When I grow up

Now that I am settled on becoming a physician, the next logical decision is what kind of physician I want to be? Granted, there are rotations in third year to help me decide. I can shadow practitioners to make an informed choice and then, of course, I must match in the specialty I hope for. But what am I hoping for? Surgery? Emergency medicine? Pediatrics?

My colleagues that the hospital have their opinion: surgeon. My friends in their internships have theirs: neonatal intensive care.

But the best way to solve this problem is clearly to take some form of internet quiz. So I took the Medical Specialty Aptitude test on the University of Virginia Health System website. Apparently, my top 5 specialties are:
1. Nephrology
2. Thoracic surgery
3. Aerospace medicine
4. Plastic surgery
5. Pathology

I no longer put any faith in internet quizzes.

Postscript to Mr. Jobs

My computer was returned to me, however it was not fixed. Additionally, there were four notches on the optical drive that were not there when I brought the computer in for servicing. While the return invoice lists two "parts or services used," the optical drive needed three attempts to eject the first disc I put in.

I must now send my MacBook back in. Since I cannot do this at the moment (I need it for school and work), I have opened a case with AppleCare and will send it in April. How many times I must I send it in before you either a) successfully fix it or b) replace it?

Regards,
S

Dear Mr. Jobs

I have owned a series of Apple products over the years, but my most recent purchase (A MacBook) has caused me more headache than any PC I ever owned.

Shortly after buying it, it began leaking battery acid. There is no Apple store in Philadelphia and the Support team did not want to mail a toxic product so I had to ask someone to drive it into New Jersey for me to swap it for a new computer. No one at Apple transferred the Applecare to the new serial number so several months later when the hard drive spontaneously failed I had to spend a day on the phone proving that the policy covered this new machine.

The hard drive was replaced and Apple thoughtfully replaced several of the case panels as well. However, the panel that includes the optical drive was warped so when I got the computer back, it no longer ejected discs. I was in the midst of exams (and there is no Apple store in Philadelphia) so I waited three weeks until I could get to NYC to take it to a genius bar. Ruth (the genius) couldn't fix it in the store but she assured me that as a bounce-back repair it would be covered and I should have my computer back in 7 days.

It's day 5 and I just checked my status online. Apparently the repair has been on hold (since March 11, it's now the 13th) and no one called me, so I called Applecare. I spoke with Dan and Kendra and neither could tell me anything other than "wait for the depot to call you, they might not cover this repair."

I'm flabbergasted. Apple took it upon themselves to repair a part that was not broken and now, after a botched repair, won't fix their mistake. This is the third time this computer has needed repair! I need my computer to do my schoolwork and pay my bills - if there was a problem or delay, why did no one at Apple contact me?

I am purchasing a new computer this summer for medical school and the experience with this latest MacBook (less than 2 years old!) has forced me to seriously reconsider my stance on PCs. They might be equally much trouble, but they are much cheaper. If the product and service are going to be this poor either way, I might as well save my money.

Mr Jobs, I'm very disappointed. I think Apple makes innovative products, usually worth their higher prices. But apparently the quality and service are inverse to your company growth.

Please, fix my MacBook and send it back!

Medical School Update

Because no, the process is still not over.

Applied: 23
Interviews: 13

Of the schools who gave me interviews:
Withdrawn: 2
Waitlisted: 2
Accepted: 5

Of the schools who have accepted me, I have declined 2.

As you can tell, I'm still waiting for 4 replies. I will be rejected by the 10 schools that didn't interview me (I received 6 of those letters already).

Deadline for the final decision: May 15th.

Yummy!

We were talking about oatmeal chocolate chip cookies all day so when I got home I just had to make some. I didn't have any brown sugar so I used white sugar and maple syrup instead (and added a little extra flour) - they came out very moist and chewy... yum!

Different and unequal

Nicholas Kristof took a break from the third world to write a column on the public perception of women leaders.

This creates a huge challenge for ambitious women in politics or business: If they’re self-effacing, people find them unimpressive, but if they talk up their accomplishments, they come across as pushy braggarts. The broader conundrum is that for women, but not for men, there is a tradeoff in qualities associated with top leadership. A woman can be perceived as competent or as likable, but not both.... Professor Duflo and her colleagues found that by objective standards, the women ran the villages better than men. For example, women constructed and maintained wells better, and took fewer bribes. Yet ordinary villagers themselves judged the women as having done a worse job, and so most women were not re-elected. Professor Duflo asked villagers to listen to a speech, identical except that it was given by a man in some cases and by a woman in others. Villagers gave the speech much lower marks when it was given by a woman.

In response there were the expected anti-Clinton posts, the sexism-is-dead posts, and the not-feminism-again posts, but the one that pissed me off enough that I had to write was this one (by Nathan N):

To think that gender or race is even remotely relevant and anything other than a complete “red herring” is an intellectual confusion. To illustrate my point, it may be interesting to wonder whether horses or oxes as a group run faster. But when you have one actual horse and one actual ox and want to know which one runs faster, all the statistics and knowledge about how fast or slow the members of the two classes of animals generally run become completely useless. All we need to do would be to let them race and see which one runs faster.

Actually, Nathan, I believe you are intellectually confused. And to boot, you totally missed the point. In your horse and ox example, Kristof's point would most closely be translated to the observation that even if the horse and ox raced with the same time, the ox would be thought of as the faster animal. In fact, your argument is negated by the example in Kristof's article - in an objective measure of governing fitness women did better but were kicked out more often.

Not to mention the fact that in a timed race there is an objective standard whereas a public election is not only subjective, but filtered by the media. The effects of this subjectivity are seen for both genders; some of the most qualified candidates lost early in the primary season due to a lack of media exposure and having more substantive credibility than stylish panache.

And to all the people who responded to his column, Kristof wasn't making a case for Hilary. He was making a statement about how in some situations democracies can empower the very prejudices the system is trying to protect against. If you're going to respond to an article, at least read it first.

It's not all in my head

In medicine, we call it emesis. The other research assistants favoured the term "booting." Whatever you call it, I was holding the sides of a toilet and vomiting neon yellow bile yesterday one hour after watching a neonatal autopsy.

The baby in question was about one week old and died shortly after surgery to embolize a vein of Galen malformation. Basically, the baby was born with an extremely large vein in the brain -- this causes low blood pressures in the arterial system and high venous pressure (reversal of normal, also termed persistent fetal circulation). One potential repair is to fill the vessels feeding the oversized vein with glue (yes, literally glue) to lessen the amount of blood flowing through the malformation and restore normal blood pressures. This baby died shortly after surgery after two mysterious distended abdomen complications and difficulty ventilating.

An autopsy is not an elegant or a respectful procedure. The body is handled roughly, like an object, and no care is made to preserve the features that viscerally remind us of the corpse's humanity. The first part of the autopsy was an excision of the brain done with incisions from each ear to the center top of the head. The face is then peeled down and the skull cut into 4-5 triangles, which are peeled open like a flower to provide unhindered access to the entire brain. Unlike television, the baby bled when it was cut; this is not CSI, the bodies are not embalmed prior to examination.

Upon opening the skull it was immediately evident that there had been a substantial subdural and subarachoid hemorrhage (bleeding in the space between the brain and it's covering layers, the meninges). Thus, there was a lot of blood and it lots of gauze was required to visualize the venous system within the brain (you can see the vein of Galen by pushing apart the two hemispheres, gently). The spinal cord was then severed and the brain extracted and placed in diluted formalin to "set" for two weeks before the brain cutting (serial sectioning of the entire brain and spinal cord).

Once the brain is removed the face is pulled back up, but the skull is left open. The next question was what substance was filling the belly. To see whether it was air, the baby was submerged in a basin of water and a hole poked in the abdomen to see if bubbles would result. No bubbles. The body was removed from the basin and held upside down to let the (empty) skull drain (it filled with water when submerged: no brain, remember).

A Y incision was made, which is really more of a U from nipple to nipple and then a line down past, but around, the belly button. Care has to be taken not to cut to deeply, only skin and fat, not the organs beneath. Once you cut into the body, yellow liquid runs off - I think it's the water mixing with the fat (adipose) tissue.

A probe was used to spread the skin around the abdomen and below - the baby had no testicles in the scrotum so, where were they? Gently the intestines were pulled out (not all the way, just a bit) and nudged sideways so that there was a view of the interior of the body cavity. One of the intestines was brown (my guess: large) and the other more greenish (my guess: small), but both smooth and slimy. The testes looked like miniature pearl onions and they were floating off on the left side, not in the track they descend down so something was wrong there.

I didn't get to see then crack the chest because at that point we had to go see another (living) patient. Frankly, I think this was about as much as I could handle... I mean, this was a newborn and it didn't look dead.

While I was in there, watching, I felt mostly fine. I had a low level of queasiness, but I was interested in what I was learning about anatomy and pathology. My brain was on board, but my body was apparently not. I think there is something primal within that rejects the desecration of your own species and produces a visceral reaction. I was told you learn to control it, but that it never really goes away and to be honest, I'm glad. I'm even a little proud that I got sick (especially that I held it together until later, when none of the doctors could see) because it proved that despite my ability to be detached, I have not lost my empathy.

You're probably thinking... but you're going to do this in gross anatomy. Well, yes and no. One, those bodies are preserved (less blood). Two, they are skinned (much less human looking). Three, the faces are draped (again, less human looking). Four, they are adults, not babies. But, yes, I will have to touch dead bodies again.
And if I "boot" when I do it, I promise to tell you all.

Why I sometimes don't like people

While waiting for the trolley this afternoon, I found myself standing near two young men and one older gentleman. In the five ish minutes we were waiting, all three of them spat at least twice. Which begs the question, when did it become kosher to spit in public? And not into a trash can, but onto sidewalks and public platforms. No one enjoys the spectacle of watching someone hock a lugie and I'm fairly sure no one wants to step on said mucus so why, oh why, do people spit in public? This is not the wild west - we are not all chewing tobacco and furnishing our living rooms with spitoons; I mean, come on, use a tissue, please?

Bill Gates never took chemistry

Microsoft Word spell check suggestion for a-l-d-e-h-y-d-e: b-a-l-d-h-e-a-d-e-d.

Get in the boat, fishes, jump in the boat!

First, 10 points to whomever gets the reference that is the post title. Not that the points are good for anything, but you can say you have them. Second, before I even describe the picture to the left: yes, I am aware that whales, even gray ones, are not fish. They are, in fact, mammals. Of the Baylean variety to be specific.

As you may have guessed by now the photo is of gray whales migrating off of the coast of California. The island shown is Anna Cappa, one of the Channel islands. This is about 15 minutes from where my parents live (well, the dock on the mainland anyway, it's another 40 by boat) so while visiting them we took a little romp on the ocean. Only one person on the boat got seasick, which is amazing, because it was so calm. Who gets seasick in calm waters on a sunny day?

The other photo is of sea lions (you can tell they aren't seals because they have ears): one male and one female. If you guessed the fat one is the male, you're right. I could insert a snarky comment here about why men are fat but in seals the women are the fat ones so it's a bit of a wash.

Next planned adventure in California: summer 2008: golf.

Oh, the things we loathe

Tomorrow morning, first thing, I will go to the dentist. I would rather walk naked through the freezing streets of Philadelphia, but no, I will go to the dentist. I would rather receive ten tetanus shots, but no, I will go to the dentist. I would rather give up ice cream for a month, but no... I will go to the dentist.

They will pick and scrape and drill and I will squeeze my eyes and fists shut. I will repeat (to myself) over and over: it's a few hours, it's only a few hours.

Freshly numb, yet somehow still in pain, I will walk the six blocks west and lie down again. My mouth will stay shut, but my legs will spread as another doctor will poke and prod inside.

Sore on two ends and probably still drooling, I will go to work.

Help.

Bummer

I had a little abstract prepared to submit to the Pediatric Academic Societies annual meeting (in Hawaii). It's customary to run these things by the Director(s) of the department(s) relevant to the abstract. Well, one of them killed my abstract. He won't let me submit it. Boo. And not because it's bad science, but because he's afraid we'll lose referral business.

Medical school admissions update

Left: Chasing sunset on a plane to St. Louis.

Applications completed: 23
Interviews offered: 12
Rejections: 3
Acceptances: 3

Organic Lab

Catalytic Hydrogenation of 4-cyclohexene-cis-1,2-dicarboxylic acid. We used a syringe to inject sodium borohydride while boiling the solution with chloroplatinic acid and activated carbon in a steam bath. The inflated balloon indicates that hydrogen gas is being produced and thus the solution is under pressure (sealed container).

It's exciting because I used a syringe. Twice.

THE reason to get a Wii

Guitar Hero.

I played it for the first time this weekend.

A Mazing.

Even XKCD commented: Comic 70

Song added to my playlist because of Guitar Hero: Monsters by Matchbook Romance

Le Nozze Di Figaro

On Saturday night we headed to the Metropolitan opera to see Bryn Terfel and Simon Keenlyside in The Marriage of Figaro. It was a spectacular performance, but Anja Harteros stole the show. She played the Countess and received a longer standing ovation than either Terfel or Keenlyside. Her act II aria "Porgi, amor" and act III aria "Dove Sono" were riveting. Ekaterina Siurina was a lackluster Susannah in the midst of such a powerhouse cast; really only shining in her act IV aria "Deh! vieni, non tardar." It was only too apparent in the act III duet "Sull'aria" which soprano was carrying the show. There were two hilarious moments; one when a prop rolled off the stage and hit a cellist in the head (she finished the act and left), and another when Figaro motioned to Susannah to spank him in Act IV. Clearly, the Met and Terfel have a sense of humor.

On a different note, the dinner we had afterwards was also quite spectacular. Yum.

Go Blue!

I'm in!

Awww...

... he bought me flowers!

A common sight recently...

No plane.

Bacon or Chocolate?

In Vegas three of us discussed a theory that any food could be improved when accompanied by either bacon or chocolate. Some are an easy call: a turkey sandwich calls for some bacon while a cheesecake calls for chocolate.

Now I would have put Diet Coke in the chocolate column, but apparently I was outvoted because somewhere you can get Diet Coke with Bacon.

Question though... diet coke is kosher. Is diet coke with bacon?

In Boston?

This appears to be a wild turkey. He was just ambling around the block in the rough vicinity of MIT. I would posit that this is a dangerous time of year for a large, tasty turkey to be out for a stroll.

...awkward...

About five minutes into my (non-Harvard) medical school interview...

Faculty interviewer: Have you ever been to Boston before?
Me: Yes, once. It's a great city.
Faculty interviewer: Was it to interview at Harvard medical school?
Me: ... yes.
Faculty interviewer: What did you think? You're exactly the type of person they like.
Me: Well, I think has good and bad qualities like every other school.
Faculty interviewer: What about UPenn, when are you interviewing there?
Me: I don't have an interview there.
Faculty interviewer: Yet. My daughter went there. She lived in University city. You don't want to live in the ghetto though. She almost went to Columbia, are you interviewing there?
Me: They have not invited me either.

I actually ended up liking the guy, but what a stressful start!

A month of travel

Someone emailed to remind me I haven't posted in a month. True. And I have no excuse because my hotels had internet access. I was in Pittsburgh, Boston, and Atlanta to interview at medical schools and in Vegas to, well, blow off some steam.

For those of you keeping score, I have 9 interview invites, 2 rejections, and 12 haven't-heard-yets.

Tomorrow I have my neuroanatomy midterm (yikes) for which I am incredibly unprepared. This is partially due to travel and work and partially due to my going to Vegas instead of studying.

Vegas was phenomenal. I gambled (and won - Pai Gow!), first with someone else's money (what better way to learn) and then with my own. I ate (a lot), I sunned by the pools (tan = no, bikini debut = yes), I watched sports and drank beer in the sports book (go Steelers go Rockies), and I went clubbing (VIP, skybox: balcony over the dance floor = awesome). I took a red eye back, went straight to work and ended up in bed by 8:30pm (totally exhausted) for a nice 11.5 hour snooze. Four days of fantastic.

Flash back to now... sore arm from a flu shot, totally unprepared for a midterm, pre-lab to write and more travel to come. Oh, and I'm cold (not a surprise).

The next two weeks: Nov 5-6 Boston, Nov 7 NYC, Nov 12-13 Cleveland, Nov 15-16 Ann Arbour

If I get in somewhere (two letters potentially on their way) - you bet your cute little butt I'm gonna post.

Spinal Innervation

We did the entire spinal cord in one night in neuroanatomy lab. Granted, from a gross dissection point of view, a lone spinal cord is not much to look at. But when you consider the rather extensive innervation it becomes quite a daunting task.

Which organs, muscles, and body parts are innervated by which nerve tracts? How many interneurons for this system and what kinds of reflexes are involved? What will sympathetic or parasympathetic activation lead to? Which lamina of the vertebrae are receiving this type of input?

For those of you with some bio/neuro, recall that activation must also involve some reciprocal inhibition, so even a basic (monosynaptic) stretch reflex stimulates a cascade of firing.

I think next week we move up the brainstem to the medulla (mylencephalon). And we'll get our exams back. Ick.

Defending the men

Apparently there is a happiness gap between men and women: the women are less happy. When economists and readers of the New York Times were asked to explain the gap, the usual suspects were brought up: women are expected to do more (paid work and house work) and suffer under the societal standard of being and looking perfect. This whole problem was then laid squarely at the feet of the men and their apparent expectations and laziness.

This is totally unfair.

First, a huge percentage of what we do is to impress other women, not men. A decent proportion of these "standards" come from women's magazines - one big reason I don't read them. It's time to accept that you cannot and will not be perfect at everything and that the only person annoyed by that is you, not your husband/boyfriend/father.

Second, men do no expect us to look like supermodels all the time. In fact, there a lots of men who prefer a girl in jeans who will eat a burger and go for a hike than one who is in 3 inch heels, a mask of make-up, and refuses to eat non-lettuce items. And this cuts both ways, the perfect male physique is shown in movies (Brad Pitt) and on magazine covers, they have the same pressure we do.

Third, when was the last time you asked a guy to help with the housework? I am willing to bet if you sat down and divided the duties, you would be pleasantly surprised with how much they're willing to help out. In fact, I know plenty of men who are quite happy to stay at home more while the wife builds a career.

It's time we stop blaming men for our lot as women and shoulder some of the responsibility ourselves. Why are young girls unhappy? Because other girls are so mean (remember the book on sororities... girls can be vicious). Who is creating this pressure to be the perfect everything all at once? We are.

Neuroanatomy

The first neuroanatomy exam is Wednesday so I am, of course, furiously trying to cram names like sulcus limitans and stria habenularis into my brain. I labeled photographs, I have made lists of key terms, I have flipped through slide sets and I have read the textbook and somehow this subject flummoxes me. Well, not the material itself, but rather, what is the best and most efficient way to study it?

It is great practice for medical school, where will have to learn more than just neuroanatomy. If I can figure out a strategy for this class then maybe I'll be a step ahead in general anatomy. If.

Medical school admissions update

# applications initiated: 27
# secondaries received: 25
# secondaries completed: 22
# confirmed complete apps: 20

# interviews offered: 6
# acceptances: 0
# rejections: 1

I deserve a cookie.

A moment of victorious immodesty: I just cranked out a 115 page IRB protocol for constraint-induced movement therapy in 4.5 days.


update: It was pushed to the October 3rd review. : (

Seen in NYC

"Beware of enterprises requiring new clothes." -Thoreau

Apparently, if you're dressed entirely in white, you can lawn bowl or play croquet on dedicated, manicured lawns in central park. Who knew?

Also seen in NYC this weekend: A man on a drag racing tricycle still living the funk, a dog wearing a pearl necklace collar, and a trumpet & tuba band playing (and wandering) the upper West side at 10:30pm.

Overheard in NYC this weekend:
uncle: I really like our hotel here. The location and service are great.
niece: Do we get HBO on demand?
uncle: I don't know.
niece: I don't like it then.

And to end... a nice bit of procrastination: me. Simpsonized.

Paying doctors less

There was an article in the New York Times recently arguing that the best and fastest way to decrease the cost of health care in the short term was to pay doctors less. I think the best way to decrease health care costs is to pay lawyers less. After all, less pay means fewer lawyers, fewer lawyers means fewer lawsuits, fewer lawsuits means lower malpractice insurance, lower malpractice costs leads to lower patient care costs. And honestly, what part of society, health care or otherwise, wouldn't be better served with fewer lawsuits?

Regardless of my lawyer pay scheme, there are several important reasons not to lower the pay of doctors and arguably, to increase it.

First, becoming a doctor incurs more debt than any other profession so salaries are needed that can cover the cost of living and the cost of paying back loans. In 2006, the average medical student graduated medical school with $130, 571 in educational loans (that does not include loans to cover the cost of living, which average another $16,689) with 72% of graduates carrying a debt load greater than $100,000. That's an 8.5% increase over the previous year (1). Assuming a 5% interest rate, a graduate needs to budget $7,363 per year just to cover the interest on the loan.

Which brings me to the second point. Doctors make almost no money until after their residency. For example, the pay schedule for residents at UT Southwestern in Texas is listed below (2). That's a 3-4% increase annually, which barely tracks the current inflation rates (3). So a medical resident is carrying a six figure debt load and earning roughly the same salary as the maintenance workers (4) (who I assume have less school debt and little specialized training). Now lets consider that residents work at least 80 hours per week, while the maintenance worker pulls only 40. Hourly, a resident makes less than a babysitter. Compare that to a law school graduate who gets a job at a large law firm and receives an average starting salary of $99,000 (5).

Third, there is the effect on lifetime salary. While most twenty-somethings are paying nice sums into their401K and reaping the benefits of matching funds and compounding interest, medical graduates are paying all their money to their creditors. Considering the average entrance age into medical school is 24 (6) and most residencies are at least 3 years, a medical graduate will be 31 before they have a chance of receiving a salary that would allow them to save for retirement or pay off the principal on their loans.

Lastly, let's look at who in the medical field is getting particularly high salaries and why. Your GP is probably barely covering the cost of his/her practice, not making millions per year. At the hospital I work in, there are some doctors pulling seven figure salaries, but they are highly specialized: pediatric cardio-thoracic surgeons for example. That surgeon did 13-14 years of post-medical school training so he was in his forties before he made any money. If you paid doctors like him less, no one would go through the incredibly lengthy training, take on that level of risk, or be able to retire before 80.

There are a few rock star dermatologists or plastic surgeons who command high salaries, but there are a few people like that in every profession. Their wages are not indicative of the thousands of doctors practicing every day and those are the doctors that will be put out of business if salaries are lowered. Not to mention how many fewer bright young people will aspire to become physicians instead of bankers or lawyers. Paying doctors less is not the answer; the result from reduced pay is fewer doctors and therefore longer waits and a lowered standard of care.


Sources
(1) http://www.ama-assn.org/ama/pub/category/5349.html
(2) http://www8.utsouthwestern.edu/utsw/cda/dept200270/files/214265.html
(3) http://inflationdata.com/inflation/inflation_rate/CurrentInflation.asp
(4) http://www.co.monterey.ca.us/personnel/SalaryPost.asp?jt=72C19
(5) http://www.collegejournal.com/salarydata/law/
(6) http://www.vault.com/articles/The-History-of-Medical-Schools-in-the-U.S.-27653519.html

Perpetually connected

I have joined the ranks of the perpetually connected... it's no longer my shadow and me, but instead, my Treo and me.

And I'm thrilled.

YAY!

# of schools applied to: 25
# of secondaries received: 19
# of secondaries completed: 8
# of interview invites: 1

Playing neurologist

I shadowed Dr. L in clinic recently and it turned out to be particularly eventful. The medicine itself is always interesting, but this time it was the patient's behavior that made it memorable. We saw a girl who was recovering from stroke for a routine follow-up examination. Throughout the exam she was staring straight at me and refusing to acknowledge a single question or command posed by Dr. L. After trying one last time to get her to follow his finger with her eyes, he sat down and looked at her. She finally looked him in the face, pointed an arm straight out at me and said "I want her to do it." Dan looked at me, nodded, and I walked over and stood in front of the girl. I have seen at least fifty basic neurologic exams performed and could describe it in lurid detail, but standing there performing it was absolutely nerve wracking. Dr. L was standing immediately behind me interpreting everything I was doing... I was in no way evaluating the patient; I was simply the body she interacted with.

The next patient was another female, clearly somewhat on edge. Dr. L introduced me and a visiting physician (also shadowing) and began a conversation with her. Three sentences in she announced "I know you don't think I'm going to discuss my business with all these people in the room." I promptly offered to leave to make her more comfortable, but she countered, "you can stay, but the other one has to go." The visiting physician left the exam room (I would later learn she was uncomfortable with men, as the visiting physician was male, it was simply a matter of gender). She began telling a (rather sad) story about recent events and while she was talking she curled up into a ball on the exam table. When Dr. L turned to get a pen from the desk, she hopped off the table, ran across the room to me, and gave me a bear hug. After a few minutes she released me and sat in my lap. The rest of the visit was conducted with her on my lap, one arm around my shoulders.

Most of Dr. L's patients have met me once, many of them at least twice now. Quite a few remember me when they come in and ask me how school is going, which is really quite remarkable to me. After all, I am silent most of the time, just watching and smiling. Apparently though, they are beginning to feel comfortable with me, which is a great feeling. I hope this carries over to my future career, that my patients feel they can trust me and be open the way these two girls were. The way all Dr. L's patients are with him.

Summer sports

Since I'm not taking classes this summer, I've been trying to be more active. I don't have a gym membership, but that's really a good thing as I much prefer excersize that doesn't feel quite so pointless as running in place indoors. Instead, I've been playing lots of tennis and have taken up yoga - the kind done in a 95 degree room.

Tennis has been fantastic since so many people here play and it's super cheap for students. I'm now playing twice a week - one day of clinic and one day of matchplay with friends. I can feel my game getting a little better each time, which is really encouraging and just makes me want to play more. I'm working on learning a backhand slice approach shot and eventually I really need a better second serve.

Yoga has been quite the experience so far... I was incredibly sore all over after the first class, but the second was invigorating. It really is remarkably calming and I don't notice the heat at all. I'm relatively flexible, but I had no idea I was so weak! Well, maybe I had some idea, but this really confirms it!

When I was in Cali visiting my parents, I went rock climbing with a friend, Mike. It was really good fun and I'm hoping we'll go again when I head back there in late August. That's definitely a sport where I need to work on my upper body strength, but it's a great feeling when you get to the top of a route you didn't think you could do. Repelling down is pretty good fun too :)

Medicine is already paying off

While in nyc to celebrate Swati's birthday, four of us piled into the back of a cab to get from the financial district to East midtown. Someone asked a question about research and I made some mildly medical comment in response. The cab driver then turns towards the backseat and says, "My hemoglobin is 9 and I have diabetes, should I be worried? What do I do?" I babbled something about glucose and blood transfusions (did he mean his hemoglobin level or his hemoglobin A1c?) followed by a strong wording of caution that I was only a student and that he should speak with his regular physician. His reply - "you are a very good doctor, I turn the meter off now."

A night in the city

It was a friend's birthday this weekend so I headed up to nyc for a celebration. Other friends from college, now in Ohio or D.C., also came up, turning this birthday party into a mini college reunion. I am ashamed to say I had been out of touch with some for two years; unless you count Facebook as meaningful interaction.
There was lots of laughter, a total of six cameras to record the event, and much frustration over the Duane Reeds in the financial district. If they all close at 6pm, where can a girl get some double-sided tape before a night out?
On the train on the way back I ran into a student from the weekly tennis clinic. He graduated to the super-secret, advanced clinic (I'm still intermediate) but after swapping stories for an hour on the railways we decided we could probably still play together. I'll just lose. Every time. Which is ok.

Application update

Anyone who has been following this little blog over recent months knows that I am applying to medical school at the moment. Or rather, medical schools. My amcas has been verified and 23 schools now have my application... scary! I've begun working on secondaries, which pretty much just ask you to re-hash your amcas under different word count limitations.

Paperwork seems to be my theme at the moment (thus no cool medical stories) because work has been nothing but IRB and NIH reporting recently. Two of the three doctors in the group are away (Korea and Geneva) so all is quiet on the Neuro front.

In the sunshine state

Going to visit my parents in southern California turned out to be the best decision I've made recently. My brother and two college friends were in attendance as well, so it was a bustling, full house. We baked bread pudding, which took about three hours, and ate fish, mexican, ahi tuna, and flank steak. We went through quite a few bottles of wine and soaked up the evenings in the hot tub watching for falling stars. We walked, we drove around in the convertible, we rock climbed (sore arms!) and we lounged around.
I'm not really ready to be back, but I guess that's the sign of a well-spent vacation.

A real summer

For the last few weeks this little academic turned into a little socialite. There was tennis, bruchetta, wine, rum runners, bread pudding and strolls though the park. I'm hoping the tennis will continue, and I may be adding in yoga too.
I am hopping over to California for the July 4th weekend to see my family, and then hopefully up to NYC for a close friend's birthday.
In the fall my academic side will return with Nervous Systems lab (brain dissection class) and Organic Chemistry lab.
As much as I am loving the time to see my friends and the absence of exams, I am still not entirely sure what to do with myself when there is no homework!

For those of you not familiar with the rum runner:
1 shot dark rum
1/2 shot 151 rum
3/4 shot banana liquor
3/4 shot blackberry brandy
1/2 shot grenadine
3/4 shot lime juice

Drink slowly.

My very own brain

This, to the left, is my brain. As in, the one in my head - the one I use every second of every day. Cool.

For those of you with no neuro background, let's name some structures.

1 Cerebellum
2 Medulla oblongata
3 Pons
4 Pituitary (right above the point of the 4)
5 Cortex
6 Splenium
7 Fornix
8 Septum pellucidum
9 Corpus callosum
10 Meninges: dura, arachnoid, pia

For the record, I have a normal brain for someone my age. The funny dark patch on the top of my head is cerebral spinal fluid (CSF), which is visible because the interhemispheric fissure was not fully perpendicular.

Interventional Radiology

I shadowed a third year fellow in the cardiac cath lab today, watching two interventional procedures. The first was the expansion of a stenotic bicuspid aortic valve and the second was the closure of an atrial septal defect (ASD).

Note: The cath lab pictured is at Columbus Children's, not where I work. They look the same, though.

During the first case it took almost two hours to get access - meaning to establish a catheter in a femoral artery and femoral vein. In this case it was important to have both because we wanted to measure the blood pressure in the left ventricle and in the aorta. Ideally there is no difference; in our patient there was a 100 mm Hg gradient. This indicates that the aortic valve is very stenotic (narrow) - a condition that eventually requires a valve replacement. Valve replacements in children are to be avoided so there are two ways to buy some time: 1) expand the valve with a balloon in a catheter procedure or 2) open the chest and scrape the valve in surgery. The procedures carry approximately the same rate of complication, but each carries a different complication. Surgery generally leaves residual stenosis and interventional radiology tends to produce aortic insufficiency (backwards flow through the valve from the aorta into the ventricle).

The second case involved using a yo-yo looking instrument to plug a hole in the septum separating the two atria. If you look closely at the picture to the right you can see it in the top, just right of center. Once the catheter enters the heart, it is threaded through the hole (technically called a patent forman ovale, patent indicating open) and the first half of the yo-yo is deployed. The catheter is retracted through the hole and the second half of the yo-yo is deployed. It's very important that the placement is correct because otherwise it could loosen and go bumping around the heart or even enter the systemic circulation (depending on the size and type of closure device used).

Interestingly, you cannot actually see the outlines of the heart when doing a cath procedure. All the monitors carry continuous x-ray images and if you've seen an x-ray before you know that it's nearly impossible to see tissue with any resolution. That's how well these guys know the heart. They can tell by the ribs and chest cavity around it exactly where they are inside it. When appropriate, they will use a simultaneous ultrasound though (on which you can see tissue and blood flow).

At the end of the day, I'm not sure this is my new specialty of choice. It was incredibly cool to see and the people who work in the group were really fun (the atmosphere resembled a sports team pre and post game), but the patients are sedated the whole time you are with them and man, those lead aprons/vests/thyroid glands are heavy and hot!

Notes from a long weekend

Borrowing from TWM... a few notes that came to me while (finally) relaxing for a long weekend.

• Shrek 3 is the funniest of the Shrek movies and it deserves kudos for not becoming a 120+ minute epic. Bonus great preview: Ratatouille.
  
• Spiderman 3 had a few thrilling moments, but they were so diluted by the marathon length of the film that ultimately its not worth the $12. If you must, Netflix it.
• A friend of mine was brutally attacked by a classmate last week. You just don't think these things happen to the people you know... but then it does. Get well L____.
• I went to three brain autopsies last week - very cool. I may have to turn this into a full post once I look up some more about kernicterus.
  
• I saw Atul Gwande speak last Tuesday. He is a charismatic man who writes medical stories with the same flair Levitt and Dubner brought to economics. If you need a good book, I highly recommend Complications or Better.
• Grey's Anatomy, much to my dismay, has become the Desperate Housewives of medicine. Remember when they had patients? Remember when there was actually some medicine on the show? On the other hand, I am loving Stanley Tucci on ER.
• Ben & Jerry's recently updated their flavours. I am happy to report strawberry cheesecake is alive and well and I am quite enjoying the new Willie Nelson's peach cobbler.
  

Hear me roar

Fortune has an article in it's current issue describing the entrance of Gen-Y into the post-collegiate working world. Apparently we are the most demanding, least loyal, most connected, least apologetic generation to date. That sounds about right.

I am a prototypical Gen-Yer. I left my cushy banking job for exactly the reasons this article outlines: I did not have a sense my career was moving anywhere. I did not feel like I was doing any meaningful work. I had no real responsibility. In fact, I had more responsibility running the job fair for my university than I had at work; why would anyone stay at a job that feels like a demotion?

We did have international training exercises, which were a good idea: we networked with other young hires at the bank and got a sense of the global business. Our mentors on these exercises were upper management (again, good idea). But there was no follow-through. We would perform well, get fantastic feedback, and go back to 60 hour weeks pushing F10 and occasionally F12.

I was willing and ready to work 80 hour weeks and solve real problems. Hard work and little work-life balance were fine with me if I had a sense I was invested in my job, if I felt like I was needed and making a contribution. I wrote a strategy paper on how to make our entire North American derivatives business client focused and the comment I received back was: it's 200 words too long. In true Gen-Y style I cut 203 words from one section and replaced them with "see Appendix C". Then I quit.

If I'm going to "do my time" I'm at least going to do it somewhere I can make a difference. I am training to become a physician and during my internship and residency, my "slog", I will at least be making a contribution to the health of the people I meet. It may be a smaller scale than global finance, but it's also a more meaningful one.

I expect great things of myself. Call it hubris, but I find it insulting if you expect less of me than I do. I do not accept that I should work at less than my full capacity because I am young. Age should not determine responsibility; ability should. I am superwoman.

And apparently there are 79.8 million of me.

Where are you from?

I have always found this to be a particularly difficult question. And I always thought this made me weird. Nationality, or a defining point of origin, is central to our way of identifying ourselves and each other. But how do I answer it? I have two passports, where I was born is not where I lived the longest, my first language is not my best language and I am an immigrant to my father's country.

While browsing Wikipedia while studying for my organic chemistry final I came across something startling: I am not the only one. Ok, so that's not the surprise of the millenium, but I certainly did not think that people who had grown up in multiple cultures would be a unique sociological group. But we have a name: Third Culture Kids.

Quirks

A little while ago TWM referenced (and a long while ago responded to) a short meme asking what he didn't like that most people did. I thought it an interesting topic of conversation and brought it up at work, where it has now become a common non-sequiter to mention an example as it pops into our heads. Here, for prosperity's sake, are a few of my own.

1. Cheese - I can't stand it. To the point where it makes me physically ill. It could be an allergy or it could just be years of loathing that have conditioned a physical response.
2. Shrek - yeah, it just wasn't that great. For me. I didn't laugh, I didn't cry... I just yawned a bit.
3. Bob Marley - his music simply irritates me. It drains my patience.
4. Doughnuts - it's something about the texture.
5. Lying on the beach - it's boring and I always always always end up sunburned.


And to add a category: things I love that other people don't seem to:

1. Neck ties - I think they look distinguished and polished. If girls didn't looks like want-to-be punk rockers in them, I would wear one with my suit.
2. Oxfords - Men have an abundance of choices for this shoe, but what happened to the women's oxford?
3. English food - scones, custard, treacle tart, bangers and mash, fish and chips, cottage pie... what's not to love?


Oh, and pet peeves is a good one too (now I'm just getting carried away):

1. Using the "is" with a plural noun (even if you pronounce it as a contraction, "there's", it's still wrong).
2. Riding the elevator down one floor (um, stairs?).
3. Answering your cell phone in the middle of a conversation with someone who is physically sitting with you.

On becoming a American Democrat

Despite being a citizen from birth, it took me a long time to become an American. I was born abroad, lived my elementary years and happiest teenage years in the United Kingdom and have travelled extensively throughout my life. As a result, I was able to see America through the eyes of the rest of world: as a materialistic, selfish, ignorant and greedy brute. For years I held tightly to my European identity, steadfastly refusing to be lumped in with the rest of the American herd.

Of all the things that could make me look past the surface of what it means to be an American, it was a popular tv show that changed my mind. The West Wing, and not my AP US History class, showed me the power of what is written in the US constitution. For all the idiotic ways it's thrown about (freedom fries anyone?) freedom really is a powerful concept. Similarly, the separation and balance of powers. If you don't get a sense of awe when you think about our constitution, I suggest you take a course on world politics or rent a few seasons of West Wing.

I will admit that my father is a republican and I inherited my first political ideals from him. But even as I began to formulate my own, there was a lot to love about the republican party. I'm not talking about Bush Jr. and what you read in the NYT each morning, I'm talking about what the republican party originally stood for: individual liberty. To be a republican was to believe that people behave best when they are allowed to choose for themselves. That government should not legislate a moral agenda and that the constitution must be held sacred.

Unfortunately, the current version of the republican party more closely resembles the Catholic church in the middle ages than the founding ideals of the republicans. Apparently we are no longer capable of teaching our children morals, so we should put the 10 commandments in schools (violating the separation of church and state in that sacred constitution). Apparently the freedom of choice does not include those who disagree with what you would do with that freedom; if you are going to have gay sex or abort your pregnancy, you should no longer have the right to make your own choices. Apparently people cannot even be trusted with information, because if teenagers were taught to use a condom, they would all be having porn-style sex daily.

Let's not forget that one of the tenants of Christianity is to convert the non-believers. Our foray into Iraq is the ultimate mission - restyle the country in our own image. Bush's use of the word crusade may have been more appropriate than we are comfortable with.

His administration at home is run like the old church too - sealed executive orders, favours to friends, corruption, scandal, and a host of falsely accused victims (the attorney generals who where fired for... anybody?). His appointees appear to be chosen on the basis of their religion and not their resumes (Paul Krugman wrote an great editorial on this in the NYT).

And so I cannot, in good conscience, support the republican party. If I must institutionalise something, I would rather codify deed than thought. I would rather legislate welfare than religion and I would rather sacrifice free markets than free choice.

West Wing made me an American and evangelicals made me a Democrat.

Summer

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.

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.

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...

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

[Chorus]
Come here doc
Do a neuro exam
Hemiplegia
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...

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

[Chorus]

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.

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?

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.

Since I didn't see the movies...

I'll just comment on the clothes.

Best dressed goes to Cameron Diaz for a fun gown that matches her personality perfectly.



Runners up: Reece Witherspoon, Helen Mirren, Nicole Kidman

Worst dressed, and this was tough as there were several good contenders, goes to Kirsten Dunst.



Runners up: Jennifer Lopez, Gweneth Paltrow, Jessica Biel

How little we know

One of the neurologists for whom I work offered this perspective on modern medicene, "we have only two cures, antibiotics and surgery. Everything else is comfort."

I think he's right. Antibiotics actually kill the organisms they are designed to fight; they are an eradication mechanism. Surgery is a more extreme method to accomplish the same; eliminate the contaminant. Neither antibiotics nor surgery (if administered or performed correctly) create any additional illness or lasting ill effect.

No other treatment can say the same. Take, for example, chemotherapy. There are people who have experienced life-long remission after chemotherapy, but they also have life-long side effects. Bone loss and immune damage to name just two. Many people laughed at a recent episode of Gray's anatomy in which a cancer patient had "toxic blood" due to taking an herbal supplement while on her chemotherapy. The portrayal may have been extreme, but cancer patients are warned not to take herbal supplements because of exactly that reason; it can cause serious, toxic interactions.

Many medications are intended to provide something your body cannot self-regulate. Examples would be insulin and thyroid hormone. Less obvious ones are vasopressors and anticonvulsents. These medications do not eliminate the condition; they alleviate the symptoms to improve quality of life.

Then there are the whole host of illnesses we cannot even begin to address. How do you treat Alzheimers or Parkinsons? MS? HIV? All we can really do there is slow the progression, sedate the patient, or mask the pain.

I am not arguing that medicene has no worth or that these treatments should not be given. Quality of life for a patient with any condition, from heachache to leukemia is of paramount importance and should be continuously addressed. But I think there is something to be said for perspective. Doctors are not gods or miracle workers and we cannot and should not hold them to that standard.

There may be much we can treat, but there is very little we can cure.

Not-so-dead language

This morning I was told that I would have to be at work at 6:15am tomorrow morning in order to do the research part of a pre-op research MRI.

This generally involves preparing the MRI suite by stocking the bed with hot packs, warm blankets, assorted pressure cuffs and blood gas syringes and programming the monitors for a neonate (baby less than 28 days old). Then, if all goes well (it's about 7am), the baby is brought down from the NICU (neonatal intensive care unit) to the scanner by the anesthesiologist who will participate in the baby's impending heart surgery and the baby is placed in the scanner for an hour. I spend most of this hour recording vitals, sedation doses, running blood gas samples and results slips back and forth to the cath lab (catheterisation lab) and, of course, eating donuts. Then the baby goes off to surgery and I go back to my usual job (it's now about 8am).

Later this afternoon, however, the scan was called off because we couldn't get consent from the parents. They were not unwilling, so far as we could tell, but unfortunately no one speaks their primary language and I honestly haven't the faintest clue where to get ahold of a translator that speaks Aramaic. Yes, that's right, Aramaic. As in, lanuage commonly believe to be the one Jesus used and is generally thought to be less prevalent than Latin. I mean, how many high school Aramaic clubs have you heard of?

In the few hours that I was seriously pursuing the idea of getting a translation made of our consent form, I learned a little about the Aramaic language. It is, rather logically, an Afro-Asianic, Semetic language whose status is not actually "dead" but "endagered". It is the original language of the books of Ezra and Daniel and is the primary language of the Talmud. 400,000+ people speak modern Aramaic, mostly Assynians, though the communities are small and geographically scattered. It is frequently confused with the Ethopian language Amharic (also a Semetic language).

In case you are curious, the baby needed heart surgery for a transposition of great arteries (TGA), which is exactly what it sounds like. The pulmonary artery is joined to the left atrium and the aorta is attached to the right atrium (in a healthy person it is the reverse). The net effect is that the blood in the pulmonary (lung) circulation does not get to the body and the systemic (body) blood doesn't get to the lungs to be oxygentated. There is a small amount of mixing, facilitated by the ductus arteriosus (a small duct between the two arteries) that is artificially kept open through the administration of prostaglandins.

A rock and a hard place

I am at the point in the get-into-medical-school process that requires the most commitment, the greatest resolve. I am taking the MCATs. Well, more precisely, I am studying for the MCATs so that I may take them on May 11th. I'm also in Organic Chemistry II, which I honestly wish would just fade into the background because I don't want to bother with it. It just seems so much less important to do well there than on the Big Exam except for the teeny tiny caveat that I've asked my organic professor for a recommendation.
I have realised that assuming I could do the above while continuing to work full time was a tad ambitous. And yet, I also have the nagging suspicion that if I were somehow to be more efficient, it woun't feel like such a burden. The thing is, I like eating with my books closed for a few minutes. I like taking a couple of hours on Sunday to eat pancakes and watch Meet the Press in my PJs. It keeps you sane - giving it up for one week, no problem, giving it up for a whole semester while you burn yourself out like a roman candle - yes problem.
Managing my time and shoveling knowledge into my head, while stressful, are not the biggest reason this requires resolve, however. No, the hardest thing to stare down is my opportunity cost - what did I give up to do this? I gave up New York City, no small thing as it's the only city I get homesick for and I've never had roots or a "home" in the classic sense. I gave up a really nice salary and all the comfort that buys. I gave up any semblence of a social life, although to be fair my job limited that too, though to a lesser extent.
I gave up the life I always thought I wanted, grew up aiming for, because I didn't want my boss' job. Or her boss' either. On some days, maybe after a hard organic quiz, I wonder if it was all a little drastic. If sacrificing the rest of your life for a little engagement at work is really such a great trade off? I'm living to work and I'm pretty sure that takes 10 years off my life-expectancy and doubles my risk of heart attack. I would love to say that stepping into the hospital makes me remember why and sometimes it does. I wanted to do something that allowed, if not forced, me to be a perpetual student and I've found it.
Maybe what I'm really feeling now is not the cost of what I've done, but more simply, reality settling in. No one job is going to make my life perfect and all the possibilities cost something. I have chosen to be happy at work even if that means sacrificing much of my outside life. Staying in finance would have meant a comfortable life but long hours at job I loathed.

I have this whole conversation with myself pretty often and I find it comforting that by the end I always conclude I did it right. Hating what I did turned me into a person I didn't want to be and even now, even with the MCATs looming I am generally happy and optimisitic. I don't have an overwhelming certainly that this is what I was meant to be or that I couldn't be happy with another profession, but that doubt makes this real. If there are no doubts, you didn't think hard enough. It's like the MCAT verbal questions: you rule two out and then go with your gut.

Adding to the family tree

At the wisened old age of 24, I have become a great-aunt. My nephew just had his firstborn, Warren Ashley.

On an unrelated and amusing note, one of the investigators I work with is doing a study on visual field cut after stroke (in children). She is testing it using several custom built (simple) games on a touch-screen computer. Recently a child turned to her mother during a testing session and asked for the game for Christmas.

Almost anniversary

We're coming up on one year of post-baccalaureate study so I thought it would be a good time to reflect on what I've learned. Put another way... chapter 9 in organic chemistry just doesn't sound like relaxing Sunday fun.

1. There really is a difference between old schools and new ones. My current institution has a huge endowment and my alma mater, well, it doesn't. Both are great schools, but the facilities the endowment affords really are nice. Several large libraries, each with sturdy wooden tables, lots of private study rooms (with laptops and plasma screen tvs), and laptops you can borrow for 4 hours. A 4 story gym with lots of equipment so you don't have to wait for machines or court times. Edible food.

2. There really is a difference between a top tier university and a middle tier. I'm sure you can do great things attending either, but at a great school the opportunities come to you. Brands, even when it comes to education, have power.

3. Organic chemistry is not as scary as Matter and Interactions II (honours physics II). S. and C. must have been out of their minds when they designed the curriculum for M&I II. They took a subject I loved and made it hell (bad enough I left the major), wheras organic is actually kind of fun. My hexane has a first name, it's c -y -c -l -o...

4. Getting into medical school really is that hard. There are so many hoops, most of them totally pointless and it costs a fortune.

5. Academia is just as political as the "real world". Grant money and tenure are no more a meritocracy than any other industry. The tweed and white coats just make it look that way.

6. Coffee. It's not longer recreational use.

7. Saturday labs really do suck, no matter how late they start. I've had Sat. lab for the last year, first at 9am, then 12pm, now 11am... and nothing sounds better than next semester when, for the first time since returning to school, I will have no lab class!

8. I am not a party girl. I used to look with envy at the people with busy social lives in college, but honestly, I very much enjoy dinner or a movie with friends and wearing my PJ's as much as humanly possible.

9. Diet coke is better than diet pepsi, and sierra mist free is better than diet sprite.

10. I'm going to enjoy being a doctor (but I'm definately not going to be a pathologist).

Back...ish

Unlike many of the more considerate bloggers out there, I simply disappeared rather than formally announcing a break. And it was a month long. Oops. Ah, but now we're heading into finals, which can mean only one thing: procrastination! And what better way to procrastinate than to write things and assume you have nothing better to do than read them?

I did my first alumni interview for my alma mater today and the student whom I was interviewing is also applying to my current institution. This worked out well for her since I was able to offer perspective on two of her choices, but now I have no formal way to notify my current school that while she's probably quite smart, she lacks that pizazz that I associate with the people I matriculated with.

In fact, she is planning on going to business school. She is the second person in the past few days that has expressed this future plan and in both cases I have proven to be a huge hippocrite. I have a business degree. I chose to get that degree. I switched out of a science degree to earn it. But I counseled both these young ones to get something else. Economics maybe, but not business. The unfortunate thing about a business degree is that is qualifies you exclusively for business jobs and you're actually still fairly likely to lose the spot to an engineer or an economist. Quant is in, so if you have the brains you are better served getting a more quantitative degree and taking the spot from a business major. I'm not saying you can't get a job with a business degree, but you better be a business kid with a whole lot of real math (not watered down business math). Well, at least in finance.

You know what the frustrating thing is? I was a business kid with a whole lot of math and do you know what I actually used when I got to my oh-so-coveted finance job? Differential equations (not required by business curriculum), writing (something employers ought to be looking at), statistics, databases, and programming. The last two also landed me my current job. It's a very good thing I got my business degree from the institution I did.

Business degrees prepare you for a job managing people, which is a job you won't actually hold in business for quite some time. Your first years are spent doing a lot of scutwork and the way you differentiate yourself is to teach computers to do the scutwork for you. That, and be able to form coherent, articulate sentences and say them without five "ums" and a "you know?". You spend four years learning how to effectively give orders and then graduate to 10 years of taking them.

There should be a new class added to the curriculum to supplement the strategy lessons: Interpersonal Politics. It should cover:
- How to get people to do what you want when you have no leverage
- How to differentiate the people you want as your allies
- How to recognise the ones trying to take you down
- How to maintain network contacts without looking like an idiot
- How to get around people in your way
- How to work with people that annoy the hell out of you
- How to deal with a boss that's dumber than you
- How to read between the lines

Actually, adding a class in No Limit Texas Hold'em wouldn't be a bad idea for the finance concentration. Poker is the Wall st. golf.

My future cat?

Vascular Neurology 101

Since a big part of my job is reviewing the charts of children who have been diagnosed with stroke, I thought it was time to put together a little quiz.

Define each of the below and label them either as 1) a stroke risk factor or 2) a stroke sign/symptom:

a. eclampsia
b. HLHS (hypoplastic left heart syndrome)
c. PFO (patent ferman ovalae)
d. PDA (patent ductus arteriosis)
e. moyamoya
f. AVM (ateriovascular malformation)
g. Otitis media
h. Hemiparesis
i. dysmetria
j. ataxia
k. aphasia
l. dysarthia
m. vasospasm
n. mastoiditis

Which pair of arteries feeds the PCAs (posterior cerebral arteries)?
Which pair of arteries feed the ACAs/MCAs (anterior cerebral and middle cerebral)?
What arterty does the PICA (posterior inferior cerebellar artery) originate from?
Where are the watershed regions located?
What is the most common pattern of ischemia for cardioembolic stroke?
What is the difference between stenosis and coarction?

For the answers... check the comments.

We have a winner!

After 2 months of haphazard testing and educated guessing I think I have identified my bacterial unknown. I'd like you all to meet the Gram +, catalse +, facultative aerobe, mannitol -, coccus that is Staphylococcus epidermis.

The same day that I identified that beauty I was given my Enterobacteriaceae unknown. So far I have concluded that it is, in fact, an Enterobacteriaceae and it is lactose negative. Soon I will be getting my PCR unknown as well... lots of investigating in micro.

Orgo continues it's march onwards... we've passed the vocab, are exiting stereochemisty, and have merged into mechanisms. Enantiomers, diasteromers, and structural isomers... oh my!

The personal statement

Part of step one in applying to medical school is writing a personal statement; traditionally discussing why you want to enter the medical profession. This is a problem because quite honestly I haven't faintest idea why I want to be a doctor. I don't come from a long line of doctors and none of my close relatives suffered a horrible medical course. While I don't entirely lack empathy, I think I'm on the selfish side to be the altruistic applicant. I'm uncomfortable unless I'm under pressure and I enjoy learning more than any other hobby, but I don't know if that really means doctor. I mean, doesn't banker fit that description too? I left that...

Let me not confuse the obscurity of my motivation with lack of it's existance. I definately do want to be a doctor. It's the right fit and I'm happy on this path, I just cannot articulate why. But I still need to write the essay.

On a related subject, my co-workers have started expressing indications of which specialty they believe I will end up in. One attending has put in a vote for surgery, the med student thinks I'll choose ER, and another attending concluded peds. Interesting that I came in saying neuro, work in a neuro department, and no one seems to think I'll end up a neurologist.

Much better than real radio

www.pandora.com

My hexane has a first name...

... it's t-b-u-t-y-l.



Having cleared the first of three exams in a 7 day period I have now "dug in" and they say and am battling it out with organic chemistry. Turns out that doing orgo is actually more engaging than many other classes. It's still work (ie, sleeping would be more fun), but on the continum of physics lab -> free ice cream it's not doing too badly. Maybe it's because building models is somewhat reminicent of the building blocks you had when you were five. Or legos. Legos with atoms.

My colleagues at work are off to the Child Neurology conference this week to present abstracts on some papers we're preparing for publication. If you happen to be in Pittsburgh and happen to be at the Child Neurology Conference and happen to come across a poster on seizures in the presentation of children with acute arterial ischemic stroke... check out the third name.

Bunny Ranch tv

Work is fairly routine at the moment, but I'll be in clinic again on the 20th so hopefully there will be some interesting stories from there. In the meantime, I thought I would give you a break from all-neuro all the time.

I was watching tv on Friday night and ended up flipping to an HBO series about a Nevada brothel. Never one to pass up an educational moment, I settled on the sofa with a glass of diet coke. Honestly, my first reaction was that none of these women was hot. The ones with the bodies have faces that more closely resemble a bulldog than a person and the ones with doable-in-the-dark faces had, shall we say, "pillowy" figures. Now I know that I am not in possesion of either a) stunning good looks or b) a figure a runway model would puke for, but I'm not selling my sex appeal for cash either.

About halfway through the program one of the women is chatting with a potential client and she's showing him around the place. He grabs her ass and makes a lude pass at her. She gets pissed off, steals his money clip and refuses to service him. I fail to see how someone who pays to let men (and women) do what they with her can get away with indignation over an ass slap. Genuinely attractive women get that and worse and dance clubs and bars... get over it.

The last segment was a women who was dating the brothel owner and was getting upset that he was sleeping with the girls he employed and she didn't feel her pedastool was high enough. Uh, he's a brothel owner and all the girls pretty much have to sleep with him or they would probably lose their jobs. Of course you're not going to get this guy to commit. Hello. Duh.

I think what we can take from all this is that the women of this particular brothel are both ugly and not-so-bright. And maybe we've also learned that I think to much when watching crappy late-night television. But then, dissecting re-runs of the West Wing probably makes for a much less amusing post (but it is better tv).