Tuesday, September 6, 2011

Fully formed

(Paul) Farmer entered Harvard med school in the fall of 84. He was only twenty-four. He told me once, "I was fully formed at twenty three." He meant, I think, that by then he had his philosophy and worldview in order, and he knew he wanted to marry them to action..."
From Mountains Beyond Mountains

How many students enter med school with an independently formed world view?
Sure, many have goals, mainly around specialty, lifestyle, etc. But in many ways the med school admissions process selects more for students who can have the world view of their institution imparted onto the next generation of doctors than for those who have their own ideas about what they want with medicine. Ideas that, in many cases, take time away from the pre-med grind in order to formulate.
I am seeing the validity of my original goals with medicine the more I get into the grey fog of action, indepenence, and socio-politics that is clinical practice. A validity that was much harder to see in the cold facts of mcq memorization that was basic sciences.

Thursday, August 25, 2011

This is clinicals

Have reached the stage of exhaustion where I am a complete neurotic, overly sensitive, giggling monstrosity. I am so toasted yet still oddly wired and excited to get up and go to the hospital and explore brooklyn and i dont even know. This is clinicals.

Friday, April 29, 2011

When Normal is Abnormal

In the last week of my Introduction to Clinical Medicine course, we had a middle aged women patient with hypothyroidism. She had a bought with Grave's disease and ended up with radioactive iodine therapy which, though it cured her hyperthyroidism, left her with hypothyroidism. She was later put on levothyroxine but ever few years they needed to increase the dose. I remember asking if this was typical to our clinical professor that day, Dr. R, and he said that this is quite common with hypothyroid patients.


My friend B also has hypothyroidism. B also developed hypothyroidism as a result of radiation, but this was for her Hodgkin's Lymphoma, which she successfully beat. B initially went undiagnosed until her Oncologist, and the best Doc she's ever had, noticed her sweating too much when she came in once, and immediately ordered a TSH test. Since then she was placed on 50ug of Levothyroxine and her TSH was typically around 1.1 (reference range 0.4 - 5, though there is some debate about this).

Sir Charles Robert Harington, discovered the structure and synthesis of levothyroxine

Over the past year or so, B started to notice her hair falling out. At first she thought it was due to two surgeries she had within a few months of each other (both for unrelated conditions). Her previous Endocrinologist took a job in another city and so she saw a new one at a prestigious university last June. After looking at her TSH (2.2) and examining her rather quickly, she told her "your hair is not going to all fall out" and rather rudely dismissed her concerns.
Dismayed by this for a while, B continued to watch her hair fall out for the next several months and then started to get some painful acne. After this she made an appointment with a Dermatologist in November. Her PCP signed off on the referral, though he didn't have much insight into her hair loss either. The Dermatologist examined her and drew some blood. Before she got any results back she prescribed spironolactone, presumably for its anti-androgenic effects to counter the acne and hair loss. She ran her own tests and noticed she had a slightly elevated aldosterone, called B and told her to take the spironolactone.
The spiro at first stopped the hair loss but didn't induce much regrowth. After a month on it without any complaints, the Derm doubled the dose to induce regrowth. Within a few weeks B started to notice some strange side effects, though not entirely uncommon. She stuck through this (she is a very compliant patient) but then started to just get plain lethargic over the end of winter and into spring. She also stopped working out and couldn't seem to keep her apartment organized. B thought perhaps it was the long, cold winter but then she started to get salt cravings and gain some weight. Again, possibly spiro side effects, at least the salt craving.
Since spiro is a potassium sparing diuretic, one must be careful about potassium intake. One day in March, B ate a bit too much broccoli and appeared to get symptoms of hyperkalemia. It could also have been just bad broc, but after that she was scared off eating anything with a lot of potassium - cutting out some of the fruit staples of her diet such as bananas and juices. After this, she started to feel insatiable hunger and, as a cancer survivor, started to get paranoid about the constellation of symptoms of tired, hunger and generally feeling ill.
Just this past week she had her yearly check up with her Oncologist. After reporting how she felt to the interns and doing some blood work, they came to a rather obvious conclusion: B needed to increase her dose of levothyroxine. It turns out that at this appointment, her TSH had risen to 3.3, while still in the "normal reference range", her oncologist knew her history and that B's typical range for proper thyroid treatment was a TSH of around 1. She prescribed a dose of 75ug and explained that her hair loss, weight gain, and lethargy were all likely due to the hypothyroidism.


Looking back on this, there are a few interesting lessons. First, the reference range does not always tell the whole story. References ranges are in fact based on the population mean for a lab value, +/- 2 standard deviations. This helps us see pathological outliers, but it doesn't always tell the most accurate story for an individual. It reminds me of another story where a fellow med student, and former nurse, said someone could have a blood sugar of 40 be not outrageously low (though we're taught <60 is low) because he could just be someone who has low sugar. While I have not had enough clinical experience to appreciate this, it seems to make sense and was certainly analogously true for B.
Also, I know my own personal clinical judgement got warped when trying to help B figure out what was wrong. Makes me wonder how much physicians can really get emotionally vested in their patients before we start to see what we want rather than what is really taking place.
However, the most disturbing aspect of this whole endeavor was the fact that 3 separate, board-certified physicians completely missed what was going on. Not only were her symptoms dismissed (endocrinologist), completely missed (primary care doc) but she was also misdiagnosed and given an unnecessary treatment (dermatologist). A year of distressingly losing hair and the psychological consequences of that, gaining weight, rising blood lipids and also some inflammation on top of it all, could have been avoided if someone had just put together her symptoms with her #1 chronic condition and what is "normal reference range" for her, individually.
It raises many questions about the coordination of care, the role of medical records, and even the attentiveness (perhaps overworked, perhaps not) of the physicians in our US healthcare system. I just wonder how typical such cases truly are... and will certainly do my best to keep this in mind on my clinical rotations later this year.

Wednesday, April 27, 2011

Science 2.0

Damn you wikipedia!
I tried to remember what the name of the social networking researchers was called, only to find out there are several competitors that look interesting. ResearchGate was the one I was looking for, but then I found Academia.edu, epernicus, and then SciSpace.com. Now instead of happily signing up for ResearchGate, I want to look into each of these but don't have the time. So I will likely forget about it for another few months and repeat the same process. Unless I can remember this blogpost...
Add these to my neglected accounts on Medpedia and LinkedIn, as well as that whole inspiration exchange thing AMSA has, and we're getting into serious social networking overload here.
Ok back to facebook.

Sunday, April 24, 2011

The Unconventionalists

Nature (the journal) is running a theme this week on the future of the PhD. Some interesting convos going on in the comments over there, and I even found another cool book to read from it.
One blog post at the nature network stuck with me though. This scientist-in-training reflected on her unconventional aspirations and how others would react:

In the cover of my unspoken reality, I dared to be disappointed with my top 5 academic institution, where to entertain creative ideas of a non-traditional career in the sciences was to be exiled from the class of 'serious' scientists. A lullaby for a weaker child of chemistry. Enjoy your dreams of a lesser biology. She couldn't make it in the big leagues, they'd say. So I hide my dreams of translating science, colorful pages lost in a library of dull covers with obscure, impossible-to-pronounce titles. Surface Plasmon Resonance Series - Nanotechnology-based Sensors. Professor, here is my secret: such a library of science begs translation for the curious non-scientists. Thrilling stories of scientific discoveries that will make our fellow non-scientists as curious as we. Put me in coach. The only thing I know better than science, is the art and draw of language.

As someone with a non-traditional trajectory in medicine, I can hear her picturing others thinking "what are you doing here"... and have had others tell me the same thing. It can be frustrating at times, but I love her "Professor, here is my secret" line, it really captures how I feel when people ask my planned specialty or wonder how what I have planned with medicine...and why I persist on reading fiction in the middle of the semester. And then I run across quotes like these and feel a little bit better about it:
I cannot serve as an example for younger scientists to follow. What I teach cannot be learned. I have never been a '100 percent scientist.' My reading has always been shamefully nonprofessional. I do not own an attaché case, and therefore cannot carry it home at night, full of journals and papers to read. I like long vacations, and a catalogue of my activities in general would be a scandal in the ears of the apostles of cost-effectiveness. I do not play the recorder, nor do I like to attend NATO workshops on a Greek island or a Sicilian mountain top; this shows that I am not even a molecular biologist. In fact, the list of what I have not got makes up the American Dream. Readers, if any, will conclude rightly that the Gradus ad Parnassum will have to be learned at somebody else's feet.
-Erwin Chargaff
Heraclitean Fire: Sketches from a Life before Nature

Friday, April 8, 2011


Awesome article about how Central Park is an ecological island, human-made in almost every sense, but the laws of nature operate - resulting in an entirely unique species of dwarf centipede,Nannarrup Hoffmani.
Made me think how Hospitals can also be ecological islands, on the microbial scale.

Oh there was also exams this past week. Went well overall. Have some experimental results to share regarding the 10,000 question method for step 1. Apparently, doing just questions for pathophysiology review gave me the same score as doing straight reading/revision type review, but was much more fun to do questions! Not sure what this means for board prep yet though....more later.

Tuesday, April 5, 2011

Celiac without the Celiac

Exam week here. Pathophysiology was yesterday, lots of confusing questions about GI and Heme, like patients with celiac that had Iron and B12 deficiency (...??) and nonanisopoikilocytosis (seriously?) but otherwise a doable exam. I did several hundred questions and started to get a sense of how different QBanks have different styles. Exammaster makes it too easy by putting things that have nothing to do with each other for answer options and many first order questions, though they have good explanations. Kaplan QBook does a better job of making the choices more difficult, but still remains pretty straightforward. UWorld is the most dificult, but you're always clear about what they want - just you don't know the answer most of the time.

SGU's style consists of descriptions of conditions associated with the disease you just diagnosed and then about a paragraph full of distractions. So out of a 1/2 page vignette, probably 2 key words that are actually relevant. Anyway, in honor of nonanisopoikilocytosis, here is a link to a neat story about when you can have Celiac without having Celiac.

Thursday, March 24, 2011

Patients Lie

icu has 4 beds for all of Grenada
4 icu beds for 100,000 people
Grenada only has 4 monitors for the patients in the ICU
no one else on the wards has a bp/hr/rr monitor
there is no beep beep beep in any other part of the hospital
i didn't notice this until this week, the 7th time i went.

Dr. g was our instructor for the day
Cuban doc, came to Grenada because his dad is a surgeon here
you do school in Cuba for free, but you owe the govt 6 years of social service
then you can go wherever you want if you pass their test
came to Grenada 2 years ago knowing no english.

There were 3 patients in the ICU
one was the girl we had seen previously in peds, with muscular dystrophy
she was alert but in need of monitoring
the other was an older man with a subarachnoid hemorrhage, apparently unconscious
and another was a middle aged lady also with a cranial hemorrhage

before we saw the tube put in, we were to examine the man with a subarachnoid hemorrhage
as usual, no one in my group is quite awake, yet i am fully caffeinated by this point
so i take the lead to examine
one of the guys in my group says we cannot touch the patients in ICU because
his friend was there before and they weren't allowed
so i am puzzled as to how we can examine this patient without doing anything
i ask Dr. g - he says yes you can examine
so we try to communicate, he does not seem response
he makes some unintelligible muttering sounds
another fellow student suggest we do the Glasgow coma scale to assess this patient

the GCS is the scale used to asses and monitor levels of consciousness
you have 3 sections and get points for each section
conscious awake aware = 15 points
you asses visual stimuli response, verbal stimuli response and touch/pain stimuli response
if you are in a coma and completely nonresponsive, or even if you are dead
you still get 3 points for showing up

So we decide to do the GCS scale
he does not seem responsive to verbal stimuli - we ask him to blink if he hears us
it is just random, and he mutters
he gets 2 points for verbal
after some observation we decided his eyes don't really open to our voice
we think 1 point maybe
however, we need to test his response to painful stimuli
so i decide to poke the patient, but not hard
he moves his arm a bit when i touch
V says no, you really can't assess that
and that that is not a response to your stimuli because you didn't get his consent/understanding
i say we don't need that, but how are we supposed to assess this?
i am told by my colleagues that we don't need to really do it
its just a textbook thing
i say that is absurd, aren't we supposed to be monitoring this every hour?
what do you guys suggest?
they are nonresponsive
Dr. g then brings us over to see a nasogastric tube put in the middle aged lady
they needed to sedate her.

After, we go outside the ward
Dr. g asks us if we have any questions
i remember to always ask a question, i read this somewhere about rotations
so i ask how are we supposed to do the GCS scale and how important is it that we really do it?

Dr. g says
instead of answering
i will tell you a story:

I was given a page to examine a patient with coma
comes in, boy, 10yo, has IV line on each arm, fluids
given oxygen nasal, given nasogastric tube.

i examined the patient - respiration is normal, rr 20 bpm, hr 80bpm, bp 120/76
airway sounds normal, so does heart
something is not right he thinks, intuitively
i does his reflexes - none
i pinched the patient, no response to pain, no response to stimuli.

i calls the nurse over and say
"nurse this patient is dead, he died 5 minutes ago" shocked looks and gasps
"bring me the tools so that i may perform the autopsy"
suddenly the boy cries "no no, i am alive!"

Saturday, March 19, 2011

Reboot and Open Access

My guilty spiral of not posting, and then having things to post but not enough mental energy/time, seemed to be stalled in a perpetual procrastination spiral, but then I ran across a fellow med student blogger - Lex MD - and realized that I don't need to write paragraphs of detail about, well, studying without internet (it really works - thank you silly campus Bradford security restrictions!) in order to keep things going here - or at my other neglected blog with Global Pulse Journal (though I have been keeping up with the twitter account). So even with Step 1 slowly creeping towards me, I hope to have a little more of a social-net presence.

Speaking of journals, I've been loosely following the Open Access debate going on in the scientific journal community. It seems that one of the journals I published at supports the DC Principles for Free Access to Science, purporting to be a middle way between traditional publishers and open access advocates like the Public Library of Science and the NIH. An interesting debate - any thoughts out there in blog land about this?

Tuesday, January 18, 2011


Med school is about not giving up on things.

Med school is about understanding how much time you have and what is possible to do.
Med school is about scheduling.
Med school is about finding time for things that you care about, like your neglected blog, even when you've got a long to do list.
Med school is about stepping back the week before exams and remembering why you have been sitting for 14 hours straight trying to download this book into your brain.
Med school is about understanding work and your duty to get things done, even when you're exhausted.
Med school is about learning how much we know of the human body, and how much (more) we have to learn.
Med school is about understanding what Oscar Romero meant when he said ""We cannot do everything, and there is a sense of liberation in realizing that. This enables us to do something, and to do it very well. It may be incomplete, but it is a beginning, a step along the way."