Breath

N.B. This post may be considered, um, politically incorrect. Let's just consider it in a clinical context.

I am jewish, well, my mitochondria is. And if I'm right, my oral microbiome, rather, my breath, is as well. I call it "Jew Breath". It resembles mothballs(note: this is not my breath all the time, only occasionally!). I've noticed it a lot at Temple and had it independently confirmed by an old jewish roommate:

"You know what I'm talking about" I said to A. "Jew Breath is real!". A put his face in his hands, smiled, and nodded slowly, admitting the painful truth. I could smell it on him too.

As an SGU'er, with my school's majority Indian population, I also noticed among some a certain "Indian Breath" (or more offensively: Desi Breath). I can't quite put into words what it smells like, but I prefer it to Jew breath. Anyways, a fellow (caucasian/goyim) med student who is dating an Indian women actually had that breath... which means either the smell is not associated with the subcontinent OR she transferred some of her oral flora to him through excessive make out sessions (how long and how many remains a subject for further study).

There is some clinical relevance to this, however. Analyzing the myriad microbiomes of the gastrointestinal tract is a hot research topic,implicated in everything from Chron's disease, type 1 diabetes, failure of anastomeses in surgery (from a grand rounds lecture pre-pub) to development of pancreatic cancer. And it turns out, some research has found a difference in the oral microbiome of different ethnicities.

So maybe there is something to Jew Breath after all...

Round, Cut, Eat, Sleep

Alarm slap at 4:45, got 20 miutes to get ready. It starts with a cold bike ride through the dark park, and suddenly I have coffee and Ins & outs. The parade of patients then flies by, soon back in the OR and the ritual scrub in begins. Inside the abdomen now, presurized camera port view - like a reverse submarine periscope. Hiding spleen and adherant umbilicus, don't forget the internal hernias. We're out and grabbing an Oxygen tank, wake up - you did well, well your GIT did, now it's up to a duel b/w your WBCs and disturbed microbes. Pass off at PACU, go grab something for $3.26 - surgery makes you hungry. But at the end of the day sometimes, you're more tired than hungry - wake up at midnight wiht the light on, turn it off - rinse and repeat.

Competitive Specialties

Entering clinicals, I never expected to like the more "procedural" specialties. But ever since I scrubbed into my first C-Section in OBGYN, I've been drawn to the OR. The excitement, the atmosphere, the sense of accomplishment, the work of having a few, long, nice projects to work on for the day and the ability to see a difference in a patient after surgery are all very attractive to me. I can see that much of my pre-clinical work was also project oriented, even if it had little to do with surgery.

If only things were so simple. I decided to take SGU up on there clinical academic advising services (something I made good use of in basic sciences with the great Dr. DB). I sent in my CV, GPA, Step 1 and goals of matching in Surg or OBGYN. I will say Dr. PB (the clinical advisor) gave me some needed advice and gave a great critique of my resume. But he basically said I have less than a coin flip's chance of matching in either specialty. Not a 0 chance, but not great either. It's tough news, but I'm thinking about what I can do to change my chances and think hard about what I like about the OR.

But it got me angry and thinking about WHY certain specialties have cut offs. Does someone need to be that much smarter to go into General Surgery than to go into Family Medicine? Is the academic training of Dermatology really more broad than Primary Care?

From my experience in medicine: No. In fact, general practice is in many ways more challenging intellectually - you really have to know the subtle signs of sickness to catch the deadly diseases early among the sea of worried well. No, there is something else at play, as DJ Shadow once alluded to...

The most competitive specialties pay the best. Lifestyle is a part of this, which is why EM - a midrange compensation - is becoming highly sought after. This is not surprising if one is a cynic, but it's disheartening if one is kinda typical on stats paper but wants to follow their interests and make a difference in a field. We live in a capitalistic society, so I guess I shouldn't expect things to be different - it's just always startling when the brutal reality of it stares you in the face. I just wonder what the distribution of Derm vs. Family vs. Surgery vs. Psych would be if all of them paid the same and had the same hours. And what that would do to the delivery of healthcare in this country. Considering how many physicians I've hear complaining about compensation cuts, I'm guessing it would be a bit different than today :)

F/U post comparing specialty distrubution in other healthcare systems (europe, canada, india) to follow...

Not Dead Yet

It has somehow been 2 months (!) since my last post, but I will be picking this up again soon... Term 2 concluded successfully and Term 3 is well under way. Had a busy, productive and fun break too... and plans to think about for the year ahead... more shortly after (or before) midterm on Friday.

Physio Testes

Or how Dr. H made physiology fun through corny jokes:

"We know that increased heat decreases the viabilty and production of sperm. Studies have shown that men sitting crosslegged with their laptop (on laps) the testicle closer to the laptop (hotter) produces less. Another quick way mentioned is to see if the male wears tightie whities. If so, tell him to change to boxers.... now, if you don't believe me consider this: ever seen batman? does batman have children? I rest my case."

Ingrown Toenails and Funny Bones

Distractable has a great post on the relevance of Physics to clinical practice - it's on old post but a good one and it came back to mind cause a friend got an ingrown toenail. Dr. Rob (distractable) discusses the physics of ingrown toenails and also gives us the following clinical rules (yes, this is on the USMLE):

This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

People step on them – scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
Heavy objects are kicked – careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

I would like to add to this the Ulnar Rule, which is observed by anyone who has taken Anatomy. Once you learn that the Ulnar nerve (or mulnar as some like to call it) is in fact your "funny bone" you are doomed to a life of hitting it at least once a week. What was once an annual event is now a regular part of your life. Thank you Gross Anatomy.

That's all for now - time to get back to Renal.

Immuno Rage

I cannot quite remember any class that has inspired such rage. It was not the material itself, which I liked, or even the obscure clinical trials, some of which were interesting but mostly boiled down to: oops, this TNF blocker for rheumatoid arthritis gives you cancer (which the FDA didn't spot until after it was approved) or uh-oh, looks like you can get progressive leukoencephalopathy from your psoriasis meds (all of which convinced me to tell everyone I know to stay away from Phase 1 and 2 trials).
I also feel like a good chunk of immunology is guesswork - we know how certain things interact and many of the big players, but ultimately it's an extermely complex system that we're just scratching the surface of. And when we mess with one thing, say nTregs, the consequences are often unexpected and vary widely from model organisms. There are many diseases that people are suffering from today and I do sympathize with the urgency to develop drugs to help them even with incomplete info. I guess that is part of the challenge of medicine: sometimes it means operating on partial info in desperate situations, especially with cancer and painful, chronic diseases.

But anyway, what really got me about this course was the questions! For some reason the way these questions were worded and presented with the material just burned me up! I have not felt this angry at a class before. I can maybe blame the heat, or that I needed on object at which to focus my unspecified rage (Dr. S), but I don't know. After the exam there were the typical discussions about questions and complaints about the course. I managed to distill my issues into two main points:

1. The material was presented poorly from the beginning without a big picture, proper diagrams, or any good interconnection and context. We were expected to straight up memorize random letters and names with little info for how they interacted and that just don't work for me!
2. There were major inconsistencies between the material presented in class, the notes provided and the lack of a real textbook meant we went shopping for various sources (purple book, white book, red book, brown book, HY, wikipedia) many of which gave conflicting info about basic topics (like HLAs that never showed up on the exam btw)

These two factors combined with poorly worded questions made for an extremely frustrating course. When I said this to a few people outside the test, one guy said the following "Those are two great points that, as SGA representatives, we have brought to her attention. She said you will thank me later for teaching you how to learn." Wow, haven't seen such arrogance and idiocy since the days of Bush II. Yet, if I did well and got within the grade range I think I did, I will admit that the trial by fire of having to teach myself the course did at least emphasize that I am a dedicated visual diagram learner. I understood this before, but I suppose now I know it for sure. But let's not be too conciliatory until the grades are out...

Immunology... or how not to teach a class

I am continuously reminded of how much of a visual learner I am and perhaps this is why Dr. S's Immunology course, until this point, has been a struggle. I cannot pay attention at all during lecture and the notes, though thorough, are very text based with few diagrams. I need diagrams!
But on top of that, the order in which the material was presented just did't work for me. Immuno was a course I enjoyed in undergrad and generally found interesting (I even shadowed at an Allergy Clinic) but I found myself starting to hate the course and the professors.
I didn't realize my problem was how the material was presented until I put together T cell activation on my own. I used a combination of Wikipedia (decent article) with a copy of High Yield Immunology. I also referenced the class notes to make sure I had what I needed to know. Then I took it all and drew out a diagram with all the relevant cytokines. And it makes sense. Macrophages are cool again, CD4+ T helper cells rock and I can appreciate how HIV kills.
I've had poorly taught courses before, but never could I say exactly how to make them better. With this course, I think a better integration of cytokines into the Th section along with more and better diagrams, coupled with big picture understanding would go a long ways to improving it. And a coherent lecture would help too.

SGU Crossroads

There are three roads from the roundabout near my apartment. One road leads to the airport, one road leads to Grenada and one road leads to Campus.
A bunch of clinical tutors live in my building. I talked to them a few times and had seen them in labs. I went to do my laundry the other night and they were having a party and invited me to join them. So I went down to enjoy some home cooked south indian meals (rasam, pulyaogre(sic) and more). Just couldn't pass that up!
Talking to some of them I learned that SGU has a program for medical graduates from other countries (in this case India obvs.) to come and teach for 2 years at SGU while they apply for residencies in the US. Turns out a lot of them do get their residencies and SGU gives them a third year to match if they need it.
It was encouraging to see that "true IMGs" that were not US citizens could make it into the states for residency through SGU. They were celebrating successful matches for four of their colleagues - all going to respectable places from Chicago, to Rochester and NYC.
It seems there are many routes to SGU, but a lot of them lead to where people want to go...

March?

Eh - what just happened? Oh, midterms. Compared to the other test takers out there, Term 4 and especially those who just took the boards, I feel a bit unworthy of logging any complaints about exhaustion from term 2. The exams went well but I am learning that med school tends to take your studying habit errors and magnify them.
I am always quite excited to get my score reports back. But I'm seeing a pattern - those things I knew that I did well, and those things that I did not understand so well I didn't do so well.... hmm, how does this help my inability to pick a method of studying?? I can say that my method of "no paper notes" and doing everything through annotating PDF docs has been working at least as good as scribbling a bunch of stuff on paper. So I'll stick with my... green studying.

Anyway, there was also whole healthcare stuff that passed. Yeah, about that. I think it's a good thing, but really cannot say so much in detail before I read up on it (June) and get the impression we will need to tweak the bill with add-ons in the years to come. I do intend on reading this wonderful Grand Rounds from SeeFirst though.

I also got a fan. I paid too much for this fan but since you apparently need psychic powers to predict when a fan will be posted on SGU POST and email that person the instant the put it on sale, I sucked it up and paid for it at the hardware store. Am very glad as my Midterm AC electric bill was more than the fan.

Evolutionary Medicine

Listening to lectures on sonic foundry can occasionally make me feel like a deranged hermit. I spend days alone at my apartment and venture down to interact with society only for small group discussions, the occasional DES session or a trip to IGA. The atmosphere is distraction free, which I think has made me more efficient and productive this semester (we'll see about that after midterms). The ability to set ones schedule and actually stay awake through lecture has certainly made my med school experience a lot less stressful, but it's not without its frustrations.
Listening to the Immunology lecture just the other day, our Prof. discussed the polymorphism of MHC and the various alleles for each MHC locus within the population. She then asked a simple question: how does this benefit us from an evolutionary perspective. Now, I know Sonic can be misleading but I could hear the crickets. One person ventured a guess but missed the point. Meanwhile, I immediately thought of biodiversity and the lessons I learned from my Evolution class in undergrad - one of those "I'm a biology major, not a pre-med major" classes that I took before deciding to go into medicine. So, I am sitting here screaming duh people, if you don't have a diverse recognition of antigen then a single microbe that goes unrecognized by the entire population can wipe out the whole species! The genetic bottleneck is a big problem in conservation biology. And yes, evolution applies to humans too - even more as we think.

Evolution is often a lost part of medical education. We learn a great deal about the immediate causes of a disease, or even how one can become susceptible, but we are generally not trained in the "why do we get atherosclerosis in the first place?" kind of questions. This piece in Aetiology discusses the med student mentality:

If basic biology and traditional medicine make up the plot of our disease "stories", evolutionary medicine would be somewhat like the moral. My roommate is a medical student and when asked, she can tell you how just about anything in the human body works and what is happening when things go wrong. When asked why things go wrong, her answer will refer to a proximate cause, such as certain foods leading to plaque build up which can lead to heart disease. If the question of why is rephrased, as in why does the disease even exist at all, then she's stumped. This is the question considered by evolutionary medicine. Why aren't our bodies able to repair clogged arteries? Why are we prone to infections? Why are our bodies so good at some things but so inept at others?

The post goes on to discuss the book "Why We Get Sick: The New Science of Evolutionary Medicine". Especially relevant to my fellow immunology students is the following example discussed later in the same post:

So if infections are one evolutionary explanation for disease, what's an example? I recently came across an interesting article about infection and it's relation to premenstrual syndrome. In the article Premenstrual Syndrome: an evolutionary perspective on its causes and treatment, Doyle et al. propose premenstrual syndrome is due to an exacerbation of a set of infectious diseases during cyclic changes of immunosuppression by estrogen and progesterone. While genetics and non-infectious environmental influences have been examined and found largely unable to explain PMS, infectious causes have been overlooked. However, it is know how immune function varies throughout the menstrual cycle in such a way that there could be less effective control of fungi, viruses, and intracellular bacteria, so making the leap to a persistent infection contributing to PMS doesn't seem too difficult. Supporting this hypothesis is a long list of chronic diseases with suspected infectious causes that are exacerbated premenstrually including Crohn's disease with Mycobacterium avium and juvenile onset OCD with Streptococcus pyogenes.

It's a really fascinating interplay between immunology, environment, and genetics. You can also consider the influence of epigenetics for good measure and I'm sure your head will start to spin! The book looks like a good read and hopefully something we'll see in the medical school curriculum of the future. Anyone out there read this book or ones like it?

Neuro

Neuroscience is like anatomy on steroids with less distinguishing characteristics and more interrelations. This makes it more challenging, but also more rewarding. And they said Term 2 would be easy!

In terms of the actual class at SGU, having quizzes where you must distinguish between the Anterior Commissure and Lamina Terminalis on a 200x200 pixel MRI with big thick lines drawn in MS Paint while at the same time labeling the Hypothalamus is the epitome of a throw-away question. Please, either don't label two things so closely together that the lines themselves cover the actual structures and surrounding features or just upload a higher resolution image - this doesn't help me learn anything.

Presentation complaints aside, I can already see the general direction of the class and the material fascinates me. The whole process of how your body is sensed and controlled through your cerebral hemispheres, as if your brain was a reflection of the body, is simply surreal. Though the myriad of structures can feel overwhelming, for each Netter card I memorize, I get information about structures with functions relating to language (Wernicke's Area, the S/I Colliculi's), sense of self (Precuneus), as well as the reflection of the body along the sensory cortex going down the post-central gyri (same goes for motor in the pre-central gyri). The latter formation is what gives rise to this guy which is a visual representation of the brain space we give to different parts of our body: In our case, Human evolution has strongly favored our hands - those nifty tools of ours - as well as our great communicators (larynx, tongue etc). There is a great run down of this on the NIH website with a nice detailed graphic.

For other animals, evolution obviously favored different body parts and structures based on selective pressures. Below is a representation of the mole rat, which has complete control over it's incisors.







This type of information makes for some fascinating science inspired artwork... would like to see more of it! Link if you know of some...

Observations of a former cubicle dweller

Two weeks into med school and a few things have stuck out about how this land of palm trees and cadavers differs from that of the flourescent tinged cubes and long lunches.

First, the commute. I live on campus and have to, gasp, walk to my classes and labs. Tomorrow, for instance I have the extraordinary commute of 300 ft to my 8am histology lab. On those really tough days, I have to walk up a 100 ft hill to get to Anatomy Lab at 7:45 am... but it's still only a 7 minute walk. Yet, people complained about this.

Being a former cubicle dweller with a 30 minute commute to work and an undergrad that made his way through the juice to the blood (er, orange line to red line) and finally the awesome crystal transport buses to arrive at campus... well, I can appreciate the short commute.

Second, length of the day. Oh my gawd - It's 3pm and we're still in class. I can't believe we have to put up with almost 8 hours of lab and class on those really really long days. I can barely handle it. What? some people do this for the entire life?? They must be crazy!

Aren't we training to be doctors, people? And don't docs work like notoriously long hours? hmmm.... some people need more adjustment than others.

Ok, so it's a bit of a cranky post, but really I can appreciate being a student so much better after a few years in the work world. Yes, I did do less work when I had a 40hr work week, but campus life is so much easier in many ways. And, if I take the 'long' way home (10 minutes) I get to see some of the ocean as well...