Another Hurdle

Well, just finished a pseudo-midterm - feels like I've been doing nothing but study lately - and in my spare time, computer games. I really need to get out more and exercise... Feels like I'm trying to do a million things at once, but I guess that's nothing all that new. I can't believe I'm almost done with my first year of medical school. It's rather intimidating because sometimes I feel like I've learned a lot, and other times I feel like I haven't learned anything. Now with the midterm done, I plan to just relax as much as humanly possible between now and Saturday night - Saturday we have a semi-dance thing on campus, it's a fundraiser for the group that is going abroad to Ethiopia and Tanzania. Unfortunately they're more established, better organized, and have the Global Health program director in charge of their group, so they have been putting on a lot more events than my group (Bolivia) and the Taiwan and Israel group.

The latest stuff we have been studying is all the respiratory illnesses - mostly those that cause pneumonia, bronchitis, that sort of thing. There was a section on pediatric illnesses and upper respiratory problems, which was okay. I'm not a fan of babies in general, and learning about the millions of ways that babies can turn out wrong frustrates me, since there are no laws permitting parents to relinquish their responsibilities for an incredibly unfit offspring. Definitely a controversial view, which as far as I'm concerned will only apply to myself and my future offspring, not the patients for whom I care (so don't worry), but human societies have practiced infanticide since before they were even humans - all animals practice infanticide if they do not have the resources or the animal is too unfit to survive and care for itself. It seems a crime to force parents to spend say, 5 years of their lives caring for a child that is 99.99% doomed to die - that's 5 years in which the child will be suffering, becoming progressively more mentally retarded, and slowly wasting away until its inevitable demise. It's an emotional drain for sure, not to mention a financial drain on the parents.

Like I said, I know it is my duty as a physician do everything in my power to keep a patient alive, and I will do that wholeheartedly - I just don't want to end up a slave to any offspring I produce with conditions that are incompatible with life for which medicine can offer no acceptable end.

In other news, still doing bacteriophage research. My medical Spanish classes have picked up again, so we're practicing those and we have our practicals next week. The trip to Bolivia is essentially ready, though I still need to get all my vaccinations...mental note: call the travel center. OMM is going well, I suppose - we're learning the high velocity, low amplitude techniques (the cracking techniques). I've had mixed success with them, so I definitely need more practice. Thank goodness we don't need to make an audible crack for it to be 'treated' - otherwise I don't know how we could get anything to treat during a practical after we've been practicing on each other for days.

Still working on balancing personal life with school, but everything's a work in progress these days... Now for the joy of computer games!

Studying, Advocating, Consoling...so much to do

Well, spring semester has been coming on fast and furious - been extremely busy. Have also had tests every other week, essentially, and our first Block exams of the semester are next week. We have had two standardized patient encounters with our small group - where we must take histories and perform a physical exam. It's amazing the things you notice yourself and your classmates doing when interacting with patients - strengths and weaknesses, the importance of listening... We have also practiced doing SOAP note write-ups (subjective, objective, assessment, plan) and worked on differential diagnoses. The ailments of the patients are in line with what we are learning, so we can apply what we learn clinically.

Tomorrow we get to explore a new aspect of the physician-patient relationship - breaking bad news. We will have 12 minutes to break bad news to a standardized patient who has been trained on how to react convincingly to the news, including shouting or crying. We will be faced with one of these: a son whose father unexpectedly died, a woman with a suspicious breast lump who needs a biopsy, a man with inoperable pancreatic cancer, a childless woman who just had a miscarriage, and a man with an STD from an affair. Should be interesting and nerve-wracking - but I imagine it will be more difficult for some of my colleagues than for me. Working in the lab, I definitely got to deal with very angry patients, and one woman I drew as a trainee had just learned her husband was going to die - that was a difficult one. You really don't know what to say to a stranger who suddenly starts crying, especially when they're still holding back so much pain and you know almost nothing about their situation. I almost cried myself that time - but sometimes all you can do is squeeze a person's hand to let them know you're there with them, even if it's for just a moment. I'm usually someone who insists on a 3 foot personal space bubble and never hugs people unless they're family (and even then not so much), but somehow I was able to recognize that at that moment, she really needed to feel physically that someone was there with her. If you're really with them, and not just going through the motion, time almost seems to stand still for you both in a good, or at least meaningful, way. They say, "You can touch patients during a bad news situation if you think they would be okay with it," and you kind of wonder, "How will I know if they would be okay with it?" Well, that was one of those moments, and I could definitely tell even with no experience - though my rule is that if in doubt, it's better NOT to touch.

On a more positive note, last Thursday we were bussed by the Osteopathic Physicians and Surgeons of California (OPSC) to the state capitol to speak with assembly members and fellows about the recent merger between the Doctor of Osteopathy and Doctor of Naturopathy boards. Essentially, bill AB X4 20 merged the boards because the governor wanted to make it look like he was cleaning up the government - busting excess bureaucracy and saving money. However, both our boards are funded by those in the profession, no tax money is involved, and they approve licenses as well as oversee malpractice issues. NDs do not prescribe medications without supervision (and even then, no category 2 drugs) nor do they perform surgeries - so having them oversee us, or even have us oversee them, is not fair to either profession. I was the designated group leader to the assembly member whose fellow we spoke to because apparently I live within the district (14). Definitely nerve wracking, but everyone seemed to think I made a very eloquent case. The fellow we spoke to seemed very supportive of our cause. One of the senators (Lee) has submitted two goldenrod bills to his boss for approval, which we need in order to get numbers on them, support, and signatures. It was really enlightening to see how the process works in state government, and that people in the offices actually will listen to you and you can make a difference. We also got to speak to one of the governor's aids right before he was going to a meeting with Mr. Schwarzenegger himself, with the promise of at least mentioning the issue with him, so that was exciting. There were a bunch of school children outside of the governor's offices as we walked in and they were all asking us to say "Hi" to the governor for them, ask for more money for schools, it was adorable. All in all, a very exciting day - here we all are in front of the capitol building!

Also, on one final note, the founder of Touro University, Bernard Lander, last night at the age of 94. All the Touro campuses were closed out of respect. I don't really know what to say about it, as I never met him or knew much about him before now, but I am kind of wondering how it will affect the universities. At the least, I was productive and used the day to get more caught up on classes.

Faster and Faster

I used to be more on the side of patients when it came to doctor visits, but now I'm feeling a lot worse for the doctors... We have gone through the general screening exam, which includes neuromuscular, cardiac, respiratory, gastrointestinal, HEENT and taking vitals thus far. If we are allowed to do it at our own pace, no rushing, talking sweetly to the patient, etc. it takes us about 30-40 minutes to do it at this point. We are expected to speed it up to 15 minutes. I have been able to do it all in about 15:45 minutes, but it feels so rushed as far as barking orders and telling the patient to jump and sit that I can see even more clearly how a patient would feel like a physician doesn't care about them. Unfortunately, when we're expected to cram exams into a tiny amount of time...it's hard to do it in a way that makes a patient feel happy.

Of course, I'm betting that's where the magic of experience and bedside manner kick in. I'm going to try to practice the exam in 15 minutes but also practice my tone of voice and memorize concise, simple instructions so that I don't feel like I need to cram my words together. That, and I need to get a really good feel for the order and routine, as well as the phrases...ugh! So much to remember! We are required to say specific "lines" when we do examinations, such as "Patient is breathing easily, quietly, and regularly" or "Patient presents with no edema and is not diaphoretic or cyanotic." It really feels like being an actor/actress almost, since they really are lines.

In other news, I got a massage table, which I plan to use for massages, OMM, and exams - so that should help a lot. Also, we're focusing on hemostasis and hematological diseases at the moment - all very interesting and familiar since I worked in the laboratory for 3 years and I've seen all the lab tests before. Goal for this is to memorize the clotting cascade, the diseases, and the treatments, as well as go back over all the stuff I've already learned and try to commit it to memory.

White Coat Ceremonies

Well, considering my dream, and the fact that the Touro White Coat Ceremony is drawing closer, I thought I would research a little more about the ceremony. I was surprised to learn that the ceremony was first performed in 1993, and is now practiced in over 100 medical schools. The idea behind the ceremony is that it lends identity and unity to the profession, and reminds physicians to lead their lives and practice medicine honorably and ethically. The ceremony was founded by the Arnold P. Gold Foundation at Colombia University College of Physicians and Surgeons. The foundation sought to focus on medical students and residents so as to positively influence young physicians and instill humanistic principles.

The ceremony itself includes several elements. There is the recitation of a medical oath (Hippocratic, Osteopathic), which represents the public acknowledgment by the students of the responsibilities of the profession and their willingness to assume such obligations in the presence of family, friends, and faculty. Students are cloaked in their first official white coats, there are notable speakers who address ethics and responsibilities in medicine, and after the ceremony there is a reception for the faculty, students, families, and speakers. Some schools also equip students with engraved stethoscopes and White Coat Ceremony pins.

Surprisingly, there is some debate about the benefit of this contemporary tradition - most notably a sense of elitism, premature recitation of the oath and celebration, and encourages antiquated notions such as paternalism. There is a really interesting article by the BMJ Journal of Medical Ethics about it. Personally I think sure, it might be a tad elitist, welcoming a select few into the secret doctor world that lay people don't understand, but it'll be fun and is a nice way to encourage camaraderie within the profession. Plus, it's a big deal, starting medical school - I don't see much wrong with celebrating the path we are about to take.

By the way, the Journal of Medical Ethics is FREE and viewable after registering with the website. It has a lot of nice reading material.

Obesity

There are times when I feel like medical research is somewhat unnecessary, such as when it proves something already widely acknowledged as true. With obesity, the number of "studies" about the health and social effects of obesity is quite staggering, and the results unsurprising. Here is a sampling of the recent findings relating to obesity.

Being obese will...increase the chance a child will have allergies, lower a man's marriage chances, decrease one's productivity, worsen asthma symptoms, lower chances of receiving a raise or promotion, increase women's chances of pelvic disorders and decrease quality of life in old age, increase the chance a child will suffer lower body injuries, hide fetal abnormalities during an ultrasound, and raise the chance of being disabled in general.

This is supposedly new data, compared to the old data linking obesity to breast cancer, high blood pressure, shorter life span, cardiovascular disease, heart attacks, diabetes, sleep apnea, gastroesophageal reflux disorder, back problems, and steeper decline in mental faculties after the onset of Alzheimer's or dementia. I don't understand why we need more proof that being overweight and obese is a serious health problem. If being told that they will get their feet amputated if they don't lose weight does not motivate them, then how will information about pelvic disorders sway them more? We also do not need data to prove that being obese makes one less desirable in general, everyone already recognizes that fact. It is mostly a superficial problem, but it is hardwired in our being to be repelled by the unhealthy. Unfortunate and discriminatory from a humanistic stand point, but logical and fair from an evolutionary view, where the population, not the individual, is most important.

To play devil's advocate, knowing definitively that something is caused by a person being obese could help physicians treat problems - they could abstain from prescribing medications they would give a non-obese person, if the potential benefits of the medicine would certainly be curtailed by the person's obesity. After all, a non-obese person may have an underlying cause for a disorder which is treatable, while the obese person may have the problem simply because of excess weight. I have been tempted to write about obesity before, and finally felt compelled by the many unnecessary "studies" posted in Yahoo!'s Weight Loss News. If nothing else, one can at least be impressed by the sheer number of health complications from being excessively massive.

Who can become a doctor?

Sorry about the lack of posts, but not much of interest relating to my going to medical school has happened lately. No news from Western U yet, they still haven't sent my official alternate list letter. And Touro still hasn't withdrawn a thousand dollars even though I gave them the credit card form weeks ago.

On another note, I came across an interesting article which brings up the question of who should become doctors. Now, if you asked someone, "Can anyone become a doctor?" then usually they would respond, "Of course! If you want something and work hard enough, you earned it! This is America after all." Then you have to ask, "What if that person molested a child, or killed a Jew in a neo-Nazi hate crime?" You usually don't picture a person like that aiming to become a doctor, but in many countries, most recently Sweden, such cases have occurred.

This article describes a current problem at Sweden's most prestigious medical school - they admitted a Nazi-sympathizing felon who was convicted of murder and served for 6.5 years before applying for medical school. In Sweden, it is almost always illegal to require a criminal background check, and apparently the screeners and interviewers did not seem concerned about the 6.5 year gap in this student's record. They have managed to make it nearly impossible for him to graduate and become a practicing physician by restricting him from clinical experience, but the issue still remains.

Being a physician, like being a school teacher or a priest or in any other position in which you have a mentor-like power status, includes certain standards of behavior and morality. Would you want your fourth-grader being taught by a physically abusive alcoholic? Would you want your priest to be an ex-child molester? Just the same, you would not want your physician, someone you trust when you are at your most vulnerable, to be a convicted rapist or murderer. I believe in equal opportunity as much as anyone, but you have to draw a line at some point in the interest of protecting people. We usually want to think that the only criteria for a job is a person's academic background, work experience, and recommendations, but there is a host of personal qualities that are equally, sometimes more, important. I know there is always the question of whether a person can change, learn from what they did, etc. I understand forgiving "mistakes" but maliciously murdering someone? I think some "mistakes" teach best by prohibiting a person from achieving their dream. If after raping or murdering and thoroughly destroying the lives of others they can spend a few years in jail and then live the rest of their life as if nothing happened, that is a crime in itself.

Artificially Extending Life

It seems most people have very mixed views on extending a person's life artificially with respirators, feeding tubes, and the like. My personal opinion is one of individual liberties, that each person has the right to determine his or her own fate, whether by dictating in a will to be on a respirator indefinitely or by ending life prematurely with assisted suicide. Personally, I want to live as long and healthily as possible. Of course, anyone seeking assisted suicide should first seek counseling and explore all options, but ultimately it should be their choice. Better for them to do it safely and with certainty while they are able, than attempt it and become handicapped for life, becoming even more miserable and unable to make a second attempt.

This topic was inspired by today's Dilbert, which was surprisingly funny with Scott Adam's take on extending life:

I understand that people object on moral (primarily religious) grounds, but I do not think other people should be able to prevent others from taking control of their own life or death. The Terry Schiavo and Karen Quinlin cases are the prime examples, where parents or spouses fight the state, doctors, or other family members for the right to prolong or end the person in question's life. I really feel for the doctors trapped in those situations, and hopefully if I face one of those cases the players will be relatively rational.