24 March 2007


This summer is simply bursting with potential. Besides the very important observation that my MCATs will be over and I will again taste alcohol and drink sunshine, it's also brimming with highly anticipated releases. A new Harry Potter movie, a new Harry Potter book (already pre-ordered!), Pirates of the Caribbean, and Spiderman. Short of a fourth Lord of the Rings, I don't think there's a better possible cluster of likely-to-be-worth-the-ten-bucks sequels.

The summer is a blissful in-between. I will have some follow-up essays to write for my applications, but I won't hear acceptances/rejections/interview invites until fall or winter. I will have Organic Chemistry Lab, but the grade will be largely irrelevant. I will be occupied, but without the pressure and weight of the rest of the year. It is as close to a summer vacation as adults ever really get. And who knows, maybe I'll even manage to flee the country for 10 days in August (Belize? Italy? Namibia?).

If I can just make it to June.

And yes, I know Tolkein didn't write a 4th Lord of the Rings.

18 March 2007

Monthly clinic

On Friday I shadowed the outpatient neurology clinic, as I do once a month, and observed a days worth of follow-up visits. Most clinic days seem to show a theme - more likely because something registers in my subconscious than any trick of patient scheduling. Considering my recent review of genetics, it's perhaps not overly mysterious that this month impressed upon me the phenotypic markers that can signal an underlying neurologic process.

Most of you are probably familiar with some of the more famous neurologic phenotypes. For example, the Down's syndrome features of a single transverse palmar crease (simian crease), epicanthic eyelid fold, flattened nasal bridge, shortened limbs, proruding tongue, and white spots on the iris (Brushfield spots). The genetic correlate of Down's is whole or partial trisomy 21.

There are, in fact, a large number of genetic or neurologic processes that can be identified by phenotypic markers. An non-genetic example would be a perinatal (near time of birth) stroke patient. His stroke included part of the internal capsule and thus affected the neuronal tract that includes motor neurons. His stroke was right-sided, so one would expect left-sided motor affects. Indeed, because the stroke was not immediately noticed during his infancy (most infants do not get MRIs) his left side failed to develop properly. His left arm is shorter than his right (atrophy) and displays abnormal tone and fine motor control. In this case, the morphologic presentation of a shortened arm with abnormal tone allows a neurologist to begin localising his stoke before ever seeing an image.

A note about fine motor control - I get a lot of questions about this. Gross motor contol is large movements: walking, throwing, and lifting. Fine motor is things like tieing shoes, buttoning buttons, and writing. One test you might see a neurologist perform is asking a patient to touch their first finger to their thumb, then their second, third, and fourth. Another is to tap their first finger and thumb together as rapidly as possible.

Regarding motor development in infants... like anything else it's hardest to assess in younger children. Babies have little to no purposeful motor control so assessment usually consists of examining involuntery movement for abnormal posturing, tone or lack of movement. Mild deficits can be difficult to note until a child fails to develop on a normal timeline (ie, cannot stand independently or sit-up on time).

And now a genetic example. I should mention that this patient has not yet been conclusively diagnosed, we simply added Wolf-Hirschhorn to the differenital because of the phenotype. There were two children who came into clinic after having been neglected by their biological parents. It was impossible to tell whether they were delayed due to lack of input or whether there was genuine neurologic impairment of some kind. The children were placed in foster care and came back speaking 3 word sentences (they are 3 and 4 yrs old), but still underweight and incapable of tasks such as putting on clothing or drinking from normal cups. The younger child displayed tremors (attributed to more than being nervous because it affected her head as well) and the older child has "greek-helmet head", microcephaly (small head), and shortened stature. Greek helmet head is characterised by a high hairline and a broad, flat nose.

If the older child does have Wolf-Hirschhorn (deletion on chromosome 4) he's both lucky and unlucky. Unlucky because it's associated with fairly profound mental retardation, and lucky because his phenotype is (apparently) relatively mild. More extreme symptoms can include cardiac septal defects, poor development of secondary sex characteristics (genitals), renal (kidney) malformation, malrotation of the intenstines, and hand/foot contractures.

One of the important notes about these phenotypic varients is that in order to dianose anything they generally occur in clusters. For example, just having wide-set eyes or a high hairline doesn't mean you have a genetic defect or a neurologic symdrome. Cleft palate is a midline closure defect - a characteristic of Wolf-Hirschhorn syndrome. However, far more babies are born with cleft palate than Wolf-Hirschhorn: about 1 in 600-800 vs. 1 in 50,000.

10 March 2007

Because procrastination is an art form

We're bringing blood flow back
Use MRI and perfusion maps
Grow collaterals to pick up the slack
Have a surgeon synangiose it back
Get an MRI...

You see the infact
You know who to page
We treat the AIS and ICH
Look at vertebrals and both ICAs
Get an angiogram...

Come here doc
Do a neuro exam
Do a neuro exam
Left neglect
Do a neuro exam
Feel this yet?
Do a neuro exam
With mild expressive aphasia
Do a neuro exam
Hop on one foot
Do a neuro exam
Finger to nose
Do a neuro exam
Any seizures?
Do a neuro exam
Any recent headaches?
Do a neuro exam
Get another scan
Do a neuro exam

We're bringing blood flow back
Fixing what stenotic vessels lack
Check for infection with a spinal tap
What if coagulation's out of whack?
Give 'em ASA...

Or moyamoya
You know who to see
PVL or white matter injury
Sickle cell or history of CHD
Get a neurologist...


06 March 2007

What do I really want?

Economists have a different way of quantifying cost that most of us. It's easily illustrated with an example: buying a candy bar at a vending machine. Let's say you have exactly the eighty-five cents in your pocket that each item in the machine costs. Most of us would say that the price of the item is, rather obviously, eighty-five cents. But an economist would say that it's not just the money you actually pay for the item, but also the utility cost of what you otherwise could have done with that eighty-five cents. In other words, buying a Snickers is eight-five cents plus the cost of not buying a Twix. The cost of options not chosen is called the opportunity cost.

This concept is actually very useful when evaluating the decisions you make about your life. In my case, choosing to be a doctor weighs against choosing not to be a banker or a consultant. Given that I can extract my expected happiness (utility) from my future career in medicene, what I have done makes economic (if not fiscal) sense. The utility gained from not being a banker outweighs the utility gained from not being a doctor. Thus, given a willingness to return to school (be it business school or medical school) it makes more sense for me to be a doctor: lower opportunity cost.

However, if my extracted utility falls below a threshold then the equation no longer holds and I would be better served returning to my previous career. Everyone has this threshold, the question is: where? Some people will go to any school and apply as many times as necessary to get into medicene - their utility difference between medicene and everything else is very large. Mine is smaller. I will not simply attend any school to which I am accepted and I will not apply year after year. This is because some of my utility is derived from my level of excellence within a given field. If I come to perceive that I would be a better banker than doctor, that will drain some of the utility from the propect of being a doctor. For better or worse, which schools you are accepted into and how many times you have to apply is a proxy for your projected ability within a field. It may not be 100% accurate, but it's a readily available metric.

This description probably all sounds very cold and calculated, but it's not really. It's simply the logical functioning of how you weigh different amounts of happiness. It quite rightly integrates the happiness lost by letting go of an opportunity. Think about how many times you have done something because the alternative - always wondering - was worse? The opportunity cost was greater than the negative outcome - it was too high not to act.

05 March 2007

The personal statement

This is a slightly unusual post. Rather than telling you a story, I am writing you a request.

It is recommended that as many people as possible read your personal statement and give you feedback and so I say - if you are willing to read my personal statement and send me feedback, I would be glad to send it to you. Provided you are not also applying to medical school and plan on stealing it if it's good.

Interesting tidbit - our advisor adminished us to not make our personal statements too self-centered. It's a personal statement, how can it not be self-centered?

03 March 2007

Welterusten, oma

On Thursday night I wanted time to freeze. I didn't want those hours counted against my MCAT study time, deadlines at work, and my ever-growing to do list. It wasn't the worst news, my parents and brother are healthy, but it was close. Apparently my maternal grandmother (oma, in Dutch) suffered a stroke and was in a coma.

I love my oma and I am sad that I will form no new memories with her, but she was in her eighties and had moderatley advanced Alzheimers. What really makes the death of a grandparent hard is watching the effect on my parents. My mother was flying out to the Netherlands, after much deliberation, and in the end missed seeing her mother lucid(ish) but just a few hours.

So when my mother returns and I am able to speak to her on the phone, what do I say? What do I say to my mother when she has lost her mother?

And then it was Friday and I had to be at MCAT class. I had to go to my medical school applications workshop - I had to catch up on the work I didn't do while I was staring at the walls on Thursday night. The computer that scores my MCAT isn't going to care that oma died. Neither will the recommendations I need, the deadline for my next vacinnation, my next organic chemistry exam, or the IRB continuing review. Nothing changes.

The biggest change between life before and life in the real world is how hard it is to keep it together. Because nothing changes.