Sunday, March 30, 2008

Simple Things

Here is a list of the simple things in life that are priceless:
1. Time with family
2. Family BBQs
3. Dinner with friends
4. Staying up until 3 AM catching up with friends you have not seen for monthes
5. Carrot Cake
6. Sitting in the backyard bathing in the sun
7. Cups of chai
8. Wireless access in the living room
9. Dinner table discussions
10. Car rides in the central valley
11. Taking endless photographs of the same people
12. All the associated memories that emerge from items 1-11

Spending my three-day weekend at home was refreshing and a welcome change of pace. I've been enjoying playing catch-up with family and friends. The book bag has yet to be opened. And it's all worth it!

Wednesday, March 26, 2008

Runner's High

In a recent NY Times Health article titled "Yes, Running Can Make You High," researchers in Germany report a relationship between strenuous exercise, endorphin release and the euphoria characteristic of the "Runner's High."

Here is an interesting fact:

"The data showed that, indeed, endorphins were produced during running and were attaching themselves to areas of the brain associated with emotions, in particular the limbic and prefrontal areas. The limbic and prefrontal areas, Dr. Boecker said, are activated when people are involved in romantic love affairs."

Interesting findings. Is the runner's high eliciting the same response that is felt during lovemaking? Or more simply, does the runner's high equal euphoria of love-making?

If so, here is another convincing reason to strap on some running shoes or exercise.

I guess I'll be spending more of my afternoons running now that there is scientific evidence that supports the runner's theory of euphory.

Tuesday, March 25, 2008

My First Delivery

When a baby emerges from the birth canal, you must remember to support his head and protect the mother. The baby will rotate his head a certain way and your hand must direct the baby as it enters the world. Once the head is out, the shoulder must be cleared and then with some careful pulling, you can assist the baby to complete his full journey out the womb.

I delivered my first baby following the steps I outlined above. The baby I delivered was really cute and very plastic (a mannequin that was propelled down the plastic womb with the assistance of motor). For some reason, the motor was not working and the baby relied on manual assistance to make it down the birth canal.

Learning to deliver a baby was part of a series of activities during an Obstetrics/Gynecologist surgical skills session organized by the department of OB/GYN with the assistance of a second year medical student. In addition to the learning about all the neat toys OB/GYN doctors use, we had an opportunity to learn from different women's health specialists about the spectrum of procedures and treatments used in OB/GYN.

Along with delivering a baby, we learned about laproscopic surgeries performed by Obstetricians and gynecologists.

To simulate laproscopic surgery, a type of surgery commonly used, we operated in a box with the assistance of a camera and long instruments. Our hands moved the instruments and we looked at monitor to guide our instruments.

Our tasks were simple and fun and included peeling avocados using the long claw-like tools to help us develop hand-eye coordination when we are working in limited space, placing beads into boxes, playing with strings to simulate "running the bowel" and writing "hi to lo" on a balloon to simulate how to make incisions. The end result of these exercises was a deeper understanding of a field of surgery and developing the unique depth and hand-eye coordination needed to fully work in such a limited space.

"I will never think of a papaya the same way," a male classmate whispered to me before we started our next activity. I agree.
We used papayyas to represent the uterus since the texture of a papaya is similar to that of uterus for our final activity: IUD placement (a form of birth control that is 99% effective). After clamping the bottom of the papaya, we inserted the T shaped IUD into the superior end and pulled back. "Go guys can go right to second year of residency," said our instructor after she watched us place the IUDs into the papayas.
Along with IUD placement, we learned how to suction the papaya (there were no seeds left by the time we arrived). Suctioning blood from the uterus after birth has saved many lives in developing countries, where women die of bleeding after giving birth. We also learned how about how to acquire endometrial samples for cancer screening.

Missing two hours of biochemistry was so worth it! Making guacamole during the peeling the avocado activity, performing my first laproscopic surgery simulation and placing an IUD in a papaya are only a few of the highlights.
If anything, I did deliver my first plastic baby today.

Sunday, March 23, 2008

Savoring a Golden Weekend

I finally got to be a tourist in San Francisco. I made a revisit to the wharf on Friday, camera in hand to visually capture the tourist pictures I have meaning to take since moving to San Francisco. One of those sights is Fisherman's Wharf and Pier 39. Aside from the hoards of tourists and overpriced nature, the wharf makes for a great photo and half-day trip--complete with ships, pirates, seafood and a cannery.There is something about three-day weekends that is so mysterious. You know you have three days, but somehow you lead yourself to believe you have an extended vacation. Your "to do" list grows and you really start thinking that time can be spread out so much farther than it really can be.

As our post-exam three-day weekend slips away, I feel like this was a golden weekend. I was able to fit so many things into seventy-two hours.
My list of accomplishments for this weekend include the following: running to the ocean, walking along the beach, strolling Filmore and Haight street with a close friend, swimming and lifting weights at Mission Bay, cooking real good food, enjoying the company of friends at a Wine and Cheese get together, having dinner with classmates, completing loads of laundry, recreating my tan lines (the lines that existed before I moved to San Francisco) after spending hours in the sun, cleaning my apartment, running in Golden Gate Park, photographing the wharf at Pier 39, being reunited with a high school friend and devouring mint chocolate ice cream at Ghiradelli Square.

After listing all the things I did this weekend, I noticed a theme--I attempted to maximize my exposure to three things: the sun, the city and friends. Basically, anything but school after such a long week of studying GI disorders and realizing that a year from now, I'll be confined in the library preparing for the BOARDS.
What a weekend to live and enjoy the sun, sights and sounds of San Francisco in early springtime.
The hours for oneself become numbered as the academic rigor steps up a notch, the extracurricular commitments expand and as we get closer to transitioning to the wards. For now, I am enjoying these moments and making the most of the time we have.
Four hours of lecture welcome us back to the second half of Metabolism and Nutrition at 8 AM tomorrow. We begin our second half, which focuses on endocrinology and more biochemistry. I flipped open to page 582- Introduction to the Hypothalamo-Pituitary-Adrenal (HPA) axis and my first thought was- is "Hypothalamo-Pituitary-Adrenal" really one word?
Ok, so I am a little distracted. But at least I am making the effort (and it is all in vain).
I think I'm better off enjoying these last few hours even if it means playing catch up for the rest of the block. Such is medical school life (always running up a hill that becomes more and more slanted until it becomes as steep as one of the famous San Francisco hills; you feel like you're walking up, all your effort is going to moving forward, but you somehow end up moving backwards--why is that? But in the end, you somehow get to the top and never really figure out how you got there.
Speaking of hills, I know my next photograph- San Francisco's curviest and most visited hill- Lombard Street! (Stay tuned for the photographs after our final, or possibly sooner). And come to think of it- Lombard Street may even be the perfect iconic metaphor to represent medical school.

Thursday, March 20, 2008

Exam Day Marathon

Today is the big exam day. Studying all these stomach disorders puts knots in my stomach.

Anatomy in 1 hour (at 9:30 AM), followed by pathology (where we'll actually have to use microscopes and look at slides) followed by the written exam at 5 PM.

The whole day will an extended exam. The only consolation for having an exam at 5 PM is the additional time in the afternoon to cram all the upper and lower GI drugs that have these long names and they promised dinner.

Our exam also coincides with the national Match Day, when fourth year medical students open a little white envelope that reveals where they will do their residency. It's interesting to think how four years of medical school lead up to this climax. I can not even begin thinking about anything that far in advance. It also happens to be the first day of spring. Happy Spring Day (and weather is even fitting for spring fever- the sun is shinning on my face and I'm blankly staring at my computer screen and all the syllabus pages sprawled all over my desk).

For now, I'll stick with thinking about the looming exam in less than one hour (sigh).

Tuesday, March 18, 2008

Red Palms

"Everybody, look at your palms. Mine are slightly pink with Irish blood flowing because of Saint Patrick's Day." Our small group was making an interesting observation. Well, it is not that interesting since everyone in my small group had normal color palms. Reddened palms are a cardinal (no pun intended) sign of chronic liver disease, a symptom called palmer erythema. It is important to see normal color palms before thinking about pathology.

For some reason, the palms turn red and the face turns yellow with liver disease (jaundice). We may have some of the most advanced technology to assist us in our diagnostic algorithms, but there is limited use of such modalities without an adequate patient history and physical. If we overlook the obvious physical symptoms, in the case of liver disease, the general symptoms are clumped together into a "stigmata of chronic liver disease," we may be led on a wild goose chase.

Our first Metabolism and Nutrition exam will be on Thursday. I am in the thick of studying 569 pages worth of syllabus material that cover a myriad of topics, everything from gastrointestinal diseases to metabolism of nucleotides to GI physiology to liver disease to GI anatomy. And there is so much in between. Being confined in the library for the last few days has been far from exciting.

My only consolation was thinking, at least I'm not studying for boards. The second years have been madly preparing, spending all hours in the library, consuming gallons of caffeinated beverages and looking so tired. I guess a year from now- that will be us first years. Right now, we'll focus on our midterm.

Needless to say, I am thoroughly distracted, exhausted, overwhelmed thinking about the intricacies of bowel movements and defection and diseases that maybe causing diarrhea, abdominal pain or steatorhea (fat in the stool).

I guess studying GI motility and absorption and all those mechanisms makes going to the bathroom that much more interesting...ok- not really. I might just know way too much about poop for my own good.

Friday, March 14, 2008

Happy Pi Day!

As I chew on the intricate details of the defecation pathway that produces feces (I am learning how poop is made) in review for our upcoming Metabolism and Nutrition Midterm on Thursday, I just realized that today is 3.14.08.

For any fellow nerds, you know what that means- HAPPY PI DAY!

In honor of Pi Day, here is a pie just for you. Hope your PI day was exciting as the number, in all its splendor.
I would be reflective right now, but I am not feeling inspired. I mean as interesting as feces and pi day is, I probably should discuss this topic some other time. For now, I really must hit the books and understand GI motility and all the intricacies that is GI physiology. Nothing but fun for me this weekend (not).
Happy studying!

Tuesday, March 11, 2008

Shadow Day

I never thought I was that interesting (at least not interesting enough to be shadowed). I wonder what physicians think when I contact them and express an interest in following them around. There is something valuable about learning about spending a "day in the life of X." And today, pre-medical students, got an opportunity to spend a day in the life of medical student.

Shadow Day was organized by the SNMA (Student National Medical Association), an day to outreach to students underrepresented in medicine. After a classmate and friend, asked me to help, there was no way to refuse such an opportunity to help students.

Three students accompanied me to small group, where they got to learn about Ischemic Colitis and Crohn's Disease and the typical presentation. As we discussed bloody diarrhea, fecal fat and maroon colored stool, I realized we are so unfazed by the material and we sometimes forget we are talking about poop. As our small group instructor, a Gastroenterologist, eloquently put it: "I am poop doctor."

After we were done with the case presentations, I escorted a group of students to the 7th floor for lunch. As we waited for the elevator, they remarked about how it sounds like we speak another language. Do we really sound that incomprehensible? I guess we forget what normal language sounds like after being fully engrossed in medicine for the last seven months. We have come a long way and it's odd it takes an outsider to tell us that we have changed.

During lunch, I somehow got recruited to be a panelist with other first year medical students before teaching anatomy of the circulatory system later on. During the panel, we got a spectrum of questions: everything from tips for writing a personal statement to how we got to UCSF to surprises in our first year. My fellow panelist made a good point: "One of the hardest things to do is to say 'no.'" He was referring to spreading yourself thin by taking on too many responsibilities. The key (again) is balance (the most important take-home point I could deliver to any group of students).

After the panel, I helped teach anatomy of the circulatory system (the heart and lungs). Teaching was a nice preview to being a MSP instructor next year, when I will be teaching first years about anatomy, physiology, pharmacology and all the other pearls during Prologue through Renal. I had my interview on Saturday was notified within 48 hours that I had been selected. I am so excited and look forward to the amazing opportunity.

Along with reviewing the heart and lung anatomy, we had some really incredible pathological gross specimens of aorta, heart, and lungs. The most striking specimens included the athersclerotic aorta with aneurysms (lots of fat deposits and black deposits that created this large outpockets in the wall). And then there were the lungs. Here is one more reason not to use crack- it destroys your lungs (turning them into black foam).

I am trying to get into review mode for the upcoming exam next week. Only problem is that the longer daylight hours are misleading (the day really is shorter even if it is still sunny at 7 PM). Oh well, at least I can say I have been productive enriching the lives of aspiring medical students. And for the first time ever, someone has actually shadowed me (I hope they got something out of it).

Saturday, March 8, 2008

Not too Early for Spring Fever

There is nothing quite like a crisp, sunny day in San Francisco. The feeling of all seventy degrees sun on your skin is sensational, the perfect chance to get all the Vitamin D we need and do not get during the winter months.
While I was running, I just wanted to keep going. There comes a point in a a long time, when you no longer perceive the pain in your joints. You just keep going to see where the trail ends. And today I followed the trail and suddenly there I was- face to face with the ocean. What a sight! Making it to the ocean is one of those small accomplishments (for me) that just made my week.
With Daylight Savings in full swing, we do lose one hour of sleep, but we gain the extra hour of daylight (in my opinion a fair trade). It is starting to really feel like spring. With the flip-flops and t-shirts comes spring fever- that desire to be outdoors at all times- at the expense of productivity. My last quarter as an undergraduate was the worst mix of senioritis and spring fever, which meant non-existent productivity but some the best days of my life laying on the quad, swimming and cycling.

Last week, the second year medical students bid farewell to lectures and class, as they turned in their last final. They will still have shelf exams during their rotations and did I mention they have to study for this one big test called the BOARDS (it is like the MCAT on steroids). Needless to say, the second years have disappeared and the first years are taking on the second year persona, assuming leadership and coordinating positions, in essence learning to run the medical school show before the incoming first years arrive (first in May to preview the school and then in August to start).

I can not repeat this enough- time flies by so fast. In seeing the second years becoming engrossed with board prep, I have realized that our carefree days are numbered. The best is really yet to come, but the days of being able to just be a student are flying right before our eyes. For this reason, I have decided to live up my first year and find balance. This weekend was truly unforgettable and made me think spring fever has sprung on me (even though it is March).

On Friday, we walked through the Mission, as part of neighborhood tour. The Mission is one of San Francisco's jem, with a vibrant culture, immense diversity and unique personality. The Mission actually has one of the highest densities of murals, which tell the story of community leaders and the struggles that neighborhood has faced, everything from the labor movement to discrimination to commercial development.
Hearing from communities leader express their concerns about genterification of the neighborhood with increased development, as well as concerns about violence and barriers to accessing health care, made be realize that as health care professionals we must really understand where our patients come from.

As easy as it is, to wear our white coats and simply discharge patients to their communities, we gain so much more by learning about where we send our patients and the challenges they face in getting healthcare services.

On Saturday, we played tag, interviewed a patient presenting with shortness of breath and reflected on our life's journeys as we helped our mentees brainstorm ideas for their personal statements during a Med Link Session. The mentees got a chance to play doctor, taking a history and directed physical of a patient presenting with a pulmonary embolus.
I spent time with my mentee; we talked about the things we have learned, our values and goals. In learning from fellow mentors, it was interesting to see how each of us came to medicine--we all came different routes to get to the same direction. The diversity in our experiences enriches our class. My mentee is well on her way to becoming a successful politician and I look forward to being present at her Med Link graduation in April.

I guess I could have been more productive with regards to getting caught up with all the GI diseases and physiology. But I figure that's what the week is for. The weekend should be lived up and enjoyed, spending time with friends and family, enjoying jazz over dinner, playing soccer in the park with friends and running.
I'll be playing catch-up during the week, but that seems to always be the case, and its all worth it.

Thursday, March 6, 2008

Why do you want the blue pill?

"Imagine two people having sex," said our doctoring instructor last week during a lecture about taking sexual histories.

When most people envision two individuals making love, they tend to think of young, attractive, beautiful people, she said. She made a valid point; it is unlikely that you think about disabled or obese individuals or older people having sex because we are conditioned by society to think about sex with a limited perspective. Such a perspective has to be challenged when taking a sexual history since your are working with diverse patients of all ages, sizes and walks of life.

In order to take an adequate sexual history, you have to be non-judgemental and avoid making any assumptions. From a medical standpoint, we have to rely on our patients to divulge all the pertinent details about their sexual lives (and without asking, it will be difficult to elicit information about sexual behavior). It is just one of those topics you do not talk about, unless you are Carrie Bradshaw and a columnist for Sex and City.

The line of questioning is unique and intended to cover a wide-range of topics pertaining to sexual health, including sexual function, sexually transmitted infections, barrier and contraception use, frequency, desire, behaviors, positions, partner interactions and relations, patient concerns, etc. The list goes on (as directed by the patient and the interview flow) and there is no way to contain the scope of the questions that go into a sexual history within a list.

Outside of a clinical environment, it gets a bit awkward to discuss such topics (or ask such questions) without getting others to raise their eye brows at you. Despite being in a clinical role, it still difficult to ask such questions for the first time.

Today, I had an opportunity to complete my first full sexual history during our Foundations of Patient Care session. My patient was James (he was a standardized patient, an actor who plays out a patient's role). Going into this interview, I was anxious, nervous, and uncertain about what to expect. I wondered if I could ask questions like "can you maintain an erection?" or "how often do you masturbate?" or "do you get an erection in the morning?" And when I met James, I knew it was going to be a challenge.

In an non-medical setting, asking such questions would be awkward and bizarre. But for the purposes of a medical interview, these questions can be essential when assessing a differential diagnosis that pins erectile dysfunction on the top of the list.

I opened my interview with open-ended question.

"James, what brings you into our clinic today," I said. The moment he responded, I knew this interview was going to get interesting; he had come in to get Viagra at the recommendation of his girlfriend due to difficulty during "love making."

So, then began the barrage of questions designed to understand why James would want the blue pill. I had lots of questions swimming in my mind- I wanted to ask how many partners he had, how frequent he had sex, if he used protection, if he had sex with men, women (or both)...but the first question that came out of my mouth was "What do you know about Viagra?"

It is interesting, the moment the words came out- I knew there was no turning back. We were about to begin a discussion of erections, sexual behaviors, and everything in between. For a moment, I wondered- am I prepared to be the recipient of all this information? And as we talked, I realized it's just another interview and there was no need to hesitate when asking the questions and processing the information.

In all seriousness, a sexual history is nothing more than asking different questions with the same goal- collecting data to help understand the patient's chief complaint.

James, a fifty year-old man, nervously responded to each of my questions, giving me specific details about how he can achieve an erection but struggles to maintain an erection during intercourse. Along with the sexual history, we were able to get a comprehensive medical history, information that is extremely valuable that helps us understand where James is coming from medically-speaking, including his past medical history (PMH) and history of present illness (HPI).

Balancing the patient history (and all its components) with the full sexual history can be challenging. There are so many questions to ask, and it's easy to get side-tracked and lose focus of the patients chief complaint. But as long as you can come full circle, you can effectively elicit both histories to help see the intersections.

At the end of the interview, James was able to step out of his patient role and give me feedback. He felt comfortable during the interview and was impressed with how I handled the interview (wow, really? I guess I hide my nerves really well).

I'd like to say the interview went smoothly (better than I thought it would go). There are definitely areas of improvement that will require practice and more interviewing. At least now, I know I can complete a sexual history and ask all those questions I never thought I would ever ask for someone seeking that small blue pill.

Wednesday, March 5, 2008


I really think every rite of passage for a UCD Alum attending UCSF is that you have to return to UCD and serve as a panelist on a UCSF medical student panel. And tonight, I completed this task along with two fellow classmates.

We made the 2 hour drive back to the college, driving down memory lane. We spent two hours presenting about UCSF, speaking about our undergraduate and medical experiences and addressing questions.

It's amazing how far we have come. The time of undergraduate education seems like another lifetime. I am barely a year out of school, but in that time I feel I have changed so much. Wow! Are we really growing up? I remember the days when I would be in the audience, on the edge of my seat, listening intently to hear the secret words from the successful applicants, which invariably resonated in the same tune of tonight's message: do what you love and maintain a balanced life.

Speaking of balanced life- I could really use some sleep (but I need to tackle tommorrow's small group questions).

Tuesday, March 4, 2008

Navigating the Sterile Field

In Kickboxing, one of the first moves you will learn is how to put your "guard up." You bend your arms, clench your hands to make fists and raise your bent arms and fists right in front of your face. The purpose of this position is protection.

Now imagine the same idea- arms out in front- after scrubbing in for surgery. In a way, you do keep you "guard up" after you scrub to prepare for surgery, except, the purpose is different: preventing contamination. You walk into the OR, water dripping down your arms with your arms out in front of your face, a cardinal help signal to get some one's attention to help you get gowned before you arms touch something.

Monday concluded our quarter-long Surgical Skills Elective with a Scrubbing and Gowning Session in a real functioning OR (obviously there were no patients just a group of medical students in blue scrubs scurrying around lost and confused). In a series of sessions, we learned the tricks and trades of how to successfully scrub into an OR without "messing things up" (as stated by second year medical students).

Here are some of the take-home points I took home:
1. Do not touch anything (well anything blue unless you are scrubbed in)!!! OK, this is an overstatement but there is a basal amount of truth to this statement. During a surgery, a sterile field is constructed where the surgery is performed to protect the patient. If you have scrubbed in, part of you becomes an extension of this field. But the moment you touch anything unsterile, you are no longer sterile.
2. Follow the OR traffic rules and do not contaminate yourself or anyone else.
3. The blue gowns are too big for most normal size people. Gowning requires a bit of coordination and help. Remember to pull the tag off, have someone grab the white part and spin in the correct direction.
4. Scrubbing in really meaning scrubbing in--it takes time and is a thorough process that leaves you smelling so fresh and clean and dripping wet
5. Wear eye protection in case things squirt
6. Once scrubbed, do not touch your mask
7. If you feel lightheaded- walk away from the table (and find an appropriate place to sit)
8. Remember to enjoy the experience and not get mired by all the details that come from scrubbing in
9. When washing you arm, you are doing an "upper cut" (another kickboxing move) through the water. You arm moves in a scooping action, fingers first and elbow last to ensure the proper flow of water and prevent contamination
10. There is complicated theory to scrubbing (lots of strokes and they are in some multiple of 5). Well, it's not complicated- just difficult to explain in writing. It's one of those things you just have to see.

Now that we have learned to scrub in, suture and tie knots, we can now actually move closer to the table and play more active roles in learning and contributing to the patients care (at least that is the goal).

We'll see how much better we can navigate this blue sterile field with our training. Something tells me that have a ways to go before we figure it out.


"Scrubbing in"

Sunday, March 2, 2008

A Weekend to Remember

All of San Francisco was outside this weekend. Why wouldn't you venture outdoors? The sun blanketed the entire city with enough warmth to awaken us from a winter stupor. The beautiful weather was long overdue, a nice reprieve from the rain of a few weeks ago.

I enjoyed this weekend to the fullest extent. We are merely one week into Metabolism and Nutrition and the work (both school and non-school related) is really starting to pile up. What's new? I finally pulled out the good old note book and starting making the epic "List of things to do," a remnant of undergraduate (and so I thought).

Honestly, there will always being something to do. It is just a matter of balancing your time and finding the right moments to be productive and not feeling guilty the rest of the time, which ends up being most of the time.

There are a limited number of sunny days in San Francisco, where you can walk out in flip flops and a t-shirt without thinking twice. I finally got to pull out the sun glasses and break in my shoes outdoors; I made my way to the expansive Golden Gate Park, exploring the rolling trails and enjoying the sights of the masses enjoying the sun. I had may fair share of Vitamin D as I basked in the sun and played Frisbee with friends.

My legs are still recovering from these two days, but my mind feels so much more clear and free of tension and stress (except for making lists of things to do during the week). I have lots of work to complete and I am already playing the catch-up game (the story of my medical school life). Oh well, here is to another week and hopefully more sunny days to venture out!