1,000

This post is the confluence of three big events! First, I am thrilled to report that I matched at Stanford University Hospitals for preliminary medicine internship and anesthesia residency. I have worked with some of the faculty and residents there, and I think it will be the perfect fit for me. Like most Stanford graduates, I love the farm so very much and can't wait to go back. This next transition in my life will be exciting, eventful, and fun.

Like every other fourth year medical student in the country, I've known about the Match results for about two weeks (further blogs on that soon), but I decided to hold off posting until I reached today's blog - 1,000! This is the one thousandth blog since I began writing four years ago at the beginning of medical school. I had no idea how much work this would be, and indeed, it's been a real journey. Someday, I will have to go back and read and reflect on how much I've changed over medical school, and I am glad to have documented so much.

On a text-only XML file (standard encoding of electronic documents), this blog spans ~260 pages in print yet only takes 3MB of memory. At an average of half an hour per blog, I have spent approximately 500 hours or almost 3 straight weeks typing on blogger (with so few crashes - much appreciated). I've written or revised 95 poems or stories. Most of what I wrote was probably rubbish, but hopefully there are some gems in there. Thank you to all the readers who have taken the time to look at these ramblings and to those who have commented on my posts. You are much appreciated. Thank you to UCSF Synapse (the student-run newspaper) for sponsoring this blog and garnering readers for me. I am also proud to have made it this far without succumbing to placing ads on this blog.

I will, of course, continue to blog (I did have a mad desire to end the blog exactly on graduation at post 1,000 in an affirmation of my OCD controlling nature, but I realized as I neared this fateful number that it would not work out). And I will continue to blog through residency as well. So I thank you for staying with me and hope you continue to follow along.

The third and last event is that this blog falls one day before April Fool's Day. I did think of posting this tomorrow in some sort of strange irony that does not completely make sense to me, but I felt that it would leave my match results and this four-digit post ambiguous and wanting in substance.

Memories were made so we could have roses in winter.

Image of the Stanford postcard is from 1920, from Wikipedia, in the public domain.

Radiology

As a whole, the radiology elective was what I was looking for as a fourth year medical student. The lectures were outstanding. I learned what I will need to know next year: recognizing emergencies on films, basic interpretation, and an understanding of how to order studies. I realized there's a lot in radiology that I don't know much about, especially extremity films. While I felt competent with chest X-rays, abdominal CTs, and brain MR's, I had trouble looking for fractures and identifying bones of the legs let alone discriminating the anatomy of the wrist or ankle. Luckily, I won't have to do too much of that in the future. But the diversity of lectures from breast mammograms to radiology of child abuse to looking at lines and tubes was really a highlight of the rotation.

Otherwise, the elective was light and I appreciated the flexibility and free time. I was able to learn things on my own, relax and recuperate, and spend time with friends who may be moving across the country for residency.

From this rotation, I've gotten a great appreciation for radiologists. What they do is hard. They have to know about every organ in the body, a host of diseases, and how to efficiently work through an enormous number of studies. They even have to understand the physics behind the technology - something I haven't thought about for half a decade. I also reaffirmed that radiology is not for me. My personality simply cannot cope with sitting in a dark room without patient interaction even though I find the art of diagnosis elegant and fascinating.

Poem: Match Day

Match Day

My calves ache and I race up the hill.
Feeling like my toes are hitting
rungs of a ladder, my heels never touching.
Today is deceptive. From the window
of my apartment, I saw blue but
out here everything is black and white.
As if my eyes cut corners, left out
color rendering to save time.
A shower of floaters greet me.

Today is Match Day. Among us
it has more significance than the holidays
we forget--Valentine's, Memorial Day--
ranking just below Christmas
and other holidays where hospitals
are devoid of students. Today
we find out where we will spend
the rest of our training
and in our mind the rest of our lives.

I dreamt that last night. Right now,
my mind is a slate. Write on me Fate.
Between two buildings:
clinic and Starbucks
a promissory of light
leaves an aftertaste on my eyelids.
I am lucky to skirt that municipal bus.
Hippos are the most dangerous animals in Africa
and MUNI buses are the most dangerous buses here.

Of all the days to be hit by a MUNI bus
or almost hit by a MUNI bus
today is one in which I am thankful
not resentful.

Other Specialties

Now that all my classmates and I find ourselves heading down separate pathways for residency, it is easy for us to discount the specialties we're not entering. After all, each specialty has its stereotypes, and we'd like to think that our specialty is the ideal. But the truth is, I'm so impressed by the talents and skill sets of practitioners in other fields. Psychiatrists have far more patience than I do and identify subtleties in conversation that pass me by; emergency medicine doctors have such quick reflexes in treating life-threatening conditions of all kinds; orthopedic surgeons understand bones. I'm amazed by the diverse goals of my classmates, and I know they will accomplish things that I could never have done. And though I still think anesthesia is the coolest field, I know it cannot exist in a vacuum and I thoroughly appreciate all the other different specialties out there.

Self-Made Man

Self-Made Man by Norah Vincent was one of the best books I've read in a long time. Written by a lesbian journalist, it recounts a 1 1/2 year experiment during which the author masquerades as a man in an experiment on gender, stereotypes, perceptions, and identity. She changes her wardrobe, dons a fake stubble, and takes voice lessons to pass as a man. She then joins an all-male bowling team, frequents strip clubs, dates women, joins a monastery, finds a job, and attends a John Bly mythopoetic men's movement group.

The idea of infiltrating a different group, whether gender, race, nationality, or other demographic is not new. But this book was an amazingly frank personal account of this experience. What I appreciated was that Norah Vincent says up front that this is not a sociologic expose or rigorous study of gender, rather, it is simply what she learned. She does not make any sweeping conclusions and indeed cautions against such stereotyping.

And yet, the content and epiphanies of this book are insightful, fascinating, and possibly true. She discusses the way men interact with each other, the differences of the job interview for a man versus a woman, the restriction on public emotion men have, the internal conflicts and burdens they carry, the attitudes about sex each gender has. She does this in a surprisingly neutral manner; she does not take a feminist standpoint and accuse men of all that is wrong in the world but neither does she coddle men and say it's understandable why they behave the way they do.

What I've taken away is that gender stereotyping ("that's just the way women are") is a myopic way of viewing the world. I've gained a little more insight into why people make judgments based on gender. I've learned a little more about gender in relationships, values, communication, and sex. Furthermore, this book has a fascinating psychological insight into personal identity and its relation to gender.

Lastly, the book is humorous and edgy. The writing is fabulous. I should note the language used and situations described may be offensive to some people. But I think Self-Made Man makes for a lot of great thinking and discussion.

Image is shown under Fair Use, from norahvincent.net.

Radiology and Probability

Like every other test in medicine, radiology tests are ones of probability. This is entirely evident in the way radiological impressions are made: "chest X-ray findings are consistent with pneumonia," "spiculated breast mass concerning for malignancy." Few things in medicine are diagnostic and most tests are functions of the prevalence of the diagnosis in question along with the sensitivity and specificity of the test. The problem is that many people, especially the general public, think of radiologic tests as perfectly precise and all-or-nothing. False positives (a radiologist seeing a finding when one is not there) and false negatives (a radiologist missing a diagnosis) are inherent in tests; very few tests are such that mistakes are impossible. Indeed, a radiologist goes through many years of training and a lifetime of practice to hone those skills and minimize false positives and negatives. Yet because patients sometimes expect 100% certain, black-or-white (pun not intended) diagnoses, lawsuits against radiologists are a major problem.

I am fascinated by this because it colors radiology reports. They may hedge when they are leaning towards a diagnosis but know they may be calling a false positive. They qualify their statements when false negatives are possible ("no evidence of malignancy seen on suboptimal study"). But I think the bottom line is this: radiological findings must be correlated with the clinical picture because both change the probabilities of various diagnoses. And radiologists, like any other doctor, are not perfect.

More Continuity of Care

In July of last year, I wrote about a patient who I had cared for in multiple rotations. This woman, initially admitted for diabetic hyperosmolar non-ketotic coma, had a rocky hospital stay with necrotizing fasciitis requiring an amputation and over a month in the ICU. I continued to follow her over my rotations; on my infectious disease consult service, we gave advice regarding her antibiotics and on cardiology, we consulted on an arrhythmia she had. Now, about a year after she was initially admitted to the hospital, I reviewed a chest X-ray and abdominal CT scan of this patient on my radiology rotation.

Continuity of care is a rare thing in medical school. We partake in a wide variety of rotations in a number of different settings, and it's rare to see the same patient over and over again. And although it is unfortunate that this one patient has a myriad of illnesses and a prolonged hospital course, I think continuity was a wonderful thing for me to have. I was able to contribute on each rotation because I knew the bigger picture; once someone has been in the hospital for a year, it's hard to know what happened at the very beginning. But I had watched this patient's case unfold, I'd talked to family members, and I felt invested in this patient's care which allowed me to add perspective and depth when we looked at her CT in radiology.

Healthcare Reform

I will have to skip this weekend's poem to blog about healthcare reform. Last night, the U.S. House of Representatives passed the monumental Senate-approved healthcare reform bill 219-212 which now goes to President Barack Obama for his signature. This is really a historic change that took a tremendous effort among politicians and still has a significant opposition. This bill will extend coverage to 32 million Americans and protect those who have coverage from losing it. It is a major step to guaranteeing that medical care is a fundamental right, not a privilege of those with money especially in this time of skyrocketing healthcare costs, an aging population, and a poor economy. Indeed, health care has almost become a moral issue; how can it be ethical for such a wealthy nation to turn away citizens (and non-citizens) at hospitals and clinics because they don't have insurance? Why should insurance companies hold such power and sway over doctors and patients? Why did we as physicians abandon that cliche of "helping people" to jump aboard the ship of the wealthy who care for the wealthy? How can we just watch as patients get sicker with diseases that can be prevented or ameliorated until they have to show up at the emergency department costing us far more with intervention than prevention? How can insurance companies spend so many resources into ferreting out ways of dropping expensive patients from their plans, keeping only the profit-generating customers? So much of this convoluted system makes no sense, and it is my firm hope that healthcare reform, Barack Obama, and the politicians who made this possible stand at that pivot-point upon which we can start taking care of people again.

War Medicine

We got a talk from a neuroradiologist who went to Landstuhl, Germany and Iraq to participate in the care of our troops. Her particular interest was traumatic brain injury, but she found when she got there that she simply wanted to participate in everything. She told us it was like being a medical student again, and she loved it. She scrubbed into the surgeries, she attended on the neuro/spinal ICU, she transported patients. I had read descriptions of how medicine is practiced in the Iraq and Afghanistan wars, but this talk brought everything to life. She began with a broad overview - a geography lesson, statistics on the injured and killed, and basic nomenclature. Then she showed us pictures of the weapons used - the improvised explosive devices, the rocket propelled grenades, the mortar, the small arms and sniper weapons. She described the medical consequences of these injuries including aspects we don't think about such as infection, hearing loss, and post-traumatic stress disorder. She then showed the protective gear used by the troops - body armor, HMMWV/humvees, tanks and described how those have changed the types of injuries seen (as a result of body armor, there are few torso injuries, but many face and extremity ones). She described the triage system whereby injured soldiers get taken to forward surgical teams that are at the front lines. These teams perform any life-saving maneuvers before sending the soldiers to the combat support hospital. There, further surgeries are performed until the soldier can be flown to the hospital at Landstuhl and finally back home. Within a period of 24-48 hours, a critically injured soldier may be on an ICU-capable plane back home. This has led to a much higher survival rate, and as a result, the system has to deal with the rehabilitation of severe injuries like amputations and psychological "shell shock."

I was really moved by this talk. Medicine exists at so many frontiers and in so many variations. The types of injuries seen here are unlike any others I've seen. The disciplined high-quality care in the setting of few resources and overwhelming demand is impressive. The dedication and courage of our troops in every setting is really inspiring.

Image of a medical evacuation flight from Balad Air Base, Iraq to Ramstein Air Base, Germany in 2007 is in the public domain, from Wikipedia.

SFGH - As Real As It Gets

I'm back at San Francisco General Hospital for radiology. I've spent nearly half of this year at SFGH and it's really grown on me. When I first started here, I was a little disenchanted by the paper charting, the hallway beds, the hectic bustle. But now I love this hospital. The faculty, staff, and administration are incredibly inspiring and dedicated to serving San Francisco regardless of insurance status, without bias or judgment, with such high standards of care. And even after taking a several month hiatus for interviews and teaching, I sit in on the medicine grand rounds, I see psychiatry faculty in the hallways, and I chat with classmates, and I realize this is a great hospital. The teaching here is outstanding, the attitude is warm and welcoming, the patients are appreciative and dynamic. I am happy to be back at the General.

The two images of SFGH, past and present, are shown under Fair Use, from ucsf.edu.

The Techies of Medicine

Radiologists are the techies of medicine (along with radiation oncology and nuclear medicine I suppose). They have all the cool gadgets. In the morning, we have a teleconference between the multiple hospitals with large flat-screen monitors communicating between each site (not as neat as the picture shown above, but pretty cool nevertheless). The conference room is equipped with multiple projectors, and they have two IT people on site during the day to fix problems. In the reading rooms, residents look off three monitors at a time, dictating, scrolling through images, and pulling up patient history simultaneously. As a mild technology junkie myself, I think it's awesome.

Image is shown under Fair Use, from Wikipedia, with the attribution: Courtesy of TANDBERG Corporation. This is a Tandberg T3 Telepresence high definition conference room.

The Checklist Manifesto

I really enjoy Atul Gawande's writing, and The Checklist Manifesto did not disappoint. This book differs from his previous ones Complications and Better because it is not simply a collection of interesting stories and topics. Instead, it has a clear thesis promoting the use of the checklist. It reminds me of the previous books I reviewed, Internal Bleeding by Robert Wachter, another patient safety advocate. In this book, Gawande spreads his survey widely, looking at how top restaurants are run, how skyscrapers are built, and how international medicine is practiced. The timeliness of his book is amazing in that he describes very current events and how they played out.

His writing style is clear, engaging, cohesive, and precise. He incorporates both the dramatic narrative we've come to enjoy and the science; he describes his clinical research with the WHO and the study design in a fashion far more convincing and interesting than the medical journal article it produced. His writing is accessible to anyone, not just health care professionals.

The argument is not particularly new, innovative, or brilliant, but the way he puts it together is persuasive. He tells us what we already know - medicine is hard. It's complicated and complex, much like flying an airplane. Checklists allow a basic framework that demonstrably improves outcomes. Communication between team members is central to taking care of a patient. All of these concepts are simple, yet their implementation in modern medicine is slow and incomplete. The Checklist Manifesto explores why and how things should change.

This New York Times Bestseller and Amazon Best Book of the Month is a must-read for anyone interested in health policy and health outcomes, and it is a highly recommended read for everyone else. It certainly has changed the way I view the world. Those who know me know that I love lists; ever since college, I've made a checklist of things to do pretty much every day (and I pretty much never accomplish all the things on my list). The checklist works; I'm sold on the idea.

Image shown under Fair Use, from gawande.com

Poem: Rain

Rain

I saw you waiting in the cold,
a plastic bag over your head
and water dripping from your ears.
You offered to carry my umbrella;
it followed me around like a cloud
shedding on your face.
You shrugged and said
you were already wet--
but so was I. The storm
had gutted the umbrella long ago, and
I only carry it when I plan to see you.

Health, United States 2009

I just read the CDC U.S. Dept of Health and Human Services report on Health in the U.S. for 2009 (available free electronically http://www.cdc.gov/nchs/data/hus/hus09.pdf; brief report at http://www.cdc.gov/nchs/data/hus/hus09_InBrief.pdf). It's quite a long report, but the truth is it simply tells us what we already know:
-Life expectancy has gradually increased and racial disparity in life expectancy has narrowed but still exists; white females have the highest life expectancy while black males have the lowest life expectancy.
-The most common cause of mortality, heart disease, has steadily declined since the 1980s while the second most common cause, cancer, has remained fairly stable. Stroke and unintentional injury have declined as causes of mortality in the last few decades, while chronic lower respiratory diseases has come onto the map as a cause of mortality.
-Socioeconomic status is highly correlated with prevalence of chronic medical conditions including hypertension, diabetes, and serious heart conditions. Poverty is associated with poor health.
-The most common cause for activity limitation in adults is arthritis and other musculoskeletal complaints; other causes include heart conditions, mental illness, diabetes (in age 55-64), and senility and vision problems (85+).
-Prevalence of cigarette smoking has declined over the last few decades; more men than women smoke, but the rate of quitting for men is higher.
-The rate of obesity has skyrocketed, doubling in the last 30 years to about 1/3 adults currently.
-More people are getting vaccinated for influenza every year.
-The rate of mammography in the last two decades has increased.
-The use of MRI/CT/PET scans in the ED and outpatient settings has increased dramatically over the last decade.

Although I haven't learned anything in particular I didn't know previously, reading this report has been a good reminder of the importance of public health and public policy in improving nationwide measures of well-being, cost-effectiveness, and chronic disease management.

Staying Human during Residency Training

Staying Human during Residency Training by Allan Peterkin is a must-read for residents and residents-to-be. Written by a psychiatrist in Canada, it addresses all the scary non-medical issues for residents: anxiety, depression, substance abuse, relationship stressors, suicide, harassment, and burnout. But more than that, it covers these topics in a surprisingly scientific and evidence-based fashion; he goes beyond the touchy-feely to engage the scientific-minded reader with numbers, statistics, and studies. We learn that 30% of emergency room residents have PTSD symptoms, 37-40% of residents report problems with their spouse or lover, 31% of doctors under 40 would not have gone to medical school if they had known what they know now, and the average U.S. resident salary works out to be less than $5 an hour.

This is a scary reality. Dr. Peterkin then delves into ways of ameliorating this experience, to temper down those stresses of residency so we can focus on patient care and education. He discusses how to find balance, stay healthy, maintain good relationships, work with colleagues, learn and teach, and remain professional. I found this book to be quite enlightening and relevant to me. He writes in a empathetic, clear, and authoritative way to openly discuss residency life and how to approach it.

Image shown under Fair Use, from universityaffairs.ca.

The Waiting Game

"O time, thou must untangle this, not I. / It is too hard a knot for me to untie." - William Shakespeare, Twelfth Night.

I should jot a note about the doldrums of waiting. We submitted our rank lists for residency programs two weeks ago. In theory, the computer takes about seven minutes to run the algorithm and has already determined the futures of some 37,000 applicants. In a palpably deterministic fashion, we know that our fate - where we'll be, who we'll work with, what programs we're at, what hospitals we will call home, and indeed whether we will have a job at all - has already been established. However, the National Residency Matching Program waits about three weeks before releasing the results. During this time, they conduct quality control, check the algorithm, and prepare the internet servers for the massive traffic it will get on "Match Day."

This has made a few of my classmates extraordinarily nervous. We are on edge, we whisper where we want to go, we wonder whether to say or not in fear of "jinxing it." For some, it's all we can talk about; for others, it's the one thing we don't want to talk about. Superstition, the worst enemy of the scientist, is abundant. Some people have nightmares.

I think I understand why. Most medical students, as such, enjoy control over our futures. We like deciding things. We like knowing all the cards on the table, having all the information, and making things transparent. The whole Match process terrifies us because our futures have been determined, and we don't know. We feel helpless in the system, and whatever is given to us, we must take. There's no turning back, yet we don't know where we're headed. The unknown is a great fear for the medical student.

I am fortunate in that my personality is such that I don't worry much. So I'm trying to avoid ulcers and high blood pressure. Free will fascinates me, and I've persuaded myself not to wrestle over things out of my control. This whole situation, to tell the truth, seems unnecessarily nerve wracking, and as a result, somewhat comical, which reminded me of Twelfth Night.

Pareidolia

I love words. Radiology has reminded me of one of my favorite words, pareidolia. A type of apophenia, it refers to that common habit of seeing, hearing, or perceiving something random and interpreting it as significant. How many times have you looked at a weird cloud or listened to a song backwards and found meaning where it was not intended? Even the image shown above, taken by a NASA Viking mission to Mars in 1976 jumps out as a face, but it turns out to be a trick of the sunlight on a random rock formation.

Human psychology is wired to identify patterns, faces, sequences, and shapes even in random data. We are biased to find things, and it's more pronounced when we're looking for something in particular. We see what we expect to see. Thus, the best clinical studies are blinded. If you are conducting a study to see whether a drug does better than a placebo, if you know which patients are taking the drug, you are more likely to get a positive result. Subjects and interpreters should be blinded to what arm of the study patients are assigned to. This takes away bias.

We must keep this in mind in radiology. I am much more likely to call a chest X-ray normal if it's in a reading room rather than a lecture because I know and expect that images shown in lecture will be abnormal. I also think radiologists should know the clinical information regarding the studies they interpret. Sometimes clinicians will hold back on giving the history because they don't want to bias the radiologist. This is silly. Giving a radiologist more information only changes their pre-test probability. If they expect something to be wrong, they are more likely to identify it, especially if it is subtle. The good radiologist will then hit all the other boxes in the checklist to make sure nothing else is wrong. We see what we want to see. If radiologists know what the clinician expects, he changes his pre-test probability and is more likely to make the right diagnosis.

Image is in the public domain, from Wikipedia.

Rorschach

The Rorschach inkblot test (example shown above) is a psychological test where a subject is asked to interpret an inkblot. His response reveals something about his personality, emotional state, and thought process. What do you see in the image? What aspects of the image do you focus on? How easy is it to create a shape or figure or description? And what could this possibly reveal to an outside observer about your psychological state?

In some ways, and perhaps unfairly so, radiology to a beginner feels like an inkblot test. We look at complex images with an overwhelming amount of information and it's hard to know where to begin. What's normal? What's abnormal? Often, findings are subtle yet significant. CTs and MRIs have hundreds of slices to look through, and watching experienced radiologists scroll through this wealth of data is both intimidating and impressive.

For example, the CT angiogram above shows a life-threatening pulmonary embolus. But it can also be "windowed" (adjusting the contrast/display) to examine the bones, soft tissues, vessels, heart, and lungs. How do you pick up on what stands out? How do you know you aren't just imaging a finding in a Rorschach inkblot test?

The residents always seem to return to a systematic method to ensure they look at everything. It's really easy for me to identify an outrageously abnormal finding and forget to examine everything else in the image. I think the other element is simply practice. After looking at enough normal and abnormal pictures, the differences start to become instinct. Radiology in some ways reminds me of that game in childhood of examining two images and finding the differences.

Image of Rorschach ink blot is in the public domain, from Wikipedia. Image of the CT angiogram is also in the public domain, from Wikipedia.

Poem: Rorschach

Rorschach

Somehow we've lost the pen's scritch-scratch,
fountain trailing ink like dewdrops, blossoming texture on paper,
lost it in favor of tap dancing fingers, a piano without sound.
And in the same way, light box engineers have gone
out of service, and no one knows the satisfaction of the flick
of film, the snap of plastic, that illume of X-ray, no--
we instead camp indoors in rooms whose bulbs never go out,
in the hum of computers and dictation, the coalescence of shadow
in some challenge of imagination-- and I imagine a trickle
of breeze in this basement, a peek of sunshine through the blinds
because technology should not make obsolete that dream of lying
in a field tall as grain, making animals out of clouds in the sky.

Image of the Rorschach ink blot is in the public domain, from Wikipedia.

Radiologist as Consultant

The radiologist acts as a true consultant; physicians rather than patients are the direct clients of radiologists. Whereas nearly all other doctors see and treat patients directly, radiologists and pathologists are once removed; they take the patient's data but interpret it for other doctors. On this rotation, I've realized that this role means radiologists know an impressive amount about general medicine and surgery. Simply from images, they can generate a rich differential diagnosis of what might be going on, offer opinions on what treatment modalities may be most appropriate, and make suggestions on further studies to better define the problem. They have knowledge about every part of the body in a way that few other specialties do, from bone to brain to bowel to bladder. I've really been struck by the amount of stuff that a radiologist needs to know.

Image of a magnetic resonance imaging angiography shown under GNU Free Documentation License, from Wikipedia.

Interventional Radiology

We got a lecture from Ernest Ring, one of the true pioneers of interventional radiology. Interventional radiology is a subspecialty which involves minimally invasive procedures done under image guidance such as ultrasound, CT, or fluoroscopy. Common procedures include injecting dye into a vessel (angiogram), putting a balloon and stent into a vessel, draining an infection, biopsying a lesion, and connecting different blood vessels (TIPS). In any case, Ernest Ring is an emertius professor here who did the first embolization to stop bleeding in a pelvic fracture and the first embolization to stop a diverticular bleed. He practically defined the field, conducting the original studies on applications of needles and catheters and coming up with new ways to treat recalcitrant diseases. He watched the field blossom and change over the last four decades. I really have a great respect for history, and it was simply inspiring to hear from someone who strode into the unknown and created around him such an exciting, brilliant, and innovative field.

Image of cerebral angiography is in the public domain, taken from Wikipedia. This beautiful image of the brain's blood vessels shows an injection in the left vertebral artery and flow in the contralateral vertebral artery, the basilar artery, and the posterior circulation of the circle of Willis.

Radiology

This month I'm in radiology at San Francisco General Hospital. The radiology elective is a mix between didactics and practical reading of radiographs. We have regular daily medical student lectures which have been outstanding, focusing on relevant intern-year problems such as the acute abdomen, chest X-rays, thoracic trauma, lines and tubes, etc. Radiology has become so much more relevant after my clinical rotations. When we were first exposed in anatomy, radiology baffled me; even the basics such as right and left confused me and I simply did not have the spatial resolution capacity to reconstruct CTs in my head. But after my neurology, surgery, and medicine rotations, I've gotten much more comfortable with common radiologic appearances and studies. So now that I can make clinical correlates of the images, these lectures have much more relevance.

This learning is paired with reading room experiences where we shadow residents as they read studies. Real images, unlike teaching files, are often confusing, vague, complicated, or indeterminate. Often, clinical teams will come down to ask for help; it's always useful for me to hear the clinical presentation of the patient. So far, I've found myself reviewing a lot of basic anatomy that I've forgotten such as the blood supply of the gut. I hope this will prepare me to read my own studies as an intern next year.

Image is in the public domain, taken from Wikipedia.

Avatar

This highest-grossing epic science fiction Pocahontas story features blue humanoids and extraordinary visual effects. In talking to one of my friends, a pharmacy resident, we realized the blue skin made us think of an unfortunate side effect of the antiarrhythmic drug amiodarone which can cause bluish-slate gray discoloration of the skin in 1-3% of patients on chronic therapy. Alas, the things medical knowledge does to us.

Image shown under Fair Use, taken from Wikipedia.