Annnnnnd.... Cut.

I am now officially a MS2.

Pretty wild.

Game. Set. Match.

No med school blog would be complete without a requisite end-of-first-year sappy reflective post. Since I know my friends love reading my entries where I get all gushy and sentimental (Hi Kate!) I figured it would be a disservice to not add my 2 cents to the plethora of bad advice on the internet. With my final exam lurking in 5 days, I figured now would be a great opportunity to procrastinate, put on some Coldplay, mix up a cosmo, and look back at myself 10 months ago (and laugh).

So, without further ago, I now present my 5 pearls of wisdom garnered along the way of the past 290 day endeavor in masochism known endearingly as MS1 (© 2008 for a future book deal, of course):

1. You will fail.
Maybe not literally, if you successfully claw above that 70% line every test, but you will fail. You will study your ass off for an exam and do significantly worse then you expected. You will make an idiot of yourself in front of a patient. You will inevitably do something that makes you turn a color of red so bright it has not existed in the world outside of a Crayola crayon box (see Torch Red).

But there is hope. Luckily, the admissions departments at medical schools do a superb job of selecting perfectionists with abnormally tight external rectal spincters and the moments of failure will become your moments of greatest insight and learning as you sadistically mull over your mess ups. Some of things that I will never forget from MS1 due to my own incompetence include how to feel for the PMI on a well endowed woman (BACK of the hand, do not cup the breast!), the many ways that steroids will destroy your body (that you don't hear about on ESPN), and the fact that the femoral nerve is lateral to the artery (stuttering is not a recommended method of answering a question when pimped). Love the failure, it's good for you.

2. You will have doubts.
Everybody is a happy, fluffy cloud of optimism when they start medical school. Unfortunately, fluffy clouds can quickly become rain clouds (wow, did I really just type that?) There are times when medical school sucks. But it's important to realize that everything in life sucks sometimes and you are not experiencing a phenomenon unique to medical school. Everyone does it differently, but one of the most important things you can do in your medical career has absolutely nothing to do with studying tip & tricks or learning to differentiate rales and ronchi or buying out the pigs feet at Fred Meyer to practice your running line stitch. The most important thing you can do to get ahead is to find something that keeps you happy. Join a pottery group. Train for a half marathon. Go to a strip club. It is those things that will make you a better medical student, since no one likes interacting with a thorny burnt out wad of pessimism all the time.

Best advice I got from a physician this year: "Make sure at least one good thing happens to you every day."

3. You will complain.
Unfortunately, medical students come off as very negative people at times to our friends and loved ones, since one of the most effective and easy ways to let out your stresses involving school is to bitch and complain. I was catching up with a friend the other day and explaining my 10 year roadmap, stating quite truthfully and rather sarcastically that I have 3 more years of medical school where I'm "everyone's bitch," following by 1 year of internship where I am "everyone's bitch... but the medical student," following by x years of residency where I am "everyone's bitch... but the medical student and intern." After finishing all he says to me is "so you wish you didn't go to medical school?" I've loved medical school so far, and don't regret my decision for a second, but can see how that can be lost on others behind the Wall of Bitch.

So, learn the art of complaining. Embrace it as a part of you. But remember when you're done complaining that you are going into a career thats pretty sweet too.

4. Make friends not enemies.
Your classmates are pretty cool people. And thankfully we are kind of self-selecting to be generous and helpful. Same goes for most people you interact with in health care. Your life can either be miserable or awesome depending on how you choose to interact with others. Sure there are bitter and evil classmates, nurses, attendings, information desk receptionists, and patients lurking out there in the shadows, but if you let them make you miserable, they win. [Insert corny Star Wars analogy about the dark side here]. Be nice, it pays off way better then being an asshole.

5. You will love it.
Medical school is really cool. You get to see and do things 95% of the population would never dream of. You get to visualize the human body in ways you never would think possible (tangent: people watching becomes really fascinating when you play the What Disease Do I Have? game). You will be continually challenged and rewarded for your efforts. Yup, most of that crap you rambled on about in your AMCAS personal statement is true.

It even has my skin tone.

I am a medical student. A big, bad learning machine. Well adapted to its environment, with skills honed at survival. That is, until the end of the year workload comes, and bites my fucking head off.

***This post in tribute to the infectious disease block we are currently slogging through, aka "101 things you do not want growing in your body" aka "I am never traveling to anywhere outside of my apartment again"

***This post also in tribute to the 5000 visitor milestone I just passed. That's cool. So are people who visit this lame blog.

***This post also in tribute to the 4 other posts I have started but not finished. I look forward to the day when I have sufficient motivation to finish them. That day is June 14th, or the mythical "summer vacation" I have heard about but lost hope in long ago.

Super Hyphy

So we just started our micro/infectious disease block, and blew through all the fungal infections in 3 lecture hours. Which included such vividly lovely descriptors such as "grainy exudate," "cauliflower-like," and "versicolor lesions."

These lectures are mind-numbingly boring, especially right after an exam. Yet, even in my fungally induced coma, I noticed there seemed to be an unwritten law amongst mycologists. For every disease of the fungus, thou must havest four slides:

Firsteth, thou must haveth a slide that talks about how common this fungal infection is and how important it is that you learn it. (BS)

Secondly, thou must haveth a slide showing a highly advanced form of the fungal infection in attempts to gross out the students. (BS)

Thirdly, thou must haveth a slide talking about Amphotericin B. Complete with requisite "Amphoterrible" joke. And a tiny aside about the azoles and how they are actually the mainstay of treatment. (Not really BS, but redundant)

And fourthly, thou must haveth a slide showing a KOH prep or biopsy slide. (see right)

Now along with every microscopy slide must come the following remark: "If you were a good mycologist, you could differentiate the species based on this slide." There are two things wrong with this statement (I'm big into lists today). One, I am not a good mycologist. Two, I have no desire to ever become a good mycologist. In fact, the odds of even one person from our class of 126 becoming a "good mycologist" are well below .500.

But I digress. Maybe we should be more appreciative of our mycologists. After all, when it comes to deadly systemic fungal infections, there isn't mushroom for error

...

I'm sorry that was in spore taste.

GUNNER!

I'd like to thank Dr. Loriaux and The Follies for a roasting good time last night. It was a lot of fun. And I want to assure my readers, no worries. This blog will always include 100% melodramatics and 100% douchebaggery. I accept no substitutes.

The First Mailbag

Well, this post was supposed to be a mailbag responding to questions for me posed by you, the reader. But since my readers seem to be the creepy type of people who like to watch me and not interact at all (Editors Note: I now know the reason behind this, and think that people missed out on a prime opportunity to bait me into embarrassing questions. I think my anonymous readers are now my favorites), I did a little work and fabricated my own mailbag, gleaned from questions that have popped up in the comments the past 9 months.

"On your surgery rotation, you should, at least once, do a perfect imitation of The Todd from Scrubs."

This is a moment I have dreamed of for a long time, namely because it combines three of my favorite activities, namely: (1) being rediculous (2) wearing scrubs (3) fake tattoos. I will sacrifice 1000 pre-meds before my surgery rotation so that I may draw a cool enough resident to let me do this my 3rd year.

Speaking along those lines, and this is too good to make up, but there is a general surgery resident at our university hospital who wears sleeveless scrubs. Which makes me wonder... can you even BUY sleeveless scrubs? The almighty google says no, which means this resident had to have made his own. At what point did he think this was a good idea? Surely he had to have had a moment before he first put scissors-to-scrubs where he thought "is this fashion forward?" Knowing my luck, I'll probably have to work with this resident during my surgery rotation. Then again, that would give me a prime opportunity to take my Todd impression to the next level. After all, imitation is the highest form of flattery.

"Wow this looks really hard. how do you do it?"

I was going to type out this elaborate response talking about inner strength and resolve and seperating the wheat from the chaff, then I realized that I'd be bullshitting not only you but myself. It's nothing even nearly like that.

You ever watch Fear Factor? Those people do some CRAZY stuff, and they do it all for money. I mean, 95 out of 100 contestants would tell the show host to eff off if they didn't have that money prize to make them compete (note: there's always one person a season I believe has a certifiable psychological disorder and would do it even if the prize was belly button lint). Well, med school is a lot like that. We have this nice enticing prize at the end (doctorhood) and as a result we reduce ourselves to the intellectual equivalent of eating cave spiders, showering in calves blood, and massaging alligator testicles (and, ironically, these comparisons are not that far off of REAL actual experiences we have in medical school!) I think that's what it comes down to... the delayed gratification. Though I guarantee you there's at least one person in my class who is that one crazy person who would do it anyways.

"Wow. That's a lot of drugs. What are your classmates like?"

Now this is a dangerous question, because I know some of my classmates read this blog (788 hits from the Portland metro area. I may check my blog a lot, but I'm not obsessive-compulsive). But there's no way I'd bad mouth my classmates anyways, since they are all great people. But I think one specific scene helps to epitomize the dynamics of my class to a T.

We had a prom. Yes, a med school prom, at a local Irish pub (yes Kells!) which I frequented perhaps a little too much over the summer. At one point, I was standing on the side, watching the dance floor (yes, closet wallflower here) and realized exactly what the scene struck me as. It was a perfect mix of a 6th grade Catholic school dance and and a thirsty thursday dollar beer night down at the local bar. There was this crazy tension between the social awkwardness and the alcohol-induced social lubrication. And one of the most hilarious dance circles I've ever seen in my life. So that's my class, a bunch of drunk 12 year olds.

As a side note, I knew the bartender who was serving drinks at the event and was talking to him for a bit. At one point, he made the observation "you sure are here a lot more than any of your classmates." Yup, that's me. Not just a drunk 12 year old, the drunk 12 year old who's a regular at the down at the local irish pub.

"What happened to you?? have you fallen into the black hole of med school?? no new blog in almost 2 weeks! What's the deal?"

My weeks long absences from posting can be attributed to one of three reasons. First, med school is incredibly busy. 90% of the time, you feel behind on the material, and your schedule is so regimented and scheduled out that when the time comes for me to have "me time" it's midnight, and I have to be up in 6 hours. Especially if you even attempt to do other medically-related things outside of lecture like go to talks or shadow on the wards or in clinic. Second, med school breeds apathy. The times I do have some free evenings, I have an overwhelming urge to do crap like watch trashy reality television or drink a beer or log on to facebook for the 15th time that day. Third, med school sucks every bit of creativity out of my soul. When your life consists of memorizing boatloads of uninteresting facts and enzymes, your brain shifts into this robotic analytical state where things like "humor" are so counter-intuitive that I feel like it would be plain cruel to expose people to the thoughts going through my brain the majority of the time. Trust me, you don't want to hear lame jokes about lame proteins as much as I don't want to type them.

"what's new?"

My shoes are new. I bought them online a couple weeks ago. That is the newest thing in my life. Well, besides the milk in my refrigerator.

This is my lazy post.

The last week has felt about as mundane and routine as medical school can be. I am sure there are some hidden insights and jokes in there, but I'm too busy just cruisin' along to notice I guess. So, this is my opportunity to poll you, my wonderful 13.8 unique visitors a day, about what you want to know. The question box is now open:

MedZag: Socially Isolated, Unloved Medical Student

So we recently had a series of sessions on "breaking bad news." The scenario we focused on was trying to tell a woman that she had leukemia - the crux of the series being that from the moment you break the bad news, Joanne goes from simply being "Joanne" to "Joannne: Leukemia Patient," until the point she becomes "Joanne: Leukemia Survivor" or "Joanne: Leukemia Victim." She will never be able to remove herself from that moment when the word "leukemia" comes out of your sorry mouth. It will forever come to define who she is and who she will be, and be a part of her from that moment on. Truly thought-provoking stuff. With all the reverence given to such a serious subject, I began to think of other correlary conversations that are equally life changing:

"Mom and dad, I'm gay."
Jenny goes from being "Jenny" to "Jenny: The Black Sheep"

"I'm sorry we didn't tell you sooner Betsy, but, you're adopted."
Betsy goes from being "Betsy" to "Betsy: Unloved Child"

"Joe, I love you." "WTF Brock?!?"
Joe goes from being "Joe" to "Joe: Object Of Man Crush"

"Suzie, I have something to tell you. Your mother, she is also your sister."
Suzie goes from being "Suzie" to "Suzie: At Risk Of A Plethora Of Consanguinous-Related Genetic Disorders"

I could offer some real and meaningful insights now about the difficulty and anxiety associated with difficult bad-news conversations, but for now I think I'll just ride the funny wave.

Because I Can't Treat Myself

So I've been pretty sick this week. I attribute this to a conversation I had on Sunday about how it was remarkable I had escaped the winter unscathed by any illness, the karma gods hearing my brash comments, and proceeding to strike me down with an acute upper respiratory tract infection.

Now being sick sucks, but being sick in medicine seems to step beyond that... it's almost taboo. Part of it makes sense, I guess - akin to a Banana Republic employee showing up to work in 10 year old sweats or an interior designer having an apartment that looks like it's a bachelor pad from the mid 70's (though I guess retro is in these days, or so my cosmo tells me). There seems to be a perception, even subconsciously held by health care practitioners, that since we deal all day with studying and treating sickness, we should be able to avoid the black magic we conjure. There does seem to be some truth to this. As a gross generalization, people in medicine seem to be much more vigilant about taking the vitamins, washing the hands, and living healthy than the general public. Maybe its a self-imposed responsibility. Maybe its hospital protocol. Maybe its expectations that in medicine we have too much to do, too much work to afford the time to give our bodies time to heal.

But being sick still sucks, and really is unavoidable in the grand scheme of life. Trying to focus your mental energy on learning the clotting cascade simply does not seem to mesh when your body is focused on fighting an infection. And my preceptor seemed almost offended that I would not be able to report to clinic because I was under the weather. Who cares if I was going to be around immunosuppressed children and could at any moment break into a coughing fit that would deposit my right lung onto said child's face? How dare you be sick. I've heard grand stories of physicians battling through their illnesses. Residents taking call with a nasty case of gastroenteritis - running to the bathroom in between patients. Surgeons operating days after having an MI. It's admirable, and I'll probably be guilty of similar shenanigans in my lifetime, but also strikes me as kind of stupid. What if that resident makes a stupid mistake because the acidic taste in their mouth haywired their brain function? What if that surgeon goes down in the OR with a recurrent MI from pushing too hard when their heart is too weak?

I guess it comes down to the age old debate of where one's responsibility to their patients clashes with one's responsibility to their self. Most would argue your allegiances lie primarily with the patient. Most would also argue that you can't adequately serve the patient if you cannot first serve yourself. Still, I wonder what a patient's reaction would be if they got a call from their doctor's office saying their appointment was canceled because the doctor called in sick?

Can I get my marrow in gunmetal silver?

$350,000.

That's a lot of money. That will buy you a lot of cool things. For example:















A Rolls Royce Phantom


















A Necklace















A Yacht















A Nice House

And most importantly, it will buy you this:










A Bone Marrow Transplant.

$350,000. That's a mortgage to some people, but its also the mortgage on your life for people with leukemia and hematological diseases. Most insurance companies will cover some of it. Only the really good insurances cover all of it. And patients have worked out some really creative ways to raise the difference. Bake sales, fund raisers, church gatherings, newspaper ads, dances, concerts, you name it, it's been used to try to gain a cancer patient a second lease on life.

My preceptor's least favorite clinical encounter is when a patient comes in expecting to talk about their transplant, and instead has to talk dollars. Such is the reality in medicine where monetary value is assigned to human life. I was blissfully naive on the state of the health care system coming into medical school. During one of my admissions interviews, a physician asked me what I thought was the #1 problem with health care today. I replied, essentially, "Drug companies. Hiking those prices. Gotta cut 'em down."

*smacks forehead* It's a wonder I got accepted there.

But the more I learn, the more I learn there aren't easy answers. The system is broken and propagated by all members of it. Drug companies propagate it through advertising propaganda and skyrocketing drug prices, which are necessitated by the financial reality that they are just a few failed drug away from bankruptcy. Insurance companies propagate it by cutting corners (aka peoples' lives) to compensate for a drying up subscriber base as more people choose to hedge their bets and go insurance-less than pay unreasonable premiums (though I definitely have less sympathy for insurance companies). Patients propagate the system by expecting a level of care beyond which our economic model can support, refusing to budge in the voters booth when it comes to lowering their standards in order to raise the standards of the uninsured. And yes, physicians are culprits, having to walk the tightrope act between all parties, often having to compromise small aspects of their own personal beliefs in the name of the evil reality called "doctors don't make as much anymore, you got a family, and you're in a crapload of debt."

Last monday, we had to talk $350,000. A woman came into clinic with her 1 year old child - diagnosed with Hurler's Syndrome, a rapidly progressing genetic disorder which, if left untreated, kills its victims by the age of 5. A successful marrow transplant means a cure - even more so than kids with cancer can look forward to. The mom is in clinic and ready to talk transplant. Only problem is, the insurance doesn't add up. The policy is bizarre. It will pay for transport of the donor marrow to the hospital of transplant. But it won't pay for the HLA typing and searching required to find a donor. It will cover part of the cost of the stay during chemo and transplant, but not all of it. All in all, the mother's policy falls about $30,000 short of the full cost of transplant, and thats if the transplant goes without any complications - opportunistic infections, prolonged acute GVHD, and such. If such things happen the hospital bill can reach 7 figures, all on the mother's tab. The mother is not poor, so she fails to qualify for state aid. She is not rich, so $30,000 would essentially financially cripple her. My preceptor can do certain things behind the scenes to cut cost - ordering diagnostic tests from the endocrinologist so it doesn't count toward the transplant cost, using cord blood instead of a full marrow donor, etc, but we're talking fractions of total cost.

I found this case essentially profound for several reasons. (1) Hurler's syndrome is a ticking time bomb with rapid progression. In the time it takes to raise the difference, the poor child's bone, liver, and brain are slowly deteriorating, to the point where he may not tolerate the necessary chemo to produce ablation of the marrow, he may develop lifelong cognitive and orthopaedic disability (2) The transplant is a cut and dried cure. There is no risk of relapse, and we've gotten very good at managing transplant complications. (3) This is a 1 year old child. A child with a chance at a normal life, or just as easily a life riddled with hardship.

Like I said, there are no easy answers. And navigating the financial landscape of medicine is one of those areas we are simply expected to learn and find our way in. We can read articles and spout statistics, but ultimately it comes down to the human relationships we build with our patients and our oath to treat these patients to the best of our ability. It's hard to treat when your hands are in handcuffs. Every physician wishes they had an easy button to push to deal with these difficult situations, a money tree to go harvest to make everything better. But unfortunately the botanists are still working on that one.

Sorry for all the depressing posts lately. I guess thats a byproduct of rotating through a difficult specialty. But its the difficult cases that ultimately hold the truest lessons. I promise a couple more humorous posts soon. We start our last integrated class tomorrow, which will take me through mid-June and freedom. The light at the end of the tunnel is finally in sight.

Med School Poker

If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.

Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.

Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.

Massive Sword of Knowledge: 1
Me: 0

Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.

But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.

Uh oh.

Wow, That Must Be Tough

The first reaction most people have when I tell them I'm working pediatric oncology right now is: "Wow, that must be tough."

And you know what, it is.

Cancer is a nasty and tragic disease, and is particularly evil when it exerts it ravages on the young and innocent. So when I started my term through pediatric hematology/oncology, I was really curious to observe how the various docs went about dealing with such heart-wrenching tragedy in this unique field. Yet, so far I've found there's no secret formula used here. Physicians treat children's cancer the same way most physicians in any area of medicine do: by separating the patient from their disease, and going like hell after the disease. By looking at outcomes and odds instead of any patient's individual fortitude or attitude. By using established regimens instead of letting bias of how well they think one patient may tolerate a specific treatment cloud their judgment. But, just like other areas of medicine, it doesn't protect you from the real tragedies - the patients who fight like hell, who beat the odds. The patients who are a true joy to work with, but who ultimately succumb to the very odds they have proven wrong for so long.

The entire clinic loves this one patient - I'll call him Ricky. Ricky is a hilarious, upbeat, smiling 11 year old boy. Who has had acute lymphoblastic leukemia 3 times. His latest relapse came last year and he had a successful 3rd bone marrow transplant about 150 days ago with successful engraftment. Odds for kids with relapsed ALL aren't good. We have about an 80% cure rate right now if it's your first bout with the disease. But for the 20% with a first relapse, their odds of a second relapse skyrocket to nearly 80%, and each ensuing relapse it more difficult to treat as the toxic effects of chemotherapy ravage the body and as each generation of cancer cells grows more and more resistant to typical therapies.

Still, Ricky was looking to beat the odds again. His 3rd bone marrow transplant had established well and they were working on getting Ricky to taper off his immunosuppressive drugs. Everything was going great, and about 2 weeks ago the mom brought in Ricky cause he was feeling a little under the weather and his sister had recently had bronchitis. Since Ricky was still on immunosuppression, we did an xray (which came back negative) and told mom to come back in 3 days if he didn't start feeling better.

Sure enough, that next Monday, Ricky and his mom were back, and Ricky wasn't feeling any better. A second xray was ordered, and bad news: something was definitely growing in Ricky's lungs.

They immediately admitted him, but this sort of thing happens a lot with immunosupressed post-transplant kids (especially if they are back to school (a.k.a germ factories) while they are on them), and it would be expected he would be home within a week after a round of our big gun antibiotics.

I saw Ricky the Monday when his mom brought him in the second time.

And I saw Ricky in the PICU a week later, being intubated because the infection has steadily progressed. The last thing I heard him say before I left the room was "I'm going to die."

In normal people who get sick with community-acquired pneumonia, the culprit is a soft gram positive little bug called streptococcus. And most immunosupressed kids who catch an infection while out and about in the world catch your garden variety strep (or one of the several other common bugs you yourself are very familiar with from every time you get a cold or a cough). We got lots of different guns (drugs) to kick their butts. Streptococcus has a characteristic way of showing up on the xray, building up down in the base of your alveoli of your lungs.

But that's not what Ricky's xray looked like. Whatever was growing in Ricky's lungs grew is a diffuse, wispy, spider-web like pattern on both sides of his lungs. Not good. Ricky had pneumocystis carinii pneumonia (PCP).

It's very rare for healthy people to get PCP, as our immune system is pretty adept at targeting and attacking it. But in the immunocompromised and immunosupressed, its a nasty, nasty fungus that is incredibly hard to treat. It was one of the biggest killers of AIDS patients early in the epidemic before we had good prophylactic and anti-viral therapies.

Yesterday, Ricky passed away. It's tough when a kid succumbs to a disease, but especially a kid who has fought so hard his entire life and was doing so well, who finally lost to the odds he had beat for so long.

But if there's a silver lining to tragedy, its that it lets us appreciate the blessings we have in our own lives. And the reason people keep fighting to beat the odds is because people have fought before them. Ricky is an inspiration, even if the end of his story didn't go as we all would have hoped for him. So we keep fighting.

Venti Coffe, No Cream, Hold the Sympathy

Good news for me: Goodbye kidney. I have now put in my requisite time for the year learning about pee. Yippee.

Leading up to this last exam, I've noticed a trend that's been developing over the last few months. See graph:


The funny thing about burnout is how it sneaks up on you. Time starts to slip away from you, the days start to blend together, and before you know it you're sitting in starbucks with 3 empty venti cups strewn about you staring bleary eyed at the same page of notes you've been looking at for the last 1/2 hour, listening to the crazy woman in the corner talk on her corded phone thats not hooked up to anything, then getting a free 4th coffee from the barista who looks at you with a sad sympathetic look in her eyes as she says "you're always here."

Thanks for the free coffee.

Luckily, I have two of the most potent drugs possible for combating the dreaded burnoutosis (its not quite developed into a full blown -itis yet). The two magical medicines are:

-SevenDaysOfDrunkenessonix (generic name: spingbreakatol)

-Guinnessium (generic name: stpatraxia)

Applying my mad pharmacokinetics skillz obtained over this last block, I had my proper loading dose of stpatraxia on Saturday and now plan to work my way into therapeutic levels tomorrow, March 17th, the greatest day of the year. Hopefully this can help keep off some of the more severe symptoms of burnoutosis until I had get onto a steady regimen of sprinbreakatol on Friday. And yes, my life has now degenerated to the point where making lame jokes turning fun things in my life into fake drugs is highly amusing to me.

I have a couple cool stories from clinic to share sometime soon (one thing I've learned about pediatric oncology - there's always stories), but given my current level of motivation (read: none) it will have to wait. Maybe when I'm sufficiently medicated with springbreakatol (I'm so funny!)

The Macula Densa and Hollywood Socialites

They say in medicine everyone has their favorite organ. I think that's true (mine's the heart). Even my preceptor, who as an oncologist deals every day with a multi-system approach in her practice, didn't even have to think about hers and rattled off the thymus right after I asked. The human body is a beautiful and awe inspiring thing, and everyone eventually finds some particular facet especially elegant and thought provoking. Personally, I love the heart for its power and its simplicity - the way it utilizes electrical and fluid dynamic principles to amazingly fine tune such a critical and demanding aspect of our daily functioning as circulation. The dramatic way disease manifests itself when things go wrong. The way, in a congenitally deformed heart, things can go from horribly awry to just fine within minutes by simply moving some pipes (vessels) around and taping (suturing) everything in place.

But I'd like to counter that point with another point. Everyone also finds an organ they hate.

Mine's the kidney.

Now I am a very fun loving and agreeable guy. I have a great sense of humor and make an easy friend. So I don't throw around the word "hate" very often. I have only used the word hate in a few sorts of circumstances in my life. I hate Paris Hilton. I hate steamed squash. I hate the Santa Clara Broncos men's basketball team (sorry guys). I hate people who try to merge onto I-5 at 35mph.

And I hate the kidney. I have since the very first day I attempted to learn about it, back in high school. I hated studying it for the MCAT. I hated questions about it on said MCAT. I hated it in anatomy. In histology. In biochemistry. In physiology.
Needless to say, we're studying the kidney right now, which puts my effective motivation to study at about... 0%. My dreams are haunted by podocytes, GFR, aquaporins, and that douchebag Henle.

Why do I hate the kidney, you ask? Well, like anything involving hate in this world, I don't really have a good reason. It's a completely irrational and unfounded hate. Maybe because it makes pee. Maybe because its involved in the renin/angiotensin system (does anyone actually enjoy learning about that?). I can appreciate how important the kidney is. I can appreciate what it does is impressive. But its not fun or exciting.

One day, I may have it in my heart to forgive the kidney. Make up with it. We can be friends. But not today. Today, and for the next two weeks, you will officially be number one of my hate list, Kidney. Lock your doors.

Charlotte's Web

They say if you want to go into surgery you have to love the OR. I've always said yeah... that makes sense. You don't become a professional baseball player if you're allergic to grass.

Which brings me to one of the most disconcerting experiences of my life. From a very young age, I was fascinated by surgery. I watched operations on the Discovery Health Channel, the UW Medical Channel (which conveniently got pumped through the cable into my dorm room in college!). I've always envisioned myself as a surgeon. Told people I wanted to be a surgeon. People always told me I looked and acted like a surgeon. Hell even my Meyers-Briggs test matched me as a best fit into... surgery. Which brings me to my first OR experience in medical school.

After the initial thrill and the incredible sight of the surgeons disassembling someone's body (dramatic embellishment) and the OH MY GOD I'M IN SURGERY! ... I was bored. I'm almost ashamed to type it, but I was. My legs ached from standing, my goggles kept fogging up, and I couldn't follow what was going on. It was horrible.

The good news: things got better. The surgeons let me do a couple menial things a few times, which helped keep my attention better. But it still felt boring. And it scared me, because I almost felt like my visions of my future self were slipping away, and needless to say that was a bit frightening.

At the beginning of our Systems Processes and Homeostasis block, we got to sign up for a variety of labs which helped reinforce a variety of the concepts we were taught in class. One of the labs was a controversial lab where we worked with anesthetized live pigs, learned how to put in central lines, and observed various effects of the cardiovascular system with some manipulation.

I signed up for it, mainly because it sounded like a cool experience. I arrived in the lab this week and found our team's pig on the table, quietly unconscious and on a ventilator. Our team divvied up tasks and the task of cutting into and exposing the internal jugular vein in order to insert the central venous line landed on me (with a little bit of coaxing by myself).

Now, I've been through 12 weeks of anatomy and dissected and studied the entire human body (which was equally thrilling and boring). Any medical student can attest to the fact that working on a cadaver is both an exciting and frustrating experience. Things adhere to each other, vessels and nerves snap if you don't meticulously search them out beforehand.

With that in mind, I made my very first incision into live tissue. Unlike preserved tissue, the scalpel glided through the dermis as smooth as silk. The capillary beds bled then closed off as the body's clotting mechanisms kicked in. I found the fascial layer beneath the dermis and slowly dissected to open the incision. Unlike in a human, where the jugular is conveniently located in the easily exposed neck, in a pig it is buried down beneath layers of muscle and connective tissue. I delve deeper, finding an experience completely contrary to that of anatomy.

And it all clicked. I saw the thyroid gland, sitting with its glistening arteries wrapping themselves around the enclosed clusters of thyroglobulin. I saw the recurrent laryngeal nerve looping back up supply CNS control. I found the carotid, briskly pulsing with the powerful pressures of the heart. The vagus running down along as its mate to its destination on the heart. And I found the jugular, slowly pulling it out of its enclosing carotid sheath.

I finally understand and appreciate surgery. The elegance of it, the concentration needed during it. The care and the meticulous nature of it. I can understand why it can seem boring if you're not locked into the moment of it, but when you're involved in it, when you're focused so intensely on what you're doing, focused so intensely on what you're planning next, its like being in 'the zone.' If I end up in surgery (and I'm keeping an open mind throughout medical school) I think this will be the experience that I can look back and point to that sold me on it. Which is funny. Because if that's the case, I didn't decide on surgery because of some dramatic and amazing experience in the OR with a human. It will have been because of a pig.

Jesus, my future professional career can theoretically now be traced all the way back to Babe. But you know what, I think I'm cool with that. Word pig, ya did good.

BTW... Props to the 480, Arizona. The land of desert, desert, concrete, and more desert. If I was a rattlesnake, or dating a professional ice skater, I'd live there.

Past Self, Meet Self.

It's amazing how thing's in life come full circle. While in college, I was a 'child life' volunteer during the summer at Doernbecher Children's Hospital in Portland. We really didn't do much of anything clinical, but it was a great opportunity to get to know and connect with a great number of brave and incredible children (and families). I operated mainly on the 9th floor acute card ward, but would occasionally float up to the 10th floor cancer ward. Needless to say, the kids I met up on the 10th floor provided me with some of the most inspirational encounters of my life, and ultimately shaped my decision that no matter what area of medicine I went into, I wanted to subspecialize into pediatrics (screw the lower reimbursement!).

Well, I'm back. For the next 13 weeks, my clinical preceptorship will be on Doernbecher's 10th floor following and learning from a pediatric hematologist/oncologist. Nearly 3 years ago, I roamed the halls with a bright blue volunteer polo with a big red wagon in tow. Now I'll be roaming those very same halls with my white coat in tow. Besides the obvious opportunity for my own personal reflection on how far I've come in those past 3 years (and even past 6 months), it gives me a great opporunity to integrate those incredible experiences which made me want to be a physician in the first place into my current medical education and growth.

Cancer is tough. When kids get cancer its really heartbreaking, on an indeterminable number of levels. But the kids in pediatric oncology also showed me one of the greatest aspects of working with children in medicine: kids fight. They fight so damn hard. It's what makes pediatric oncology one of those most interesting areas of medicine in my eyes. The failures are that much more gut-wrenching. But the success is even more rewarding.

I think this is a great way for me to round off my preceptorship experience for the year. I got to work with an orthopaedic trauma surgeon... and learned that really wasn't for me. I got to work with a cardiology specializing in congenital heart disease... and learned that right now my passion still lies along those lines. And I get to work with a pediatric oncologist... which means I finally start to get to see and work with kids again.

That's my update for now. We just finished a particularly brutal stretch of the curriculum, 3 exams and 2 quizzes in 4 weeks. One more exam next week and I'm back to normalcy. And on that note, I'm out.

So easy a monkey could do it.

As a first year medical student, they don't trust you to do a whole lot around the clinic or on the wards (and frankly, I don't blame them). So we make do by finding excitement in the little things. "Dude, you got to TAKE OUR SUTURES today? Awesome!" "I can't believe they let you disempact the patient's bowel!" "Whoa, they actually let you CUT the tendon?! NO WAY!" This week, I got thrown a bone of my own.

I got to push a button.

Now, I know what you're saying. But this wasn't just any button. This button was hooked up to a machine. A defibrillator more specifically. And pushing that button delivered 250 joules of energy through a man's chest, lifting him several feet off the bed and returning his heart from abnormal atrial flutter to boring sinus rhythm. Ah, cardioversion.

It went down like this. It was my last week in cardiology clinic and we had a whole two patients to fill the next four hours of time. So my preceptor, bless his soul, decided to send me up on the hill to follow a patient from earlier who was being admitted to observe his cardioversion. Y'know, last week in cardiology, might as well see the cool stuff. So I find the appropriate room, give the fellow the rundown, and we go in and meet the patient. Really nice guy, with a great attitude and sense of humor. And as I introduce myself, I say "Hi, my name is MedZag, I'm a medical student who is going to be observing your cardioversion. Don't worry, they won't let me push any buttons or anything. Ha. Ha. Ha." Wow, either I'm a horrible psychic or have an incredible sense for irony. We get the pads all hooked up, get him sedated, and page the attending. The attending arrives (*dramatic music*), checks all the numbers, and gets ready to give the go ahead. Just as the moment arrives, he turns to me, standing in the corner (oh my god! he noticed me!), and says the words that made my week:

"You want to do it?"

Now the appropriate response would have been something along the lines of "Yes, sir, I would appreciate the opportunity to further expand my medical experience." Instead, all I was able to mutter was a highly confident and assured... "Sure." So the attending shows me how to set the appropriate knobs and dohickeys on the defib (yes, $40,000 a year towards my education and I still use the word 'dohickey'), shows me the charge button and the big red discharge button, and makes very damn well that I "hold down the button" when I press it. Then the time comes. The countdown... 3... 2... 1... and BAM! I press that button better than any first year medical student has ever pressed a button, held it down TWICE as long as needed to prove that I'm a good listener, and watched as the patient's back arches and his body rises two feet off the bed. The EKG goes crazy then slowly settles down and... normal sinus rhythm. Damn, he's good.

The attending says "good job," I reply with an equally confident "thank you," while my brain is screaming "OH MY GOD! That was freaking AWESOME! OH MY GOD! WOW! JUST WOW! OH MY GOD!"

It's the little victories that get me through the day. Soon enough, I'll yawn at such experiences as I move on to bigger and grander things in my medical career. But I'm really just trying to enjoy the journey along the way (said after a long weekend slaving over autonomic physiology and pharmacology which has subsequently leeched all the joy out of this week). And damn, it's never been so much fun to push a button before.

BTW... 1000 visitors. CHEYYYAAAAA!!!! Visitors from Libya, Nigeria, Pakistan, and the Netherlands. New Hampshire, Minnesota, Tennessee, and Nevada. Very cool stuff.

Drugs For Me

We've reached the pharmacology segment of our education.

They say we will know 100-200 drugs by June. 500 drugs by the ends of second year. And over 1000 by the time we graduate. Right now I know... 12 (and three of those are aspirin, ibuprofen, and acetaminophen - I know, I'm so smart).

There's a lot of hate directed at the pharmaceutical companies in this nation these days, with their high prices and shady marketing tactics. I've started to hate the pharmaceuticals too, but for an entirely different reason: they have to come up with their own damn propriety name for every drug they make.

Say you're riding on the light rail and overhear a guy talking about how he had a bad experience with his sildenafil and had to go to the emergency room cause of... complications and the misses was hysterically crying the entire time in the waiting room. You would probably shrug off his comments, feel a little bad, go back to reading your New Yorker (you trendy ass), and queue up the next indie track on your iPod.

Now what if I say you're riding on the light rail and overhear a guy talking about how he had a bad experience with his Viagra™ and had to go to the emergency room cause of... complications and the misses was hysterically crying the entire time in the waiting room. Well then you'd probably laugh, dial up your college buddy on your phone, tell him the story then when he picks up then blast The Starland Vocal Band's "Afternoon Delight" from your iPod headphones loud enough the dude might hear it.

And its all Pfizer's fault that you might have missed a perfectly good joke in scenario #1 because they marketed their pill as "Viagra" (what the hell is that supposed to mean anyways?) instead of it's drug name: sildenafil.

Ibuprofen? or Advil?
Carvedilol? or Coreg?
Simvastatin? or Zocor?

Hell, the brand names don't even make sense. Celebrex? Sounds like a weird sex fetish, not a COX II inhibitor. Zoloft? Sounds like a planet in a galaxy somewhere, not a SSRI. Lipitor? Sounds like a name of an evil alien warlord out of Scientology (zing!)

But mainly I'm just pissed because it doubles the number of drug names I have to memorize.

Of course, it'll be worth it. We're finally reaching the part of our education where our lectures are for the most part directly related to the clinical aspect of medicine. Which is cool. Cause I kinda got into this doctor thing for the whole "helping patients" part and not the whole "memorizing 500 different enzymes" part. And its always fun when you start a new subject in medical school. It brings back a little bit of that "WOW! COOL! MED SCHOOL!" in me that was running out of my nose back in August.

So, for now...

WOW! COOL! DRUGS!

P.S. A big props to the people who have left comments recently. I love comments. They remind me people actually read this thing and I am not talking to myself all alone out in cyberspace. Way to go readers!

P.P.S. Just learned today that the propriety name for Benzocaine is HURRICANE®! Now that's what I'm talking about UltraMed! A name which inspires fear and confidence in your product!

Any Given Sunday

Being a former football player, I am well familiar with the saying that football is a "game of inches." Well, so is medical school.

Yes, my enjoyment in life is directly proportional how many inches thick my syllabus is for that given block.

To keep my football analogy going (you know how much I love analogies), I have established the "how much my life sucks at any given moment" scale - complete with football comparisons.

Syllabus is 1" Thick
Football Analogy: This is like having a three touchdown lead in the forth quarter. You're calling a running play every time just to chew up the clock, the other team knows you're calling a running play every time, and you're still averaging 5 yards a play and the game in totally in the bag. No anxiety, the fans are cheering their heads off, you're sipping some mighty fine gatorade on the sideline, just soaking in the scene.

Medical School Translation: Yeah, I love when my syllabus is this skinny. This is when I truly love medical school. The amount of material is manageable enough you can take a good number of days off from studying. I can find time to do more actually medically related things like scrubbing in on surgeries or reading the new england journal of medicine. But mostly I am finding time to go to the gym, go on runs, frequent bars, drink beer, and watch sports. Ah, life is good at 1" (that's what she said).

Syllabus is 2" Thick
Football Analogy: This is like having a one touchdown lead going into halftime against a team that on paper you should beat but is putting up a good fight. The other team is good enough you can't coast and the game isn't nearly in the bag yet. But at the same time, you got the lead and you got the better team. You should win, but there's just enough of a question mark about the outcome you got to be on your game.

Medical School Translation: This is status quo for medical school. Everyone should theoretically be able to handle the amount of material just fine, but at the same time, its just enough to strike a small bit of fear into you. You can't coast on two inches, but at the same time, you can handle it just fine. If you stay on top of your shit.

Syllabus is 3-4" Thick
Football Analogy: This is being down by two with two minutes left and you just received a punt on your opponents 40 yard line. You got a proven clutch time quarterback and all the pieces to drive within range to kick the field goal for the win. But you're down. And time is your enemy. Will you be the hero or the goat?

Medical School Translation: This is where you start to go "oh shit." It seems like a LOT of material and you wonder if you have enough time to get all your studying done. But at the same time, you have a proven clutch time quarterback (your brain). This is make or break time in medical school, when you need to start giving up an inordinate time with things you enjoy (beer and sleep) for time with the books (lame). But when you kick that field goal for the win (pass the exam), damn, it almost makes it all worth it. This is where legends are made. At least thats what I tell myself. Wow, I'm lame.

Syllabus is 5"+ Thick
Football Analogy: This is where you're out of timeouts and down by a touchdown with 45 seconds left and attempt an on side kick to get to ball back to try and tie the game. Only the other team recovers the on side kick and just has to kneel to run out the clock. Game over. You lose.

Medical School Translation: Thankfully, I have yet to experience a syllabus of 5 inches. And hopefully I won't have to anytime soon. But I know I will have to at least once in my medical career. One word: Boards.

So where am I right now? Squarely at 3.5":


By my very definition, I should be giving up things I enjoy right now, so why the hell am I posting a new blog? Well, I might just have to chalk that one up to ego. Or being an idiot.

Cue the theme music

Welcome to my PCM small group.



Last week marked our first experience with the so called "case study" that med students know and love. We're given a workup of a new admission, complete with chief complaint, past medical history, all that jazz, then they let us loose with our minuscule medical knowledge to run a differential diagnosis on the case.

Now anyone who's watched their fair share of House knows there is one unifying theme to all of the differential diagnosis they run through. No, its not House's asshole attitude or Dr. Cameron's thin shirts.

It's lupus.

Yes, no matter how bizarre the symptoms or the case, House and his crack team of whatever-kind-of-doctors they're supposed to be (here's a hint, such a doctor doesn't really exist) always have lupus in their differential when trying to solve the puzzle of that week's episode. One week the person even had lupus - which was a cause of great celebration (and drinking) for me and my friends.

So we were given our first case study, a poor 45 year old woman coming in with the responsibility of saving her life falling squarely on our shoulders. We start talking about symptoms, her family's medical history, her traveling habits, and begin to come up with a list of ailments most likely to be the cause of her problems. We narrow it down to a top 10 list, and sitting there squarely at #1 was...

Lupus.

Yes, that moment marked a defining checkpoint in the progression of my medical career. I have now reached the technical and mental proficiency of the fake doctors you see on TV. I couldn't be more proud. Maybe now should be the time to pitch myself as the subject of a new medical TV show...