Revision: About Suffering They Were Never Wrong

About Suffering They Were Never Wrong

One half of the room curt and drawn, diagrams
across parchment, labeled strings to ants
warbling into seashells and the echoing ocean,
cataloged cones of conifers, pelts of beach-strewn animals,
feathers and feathers, some plastered with glue,
hourglasses and spectacles and units of measurement.
The other side, a half-made bed, feathers spewed
from pillowcases, a doll with eyes blooming in cataracts,
an etched stool and desk, marbles scattering a phalanx
of toy soldiers, shield and spear discarded. On the sill
two small footprints where they jumped. Tell me,
could the blind prophet have known that curse?

The Financial Woes of the University of California

The economic downturn has affected everyone, but the University of California took a big hit to an already strained budget. Budget cuts always seem to affect health care (especially mental health and services for children), education (though higher education often skirts by), and corrections facilities. This year, state funding for the University of California was cut by $637 million, a 20% reduction. Furthermore, certain mandatory costs like health benefits, unfunded enrollment, utility costs, and inflation are increasing without compensation by the state. Further cuts may still be in the future as the state is projecting a $7-8 billion budget deficit for 2010-11.

This has sent University officials into a flurry. All employees have a mandated furlough averaging an 8% pay cut, and many may be laid off. However, what has really struck students is a mid-year fee increase; mine are a 24% increase. Overall, the Board of Regents voted to increase undergraduate fees by 32% next fall. Moreover, students are feeling a crunch in terms of educational services such as reduced library hours. Even doing my teaching rotation this month, I've heard how resources that we had in the past are no longer available due to the budget crisis.

I fully appreciate that this is reality and the state cannot run a budget deficit. And since I'm graduating, I'm pretty much out of the woods in terms of tuition and fees. But I cannot help but worry about the effects of this belt tightening on education. I chose UCSF for medical school because of its outstanding educational opportunities, but with the professor furloughs, the decreased student services, the lack of resources, and the overall demoralization of the University, I don't know if the quality of education which has made this place so good is sustainable. I don't have any solutions unfortunately, though I've heard proposals from online courses to dismantling research at other campuses to accepting more out-of-state students who pay more. But the state government must not forget that higher education is a responsibility whose effects are vast and life-changing. The state government must not forget that the University of California is a long term commitment and hamstringing it now for a short term benefit will lead to long term consequences that may be hard to repair.

Thanksgiving

Today, I am thankful for my education. I have been in school for 80% of my life, a remarkable investment of time, money, and labor by my parents, the public school system, a private college, a public medical school, countless teachers, professors, and teaching assistants, peers, and patients. I gripe as much as anyone else, but the persistent encouragement of my mentors has really helped me through those doors afforded by education. Very few people are as lucky as I am. Some fortunate confluence of societal, social, and circumstantial factors have gotten me to where I am now. In understanding disparities in our society today, education plays such a fundamental role. We need to advocate for those who can't advocate for themselves. Improving educational disparities is as much a part of improving health care in America as research, expanded coverage, more primary care, preventive medicine, and any of the other major health care reform concepts. Education both directly and indirectly empowers patients to take control of their lives, medical decisions, and illnesses. I am thankful for my education. Happy Thanksgiving everyone!

Behind the Scenes in Teaching

One of the other things I've realized during my teaching month is the amount of work that happens behind the scenes. As a student, I showed up to lecture and small groups and labs without any thought to the construction of the curriculum and the preparation for each session. I only had a vague idea that faculty were volunteering their time to teach, that they had many other clinical, research, and administrative responsibilities. But now I get to see the other side. All the instructors and small group facilitators get together before each small group and spend hours debating the problem sets. We have clinical faculty, basic science researchers, pharmacists, and medical students, and all of us argue over the clarity of the clinical cases, the best way to teach something, potential questions, and anticipated quagmires. The sessions are tiring but really educational. I've also gotten to see a little about the organizational side of things, and it's crazy. From scheduling a dozen rooms to keeping track of a dozen instructors all with different schedules to fielding questions on the message boards to dreaded committee meetings, the course administrators have their hands full. This has really helped me appreciate the tremendous amount of work that goes into education.

Teaching

Over the last few weeks, I've been leading small group sessions for first year medical students and teaching labs. You don't realize how much you don't know (or how much is unanswered) until you try to teach something. Furthermore, there are certain concepts like EKG axis that make a lot of intuitive sense to people with a strong math or physics background, but my challenge as an instructor is to figure out how to explain it to someone who doesn't think mathematically. I think there is an advantage to being a fourth year instructor in that I understand what background first year medical students have and I remember the kinds of explanations that worked for me. And I think the students I'm teaching have responded really well to my enthusiasm and trouble-shooting for difficult topics.

But more than that, I've been learning a whole new skill set for small group facilitation. Thrust into a leadership role, I have to figure out group dynamics, time management, communication skills, and how to cater to different learning styles. As small group leaders, we're not supposed to lecture, but instead, we're supposed to facilitate a dialogue of teaching and learning between the students. I think this is a lot harder. Some groups are dominated by that one loud person; other groups get sidetracked easily; other groups are less prepared. But the best way to learn leadership is to do it, and I think this teaching experience is really fantastic to my preparation to become a resident.

Poem: Astronaut Love Triangle

I once took a creative writing class from a short story writer of the bizarre, Adam Johnson (Parasites Like Us, Emporium). One of our prompts was to find a tabloid heading for a title; the inspiration was Robert Olen Butler's "Jealous Husband Returns in Form of Parrot." It was fantastic; I still remember writing "Aging Burglar Robs Own House." When I came across this news title, I couldn't help but scribble the phrase down, and flying to Seattle for an interview today, I got a moment to make it a poem.
-
Astronaut Love Triangle

You can't say I didn't warn you.
My FAQ had this situation:
"What to do with an astronaut love triangle"
right below "When robots take over."

Somewhere between Earth and stars
hovers that maiden of fantasy.
You send men out there to harvest moon rocks,
build satellites or talk to Martians
and soon they'll realize the only pull
in space comes from themselves.

A year and they come to know the shuttle hull
pretty well, the air lock between now and after.
Astronaut love triangle:
it doesn't follow any of the laws of our world,
doesn't obey our sublunary flails in fetters and ideals. No--
up here, strip men of jobs, clothes, families, pets,
first loves, last loves, nationalities, alcohol,
and what could be purer? Here,
in the absence of money and guns
and locations more romantic than the infirmary,
here in the absence of poetry, the undiluted
emotions perspire. Envy, obsession, infatuation, hatred--
what else could there be
in a world with only Saturn's iridescent
rings, Jupiter's hot spot, all the stars you can imagine.

The House of God

The House of God by Samuel Shem is a classic medical satire and a must-read for all medical students and residents. Written by a doctor who did his internship at Beth Israel Deaconess in Boston, it captures amazingly the brutal callousness and coping mechanisms of intern year. When I first read it prior to medical school, I was taken aback by the gallows humor, the coarse views about patients and patient care, and the ridiculous situations encountered. But after third year of medical school, I've realized that though the medical system has become much more humane since the 1970s (when the book is set), much of the underlying themes ring true. It has become a fiendishly bare yet funny expose of the medical training system.

The main themes of the book can be summarized by the Laws of the House of God as given by the Fat Man, a brilliant nonchalant resident who guides the interns through their harrowing year. Law #5 ("Placement comes first") describes how the intern's goal is to figure out how to make his service smaller and turf patients to other teams; Law #4 ("The patient is the one with the disease") describes how interns cope with the horrors of dying patients; Law #3 ("At a cardiac arrest, the first procedure is to take your own pulse") teaches interns how to approach emergencies; Law #10 ("If you don't take a temperature, you can't find a fever") warns against unnecessary tests and procedures ("Law #13: The delivery of good medical care is to do as much nothing as possible."); Law #7 ("Age+BUN = Lasix dose") captures some of the randomness of medical care.

The book captures beautifully the psychological impact this year has on the main character; with the long call nights, the dreaded patient population ("gomers" - the elderly with complicated but uninspiring medical conditions), and the oppressive hierarchy, the main characters turn to coping mechanisms like sex. They soon find their personal relationships falling apart. The book hits upon so many details of the hospital experience: minorities, the intensive care unit, needle stick accidents, autopsies, relationships with nurses and staff, clinic, medical mistakes, euthanasia, and the "lifestyle specialties" (rays, gas, path, derm, ophtho, psych).

I highly recommend this book to anyone in the medical field with a cautionary grain of salt; it portrays not the idealistic white coats that we would like our doctors to be but the filth they have to wade through in their training. Though extreme, moments ring true and that authenticity, often veiled in humor, rings a chord in me. The writing style isn't the best and the plot gets bogged down in the latter half, but it is still a worthwhile read.

Image is shown under fair use, from Amazon.com.

The Novel H1N1 Vaccine

"Swine flu" or the novel H1N1 influenza this year has created an interesting mix of reactions. Since the first outbreak in March/April of this year to the declaration of a pandemic in June to the development of a vaccine, some have become terrified of this disease and others have become terrified of the vaccine. Should we vaccinate? Is the lack of widespread equitable distribution of the vaccine a failure on the part of the government?

The vaccine is created similarly to seasonal influenza vaccine, and side effects are expected to be similar. Several trials looking at dosing of vaccine and antibody titer response have shown that getting the vaccine effectively induces an immune response against those antigens. The hope is that this will prevent transmission of the influenza virus from an infected host to an immunized individual.

However, we don't have any data that this works. The theory is sound, but there are no studies on whether the H1N1 vaccine prevents infection. Indeed, it'd be hard to design a study; you'd have to randomize people to getting vaccine and placebo and see if they make it through the flu season without getting sick. So do you believe in evidence based medicine? If you do, you have to concede that all this hullabaloo over vaccination can't really be supported by numbers. We think it works, but we simply don't know.

I fully support getting the H1N1 vaccine; I believe in the biology and immunology, and I think it works. But not having numbers bothers me. What if the vaccine isn't all that good and only prevents 10% of infections? Are we spending our money wisely? Are we rationally weighing risks and benefits? That being said, there is a study modeling the cost-effectiveness of vaccination that suggests that vaccinating 40% of a large U.S. city with a 75% effective vaccine would avert 1468 deaths and save $302 million. This would require 3.3 million vaccine doses (if one dose is effective for an adult). I'm always iffy about modeling studies, but that's the best evidence we have so far.

Breast Cancer Screening II

The meta-analysis conducted by the U.S. Preventive Services Task Force result in these numbers: the relative risk reduction of screening mammography on breast cancer death in women 40-49 is 0.85 (CI 0.75-0.96; 8 trials). Due to the lower incidence of breast cancer in this age group, the number of people needed to invite for a screening mammogram to prevent 1 breast cancer death is 1904.

Therein lies the rub. Are we, as a society, willing to do 1904 mammograms to prevent one breast cancer death? Mammograms aren't completely benign. False-positive results are very common and lead to unnecessary invasive procedures and undue anxiety. This is not trivial; biopsies and surgeries as a result of false positive tests can be extremely costly and entail their own consequences. Other issues include discomfort of the procedure, overdiagnosis, and dangers of radiation exposure.

The problem is this: any woman would rather face the anxiety of a false positive test than have cancer. Furthermore, of the 1904 women screened, if you're the one with the actual cancer, then screening matters. But this kind of reasoning leads to a slippery slope. Why don't we mammogram women 30-39? They get breast cancer too. We'd have to do more mammograms to prevent a single death, but there are potential lives to save.

Where do you set the cut-off? If we do screening mammograms on women 40-49, we pay $190,400 to save one life (based on average cost of mammogram $100). Is that worth it?

Think of how many swine flu vaccines we could buy with that amount of money. (Don't worry, my opinion on the novel H1N1 vaccine is coming soon). My opinion doesn't really matter as I'm not going into primary care. But in looking at the numbers, I think it's reasonable to be ambivalent, and either side can be defended. For me, given a patient from age 40-49, I would assess her risk factors, and absent any red flags, I'd reassure her and schedule her for a mammography when she turns 50.

Breast Cancer Screening I

Recently, the U.S. Preventive Services Task Force (USPSTF) revised breast cancer screening guidelines to recommend against routine screening mammography in women age 40-49. This is a landmark change. Previously in 2002 the recommendation was routine screening mammography every 1-2 years for women 40 and older. The USPSTF is an independent panel of experts in primary care and prevention (not including oncologists) that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This change in recommendation has garnered quite a bit of press and criticism from patients and providers alike. It is not clear-cut; the American Cancer Society and other expert panels argue against this change.

I think this is a great moment for several reasons. First, it is a bold move for the task force; how can you recommend against looking for something that kills so many people each year? Indeed, the USPSTF has remained neutral on many cancer-screening recommendations; they conclude there is insufficient evidence to recommend for or against screening for skin cancer, prostate cancer, or lung cancer. (I'm not even that ambivalent; I reviewed the literature on CT for lung cancer screening and concluded it is neither effective nor cost-effective.) But here, the USPSTF has taken a bold move, changing a previous recommendation to screen to one against it. Millions of women 40-49 have faced the discomfort of mammogram; many have had abnormal results; some have had cancers detected that otherwise would have been missed. Now, the USPSTF is simply saying stop. Don't do it. It's not worth it.

This is also a great moment because it shows that evidence is dynamic and recommendations evolve. What we learned as dogma (I'm certain this appeared on my Board examinations) changes. This is real life medicine. Nothing is certain; nothing is set in stone. As we learn more, we change what we do. Good doctors must be skeptical; they must challenge what is foisted upon them, and if new ideas persevere through those challenges, they must learn to adopt them. Research, and understanding the principles of solid research are fundamental to the practice of good medicine.

I'm going to reserve my opinion on the change for tomorrow's post. But I want to encourage you to look at the evidence. Why did they change their recommendation? Do you believe their reasons are valid? This is what I did as an undergraduate philosophy major. It doesn't matter to me what you conclude, only that you can support your reasoning. Don't use anecdote (we've all seen that unfortunate 45 year old who has metastatic breast cancer); don't use a gut feeling. Use real data. As much as you need to convince yourself. What will make someone a good doctor has nothing to do with whether they mammogram their patients 40-49; rather, a good doctor will think independently, use guidelines as guidelines, apply research to individual patients as best they can, educate the patient, and decide in a patient-doctor partnership.

Poem: Portland, 2009

Portland, 2009

Rain racing down eaves of the bus
like hair winding its way behind your ears,
and the chatter of droplets cast
white blurs over the faces - this
is what transparency is,
a city stirring and groaning
under the pressure of decompressing clouds,
weep and weep again, droplets
that sheer with acceleration
throwing motes of rainbow
through the windshield. A woman
stumbles on board, and the driver
does not press for a transfer.
Here, it is warm; the rumbling of womb
over bridge, the plumes of fog,
the soothing greens. Here, buses stop
for the biker, wheels leaving a wake,
water water everywhere.

You were never perfect,
and that's why I stayed.

900

It scares me that I'm 6 months shy of an MD. In 6 months, there will be an expectation that I know something, that in the event of childbirth, a car accident, a natural disaster, I will spring into action and make things right. If a flight attendant asks, I will be expected to stride to the front of the plane with confidence and resuscitate a peanut anaphylaxis or reverse a choking hazard. There will be a responsibility in 6 months that I act not out of self-interest but on the behalf of others, some of whom may be unable to advocate for themselves. In 6 months, my signature will no longer need a co-signature; it will have the force of an "order" and the gravity of a legal document. I will need to know when to ask for help, when to have someone double check my work, things that will not happen automatically. In 6 months, I will be responsible for a medical student in the same place I'm at now. Where will I be in 6 months? Will I be ready?

Conversations

One of the great things about interviewing for residency is the conversations with other applicants and interviewers. Talking to others allows me to gauge a nationwide opinion on medicine in general and anesthesia in particular. Most of my classmates applying into anesthesia are like me, looking to do fellowships, excited about research, interested in academic positions. But talking to those from other schools on the applicant trail introduces me to a wide array of other career goals, equally important and valid. Some are interested in private practice high efficiency anesthesia, others are interested in outpatient pain clinics, yet others are interested in regional techniques for local anesthetic blocks. Some applicants emphasize their leadership skills because of the increasing role of oversight of certified registered nurse anesthetists; others focus on their interest for one-on-one patient contact in high acuity surgeries. The other wonderful thing is getting a sense of where people think medicine and anesthesia are heading. Talking to peers, residents, and faculty from other institutions, geographical areas, and backgrounds is intensely enlightening. How do Kaiser doctors feel about the uninsured? How do county doctors think health care reform will change what they see? How do applicants feel about the programs at their home schools? Where do people think anesthesia will be in 10 years? Interviews, though exhausting, provide great opportunities for fascinating intellectually stimulating conversations.

Hand Film

I think this picture is fantastic. It's a print of one of the first X-rays, taken by Wilhelm Rontgen. The hand belongs to his wife Anna and was taken in 1895 and presented at the Physik Institut, University of Freiburg. Although the image itself might not be all that impressive, I'm astounded that just over a century later, we've transformed this into a critical medical field with rapidly changing technology and greater and greater precision. Image is in the public domain, taken from Wikipedia.

Medicare and Residency

Interestingly, Medicare also pays for residency education. Residents are the poorly paid workhorses that do the day-to-day work in hospitals and clinics. Although governmental subsidy of post-graduate training is not unexpected, the fact that Medicare covers it surprises me. Taxes collected for Medicare pay residency programs to train future generations of physicians. In 2008, 2.7 billion dollars were paid as resident salary and benefits, and 5.7 billion dollars were paid to teaching hospitals for indirect costs. Because funding has remained fairly constant, the number of residents trained is constant. However, we're reaching a point where there aren't enough doctors; patients are getting older, health insurance is expanding, but there simply aren't enough providers to see everyone. Furthermore, we can't increase the supply of doctors because Medicare doesn't have the money to do so. Even if medical schools increase enrollment (which they are), the physician supply will be limited by residency spots which, in turn, is limited by Medicare's budget. This is a strange and perhaps unwieldy system, but it seems to be here to stay.

Medicare and Money

Medicare, which provides health insurance to Americans 65 and older, will face a financial crisis. In the 2008 report to Congress, the Board of Trustees estimated that the program's hospital insurance trust fund could run out of money by 2017. This is a problem. Despite the health care legislation being discussed right now, it's not clear that government health insurance can remain solvent in the near future. Any new health care bill must account for long-term planning. Where is our money going to come from? How can we keep costs down? Can we guarantee that this major health care overhaul will remain stable in the future?

I feel that a solution to health care must encompass wide-reaching policies in different fields. For example, to keep Americans healthier and control costs, we need to target chronic diseases that are rising in prevalence like diabetes and obesity. To make headway on problems like that, we need to step out of the health care box and push for policies in other arenas. For example, how much does the government subsidize commodity food products like corn? Food companies have a huge incentive to produce corn products including high fructose corn syrup because the infrastructure and government favors this. But high fructose corn syrup products, fast food, soda, indestructible sugar-laden foods are all responsible for driving up our health care costs and increasing the prevalence of obesity and diabetes in children. If government is to take a stance on health care costs and if we are leaning towards a role of bigger government influence, then it needs to subsidize fruits and vegetables, not candy and chips. We need to favor local small markets rather than multinational corporations.

In the same way, we need to figure out how to prevent people from starting to smoke; prevention is a lot easier than intervention, and cheaper. There is a fair amount of research and a number of medications that help people quit tobacco, but what we need is research figuring out how we can stop people from starting in the first place. If we want to keep health care costs down and people out of the hospital, we need investigate how people make those personal choices.

We don't want to tell people what to eat or how much to exercise or whether they can smoke or not. We don't want to interfere with their personal decisions and free will. But if we're serious about taking on the responsibility of health care and if our funding is not inexhaustible, we need to put pressure on people to stay healthy.

How much money do we spend on mammograms and prostate cancer screening? How much money do we spend on getting kids to eat vegetables and exercise? Which, in the long run, is most cost-effective at increasing health? I don't know what the answer is, but I want to suggest that if we take a stronger stance on prevention, even if it means more government, we can get people to be healthier and perhaps save on our health care costs.

Art II

Why write? For me, writing provides a necessary outlet to organize in my head and express the complex emotions, unfamiliar situations, and difficult moments that are inherent to medical school and taking care of sick people. Blogging every day, even if it is not directly about my day-to-day experiences, allows me to decompress about the faults in medicine and brainstorm on ways to fix it. More and more, reflection is seeping into medical education, but I am not sure it should be universalized. Reflective writing works for me, but that doesn't necessarily apply to everyone. By now, most students know how they deal best with stress; writing is only one of many ways to let that out.

But stories and poetry are also more than that. Narratives are how we describe the world. No matter how hard science tries to sterilize or objectify medicine, it remains in a world of human experience. Each patient and her illness unfolds as a story over time. Each patient will tell a unique story, if only we listen. Stories are a dynamic, probing, and interactive art form. They challenge readers, create worlds, stimulate imagination, and confront human emotion. Underlying each different perspective is some unifying shared human experience, allowing great stories to speak universally.

In any case, art is important. What we create in this world lasts. Why do doctors take care of the sick, prevent patients from dying, try to extend quality of life? So those people can live and create and love. We are not an end in ourselves. We exist to support those human activities that create art, build community, push the frontiers of discovery, and celebrate humanity.

Art I

What happened to art? I used to play the viola and read voraciously. At one time, I studied philosophy, loved history, enjoyed musicals and plays. Now, I surround myself with textbooks and charts and Internet follies. For the last four years, medical school has dominated my life, and now I'm trying to push back. I think the path of the medical student funnels us into greater and greater specialization until we lose perspective of what's important in this world. For some students, residents, and attendings, medicine is what they do; they have precious little beyond that. But I refuse to fall into that trap; I fight to keep writing blogs and stories and poems. Before bed, I read for fun. The dance group I'm in reconstructs historic dances from the Victorian and Ragtime eras, complete with costuming. My nightstand has novels stacked on them; some even have bookmarks at a respectable distance into the book.

Here's the problem. There's a considerable amount to learn to become competent in medicine. The premed curriculum gets larger each year. Medical knowledge is expanding at an exponential pace; textbooks are being constantly revised, and by the time one edition is published, it's already out of date. There's an infinite amount of information to learn, and for those interested, an infinite number of questions to be investigated. Medicine is a black hole of erudition to which great clinicians and academics disappear. It's wonderful, it's fascinating. I signed up for a life of learning and I love it.

But what about everything else? How much of our lives outside medicine do we sacrifice? I have a dozen ongoing projects and ideas for a dozen more. Here is one project that has been on indefinite hold. I first started learning to code in elementary school on the operating system Turbo BASIC (sixth grade) and moved onto coding on the TI-83 graphing calculator (ninth grade; calculators were perfect because your math teacher just thought you were working) to C++ (junior year of high school) to Java (senior year of college). I love programming; I love thinking of cool applications to write and putting them into action. I could have easily gone into computer science. I still have a ton of ideas to try, and I tell myself when things get less busy, I'll open up the old compilier. But up until now, things have just been too hectic. Perhaps this year, with the flexibility of fourth year scheduling, I can start again. It takes a little impetus, but it's important. "But at my back I always hear / Time's winged chariot hurrying near." That, of course, is from Andrew Marvell's "To His Coy Mistress", and tomorrow's post will be on poetry and writing.

Medical Education

It seems to me that medical education research is a fairly new field, but it's very interesting. We have to learn a little about how to teach small group sessions so I've been reading some articles. Although these articles are older, they appear to be expert opinion. Only recently has medical education trended towards evidence-based research, but I really don't know much about how medical education research works. Nevertheless, it seems that medical schools are moving towards small group problem based or case based learning. Indeed, when I was applying to medical school, that was the big difference between medical school curricula; some would be "traditional" lecture heavy environments while others encouraged student teaching in a smaller setting. Personally, I think different students have different learning styles and no single model of teaching works for everyone.

In interactive case-based sessions, students work through a hypothetical patient case to discuss diagnosis, pathogenesis, epidemiology, and treatment of a disease. It's great because students see how information is applied to clinical medicine. What's interesting to me is that pre-clinical curricula are emphasizing this style of learning, but clinical didactics still remain lecture-based. In my third year rotations, nearly all my teaching was done by lectures even though third year of medical school is about learning to think through patient cases. I'm not sure why that is. Perhaps lectures complement the case-based learning we're already doing, or perhaps, medical school education changes are trickling down and will soon reach third year didactics. To tell the truth, my favorite third year teaching sessions involved cases where my classmates would present a case and we would discuss how we would manage those cases. Because of our greater clinical knowledge as third year clerks, those discussions tended to be much richer, more thoughtful, and more educational than a passive lecture (especially since third year rotations are so tiring).

Teaching

I'm actually teaching for the next month. Fourth year is quite flexible and we have opportunities to teach, do research, or go abroad. I will spend a total of two months teaching; right now I'm a small group leader for the first year medical student cardiovascular block. It's fun. I feel that attempting to teach something helps me know how well I understand things. Today, I spent the entire day (from 9:30 to 7pm) teaching an EKG lab. We went through the basic science of electrical dipoles, vector math, and Einthoven's law, and then we took EKGs on students. Leading multiple sessions really helped me recognize various ways to effectively teach difficult concepts and work with the range of student learning styles. I also try to get the first year students to teach each other since I think that is a very important skill to learn. I'm a small group leader for physiology, pharmacology, and medicine. Not only is it fun to review stuff I've forgotten (all those channels creating the action potentials) but it is a great opportunity to work on leadership, presentation, and communication skills. We get very good training and preparation sessions from the session coordinators. I'm really looking forward to it.

Anesthesia in Rhyme

Perhaps I'm seeing things, but I notice anesthesia references everywhere, from early 20th century poets to contemporary rock bands.

"Let us go then, you and I, / When the evening is spread out against the sky / Like a patient etherised upon a table" - T.S. Eliot, "The Love Song of J. Alfred Prufrock."

"And well, he's on the table / And he's going to code / And I don't think anyone knows." - Third Eye Blind, "Jumper"

Poem: Buenos Aires, 2005

Here's another 31 word poem, written on the plane.
-
Buenos Aires, 2005

The gaucho entwined your leg over
mine in a manner that seemed
anatomically impossible.
Like wind over roses, you dipped another
two inches. Cowboys stamping
heartbeats as you let go.