Adherence

Medical adherence or compliance (the less PC but more commonly used term) is the concept that patients don't follow through in filling prescriptions and taking their medications as recommended by the physician. When I first thought about this, I thought, "Who would ever do that?" After all, many drugs have double blind random controlled trials showing their effectiveness in reducing mortality and morbidity. After memorizing the pharmacokinetics and mechanisms of action and indications of each drug, I thought, "That's all I need to know." You figure out what the patient has, you prescribe the treatment, and you're done.

I have realized it's not all that easy. After being sick for the past few days, I realize that no one wants to take drugs. There are lots of reasons, most I probably haven't even fathomed. However, I didn't want to medicate (even just over-the-counter) for several reasons. It's an admission that you're sick. It's inconvenient. There are side-effects. Now, I know I will be fine whether or not I take NSAIDs. And I would assume that if I had something life threatening that could be cured with medication, then I would comply. But I can already see that it is not as easy as I originally assumed.

Drug Delivering Robots

I have to say one of the coolest experiences in Clinical Interlude was going down to the pharmacy in the basement. We got a tour by one of the managers who described the process of filling a prescription. In Moffitt, drugs are delivered by these cool air tubes. But in Long, drugs are delivered by R2D2-like robots. These robots are fairly big, with speakers, a monitor, and motion sensors. They can even sense when you are nearby, and they will talk to you. In the basement, pharmacists will load up the robots with drugs and give them instructions. Then the robots move about the hospital completely autonomously. They will locate the elevators and command down an elevator. (Since I have been asked this by multiple people, they control the elevators through some sort of electromagnetic frequency, not by actually pushing the buttons). Then they will navigate into the elevator and tell all humans to exit. They go to the correct floor and dispense the drugs for that floor at the nurse's station. It's really nifty.

Clinical Interlude II

I found that the team was structured to teach the least experienced. When a question came up, the medical student first described what she knew. Then the intern would add or embellish the answer. The attending or resident would only step in if necessary to revise the answer (or to throw in a completely random trivia fact: guttae in Latin means drops, so sometimes prescriptions have the abbreviation gtt).

The pace was fast and busy. On the first day, our team was on call and received an admission during morning rounds. The third year and an intern rushed down to the ED to admit her while the rest of us rounded on the other patients. During rounds, pagers would go off, people would make phone calls, and others would hunt down a computer to show an X-ray. Sometimes, less than half the team was paying attention to the person presenting the patient. Of course, everyone on the team was already familiar with the patient, so I was not alarmed.

The culture of medicine struck me as highly intellectual. While surgeons and anesthesiologists seem to favor procedures, the medicine service enjoys standing around and figuring out odd cases through discussion. Being able to do an effective differential and explain it was very important. The chief residents stood out during the noon conferences because they clearly knew the most. It was important to some members of the team to be able to pull out an article from JAMA or cite relevant clinical research.

Clinical Interlude I

Clinical Interlude is a nifty three-day event that happens right before winter break. In order to introduce us to hospital in-patient medicine, the school assigns the first-year students to different ward teams at UCSF affiliated hospitals. This allows us to gain a context for the material we're learning in the classroom. We also get to practice our patient-doctor skills by taking a medical history and doing a physical examination on a patient. We observe team dynamics within the hospital and interact with non-physician members of the health care team. Perhaps most importantly, we acquire some stories about being in a hospital to bring home to our families for winter break.

I was assigned to Med Team G at Moffitt (the main UCSF teaching hospital). Other students were assigned to disciplines as diverse as emergency medicine and psychiatry to neonatal ICU and labor and delivery. I loved being on the medicine team. It was a lot of fun, and I did not feel completely bewildered. I tagged along with a third-year student who was great.

I was most surprised by how easily I was integrated into the team. I felt that I was considered a member, if only for a short while, rather than an outsider observing the dynamics of the medicine service. For example, I was encouraged and perhaps even expected to contribute to the intellectual discussion of the issues facing our patients. This was a lot less intimidating than I expected. I didn’t feel bad or ashamed to say I did not know anything about the subject. The team was delighted when I would say something, and then they would politely correct whatever egregious mistake I had just made.

Happy Holidays

Warm wishes to everyone for a lovely holiday season.

Clinical Ethics

You are a transplant surgeon faced with an ethical dilemma. There is a 16-year-old child in kidney failure who needs a kidney transplant. The mother asks you to take a kidney from the father and give it to the daughter. However, the father has already donated a kidney to the daughter before (and after many years, that kidney was rejected). Taking the second one would require him to go onto dialysis and severely decrease his life expectancy. He is in jail, and the jail agrees to pay for medical expenses. The father, who is divorced from the mother, consents to the procedure, saying that he is willing to sacrifice years from his life in order to improve his daughter's quality of life. It is important to note the daughter will not live substantially longer with the kidney transplant, but she will have a much better lifestyle.

The principle of autonomy grants patients the right to make decisions (even bad ones) about their health care. The principle of beneficence compels physicians to act in their patient's best interests. Yet the principle of non-maleficence says to "do no harm." (One should point out that nearly all procedures do harm, but we weigh the benefits with the costs. A blood draw harms the patient by causing pain, breaking the skin, etc., but benefits outweigh the costs).

What do you do? The mother and the father both consented to the procedure (and the daughter assented). You want to act in the patient's best interest and do no (unjustifiable) harm. Yet who is the patient? In a transplant, both the father and the daughter are patients. You would be taking years from the father to improve the quality of life for the daughter. Is that morally praiseworthy or blameworthy?

It's a complex case, further complicated by biological reasons (if the daughter rejected the first kidney, wouldn't she reject the second?). No surgeon would actually take this case. Luckily, this is based on a true story; a relative was found to be a match and underwent the kidney transplant without complication.

"If the father wants to run into a burning building to save his daughter, he can do so, but I cannot hold the door open for him."

Patient Simulator

At the end of the cardiovascular block, we had a session with a patient simulator at San Francisco General Hospital (SFGH). The patient simulator is a "souped-up" CPR dummy. It can breathe, has pulses, has pupils that react, and talks. You can listen to heart and breath sounds and do a fairly comprehensive physical exam. They put us in groups of seven as a team to treat the patient.

I was one of two history takers. It was a little nerve-racking. Something was definitely wrong with the patient. He was very light headed, had a pulse of 120, and a blood pressure of 60/40. It was hard to concentrate on which questions were pertinent - clearly, we would not care about where he lived ("social history"), but we might care about whether he had shortness of breath. My peers did a physical exam, set up an EKG, and got the vitals on the monitor. One first-year was the fake resident who supervised us.

We took a quick time-out to discuss a differential for the patient. We came up with a plan of diagnostics and treatment, and began to administer the plan. Afterwards, we gathered in a conference room where a fourth year explained the pathophysiology of the condition. It was highly educational. In a real situation, would we have been as successful? I don't know. Though we pretended the mannequin was a real person, it's hard to picture what we would do if a real person was dying on us.

Denying Medical Care

What do you do with a patient who does not want medical care? On the one hand, he/she (as long as he is older than 18) is in control of his body. He can sign out "AMA" (against medical advice), which means that you covered your legal grounds by telling him what you suggest as a doctor, but he declines following that advice. Jehovah's witnesses are free to refuse blood and blood products, and then you do the best you can with things they might accept like saline or erythropoietin (EPO). In these situations, the patient decides what kind of care he would like.
But on the other hand, a physician can detain a person seriously contemplating suicide. We won't let him kill himself. He does not have control over his body. And if we aren't sure whether someone wants medical care, we treat him as aggressively as possible, assuming that's what's in his best interests.

Clearly, this post brings up many emotion-laden and difficult issues. Are there cases when not-treating is better than treating? How do we approach those cases? Where are demarcations to be drawn?

EMTALA

EMTALA was an act passed by Congress in 1986 which requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status, and ability to pay. This was created in response to concern that emergency departments were turning away patients because they could not pay. So now all emergency departments are required to do a basic screen of anyone who walks into the ER. In principle, this sounds like a wonderful thing. Everyone should get medical attention, especially for illnesses that can be life-threatening.

Unfortunately, this is an unfunded mandate; there are no reimbursements. As more and more people take advantage of this act (by coming into the ER without any particular problems or with minor symptoms), hospitals have sustained increasing financial costs to the point that they have to shut down their emergency departments. Waits have greatly increased in length, jeopardizing those who do have medical problems. Those without health insurance turn to the emergency department as their primary care because they cannot get health care elsewhere; however, the ER is not a primary care facility. In practice, EMTALA seems to have hurt emergency departments as well as patients requiring those services.

It's a hard line to walk. You can't deny a basic screen for someone who may have a life-threatening illness. After all, that's what emergency departments are for. However, when people start misusing such resources and when such a mandate is unfunded, it creates an incredible strain on resources to the point that the hospitals have to close their ER. I am unsure whether there is a good solution for this problem, but it is certainly something that we should be aware of.

Asymmetry

A patient has the right to choose the kind of doctor he or she sees. That is, a woman can ask for a female (or male) gynecologist. For cultural reasons, a patient may request to be seen by a doctor of a particular ethnicity. That makes sense. A patient's body, health, and illness are incredibly private things, and they should have some control over who sees them.

On the other hand, a doctor cannot refuse to see a particular kind of patient. We cannot limit our practices to a particular religion or gender or race. That makes sense too. Discriminating based on such divisions would be highly unethical. Everyone deserves medical attention and care regardless of their demographic labels.

Both of these arguments seem sound and nearly incontrovertible. Yet they create this dynamic of asymmetry which is very interesting to me. Can we find some philosophic justification of first principles for this? That is, can both these ideas in medical care be derived from one higher level principle? I haven't put too much thought into this, but it is certainly worth contemplating.

Opthalmology

For my opthalmology elective, we finished with a dissection and practicum session. It was a lot of fun. We dissected sheep's eyes, going through the motions of taking out the lens in the fashion of old cataracts procedures. It was the first time I'd ever done microdissection. The tools were really nifty. The microscope was controlled by foot levers, allowing you to move it around, focus, and zoom. We used actual surgical tools which were highly complicated. I don't think I'm particularly proficient. It took a while to get a feel for the tools and the movements necessary to make incisions or extract a lens. The professor and a resident were both incredibly helpful and encouraging. We then sutured up the incision, which was definitely the hardest part of the procedure. Everything was so small it was difficult getting the sutures through the tissues and pulling the thread through. All in all, I learned a lot. I didn't realize I'd like microsurgery so much, though I am painfully aware of how lacking I am in skill.

For the practicum, we learned to use our opthalmoscopes to visualize the retina and the slit lamps. It was tough. It was the first time the first years had ever picked up an opthalmoscope, so we really didn't know what we were doing. But with some eye dilation and trial and error, we managed to learn a little about the equipment used in the eye exam.

PBL

Over the last two weeks, we worked on a problem based case in FPC small groups. It began with a standardized patient who came in to talk about a family member's medical problem. I was the interviewer for that week. I won't actually go into any detail about the case since it's probably going to be used in future years (and we are supposed to treat it as if it were a real patient, preserving confidentiality). However, the interview was interesting for several reasons. I was talking to someone about her family member, rather than to the person himself. I had to break bad news. And the patient reacted very emotionally and was not happy. It was difficult, but I enjoyed it greatly. It was an incredibly fun and educational experience. When I was talking to the standardized patient, I really got absorbed in obtaining a good medical history; I forgot we were in our classrooms with my peers and small group facilitators. It was just me and the person I was building rapport with.

The case unfolded over the next week. In these cases, we get information about the present illness, physical findings, family history, etc. We begin to form our differential of what's going on and also discuss labs and diagnostic tests. At the end of the session, we each decide on a learning issue to research for the next week.

On the last FPC PBL, like many others, I wikipedia'd my answer. However, we had a special library session to learn to use the resources available here. I was very apprehensive at first. Not only was it a Friday afternoon, but it was about things like PubMed. Even if you hadn't used PubMed, it's easy to figure out (especially for this generation of medical students, though I will say that PubMed doesn't have the best user interface). But I actually enjoyed the session a lot. There are a good deal of other resources available through the university. Many medical texts and references can be accessed, and these will become essential throughout my training here.

In the end, we came back and solved the case. It was fascinating. While a curriculum based strictly on cases may easily leave stuff out, I feel that a curriculum without PBL lacks a connection between lectures and what a doctor actually does. Here, they equip us with many skills. We learn to work as a team, to learn from and teach each other, to answer questions ourselves, and to think independently as well as with others.

Yet Another Exam

The dearth of blogs recently can be attributed to yet another exam. Exams, unfortunately, will become a routine part of my life. While UCSF has fewer exams than many other schools, they continue on through our clinical years, through boards, and then through recertification during our careers. I am unsure how good tests are at estimating one's aptitude for medicine. Clearly, some form of standardized evaluation is warranted. However, through many, many years of test-taking, I have realized that learning to take a test is as important as knowing the answers. Raised in an exam-taking culture, you sort of realize what kinds of questions are likely to come up, what kinds of traps are usually set, and what kinds of answers will satisfy the reader. Since all we have to do is pass with a 70%, by now most students have found a good balance to our studying. I think many of us found preparing for this test to be a lot less stressful than preparing for our first one. Rest assured, we will learn everything we need to become good doctors.

A Zero Sum Game

Knowing nothing about economics, I can't say whether "zero-sum game" is technically the right phrase here. What I mean is that nearly everything done in medicine comes with a cost. In studying for my exam tomorrow, I'm looking at laboratory medicine where "shotgun screening" is not encouraged. You can't just order all the tests for every patient and see what happens. Each test is a drain on resources: money, time, reagents. Tests should only be ordered if they will change the diagnosis or alter patient care. It's easy enough to do a blood draw and send it in for "the works," but is that really cost-efficient? Is it really the best thing to do for your patient and for health care in general? Furthermore, even if all tests are 95% accurate, if you order 20 tests, one of them will come back a false positive or a false negative. I guess I wanted to point out that you can't order all the labs "just because." You have to use medical acumen to determine which tests are useful. I think many times, we automatically overestimate what we need to cover our bases, and this is not a good use of resources.

Big Pharma

Drug development is a complicated, expensive, resource-intensive process. Though pharmaceutical companies invest about a billion dollars for a single new drug (Wikipedia), the pay-off is worth it. Drugs like Lipitor (atorvastatin) and Plavix (clopidogrel) have made many billions of dollars in global sales (12.9 billion for Lipitor). However, the patent on these drugs start ticking once they are discovered, and after patents expire, cheaper (equally effective) generic drugs are allowed.

To delay the flood of generic drugs lowering the market price of the moneymakers, big pharma has entered into agreements in which they pay generic drug makers to drop challenges to patents. By offering generic drug companies perhaps a hundred million dollars, they can keep generic versions of their blockbusters off the market, effectively extending their patent by several years. In the end, the cost is transferred to the consumers. The FTC has tried to block such agreements, but last year, it was ruled that the FTC was beyond its jurisdiction.

While I cannot say legally what ought to be the case, I think this is a very interesting question and brings up one side of pharmaceutical companies that I had not considered before.

Lesson

This is a poem I wrote and submitted to the online Tabula website, part of Synapse (the school newspaper).

Lesson
By Craig Chen

To read the EKG, you have to examine
the ST elevation – that means there's an MI.
With acronyms, you can convince anyone
you know what you’re talking about, even me.

The nurses here wear make-up,
and all the doctors are available.
When patients seize, swimming up from their beds,
you wonder if they, too, have a crush on the intern.

We learn medicine from our couch
paying TIVO tuition, watching thrice married
surgeons save their ex-wife's ex-husband in time
for Southpark, another Great American Show, at 10.

You never miss an episode; in fact,
I know about the notebook with the love letters
to Dr. Cameron, jotted with suture-supple
hands, starving for validation.

You can do this, you think, as the patient
waits patiently on the screen. The only
motion in the room: the buzzing of the lights,
the sterile surfaces staring back.

How to be a Doctor

You don't have to be a genius to be a doctor. That sometimes surprises people. True, we are in school for forever. There's a lot of material to learn. Most of us are pushed to our limits in mastering all the information. You have to be not only a jack of all trades, but also a master of some. There are so many disciplines that one cannot find them all easy. But despite that, you don't have to be brilliant. Many of my classmates are, but I also have peers here whose strengths lie elsewhere: in leadership, dedication to service, the compassion necessary for a patient-doctor relationship. Doctors need to have many different skills, talents, and abilities; in some cases, photographic memory and amazing critical thinking are not the most important of these. The more I think about it, medical school is not difficult in that there aren't any concepts I'm afraid I won't get. Instead, it's the volume of information that pushes my mental organizational skills.

Shadows

After my midterm, I arranged an anesthesiology shadowing experience in the operating rooms here at Moffitt-Long Hospital. It was a great experience. The ORs here have really amazing and high-tech equipment. I saw one of the great GI surgeons Dr. Way do a laparoscopic surgery. It was impressive. With a few small incisions, the doctors inserted a camera and several tools into the patient. Guided by several screens, he pulled out part of the intestine that had herniated into the chest cavity. It reminded me a lot of video games with the sophisticated controls, the video screens, and the equipment as he used heat cauterization to prevent bleeding.

The anesthesia side was just as impressive. The anesthesiologist explained a lot of the equipment they use in the OR. I got to see many of the different physiological monitors and drugs available. He explained what anesthesiologists do to prep the patients for surgery. Anesthesiologists worry about the big picture while surgeons do their thing. They play a vital role in resuscitating patients in the case that something goes wrong. All in all, I think the OR is not a bad place to be. The complexity of procedures and cases there along with the sophistication of tools makes it quite an alluring place.

Application of Knowledge

We had our first cardiovascular test right before Thanksgiving break. I found that the questions I enjoy most are the ones involving clinical scenarios. For example, the pathology questions involved an image of a gross specimen and asked which patient would exhibit this heart: a twenty year old male living in Africa, a forty-year old intravenous drug user, or an eighty year old man with diabetes and hypertension. Or a question would describe a clinical presentation of a patient and ask for the diagnosis: III/VI crescendo-decrescendo systolic murmur at the right upper sternal border. While there were the standard basic sciences questions, the very applied questions were most fun to do.

The Big Picture

During Organs, we've been introduced to biostatistics, epidemiology, and genomics. These represent more of a big-picture view of medicine. Biostatistics is critical in helping physicians understand and interpret papers. Furthermore, it's a fundamental basis for designing not only clinical but also laboratory experiments. Epidemiology studies the distribution and determinants of disease frequency. Genomics looks at genome-wide interactions and steps beyond single Mendelian mutations to examine humans as an integration of many genes and environmental factors. Thus, we move beyond the single gene and single patient to look at the complexity of nation-wide and genome-wide health and disease.

I was initially surprised that they introduced this to us during our cardiovascular block. At first, it didn't seem to fit. But we focus our attention on papers that are cardiovascular related, and it seems to work fine. We have to learn all of this sometime, and sooner is better than later.

Pharmacology

Organs block has a considerable amount of pharmacology. It's tough. We have to familiarize ourselves with drugs, many of which have random names (except the beta blockers). We have to know their indications, their contraindications, their mechanism of action, their duration of action, and their side-effects. It's a lot of memorization. It's not unimportant since we need to know these drugs at some point, but it's not easy as we haven't been immersed in clinical practice. I trust that in time, knowing the drugs will become very useful and rattling off their dosages will become second nature.

Thanksgiving

This year, more than ever, I find myself thankful to be in good health. Health is one of those things that we all take for granted until something goes wrong. Now that I am at the intersection between health and disease, I begin to appreciate the wonders of the human body and its operation. I hope everyone has a meaningful and memorable Thanksgiving.

Labs

We have several different kinds of labs this block. For anatomy, we only have two sessions, but they were fun. In the first, we took the heart out of the mediastinum and dissected out the chambers and coronary vessels. That was really neat. While I don't find most anatomy labs fascinating, I really did like following the flow of blood through the different chambers and tracing the coronaries (sites prone to heart attack) on the outside of the heart. I dissected a pig's heart at Stanford in an introductory seminar, and I was thoroughly confused then. Now, I have a much better idea of what an actual heart looks like and the importance of anatomy in determining physiology. In the other anatomy lab, we dissected out vessels in the neck. This one was much harder; the neck is a very complex area. But it was very educational.

We also have pathology labs. We look at diseased tissue under a microscope, very similar to histology, but there's a lot less. The more exciting part, though, is seeing actual specimens. We have been able to feel the thickness of hypertrophied hearts, poke our fingers through calcified valves, and look at scar tissue from a myocardial infarct. It's immensely interesting. One of the labs, they had specimens out and we had to try to guess the pathology from simply inspecting the hearts. That was difficult, but very fun.

Lastly, we have physiology labs. These labs mainly help us solidify material we learn in class. We have taken EKG's and PV-loops on each other, helping us learn how these tests work and how they help diagnose clinical condition. That's pretty fun, though it's extremely crowded.

Quote of the Day

We have these small group coaching sessions to improve our small group dynamics. Today, one of the questions was, "What role do you think you have in your small group?" Tim answered, "Well, I suppose, I guess I would say that my role in small group is...eye candy."

Education

Some students and I had lunch with Vice Dean of Education Irby. It was an informal discussion about how we felt about UCSF. In general, comments were very positive. One of the great things about this luncheon was that I realized how much import UCSF puts into education. The curriculum has changed dramatically over the past few years, and all their changes seem to be for the better. The curricular committees listen to feedback, think of ways to improve, and evaluate other medical schools to see what works best. We might have changes in the clinical core, which will be interesting. They're saying that instead of traditional separated rotations, we'll have a more integrated approach. Perhaps you will be on call in the Emergency Department one night and you get assigned a patient. If he goes to the ICU, you follow him. If he needs radiology tests, you work with the radiologists. If he needs a kidney transplant, you learn both nephrology and surgery. There is a core group of mentors that makes sure you're on track. It's a different kind of approach and incorporates more longitudinal experience rather than experiencing disciplines separately. I'm not sure whether or when this will happen, but it's certainly interesting. In any case, they're constantly trying to improve things around here, and that's what I love about it.

Learning Patient Care

Last Thursday, my Foundations of Patient Care group went to interview an inpatient at the hospital here. We had barely said, "We are first year medical students here to talk to you about your health," when he immediately replied, "Oh, the patient doctor relationship class!" He had a big smile on his face and was really welcoming in helping our education. It turns out his wife is a nurse, and he believes doctors need to learn to interact with their patients.

At preceptorship the other day, I asked an elderly lady whether it was okay for me to take her blood pressure and listen to her lung fields. She replied, "Whatever you say, you're the doctor." I quickly explained that I was hardly a doctor, but the message was clear. By virtue of wearing a stethoscope around my neck, I had privileged access to whatever I needed in order to understand her health and illness.

On the other hand, my FPC group went to interview an in-patient once, but we were late. The patient berated us for being tardy, rightfully saying that her time was equally important as our time. She then told us she didn't want us to interview her. It was a lesson learned for all of us. We owe patients the respect that we would give our grandparents and grandchildren.

This last Friday, we had a standardized patient presenting with a cardiac illness. With a partner, I took a history, trying to catch all the possible related factors: presentation of the pain, past medical issues, behavior, family history. We then did a focused physical exam on him, listening to his heart sounds and looking at his jugular venous pressure. It was a great learning experience in how to approach a real case as well as how to talk to a patient worried about his health.

Organic Chemistry

If you condense "alpha-methyl-phenyl-ethal-amine," you get "amphetamine," exactly what it is. Pretty cool.

Electrocardiogram

We started off the cardiovascular block with the electrical activity of the heart. EKGs are amazing diagnostic tools. They are also very fun to read. While at first, the twelve-lead EKG looks pretty intimidating, after a while, you get pretty quick at determining rate, rhythm, axis, etc. I was first introduced to EKGs in research a few years ago: we took them on mice. Since then, I've grown quite fond of the little P waves and QRS complexes and ST elevations. You can really tell a lot about a patient from simply looking at the EKG. We had a physiology lab which was quite fun in which we took an EKG on a student volunteer. We also had some small group sessions correlating EKGs to clinical diagnoses.

Leap of Faith

Reading X-rays takes a leap of faith. To distinguish some of the subtleties, you have to really convince yourself that you are seeing an anatomical structure and not a smudge. It's one of those things where you see what you're looking for. If you're hunting for it, you'll find it. Otherwise, it's a polar bear in a snowstorm.

Class Show

Traditionally, the second year students put on a show for the first year students. The show this year was "The Anatomy Awards," parodying the Academy Awards (complete with the Golden Femur award). It was great! Most of it was video skits making ridiculous puns on TV shows. My favorite was "Ocean Beach - the real UCSF," a parody of "Laguna Beach - the real O.C." The show centered around some students trying to find dates to the med school prom. At one point, one of the students, the nerd, tells his crush to check iRocket/WebCT - our online message board. There, under the message board "Critical Course Info," he posted a thread, "Will you go to prom with me?" His crush replied "Yes!!!!" The next scene cut to our course organizer last block Dr. Kruidering. She said, "Oh, those kids are hopeless," and replies with a message that said, "this message board isnot fordating purposes!!!!!!!" It was hilarious, because that was written exactly in her style.

We also had a live performance of "M&N" (metabolism and nutrition), which parodied Eminem's "Without Me." It was quite good, because you really are quite empty without your GI tract. It had such bad rhymes as ATP and energy and without me. The next skit was "America's Next Top Medic," quite entertaining. The radiologist had to have a photoshoot with a blood pressure cuff, but she had no idea what it was, saying "I haven't seen a patient in years." The MC's were very good too. The finale was "Les Med," a really hilarious and talented performance which touched upon many medical student experiences, from the exciting to the dreaded. We really do have a lot of talent here.

Organs Block

This next block, Organs, hits some of the fundamental systems of human biology: the heart, the lungs, and the kidneys. We have about 6 weeks of cardiovascular, 3 weeks of pulmonary, and 4 weeks of renal. It doesn't sound like a lot, but it is. In undergrad, I took human physiology and we spent about 3 weeks on each system, and class only met 3 times a week. Now, organs is all we're doing. We're going to get a lot of it, and by the end, we'll hopefully be somewhat comfortable and proficient with its related anatomy, physiology, pathology, and medicine.

In any case, I'm very excited about cardiology. I love the heart. It makes a lot of intuitive sense; the electrical activity and mechanical characteristics are very logical and straightforward. As an undergrad, I took a medical physiology seminar and the human physiology course, so much of this is review. My research focused a lot on adrenergic receptors, so I have some grasp of pharmacology. In my research, I took EKGs on mice, looked at PV-loops, and studied the molecular basis of cardiovascular physiology. This block will be fun. I will definitely keep cardiology a possibility in the future.

Change in Blog

I have been asked whether this blog can be linked to the website of Synapse, the UCSF student newspaper. That means this blog will shortly become publicly accessible. As such, I'm in the process of moving private posts (ie. those that reference people who don't want to be in a public forum and those that have very little to do with UCSF or medicine) to a different location. In any case, this blog will remain much the same, discussing issues that get raised during my time here as a medical student.

Not All That Glamorous

I've become very aware that doctors are called upon to see things society may not find palatable. From the loose, wrinkled, scarred skin of an eighty year old patient to the purulent bleeding eye of a victim of a dog bite, we deal with things that we might, under closed doors, consider to be gross. I admit it. I know it's wrong. But I recoil when I see the effects of gonorrhea-induced conjunctivitis in babies or hear about parasites burrowing into the skin and laying eggs. I mean, I haven't even been in this for ten weeks; I haven't changed the way I look at things. I still avoid bad smells and bodily fluids.

But I know that my visceral emotion will not prevent me from treating these patients. After you dig through the fat of the ischioanal fossae of a cadaver and dissect away the plantar aponeuroses, there's not much that will completely gross you out. And when you see these patients, you really understand that they need you, and you have the training to treat them. The visceral response may even help us as physicians empathize with the patients. No longer is it a clinical infectious disease or an avulsion or a third-degree burn. Now, this is something ruining the life of the person in front of you, something wrong with their body that they hate, something that the parents are terrified will scar the child forever. When we see such disgusting, revolting, blood-and-pus-spewing sights, we should be moved, not only by duty, but by some desire to restore humanity to an injured individual.

Physical Exam

One of the exciting things about UCSF is that we learn to do the physical exam early on. They frontload taking an H&P (history and physical) so that we can participate more in our preceptorships and at various other clinical opportunities. Last week, we had an observed physical exam where we performed the entire thing on a partner in a formal setting. We had a practice with some second-years and we were observed by a fourth year, which was very useful since everyone has their own method, and we could get tips and tricks from more experienced students. In any case, the whole physical takes a while and you would rarely actually do all the steps unless it was a new patient.

But it was fun: we started with vital signs and basic appearance. Then, we looked at the head, ears, eyes, nose, mouth, and neck. A lot of that was cursory since we haven't yet learned how to use our oto-ophthalmoscopes. After that, we did a back/pulmonary exam, a chest/cardiac exam, and an abdominal exam. Lastly, we finished with a musculoskeletal exam focusing on shoulders and knees. It was very useful, and I feel a lot more comfortable if I were asked to do parts of or an entire exam on a real patient.

Closure

We recently finished the first block Prologue. Unfortunately, I do not feel that all the loose ends were resolved; we got a bit of this and that, but they haven't fit together in a big picture yet. The purpose, I suppose, of Prologue is to set the stage for the rest of the blocks, and I think they did that fairly effectively. I have a good grasp of anatomy (and supposedly radiology), cell biology (including histo/path and immunology), and molecular biology/pharmacology to tackle the more complex issues of the subsequent Organs block. The exam was very fair; in the anatomy practical, they didn't test all the detailed muscles of the limbs, but rather key concepts like the innervation of a certain compartment or the dermatomes that can be tested by poking an area of skin. On the written test, only the immunology problems were a little far-fetched. Unfortunately, per exam policy, I can't give an example of such a question. I felt that we only touched the surface of the different subjects, leaving many complex issues up in the air, to be confronted as the year goes on.

Pun Demon

In one of my electives on pregnancy and childbirth, we had a guest speaker today who has three children, all delivered through different methods. Her first was a C-section, her second was with a doula, and her third occurred in her home. She was describing her third birth: she felt her water break and was hobbling out the door to get to the hospital when she realized that the baby was on its way. They didn't make it to the car, and she had her baby on the front porch. She and her husband sometimes refer to that kid as their "step-child."

We Scare Because We Care

There were some awesome Halloween costumes today. I saw a stranger in a Captain Jack Sparrow costume that looked awfully authentic, with braided hair and jewelry, the make-up, the clothes, hat, and boots. It was quite a good costume. One of the shuttle drivers dressed up as Indiana Jones, complete with whip. When he was driving, he suddenly yelled out, "Oh no! Up ahead! There's a huge traffic jam! We'll take a detour." I'm not sure that's very Indiana Jones-like, but it was quite funny. Also, when we were waiting for some people crossing the road, he yelled out the window "Great costumes! You look just like little kids!" They were in fact, little kids.

Our class had even better costumes. Three guys dressed up as a huge yellow bottle of mustard, a matching red bottle of ketchup, and a can of Coors lite. The professor then commented that "All we need now is a hot-dog and a baseball game." Immediately, we started clamoring for the hot-dog and applauded when the fourth guy came in, fulfilling our wishes.

Then, there was a guy dressed as a hippie with a huge 80s hairdo, sparkling, glittery, and elaborate. Half-way through lecture, while the professor was answering questions, we hear this odd spraying sound in the back. We turn around and there he is, with a can of hairspray, looking into a small pink mirror, fixing it up. It was hilarious.

Christina just IMed me and said, "You'll like this. One of my coworkers dressed up as a 'cereal killer.'" I love it.

Preceptorship

We have preceptorship about once every other week. A preceptor is a physician who volunteers his time to teach a medical student in something like an apprenticeship. It's pretty close to shadowing doctors as an undergrad, except you get a lot more freedom in what you can do. This acts as a precursor for third year clerkships to get us more comfortable and knowledgeable about the health care delivery setting. Our responsibilities include interviewing patients (taking the history), presenting the patient to the preceptor, and doing physical exams.

My preceptor is in Oakland. He is an internal medicine doctor, but the day of my preceptorship, he moonlights in a retirement facility. Our patients are older, often with complicated and chronic conditions. This makes the practice of medicine fascinating. My preceptor is very nice and has done this for several years. The first day, he had me interview two patients on my own. It was quite an experience. In theory, taking a history is not hard; there's a checklist of questions you want to ask and things you want to elicit. But in practice, it's very difficult keeping track of everything; patients obviously don't present things in order, prioritize things differently, and take divergent lines of thought. Even presenting the patients to the preceptor ("a 55 year old female enter with a chief complaint of...") takes practice. But I am sure in time I will become more familiar with it.

White Coatness

Simply being in medical school, wearing a white coat, and sporting a stethoscope changes the way people view you. I noticed this the second week of school when I had to find a patient for my Patient Care class to interview. I explained that I was a first year medical student (or rather, I had paid tuition for my first quarter just a week ago). But the patients implicitly trusted me, as if I knew what I was doing, and they agreed to whatever I requested. On my first day of preceptorship, the nurse asked me if I was already to be called "Dr. Chen." Uh, no. Not even in four years. I don't know what I'm doing. And I'm fairly certain I won't know four years from now. It's a weird sensation, as if somehow I have unknowingly (or rather, without realizing it) acquired some aura or magical power. People look at me differently. They treat me differently. I'm not sure how I feel about it, but it is a transition that I cannot reverse. I do think I have begun to see the world in a different way. Perhaps the subject of a future blog.

Finishing up Prologue

After taking molecular and cellular immunology as an undergrad, I don't feel intimidated at all by the basic immunology presented in the second half of our first block (Prologue). When you first learn immunology, it's pretty overwhelming because there is a lot of nomenclature; luckily, I feel pretty good about this stuff. The other major component of this block is pharmacokinetics, which isn't too bad either. In any case, we just finished the Prologue block. Now I should have a little more time to catch up on these blogs.

Out on a Limb

The last four anatomy labs have focused on the extremities. They are really complicated, but that's in part because I have never studied them in any depth before. The arm, forearm, thigh, and leg are all divided into multiple compartments. Each compartment has several different muscles (some muscles have four words in the name: extensor carpi radialis brevis), unique innervation, and its own vascular system. The hand and foot have a range of motions, muscles, and neurovascular structures. This is very good for people in general, allowing us to type out blogs and such. But it's very bad news for medical students. I'm never going to be able to say, "I know that like the back of my hand" again.

More on Specialties

The most common question beginning med students get asked is what field they want to go into. We have no idea. Really. It's like asking freshmen what they are going to major in. They might have an idea, but it'll change. I remember having intense contemplations on deciding my majors as an undergrad, and I expect this may be even harder. However, even after just 7 weeks of medical school, I have a sense of things that interest me and things to rule out.

I have always had anesthesia on the table, though my old PI Drew has very compelling reasons why it may not be the best field in the future (surgeries are becoming more and more noninvasive that anesthesiologists in the OR will not be as necessary). I also think cardiology is fascinating. I'm drawn to fields with lots of physiology (pulmonology, nephrology) or potential to change (infectious diseases, interventional neurology). The best thing at this point of my career, I think, is the ability to rule out specialties that do not interest me at all. So far, these include orthopedic surgery (I don't find bones and muscles that riveting), radiology (I don't like staring at films), and histopathology (tissues under microscopes aren't that fascinating to me). Hopefully as we start our organs block soon, I can narrow down the fields even more.

Specialties

There are several divisions you can make among specialties in medicine. They can be surgical and nonsurgical. I don't think I want to go into a surgical specialty because they emphasize technical skills (which I may not have) over cognitive ones. They focus on anatomy of a specific region of the body. The training is longer, and there is a culture of surgeons. You can also split specialties by procedural and nonprocedural. Procedural specialties (like surgery) do technically difficult stuff; they put in central lines and Foley catheters and repair cataracts. Nonprocedural specialties include pediatrics and family medicine and infectious diseases. They see patients and do regular check-ups and are involved with a lot of the intellectual differential diagnosis. But they don't do technically challenging (and expensive) maneuvers. Finally, there's a division between patient care and non-patient care. This is a little confusing for people not familiar with medicine. All doctors are involved with treating patients, but some are more direct than others. Primary care doctors (family practice, pediatrics) are all patient care; they are the first people you go to when you have problems. Non-patient care specialties include pathology, radiology, and dermatology. These doctors will analyze tissue biopsies, X-rays, and skin disorders, but they don't have a regular cohort of patients. Sometimes the best way to choose a specialty is to decide which of these divisions plays out best for you. I think I would lean toward a nonsurgical procedural specialty, but I don't know at the moment.

Midterm

We had our first exam last week. Most people (including me) were stressed about it because there was a lot of material, and we weren't sure what to expect. In any case, it turned out fine. I thought it was a very fair test, somewhat harder than undergrad tests. There was a three-hour multiple choice section, with the distribution of questions reflecting the amount of time spent studying those topics. We also had some short answer questions, one of which was on adrenergic receptors. In the afternoon, we had an anatomy practical exam. Luckily, they had a practice practical the week before to familiarize us with the protocol. They have a large circle of cadavers, each with two flags marking organs, anatomical structures, vessels, or nerves. We have 45 seconds for each flag, and each minute and a half, we switch from station to station, frantically trying to locate and identify the marked structures. It's quite an experience. Sometimes, the body is covered such that it's not easy to tell whether it's the front side or back side of the patient, or the right half or the left half. It's definitely a medical school experience. You learn to compartmentalize things, use landmarks, and recognize structures that look different in different people. As a whole, I learned a lot, felt the test was fair, and did okay on everything.

FPC

Foundations of Patient Care is a longitudinal course through our first two years to teach us to interact with patients. It's a bit of a relief to have such a fuzzy course, but it also helps us feel more like doctors. We've been learning the medical interview and how to talk to patients. I feel fairly comfortable with most of that because of volunteering at the VA when I was an undergrad; I can deal with fairly sick patients, problems in communication, and stuff like that. However, taking a history seems fairly complicated; there's a lot to cover in a short amount of time, but with practice, I am sure I'll get the hang of it. We've started a little on learning the differential diagnosis diagnosis process (like House, MD).

The other aspect of the course is the physical exam. We've covered vital signs, abdominal exam, pulmonary exam, and cardiac exam. We'll also learn the musculoskeletal in the next few weeks. That's pretty exciting; we get to play with our stethoscopes and stuff. It's not an easy thing to do, but I guess that's why practice is so important.

Electives

The electives I'm taking this quarter include something called Medical Scholars Program. It sounds nifty and official but really, it's just an anatomy review/discussion section. It's run by second-year students and pretty useful. It's important to see different cadavers in anatomy since anatomical structures vary a lot depending on lifestyle, age, gender, etc.

I'm also taking Introduction to Ophthalmology, which is important for me since it might be a field to pursue. It's a seminar-size lecture-style class that covers a lot (in my opinion). We've done a basic overview of eye anatomy (which I know very little about) and covered a few eye diseases and disorders. At the end of November, we'll have a practical clinical skills session where we play with our ophthalmascopes and try to inspect each other's optic nerves. We'll also get to use the microdissection lab to dissect a cow's eye I believe. Hopefully by the end of this quarter, I'll know whether I want to be an ophthalmologist. One big downside, however, is that I can't spell ophthalmologist.

The last class I'm taking is a course offered in the Ob/Gyn department. I attend a weekly lecture series on childbirth and am paired with an expectant mother. I attend her prenatal visits and am also present at the birth. It sounded like a pretty interesting program (though I have no real interest in going into Ob/Gyn) and I expect I'll learn a lot. Originally, I was thinking of a more standard elective, but I decided to push my boundaries with this one.

Exam Week

The exam is this Friday, explaining why I'm so slow at blogging. Our classes have made a genetics turn and started encroaching upon fuzzy subjects dealing with behavioral and social biology (especially on race). We moved from abdomen to pelvis, dissecting much of both, which was an interesting experience. I feel like I'm less inclined to go into gastroenterology or urology. The exam Friday covers a whole lot of material and includes multiple choice questions, short answers, and an anatomy practical. We do have a dead day ("reading day") to focus on our studying. The exam is completely pass/fail, with the threshold set at a very meager 70%.

Quotable Quotes

Professor: Are there any patients in which you would not use a blood pressure cuff on the arm?
Student: Amputees.

The answer was mainly women who had a masectomy due to lymphadema and hemodialysis patients with vascular grafts.
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The professor who gave the lecture on the pelvis was so great. She not only explained the anatomy really clearly, but also threw in random jokes, as if it were a stand-up comedy set. At the end, she said, "So...yesterday, I had some problems with urination and I called the urology department here. I got their answering machine which said, 'Can you hold?'"
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In anatomy, we were looking at a prosection of the pelvis. (A prosection is a specific part of the cadaver pre-dissected by anatomy faculty to show things that might be hard to find). The problem is that a prosection is an isolated body part removed from the whole body. The second-year student explaining this said, "Sometimes, you can't tell what part of the body the prosection is from, and that can be a pain in the butt," as he pointed to prosection of the pelvis we were examining.

Talks

Like grad students, medical students develop a keen magnetic sense of free food at various talks. Pizza places must love us. I attended a panel discussion on primary care a week ago. It focused on allergy, immunology, rheumatology, and infectious disease. The lifestyles for those specialties is not bad, but the salary is relatively low. They love doing it though. A specialty like infectious disease ("fx dz" or "ID") requires someone really smart for tough differential diagnoses. It also puts the physician in a position to affect large amounts of people through policy, community health (such as HIV in San Francisco), international work, and regular patient care. Rheumatology deals with systemic inflammatory diseases like arthritis, and it's appeal for me is its systemic basis; I like thinking of the body as a whole. I remain interested and undecided about specialties. I learned a lot about the role of primary care and those particular disciplines, though, so it was a good panel.

I also attended a research presentation by the department head of Pathology here. It was a good presentation on current clinical trial issues, basic immunology, and the specific research the professor was interested in. I think that from hearing all these people, I have realized you can't do the triad of teaching, researching, and clinical medicine for long periods of time unless you don't sleep or have 30 hours in a day or something. His research was definitely interesting, and he teaches some of our core classes, so I enjoyed it a lot.

Interprofessionalism

We had an interprofessional education day last week with the schools of medicine, nursing, dental, pharmacy, and physical therapy. The goals, I think, were admirable; the theme was patient safety and teamwork. They really put on the table issues of working with different professionals, problems with hospital health care, and avoidance of medical mistakes. We got a complimentary book of "Internal Bleeding," cowritten by a UCSF professor Dr. Wachter. It explores the terrifying and shocking stories and statistics of preventable medical errors and tries to show how health care needs to move towards a system like aviation where there are very few (if any) mistakes.

The problem was our schedule that day sucked, so I was not too attentive. We went from 8 in the morning to 9 at night, though after the interprofessional education talk, we had a really nice reception with excellent food. In any case, I think the issues of working in a team, communicating with other professionals, and utilizing all resources are integral parts of health care.

Technological Dependency

Recently, my cell phone battery died. As far as I can tell (differential diagnosis), it's lost the ability to be recharged. I'm trying to get it replaced as soon as I can. What I've found out with this and the lack of Internet is that we (or I) really do live in a state of great technological dependency. I get anxiety traveling somewhere new without a cell phone. I have an itch to check my email at least once a day. It's just irritating when I lose these staple communication devices. I'm not sure how we operated before cell phones. No doubt the world was a more peaceful place.

Histo/Path and Small Groups

Histology is the microscopic study of normal cells while pathology is the study of abnormal cells. Every week, we have one or two histo/path labs (2-3 hours each). It's pretty tedious. I'm not thrilled about cell biology, and while I see the relevance to pathology, it's hard to see whether a lot of doctors need to know this stuff. A lot of people seem to hate histo/path, but I guess it's pretty cool when you finally find that monocyte when looking at a blood smear. In any case, all of this stuff is new; I didn't really do too much microscope stuff as an undergrad. I would have never guessed that I would be doing more of it as a medical student. We also have small group discussions, sort of like sections as undergrad where we work through problem sets. It's fun; I like my group, and the professor always brings in food.

Suturing

Today, we learned to do simple interrupted sutures and a simple running suture in anatomy lab. It was exciting using all the real equipment on actual fascia. These sutures are really useful, pretty much all you need to know for lacerations. I think I can do them decently, but it takes me a long time. I guess you just need practice.

Gray Anatomy

I've had two anatomy-related (scary) dreams. Also, I was eating chicken today and suddenly became very aware of the directions of the muscle fibers.

Greek Coincidence

My soon-to-be-defunct email address at Stanford was muses at stanford. My current address is on Parnassus Avenue. Mount Parnassus happens to be sacred to Apollo and home to the muses. Thanks to Rev for pointing that out.

I am the IHum Kid

Professor: Can anyone tell me what's special about buffalo lungs?
Me: Buffalo lungs have one pleura.
Rest of class: [silence]

So buffalo (and bison, incidentally) have a single pleural cavity, which means that if you shoot one arrow that pierces the cavity, their entire lung will collapse (called a pneumothorax). Nearly all other mammals, including humans, have separate pleural cavities (making up a left and right lung). So an arrow wound (or broken rib) piercing the pleural cavity will only cause collapse of one lung. I learned this freshman year from an anesthesia seminar.
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One of the anatomy texts we use (as well as most medical schools) is Netter's Atlas of Human Anatomy.
Elaine: Does anyone know if Netter is still alive?
Me: He died in 1991.
Elaine: [incredulous look]
Me: I read the preface.
Rest of anatomy group: [incredulous look]

Um, yeah.
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Professor: Can anyone name an effect of the sympathetic nervous system?
Another student: Bronchodilation (opening of blood vessels in the lungs).
Professor: [to that student] Do you know what receptor mediates that effect?
Me: The beta-2 adrenergic receptor!
Professor: [looks over, slightly annoyed]. Does anyone know another effect of the sympathetic nervous system?
Yet another student: Tachycardia (increased heart rate).
Professor: [to that student] Yes. Do you know what receptor mediates that effect?
Me: The beta-1 adrenergic receptor!
Professor: Who the hell is that guy?

Actually, the questions weren't that hard, but I had a leg up doing adrenergic receptor research for a couple years. Some people made some pretty funny comments about that incident later on.
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(The reference to "IHum kid" is a Stanford thing. Nobody likes an IHum kid.)

Foundations of Patient Care

One of our fuzzy longitudinal courses is Foundations of Patient Care. In small groups, we learn the patient interview (medical history) and the physical exam. Amazingly, by December or so, we should be capable of doing a complete basic physical (minus neurologic, breast, and pelvic exams). They put a lot of emphasis on the "touchy feely" aspects of patient care; we have to develop rapport with the patient and make him or her comfortable in a professional setting. To tell the truth, it is a welcome diversion from the regular bread and butter science lectures. But there's a lot of it. In any case, I have enjoyed my small groups were we have interviewed actual patients, learned to take blood pressure, and discussed working in a hospital setting. In October, we begin preceptorships, which allow us to work with and learn from a primary care doctor. It should be interesting.

Gross Anatomy

We had anatomy lab on our first full day of class. I realized at that point what I was in for. There was little preparation, no buttering us up for what was going to happen. It was the first day of school, and they handed us a scalpel and said, "Here are your cadavers. Go to it." As if we had an inkling of what we were doing.

Gross anatomy happens to be one of the defining experiences of medical school. Few other professions require training where one cuts apart a human body. When I came in, I had anxiety about it. Not too much, but enough. I wasn't sure how I felt about this endeavor or how to approach it. I have never been in a situation like this.

Luckily, a good friend from high school is in my anatomy group. Two other members of the group have done anatomy before. All of us are mature and professional. Roaming professors, physical therapy students, residents, and faculty help us out. It is not that the experience becomes completely detached and scientific; we appreciate that this person made an ultimate sacrifice to education, giving everything he had. I approached this exercise at first with great apprehension and hesitation. But over time, I have gotten much more comfortable.

We have, so far, dissected the muscles of the chest, back, and abdomen, opened up the abdominal cavity to locate those organs, studied the lungs and heart in situ, and examined the spinal cord. We have performed some clinical procedures including a chest tube, a cricothyroid emergency airway, and a lumbar puncture.

All in all, I am not enthralled. The experience is smelly, dirty, and slightly repulsive as you cut through tissue and reflect skin and muscle to locate organ. But I do realize that it is infinitely educational; there is nothing like looking at a real human heart with its great vessels. A book cannot teach us in the same way as this hands-on approach. I see how it is a necessary part of medical education. It has a morbid fascination, a scientific beauty, and a humanistic realism. Death takes on a new face, and as doctors, we have to recognize this and appreciate those who have made such a sacrifice. We realize that we have to distill from this experience as much as we can, since it is unique and fundamental to understanding the human body.

Courses

It is hard to explain how classes work here. While we are officially on a quarterly schedule, we operate on a block schedule involving Essential Core Classes. The blocks for first year are Prologue, Organs (heart, lungs, kidneys), Metabolism and Nutrition (gastrointestinal, endocrinology, metabolism), and Brain/Mind/Behavior (neuroscience, neurology, psychiatry). We also have a "Foundations of Patient Care" class that runs through the entire first year. These blocks aren't individuated by quarter; Prologue runs for 8 weeks, then Organs spans the rest of fall quarter and goes into the beginning of winter quarter.

In these Essential Core Classes, we take an integrated, interdisciplinary course rather than separate biochemistry, cell biology, physiology classes. In Prologue, they are trying to level the playing field (as many people have been out of school for several years or were humanities majors). Subjects that are new for me are anatomy and radiology. These are integrated with basic physiology. I am also new to histology and pathology (staring at things through microscopes). These are further supplemented with lectures on cell biology, biochemistry, molecular biology, and pharmacology. They also tell us we'll get a taste of fuzzy subjects like epidemiology and social/behavioral sciences.

In Foundations of Patient Care, we will learn how to interview patients and do the basics of the physical exam. They put a lot of emphasis on professionalism, developing a good relationship, and other warm fuzzy stuff. But we have already begun meeting patients and learning to use our equipment.

An odd byproduct of just taking this one integrated 19 unit course is that we don't have a regular schedule. Each day and each week is completely different (though there are patterns). This is because they organize classes by relevance of subject matter rather than convenience of habit. So we may have a physiology class of the pulmonary system and circulatory system. Then we may have an anatomy lab opening up the chest plate and studying the thoracic organs and great vessels. Then we may have a radiology of the chest lecture and a lab on epithelial cells. It makes a lot more sense in practice than it does in words.

We can also take electives. I'll blog specifically on all these classes in time.

'Frisco

I am growing to like the city. With the sun out and the fog lifted, I can see the bay and Golden Gate Bridge (a guess) from the anatomy labs. It's not unbearably cold, it's bustling yet comfortable, and I've felt out all the important landmarks around here. The bus system works, I can get down to Stanford when I want to, and I am enjoying life in an apartment. Things are going well.

September 11, 2006

Inevitably, life goes on. The media has started circling, respectful vultures treading the water with webbed feet, a pool that has for the last five years only been broken by teardrops and hurricanes. Some of us still live in flooded homes, sewage seeping under the doors and engorging the alleyways to peek through the windows. Others of us have long abandoned our shelters and have tried to rebuild something atop the water's reflection. But imagine this: a few of us have never ducked our heads below the water, waded the shallows, dived into the mud to look for picture frames and buried pets. A new generation emerges that will learn our shock and grief through history books. Sadly and undoubtedly, a new edition probably surfaced months after the fateful planes hit the World Trade Center. The media hound the literal and figurative blood-money, encapsulating emotion into paragraphs, soundbites. I pass no judgment for thus far, the hunters know what it is like to be victim. But what will happen when this next generation grows up? How will they feel? How can they feel? Optimism carries the winter's lantern, but I fear it may lead us down folly's path. My voice carries no accusation, but I offer these words of warning to renew a lease on the protection of our lake of memories. No whisper is unheard. 09.10.06

Thoughts from previous years can be found here on my personal website.

White Coat

Friday morning, we had our first class which was a case study of a motor vehicle accident. It was actually a whole lot more exciting than I expected, but I can't give away why because it's a surprise and I expect some people reading this might end up at UCSF. In any case, we learned a little about trauma and pneumothorax (collapsed lung) as well as diagnostic and therapeutic interventions.

My parents came up for the White Coat ceremony. Before the ceremony, I didn't expect too much. I'm not sure why, but I usually don't think these things are such a big deal. It was held at the new Mission Bay conference center (near SBC ballpark).

Everyone was all dressed up (which was nice, and we probably won't achieve that again until graduation). They had a string trio, elegant programs, and (I realize this is an odd observation) really comfortable chairs. Dean Kessler welcomed all 153 of us as people who are "willing to treat all patients equally, touch what others see as untouchable, sign up for the promise of blood, toil, tears, and sweat." Several of the other big names spoke, and I really enjoyed their comments. Unlike undergrad, the talks were all very specific to the practice of medicine and its relation to science and society.

We were then coated by our advisers, very reminiscent of grad students being hooded by their mentors. It was neat, and I was glad I didn't fumble putting on the coat. We also recited the modern version of the Hippocratic Oath, called the Oath of Lasagna (I'm not kidding, it's named after Louis Lasagna).

Afterwards, they had a very nice reception. My parents were really happy, the food was very good, and I got a lot of congratulations from the other people in my class and their families.

The Orient

Orientation was absolutely exhausting and slightly stressful, from eight to dinner pretty much all week. But it was fun meeting everyone, getting to know the campus and city, and having the white coat ceremony. At the very beginning, we had a welcome from the Vice Dean of Education and Associate Deans and stuff. One of them (Dr. Wofsy, Admissions) was very entertaining. He told a story about a kid whose dad was a rheumatologist. In kindergarten, the kid was asked what a rheumatologist was from the teacher (who didn't know). The kid answered that his dad went to the hospital every day and told people what rooms they had to go to. I was quite amused. Dr. Wofsy also had phrases like, "You may wonder how you got here, and indeed, at some point, we as faculty may wonder the same thing..." As a whole, the speeches were good; the usual inspiring, congratulatory stuff.

We had a registrar information session and an entrance financial aid thing (very boring). We got a lot of Orientation materials, including a free book on safety in the health profession. It was a little hectic, but fun. That afternoon (Tuesday), we had HIPAA training, which is incredibly dull (but, I suppose, necessary) and an introduction to the very odd curriculum here.

We don't actually have separate classes. Everyone takes this monstrous interdisciplinary essential core class, which covers all the subjects of medicine. So I won't be taking like "Biochemistry" and "Anatomy" and "Radiology" separately, but these core blocks called "Prologue" and "Organs." We were introduced to the computer system ("iRocket" = Stanford's "Coursework"). Then that evening, we went to the med student organizations fair where I signed up for way too many groups. Unlike college, medical school groups are very focused, and they all sound interesting ("Surgery Interest Group," "Internal Medicine Interest Group," etc.).

On Wednesday, we heard a little about clinical training and diversity, picked up our ID, and had advisory college lunches. Our entire class of 141 is broken up into 4 "advisory colleges" randomly. My advisers are an ENT (Head and Neck Surgeon) and an Anesthesiologist, and they seem very nice. Then, I slept through a talk on student health services and got scared by introduction to gross anatomy. Anatomy starts on virtually the first day of school! That night, we had a BBQ hosted by the alumni association, which was very yummy. Most of Thursday morning was spent figuring out technology issues like setting up internet and learning about small groups.

A lot of logistics, but at the end, I felt like I was pummeled by all the things involved in being in a new place.

Explanandum

I'm having difficulties establishing internet service in my apartment. This is the explanandum for the lack of blog. I really did mean to blog more often, and I'm sad this happened right at the beginning of medical school. Basically, I unknowingly signed up for internet through a (valid) third-party. However, that caused a lot of confusion between me, the internet company, and the third-party. They are sending someone to fix it next week. Currently, I am accessing internet through UCSF wireless. But never fear, I will catch up on blogs and all the things that have happened since orientation to the present.

Orientation Camping Trip

The first event of UCSF Med '10 Orientation was a two-day camping trip for us to meet the others in our class. It was at Huddart Park, which amusingly was near Redwood City (close to Stanford). It's beautiful with lots of towering trees, open fields, and trails. The day started early at 8:30. We drove down to the camp site; I was in the carpool with Ben, Dave (recently married), Pratheepa, and Elaine (from UNI). There, we mingled (awkward, but necessary) and had a few icebreakers. There was this pretty standard activity where we simulated a world on the ground and stood where we were from, where we went to school, etc. Stanford apparently has the largest contingent in this year's class, and we were highly obnoxious. While everyone else just said their school name, we spelled out "Leland Stanford Junior University" (some silly thing the band does). In any case, I met a lot of people; we seem like a cool and diverse bunch. One student, a capoeira expert, was a stunt double for Halle Berry in Catwoman.

We had some team-building activities in a group of 14 random students. We went around completing challenges which were really quite fun. They were reminiscent of middle school science camp. I never went to middle school science camp, but it was exactly how I imagined such a camp would be so I'm making up for lost childhood. One of the competitions had a six foot pipe open on one end with holes all along the length of the pipe. In the pipe was a ping-pong ball. The mission was to stop up the holes with our hands and pour in seven gallons of water to get the ball out. It was ridiculous; I was soaked, but it was quite fun! In another competition, we were partnered up. One person was blindfolded and the other person had to verbally navigate them through an obstacle course. Yet another required us to throw balls into buckets. In the end, we won first place! Which was surprising and quite funny. I enjoyed it a lot.

Then, I hung out with and met new people. I don't particularly like the awkward socializing, but the crowd seemed really nice. We have quite a unique group; though most people came from California schools, we had a good representation of people from all over the country and world. After dinner, two kegs appeared and people started drinking. That night, we had skits, many of which were highly inappropriate but quite funny. I didn't sleep too well due to the coldness of being outside, but it was very pretty. Our tent had a net top which allowed us to see the stars. The next morning, we had breakfast and went home. All in all, I learned the names of some people, became acquainted with many, and enjoyed myself.

First Impressions

I moved into my apartment last weekend (8/26-27). It's two blocks from the medical campus, which is very convenient. My family helped me assemble some basic furniture, clean, and settle in. Like all moving days, it was quite hectic; we were pretty rushed at the end and we didn't have a chance to pick up some staples (but I haven't needed a stapler yet). My apartment itself is quite nice and spacious (imagine, four years ago, I lived in a Lag mini-double). The kitchen, bedroom, and bathroom are pretty standard. The manager is quite a nice guy and has helped me take care of repairs and such.

Inner Sunset is unfortunately a wind-tunnel. It's foggy, wet, and cold. This reminds me of Oxford, with all the buses and old buildings and walking. UCSF is on top of a decently formidable mountain. I actually like it a lot, though it is very different from Stanford and sometimes a hassle to go outside. Several MUNI lines come very close (the 43, 6, and N-Judah) which makes it pretty easy to get around the city. Within walking distance (though not exceptionally close), there are restaurants, shops, and cafes. It's quite a nice area, and I think I will come to know it well.

Asclepion

Memories were made so we could have roses in winter. This blog is intended to chronicle my time during medical school. It's ambitious, I know, since my daily blogging from high school deteriorated to very spotty entries when I went to Stanford. However, I know that someday, I may be old and gray and want to indulge in the mindset and experiences of an earlier time.

My goal is to write at least three posts a week. I am starting on September 1, the day before orientation begins. However, I suppose I will include the events that have occupied my time since coming up to San Francisco. I am writing to no particular audience (other than myself), but I hope you find this educational, entertaining, or at the very least, a decent way to procrastinate.