's incredible. I don't know how much suture we use in a typical operation, but it's certainly much more than four. The reason? Some hospitals in China have patients purchase their own surgical supplies, and as a result, practitioners have figured out the maximum efficiency to minimize waste. Consumers demanded it. But in the U.S., I've not seen such pressure to minimize resource usage.

The big picture, however, is not in how many disposable gloves or masks I use (though I try hard not to waste anything). Many of the hospitals I've seen are old, built decades ago, without technology that saves energy, reduces waste, or operates efficiently. To really move toward green hospitals, we need to look at how electricity is distributed, how heating and cooling systems are managed, how we can provide optimal care with the least carbon footprint. Hospitals generate so much waste, and much of it is toxic and hazardous, but much may also be excess. How do you maintain sterility without double or triple or quadruple packaging materials? Can we dispense with overflowing, unorganized paper charts (much of which is illegible anyway) to save paper, reduce shredding costs, and free up physical space in medical chart storage? Can we build hospitals that employ green architecture, taking advantage of sunlight, ventilation efficiency, sustainable building materials, and responsible energy production methods? Who are the administrators that need to approve this? Who are the engineers that need to work this out?

This needs to happen; there's no question. Everyone, everywhere needs to change in order to preserve the limited resources of our planet, and hospitals are no exception. They are behemoths to move, but I hope my generation of physicians, administrators, practitioners, and thinkers can loosen the inertia and begin planning how to go green without compromising patient care.

Medicine and Money

How do we figure out how much to pay doctors? In medical school, we get taught nothing about business management or medical economics. What forces determine compensation? How are salaries decided? How come primary care is reimbursed at such a lower rate compared to specialists? Atul Gawande has written an interesting article describing how procedure reimbursement rates were set, but other than that, I don't know much.

In medical school, we are taught the idealistic approach: we see and treat whoever walks through the door, regardless of ability to pay. Like church and state, medicine should be cloistered from economic forces; we hope we are above such influences, though they drive so many other human interactions out there. No one should go into medicine for the money; indeed, the amount of time invested makes it a wholly unlucrative proposition.

For me, money was never a big factor. But now that I am thinking about residency and specialties, these issues are exerting more pressure. With the recent economic downturn, my friends in other fields have found themselves unemployed. Medicine may be insulated against such ebbs and flows and offer a measure of security, but these current events have raised the question of money. Many people I know are pursuing the heavy hitting specialties: orthopedic surgery, ophthalmology, dermatology, radiology. These "lifestyle" specialties were never attractive enough to me to pursue them, but I wonder: what makes them so high-paying? Should they be so high paying? Or should there be more balance compared to those in the front lines, the primary care physicians?

How Doctors Think (Groopman)

I also recently read How Doctors Think by Jerome Groopman, a hematologist-oncologist at Harvard. This New York Times bestseller is written for the lay public regarding how to understand a doctor's thought process and how a patient can help maximize the care he or she gets. Drawing on stories of patients, he describes the difficulty of diagnosis from the clinician's standpoint, the importance of communication, and how doctors ought to work with patients. His writing style is accessible, eloquent, and moving. It has the feel of an Atul Gawande book, and I highly recommend it.

Image shown under fair use, from media.npr.org

How Doctors Think (Montgomery)

I recently read How Doctors Think by Kathryn Montgomery, a PhD in English Literature teaching at a medical school. Her book is ambitious; it attempts to describe how clinical judgment works, how medical education tries to teach it, and how it is not science. She attempts to characterize contradictions in medical practice, the problems of practical medicine, and the stark difference between a patient in an office and a statistic from a scientific study. It's interesting and thought provoking.

However, I was not persuaded by her thesis. Her writing style reminds me of a philosophy essay, defining terms, clarifying assumptions, and building up an argument against medicine as science. However, her scope is too narrow, her definitions too constrained. She addresses science in "the narrow, old-fashioned, positivist sense [...] certain, replicable, dependable." She acknowledges this as a straw man but proceeds to spend chapters trying to dissect it. I don't think it's a novel, useful, or applicable thesis. We already know not every patient is the same, not every diagnosis foolproof, not every medication replicable and dependable.

Her observations on clinical judgment are interesting but not revolutionary. She discusses our need for certainty in medicine, the strangeness of narrative in "science," and the role of medical student education. Her evidence base is unusual; she draws on literature, poetry, plays, maxims, and even a study she conducted on seating patterns at a conference. She draws on a personal story of her daughter and breast cancer which applies emotional leverage yet undermines her attempt at objective analysis. In the end, I think How Doctors Think makes interesting observations from the perspective of a non-clinician, yet it falls short in convincing me to change my perception of clinical judgment and medicine.

Image from Amazon, shown under fair use.

You Don't Learn Everything in Medical School

One of my friends had this status message: "I think I might be dying of kurtosis." Kurtosis? Are you sure that isn't ketosis? Or kuru? I was panicked that my friend was afflicted by some rare disease I had never heard of.

Wikipedia says kurtosis is the measure of the "peakedness" of the probability distribution of a real-world random variable. Higher kurtosis means more of the variance is due to infrequent extreme deviations as opposed to frequent modestly-sized deviations. Then, they show this image with the following caption:

"Caption: The far red light has no effect on the average speed of the gravitropic reaction in wheat coleoptiles, but it changes kurtosis from platykurtic to leptokurtic (-0.194 -> 0.055)."

Image from Wikipedia, shown under GNU Free Documentation License.

Poem: Golden Fetters, Diamond Shackles

Golden Fetters, Diamond Shackles

Self-imposed, this intellectual oubliette
on this beautiful San Francisco afternoon,
the rumbling of the municipal railway
rattling my teacup as I steep myself
in those wonders that happen between week two
and week three of embryonic development,
book open, test impending, sleeplessness
streaked across my forehead.
The sunlight dances on retreating puddles,
evidence of last night’s thunderstorms
which have swept the dust and fog away,
and the dogs passing by wag their tails.
The world full of golden fetters, diamond shackles
that I yearn to shed, freeing this medical anchorite,
if only to feel the sweep of the shops downtown
the slap of the running grass in the park.

Two Week Vacation

I'm in the middle of a two week break, appended onto six week rotations like ob/gyn. I'm spending this week in the city and next week at home in Irvine. It has been absolutely fabulous having time off. I've explored the city, visited the new California Academy of Sciences, seen Wicked, hung out with friends, danced. I've also been figuring out residency stuff, doing some reading, researching specialties, meeting with advisers, and planning fourth year.

Image from Wikipedia, shown under fair use.

Ob/Gyn 110

I enjoyed my obstetrics and gynecology rotation a lot more than I expected. I had a great time on labor and delivery. The attendings and midwives were dedicated to teaching, the teams were great, and the subject matter interesting. Though the hours were long, the work was fun. I loved deliveries and working with healthy women at a joyous time in their lives. By my seventh delivery, my attendings had enough confidence in me simply to gown, glove, and watch. There was a bit of emergency medicine (triage), surgery, and medicine (complicated antepartum patients).

My gynecology weeks were less satisfying but solid outpatient experiences. I appreciated seeing REI, dysplasia, and women's options clinic. I feel pretty good about doing a pelvic speculum exam and working up some basic gynecology complaints. For me, there was a big learning curve; I knew very little about pregnancy and women's health going in. But I think by the time the shelf exam came around, I had a decent knowledge base. Cancer surgeries involved intriciate lymph node dissection and beautiful anatomy; benign gynecology surgeries involved both laparoscopic, transvaginal, and open procedures. It was cool.

In the end, though, ob/gyn goes up on my list of interests, but doesn't top the list. If I went into it, I'd be most interesed in perinatology (high risk obstetrics) or possibly reproductive endocrinology and infertility. However, I realized the surgeries and gynecology are not that interesting to me; I really mostly like the medicine and obstetrics aspects. I tend to like working with sicker patients than those normally in ob/gyn. And I don't think I want to limit my patients to women. I had a few attendings try to convince me to go into the field, and I really appreciate it, but I'm not sure it is right for me.

Ob/Gyn Clinic

My last few weeks on ob/gyn was spent in outpatient clinic settings. In prenatal diagnosis clinic, I learned how genetic counselors advise women and their partners about birth defects like Down Syndrome and saw incredibly skilled ultrasonographers do first trimester screening. Though much of that was passive, it was pretty educational. In obstetrics clinic, I saw new ob patients, routine visits, and 6 week postpartum visits. This was actually a lot of fun since I had already done labor and delivery. One of the attendings did a great job teaching me how to examine the gravid uterus (pregnant belly) - how to predict how far along someone is by the size, how to feel the fetus' head, spine, and butt, how to find fetal heart tones with a handheld Doppler machine. Having done labor and delivery, I was able to do more patient education and preparation about childbirth and expectations. I knew the attendings and midwives, and so that experience was excellent. Lastly, I worked a few afternoons in gynecology outpatient clinic. The range of diseases involved fibroids, endometriosis, irregular periods, and other menstrual abnormalities. I got to do a number of pelvic speculum exams with Pap smears, which wasn't all that difficult once I got the hang of it.

Revision: Restraint

I decided to play with slant rhymes while revising this poem.
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Restraint

An octopus, serpent, tumor grappling the lung
angry tentacles sliding along
dodging napalm scattered at this throng
Speckled black with soot and remorse
brandishing brandy and sword
splitting pink tissue, letting blood pour

Too late we arrived, too deep for dynamite
how my trigger finger itched at the sight
of winding caverns, yawning chasms, this fight
Hand me a cloth, I’ll clean my spelunkers hands
as we mutter coprolalic war chants
let me at it, give me a scalpel, I want to dance

Time to go, He said, time to stop
took axe from my hand, time to pack up shop
Napoleonic triage, the dying left to rot
This is our limit, He said, drawing a line
pulling gloves off one at a time
backing away from this field of mines

Wicked

My classmate Paul organized a trip to see the musical Wicked. I loved it. I had so much fun. It's a really entertaining, witty, and clever story. The auditory and visual presentation is astounding, the music fantastic, and the cast memorable. I love musicals, and it's one of the wonderful perks of being in San Francisco.

Image from Wikipedia, shown under fair use.

Epiphany

In the last few weeks, I delivered seven babies. Compared to other medical students, it's modest, an average number of deliveries. I don't think much of it, the same as not thinking much of putting a few stitches into someone, picking an antibiotic, or teaching a patient about diabetes. But as I spoke to a friend yesterday about it, I realized what delivering babies sounds like to a non-medical person (she is on the opposite spectrum, a philosophy major). Her eyes widened, mouth open in disbelief and curiosity. What is the process of childbirth like? What did I do, from the very beginning to the very end? How did it feel? She wanted to know all the details, eyes like an inamorata, a grin from cheek to cheek. I realized the stories I toss around with such nonchalance and aplomb carry in it some measure of privilege, that as health professionals, we enter people's lives in unique and pivotal moments. We take so many things for granted that are quite remarkable in and of themselves. We've joined that small class of individuals who have delivered a baby, participated in a surgery, and seen somebody die. Patients trust us, they listen to us, they allow us to lay hands in order to heal. This is no light task. This is no light responsibility.

REI

We had a half day in REI clinic or reproductive endocrinology and infertility. I had an awesome time. It was incredibly educational. I worked with an excellent preceptor who demonstrated how to counsel couples trying to get pregnant. We reviewed the work-up of infertility, from sperm analysis to imaging to menstrual abnormalities. And I began to get a sense of how to decide treatments like intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection. I think equally important was understanding how to talk to couples who were frustrated with the inability to have kids. I realized the limit of our technologies; there were people who came in who we could not offer anything to. I was struck by the coincidence that the women's options center was a floor below, that there were women who already had half a dozen children and did not want anymore entering the same building as women who desperately wanted a child but were unable to conceive.

I was also able to observe an egg retrieval. An egg donor had her ovaries stimulated, and an infertility specialist removed them transvaginally by ultrasound guidance. It was a fast but fascinating procedure. I then toured the embryology lab, an amazing place where they are able to preserve sperm, embryos, and most recently eggs. They do pre-implantation genetic diagnosis, semen analyses, and in vitro fertilization. Though I witnessed our limitations, it's amazing what modern technology can offer.

Quotable Quotes

"We work in the dark--we do what we can--we give what we have. Our doubt is our passion and our passion is our task. The rest is the madness of art."

-Henry James, The Middle Years

The picture was taken by my friend Julia Hu.

Evolution and Modern Obstetrics II

There is also a very fascinating question about artificially changing evolution with modern medicine. With our C-section rate of 30%, presumably a number of those deliveries would have been unsuccessful and ended in maternal or fetal demise without intervention. Likewise, we have amazing interventions for premature infants: the neonatal intensive care unit, incubators, intubation, betamethasone for lung maturation. We can also keep many people with previously fatal genetic diseases alive longer. With modern technology, we are able to support those who would have previously died. And in doing so, if they mature to reproductive age, we are altering the substrate upon which evolution acts.

Genes that were once detrimental because they lead to a fatal genetic defect, premature birth, or inability to allow a normal spontaneous vaginal delivery can now be supported and maintained. How will this change the evolutionary trajectory of humankind? Even other advances like assisted reproductive technology put different pressures on the genetic pool than those for the last thousand years. Is this a significant change? And where will it lead?

Evolution and Modern Obstetrics I

This is an interesting concept that came up one evening on call. Why do humans have such complicated deliveries? Although most deliveries proceed easily and mimic thousands of years before modern medicine, there is the disturbing fact that the C-section rate in the United States is over 30%. Our labor abnormalities are numerous: arrest of descent, failure to progress, preterm delivery. Furthermore, newborns don't even look like they're ready for the world. They have no way of escaping predators, caring for themselves, scavenging food, or communicating effectively. A newborn human without a caring mother will die. We are incredibly vulnerable and dependent.

In comparison, animals can't do C-sections. Any sort of labor abnormality has been weeded out by evolution. They give birth just fine. And their offspring are surprisingly able. Horses walk right at birth; according to Wikipedia, a foal will stand up and nurse within an hour, trot and canter after a few hours, and gallop by the next day. A joey (newborn kangaroo) is born almost in a fetal state, blind, furless, the size of a jellybean yet is still able to crawl into its mother's pouch.

Why? Why do humans have such difficulty in labor and such vulnerability after delivery whereas animals do not? Are these issues related? One hypothesis is that humans develop a proportionally large brain in utero compared to animals. With the evolution of using hands and language, the cranium has to get larger and larger. The trade off is that if the head is too big, the mother can't deliver the baby. So here we have two opposing forces (reflecting Richard Dawkins' Selfish Gene): the fetus, who wants to develop a giant head in utero versus the mother who has to deliver the fetus before it gets too large. Thus, we get the two problems that aren't seen in animals: difficulty delivering and newborns who are vulnerable and dependent.

Poem: Guilt

The sounds in this poem came together five years ago in a jotted draft during one of my core biology classes. This is the first time I've really worked with this poem since. My high school British literature teacher taught me about the caesura, an audible pause that breaks up each line seen in Greek poetry (Iliad), Latin poetry (Virgil), and Old English (Beowulf), and I tried very hard to use that literary device in a productive manner.
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Guilt

Flee, star princess, flee from me
satchel in hand, go to the sea
stare at those waves, the starry starry waves
that, moonlit coerced, reflect the graves
of men who you loved. In this gloomy dusk
you will shell from your cocoon, shed the husk.
Look into the water, rippled and pine
finger tracing an image, running a line
that parts the sea. Walk with me
out of your stone walls, the entropy.
Sleep, star princess, sleep with me
constellation made from a plea
hand in hand, we sink together,
satchel releasing the worldly tether.

Women's Options Center

We spend half a day in the Women's Options Center which provides abortion services, education, and care to those with undesired pregnancies or pregnancies complicated by fetal abnormalities or maternal conditions. I know this is a controversial topic to bring up in a public forum. My clinic experience was extremely educational; they prepare us by providing a good review article to read about methods of elective abortion. We then follow patients through their visit. We see the counseling they get from the medical educators, their interactions with the physicians, and the preparation for medical abortion or procedure for surgical abortion. The entire experience is from the patient's perspective.

I think that it certainly helped me better understand the process of abortion. It's serious. It's emotionally intense, difficult for patients, and often involves complicated social or medical situations (a single teenage mother already with several children, a fourth miscarriage in a woman who wants to be a mother, a fetus with a chromosomal abnormality). Even medical abortion which involves only pills and suppositories, the process is not a simple one. It's educational listening to patients' questions and concerns. I think all medical students should have this as part of their education; even if one doesn't provide abortions, it's important to know what one's patients have gone through or may request in the future. I also think that those taking part in abortion debates for either side should really learn about what happens in these clinics.

Gyn Onc

I had a few days of gynecologic oncology. I spent a morning in dypslasia clinic where we reviewed Pap smears (one is shown above) and saw patients who had previous cervical abnormalities. I got to do a few Pap smears and see a few abnormal exams. The following day, I spent clinic with the gyn onc service. I realized that while the majority of obstetrics and gynecology involves generally healthy women, the oncology service deals with very ill patients. One of our patients who wanted a surgery for cancer was not an ideal candidate; she was on dialysis for end stage renal disease, had a previous MI, diabetes, hypertension, hyperlipidemia, and hypothyroidism. At her clinic visit, her systolic was over 200 mmHg. Another patient I saw had presented to the emergency department with a hemoglobin of 2.7 (normal 13.5-15) from severe menstrual bleeding. This population of patients was a lot more serious than any other patients I had seen on the rotation. I was in the OR today with two long surgeries involving ovarian tumors; we did a pretty extensive pelvic and lymph node dissection, even resecting bowel for one of the cases. I also saw a cone biopsy for a cervical carcinoma in situ. It's been an interesting and educational week.

Image from Wikipedia, shown under GNU Free Documentation License.

Being a Male Medical Student

Going into my obstetrics and gynecology rotation, there was a little apprehension because being a male medical student. How does that change things? How receptive are patients to my participation? Will I be declined as part of the health care team because of my gender or role? I think that generally, things have gone really smoothly. Although I've had patients decline my involvement, that only happens a few times a week. The overwhelming majority of patients don't mind at all, and I've felt that many have especially appreciated my role in their care (particularly on labor and delivery). Given how personal and sensitive this area of health can be, I have been pleasantly surprised by how willing patients are to having me talk to them, examine them, deliver their baby. I've also been surprised that attendings have really been trying to persuade me to go into ob/gyn.

Women's Health

This rotation has really taught me a lot about women's health. In the first two years and in the other rotations, I learned about the basic biology and medical problems that can arise from obstetric or gynecologic issues, but I never really thought about the impact on women's lives. Only after seeing patients do I realize how difficult it can be to have menstrual irregularities, to worry about pregnancy, and to deal with hot flashes. Women having surgery are young, yet face grave diseases like endometriosis or ovarian cysts or cancer. I've only begun to appreciate how difficult the postpartum course is, with mood swings, breastfeeding, waking up every hour. I'm finally getting a glimpse into the changes and challenges of pregnancy. This is a very important introduction to women's health and a fundamental part of medical school.

Poem: Deirdre

This week, I decided to return to form poetry to work on rhyme, rhythm, and meter. This is a sonnet about Deirdre, the foremost tragic heroine in Irish mythology. She was prophesied by a druid that she would have unparalleled beauty with twisted yellow tresses and mesmerizing grey-green eyes. Kings and lords would go to war over her and Ulster's three greatest warriors would be exiled for her sake. Thus, the king of Ulster had her brought up in seclusion. In the sonnet, I make an allusion to Yeats and Woods who both wrote plays based on Deirdre's story (Deirdre 1902 by WB Yeats and A Cry From from Heaven 2005 by Vincent Woods). I'm not entirely satisfied by the last quatrain and the couplet, but I am working on it.
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Deirdre

Had I but one wish, I would ask for eyes
to see beyond those stones of seclusion.
For beauty defines that visage which lies
guarded by mythology’s illusion.
Chatoyant pupils, and a voice like glass,
her tragic song crumbles wall after wall.
A last curtain call from a bonnie lass
would even Ulster’s greatest men enthrall.
Who could know that her siren lullaby
would forever sleep the men that chased her?
Entombed in tale, she could even defy
Time’s scythe, Yeats and Woods would concur.
Knowing this, I must still pursue her voice
for her greatest sin was to take men’s choice.