Some of the things I don't know

This week we began our "Physical Diagnosis" sessions. This is when they'll teach me to do all of the things that doctors on tv do: listen to stuff with a stethoscope, grope people's internal organs (though we've already been told to use the verb "palpate" when talking to patients), tap on a belly with my fingers, rub up against some lymph nodes. You know, doctor stuff.

So when the day came for my first session, I packed up my bags, grabbed my passport, and joined three of my classmates for a journey over the East River and across the border into Brooklyn. When we arrived at our designated hospital, we met up with Dr. F who herded us into a conference room and began to outline the physical exam on a white board. Now, we've had virtually no meaningful instruction regarding the physical exam, so this brief outline - which contained little more information than can be discerned by an attentive bout with Hasbro's "Operation" - was riveting. But I didn't want to just hear about spleen groping, I wanted to watch it up close. So when Dr. F announced that we were going to hit the wards to meet some patients, I leaped from my chair. I'll get to watch Dr. F listen to stuff! And palpate stuff! Just like they do on tv! And when she finds a patient with an upside-down spleen, Dr. F will turn to us and say, "Now Medical Students, come palpate this upside-down spleen." Then we'll all shuffle over to the bedside to fondle that spleen while we solemnly nod to one another and mutter things like, "that's assuredly upside-down."

So out we walked into the corridors of the hospital, imagining all of the great anatomical oddities that Dr. F would reveal to us. But when we stopped at a patient's room, Dr. F looked at me and one of my classmates and told us, and I paraphrase here, "to go on in there and get us a physical exam." Then she turned around with the other students and left.

"Shit. Do you remember where the liver is?"

So my partner and I walked into the room and found Mr. S sitting on his bedside. He was a thin man with neatly trimmed hair and a quick smile. He was delicately folding his clothes and placing them in a drawer at his bedside. Mr. S was more than happy to discuss his case with us, and generously allowed us to examine him. Unfortunately, neither of us were familiar enough with the physical exam to really learn much from that component of the visit. However, we were both well-versed in taking a good history, and the story Mr. S had to tell was certainly a memorable one. It goes something (but not exactly) like this:

Mr. S had been diagnosed with diabetes decades ago, but he wasn't all that good about taking his medication. He tells us that he always felt alright, so he didn't think it was necessary to pop all those pills. After failing to control his condition for about 20 years, his peripheral nerves and blood vessels started falling apart, and doctors were forced to amputate his foot. Now, some years later, Mr. S is back. He hasn't been taking his medication, and he's had his second foot amputated.

Mr. S had worked as a paper pusher in an office before his first surgery, and had been put on disability shortly thereafter. I never asked whether he had been insured during those first 20 years, so I don't know whether his personal finances played a role in whether or not he took his medicine before he lost his first foot. However, he has been eligible for Medicaid since his first surgery, and the pattern hadn't changed. In fact, he continued to smoke two packs of cigarettes each day.

Recently, we've had a series of lectures on the economics of health care. One of the lectures was delivered by the President and COO of GHI in New York, Dr. Aran Ron, MD, MPH, MBA. GHI has recently merged with HIP to become the largest health insurer in New York. At one point in his presentation, Dr. Ron referenced studies that illustrated one of the problems that insurance companies - and the health care system at large - are confronting. When a patient with insurance walks into a hospital, they have no reason whatsoever to curtail spending. I can imagine that if I were lying in an emergency room with an excruciating pain in my back and a doctor says to me, "I'm 99.9% sure you've got a kidney stone. I've seen thousands of these things and you've got all the classic signs. But you MIGHT have something else. The only way I can know for sure is to order a very expensive CT scan for which you will pay precisely nothing." At that moment, I would be gasping incredulously while trying to muster the strength to punch the guy in the nuts for wasting all of that time talking to me when he could be wheeling me to his very expensive scanning machine.

Dr. Ron's claims were echoed during another lecture by Dr. Sheri Glied, Ph.D., who is the Chair of the Division of Health Policy & Management at Columbia's Mailman School of Public Health. Just to avoid anyone misinterpreting the reason for me writing about this, Dr. Ron, Dr. Glied, and I are all proponents of universal health care (though Dr. Ron can't have the GHI higher-ups finding out about this, so please, Mom, Dad, and Dan, don't tell Dr. Ron's bosses). Much of our health economics lectures centered around elucidating the profound challenges involved in implementing universal health care in America - not just politically, but in terms of controlling costs and ensuring high quality care.

During Dr. Glied's lecture, she referenced other studies that claim to show, not surprisingly, that people who are insured visit the doctor more often than those who aren't insured. Consequently, she said, if the 47 million uninsured Americans suddenly became insured, our health care system wouldn't be able to handle the surge in demand. This argument didn't sit well with some of my classmates, one of whom became particularly vocal. This student believed that it was absurd to believe that anyone would go to the doctor for any reason other than that he or she was sick. Nobody would take time out of their day - often several hours - to go sit in a waiting room if they didn't think they really needed it.

A medical curriculum is based primarily on repetition. We hear the same stuff over and over again to be sure that we remember it when it matters. And one of the things that I've learned over and over again is this: "there are lots of people who show up in hospital beds who don't think about the world the way I do." I agree with my classmate that it would be absurd to take three or four hours out of my day to see a doctor for a headache when I could much more easily wash an aspirin down with a cup of coffee. But I fully believe that there are plenty of people who would be lining up outside the MRI scan to rule out brain cancer before returning to work.

And what can be done about patients like Mr. S? Is there any way to put the onus on him to take care of himself? It's one thing to spare no expense to keep someone healthy, but is there any alternative to keeping someone alive while he fastidiously tears himself apart?

When closets risper

In my seventh grade french class, my teacher would try to come up with the most absurd mnemonics to help us remember french vocabulary. For the most part, it worked. To teach us the word for "lobster," she suggested imagining coming home from school one day to find that your mother had been turned into a giant lobster madly flailing around on the floor. You would almost certainly yell, "oh, Ma!" Which is the way the french pronouce "homard" (because the french pronounce things incorrectly).

I've been doing very little learning over the past year. Primarily, I've been memorizing. So it's no surprise that I've come across my fair share of mnemonics. What is surprising is how truly awful these mnemonics are (with the exception of the very memorable, sexually-explicit ones which I won't be sharing on this site). For instance, to teach us that the deep cerebellar nuclei, from lateral to medial, are the dentate, emboliform, globose, and fastigial, our textbook suggests, just remember DEGF!

It sometimes even seems like these text books prefer the useless mnemonics to the memorable ones. All of our books and lectures constantly refers to "SIG E CAPS" as a way to remember the diagnostic criteria for depression. Those are:

1. Sleep disturbances
2. Loss of interest
3. Guilt or feelings of worthlessness
4. Loss of energy
5. Loss of concentration
6. Change in appetite or weight
7. Psychomotor retardation or agitation
8. Suicidal ideation
9. Depressed mood

Notice that #9 doesn't even play into the SIG E CAPS criteria for depression.

A much more accessible mnemonic is "Depression is worth studiously memorizing extremely greuling criteria. Sorry." Which correlates with: depressed mood, interest, weight, sleep, motor activity, energy, guilt, concentration, suicide. I've only read this mnemonic once in any text.

Today, I was studyig the atypical antipsychotics (the first generation of these antipsychotics are now called the "conventional antipsychotics", and the most recent iteration of these drugs is called - I kid you not - the "atypical atypical antipsychotics"). Three of the more important atypicals are clozapine, olanzapine, and risperidone, and next to a list of these drugs in my review book is the mnemonic "It's not atypical for old closets to RISPER."

That's right. Normally closets risper. Specifically when their old. Don't forget!

In the opening weeks of this year our course directors overwhelmed us with labels for parts of the brain and told us to memorize them. To our untrained eye, none of these parts looked any different than any other parts. The brain's just a big ball of wrinkly mush, and we were expected to remember the names of the wrinkles. In an email to the class, one of my classmates wrote "I always had a tough time remembering where the calcarine sulcus was until I realized it was right between the cuneus and the lingual gyrus." I thought the sentiment was funny enough to repeat to other people, and now, ironically, I never forget where to find those three parts of the brain.

So here's my new plan. I'm looking for the most nonsensical, useless mnemonics to compile into a list that I can routinely look over and make fun of. As these nonsensical strings of letters vie for the title of the most useless string of letters, hopefully, in the end I'll at be able to remember the battle and, by extension, the relevant medical knowledge.

New year, new body parts, new patients

The last time I posted, I was just a first year medical student, naive to the ways of the world and ignorant of the practice of medicine. Much has changed since that last post. Specifically, two things have changed. First of all, I'm now a second year medical student which means I'm allowed to shove first years into their microscope lockers or slip cholera bacteria into their drinks in the cafeteria. The second change is that I've almost completed our Brain and Mind course. So, while I'm still entirely ignorant of the practice of medicine, I'm only largely ignorant of the way a healthy head is supposed to work.

Last year, most of my patient contact was with patients from a small general practice. These folks were typically getting checked up to make sure their diabetes or hypertension was under control. Later in the year, I hung out at the lymphoma clinic at the cancer hospital next door. While lymphoma can be a serious and life-changing diagnosis, the patients I worked with weren't acutely ill. More often than not, I would spend my time chatting with them about their medical, social, and family history then watch the doctor glance over a few charts and say something along the lines of, "I see no reason to begin treatment now. How about you come back in six months?"

Over the course of the year, I became very comfortable taking a patient history, so I didn't think much would change this year when we started interviewing our psych patients. It's just an interview, right? I ask questions, write down answers, smile when it's appropriate, frown when they frown. Piece of cake, right?

So there are a couple of reasons why my interviews with psych patients have been difficult. The first is that some of my patients have had fairly profound cognitive deficits. Before my first interview, I had assumed that the course administrators would start me off slowly. Maybe a patient with a mild mood disorder that's in remission. Maybe someone with hypomania and I'll diligently write down that "the guy talks fast." But, no. My first interview with a psychiatric patient in a clinical setting was with a schizophrenic patient with a string of suicide attempts on her record. The interview was not much like the medical histories I'd taken before (and, of course, the details I'm about to provide are changed from the patient's actual story, but the gist is there). The patient, who was bandaged up pretty well and confined to a wheelchair, told me that she was brought to the hospital after she fell off a subway platform and was hit by a train. Her expression didn't change, but I frowned anyway. It seemed like the right thing to do.

"So, can you tell me what happened before you fell off of the platform?"

"I needed to get away. I needed to get away to join the army, but I couldn't get on the train because I'd get caught and taken back to the hospital, so I jumped into the tunnel."

You know what's not an appropriate follow-up question in a medical interview? You're about to find out.

"Seriously?"

I was rarely able to elicit both a relevant and decipherable answer from this patient. The rest of the interview involved tangential and nonsensical discussions of whatever she wanted to talk about.

The second reason that I've found these interviews so difficult is because the information is so unreliable. This isn't because psychiatric patients are unreliable (though, obviously, there are some conditions that impair cognitive function to a degree that the history you get is clearly untrue). Rather, the information is unreliable because the interviews focus on the one subject that elicits the most guilt or embarrassment from the patient. If I spent forty minutes talking to a hypertensive patient about his salt and cholesterol intake ("Oh doc, I've been eating real good. Last night I had this, like cauliflower gratin with capers, it was DEE-lectable!"), I guarantee you that the meals he describes would all come from Weight Watchers commercials he watched while eating potato chips and licking sticks of butter.

Psychiatric patients often know exactly what would concern their doctor, and if they're not concerned about it, their doctor's not going to hear about it. Often, it's not until I get back to the nurses station and read reports from other clinicians or family members that my questions get answered. Like all those questions I had about the kindly, older woman who thinks I have "just the most beautiful smile!", who houses stray dogs, and who told me that she never drinks and didn't even touch alcohol until she was 28. It turns out that woman has about a half dozen drinks a night to wash down her benzodiazepines.

Accordingly, most of our patients don't think they have anything to discuss, but they'll chat with me to help me complete my school assignment. And at the end of the interview, I have to determine exactly what it is that the patient is most worried about. That thing, their chief complaint, is listed first our reports. Last year my reports started like this:

CC: Patient has had a productive cough lasting two weeks

or

CC: Patient is experiencing acute lower right quadrant abdominal pain

This year the chief complaints look different. Like this one for the homeless, alcoholic who believes the CIA is watching him from cameras in traffic lights:

CC: "The nurses won't give me a second cup of apple sauce."

Or from the woman addicted to an enormous list of prescription drugs:

CC: The doctors here are too young, and "lack the sophistication to understand me."

I graduated college with a double major in english and psychology. By the time I completed my psychology coursework, I had become one hundred percent certain that I didn't want to pursue it as a career. But many of my closest friends and family members have been treated by a psychologist or a psychiatrist, and I've always been aware of the profound impact a psychiatric disorder can have on a person's life. The science behind psychiatry is only now starting to catch up with the theoretical component of the profession. For that reason, I've heard lots of doctors and future doctors scoff at psychiatry, saying that it's make-believe, not a science. But over these last 10 weeks, I've found it hard to imagine a more important area of study.

Schizophrenia affects more than 1% of the adult population, a figure that I find absolutely staggering. Now I understand that, unless schizophrenia drives you to suicide (and teens with schizophrenia have approximately a 50% risk of attempted suicide), you're not going to die from a psychiatric disorder. But I suspect that if you had to wake up tomorrow morning with schizophrenia, an unremitting major depressive disorder, or lung cancer, you probably wouldn't mind rolling the dice with surgery and some chemotherapy. For precisely that reason, I believe we need our best minds researching treatments for psychiatric conditions.

Fortunately, mine is just a mediocre mind, so I can do whatever I want.

The Scholar Athlete

Sometime in the early spring, one of my classmates was inspired to start a dodgeball league for our class. He sunk hundreds of dollars and an unseemly amount of time into running this league in the gym underneath the school's dorms. As ridiculous as it may sound, by the time the first whistle was blown, our league had eight teams of 7-10 people each. In a class of a hundred neurotic science geeks, that's not so bad.

Slowly over the course of the spring, I began to realize exactly why the neurotic science geeks flocked to the dodgeball courts. As it turns out, the students in my class are some of the most wildly competitive people I've ever seen. The idea of beating someone else at something - anything - is like heroin to these folks.

It should be noted here that I am purposefully not including myself in this description. I've been working fastidiously for the last four years - since The Monopoly Incident - to prove to the fiancee that I can be trusted to control my competitive instincts during playtime. For the purposes of this post and for the sake of my upcoming marriage, let's say that my behavior on the court never wavered from that of a good-natured sportsman.

The games varied pretty widely from a rollicking good time to endlessly frustrating. Even while watching other teams play from the sidelines, I would see the same guys get hit, sometimes three times in one game, without ever leaving the floor. Competition's one thing, but doesn't the face-rubbing lose a little bit of its joy when you're the only one on the court who believes you won?

You wouldn't guess it from the victory dances.

In some ways, the unbridled competition was impressive. Even inspiring. One of my classmates, K, absolutely sucked at throwing the dodgeball. It's clear that, though K keeps himself in good shape, he did not grow up playing baseball. Actually, it's unlikely he threw anything at all, though even that couldn't explain the motion of K's arm when he throws a ball. I imagine that K probably grew up with his elbows sewn to his nipples. Nonetheless, he seemed to spend hours each day down in the gym working out with the dodgeball. His progress was remarkable. By the end of the season, K was one of the better players on his team. He threw reasonably well and nobody could get him out. No matter how many times they hit him with a dodgeball.

Who doesn't love a pygmy marmoset?

In between the last post and this one, I had a course in Host Defenses. It was a nice course, but generally unremarkable. Except that now, on top of all of the other specialties that I've been certain I'll make a career out of, I've added infectious disease to the list. Do you think they'll let me be an emergency orthopedic neonatologist that specializes in infectious disease?

They would if I worked at Seattle Grace.

So first year is done with, and I've started an eight week research fellowship at the Hospital For Special Surgery. The goals for this summer are two-fold. First, I need to get some research experience under my belt. Strangely, my teaching resume is pretty sparse when it comes to basic science or clinical investigation. Second, I would LOVE to rule out surgery as a future profession. Getting into surgical residencies can be pretty cutthroat... and if I could avoid that, it'd be nice. My hopes that orthopedic surgery will be profoundly unfun spring primarily from two sources.

Source A: I've said it before, and I'll say it again, cutting people open is gross. I remember when I studied abroad in Scotland, I used to walk into their fry shops (shops in which they fry things), and ask them to drop a Mars bar into their frier for me. I can't accurately describe the taste of this beautiful, deep fried, golden brown confection. But I remember that when I bit down on it, I'd pierce its thin, tough fried skin, and out would ooze this melted, gooey, chocolate center. After my first experience watching surgery, I don't think I can eat a deep fried Mars bar ever again. I have a new rule: If something's got skin, the skin should stay on.

Source B: Rumor has it that orthopedic surgeons are misogynistic, weight-lifting, ass-slapping, scalpel jockeys. I did notice that some of the young, male orthopedic attendings who dropped in on our anatomy labs used to spend inordinate amounts of time at the tables of the more attractive female med students. But I have a cousin who's an orthopedic surgeon, and he's not one of those guys, so the jury's still out.

So far this summer, the surgeons and staff that I've met at HSS have been terrific. Funny, down to earth, with just the right amount of ass-slapping.

This week, I've been going to the residents' lectures. It's nice, because I get to get up before 6 am and go sit in a lecture hall and watch powerpoint slides. This morning, as the lecturing pathologist was poring over slide after slide of unhealthy bone, he turned to a slide that looked much like this inset picture. He summarized by saying in the droning monotone he'd used since slide 1, "so if you notice anything in a histological section that shouldn't be there, well, it's probably pathological. Like this, for instance."

Pause, no reaction from the residents.

"This baby, pygmy marmoset does not belong on anyone's finger."

Pause, no reaction.

"It belongs on your stethoscope"

...

"In the pediatric wards."

Still nothing.

"They are a... they're a hit."

So, now I'll have to add pathology to the list. Those guys are a riot.

Hurts so good

Today was the last day of our Human Structure and Function course. During the closing lecture, one of our professors, Dr. Palmer, offered this quote from Rene Descartes:

"It is not enough to have a good mind; the main thing is to use it well."

Dr. Palmer then told us that we might recognize the quote from the opening lecture, presented by a different instructor, Dr. Maack. Dr. Maack, it seems, felt that the quote was more critical in inspiring students to perform well in the course, whereas Dr. Palmer believes that "one should never put Descartes before the course."

And this comes only a handful of hours after my reflections on punning. Bravo, good sir.

"Words, words, words."

If I've learned nothing else this semester, I've learned this: medical students love puns. Admittedly, punning is not the highest form of comedy, but it's arguably a form of comedy. And, though I feel like I'm standing alone on this one, I have great admiration for puns and punners.

For reasons that aren't entirely clear to me, I've compiled a list of some of the most egregious puns and other acts of wordplay that I've heard on campus. I present them here for your - for lack of a better word - enjoyment.

• Before even arriving at school, we were invited to a wilderness orientation weekend. The awkwardly formatted name of this trip was both descriptive, and is the common abbreviation for the intracellular signalling molecule "cyclic Adenosine monophosphate." Or "cAMP." Awesome.
• Our anatomy TA's name was Won. Invariably, when we couldn't find a structure, one of us would cry plaintively, "Is there any Won who could help us?"
• The name of the school's a Cappella group is The Aneurythms. Though, to be fair to med students, there has never, ever been a cleverly named a Cappella group.
• Punning does happen to come in handy when naming dodgeball teams. For instance, the season opener will be played by my team, "The Supinators," against the formidable "Smooth Obturators." Though it's not a pun, my favorite team name in the tournament is the aggressive and intimidating, "Incompatible With Life."
  
• When asked by an instructor in biochemistry how much we knew about the biological molecule lecithin (pronounced "less-uh-thin") I regrettably remarked, "less uh than you might think." I was told the next day that one of my friends now has that as her away message on IM. And, damn it, I was proud.

And the award for the best pun I've heard all year goes to one of the members of my dissection team who unabashedly spews puns as fervently as I do. The following double pun took place while one of our instructors was trying to clear off some goo in our cadaver to show us an element of the diaphragmatic crus.

• I say, "Don't you think we could get in there and find the crus ourselves?" To which he replies (...drumroll...) "Hey man, it's her crus to bare."

I know. I know. It's simply beautiful.

Bringing Culture Club to the Anatomy Lab

It's difficult for me to describe what it's like to dissect a cadaver. I learned in college that when a project appears difficult, one should do that project poorly or not do it at all. Accordingly, I haven't written anything about gross anatomy. But now, after hearing the outcry of one voice (hi Mom!) wondering forlornly why I haven't posted in WEEKS, I've decided instead to complete my project poorly. Prepare to be either underwhelmed or offended. Maybe even both.

I've been hesitant to write about the dissection of my cadaver, because my description might appear as though I'm unappreciative of those people who've generously donated their bodies to medical schools. That is certainly not the case. Inside the lab, it's almost imperative that the body itself be depersonalized. That's one of the reasons why I consider a whole-body donation such an tremendous act of generosity. Organ donation seems inherently less personal. Most people draw a clear distinction between their liver and their self. Organ donors often rationalize their gift by saying something like, "why not? I'm not using it anymore." It's much harder to draw the same distinction between your body and your self. If your family sees your body on a table, they'll say, "hey, that's Joe! He was a nice guy. I miss Joe." If they see your kidneys there, not even your family would say, "hey those're Joe's kidneys! Those little suckers could really concentrate Joe's urine when he needed it. I really miss Joe's Kidneys." But when a medical student sees either a body or some kidneys, they're not thinking about either in an emotional context. Body donors know this. They know that the student of anatomy, a perfect stranger, isn't remembering the self that once animated their body. Whether or not this makes a prospective donor uncomfortable, they view the education of future healthcare professionals as a more important goal than the clean and pretty burial of their intact husk.

For me and most of my colleagues, dissecting a cadaver has felt peculiarly unstrange. Navigating my way passed 26 tables of corpses on the first day of anatomy, evoked more emotional discomfort than actually working on the bodies. Before the covers were lifted from the cadavers, we were all very aware that underneath lay recently deceased people. We wondered about those people's names, their ages, their lives, and their causes of death - the kinds of things that most people outside of medical school ask me about my cadaver. But once the covers were removed and we started working, those questions rarely came up. Only once has a classmate described to me any emotional connection to the dissection. That student was working on the upper extremities of a cadaver whose fingernails still shone with bright red nail polish.

For the most part, however, cutting those bodies open and identifying, isolating, and cleaning off relevant structures is nearer to boring than emotionally taxing. Sometimes it feels like I'm carving a turkey, but more often it feels like I'm rooting around in an overfull toolbox looking for an instrument that does a job I'm only vaguely familiar with. It's as if someone were rebuilding a car engine and said, "hey, go into my toolbox and grab me a gasket scraper. Oh, and this morning I poured 10 liters of oatmeal in there. My bad."

Cutting people open is a privilege afforded to a very few people. If an MD does it, it's applauded. If an MFA does it, it's assault. Similar rules apply regardless of whether the person being cut open is dead or alive. MFAs aren't allowed to tinker with a corpse without being arrested. Clearly this has nothing to do with the safety of a patient. An MFA couldn't do any harm to my cadaver. IT likely stems from a collective belief that the human body is, at least sort of, sacred. We want to ensure that corpses aren't picked apart unnecessarily. Healthcare students and professionals can learn on bodies, because that's a good enough reason to desecrate a corpse. Funeral directors can cut open a corpse to make it look nicer for the funeral. But nobody thinks it's ok to be opened up by a some guy just because he always wanted to know what someone's insides look like.

So, is it wrong to think of another human as a toolbox filled with oatmeal? Maybe. Should I have restrained myself from speaking to my classmates through the two halves of a sliced-open kidney for an entire 2 hours lab session? Almost certainly. Was singing through the kidney an irrefutably bad idea ("Do you really want to huurt meeee... do you really want to make me cry...)? Of course. But if I were constantly aware of the person on the table, I don't know how effectively I'd be able to teach myself the relevant anatomy. If I were overly concerned with how my cadaver's liver tumors may have affected her relationship with her family, I would be distracted from identifying the vessels supplying that liver. In a sense, I'd be thwarting the intentions of the woman who chose to donate her body to educate medical students.

Five reasons why I almost passed out while watching my first surgery, and a rebuttal by interested parties

#1 It was way too hot in that operating room. Anybody would have felt faint in that heat. Sure the patient was shivering, but she was in surgery. She was losing blood. The rest of us, those of us with all of our blood, we were way too hot.

You only lasted about fifteen seconds into the surgery. By the time you were squatting in the corner, all they’d done is nicked her skin. You lose more blood every time you shave.

#2 And I’m always cold after I shave. Plus, I was wearing one of those gowns. And two pairs of gloves. And these absurd space boots up to my knees. And a face mask with a plastic shield that covered my eyes. It was sweltering under there. As soon as the surgeon made the first cut, that whole shield fogged right up and I couldn’t see. That’s hardly my fault. Those things are a liability.

Those things? The sterile surgical masks? Those are a liability? Were the other folks in the room wearing the same masks?

#3 Of course they were, don’t be ridiculous. That doesn’t mean it’s a good idea that they were wearing them. I mean, what if all of those masked folks overheated and passed out? What then? You have an anesthetized patient lying on a table with unconscious surgeons and nurses splayed out on the floor all around her.

Did everyone else wearing a mask pass out, too?

No, but can you imagine if they did? It’s like that episode of Gray’s Anatomy, when that patient was taking some sort of herbal supplement, and it combined with the drugs in her body and made her blood toxic and it almost killed all of the surgeons at Seattle Grace. It’s like that.

…you should never be allowed in an operating room ever again.

#4 I know, I know. Nobody actually passed out. And most of the surgeons and nurses in the room made it through the whole procedure. BUT! the scrub tech felt nauseous, and she ran out of the room to throw up.

What? Really? Was she overheated? Did her face shield fog up?

#4 No, she wasn’t wearing a face shield. But she said she’d had fried fish for lunch, and SO DID I. I'm not denying that fish and chips is a terrific meal, but probably too heavy for this particular occasion. I ate it way too quickly and didn’t drink anything with it. So I was dehydrated with a stomach full of fish batter.

So you’re saying that the reason you felt squeamish is because of the fish you ate for lunch?

#5 Yeah, mostly. And because cutting people open is disgusting.

You know what bore me? Lungs.

The only good thing about lungs is that they keep me from dying. Other than that, they do squat. These enormous tissue-balloons take up way too much space in both my chest and my textbook. In an ideal world, they would plod on with their horrible, Sisyphean fate of inflating and deflating and inflating and deflating without impinging on my consciousness. Alas, I was forced to learn all about these monotonous windbags for the last week and a half. The highlights (of which there are precisely TWO) are as follows:

1. During one particularly painful lab session, some 12 of us were forced to watch one student breathe awkwardly into a computer monitored spirometer. While that was happening, Byron and I sat on the other side of the room and watched an episode of 30 Rock on NBCs website. Sure, we couldn't watch it with any sound, but it was still a much better use of our time than watching readouts of lung function flutter up and down across a computer screen. And that Tracy Morgan is a CARD.

2. Shortly after our computer session came to its riveting conclusion (it turns out, Max's lungs both inflate and deflate), we moved on to a significantly more entertaining lung function lab. To be accurate, it was more of a lung "non-function" lab - maybe that's why it was fun. The dozen of us shuffled out of the computer lab and into a lecture hall. There, we were asked to time each other while holding our breath. It was like med school and third grade summer camp all rolled into one.

After holding our breath, we calculated the changes in the various blood gasses in our circulation. Oxygen levels would drop, carbon dioxide levels would rise - makes sense. It was interesting to note that the sensors in our body that tell us we're suffocating would be, in this case, going berserk due to the high carbon dioxide levels rather than the low oxygen levels. In order to hold our breath for even longer, we'd need to somehow depress the level of carbon dioxide in our blood.

So we hyperventilated for a while before holding our breath. And voila, it worked. After blowing off all that carbon dioxide, we could hold our breath for much longer. Then we ran through some more calculations to discover that, this time, it was the low oxygen levels that compelled us to breathe again. So we decided to see how long we could hold our breath after first hyperventilating then finishing off with a few breaths of 100% oxygen from a tank.

Up until this point one of my classmates, Curtis, had demonstrated a particularly prodigious ability to hold his breath. He went almost two minutes on his first try, then about three minutes after hyperventilating. Curtis drew tremendous attention from the rest of the crowd due to both his lung capacity and his showmanship. Each time Curtis took his final, pre-breath-holding inspiration, he would close his eyes and drop to the ground. There he would sit motionless with his head down until he took that next breath minutes later.

Though there were only a few of us, this session was held in a large auditorium that could seat over a hundred people. As this final chapter of the experiment was about to begin, we all gathered around Curtis at the front of the room. He was hyperventilating and holding an oxygen mask in one hand. When he was ready, he brought the mask to his mouth, took five deep breaths of pure oxygen, closed his eyes, and dropped silently into a seated position on the floor.

As if that were their cue, two doctors in white coats strode into the room. They approached our instructor and explained that there was a developmental biology seminar being held in this lecture hall in a couple of minutes. They looked disapprovingly at Curtis sitting cross-legged and silent beside the lectern. Our instructor told us that we wouldn't have time to calculate the blood gasses for this particular experiment, and that we should pack up our stuff and prepare to leave. So we did. And as the room quickly filled with more and more white-coated, developmental biologists, Curtis remained silent and unmoving at the front of the room.

After about 3 minutes the seats in the auditorium were full. I, along with the other med students, had put on my backpack and moved to the periphery of the hall, leaving Curtis alone at center stage in front of an audience of strangers. And there he sat silently for over seven and a half minutes before finally taking a gasping breath and opening his eyes to a crowd erupting in applause.

Cleanliness, Godliness, and... Terror

Recently, Miya and I came home to find piles of furniture wrapped in plastic wrap on our sidewalk. Hooray! Right? Free crap! Right?

Wrong. Never forget to look a gift horse in the mouth. There might be bedbugs in there.

That’s right. This furniture came covered with signs denoting its infestation with bedbugs, which, as we all know, are awful. Unfazed, Miya and I continued into our apartment building and dared those vermin to climb five flights of stairs just to eat us in our sleep.

The good news is that our apartment is still bug-free. The bad news is that our neighbor’s bedbug infestation corresponded almost precisely with our laundromat’s decision to try out a new detergent. So when Miya and I woke up the next morning with irritated bumps and rashes on our arms and feet, we immediately ran out to buy a vacuum cleaner, bed risers, and double-sided carpet tape to begin our war against the bugs.

The good news is that our war against the bed bugs involved a thorough washing of all of our sheets, towels, and clothes with good ol’ Tide. Our skin is no longer irritated, and we have yet to see any bugs in or around our apartment. The bad news is that Dexter is terrified by each of the following: vacuum cleaners, bags filled with anything, frenetic cleaning, leisurely cleaning, and anything being lifted into the air. Sufficed to say, that was a pretty tough day for him, and 24 hours after it had finished, he had still eaten virtually none of his food.


We weren’t all that worried about Dex. He’s a finicky eater with a sensitive stomach, so going a day or only grazing at his bowl is expected on occasion. The previous weekend, we’d watched the Superbowl at our friends’ apartment with our friends’ new kitten, Mukluk. As we all watched the game, Mukluk never once took his eyes off Dexter. Perched safely on his carpeted shelf, the only time the kitten moved at all was to shift slightly to one side to keep Dexter in view whenever he sauntered towards the kitchen. Then, shortly before halftime, Mukluk unleashed an intensely foul, room-clearing stream of kitty-vomit. So I figured, if Mukluk could develop a rancid ulcer during only a couple of hours of football, then Dex’s stomach certainly could have been sufficiently turned during a day of unrestrained cleaning, lifting, and bag-filling.

After about a day and a half of watching Dexter eat only snacks on his walks and Kongs filled wet dog food, Miya – my better, smarter, and more compassionate half – took action. As poor Dex sat on his mat, staring forlornly at his full bowl of food 15 feet away, Miya went to the closet door beside his dish. She opened the closet, pulled out our new vacuum cleaner, and carried it (terrifyingly) to be stored in the other closet, far from Dex’s food.

Dex finished the entire bowl, and a second helping, in a matter of minutes.

What the internet should know about Dexter's penis

Almost two years ago, during a trip to Humacao, Puerto Rico, my friend Bailey found a tiny, five-pound, fungus-ridden mongrel under a car. Smitten, she took a picture and emailed it to Miya with a message that read something like, “you want this?” Miya, smitten, wrote to me. Miya knew that adopting Bailey’s Peurto Rican street mongrel was a terrible idea. She needed me to be the strong one. She needed me to say, “listen, we’re about to move across the country, and finding an apartment in San Franciso is going to be painful enough without jobs. We certainly don’t need to try to find a place willing to house two unemployed twenty-somethings and a mangy fungus incubator.” But that’s not what I said.

Down in Humacao, Bailey went to a vet who administered the pup’s first distemper shot and wrote a note that gave the general impression that, if we’re lucky, this dog is only covered in fungus and brimming with worms. Apparently, that note was good enough for Delta, who let Dexter fly home on Bailey’s lap.


Though Miya and I fell in love with him right away, there were some immediate concerns about his overall health and - because Miya wanted him to look sharp in a handbag - his aesthetics. Dex was so malnourished that when his puppy hair fell out his adult hair didn’t grow in. So we believed we’d adopted a mangy, bald dog. Though, on the upside, four different vets assured us that Dex would probably grow up to be about 20 pounds, and that’s a perfectly reasonable size for a handbag.


Our boy is now a well-nourished, handsome, happy, 60-pound dog. But, his misspent youth has left him no stranger to disease. So I wasn’t too concerned when he started peeing all over himself.

Well, I was a little concerned. But mostly for our comforter.

Here we were, in the weeks leading up to Christmas, with a newly incontinent dog. He didn’t seem to mind that he was piddling all over the place. He was totally unmoved by my motivational taunting. “Oooh, did you pee on the floor again, you little baby?” No reaction. “Do you need a nap in your crib, stupid baby?” Nothing.

We took him to the vet, whose blood and urine tests were equivocal. She decided to put him on an antibiotic to treat a urinary tract infection, mostly, it seemed, because there wasn’t much else to do. As we waded into the new year, Dex’s puddles were smaller, but hadn’t been eliminated. Back at the vet, there still weren’t any good options. She suggested we wait for the antibiotics to wear off, then catheterize him and get a urine sample from his bladder. The vet admitted that this was unlikely to turn up anything new. Though I know nothing at all about sticking tubes up dog penises, I don’t think this particular procedure would qualify as a “good option.”

So we went home and waited. The antibiotics were metabolized and we never called the vet back. Dex still didn’t seem like he was in any discomfort. For a while we assumed that his peter must be bothering him, because he seemed to be constantly licking it. But we soon realized that he was more frequently licking his leg, stomach, and the comforter beneath his peter. He’d be relaxing and unconsciously dribble a little pee on his leg. Then his anal retentive nature would kick in (it’s hard to believe he’s not my biological pup), and he’d frantically try to clean up the dribble.

So I set about diagnosing Dexter myself. For any reader unfamiliar with my diagnostic regimen for assessing all illness, I typically begin by determining the patient’s humoral composition. Hippocrates believed the four primary humors to be blood, phlegm, black bile, and yellow bile. I think it confers no disrespect on that great physician to modernize his theory. Accordingly, I assert that the body exists as a dynamic equilibrium between the following four elemental fluids: orange juice, coffee, beer, and water.

If we haven’t already established that a major in English and a stint teaching first graders in the Bronx doesn’t qualify someone for admission to medical school, let’s all declare this to be an unequivocal truth right now.

Back to Dex. It would appear that, in this case, his diagnosis would be easy. To my knowledge, Dexter drinks water exclusively. One might claim that this would throw his humors completely out of whack. If one believes that, one’s an idiot. We’re talking about a dog, kids. This isn’t a person. Dogs don’t drink coffee or orange juice, so clearly this schema is applicable only to people medicine.

I began to think harder. I mean really hard.

And then it came to me. Dexter started leaking only when the weather started getting really cold. Being an island dog for generations back, Dexter was not equipped for the kind of sub-freezing misery that accompanies a New England winter, so we went out and bought him a snazzy coat to keep him warm. If he’s neurotic enough to lick up any drops of pee in our house, it’s perfectly likely that he would go to great lengths to not pee on his gorgeous new coat. Thinking back, Miya and I remembered that he didn’t leak at all during our trip to New Hampshire for Christmas. During this time, of course, we were too embarrassed to show our loved ones that our dog wears a coat, so it stayed in the suitcase.

Poor Dexter unfortunately gained control over his small bladder problem at precisely the same time that his dad developed this completely nonsensical, dog-psychology-based hypothesis for his condition. So our poor pup, snatched from the beaches of sunny Peurto Rico, now wanders the streets of New York City protected from the winter elements only by his God-given fur.

In conclusion, if anyone knows the helpful gentleman on 10th street who told me yesterday that I was irresponsible for not putting a coat on my short-haired dog, could you give him a swift kick in the nuts for me? It’ll really hurt, so you may need to follow it up by giving him a pint of beer and a half of a glass of OJ. Thanks!

A Dangerous Mind

Since 8 AM on January 2nd, I’ve been engrossed in a new semester. My three readers (hi Mom, Dad, and Dan!) may have noticed, not coincidentally, that I’ve posted only once since the new year. You can imagine that the course directors who wanted me back in the class at the crack of dawn after New Years Day probably don’t much care about my complaints that they’re sucking time away from my blogging.

The new course combines embryology, anatomy, physiology, and radiology into one glorious package. It’s the dopest. I learn how the heart forms, what the heart looks like in my cadaver (hi Judith!), how the heart does what it does, and what the heart looks like in blurry x-ray images all at once. It really is a blast, but it’s taking up way too much time.

As I while away my weekends with books and flashcards spread out all over my apartment, I thought it would be nice to revisit the time in my life when I made the decision to start a medical career. That occurred five years ago when I found myself in the South Bronx, locked in a classroom with three dozen six year olds and one terrifyingly under qualified assistant teacher.

The kids were great, and stories about them will follow later. The assistant teacher, however, defies description. Let’s give her the briefest of introductions and then try to paint a more complete picture with a short vignette.

Though she’d never married, Mrs. W always introduced herself as “Missus”. She was fifty-some years old and had been teaching in some capacity for several years, though she'd never earned credentials or undergone a formal observation by the school administration. At least two or three students in my class read at a higher level than she did, and the class routinely taught her our first grade math content (on the first day, I kid you not, they taught her how put the numbers one through ten in numerical order). She referred to make-believe stories as “friction,” a line that’s level to the ground as “horizona,” and the tusked marine mammal from the arctic as a “walrusaurus.” From day 1 until the end of the school year, Mrs. W called our one Chinese student “Ching Chong.” To be fair, she didn’t remember the actual names of any of the students. But this particular student’s name, Jackie Chen, should have been easy to remember.

One day, Mrs. W was reading to the class from a story called Three Friends Together. The story was about a penguin, a whale, and a seal who were the best of friends. But, as the three of them played together day after day, one of them invariably felt left out. One time it was the whale, who couldn’t play with the penguin and the seal up on the ice floes. Another time it was the penguin, who couldn’t hold his breath underwater as long as the seal and the whale. And then, if I remember correctly, the seal upset his friends because he wanted to hug the penguin’s sister inappropriately. It’s a good story.

When Mrs. W finished reading the story to the kids, she closed the book and declared, “I like that book. It makes me think of when I was a little girl trying to learn to roller skate with some of my friends.”

If you’d ever seen Mrs. W improvise a lesson, you’d understand how worried I was at this point. Undaunted, she continued.

“You see, my friends were all real good at skating, but I never skated before. So they all got up and were skating around real well, and I couldn’t go fast at all.”

What’s this? Did Mrs. W grasp the moral of the story she just read? Did she make a meaningful connection between the text and her own life? Is she not even going to mock the children?

“So, we was skating. And all my friends was getting father and farther ahead of me, and I was getting farther and farther behind. And they all made it to Manhattan and back, before I left my neighborhood in the Bronx. And I remember, I was so sad. I went to tell my dad what had happened. And he said not to be so sad. He said that all my friends were good skaters and that I was just learning, and that soon, I’d be able to skate to Manhattan and back with my friends. And you know what? I never learned to skate.”

Ta da! That’s the stuff!

So thank you, Mrs. W, wherever you are. Even if your roller skating story never truly inspired the students, it continues to motivate me on a daily bases. Every time I feel exhausted or overwhelmed, I recall the emotions I felt upon the conclusion of that tale, and I enthusiastically return to my piles of reading with a renewed sense of purpose.

Stranger in a Strange Land

Medical school’s a strange place for an English major. It’s not just that I’m grossly underprepared for a basic science curriculum (though that’s no small part of it), but the comfort and familiarity with English prose that I’d developed as an undergrad is absolutely useless in medicine.

I’d been told that a medical curriculum is primarily about learning a new language, but I rarely listen to what people tell me (I’m going to be a great doctor). Maybe I hoped that my doctors didn’t just sound like they knew what they were talking about, but, in fact, had some substantive, applicable knowledge that they could use to cure me of whatever disease might come my way. It appears that medicine involves a healthy mix of both comically abstruse language and a useful breadth of real knowledge.

I knew that learning the science would be tough, but I didn’t anticipate the difficulty learning the language. I like it when authors use as few words as possible to describe something, and I’m just not accustomed to wading through drawn out prose. In some cases, my anatomy text employs a perfect economy of language. For instance, the artery that turns behind your shoulder and then wraps around the bone of your arm, that’s called the “posterior circumflex humeral artery.” Terrific! I can remember that. It’s the goes-behind-then-around-the-arm-bone artery. Beautiful! But then, just when I’ve reconciled myself with medical language, I come across this:

“The articulations between the superior articular surfaces of the lateral masses of the atlas and the occipital condyles, the atlanto-occipital joints, permit… the neck flexion and extension occurring when indicating approval.”

Now I’m not complaining about the unfamiliar words in the first part. I know that there are lots of names of lots of body parts that I’ve got to learn. My concern is with the stuff that follows the ellipses. If these authors are unwilling to lower themselves to using the two-word phrase “nodding yes” instead of “the neck flexion and extension occurring when indicating approval”, can I trust them to clearly describe the thousands of other anatomical phenomena out there? Unlikely.

Geneticists are one group of folks who are trying to take these erudite physicians down a few pegs. They’ve found a back door into the clinician’s lexicon, and they’re doing some tinkering. It turns out that (for the time being, anyway) geneticists have free rein to name whatever genes they discover. Typically this begins in some non-human organism like the zebra fish, so the geneticists will name a gene something clever like, say, “one-eyed pinhead.” Once the equivalent of the “one-eyed pinhead” gene is found in humans, well, nobody really wants to go through the effort of renaming the gene, so they just hang on to the old name. This makes it really difficult for clinicians who are forced to discuss genetic abnormalities with their patients. Imagine listening to an obstetrician discussing a newborn child’s severe facial malformation with the child’s parents. The obstetrician would have to explain that their child’s condition was due to an improperly functioning Sonic Hedgehog gene.

Other genes out there that may make their way to the clinic have names like “faint sausage,” “fear of intimacy,” and “lunatic fringe.” Anyone out there who thinks it’s a good idea to let geneticists name their own genes, generate the neck flexion and extension necessary to indicate approval.

Over the next four years, I’ll have to learn to make sense of the elements of this awkwardly cobbled language: the concise Latin terminology; the unnecessarily verbose phraseology of textbook writers; and the sophomoric jokes of lab scientists. I’m not worried, though. I’d guess that a patient would understand perfectly well if I told her that a piece of her DNA’s garbled, or if I told the victim of a car accident that his goes-behind-then-around-the-arm-bone artery was nicked in the crash. That would certainly make more sense than if I pointed out a patient’s fully functional fear of intimacy or his appropriately sized faint sausage.