Eisha'z Inner world

On the Eve of Graduation

2011-05-15T22:49:00.000-07:00

“Open your eyes. School is done.”

The voice of our faculty member echoed through the lecture hall as he culminated our medical school training with one final session. Earlier, he had lead us through a period of meditation in the last moments of class, guiding us through reflecting over our time as students and thinking about the individuals that have impacted our growth as physicians and humans.

I found myself thinking back to my first experiences as a medical student-- the first moment I stepped foot on the UCSF campus during my interview, my first day of medical school in the same lecture hall, my first patient interview in Moffitt hospital, my first time teaching an MSP session, my first clinical clerkship, my first surgery, my first delivery, and my first residency interview. As these memories whirled in my mind, I felt an overwhelming sense of gratitude to the people in my life-- my family, friends, teachers, mentors, and patients--who have been the foundation of my education and identity.

On the eve of graduation, I am overcome with a myriad of emotions--it is a confusing mix of excitement, anxiety, nostalgia, and fear. As I leave behind four years of medical school, some amazing friends, and an incredible city, I embrace the opportunity ahead. I look forward to finally being able to take care of patients and practicing medicine. With a higher level of responsibility, I know the learning curve will be steep and that I will be unprepared.

To help guide us through the unknown and nebulousness that has come to define internship, our faculty members have peppered advice into our concluding lectures.
If there is one unifying theme threaded through the lectures, it would have to be that one must remember what they do not know and to ask for help.

“If you do not know, just say ‘I do not know.’” This line was repeated to us multiple times by our faculty. It seems simple enough.

The following is a small sample of some of the advice passed on to us (listed in no particular order). I include this list as a reference to myself and as a way to calm my nerves right before I am gowned and donned the title of doctor tomorrow morning, a designation, I still feel I need to earn.

Advice from my faculty:

1. Absolute honesty is a must.
2. When working with patients and their families, remember their vulnerabilities
3. You are the intern; therefore you are at the bottom (again). Just remember that.
4. There needs to be a free flow of information up and down the chain of command similar to that in a military hierarchy.
5. Take the time to know yourself--the core you--not influenced by being a doctor
6. Realize your limited competence.
7. Do not take things personally.
8. Learn from your patient’s stories
9. Look like a doctor. And that means that men need to grow their beards on vacation. 10. No comment on the women’s dress.
11. Remember why you went into medicine in the first place--to help people
12. Find balance in your life and take care of yourself

Graduation tomorrow...

Match Day

2011-03-22T22:01:00.000-07:00

The dust has settled. Decisions have been made. Envelops have been opened. And now we are all on the same page.

Allow me to recount the details of the Match Day.

Match Day was surreal.

8AM. The celebration started with breakfast at 8 AM. I decided to skip breakfast altogether since I had very little appetite. I made myself a cup of chai. I sat in my living room and sipped the warm chai, thinking through my submitted rank list and every possible outcome. And the more I thought about it, the more I realized the futility of my thought process; I would find out soon enough. I recalled what someone had told me, "trust the match."

8:30 AM. I nervously made my way to the conference room. Before entering, I took a moment to stare out the windows and marvel at the view. The sun was starting to shine through a thin blanket of fog and the entire city along with ocean was emerging from the haze.

By the time I arrived, the room was brimming with fourth year medical students. Although the anxiety and tension was palpable, there was an overwhelming sense of community and unity that was rooted in sharing the universal experience of the match process. We had all undergone the same uncertain process, survived, and had to wait out the last moments.

More than anything else, it was so nice to be reunited with my classmates after many of us had splintered off for interviews and electives. Being in the same room reminded me that many of us had all started together and had grown together.

As students congregated in small groups around the circular tables, some picked at their breakfast, while others talked amongst themselves. To distract myself, I walked around the room, meeting my classmates.

8:45 AM. As time passed, we became more anxious, wondering when the envelopes would be laid out. Our course administrators went to the podium to welcome and congratulate us. I could barely pay attention to their remarks. My attention was divided. I only remember them instructing us to pick up our envelops in the next ten minutes.

8:50AM. The envelops were laid out, placed in three piles by alphabetical order. Masses of students made their way to the table to pick up the envelop. I stood in the corner and waited.

8:55AM. I finally separated myself from a conversation and made my way to the envelop table. The envelops were not white; they were actually manilla. As I had expected, the envelop was thin. A small label with my first and last name was on the middle. Once handed my envelop, I stood and waited for the moment of the truth.

8:59AM. Our administrators returned to the front." Congratulations to you all, we are so proud of you. Now join me, in counting down from 5 seconds." In unison, we counted down the last five seconds.

Photo c/o Sarah Paris

9:00AM. My hands were shaking. The envelop quivered in my hands. Once the envelop was opened, a white paper that came from within dropped to the ground. I picked it up and unfolded the paper, the text was a little blurry. I was not reading any words, my eyes scanned to the bottom, looking for the location of my residency.

And there it was, my first choice for training in obstetrics and gynecology- University of Michigan in Ann Arbor.
Go Blue! I was overjoyed.

I reread the page three more times and breathed a sigh of relief and smiled to myself, knowing I had matched exactly where I was supposed to match. As I had been told by several mentors and residents, "the match just seems to work out." Although I had heard it, I could now believe it.

***

To celebrate, I have enjoyed many cakes thanks to my family and friends.

Having lived in California my whole life, it will be difficult to leave my family and friends, the bay area, and the running in San Francisco. With that being said, I am looking forward to a new beginning and am excited about this Midwestern adventure; it will be an incredible learning opportunity, professionally and personally.

Above all, I feel so lucky to have made it this far and to have the support of my family, friends, and mentors. I would not be here if it were not for all these amazing people, who inspire me every day and teach me how to grow and become a stronger person. My love and respect to you all- Thank you.

Let the next adventure begin...
***

Thin White Envelopes

2011-03-16T21:23:00.000-07:00

Tomorrow we will face a table of thin white envelops. These white envelops will reveal everything, answering the questions we have been pondering for the last few months. We will finally see how our lives will unfold in the near future as we see where we will pursue our residency training.

In unison, I will open up my thin white envelop with thousands of other medical students at 9AM. After months of waiting, we will finally know where we matched.

As I count down hours, I feel a mix of emotions. A part of me has been desiring Match Day--March 17th--for some time. The anticipation and anxiety of not knowing has been unbearable. It has been like walking in a haze, knowing you can not make any plans with a big question mark lingering ahead.

At the same time, I also realize that Match Day represents a point of no return. With Match Day, I will see my future and there is a chance it may not be anything close to what I anticipated. Either way, the fear of the unknown, makes it harder to wait and face the day head on.

It will be interesting to see how the question mark that has been my life shapes up after tomorrow. Will I match to number 1? 2? 3? 4? 5? 6?...12? Will I stay in California or leave all my family and friends and venture to an entirely new US territory? Will I be happy?

My thoughts are with all the other matching medical students who will open thin white envelops with me tomorrow.

There is no turning back from here.

Coming Full Circle

2011-01-30T22:07:00.000-08:00

I can add cutting bagels to my skills, right next to writing test questions, making algorithms, revising syllabus sections, and proctoring exams. Being a life cycle intern has some interesting responsibilities.

During the second year's first midterm last week, the most important job for the teaching interns was simple- cut the bagels before the students assemble in the front. We started at 8 AM. There were 11 dozen bagels piled in paper bags awaiting our arrival. On the grand piano that sits in the front of the lecture hall, we threw a table cloth and began slicing the circular balls of bread on a square wooden cutting board. One by one- we made our way through the whole wheat, raisin, sesame seed, onion, poppy seed, plain, and everything else bagel. As students assembled in the lecture hall to take their exam, we stood in the front facing our cutting board, carving away, slicing the bagels as even as we could.

As I cut, I realized how nice it was not to be sitting down to take a test.

After the bagels were cut, I sat in the front and helped proctor the exam.

Proctoring an exam is an entirely different experience. It's unusual. You sit in the front of the room and do one thing- watch the test takers. During tests, people do all sorts of things. Some stare at the ceiling (or at you). Others blankly stare at the scantron or test. Others just scribble all over the test. And some come up to ask questions about the questions.

Answering these sorts of questions is an art--one I have yet to master. As you are asked a question, an information exchange tug of war develops since you now know the answer. In the process, you come to see that some tests questions are hard to understand for a myriad of reasons--some are poorly written, vague, wordy, or just unclear. Having taken the same test a year back, you are also amazed at the level of detail you once remembered. And now on the other side, you have to find a way to answer those same questions you had when you took the test.

You have come full circle.

Flashing Backward and Forward

2011-01-19T10:05:00.001-08:00

The Great Highway hugs the Pacific ocean. Follow the great highway North and you will make your way to the Presidio. Along the way, you have to climb a hill. As you gain altitude, the views become even more spectacular; you see the depths of the deep blue ocean as it grows bigger and bigger. On a sunny day, the ocean sparkles as if a thousand diamonds were thrown in the water. By this point (Mile 5 on a good run), I am usually out of breath, sweating profusely, and in pain. The endorphins have yet to set in. My only saving grace (aside from the views of the coastline and ruins of Sutro baths), is arriving at the Cliff House. Here, I pause and stretch, stare at the ravishing scene, while sipping some water.

For the last three years, I have run past the Cliff House on long runs en route to the Presidio. Before last night, the only thing I had really seen was the bathroom and the bar (the bathroom is to the left). Since discovering the Cliff House over three years ago, I have always wondered when I would experience the unique ambience and taste the masterful culinary creations in one of San Francisco's historical landmarks. Our meager financial aid checks can not really support an appetite for fine dining. After years of wishing and whizzing by the beautiful white fixture, I finally got to actually enjoy the views of the Pacific Ocean from the inside.

Thanks to San Francisco's Dine about Town, a three course meal can be enjoyed for only $34.95. Admittedly, that is the cost of my groceries for two weeks, but sometimes exceptions need to be made. Life needs be lived. And to make dinner even more special, I was joined by three of my high school friends for a long overdue reunion. After being MIA for so long during sub-internships and residency interviews, I have resurfaced and am reconnecting with my friends. I am regaining time lost from all the cancellations, rain checks, and delayed responses.

When we were all reunited, I was warmly welcomed by my friends, who ignored my resounding apologies. As we made our way to the brightly lit Cliff House, we paused and look out at the black water.

"This is an epic view. And I hardly use the word epic." My friend said.
I agreed. This view was entirely new for me and it was epic.

We were seated in a square corner table that was dimly lit by a small candle situated in the middle of our table. Vertical lights dangled from the white ceiling. Wall to wall windows provided panoramic views. From our large window, the outlines of the crashing waves were visible in a black backdrop. The inside of the Cliff House had shades of modernity sprinkled with historical relics from the ruins of the Sutro baths, including photographs, jerseys, and building fragments from Sutro Baths.

Our table was the liveliest. The conversations flowed as seamlessly as the three courses of our delicious meals were placed before us. As I finally got up to speed on each of my friend's lives, I was simply amazed at how far we have come. My friends are a unique and ambitious group of individuals--true visionaries. In our group, we have an urban planner who returned from India and will soon be moving to Mississippi for city planning; another friend just completed her masters in education and has taught Kindergarten in Oakland and now teaches Sunday School and works in a craft store; and my other friend is getting a masters in global policy after working as operations manager at a museum in China Town.

We are an eclectic group with a wealth of talent and experience. It is refreshing to hear about how others solve problems that afflict our society. I am learning about entirely new ways to think.

We have grown up. Years have passed, but some things are the same. We are still friends. And even though we see each other so infrequently, we learn from each other. And we will always share those moments of unstoppable laughter, those secret smiles, those inside jokes, those stories, and those conversations that we hope never end.

As quickly as we flash back to the memories of years that have escaped us, we quickly flash forward--setting our sights on the years to come, big professional and personal dreams, and more dinner reunions at the Cliff House (or restaurants as upscale).

Schedules and Handouts

2011-01-11T16:16:00.000-08:00

I find myself with a windfall- a predictable schedule and time to breathe, catch up with life, and make handouts.

I am doing something that was unthinkable a few months ago when my schedule was up in the air (literally) due to traveling and interviews. That is, I am making plans. With interviews tucked away, I am slowly filling in my calendar days with long overdue dinner dates with friends, dental appointments (finally), gym visits with my gym buddy, midday swims, shopping trips to update my wardrobe, and weekend trips. Although I always strive to be more spontaneous in my life by relying less on schedule, I am finding a schedule is exactly what I need to structure my life.

Outside the scheduled events, my calendar mirrors that of a second year medical student as I go back to the basics. My official title is medical student intern (which is an oxymoron if you get my drift). In essence, I am a glorified teaching assistant during the life cycle (reproduction and embryology) block. My job is multifaceted, and involves facilitating small groups, making handouts, revising course materials, holding office hours, and attending lectures (for the second time).

From attending lectures, I am quickly learning how hard it is to learn. It's amazing how little one can retain, even the second time around. I have learned that the key to maximizing retention rests in minimizing distractions, which includes laptops with Internet access and iPhones. Wifi is truly a mixed blessing in lecture halls.

While I am blessed with this schedule, I daresay, I will try to complete a couple of essays I have been working on. At this point, revision represents the bane of my existence. While I await for creative juices to help me with revisions, I have also been able to make handouts, an old talent from my teaching days as a second year medical student.

I have included a screen shot of an algorithm to secondary amennorhea that I created, in case you were interested...

Retiring the Black Suit

2011-01-08T15:28:00.001-08:00

I can now hang my black suit in the back of my closet.

Selecting this suit was an achievement, purchased 24 hours before my first residency interview, when I was in Union Square madly rushing through virtually every possible store that sold suits. As I tried on more and more suits, I became increasingly frustrated with the suits making the "no" pile. Some were too tight or big, others were too dated, and some were just plain unsightly. It was like every line of women's suits were meant for the figure of a man or a women without curves. Just when I was about to give up and resort to recycling my suit from medical school interviews, I unexpectedly stumbled on the suit. It was staring at me from the large display window.

I instantly loved it for it's simplicity and elegance. A classic look. It was solid black with a stylish fitted blazer and tailored trousers with a slight flare. It was a perfect fit. Well, as perfect can be for a misfit, like myself.

Although I have become accustomed to the loose-fitted and unflattering appearance of scrubs, I was looking for a new look. My little brother, Musa, has an eye for fashion with the ability to pull off any look--business, sporty, or casual. He has compared my fashion style to that of a glorified graduate student (on a good day) and a grade school teacher (on every other day). Although he is my biggest fashion critic, I appreciate his brutal honesty and I do agree. I can sometimes go overboard with argyle, cardigan sweaters, khaki pants, and black trousers. For once, I wanted to prove to him that I do know a thing or two about style.

More than anything else, a new sleek black suit accompanied with stiletto heels was exactly what I needed to for reinvention and a new beginning--the start of residency interviews.

***
My black suit has become my travel companion through a series of interviews throughout the nation. Before each trip, I carefully folded the blazer and trousers to preserve the natural creases. To accompany the suit, I selected two shirts, one traditional green collar shirt and one purple blouse with a scoped neck. The night before each interview, I completed my preinterview ritual; I pulled out the suit and ironed out the wrinkles. With all this experience, I have become quite skilled with the iron.

Initially, the black fabric was like armor, snugly hugging my skin, making moving uncomfortable, sitting impossible, and breathing uncomfortable. The suit forced me to pay close attention to my posture. So, in my first interviews, I initially squirmed in my seat, but later learned to sit up straight. And with every subsequent interview, the stiff suit loosened it's grip on my body, allowing me to breath and move with ease from one interview to another.

Now, with my last interview completed, my suit has been scarred from the interview circuit. The once sleek and sharp suit has become overpowered by signs of overuse. The previous fitted blazer and trousers have become looser and the sharp creases have become less defined and are replaced by new wrinkles. The perfect black fabric has been sullied with food stains from the interview lunches, patches of lint from sitting in my luggage, and burn marks from my initial attempts to master the intricacies of selecting the correct temperature settings on irons at different hotels. A loose button dangles from the front of the blazer, sustained by a single thread.

In many ways, I feel like this black suit. At the start of the interview trail over three months ago, I started out fresh, vibrant, and energetic. I was excited to travel and visit new cities and share my story and passion for the career path I have chosen with complete strangers. And with more interview experience, I have become accustomed to the regimented interview schedule, usual interview questions (why obgyn? why our program?), traveling in whirl-wind trips lasting less than 24 hours, and navigating new cities. And through it all, I have quickly learned how arbitrary this process becomes as you are reduced to a number on a rank list.

If I had to sum up the entire residency application process, it can best be described as professional speed dating. With limited information, applicants and programs engage in an unusual courting ritual. Before the interview, we get a preliminary look of each other. Programs view our lives on paper and we do our homework, learning from each program's website. And if we like each other, we get to meet during the interview. And when we meet, we put our best face forward. We have only a few hours to learn about each other and figure out if we are suited for each other. That is, we must decide how much we are willing to commit to each other for a four year professional marriage. And in this odd dance, we are forced to make crucial decisions with limited data, sometimes relying on the feeling we get from our visit and awkward interactions.

Like the over worn black suit, I am starting to feel overextended and tired.

The process has been expensive and exhausting. Along with interview invitations, a string of rejections have been trickling into my inbox. The feeling of rejection stings every time you read the words "we regret to inform you..." At times, I know that being placed in the "no" pile is just a necessary part of a process that stratifies applicants based on their worth to a program. But it still hurts to feel worthless by these program's standards.

Even after I am granted an interview, I find myself evaluating who I am on paper--my board scores, grades, medical school achievements, and personal statement--wondering about my professional value. Do I sound smart or interesting enough to make the rank list at each program I visit? And as unique as I am, I am starting to feel like one suit in a sea of hundreds of black and gray applicants.

I wonder, when hundreds of suits walk through the process, how will I be remembered? I am good enough? I still worry if I left a lasting (or any impression) at the programs I visited. I can only hope my package is sleek and chic enough to impress the interviewer I met for thirty minutes before she makes a decision about my ranking and my future.

Despite the complaints and griping, I feel lucky to be considered at many unique and exceptional program throughout the United States. In addition, the process is a learning experience and I have been able to visit many new places in our great country, rack up frequent flier miles, and meet so many interesting people on the circuit.

In my heart, I know things will work out. At this point, a part of me has accepted the inevitable, knowing there is only so much I can do control the outcome in this arbitrary process. Ultimately, I can just hope and pray for the best.

At least the interview process has ended. It's time to retire the black suit and move to the next phase of the process, which is even more daunting. I have to generate a rank list.

In the meantime, I will work on redefining my style. Recommendations are welcome.

The Black Box

2011-01-04T05:23:00.000-08:00

The city sleeps. The bay is dotted with gold specs of light as if someone threw glitter onto a black canvas. The ride is bumpy and dizzying. As the city whizzes by and we approach the airport, I feel that my life for the last couple of months has been something of a blur like the early morning drive.

This makes my fourth airplane ride. And I am finally traveling to my last interview. I am venturing to the midwest, where it is forecasted to be around 28 degrees with a a forty per cent chance of snow. As instructed by my midwest friends, I have packed layers of clothes. Along with the long wool coat, I am wearing boats lined with synthetic fur (not my first choice of shoes given their boxy appearance, but useful for warmth purposes).

Despite the bitter cold, I look forward to seeing snow. It will be an interesting change in scenery.

Now that's it's January, I feel guilty for being somewhat amiss in updating my blog. I wish I could have a steady stream of insightful entries. Unfortunately, my schedule has been somewhat fractured. And in my two weeks of vacation, I decided to just lounge on my parent's couch, savor the home-cooked meals, catch up with family and friends, watch reruns of Ugly Betty (one of my favorite shows), and run (during the few days that it did not rain).

In truth, I did do something. I spent a great deal of thinking and reflecting on my life. I know it sounds existentialist. If I could sum up my thoughts, it would amount to mostly scattered memories of my life (the past) and a large black box with a humongous question mark representing the future as I think about residency. The big question really is where will I end up. And without knowing this, I can't help but feel a little bit anxious and excited at the same time.

For now, there are lots of questions and anxiety. In a few short months a single envelop may hold the answers, or just create more questions. We'll see...

Inspiration

2010-12-21T10:46:00.000-08:00

After flipping through JAMA, I stumbled across these words of wisdom. I thought I'd share. Timeless wisdom.

"It is not the critic who counts; not the man who points out how the strong man stumbled, or whether the doer of deeds could have done better. The credit belongs to the man actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly, who errs and comes short again and again; who knows the greatest enthusiasms, the great devotions; who spends himself in a worthy cause; who, at the best, knows in the end triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those timid souls who know neither victory nor defeat."

-Theodore Roosevelt (1858-1919)

Devouring Donuts at 8AM

2010-12-06T16:04:00.000-08:00

As I looked at the pink box, I thought to myself about whether donuts were such a good idea. After all, donuts are simply balls of fried dough coated in sugar syrup, not the most healthy choice for breakfast. The lack of nutritional value is probably the last thing one thinks about when devouring this tasty treat. Despite the initial hesitation, I realized that donuts can also be a wonderful gift, especially at 8 AM.

So, I walked to campus happily carrying the pink box and made my way to small group. Today, I was facilitating a group of twelve first-year medical students. We were going to discuss a case of coronary artery disease. So, maybe the donuts were actually a bad idea. Whatever the case, donuts were well-received.

Interestingly, I was leading the same group I had attended as a first year during the cardiovascular block. It's so odd and funny how quickly times flies. One day, you find yourself squirming in those uncomfortable seats, dreading the 8 AM small group. And then you wake up a couple of years later, sitting in the front, teaching and hoping your students like you and learn something (anything) during the two hours you spent with them.

It's really easy to stand in front of a class and lecture. What is harder, is having students discover critical learning issues and topics on their own and having students teach other. Our job as small group facilitators is to guide students to discovering and disseminating knowledge. We have the answers, but at the end of day, it's not the answers that are important, it's the learning that takes place in the process. Consequently, we hope students can start to see things from different perspectives.

Small group can be a battle to stay awake. I remember those days. The donuts were a peace offering. By feeding my students, I hoped to appease them and make them happier people, so they could engage in the material just a little more. Maybe peace offering is a little extreme. The correct word should be incentive.

Surprisingly, none of that was needed. My students came prepared to learn, asking questions and teaching each other, which made my job so much easier and rewarding, even sweeter than a traditional glazed donut.

Giving Thanks

2010-11-28T19:46:00.000-08:00

Thanksgiving is my favorite holiday. At it's core, it comes down to two simple things--food and family.

I had the pleasure of celebrating the holiday with my family in Davis. The four days at home were a welcome respite from residency interviews and the ongoing city trekking that has consumed my life during the last few weeks. After making the decision to apply into obstetrics and gynecology, I feel like my life has been moving so erratically with residency applications, interview invitations, rejections, and wait lists. Above all, I feel like a broken record, repeating my life story over and over again to complete strangers around the nation to prove my commitment to the career I have chosen to pursue for the rest of my life.

When I first stepped foot in my parent's house, there was the initial barrage of questions relating to the places I have visited. "So, which place did you like the best?" my mother asked.

"What's your number one, Eisha?" my dad asked.

After dodging the obligatory questions (I have yet to figure all this out), I was able to settle down and finally sit still in one place.
The serenity and calm of being home was a welcome change and reminded me about the simple pleasures of life-- the aroma of curries, warm blankets fresh out of the dryer, crunchy red and yellow leaves, runs on crisp autumn days, cups of chai with my mom, walks with friends, and family dinners around the kitchen table.

I know many families have Thanksgiving traditions. Interestingly, our Thanksgiving dinner is so far from traditional, we have created our own culinary rituals that have been inspired by western and Indian traditions. We have never had turkey. Every year we have baked chicken with potatoes, boiled corn, baked fresh naan, and cooked curry; it makes quite a feast.

As we gathered around the table and savored every morsel of food, I felt so lucky to be surrounded by family.

For me, Thanksgiving is a time to remember all the blessings we have in our lives. I came up with a list (in no particular order) to remind myself about all the blessings in my life.

1) My Health- having the ability to see, breathe, get out bed each morning and face each day
2) My Family- the people in my life, who love me unconditionally, define and support me. I owe them everything,
3) My friends- the people who ground me and care for me, functioning as my extended family.
4) Learning opportunities- being able to pursue my dreams and creative endeavors
5) Food- makes life worth living. I live to eat and exercise to eat.
6) Shelter- despite the high cost of living in the city, I am lucky to have a roof on my head, a kitchen for cooking, and a place for entertaining
7) Golden Gate Park and Running trials- the natural beauty in an urban setting rejuvenates me
8) Running- a pass-time that has helped me maintain my physical and emotional health, taking me to new heights
9) Medical school- a place where my dreams started and have only begun to evolve as I venture forward
10) My patients- their stories inspire me and remind me why I chose to pursue a career in medicine
11) My teachers and mentors- their patience and dedication to my learning has allowed me to grow
12) My experiences- have shaped me
13) Living in San Francisco (and California, for that matter)- the possibilities are endless
14) My blog- having a place to express myself, reflect, and communicate with an audience (although I have not met you, I hope I have affected your life)
15) Freedom of speech- I talk so much (so I benefit from this protection)

Before I left home, my mother repeated to me the same advice she gives me every Thanksgiving.
"Eisha, we celebrate Thanksgiving once a year. But, remember every day is a day to give thanks for all the blessings we have."

She is right. Among the blessings in our lives, each day serves as a blessing and an opportunity to give thanks.

Lessons from the Bedside

2010-10-30T08:45:00.000-07:00

When we donned our pristine white coats three years ago, we were told that we were about to embark on an exciting journey of lifelong learning. We have only just begun. In four years we are expected to transform from civilians to student doctors charged with taking care of patients. During the process, we become like-minded beings, equipped with the knowledge and skills to think and act in a particular way. We also become problem solvers, who are programmed to quickly work through differential diagnoses. Most of this reshaping happens at the bedside, where our patients guide the trajectory of our development into physicians.

In medical education, we are grounded in two years of preclinical education, when the basic sciences marry the clinical medicine. We start with the basics and build a foundation, fact by fact, during a series of structured, small groups, labs, and exams. A problem-based approach is applied to simulate what we will experience in the world of patient care. With our glossy syllabi, objectives, and neat clinical cases, we venture forth, mastering the pathophysiology of disease, highlighting every word and digesting the well packaged information, fully aware of the expectations, while completely sheltered from the reality of patient care.

When we transition to the clinical years, reality hits us hard. We are indoctrinated into an entirely new culture, where we feel alien in our short white coats and lack of experience. In recognizing our limitations, we also remember that we are bestowed with the responsibility of taking care of human life—a great privilege and challenge. We quickly realize that lessons from our early doctoring class have little place in the world of 10-15 minute clinical encounters and overflowing emergency rooms.

“Human lives are just plain messy,” my medicine attending once told me.
He is right. Although the first two years prepare us with an extensive knowledge base, nothing can truly prepare us for the reality of the clinical years. The complicated pathophysiology of disease pales in comparison to the intricate complexities weaved in the stories of our patients.

As we serve patients during the lowest points in their lives, we become acquainted with the intimate details of their histories. In managing my patients, I have seen a spectrum, everything from the IV drug user who overdosed to the wife abused by her partner to the patient dying from his metastatic cancer to the homeless patient with HIV to the victim of nonaccidental trauma to the pregnant patient actively using meth. The spectrum of disease pathology is oftentimes grounded in social pathology that exposes us to the dark sides of human nature and cruelty of society. When we see the intersections, we are reminded about the fragility of life and complexity of managing diseases.

In these encounters, we fumble through our words, break down emotionally, and struggle to understand. With new admissions and high patient turn-over, there is no time to process and we are not equipped with the coping skills to process the gravity of what our patients tell us. We initially fall back on the pearls we were taught during our first year of medical school to express compassionate words that merely fill the silence and void that separates us from our patients. Slowly, we outgrow our discomfort and we begin to learn, gaining valuable experiences. And despite our inadequacies, we are humbled, when our patients turn to us and call us “doctor,” a reminder that we are growing. We may not see the change, but our patients recognize the doctor in us.
***

Although the reality of patient care challenges us, the best lessons in medical education rest in our patient encounters, where disease takes on a human form and becomes cemented in our memories. On the wards, we are oftentimes assigned patients based on the learning value of their presentation. The “active patients” represent the gold, a source of intellectual stimulation, full of learning issues and “pimping” topics. Interestingly, when the diagnosis and assessment have been made and the plan is implemented, many physicians feel there is limited learning to be garnered from the “rocks” of the service.

As students, we adopt these patients as our own patients. Physicians, teams, and nurses switch, but the medical student remains, representing the one constant for these patients. We outlive the transient teams, oftentimes relating more to our patients than to the long white coats that surround us. And each day we arrive like clockwork to preround, round, and check-in on our patients. In following patients through their hospital course, we learn more than just the details of managing disease, we learn how to become healers through lessons that can only be experienced.
***

As medical students our learning represent a series of firsts, where our first exposures to disease manifestations and patient encounters shape our subsequent learning, oftentimes reinforcing the concepts that were introduced during the preclinical years. Initially, we lack the ability to actively apply our knowledge in the moment, while everyone around us processes and works at rapid paces. We lag behind because we are constantly readjusting to new environments with limited experience.

At the times, the process can be numbing. As a student, your role remains somewhat undefined. Your primary job is to take care of patients and learn medicine, in all it shades—the language, the skills, and the details of the culture. Many of us place unreasonable expectations on ourselves. We always forget that we are nomads, traveling from one rotation to another every couple of weeks, whereas our fellow residents and attending physicians have far more extensive experience.

The uneven learning differential skews the expectations. And we oftentimes remain uncertain, unprepared, and overwhelmed by the constant pressure of being evaluated. We strive for completeness and efficiency, streamlining our patient’s stories into one-sentence sound bites—the one liners. Like a shadow, we follow our intern around, unsure where we are supposed to go. We are driven to impress our team by referring to obscure references or citing the evidence-based medicine. In this process, many of us take on a new identity, while losing a piece of ourselves. But no one really teaches us how to learn.

In speaking with fellow medical students, we agree that the clinical years require a great deal of relearning; we have teach our selves how to be self-directed learners. Aside from the occasional didactic session or presentation from the attending, we are responsible for our learning. We spend our spare moments reading and reviewing the literature. At the end of the day we remember very little and our patients represent the best teachers. Education comes from managing our patients, even when we are just beginning to figure out the basics.
***

When we look at ourselves in our soiled and overstuffed white coats three years after beginning this journey, we can acknowledge how far we have come in such a short amount of time. We have become somewhat conversant in the medical language and familiar with the details of the medical culture. More than anything else, we have gained unique experiences that have changed us. The budding physician in us is slowly emerging.

With one year standing between me and residency, I feel frightened and excited. As I move forward, I know I will always feel unprepared. However, I will always remember that my patients will continue to be the best teachers.
There are many lessons I have learned. They can be best summed as follows:

1. Be present for your patients.
2. Listen to your patient.
3. Do what is right.
4. Be true to yourself
5. Treat your patient like you would want to be treated.

Although these principles are fundamental, these lessons are sometimes forgotten. Such lessons have a central role in the education of not just medical students, but also represent an integral part of the lifelong learning we will experience in our careers.
***

This essay was recently published in the San Francisco Medicine Magazine.

Sea of White

2010-09-26T22:48:00.000-07:00

The new first year medical students filled the auditorium floor, a sea of white coats.

The UCSF Alumni center president provided some interesting advice to this eager group of soon-to-be doctors.

"Now do not get khaki. Even butchers wear white coats."

I recently attended the white coat ceremony to celebrate the induction of the class of 2014. I had a unique perspective--that of a fourth year student and of a photographer capturing the key moments of the ceremony.

When our Dean stood on stage to introduce the 150 first year medical students, I was struck by what she had to say.

"You are just starting. And in about 45 months, you will be attending another ceremony--graduation."

It's interesting how graduation lurks ahead, and I feel like I just started--eager, excited, and ignorant, just like this new batch of students.

Three years later, I feel like I have grown a litte bit, but at the same time, feel like I have so much more to learn.

In addition, I find so much more meaning in the Oath of Lasagna, a modern-day version of the Hippocratic oath, that the newly coated medical students recite in unison to culminate the white coat ceremony and commence their journey into medicine.

I have included it below. I'll be reciting it again about nine months from now...

Oath of Lasagna

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Source: http://www.pbs.org/wgbh/nova/doctors/oath_modern.html

All Eyes on Me

2010-09-16T21:03:00.000-07:00

Do you ever get the feeling you are being watched?

When I sat down in the reserved chair, a part of me was a bit anxious and part of me was scared. And there was a small part that felt calm and ready to take on this challenge. Having finished three years of medical school, I have learned that sometimes courage is all you have at the end of the day, and that is ultimately what takes you a step further.

So, I sat there. I could just feel all 100 eyes starting at me, taking me in. Analyzing me, the way I sat, what I wore, my choice of shoes, my messy hair style, my overstuffed and sullied white coat. They were all processing the minute details that defined me--I am sure. It was not so long ago that I sat in their seats doing the same. I shut them all out and just focused on the task ahead of me.

***

In medical school you are always being watched. You are supervised at every step of the way. At times, it's comforting knowing that someone double checks everything you do, from writing a note to writing an order to performing a physical exam. You always have confirmation. But at the same time, you also find yourself wanting to develop autonomy and independence to prove to yourself that you are capable of being a doctor, who will one day be responsible for patient lives (on your own).

***

My patient was fifty-something year-old woman. Her dark brown hair was neatly party. She had dark red lipstick and blue clothes. She sat down in front of me. And I began the interview. She had abdominal pain and her son was recently hospitalized in the ICU after a motor vehicle accident.

It was just like any other interview and I focused on my patient in front of me, fading out the sea of white coats.

There were over fifty first year medical students watching me perform this interview for their doctoring class.

I got through the interview and was able to an adequate patient history, while drawing on the clinical pearls they taught is in the first two years of doctoring class.

By the end of the interview, I looked out and saw the glowing and exciting faces of the medical students. They are just in the first week of their training and I could see the excitement in their eyes, the same excitement I had in my eyes three years ago, which I hope I can carry with me in the years to come, when I am not being watched.

Step by Step

2010-06-30T19:36:00.000-07:00

There is nothing quite like a double choclate chunk cookie that has been melted due to the summer heat. I can honestly say that I rarely indulge in such a wonderful creation. However, we all have exceptions to our rigid rules. And today, was the perfect day to indulge. The best part is devouring the cookie after a 9 hour test.

I completed Step 2- Clinical Knowledge Today. The mental marathon was long and at times felt endless. Every click got me one question closer to being done.

I am releived it's over. Now, it's time to catch up on life.

Lessons in Urban Survival

2010-06-25T18:08:00.000-07:00

“You can tell a lot by a person’s shoes. One look tells me if they are worth my efforts.” he said.

My patient, a forty-something gentleman, was educating me about what he called “urban survival.”

As a native of the Tenderloin, he relied on certain tactics to make ends meet. He was an expert-level street hustler. He was one of the successful ones and was capable of making a small fortune, probably enough to pay rent and live comfortably in a nice SF apartment somewhere outside the Tenderloin.

Sadly, he burned through his earnings, spending massive amounts on one thing—crack cocaine.

“Sometimes, it feels like I am drowning just thinking about how much money I owe. But I want it (crack). I need it. And I have to get it.”

***
Cocaine is derived from Erythroxylon coca leaves, a plant endemic to the Andes. In historical records, cocaine chewing was documented in South America as far back as 4000 years ago and for the last hundred years has had medicinal uses because of its vasoconstricting effects (1,2). Cocaine has multiple actions, acting as a local anesthetic effects, CNS stimulant, appetite depressant, and vasoconstrictor. The effects are largely mediated through the inhibition of norepinephrine, dopamine, and serotonin (3).

Cocaine has become a popular street drug, which can be sniffed, smoked, or injected intraveneously. As a recreational agent, cocaine has variable purity. The purest forms are white powder, while less pure forms are more yellow and have been cut with other drugs, such as lidocaine, caffeine, methamphetamine, ephedrine, and phencyclidine (3). When cocaine is heated in an alkaline solution, it transforms into “crack,” which is sold in 100-150 mg “rocks” and can be smoked, while a “line,” weighs 20-30 mg and is snorted (3).

***
When I first met him, he was completely suicidal and was brought into the SFGH Psychiatric Emergency Services after being placed on a 5150 hold for being a danger to himself. After the initial evaluation, he was transferred to the inpatient psychiatric unit. At the time, he had no home and was completely out of money.
He was a tall, thin middle-aged man with a pinkish complexion. His hair was combed and slicked back. He wore a lime green collar shirt over blue hospital gown pants. His two front teeth protruded outward and had been eaten away and were stained brown.

During our first meeting, it was like everything was in slow motion. He moved aimlessly and spoke slowly when recounting the details of his suicide attempt. He had a flat affect, showing very little facial expression. He appeared remorseful, but remained deeply depressed. At times, he would become teary eyed when talking about being abused as a child and his life in the Tenderloin. He was diagnosed with bipolar and polysubstance dependence.

“When I get low, I get really low and go into these dark bouts of depression. There is no reason to live for me. No one gives a shit about me.” he said.
His past addiction was alcohol; his current substance was cocaine. His heavy drug use required excessive amounts of money, which he often did not have. Thus, he borrowed from street lenders and still had to pay back his debt.

The chronic use had left his life in shambles. He went from having it all—a condo, a girlfried, and a stable job—to now having nothing. He was living on the streets, had made many enemies, and relied on hustling to get his daily fix.
He had been admitted to our inpatient unit numerous times before for suicide attempts and was in and out of residential treatment programs. He was followed by a case manager and was plugged into an extensive network of social support services, but had difficulty committing to appointments and taking his medications. The hospital had become his security net, a revolving door for him.

***
Addiction to drugs results from alterations in neurochemical processes, which ultimately lead to increased drug-seeking behavior. Cocaine, like many other drugs of abuse, is highly addictive because it blocks dopamine uptake and results in increased dopamine levels in the nucleus accumbens (4). With respect to behavior, dopamine promotes reward-seeking behavior (5).

Interestingly, with increased cocaine use, dopamine release results in the setting of exposure to certain stimuli, such as drug paraphernalia or environmental cues, findings that have been demonstrated in animal models (6). This conditioned response explains the drug-seeking behavior observed in chronic users, who are driven to do whatever it takes to get their neurochemical fix.

***
Over his two-week hospitalization, I came to know him really well. Although initially reserved, he opened up and enjoyed talking about himself and his urban life; he was always seeking an audience. He became animated when he described the subculture of street hustlers.

He was vague when describing exactly what he did when he stood on the streets of the financial district wearing an expensive European blazer and pair of polished Italian shoes. He had mastered the art of “talk,” and was able to assume an entirely different persona, when he worked in the shadows of the black suits, he desperately desired to be.

Like himself, many of his colleagues were substance abusers, who generated funds through a similar fashion. He admitted that his tactics were aimed at getting money from the “sharks,” the men in business suits. Unlike other hustlers, he felt his tactics were less seedy; he did not pursue women and was not overly aggressive.
“I just have a way of getting what I want,” he said.

Despite his skills, he was consumed by what he called “self-destructive behavior.” He had made many street enemies and there was no escape living in the Tenderloin district, where every street corner harbors a dealer and the environment reinforces his addiction-forming habit. He felt powerless and weak, completely disabled with an inability to break the habit.

“I am spiraling and digging himself deeper and deeper in an early grave,” he said.

***
With an expanding drug economy, a subculture of hustlers has emerged as a powerful force with a unique social identity. In a study that examined the social identity formation of street hustlers in a group of 28 criminals prosecuted for violent street crimes, the authors cited how hustlers involved in the drug economy made every effort to differentiate themselves from the crack-heads, who represent a lower social status (7).

The following qualities were identified as central components of the hustler identity:
1. Being Clean- The hustler has morals and pays close attention to hygiene and dress.
2. Having Things- The hustler seeks to acquire material wealth
3. Being cool- The hustler is characterized by a detached persona and calm demeanor.
4. Being criminally able- The hustler has the knowledge to accomplish the necessary acts to sustain a living
5. Having heart- The hustler can protect oneself from victimization or danger.
The authors conclude, “The self-described hustlers in our research succeeded, at least in their own minds, in establishing an identity whose status is at the top of the crack economy rather than at the bottom,” much like my patient who prides himself for being successful at his line of work (7).

***
Closer to the end of his hospitalization, my patient laid out his requests— he wanted to be admitted into one particular residential treatment program in San Francisco and after he completed the program, he wanted a new apartment outside the Tenderloin. These were his stipulations for recovery.

At times, it felt like we were negotiating the terms of an agreement. And when we could deliver, his attitude changed. He instantly became invested in recovery and the treatment program, seeking immediate discharge even before the bed was made available. When we had trouble securing the bed, he drifted into a depressed mood and pleaded with us.

He intrigued me. A part of me was drawn to him, sympathizing with him, completely consumed by his story. I could not even fathom how he survived years of childhood abuse, living in the streets, and relying on urban survival. I wanted to see him recover to help me get back the life he once had.

At the same time, the skeptic in me awakened. At times, I wondered how much of his story was true and how much of it was actually concocted. He was well-versed in the art of talk. He knew exactly what to say to get what he wanted. After all, he was an expert hustler. I often wondered, was I being hustled like everyone else who had entered his life?

When he left the unit, I wished him well. I never knew what became of him. One can only hope he was successful this time in his residential treatment program. A part of me fears he might have tried to kill himself again, while another part of me thinks he may have ended up back on the streets, hustling his way to bricks of crack.

Whatever the outcome, his story reminds me about the intersections of substance abuse, addiction, and psychiatric illness, a sad reality in our urban neighborhoods. Although it easy to blame the patient for his addiction, we must remember that addiction is an illness, which like many other medical diseases, requires an interdisciplinary approach to treat the neurochemical and psychological basis of disease.

***
Works Cited
1. Nunes E,. “A Brief History of Cocaine: From Inca Monarchs to Cali Cartels: 500 Years of Cocaine Dealing.”NEJM- Nengl j med 355;11 www.nejm.org 1182 september 14, 2006
2. Murphy Nancy G, Benowitz Neal L, "Cocaine" (Chapter). Olson KR: Poisoning & Drug Overdose, 5e: http://www.accessmedicine.com/content.aspx?aID=2683517
3. Luscher Christian, "Chapter 32. Drugs of Abuse" (Chapter). Katzung BG: Basic & Clinical Pharmacology, 11e: http://www.accessmedicine.com/content.aspx?aID=4519820
4. Volkow N, Wang G, et. al. “Cocaine Cues and Dopamine in Dorsal Striatum: Mechanism of Craving in Cocaine Addiction.” The Journal of Neuroscience, June 14, 2006, 26(24):6583-6588; doi:10.1523/JNEUROSCI.1544-06.2006
5. Schultz W, Dayan P, Montague PR (1997) A neural substrate of prediction and reward. Science 275:1593–1599.
6. Di Ciano P, Everitt BJ (2004) Direct interactions between the basolateral amygdala and nucleus accumbens core underlie cocaine-seeking behavior by rats. J Neurosci 24:7167–7173
7. Copes H., Hochstetler A., Williams JP., “‘We Weren’t Like No Regular Dope Fiends”: Negotiating Hustler and Crackhead Identities.’” Social Problems. Vol. 55, Issue 2, pp. 254–270, ISSN 0037-7791, electronic ISSN 1533-8533

A Long Overdue Update

2010-06-25T18:02:00.000-07:00

I've been spending my days staring out the window and at a screen, clicking away. I am still here. Officially a fourth year. And with that transition comes another test-Step 2.

Studying has been unexciting, to say the least. Needless to say, there is not much to write about. Just counting days to test day and being done with these artificial case vignettes.

Once this exam is over, I look forward to reflecting as I begin my fourth year.

For now, I am posting a recent essay I published in the San Francisco Medicine titled "Lessons in Urban Survival."

Warm Blue Water, Beaches in France, and Spinal Anesthesia

2010-05-09T17:34:00.000-07:00

“You are tentative,” she said.

My patient was a 73-year old women, who spoke with a heavy Russian accent. I met her in the Preoperative area, where I initially caught a glimpse of her limping and approaching the nurses complaining about how she had been waiting over an hour to go to surgery. She looked her age. Her silver hair was thin and her pale skin was streaked with a yellow hue. She was frail. Her face was sullen and wrinkled, covered with dark pigmented freckles. Her teeth were brown and chipped.

She was already annoyed with me when I asked questions relating to her medical history.

“I do not see why I have to tell you. I already gave all that information. It’s in the chart,” she said.

After eliciting as much of a history as I could, I carefully gripped her hand and pulled her paper-thin skin back to better visualize her veins. Even with tourniquet in place, the blue threads that coursed her hand, left little room for error. I knew that I had one shot to pierce the needle.

The tension was palpable in corner of the room occupied by her bed. She was anxious and she made me fully aware of my role as a student. She could sense my anxiety. I could feel her eyes on me, watching every move I made. Later, I was joined by my resident. And I knew the last thing she needed was to hear a resident instructing me how to pierce her veins.

Despite her overt discomfort, I stayed calm, visualizing the steps of placing a peripheral IV in my head. My resident talked me through the steps, giving me confidence and direction; I had done this before and I knew I could do it again. But at the same time, I knew that the more he talked, the more she doubted my ability.
As I made my first move, positioning the needle in my hand, holding it like a pencil at an angle parallel to the vein, I pierced, and before I advanced, my residence instructed me to reposition. Before I could move the needle, my patient interrupted us.

“Can I have someone who knows what they are doing do this,” she screamed.
Her words were stinging, reminding me about my inherent limitations as a student. Without saying a single word, I handed the needle to my resident, who was able to complete the job, which I had meticulously planned out in my mind. I resumed my position as an assistant, handing him the tape and cleaning up the mess—a familiar role I had come to know as a third year student.

Although I was taken aback by her response, I can understand her frustration. She was alone and exposed in a completely sterile and unfamiliar environment. Strangers rushed passed her and she was completely ignored. She wanted general anesthesia, but the surgeons had decided spinal anesthesia was a better option, given the lower risk of blood clots and quicker recovery. She did not want to feel any pain or be aware of the surgery. And from her perspective, she was not being heard.

Although she was keenly aware that our hospital is teaching institution, she had very limited patience. She was simply expressing what we would all want if we were in her situation. She did not want to be pricked like a pin cushion, or be treated as an experimental subject.

At the same time, her case made me think about how to balance learning with deliver high quality patient care. As a student, you are stuck in the middle. Your patient’s needs come first. However, we all need to learn, so that we can take care of our future patients. A part of me always feel guilty when I am performing a procedure for the first time—be it delivering a baby, suturing a wound, performing a LP, or a placing a peripheral IV—knowing that a more trained provider could do the same job in a shorter amount of time (and probably more successfully). But everyone has to learn and we all have a first time.
***

When we arrived in the operating room, she became visibly anxious.

As the resident began prepping her back for the spinal anesthesia administration, she kept repeating, “Why can’t I have general?”

At first, I was hesitant to go to her side, having just been berated by her. However, I knew she was vulnerable and could really use emotional support. I moved from watching the placement of the spinal and came to her side. I grabbed her hand and attempted to engage her in a conversation.

Using visualization techniques, I worked with her to think pleasant thoughts. She saw herself sitting at a beach in France with rolling mountains in the background. She was sitting next to good friend and her feet were immersed in warm blue water. French music could be overheard.

As the needle pierced her skin, she gripped my hand and I reminded her about her special place, repeating the details of the French beach. And with each detail, she became a bit calmer. And before we knew it, the spinal was in. She looked at me in surprise at the end of procedure.

“That’s it?” she said surprisingly.

“Yes. They are done.” I responded.

In my role at her bedside, I was able to talk her through a procedure that she had deemed impossible. In doing so, I was able to develop rapport with my patient and optimize her care. I was able to salvage our therapeutic alliance. I put her needs first and enabled her to overcome her fears through visualization techniques.

My experience working with her reminds me about the power of mind over matter. In many ways, these types of experience are just as important as learning technical skills. And sometimes it’s this connection that makes all the difference for our patients.
***

The Lottery

2010-03-29T19:36:00.001-07:00

It's that time again. LOTTERY TIME!

Nation-wide, the lottery is exciting because there is a chance of winning a jackpot. Our medical school lottery does not promise such fortune. Instead, it's anxiety-provoking as we rank our preferences for our fourth year schedules. Once everyone ranks their preferences, a computer goes through and randomly assigns us our electives.

As I rank numerous selections, I am reminded of highschool precalculus, thinking about all the possible permutations. If only I knew game theory to maximize my chances of constructing a perfect fourth schedule.

In truth, it feels like being back in college. Having spent my whole life in public school, I am familiar with the process that comes with allocating scare resources to meet a high demand. In our cases, there are just way to many students coveting the same spots in certain sub-internships, fourth year electives.

Inevitably, we all have to compromise and realize we will never get the perfect schedules. Regardless of the lottery results, I hope my schedule has some resemblance to some of my 60 rankings.

The Small Things

2010-03-22T22:46:00.000-07:00

Sometimes, it's the small things that make your day.

Today, I was moved when my patient gave me the gift of chocolate to celebrate the birth of her son. The choclate was wrapped in light blue foil, one was a square piece with a picture of baby boy and the other was cigar-shpaed piece. My first patient gift.

As I was walking be her room, her mother greeted with me a hug.

"Eisha, it is so good to see you. You need to come and see the baby." she said.

I walked into the room and was instantly greeted by the patient, who looked up at me with relief and joy.

"He is big. 9 lbs and 11 ounces. My pelvis was just not big enough for his big body. So, we had a C-section. It was not what I had expected, but he just was not coming. Oh well, it was worth it."

She smiled as she looked at her son with his chubby face and full lips. He looked just like his dad. He was sucking on his fingers and sleeping quietly.

***

Over the course of the three weeks I spent on labor and delivery, I got to know the patient and her family very well. This twenty-something year-old,, first time mother, had recently moved to SF from the South. She retained her southern accent and her mother maintained a certain amount of Southern hospitality. The patient always wore her straight black hair down. Her face was framed by thick-rimmed glasses. She was friendly and seemed to always be concerned.

She had become my longitudinal patient. She always came with her mother. I had seen them regularly in triage, where she came concerned about contractions that the she thought were the harbingers of labor. Each time she came in, we would connect the monitor and reassure her that she was not in labor.

She returned in the days leading up to her delivery due to concerns that she was not feeling her baby move. There were also some non-reassuring changes noted in her fetal heart strip. For some reason, when she showed up to triage, everything returned to normal.

"He makes a liar out of me," she would say, right before we let her go home.

On her last triage visit, she realized she was not in labor. She was close to her due date, so we decided to induce her labor. We all knew that if we discharged her, she would be back soon enough.

***

I gave her hug and made my way to the crib. I was finally getting to meet the baby we had been monitoring with ultrasounds, fetal heart monitoring, and cervical exams over the last three weeks. I had come to know his 2-d black and white ultrasound image, as well as the amniotic fluid levels that bathed him in his in-utero home. He had been a constant source of worry for his mom. Now, he had entered our world. And it was such a pleasure to see his face and his little hands.

Over three weeks, I felt like I had really become a part of my patient's life. In her room, I was surrounded by strangers, who had come to know me.

It these small things that make it all worth it.

Great Catch

2010-03-06T21:40:00.000-08:00

"Is this your first catch?" My patient asked.

"Yes." I responded sheepishly. Is it that obvious, I thought.

"Well, Great catch." She responded

"Cheers to you and cheers to the baby." Her husband said.

Five days ago at 1:19 AM, I delivered my first baby. The baby boy, weighing 8 lbs and 4 oz came into the world crying loudly after his mother labored for nearly a full day. I held him in my arms and watched as he opened his eyes to see the world he had just entered.

***
I remember the first time I went to the labor and delivery floor. It was within my first weeks of medical school. I made my way up to the fifteenth floor, where I attended three births and stood behind a gowned team of doctors. I was a spectator, the mirror girl holding a large oval mirror to show the patient her baby emerging into the world through her legs.

Almost two years later, I returned to the same delivery rooms. I am currently on my OB-GYN rotation. And for my first week, I have solely worked nights, from 6 PM to 8 AM. Surviving these unnatural hours has required a large cup of coffee and many cups that follow during the night.

In many ways, things have changed. This time around, I am standing in an entirely different place with a completely different job. While I have grown in my role, some things have not changed; I continue to marvel at birth and the views of SF from the 15th floor.

***
My patients room was in the East corner. The glittering lights of downtown skyline were visible through the darkness. The room lights had been dimmed. Her bed was close to the window right next to a pull out sofa. The infant exam area was nestled in the opposite corner of the large room.

When I met my patient for the first time, a woman in her late twenties, she was lying in her bed wearing a hospital gown. Her black hair was pulled back and beads of sweat were forming on her light skin. She had gray eyes. And the only clue to knowing she was pregnant was her gravid abdomen. She was well-trimmed, the result of weekly sessions with a personal trainer. Her toenails had been painted a nice shiny silver. She breathed through the contractions and spoke through the contractions.

She was joined by her husband, who was by her side the whole time, holding her hand. He was in his late twenties. He had brown hair and dark blue eyes. He looked like the poster child of fitness; he was thin with a build of a runner.

"We are hoping, the baby will have a mix of my blue eyes and her gray eyes. And maybe a touch of my brown hair." he said.

This was their first baby and he was arriving close to his scheduled estimated date of delivery. She started having contractions at 3 AM of the previous day. When she arrived to our triage room, she was examined, after which her water broke. She was placed in a delivery room because she was in active labor and had been laboring all day.

During my shift, I coached her through the last five hours of her labor. With the guidance of a seasoned labor nurse, we encouraged our patient to take deep breaths and then push. Breath and then push. Over and over again. This became our mantra. And slowly, the baby made it's way down.

In between the painful pushing; she would briefly pause and take a deep breath. Through the entire process she requested on only one thing.

"Can I have some ice chips?" She would ask.

She had decided to have a natural delivery, so there were no epidural or pain medications. There was no IV sticking out of her arm. She was able to move out of her bed and change positions as needed to help position herself more comfortably, which became incredibly difficult. As the labor progressed, the deeps breaths turned into grunts and screams as each contraction became even more painful and intense.

With no pain medication, we could only offer encouragement, guidance, and ice chips (by the end she had gone through three large cups of ice chips). And that's what we did. And slowly, she was able to push harder and harder, until we started to see the black hairs on the baby's head.

"Babe, I can see his hair. He's almost here." Her husband said minutes before we went on to deliver the baby.

The delivery itself represented a small fraction of the entire of laboring process. It was the climax of an entire day of contractions and pushing. Once the head started to crown, we prepared to deliver the baby. So much seemed to happen in the those minutes. The instrument tray was uncovered and we quickly put on our masks, gowns, and gloves. The lights were turned on. We were joined by the other doctors. With my hands and some assistance, I guided the baby's head, while protecting the mother's perineum.

Inch by inch, and with each push and contraction, more and more of the head could be seen. Between pushes, the head would pop back in, almost like playing peek-a-boo. Eventually, we were able to safely guide the head, followed by the shoulders and then the rest of the body out. Before I knew it, he was in my arms, covered in blood and fluid. He was also very slippery and warm (as I had been warned).

There was a sudden calm, as we rejoiced in the end of the delivery and waited to hear the baby to introduce himself with a loud cry.

For a second he was a silent, but within seconds, he started to cry. His color transformed from a ashen blue to a dark pink. We clamped his cord and dad cut the cord between our two metallic instruments. I handed the baby to the pediatrician, who was standing behind me with an open blanket in her arms. After he was evaluated, he was returned to mom and dad.

We went on to deliver the placenta by applying supra pubic pressure and applying traction of the cord. Once the floppy structure fell into the bucket, we worked on repairing the laceration that comes from having a baby pass through a vagina.

***
The whole process of birth, from labor to delivery, is simply magical. At times, it can be difficult to watch as you see the mother experiencing such intense pain with each contraction. At the same time, you are simply amazed by the instantaneous change that happens with the birth of a baby. You see the whole spectrum of human emotion, everything from pain to anger to anxiety to joy to happiness all in the course of delivery.

In many ways, it's transformative process for the people involved. In one day, many lives change. The nine months of waiting and wondering and worrying culminate with a new addition to a family; parents are sloe born.

In my small role, I helped my patient and her husband transition to the next phase in their lives--parenthood. For me, it was more than just catching a baby; it was one of the most memorable experiences of medical school, one of the greatest gifts anyone could have given me. I feel so lucky to have delivered their baby; to have held their baby for the first time. I feel so humbled and thankful for this catch.

Marveling at my Greeters

2010-02-26T16:21:00.000-08:00

For the last month, my morning has always started the same. I turn my key clockwise until the light turns green and the door unlocks. Before opening the door, I carefully make sure no patient has crossed the yellow line and will AWOL the moment the pink door opens. I quickly slip in and close the door, letting myself into the unit, while gripping my coffee in my hand. And my day begins.

In may ways, it's like Groundhog Day, it is the same routine over and over again.

***

And it always starts with my greeters, who have become a part of my routine. *Lena and Joe, without fail, have been there to draw me into their world, daily reminders of this new habitat I visit.

From the common room, Lena stares at me. She is a forty-something year old woman, with the mental capacity of a child. She intermittently laughs, claps, or throws tantrums. Her frizzy black and gray hair is pulled back in a pony tail and she wears a stained white t-shirt that tightens around her mid section. Today she wears blue hospital pants instead of her usual patterned dress. The daily antipsychotic medications have calmed her down, but caused her to gain weight and retain water; her face is swollen and she looks sedated as she pouts with her arms crossed across her chest. This morning, she ran up to me to give me a hug. Later on, she finds me while I interview a patient to give me some of her half-eaten animal crackers. I politely decline and she moves on to offer the food to one of her peers.

In many ways, she appears blissfully unaware of her mental illness and the discussions that happen each morning during acuity rounds that focus on transferring her to another facility. "She was evaluated, but they don't think she is eligible for placement," her providers say. So, she has taken residence in the unit. As far as she knows, the unit is her world; her major concerns are when she gets to eat and if she can get an extra soda.

There there is Joe. An older gentleman in his seventies, whose face has been thinned down to the bones. With his dark eyes and bony face, he reminds me of my childhood image of a walking skeleton, who lurks in the shadows. He speaks no English and when he talks, you can barely understand what he says; he has barely any teeth. He likes to opens his mouth, which reveals the darkness of his oral cavity. His yellow skin is accentuated by his silver hair. You intermittently hear the gurgles from his throat when he sits quietly to watch the afternoon Court TV.

He is infamous for his pranks, which have included clogging sinks, jamming locks, and hiding things. He always wears the same dark blue jacket with red stripes over blue pants. He shuffles around the unit with small steps, shifting from one chair to another. Each morning, he utters something incomprehensible to call my attention. Each day, his goal has been the same- "get out of the hospital."

But for some reason, he has remained in the hospital, becoming a resident of the unit.

Similar to how the greeters have become a part of the unit, they have become a part of my world.

***
At 9:30 AM every day, the chairs and sofas are arranged in a circle. Patients emerge from their rooms to congregate for the community meeting. Some patients stroll in after being prompted, some wander after being waken up, while other patients are already seated from the previous stretch session. The providers join the meeting later.

It's the same process every morning. Go around the circle, introduce yourself, tell everyone how you are doing, and state a goal for the day.

Today, many patients were feeling good. A common goal was to get out of the hospital, or go to the patio. One patient declared he wanted "to take over the world." Another patient, said, "F*%@ you all. I do not belong here."

It's also a time to bring up community issues, read the unit rules, and orient new patients to the staff and daily schedule. Today, occupational therapy had scheduled an art exercise and a movie matinee for the afternoon. Patients would be able to select the movie to be played.

You can learn from the community meeting. You get a sense of the patient's mood, their goals, and how they interact in a group setting. I could see Lena pouting at me from the corner of the room. Joe arrived late and slowly made his way to his usual seat. Today his goal, like every other day, is the same. "I want to get out of the hospital," he said in the few English words he knows.

"If the weather holds up, we'll go out to the patio. You need a patio pass to go. To get a pass, participate in your care and go to groups," said the occupational therapist.

To conclude the community meeting, one of the patients picked an affirmation from the "I Can Can." Today, the laminated card echoed Aristotle's words. "In all things of nature there is something of the marvelous."

"You can marvel at your recovery. That concludes community meeting. Now, go have a good day." the group leader said.

***
The patio is in the center of the seventh floor surrounded by the units. You have to use your key to enter and leave the patio. The square area has a basketball hoop and a seating area made of metallic-shaped blue sofas. There is a painting on concrete the wall of a nature scene. The patio can be viewed through the windows from inside the unit.

Lena and Joe had both earned patio passes and were outside in the patio. Everyone was standing in a circle completing a series of stretches. I joined the circle, feeling weird standing still. I was reminded of the childhood game, Simon Says, where you imitate the action that someone tells you to do. During the exercise, we each went around the circle and choose a stretch and we all followed. I was amused, when the taller more fit patient, had the patients run in place; many of the patients could not keep his pace. The more unsteady patient had us roll our heads. I choose the calf stretch, since my legs were tight from my morning run. Lena had us put our arms in the air and move side to side. She was uncoordinated and clapped afterwards.

She always know how to put a smile on my face.

It's an odd scene. A bunch of grown adults locked out, standing in a circle and performing stretching exercises. I could see the staff watching us from inside.
It's a strange feeling to be watched.

***
Although I did not directly take care of Lena and Joe, I feel as though I have come to know them vicariously through our daily interactions. They have been the constant during my time in the unit. My other patients have come and gone. But Lena and Joe have been in the unit on conservatorships, completely distanced from the outside world. The unit has transformed into their homes; they have outlived many previous residents and medical students.

They will repeat this same cycle when they are transferred to another facility during the remainder of their lives. I wonder what their lives were like before they were admitted to the unit.

Lena and Joe remind me about some of the greatest responsibilities we possess as physicians. We are charged with making decisions for our patients, who are gravely disabled, either because of medical or mental illness. Joe and Lena can not function in the world we live in; they would be unable to feed themselves, take their medications, communicate with others appropriately, pay their bills, ride the bus, and find their way around the city. They are severely impaired and vulnerable. We become their conservators, taking on a parental role in these patient's lives, figuring out what we view as being in the patient's best interests. And it comes down to one thing--institutionalization.

For these patients, I feel we are placed in a precarious position. We are limited by our lack of understanding of our patient's true wishes. They have no family and our patient's can not clearly communicate with us and they lack insight into their illness. We resort to using the medications in our tool box. And when the medicine fails, we have to move to the next step, placing our patients in a facility. It's a bitter bill we swallow when we have exhausted all of our placement options, even when our patients do not want to go. What other options do we have?

It's a daily reality we confront on the unit. Today it's Lena and Joe. Tomorrow a new patient will arrive in the unit with a similar story (and probably the same outcome). And the cycle continues.
***

On my last day, Joe and Lena were in the community room watching Court TV. They were there greeting me, reminders of the world I was about to leave and the reality of the inpatient unit. As I walked out of the unit for the last time, I marveled at the lives of my greeters.

*Names have been changed to protect patient identities*

Trapped

2010-02-23T21:48:00.000-08:00

The pattern in the brown wooden floor is quite ironic. A small square is encompassed by another larger square, which is surrounded by another square. The pattern screams entrapment. It's an odd design choice for an inpatient psychiatric unit. Perhaps, it's just a mind game.

When I started my psychiatric rotation over three weeks ago, I instantly noted this pattern on the floor. I'm not sure why it called my attention. One of my colleagues elegantly pointed to a reason, drawing on Freudian themes.

"Perhaps, the pattern in the floor reflects you own internal preoccupation/conflict with being trapped on the unit," he said.

Quite an insightful comment not to far from the truth. Sometimes, you can feel trapped, even when you know you can leave.

***
The Seventh floor inpatient psychiatric unit at SF General Hospital is an interesting place. I'm situated in what used to be a themed women's unit. However, the themed units have disappeared due to budget cuts and the need to place acute patients in inpatient beds for stabilization.

The unit is set-up much like a traditional inpatient psychiatric hospital. There are individual units on the seventh floor with a central patio area. A key is required to enter and exit the unit to prevent any patients from AWOLing. A common room set up with chairs, tables, a TV and a piano, is located right next to the entrance. The Nurse station sits in the middle of two long pink hallways; one hallway for the male rooms and the other hallway for the female rooms. The charting room, where the physicians, nurses, and social workers congregate is just across the Nurse's station. The charting room door remains open during the day and patients pass by, sometimes demanding to see their physician or asking to be discharged, other times requesting for Ativan or food, or stopping to stare at you.

My experience on the unit has been a unique experience with it's share of ups and downs. In many ways, it's been a whirlwind learning experience that has made me reevaluate my emotional boundaries.
***

With inpatient psych, you bear witness to some of the most difficult patient situations you will see in medicine. You will see patients at the lowest points in their lives. You see the entire spectrum, everything from suicidal patients that attempted to jump off the Golden Gate Bridge to manic patients who in a fit of rage threatened to hurt others to psychotic patients who believe they are emperors of the world to violent patients with personality disorders to psychotic patients who hear the voice of God telling them to hurt others to delusional patients who believe they have HIV despite negative testing.

While on the unit, I've had patients yell at me, flirt with me, lie to me, cry in front of me, refuse to speak with me, talk only to me, write notes to me, or stare at me.

Many of our patients are admitted from the Psychiatric Emergency Services, where they are initially evaluated. Typically, patients can self-present, be transferred from the medical emergency ER, or brought in by the police or other providers. In the process, some patients are placed on a 5150 legal hold for either danger to self, danger to others, or grave disability.

The stories of our patients are heart-wrenching; you see the frailty of the human mind due to mental illness. You also see the darkest shades of human nature and behavior. Common themes thread through many of their stories-- histories of substance dependence, violence, abuse, neglect, lower socioeconomic status, marginal housing--just a few of the common themes that pervade the lives of our patients.

Mental illness deteriorates the lives of our patients. Some patients are just driven by basic instincts to survive, while other patients are completely out of touch with reality. Sadly, many of our patients with debilitating mental illnesses crumble in society; the hospital becomes a revolving door and their only security net. We become responsible for these patients.

Amidst the emotional turmoil, you (the provider) must take a history and determine the next steps. You are called to "stabilize" these patients and develop an appropriate discharge plan. For patients placed on a hold, we are given a 72-hour window to act (unless we obtain a 5250 hold, which extends th hold to 14 days). At any point, a patient can contest their hold in front a judge. Until the patient demonstrates insight into their condition, you make decisions on their behalf, quite a responsibility.

At times, you find yourself getting devoured by patients who seek your undivided attention so they can yell at you for hospitalizing them.

Other times, you struggle to process the gravity of your patient's words, trying to assess if they actually plan to hurt others, or if they are truly that ruthless. You find yourself losing your patience, having to remember to monitor your countertransference.

At times, you are simply overwhelmed by a patient's history of abuse and the tragedy of their life that you find yourself searching for the empathetic words to say (those PEARLS we were taught in first year), knowing well that what you say can not change or offset the damage. You remain silent, as your patient cries.

You either become skeptical and jaded, or you become emotionally overwhelmed and confused as you process the unimaginable. The constant exposure chips away at you, testing your boundaries and patience. Despite the challenges, you must find a way to remain dedicated to helping your patients.

All day long, you hear similar strokes of the same song. Through it all, you try not to let your own voice be silenced by the noises of the unit, so you can find your escape.

My First Half Marathon

2010-02-07T15:20:00.000-08:00

After many years of contemplating and many years of running, I finally did it; I ran my first half marathon (13.1 miles) and finished within my time goal.

It was a perfect running day. "The weather was selected specifically for this race," the commentator joked during the finish.

After many months of rain and cloudy weather, the sun shined. There was a light breeze. We were able to fully enjoy the outdoors as we traversed the path through the Golden Gate Park past the Pan Handle back to park all the way down to the great highway right along the Pacific Ocean. The views were breathtaking.

10,000 runners registered for the Kaiser Half Marathon and 5K. And the masses could be visible at the start line, jumping in place, stretching, conversing, or standing still. Proceeds from the race benefit organizations such as the Koret Family House, The Harbor Light Center for Alcoholism and Drug Abuse, and Support for Families of Children with Disabilities.

Although I've run these paths before, today it was special, because I went non-stop and was in the company of many other runners. The feeling is electrifying to be in the pack, and you are pushed to go faster and farther.

In many ways, running has been therapeutic over the last three years of medical school, getting me through the stress of exams, anxiety of evaluations, and uncertainty of third year. I felt so lucky to have this opportunity, counting my blessings for the strength, health, and determination to make it to the finish line.

My calves were a little tender at the finish line. But after some hydration and a hot long shower, the soreness has improved and I can say I feel good. We'll see if I can take the next step and train for a full marathon in July.

For now, I'm going to savor the feeling of completing my first half marathon.

Open Head

2010-02-03T22:03:00.000-08:00

"I left my heart in San Francisco." In the background, the muffled voice of Tony Bennett coming from the old AM/FM radio was barely audible over the drilling. With the hand-held drill, the neurosurgeon slowly moved along the purple line he had drawn on the skull of the patient. As he moved his drill, the bone slowly detached from the skull. White bone powder sprinkled all over the field.

"Irrigate!" he said.

With a green dropper that fit in my palm, I carefully squeezed the bulb and a couple of drops coated the cracked skull, caking the bone dust. I squeezed some more not sure how much pressure to apply. It was not coming out fast enough. The surgeon grabbed the dropper from my hand and proceeded to squeeze all the clear fluid out.

"I never liked this song, until I moved to San Francisco," the neurosurgeon said to scrub tech as he continued to irrigate.

He said little to me except instructing me to irrigate. He spoke in a low voice and made general conversation with the operating room staff about everything from football to abstract art to the Grammy awards to weekend plans.

He had dark wavy hair streaked with some specs of silver and wore glasses that framed his dark eyes. He would squint periodically and the fine wrinkles around his eyes became more prominent. He was a couple of inches taller than me with a medium build. Originnaly from the East Coast, he had moved to SF and was completing his neurosurgery training, which probably made him thirty-something years old. He spent most of his hours in the hospital, either operating or attending to patients in the ward or ICU.

The circular bone flap eventually became detached and the neurosurgeon (with some pressure) pulled off the bone piece.

"These are good drills for these kinds of case. But probably would not be fast enough during the emergency craniotomies," he said to the company rep.

Prior to drilling he had started by making a horseshoe incision along the hair line just above the ear, he reflected the skin back. The skin was tethered with white plastic clips.

With the bone removed, a glistening layer of tissue could be seen. This was the dura mater, also known as the "hard mother," a protective covering of meninges that sits below the skull and over the brain.

To get to the tumor, the neurosurgeon carefully cut along the layer of exposed dura until he uncovered the maze-like structure below--the brain.

This was my first time seeing open brain surgery. As part of our neurology rotation, we have the opportunity to observe neurosurgery cases. On my last day of neurology, I was able to finally see the brain, a subject we had spoken endlessly about during our case discussions and rounds.

Open brain surgery is quite something.

***
The last time I had seen a brain was during anatomy of my first year. We had sawed the skull and pulled out the brain after identifying many anatomic landmarks, which have escaped my memory. With the brain outside the head, we used a kitchen knife to slice the brain in horizontal planes to see the cross sectional anatomy. The light brown slices were uneven and moist to the touch, having been soaked in tissue-preserving chemicals.

***

Our patient, a seventy-three year-old gentlemen had presented with acute-onset seizures a couple days prior to his surgery. After the seizure, he had imaging studies, including a CT and MRI, which demonstrated that he had a large mass in his left hemisphere with radiographic characteristics suspicious for a meningioma.

A meningioma is a tumor of the meninges (the layers covering the brain) arising from the cells the produce the cerebrospinal fluid, liquid that coats the brain and meninges. Over 90% of cases are benign and have a low recurrence after surgical resection. Oftentimes you'll hear the neurosurgeons say that "if you have a brain tumor, you want to it be a meningioma." The prognosis is usually pretty good.

Before the case began, we closely examined his MRI scans to strategize the surgical approach. The bright circular mass was penetrating at least 2-3 cm into the brain parenchyma, which means resection is a slow and meticulous process.

Grossly, the tumor was visible on the exposed portion of brain. The oval, light purple mass looked like it could be scraped off the brain. But the mass went deeper than the surface.

The neurosurgeon, examined the mass with fine instruments and started dissecting the tumor with a fine scissor, periodically cauterizing. I was surprised when he turned to me and asked, "why do I start dissecting here?"

As he asked the question, he pointed to nondescript area of the brain away from the midline. Although the terrain of the sulci and gyri of the brain looks identical all around, you always remember that there are some regions that are sacred.

"To avoid the motor and language areas." I said. (The most obvious answer I could conjure)

Satisfied with my answer, he continued to dissect away silently. He looked through a microscope to magnify the margins of the tumor.

As I stood there looking into the scope, I continued to wonder how deep he would dissect. He was guided by the MRI because the tumor tissue is almost indistinguishable from the brain parenchyma. But I still wonder how one really knows. That's probably what distinguishes "us" from "them" (the neurosurgeons), who from experience just know.

Whatever the approach-- it was slow, deliberate and meticulous. Every motion is precise. He would snip and pause, repositioning his pick-ups. He would take a closer look and then snip some more with a pair of fine scissors. And would repeat the same steps, slowly resecting the mass.

I stood there watching the fine cutting, in awe of the sight in front of me. With an open skull, we had a window to our patient's brain and we were cutting this man's tumor out slowly.

It was only hour two of the operation and there was long way to go to fully resect the tumor...

The Last Breaths

2010-01-31T14:44:00.000-08:00

It had been raining all week. The soggy gray weather had shrouded the city in a wet blanket of haze. Today, the sun was actually shining. I got a glimpse of a crisp San Francisco morning through the window of Mr. W’s new room.

Earlier that morning, I had walked into his old room. As I made my way to this room, half-stumbling through early morning sleepiness, I looked in the corner, where he usually lay. I was surprised to find an empty bed covered in freshly laundered white sheets. I searched the room, identifying the three other patients, only to realize Mr. W was not in the room.

I turned my attention to the sitter, who was staring at me from behind a computer in the middle of the room.

“They moved Mr. W’s body to Room 10,” she said.
***

Mr. W had died earlier that morning. I still hear the words echoing in my head as I sat and listened to our resident dictate the discharge/death note, “he expired at 5:50 AM.”

I had been following Mr. W through the later course of his illness during the last week. I never directly spoke to him; I made use of translator phone, which connected me remotely to an interpreter, who echoed my questions in Cantonese.

This 84 year-old man had been admitted to the Neurology service two weeks ago after he had been found unresponsive in his bathroom. The CT would later show that he had suffered a right-sided stroke after a major artery (middle cerebral artery) had been acutely occluded. As a result of the ischemia and subsequent brain damage, he was left with a left-sided paralysis and facial droop; he neglected his left side and preferred to look at his right.

Even before his stroke, his days had been numbered. He had advanced lung cancer with metastasis to his liver and bones.

He was initially observed in the ICU and later transferred to our ward team. When he first came out of the ICU, he was coherent, answering our questions, verbalizing his complaints and actively trying to move his flaccid left arm, using his good arm.
Initially, he was set on participating in acute rehab, despite the intensity. His family remained committed to recovery and even interested in continuing his chemotherapy for his lung cancer. But within a couple of days, his health started to decline.
***

Mr. W finally got his own room with a window that overlooked a busy SF highway. As the cars buzzed by, the stillness in Mr. W’s room could be palpated. A big red sign that said “Caution, Fall Risk” hung over his bed. I could not help but note the irony in a note that hung over the body of a dead man.

His mouth was still open, as though he was gasping for air. His two large brown front teeth and a row of overcrowded bottom teeth were visible. His face had a yellow hue and his eyes were closed. His frail body looked stiff. A name tag was tied around his big right toe and a large white bag was folded below his feet.
I walked up to his body. I lay my hand on his right side; his skin was still moist and slightly warm. I stood there alone, lamenting his death—wondering about how he suffered while he gasped for his last breaths. I closed my eyes and prayed he would find the peace he had been denied during the last days of his life. And I said good bye.
***

In the week that I took care of Mr. W, I had become familiar with his neurologic exam. He could not move the left side of his body and did not even withdraw from painful stimuli. He had a left facial droop and looked to the right. Initially, he was alert and oriented and would follow commands.

Sadly, during the last week of his life, I watched him decline, becoming more delirious and agitated. He became hypoxic and required more oxygen to be comfortable. Because he was at risk for aspirating the food he ingested, he required a feeding tube, which was placed in his nose. He had to be restrained because he tried to pull out the plastic tube. And he was flailing his right leg and tugging at his restraints to be freed. A shrill moan was audible from the hallway anytime you passed by his room.
He was miserable.

Each morning, I could hear him groaning. And each day his mental status declined. He went from verbalizing his complaints, to responding to yes/no questions, to becoming completely unresponsive and only communicating with mumbling. The translator could not make out his responses. He needed a diaper because of his incontinence and would swat me when I examined him.

He lay in a room surrounded by three other patients; a sitter sat in the middle of the room. When I watched him flailing his leg and restrained arm, which was contained in a large white mitten tied to the bed, I felt pity for this man. It was undignified to keep him tied down during the last days of life. He was suffering and a part of me wanted to tell his family, he was better off at home surrounded by his loved ones instead of being surrounded by strangers in an impersonal hospital room tied down.

But his family could not make the decision we (the neurologists) felt was in the best interests of the patient.
***

Doctors are not very good at prognosticating, especially when it comes to predicting someone’s life expectancy. Thus, lifespan is presented in ranges—days to weeks, weeks to months, and months to years.

We gave Mr. W weeks to live. His death did not come as a total surprise. The writing was on the wall from the day he came out of the ICU. We (the neurologists) could all could see it, but the family did not. He was not a good candidate for acute rehab due to his weakness. And when his health started to decline, we all knew he would be better served by comfort measures.

Despite the inevitable, we were not able to communicate our expectations to the daughter early in the course of his hospitalization. The daughter, who was charged with making medical decisions, initially insisted on acute rehab and chemotherapy because she did not realize his days were numbered.

We did not discuss goals of care until after Mr. W had become restrained and started to decompensate. It was only after he had repeatedly expressed- “please let me die. Please let me die,” that we consulted the palliative care service.

Even when we presented the options relating to removing life-sustaining measures to the daughter, she could not make the decision we all wanted her to make—she could not withdraw care. And wanted to suspend making a decision.
***

At the end of life, we place a large burden on the families of our patients. We look to the families to make decisions with limited information because we expect the families to know what the patient would have wanted. As easy as it is for us to make our recommendations, we do not have to live with the consequences of such decisions. I can only imagine the anxiety Mr. W’s daughter faced, when she had to make the final decision about Mr. W’s end of life care.

We ended up agreeing on comfort measures, such as Haldol to help the agitation and morphine for pain. But his feeding tube remained in place and he still had to be restrained. He continued to groan.

In the end, Mr. W died of respiratory compromise, gasping for air.
***

When I left the hospital, I felt a heaviness inside me, feelings of guilt and sadness. I wondered what I could have done differently to help Mr. W in the last days of life. I respect the family’s wishes and only wish we could have included Mr. W in the discussion earlier to better understand what his wishes were. I kept replaying the conversations we should have had with the patient and family.

But in the end, I realized that we sometimes just need to accept death as it comes, even if it does not meet our criteria for a dignified/comfortable death. These are the things we do not control.

As I drove away, the rain started again.
***

Speechless

2010-01-21T23:25:00.000-08:00

I'm probably one of those people, who can always find something to say. For some reason, I was searching tonight to find words to express gratitude. I had to improvise...a skill I have learned from being a third year medical student.

There is something to be said about accepting an award. It's harder than they make it out to be on the Academy Awards. It can be hard to collect your thoughts, when you are overcome with excitement and are faced with an audience looking to you. It puts new meaning to the old saying "all eyes on you."

Tonight I felt extremely humbled and moved, when I was named as the recipient of the David Perlman Award for Excellence in Journalism presented by the San Francisco Medical Society during the Annual Dinner for my contributions to San Francisco Medicine Journal. I am extremely grateful for this award and thank the Society immensely for the recognition.

For a writer, one of the biggest honors is to be recognized for your writing. In many ways, it reinforces your desire to write and makes you realize that there is someone out there actually reading and listening to your story.

It gives your writing purpose; it gives you purpose as a writer.

More than anything else, it is an honor, in itself, to share my stories and reflections with an audience. It brings my experiences to life.

Tonight, I count my blessings and also thank (you) the reader for being there to hear my story. I am inspired to continue writing. We'll see where this takes me.
Stay tuned...

Following the Limbic System

2010-01-16T19:51:00.000-08:00

"The problem is that humans are driven by their limbic systems. As long as things are pleasurable, they will continue to do things even if they are harmful."

The words from our neurologist.

***
Another patient had been found down after using excessive amounts of cocaine; she had a history of previous neurologic insults and intercerebral bleeds. The CT scan was consistent with an intercerebral hemorrhage in both her hemispheres.

The patient was admitted for emergency neurosurgery to evacuate the bleed and to decrease the increased intracranial pressure, an operation involving removal of part of her skull. She then went directly to the ICU for very close monitoring.

The prognosis was unclear; she was comatose and her neurologic exam did not change--her eyes remained closed and she barely responded to painful stimuli. She had seizures continuously and no matter how high we titrated the anti-epileptic medications, her seizures remained.

Her pressures started to drop. And it was decided that her prognosis was poor in the setting of her decompensation. Life-sustaining support was withdrawn and the patient expired.

She died alone in the noisy ICU surrounded by machines.

***
In many ways, my neurology rotation has been sobering. Each day, I am reminded about the devastating impact of neurologic injuries on the lives of our patients. It's dramatic; one day the patient is normal and the next day everything changes.

I see it in the faces of our patients with facial droop, I hear it in the voices of our patients with dysarthric speech, I feel it in the muscles of our patients with hemiparesis, and I sense it in the frustration of our patients with aphasia who communicate with a word salad.

You see it too in the eyes of family members, who look to you for hope that their loved ones will improve, when you know the prognosis is poor.

You localize the lesion and can explain the pathology, but sometimes have very little to offer for treatment.

***

"Will my husband every be normal again? Will he be able to walk again?," my patient's wife asked.

My patient could not move his entire right side of his body. He had bled into his left hemisphere.

The answer to her question is the same answer we give to many families.

"We do not know. We will just have to wait and see." I said.

***
I'm half-way through my Neurology rotation. I returned to SF General Hospital for this four week rotation. In taking care of patients with neurologic conditions, our focus has been on localization of lesions. Using the patient history and neurologic exam, you learn how to correlate symptoms with neuroanatomy. It's a constant puzzle; sometimes it's textbook, while other times, you struggle to put the pieces together.

More often than not, the neurologic symptoms are unusual and present in many ways depending on the location and severity of the injury. The exam is the key to help localized and clench the diagnosis before confirming with neuroimaging.

So far, I have seen a myriad of neurologic conditions--everything from ischemic and hemorrhagic strokes to headaches to intercerebral bleeds to degenerative diseases to CNS infections to Parkinson's Disease to neuropathic pain to seizures to CNS lymphoma, as well as the unclear CNS diagnoses. One of my patients remains a diagnostic dilemma. We are still trying to find an explanation about why he can't walk and why his face is weak.

***
Having returned to SF General Hospital, I am reminded about the harsh reality many of our patients face. Whether dealing with being uninsured, substance abuse, HIV, homelessness, social factors- you quickly learn about the intersections of the medical and social history, since both topics go hand in hand. Prevention sometimes is an afterthought in patients, who have had uncontrolled hypertension because they could not afford the anti-hypertensive medications or the doctor visits. It's too late, once they have a stroke.

The damage has been done. Sadly, it's irreversible.

***

Happy New Year's!

2010-01-03T19:25:00.000-08:00

Happy New Year's!

I'm leaving vacation and heading back to SF to start Block 5 (out of 6 blocks).
I start neurology tomorrow.

So, it begins...again...

Making Round Chappitis

2009-12-30T10:55:00.001-08:00

Thought I'd share two of my passions with you- Cooking + Photography.
Here's a glimpse into my foray into the kitchen as I attempt to master the fine art of making round chappitis (among other things...). Enjoy!

Naan.

Keema Naan.

Burfy

Milk and Cookies.

Shaami Kebabs.

Finding the Horse among the Zebras

2009-12-18T17:13:00.000-08:00

"What do you do when an elephant sits on your refrigerator?" asked the five year old girl during clinic.

After she asked this question, I started thinking.
Well, I suppose there is a logical next step. But no matter how logical, I also know jokes coming from a five-year old usually have some punchline that becomes clear after it's mentioned.

"I really do not know," I said.

"Get a new fridge." she responded.

Of course, that makes sense now that she mentions it.

***
I completed my pediatrics rotation over one week ago, after which I rolled right into the winter vacation. And with vacation comes a completely altered state of mind-you get caught up in the simplicity of life-- eating three meals at home, spending time with family and friends, watching movies, running in the bitter cold, relaxing and getting away from anything medical. Hence, the hiatus from writing.

My last week in pediatrics was spent in the primary care clinic, a completely different world from the inpatient setting, where I had spent the three previous weeks among a team of providers handling the care of more "complicated" patients.

In the outpatient world, the clinic visits focus on well-child visits, anticipatory guidance, growth charts, and immunizations (among other things). It's an opportunity to verse parents about developmental milestones in motor, social, and language areas. You see mostly healthy patients of all ages, from newborns to teenagers.

***
Before starting my third year of medical school, I was told by a master diagnostician that there are two types of patients at extremes. There is the "horse," which represents the common conditions who follow the text books and can be diagnosed by relying on history, physical exam, and certain studies. And then at the other end of spectrum exists the "zebras," which are the diagnoses that are unusual and bizarre. They follow no text book description and often represent a diagnostic dilemma- the types of cases that have become glamorized by television shows, such as House.

When I spent time on the pediatric wards, I was surrounded by many zebra diagnoses with some interspersed horse diagnoses. Only at a tertiary care center...

The medical complexity of their conditions coupled with juggling multiple social factors and medical consult services, makes providing care challenging and rewarding. While on service, I took care of patients with a myriad of conditions, including Guillain-barre syndrome, asthma, whooping cough, inflammatory bowel disease, recurrent arteriovenous malformations, and encephalitis.

While some of my patients were acutely ill, others were recovering and undergoing intensive rehab after suffering neurological injuries. While admitted, these patients meet with the physical therapists, attend school, and participate in social events. In many ways, the hospital becomes a transient home. And it's remarkable to watch how these patients improve, slowly regaining the ability to stand, walk, swallow--exceeding our expectations.

Some of the patients were well-differentiated, having been diagnosed prior to transfer, while others came undifferentiated and were transferred from an outside hospital for further work-up (or because initial work-up did not point to any particular diagnosis).

As the hospitalist team on the wards, we certainly had our share of diagnostic puzzles, which become more complicated when you have to rely on other sources, namely the parents, for an accurate medical history. As the result, the eyeball tests becomes even more paramount in helping guide the diagnostic work-up. And when you add multiple consultants, who have very specialized expertise into the mix, you face an entirely different problem. It's just like having too many cooks in the kitchen. The primary team then becomes charged with coordinating care for the patient, managing the consultants requests and completing a barrage of blood tests and imaging studies.

In many ways, the "horses" (the more common diagnosis) become the "zebras."

Despite the complexity of diagnosing patients who present with an atypical presentation of a disease or patients with uncommon conditions, there is something rewarding about making the diagnosis and being able to make our patients feel better.

One of the most memorable parts of my rotation was the patients. I am simply amazed by children and their ability to cope and heal despite the challenges.

Crunching Leaves

2009-11-22T08:40:00.001-08:00

Autumn is here. Getting away from San Francisco reminded me about the seasons and the leaves with all their color changes--yellow, red, orange, brown.

As I ran around my neighborhood, I crunched the leaves that had fallen and blanketed the side walk. It took me back to the days of childhood. When I was younger, I would help my dad rake the leaves into nice neat piles before jumping on the piles and recreating the mess we had just cleaned. The good old days.

I had my first extended vacation of third year over the last two weeks. During the first week, I made a trip to Chicago for my brother's wedding. After the wedding, I came back to Davis to spend a week with my family.

It was so refreshing to get away from the medical world with all its differentials and histories for a short time to spend time with family and friends.

It's very simple to get completely consumed and to forget your human world. I had an amazing time at the wedding; it was so nice to be leave the medical student role behind temporarily to live life as a daughter, sister, friend and photographer.

As the old saying goes, "all good things comes to an end." And so too, does my vacation.

Despite having to give up unstructured days and three square meals, I am ready to return after a short hiatus. Being away has made me realize how much purpose I have as a medical student. There certainly are days when you feel inadequate and wonder if you will ever move forward. There is so much learning to be done, but you realize that you have come so far and and are moving ahead, albeit with small steps.

And each day is a gift that gets you a little closer...

I return to San Francisco today and the world of pediatrics. I move from the world of urgent care to the pediatric wards. There are four more weeks left in the rotation.

Hopefully, there will be time to crunch leaves during the next couple of weeks.

Halloween & Hand, Foot Mouth Disease

2009-11-02T21:35:00.000-08:00

I was reminded of how much fun Halloween can be last week during the costume contest on the wards. The day before, our chief resident made an announcement during noon conference to remind us to dress up for the kids. I was a gypsy, which was not nearly as creative as the Mickey Mouse, pirates, fairies, cowboys, Pippy Long stockings, and other characters. As we walked around the wards, it was uplifting to see some of the patients dressed up and getting to Trick-or-Treat at different places on the floor.

Post-Halloween, I spent my day in the ED during a day shift.

When I spoke with a kid with a possible wrist fracture, I asked him why he waited to come to the ED (he had sustained the injury the day before) and he had the most adorable response.

"I would have come on Saturday, but I wanted to go Trick-or-Treating."

Now, there is a kid with his priorities straight.

***

For the first time, there is something in medicine that is appropriately named- hand, foot and mouth disease.

During urgent care clinic today, I met a very cute four year old boy, who was been feeling awful over the last weeks with fevers, diarrhea, mouth ulcers, and diarrhea. He also had some interesting rashes on his palms and soles. As I listened to the story from his grandma, I started to put two and two together; he has problems with his hands and feet (rashes) and mouth (ulcers) in the setting of an infectious process (fever and diarrhea).

Like a simple math equation, it all added up to one thing- hand, foot and mouth disease, which is a coxsackie virus infection. Treatment is mostly supportive (fluids, rest, and Motrin) and the symptoms will likely resolve with time. Poor kid.

***

My days in urgent care have been a mix of evaluating upper respiratory infections (mostly coughs, runny noses and fevers) and some other interesting things, including jaundiced newborns, kids who have been vomiting, kids with diarrhea and strep throat.

On my call days in the Emergency department, I took care of a six year old boy, who sustained a wrist injury while dribbling a ball in a soccer match. I was the first to sign his cast with my signature sparkly Sponge Bob stickers. I also saw a toddler with gastroenteritis and a 16 y/o with vomiting.

In my one week of experience, I am really enjoying working with the kiddos and am beginning to see the "bread and butter" of pediatrics, which is still very novel to me during my second week of pediatrics.

The Eyeball Test

2009-10-28T20:53:00.000-07:00

These days, I walk around with pockets that are less bulging.

I traded the gauze, suture removal kits and medical tape for stickers and a doggie pen. I am proud to say that I walk around with stickers in my pockets, including Sponge Bob and an assortment of dog stickers. My favorite part of my job involves giving stickers to my younger patients.

I have moved from the world of surgery to pediatrics, two completely different worlds. I went from waking up before the sun had risen to waking up to the sun shining (I am currently working in the Urgent Care Clinic). I move away from focused abdominal exams to full head to toe exams, including looking into patient's ears and noses. It's a constant battle to get the otoscope into my younger kids, who cry and squirm. Even getting kids to open their mouth can sometimes feel like moving mountains. And yet, despite the challenges- it's such a pleasure to work with kids and families. When they smile, you feel a little less guilty about having to probe their ears.

In many ways, it's a stark contrast. I'm well-rested these days, catching up with friends and starting up my half-marathon training. The chief complaints have primarily been lots of upper respiratory symptoms and ruling out swine flu in kids having flu-like symptoms. In summary, lots of runny noses and coughing. Surprise surprise.

I do miss the intensity of surgery, the operating room and the complexity of the pre-operative and post-operative management. There is something remarkable about cutting someone open, visualizing the anatomy and defect, and fixing the problem with your hands (or instruments). I will miss the suturing for sure. There is no experience quite like it. A part of me will always be in love with surgery.

***
I do look forward to working with younger patients and developing an understanding of how to best approach common and not so common pediatric problems in the outpatient, urgent care and inpatient settings.

Although pediatrics and surgery are so different, there is one thing very similar to both fields--the eyeball test.

In pediatrics, you are oftentimes working with patients, who can not speak for themselves or give accurate histories. So, you rely on the caregiver to convey the history.

One pediatrician jokingly compared pediatrics to "veterinary medicine," since the patient is a poor historian for obvious reasons and you have to consult the owners (or the parents) for information.

As a result, you rely on your ability to "eyeball" the patient, which involves observing the patient and taking note of how they look, how they interact with others, and if they look sick. In doing so, you can answer some really important questions- "is this patient sick or not sick? Does this patient need immediate medical intervention?"

In surgery, you apply the same approach when evaluating a patient. You "eyeball" a patient to get a general sense of their disposition and health, which enables you (as a surgeon) to quickly decide if the patient is sick and if they need immediate surgery.

The eyeball test can also replace lack of knowledge; it's almost an instict or gut feeling. It got me through my surgery rotation and has been useful for me in my first days of pediatrics.

Excellent, the New Average

2009-10-21T21:38:00.000-07:00

Sometimes we all need to remind ourselves about the light at the end of the dark cavernous tunnel that is the third year of medical student. It can get murky when you are constantly being watched and evaluated and when you learn about what to expect in the near future.

The fourth year has become uncovered and now we are learning about the residency applications and the MATCH.

The cycle starts all over again.

Our third year creeped up on us not so long ago, and now it's starting to feel like it is slowly coming to an end. We are over half-way through and the fourth year discussion has already begun. Over fifty per cent of our class will choose to extend their education by at least one year, during which time they may travel, perform research or work. I am still on the fence about whether I want to take an extra year to sort things out. Medical training already seems so long. And having gone straight to medical school from college, I am accustomed to moving forward non-stop. At the same time, I want to certainly keep my options open and am considering research fellowships or an advanced degree in either public health or education.

Amidst all the lectures about fourth year planning, the Step 2 exam, clinical performance standards and extending medical school by taking a year off- we are learning more about the process involved in applying for residency and the match. The process and timeline remains very unclear and represent a source of anxiety for many third years.

But one thing is for sure, the third year is all about labeling. Our clinical performance is packaged into a one word adjective. You can be any of the following- "Superior, outstanding, excellent, very good, or good." With over 53% of the UCSF class labeled as "excellent," excellent has become the new average. Seriously.

This culture of labels makes me wonder about the utility of such characterizations. First, the entire process is subjective and determined purely based on other's opinions of you. Second, medical students are unique individuals with very diverse backgrounds, opinions and perspectives, who really can't be characterized by a single number or adjective. But despite such issues, we continue to label each other.

To standardize the process, we are evaluated and given a numerical value that reflects a number of fabricated categories that are intended to measure our fund of knowledge, clinical reasoning and patient relationships. In many ways, the numbers marginalize us, and we may even see ourselves in light of the label we are given. The feedback that accompanies the number oftentimes does not always correlate and we wonder what we could have done differently, or if we should do anything differently. There is only so much any individual can change.

The system exhausts me. It's tiring to always think about what others think about you. A number of us (myself included) have decided to make the most of our third year by focusing on learning and taking care of our patients. And in the process, we hope the evaluation will reflect that. But as much we tiptoe around the inevitable evaluation conversations, there really is no way to avoid the unavoidable. It's on all our minds akin to the white elephant in the room. We all think about it and wonder about it. Some of us complain or try to rationalize the process. No matter what, we work hard and hope it all works out.

And last time I checked, there is nothing wrong with being excellent.

The End of Surgery

2009-10-18T18:08:00.000-07:00

Friday was the last day of surgery. We ended on a somewhat anti-climactic note with the surgery shelf exam, a somewhat arbitrary measure of knowledge and clinical reasoning. I was experiencing flashbacks (nightmares) to preparing for the Step 1 exam, as I hopelessly reviewed esoteric details of diseases I had never encountered. It was certainly one of the least pleasant testing experiences I've had with 100 long questions in 2 hours- marathon test taking at it's worst. Sigh.

"If you finish you are ahead." I was told by another medical student.

As I studied for my shelf, the fellow on my service was preparing for his oral boards. Sadly, the tests just never end.

I left the exam feeling numb and bit flustered. Before I could start thinking about the test, I plugged myself into my headphones, tied my running shoes and set out for a long run. Actually, a really really long run- the longest run I've had thus far (14miles).

With the sun beating down on me, I just had the urge to keep going as I took in the sights of a city I had become estranged from while being on my surgery rotation. Moving one step forward, not looking back at all. This is definitely the year to run a half marathon.

Despite the challenges of surgery, I will definitely miss the rotation.

***

My last two weeks of surgery were spent on the kidney transplant unit. The best night of my rotation was on Monday, when I joined our team during an organ procurement. At 10:30 PM, we set out from San Francisco in a black van and made our way to a local bay area hospital, where we procured the liver and kidneys from a donor. The experience was surreal.

I felt disconnected at times-- not quite fully thinking about exactly what we were doing. But I also kept reminding myself how the organs we harvested could potentially save lives. No matter how I justified it, I could not forget the reality of what we were doing. We were removing organs out of a patient, who had been proclaimed brain dead. I got my best anatomy lesson that night. The heart continued to beat and the organs remained perfused, as we dissected away one organ at a time.

***

After my shelf and long run, I spent my golden weekend in the company of family and friends. My weekend was filled with quality time and food. I was able to recharge and refocus my energy.

I move now to Pediatrics, which starts next week.

Before moving ahead, all third year medical students will congregate in the classroom for a week of intersession, a series of lectures and small groups dedicated to ethics and clinical reasoning. Even after being lectured about how to resolve ethical dilemmas today, I feel more confused and uncertain about how to grapple key ethical topics, including allocation of scarce resources, end-of-life care decisions, euthanasia and patient autonomy. I hope this week will shed some light on these topics.

It's hard to believe that we are over 50% of the way through our third year of medical school. We reminded of this during one of our lectures, which focused on planning our fourth year of medical school. Already? I'm still just getting the gist of third year.

Shelf

2009-10-16T06:43:00.001-07:00

About to take the surgery shelf exam.
And will then be done with the rotation.
Stay tuned...

Empty Crib

2009-10-05T07:42:00.000-07:00

I will remember the empty crib. On my last day of my pediatric surgery rotation, we returned to round in the intensive care nursery. As we made our way to the west side, we walked to the crib and the baby was not present. Right away, we all knew what had happened-- the baby had died.

My fellow medical student and I had been following this infant's course during his hopsital day. Each day we reviewed his numbers, noting little signs of improvement. We would come by and examine him and speak with the mother. At one point, he was being maximally sustained on pressors and the maximum ventilation support. Despite all the interventions, the infant failed to improve, something we had expected from the start.
***

In the neonatal intensive care nursery, each infant receives the most specialized attention from a large team of healthcare providers, including physicians, nurses, social workers and students. Every conceivable piece of information is recorded on large elaborate flow sheets, everything from vital signs to infusions to amount of urine and stool to when the baby moves or sleeps. The life of an infant is chronicled by the hour. The fluids and output are meticulously measured. Medications and drips titrated exactly to the infant's weight. The amount of detail is nothing short of perfect.

And when the decision to withdraw all forms of life sustaining treatment is made- the flowsheet detail decreases, eventually disappearing. The infant is whisked away to a seperate room, where he can be with his family for the last few moments of his young life.

***

During my last week of pediatric surgery, I observed the spectrum of interventions to sustain life, from basic to complex procedures.

I watched as we sewed the ends of an esophagus for a baby that was born with esophageal atresia, where the esophagus ends in a blind pouch. The physician meticulously laid each suture to create an anastomosis between the blind bouch and the remaining esophagus, which was located more distally.

I watched how we managed acute renal failure in a baby with an obstrution secondary to a large cyst. I saw numerous inguinal hernia repairs and catheter placements.
I saw how we fix congenital diaphragmatic hernias, a defect in the diaphragm that develops when the diaphragmatic folds fail to fuse during development, which results in abdominal contents herniating into the thorax and preventing proper lung growth. Infants with this defect are born in respiratory distress and typically require ventilatory support prior to surgery.

We performed two repairs this week, on infants who had severely defected diaphragms. With the thorax open, the abdominal contents were carefully redirected into the abdomen and the diaphragm defect was patched and sutured close.

When I asked the neonatologist about the prognosis for infants with severe hernias, he told me the following-

"Fifty per cent of such infants will make it out of the hospital alive."

He was right. Only one of our infants survived.

Venturing into Pediatric Surgery

2009-09-27T19:27:00.000-07:00

The sun was shinning today, beckoning me to come outside. Despite the impending surgery shelf exam and a pile of incomplete reports, I made a decision to go running. A run to the ocean and some sunshine was exactly what I needed to recharge before another week of surgery. I have come to realize that it's better to live life when you have a chance rather than put things off for a more convenient time.

It's evident the list of things to do just gets longer.

***

"Medicine is like music. You have to listen for notes before you can appreciate the melody."

A truly insightful comment from the pediatric surgeon I worked with last week.

I am still struggling to put the notes together.

My first week on pediatric surgery was interesting. Just when I started adjusting to the world of general surgery, I was transplanted to an entirely different place, where the patients are smaller, have rare congenital anomalies and typically can't communicate directly with me.

You see the entire spectrum, everything from neonatal in the intensive care unit on bypass for respiratory failure to toddlers undergoing hernia repairs that require no hospitalizations to children with appendicitis to teenagers with midgut malrotation.

I spend my mornings in the neonatal intensive care nursery, collecting the numbers that reflect the respiratory, cardiovascular, fluid, electrolyte and hematologic status of the critically ill infants. I feel more like a recorder, writing and reciting the numbers without fully understanding the meaning. I was only beginning to understand adult ICU values. Neonatal intensive care is far more complicated and requires more than one week to grapple the ins and outs of management.

I have come to really appreciate the complexity of pediatric surgery. The operative approach is unique in pediatric surgery. The instruments are so much smaller and special attention must be paid to every little motion. When I watch the surgeons, I am amazed at how they navigate through such small holes to identify vital anatomical structures.

I have three more weeks of surgery left. We'll see what my last week of pediatric surgery brings...

Golden Weekend

2009-09-19T11:20:00.000-07:00

"No one ever tells you that you are doing a good job. But everyone yells the moment you mess up. It's a thankless job. Welcome to surgery."

While we were operating on Friday, the surgeon made this statement as I drove the camera during a laparoscopic hernia repair. His statement is true on many levels.

In the OR, you move when told to move, or you stand and watch. It's almost paralyzing when you are called on to do something. Time stops, as everyone waits for you to complete your task. You pay close attention to detail to make sure you do your task right- be it cutting suture (no matter what you do it's either too short or too long), suturing (it's always a struggle to approximate everything properly and you move too slow), driving the camera during laparscopic cases (following and keeping the horizon straight takes some experience), or retracting tissues (you never quite know how much tension to apply).

Whatever the task maybe, you always find yourself fixated on the smallest details. It's perhaps this close attention to detail, which makes surgeries successful and makes surgeons perfectionists.
***
Friday was my last day on the general surgery service. I move from the world of hernias, appendectomies, cholecystectomies, fistula repairs and gastric bypass procedures to an entirely different world- pediatric surgery.

I've had my first preview of pediatric surgery over these last two weeks, while I took care of a patient with midgut malrotation. I was the first to meet this family in surgery clinic and review here films. While in the hospital, I have been their point person. In working with the family and patient through her admission and surgery, I was felt lucky to work directly with my her and her family. In getting to know her story and in interacting with the family, I was able to learn far more than any pediatric surgery book could teach about such anomalies. It's such longitudinal experiences which make this rotation so memorable.

Before venturing forth to my next surgical rotation, my chief resident graciously gave me this weekend off. I have to stay this is true golden weekend. I am lucky to be spending time with my family and friends during the last day of Ramadan (the month of fasting) and Eid (the holiday marking the end of Ramadan). I am looking forward to eating my mother's home-cooked meals (actually anything other than crackers), catching up with my friends, having normal people conversations that do not conist of asking about bowel habits, sleeping, studying and exercising.

A perfect balance. I am now officially half-way through my general surgery rotation.

Surviving on Crackers

2009-09-13T13:52:00.000-07:00

I was once told by an anesthesiologist that he made his way through residency by surviving on saltines and water. When I heard this, I did not entirely believe him. But the more I think I about it and having spent 3 weeks on surgery, I can see the truth in his statement.

My daily diet (when I'm in the hospital) has been mostly consisting of two things- saltine crackers or graham crackers (and if I'm lucky- a whole wheat bagel with peanut butter). With ice water. Very appetizing.

While in the hospital, you sometimes go hours without really eating or thinking about stopping to eat. Between pre-rounding and rounding early in the morning, meeting patients before the case, prepping the patient for surgery, scrubbing in on the case and accompanying patients back to the PACU to write orders- you are left to scavenge for bites of food in the few minutes you have before the next case starts. And your body gets used to it. This is why dinner has become my favorite meal. I can actually sit and chew my food.

There a few things I have come to appreciate while being on surgery.

1. There is nothing like breathing air. By that I mean, being able to take a deep breath in and out without a mask on your face. It never felt so good.
2. Sitting- it's a wonderful thing. Wow, what a different it makes for your back, legs and achy feet.
3. Medical students do have a useful job on surgery. We are glorified supply cabinets. Need four by fours, gauze, tape, saline, suture removal kits? Don't worry- we got it on our person, or know how to get some.
4. I think my patients think I am preoccupied with bowel habits. Because every morning I ask the same questions- "have you passed any gas? Had any bowel movements yet?"

With three weeks down, I can truthfully say that surgery has consumed my life, taking up most hours of my days. There has very little time to see friends, sleep, study and exercise (although I think standing all day and running around rounds qualifies as exercise). I leave my apartment when it's dark and return home when it's dark. The only glimpse of sunlight I get is when we round on our patients, I can sometimes catch a view of the sun setting on the city. Even when I'm not in the OR or hospital, I am thinking about my patients and their diseases, the surgeries of the day, the suturing techniques I have learned, and the hospital course of my new patients.

The hours are long. And you work hard. Despite the challenges (namely lack of hours in the day to sleep and study), I feel lucky to be actively involved in my patient's care. There is something very special about taking care of the patients you have operated on. By performing surgery, you not only become acquainted with your patient's anatomy, but you are also able to use your hands to fix a problem, whether it is a hernia or enterocutaneous fistula or excision of a mass or a bowel resection. Postoperatively, you see how your patient regains bowel function, has improved pain, and starts eating food. The transition can be rewarding, when you see your patient discharged in good condition. It can also be frustrating, when your patient does not improve and remains hospitalized and you are left to wonder what went wrong.

I spent Friday night taking trauma call at SF General Hospital. The motto for SFGH is "It's as real as it gets." The SFGH Emergency Department serves as the only Level-One Trauma Center for the City and County of San Francisco and northern San Mateo. With over 58,000 visits annually, the Emergency Department serves both critically injured patients, as well as a large underserved and urban population.

The night was fairly mellow. We had a couple of 900 emergent pages (a gunshot victim and motor vehicle accident), which upon further evaluation did not require surgical intervention. We also had some patients with acute appendicitis, a patient with pneumothorax requiring chest tube placement, and a patient with an abscess. I performed my first incision and drainage on this woman's abscess. In doing so, her pain was improved and she was able to go home.

My first overnight call (with 2 hours of sleep) done. I left at 10 AM the next morning, completely exhausted and hungry- looking for some crackers.

Completing an Important Job

2009-08-30T15:01:00.000-07:00

Week 1 of surgery is done. 7 more weeks to go.

Within the first few days of this surgery rotation, I realized I had entered an entirely different medical culture. The structure of the day, the language, the clinic and the operations all represent eleements of a completely new experience.

One thing is for sure, I'm getting used to going through the entire day without seeing the sun shine. I wake up at 4:30 AM to make it to the hospital by 5 AM. I pre-round on my patients and help prepare for rounds, which start promptly at 6 AM. We round as a team on over 20 patients from 6 AM to 7:30 AM to make it in time for the first OR cases, which start around 7:30 AM. At this time, most other teams are just beginning to arrive at the hospital. We move fast and quick.

Then we spend the day in the OR, operating. As a medical student, you scrub in and wait for instruction.

"You have the most important job. We rely on your precision," said the attending surgeon during a laparoscopic gastric bypass surgery. Surprisingly, he was addressing me- the camera driver during a laparoscopic case.

I was able to admit my first patient from the ED. A 60-something year-old gentleman, who presented with diffuse abdominal pain localizing to the right lower quadrant. He had the classic presentation of acute appendicitis. Once he was admitted to our service, I stayed and scrubbed in on his case--a laparoscopic appendectomy. Within his abdominal cavity, we found the worm-shaped structure, inflammed and engorged, covered with white pus.

Friday was a special day. The third year surgery students from all the different sites congregated in the skills lab and learned the basics of knot tying and suturing. With the guidance of a plastic and reconstructive surgeon, our group learned how to close skin and layers of deeper tissues. We made incisions on pig's feet and sutured the wounds closing, using a diverse set of suturing techniques. Hopefully, these skills will be put to good use during the rest of the rotation.

The week has been busy. The hours have been long (the longest of any rotation so far). Time to study has been scarce. The pace has been rapid. And the learning enviroment has completely transformed.

Learning the steps

2009-08-25T22:07:00.000-07:00

"It's like dancing. You got to know the right moves," said our surgery block director during orientation. He was referring to scrubbing in on cases in the OR and navigating around the carefully orchestrated flow of nurses, physicians and OR staff. The movement of instruments, the position of drapes, the placement of surgeons--all part of this dance. The medical student has to learn his or her place.

I attempted to better learn these steps when I ventured into the OR today on my first case as a third year medical student. The case was a laparoscopic cholecystectomy, gallbladder removal to treat gallstones that were causing agonizing pain in our patient. Through small incisions on the abdomen, we placed ports that held different instruments and a camera that gave us a view of the abdominal cavity. I scrubbed in, held instruments, drove the camera and watched the monitors as the the instruments navigated through the biliary geography.

Once the gallbladder was removed, I made a longitudinal incision to slice open the gallbladder, which contained multiple green pigmented stones. It was impressive to see how the entire pouch was brimming with stones; each stone has the potential to block the ducts that carry bile to the colon and cause excruciating pain.
***

Hard to believe that I have officially begun my eight week surgery rotation. During orientation, I also found out that one of my photographs from Med Link, a mentoring program that pairs medical students with underrepresented high school students, was selected as honorable mention for the 2009 School of Medicine Summer Photo Contest: "Learning Moments." Thought I'd share the photograph.

As days go by, I look forward to learning the steps to make it through the next eight weeks.

A year wiser

2009-08-21T20:04:00.000-07:00

"One year older, one year wiser." The words of a family medicine doctor on our last day, which happens to be my birthday.

I found my first gray hair today. I'm not sure if it's a sign of aging, or a product of being a third year of medical student.

Whatever the case, it's a sign of more to come.

On our last day of family medicine, we took an exam (what a way to celebrate a birthday) and had a cultural competency lecture. Lunch was a celebration of my birthday and the end of family medicine rotation with the three other medical students over lunch, a slice of pie and singing waiters. Oh, how I love surprises.

I look forward to this weekend off. A time to relax with my family and friends, reflect and celebrate being one year wiser and 33.33% done with third year of medical school.

Breaking in the New Shoes

2009-08-16T15:47:00.000-07:00

This weekend has been all about breaking in the new running shoes. As much as I love the feel of worn-out ripped running shoes that have faithfully served me over 100s of miles, I finally decided it was time to start the cycle again with a new pair. So, I laced up my new shiny, silver, white and turquoise shoes and broke them in this weekend with some long runs to the beach.

Yesterday, I made my way through Goldengate Park to Ocean Beach up to the Cliffhouse. Today, I followed the same path and went farther up to Land's End. With the sun shining over my shoulder, I took in the scenes and sites of a familiar running trial with all of it's climbing, descending and incredible views of nature and water. I have to say running (along with friends and family) has gotten me through my first two years (and now my third year) of medical school.

As I run, I always take time to reflect and think, mentally sorting the loose ends of my life- everything from pondering about existential thoughts (what is the meaning of life) to thinking about my personal life (how can I make time for my friends and family given such limited time with rotations) to thinking about my professional trajectory (I have so much distance to go before I feel like a real doctor).

It's interesting how we sometimes seek escape from thinking of anything medical the moment we leave the clinic or hospital. But our minds have a way of redirecting us back. As I ran, I started thinking more about my inpatient medicine rotation and my past patients and experiences-- the moments of triumph in taking care of patients and the many moments of defeat in coming to terms with the reality that we are students at the bottom of this immense hierarchy.

We are surrounded by other long white coats and members of large teams that march around the hospital, rounding on patients. Despite being part of this team, we can't help but feel alone in our lack of knowledge on many fronts. The culture of each field is initially foreign to the nomadic student, who has to quickly adapt to a new environment every eight weeks.

We never know what to say (everything sounds significant at first), or how be efficient with our words. We stumble through our long-winded presentations (we have yet to understand the "pertinents"), talk to fast, take up way too much precious time, ask too many questions and know nothing.

Third year is about learning. But how do you balance learning with the pressure of being evaluated based on your performance. It's almost like you're always on a stage, constantly being watched. And the feedback overflows. Constantly being told how you can improve definitely chips away at your sense of self-security, or makes you more insensitive to any type of feedback. I have interacted with classmates that have either valued or completely disregarded the feedback. I'm in the middle. At a certain point, you reach your threshold and decide how to process the critique; I run.

The process of becoming a doctor is truly a unique experience. Despite the inherent challenges, students are privileged to be working directly with patients in their times of need. In truth, memories of my patients stay with me; my patients have been the best teachers. In managing their diseases and learning about their lives, I have learned far more than any lecture, physician or textbook could teach. At times, you relate more to your patients (rather than the long white coat you are supposed to become), as your patient turns to you for guidance in medical decisions, addressing you as his or her "Doctor." The small moments of triumph carry you afloat during the tumultuous waves of third year (and probably beyond)...

You learn to pick your battles and decide how to focus your energy. From Day 1, I knew my focus will always be the patient. Third year is about learning. Sometimes, I have to repeat that to myself (a maantra to remind oneself to find a higher meaning in a somewhat unstructured and difficult year).

***

As I ran and watched the waves crash, I looked at the depht of the ocean and directed my focus to the life around me- surfers emerging from the ocean, runners, tourists. I quickly stopped and looked at the deep blue water. I could only think about one thing- what an incredible view. I took one more look, and with a deep breath in- I picked up my feet and start running again to fully break in my new shoes.

The Inner Child

2009-08-11T21:53:00.000-07:00

As I walked out of a clinic today, I saw a familiar face. He instantly recognized me and smiled. "Do you remember me?" He said.

It took me a second, before I remembered. He was the dad. And sitting next to him was the mother and the baby. They were the family who I had just seen last week on Labor & Delivery (I delivered their placenta).

I was amazed they remembered me. As a student, you always wonder who remembers you (or if anyone will). And it was truly wonderful to see the whole family after the labor and to have them recognize me.

***
My whole day has been about infants. I performed a head-to-toe newborn exam on 16-day old infant, evaluated a two-year old with fever of unknown etiology, as well as examined a rash in a young girl.

Pediatric clinic is always enjoyable because of the patients; I can give high fives, make funny faces and play games (and it's completely ok). The inner child is welcomed and it's such a pleasure to learn from kids.

Slippery

2009-08-06T22:41:00.000-07:00

With the umbilical cord clamped, I placed my left hand just below the abdomen as my right hand gripped the cord, tugging and pulling to slowly liberate the placenta from the uterus. As I held the cord, my glove turned red, covered with blood and other uterine contents from the delivery. With more pulling, the placenta moved closer to the opening the of canal. With a final push (from the exhausted mother), I could see the reddish blue disc-like mass advancing. I repositioned my hand, and pulled the cord.

Before I knew it, the placenta slid out and fell into the bucket that was precariously resting on my knees. As the placenta fell, so did the other bloody and gooey contents- some splashing on to my blue gown.

My first placental delivery. Two words- very slippery.
Mental note- do not wear porous shoes and eye protection is a must.

Just earlier, I watched how the 7-lb baby boy emerged with some assistance and careful maneuvering/pulling from the resident (first the head, then each shoulder and then the body). With the baby in the crib, I was summoned to take over. With the guidance of the resident and attending, I positioned my hands and soon caught the placenta.

Next step (logically at the next delivery) is to catch the baby.

My last trip to labor and delivery was during my first year of medical student. The view was quite different; I stood in the background, awkwardly positioning myself and acting as the mirror girl, holding up the mirror for the patient to see. Things have changed since then. Today, I had a closer view and was able to finally take an active role in the delivery.

The one draw-back to being closer- you will walk away covered in some sort of fluid. A small price to pay for what you see- the process of birth.

***
As week 4 nears an end- I'm really appreciating the scope of Family Medicine. In this last week, I've gained a spectrum of experiences. I spent some time in my continuity clinic, the ED, labor and delivery, gyn clinic and pediatric clinic.

We even found time to visit the Sonoma County Fair, where I got pet a llama (I think I was the oldest one in the petting zoo), taste my first funnel cake and people watch. The fair is an interesting cultural experience filled with bright flashy lights, intoxicating smells of fried food and lots of overpriced rides. It was a flashback to my last childhood fair visit in Fresno, CA...

The diversity of clinic is both rewarding and challenging. Every day is so different-you work with all sorts of patients. But at times, it feels like you are always switching mental gears. With different patient populations, there are different considerations, although the bottom line really remains the same- PREVENTION.

With kids, we immunize and educate about diet and exercise. With adults, we still educate about diet and exercise and try to reduce the risk of developing hypertension, diabetes, hyperlipidemia and other chronic diseases (or we just continue to treat the best we can, when prevention has limitations).

The experience so far has been interesting and look forward to the learning opportunities in the last two weeks.

2009-07-25T16:12:00.000-07:00

From the inpatient wards of the SF General hospital and the fourth floor operating rooms in SF, I have migrated to an entirely different world-- the outpatient world of family medicine.

Two weeks ago, I packed up my car and traveled 55 miles North to Santa Rosa, a city that prides itself for it's proximity to a diverse array of natural attractions, including vineyards, redwood forests, rivers and lakes, as well as a unique downtown that features a year round Farmer's Market. I left the fog behind and discovered a real summer filled with sunshine and heat.

In my two weeks of family medicine, I have learned about the broad scope encompassed by family medicine. So far, I have counseled several patients with metabolic syndrome (the triad of diabetes, hypertension and hyperlipidemia), examined pregnant women during their prenatal visits, listened to fetal hearts, performed well child visits for babies, evaluated numerous pediatric rashes, performed a PAP smear, participated in a wellness group therapy session, attended homeless clinic and learned about mental health issues in the homeless, interviewed patients in a community clinic as well as in a Kaiser clinic, burned warts off, counseled almost every other patient about lifestyle changes, and so much more.

I am lucky to be taking a hiatus from my beloved SF and learning about family medicine in a community-based program in a city that has few specialists and a large underserved patient population (mostly Spanish-speaking). I am starting to see how medicine is practiced outside an large academic institution (its pretty similar) that is equipped with specialists for every possible disease.I've had to draw on four-years of high school Spanish to communicate and in the process I have probably sounded absolute ridiculous. Oh well.

In such a community, patients rely heavily on their family medicine doctors for most every aspect of healthcare maintenance.

"One of the best things of family medicine is really the longitudinal care. For example, we take care of a pregnant woman, provide prenatal care, deliver her baby and take care of the baby and mom afterwards," said one of the family residents.

Family medicine is truly unique because of the focus on taking care of a patient through their entire life, requiring a comprehensive medical knowledge and solid patient-doctor relationships. At the same time, healthcare providers are limited by 15-minute appointment visits, healthcare cuts, a growing patient population and lingual barriers.

Despite the challenges, the process of interviewing patients, learning about their lives and developing meaningful relationships represents a incredible learning opportunity. We'll see what the remaining four weeks bring.

Venturing into Urology

2009-07-04T20:55:00.000-07:00

"We help our patients pee and have sex," said the urologist, who was giving us a talk about erectile dysfunction.

Since completing my medicine rotation, I started my two week urology subspecialty rotation. With one week down, I can definitely say there is some truth to the statement (although urologists definitely do so much more for their patient). I've had the opportunity to observe a wide array of cases, everything from prostate cancer to vesicovaginal fistulas to circumcisions to labial reductions.

In addition to spending hours in the operating hour observing surgeries that utilize advanced technologies, including lasers and a robot, I have been learning about the preoperative and postoperative management of patients with common urological conditions. I have worked with patients, greeting them early in the morning (before 6 AM) and assessing their health (asking about passing gas, walking, eating and pain) before presenting their cases to my team to determine the best plan.

Coming from a medicine rotation, it's interesting to be involved in the operative management of patients. Surgical morning rounds are also so much shorter and so much earlier. Observing the operations has also been interesting; sometimes it's simply amazing to watch the urologists use laproscopic devices to remove the prostate or use basic surgical tools to reconstruct labial folds.

I have thoroughly enjoyed my first week. And the urologists I have worked with have been friendly and welcoming. I look forward to the next week and hope to continue learning about what urologists do...

Block 1

2009-06-17T21:34:00.000-07:00

I am still here. I still exist. I have just been caught in the whirlwind that is third year.

Since last reflecting before beginning third year, I wonder why it has taken so long to write. In fact, the only thing I can really say is- where do I begin? So much has happened. I have been sleep-deprived, a bit overworked, and completely immersed in this new culture, learning the reality of being the student on the bottom, always on the spot and unsure.

I meet my patients when their lives intersect with diseases. When my patients are the most vulnerable, I am at their bedside- learning about complications of their disease and lives, in an attempt to make sense of it all.

Tomorrow will be the last official day of inpatient medicine; after which I will reflect on block 1 and write my thoughts.

Stay tuned...

On to Year Three

2009-04-26T09:30:00.000-07:00

Friday marked the end of the formal education we have come to know since day one, when we sat in classroom and were spoon fed doses of information for the purpose of tests that evaluated how well we could study. We go from being students and passive learners to starting our doctoring apprenticeship. We take on the role of the student doctor and become responsible for the care of our patients. We now must take charge of our own education.

We have been told that we start out as students, who closely identify with our patients. By the third year, we begin to see our patients as a list of symptoms. And by the end of our fourth year, we closely identify with the doctor.

The third year has been compared to a socialization process, during which we develop our identity as a physician. As part of process, we learn to function as part of a medical team. We may oftentimes feel outside our team, standing on the periphery, watching and not really understanding or associating with others, especially when begin to navigate the complexities of the wards and the details of our patients lives and diseases.

You are also charged with advocating for your patients. The major challenge for any student stems from the dichotomy that exists between fulfilling the goals of the team and serving the patients, especially when the goals do not align.

As students, we are naïve and unaware about the social norms of the medical culture. We maybe referred to as dead weights or speed bumps on teams. We ask lots of questions, slow down the team’s progress, seek endless guidance and affirmation that we are doing things right. We have not yet been completely exposed to the realities of medicine and we are on the bottom of the todem pole, which makes us powerless.

At the same time, we do offer a different perspective because we spend the most time with our patients. In this regard, we are the closest to our patients and places us in a position to speak for our patients.

As we move forward, I know my life will change drastically. I know I will have to make sacrifices to excel in the third year. Fourth years have told me that you can pick two: sleep, exercise or a social life. Not sure which two I would pick, but I know I would focus on maintaining some sort of balance in my life (if possible). Most importantly, I hope I can draw on my sources of strength (family, friends, mentors, exercise and inner peace) to help carry me through the most difficult times ahead.

As we descend into the wards, we are about to enter an entirely new culture and we will soon be learning a new language that changes every 6 to 8 weeks. We are like nomads, traveling into strange lands without a map. We will fixate on what to wear, what to carry in our pocket, what to present and how to write a note. We are undergoing a transformation from a lay person with two years of formal medical education, to becoming fully indoctrinated into this mysterious medical culture.

From other students and physicians, I have heard that each field has a personality. As impressionable students, we will be tempted to change ourselves to excel. I know a number of students will change to please the attending of the month, like a chameleon that learns to blend in. At the same time, I know I will have to resist such dangerous temptations and remain true to myself and accept my limitations.

On day one of clerkships, we will be given a lifelong responsibility- “here is your patient, take the very best care you can.” I hope I can fulfill this responsibility and look forward to the challenges and learning ahead.

Wish me luck!

Turning up the heat

2009-04-20T18:03:00.000-07:00

April 20th record heat- 88 degrees in San Francisco. On such a day, residents of SF flock to Ocean Beach, savoring every moment of heat, since we can probably count the number of hot days we expect in the year on one hand. The sun was out, beating down on the city today. No fog in sight. A prelude to summer in most other places. A unique time in SF. The time to be outside.

Transitional Clerkship has a fair amount of work. We've been transplanted at different hospitals and paired with preceptors, who help us refine our case presentations and SOAP notes. I've spent my days in the General hospital learning about the stories of homeless individuals, HIV-positive patients and patients with heart disease.

The days have been spent working on becoming functional medical students. The nights and weekends have been spent enjoying our freedom. I finally made my way to the California Academy of Sciences located in Golden Gate Park, during Night Life, which transforms the academy into a hip hangout for the 21 and over crowd. During evening hours, my friends and I enjoyed the sights of a tropical rain forest, an aquarium and an albino alligator (among other things). And the best part of all- there was music and people dancing.

Imagine this- science set to the tunes of techno with a dance floor around the Galapagos Island display. Interesting...

I got a taste of what it feels like to be on-call, when we were playing The Game on Saturday- an all night scavenger hunt that involves solving puzzles and looking for clues that have been scattered all over the bay area, everywhere from Golden Gate Park to the Dutch Windmill to Lombard Street to Coit Tower to Stanford. The combination of the dark, adrenaline and intellectual curiosity got my team through the endless clues and long hours.

I am definitely savoring each moment of free time and catching up with friends. After studying for the boards non-stop, I remember how I used to feel guilty about doing anything that did not involve memorizing voluminous amounts of medical knowledge. Now, I can breathe and enjoy the sunny days (rather than curse them when I used to have to stare at the sunset and sunrise from my library window)and time spent with my friends. Long ocean runs in the heat have never felt so good. I welcome back tan lines with open arms.

I'm taking it all in- the sunshine, the realization that we will soon be treating patients, the spare time we get in between learning to be doctors- it's exactly what we need before being thrown into the next phase of our training. In less than one week, we start on the wards; I start with medicine at the General hospital and will be working 6 days a week and will be on call every sixth night, leaving me with 4 days off per month. By the looks of it, rotations will surely turn up the heat too.

Stepping Ahead- Transitional Clerkship

2009-04-14T20:06:00.000-07:00

There is some comfort in knowing that we are not quite starting just yet. Two weeks of transitional clerkship is exactly what we need to ease back into the whirlwind of the clinical core post-boards.

It's a step by step. Ok, more like- baby step process.

On the first day back, our professor compared medical school to skiing down a steep hill. In the first two years of medical school, we have climbed the mountain. Now, we've made up to the top and are looking down.

The view can either be extremely scary or spectacular. I can appreciate both views.
Regardless of how we see the challenges ahead, our goal is to simply learn how to ski down that hill without falling. In transitional clerkship, we will learn how to put on our equipment to prepare us for the next two years.

We spent the first day learning about the patient interview (again) and presentations. This time, I think we all paid closer attention, since in less than two weeks, we'll be delivering patient presentations to groups of superiors in white coats. Like anything else in life, we need to "practice, practice, practice."

I spent this afternoon drawing blood, performing a blood ABG, inserting peripheral lines, learning basic life support and suturing. All procedures were performed on mannequins and the suturing was done using pig's feets. Our blood sample was red Koolaid. Somewhat realistic.

We also celebrated the essential core by acknowledging the lecturers, small group instructors and clinicians that have made an impact on our education. In doing so, we close the chapter of classroom learning as we move to learning on our feet in the wards. I had the privilege of introducing the award for outstanding lecture series to a physician that taught us everything we need to know about parasites. We may never look at pork, beef or sushi the same way- but we did learn a great deal about these interesting creatures that have complex life cycles and cause so much harm globally.

As we go through the next two weeks, we are constantly reminded that third year requires a serious paradigm shift. During the first two years, we showed up with a "backpack, ipod and whenever in a controlled environment." And now, things change, we become professional and show up for a job. The student goes from being the center of the academic universe to becoming the bottom of the totem pole. Third year is a time of learning, but it may also be a "spectacular opportunity for failure."

We were told that it's normal to be anxious. In fact, you're probably abnormal if you're lack nerves. I'm definitely nervous (an understatement). Yet, I'm curious about the unknown.

We'll see how this transition goes. I'm slowing making those steps forward.

We're only Human

2009-04-12T11:34:00.000-07:00

A week has passed since I took my board exams. Although it has only been one week, it feels like I took the exam months ago. As expected, I have already forgotten all those facts that were crammed into every nook and cranny of my brain. I've done everything I can to suppress the memory of the exam, including forgetting all those questions that came out of left field. Oh well- it is what it is.

Older classmates and physicians have told me that completing the exam is an accomplishment in itself. This is true. We always seem to forget that point.

Generations of physicians have taken this exam before clerkships. In a way, the Step 1 represents a rite of passage for medical students transitiontioning from the lecture hall to the wards. But at the same time, taking the exam left me feeling numb and inadequate. After answering my last question (question 336), I realized that no matter how much you study, there will always be things (mostly trivial details) you'll never know on an exam.

We're only human.

As I continue to distance my mind from the post-boards anxiety, I'm enjoying the oblivious bliss that comes with finishing the exam and not knowing that three digit score that has been rumored to play some role in determining the course our future. I spent the last week doing nothing but relaxing, sitting in the sun, running, biking, kickboxing, exercising, and catching up with friends and family. I tucked away all the board review books and flashcards (out of sight and now out of mind) and finally caught up on some of my favorite tv shows, including Ugly Betty.

This unenventful and unproductive week was exactly what I needed to culminate the end of my second year and the monthes of endless studying that go into preparing for the Step 1 boards exams. Now, I feel refreshed and mentally prepared to embark on the next phase of medical school- third year, which reminds me- I need to update my email signatures.

Before being thrown into the wards, we have transitional clerkship (TC)- a two week buffer. TC represents the perfect time to be reminded of how to present patient findings and perform focused physical exams, learn necessary skills (suturing, blood draws, ABG, etc.) and be reminded that we will survive what may feel like one of the scariest moments in our medical school lives.

I'm not sure what to expect from the third year. I start off with medicine at the general hospital. I've heard so many different stories (some uplifting and some not so promising). I'm not sure how I will cope with working 6 days a week and losing sleep on my call nights. I'm not sure how to maintain my life outside medical school, when I'll be spending most of my time in the hospital. I'm really just not sure about anything...

Time and experience will tell how I will adapt to the third year. I'm keeping an open mind to the possibilities.

I am looking forward to being reunited with all my friends and classmates. It will be nice to touch bases and form support groups as we venture into uncharted waters. Hopefully, transitional clerkship will teach us the basic strokes we need so that we coast through our first clerkship rather than drown.

The Homestretch!

2009-03-29T10:02:00.000-07:00

I'm 5 days away from regaining my life and getting out of the library.

5 days from an extremely long run.
5 days from watching countless movies from my list of "movies to watch."
5 days from spending time doing nothing.
5 days from relaxing and lounging around in the sun.
5 days from freedom.

Short-term memory utilization has begun. It's time now to memorize all those rare lysosomal storage diseases, biochemical defects (that have extremely long names and look the same) and the complement cascade. Plus- all those drugs with their rare toxicities. The next 5 days are going to be splendid fun, full of forceful memorization.

I just hope there is space in my brain, which is overflowing with medical facts that keeping spilling out.

Until test day, I'm staying calm and thinking of this time next week, when I'll be done!!!!!

Counting Days

2009-03-19T15:10:00.000-07:00

I'm still here, counting days to freedom.

Nothing too interesting going on. Just the usual studying marathon. Enough said. Watching spring time emerge from my window, yearning to be outside.

This shall pass...

Almost 50% MD

2009-03-10T20:46:00.000-07:00

We bid farewell to the Essential Core today. The Essential Core represents the pre-clinical years, where we are learn the basics of medicine.

We completed our clinical final over this past weekend, with a series of patient interviews and physical exams. We officially ended our second year with a small group about common ethical dilemmas in older adults followed by an interview with an elder, who spoke about her life and the challenges she confronts as she gets older.

After the interview, we were joined by our deans and administrators, who congratulated us on making it to the half-way mark of our medical education. It was more of an early congratulations, since we still have to take our life cycle final and that other big test (the boards). In what has been described as a "milestone," we will now see a shift, where the center of education shifts from the medical student to the patient, as we move to wards.

With some games, a raffle and a burrito, we walked out of the lecture hall- to the library to study for the upcoming exams (it's like a marathon). As I walked away, I realized that were all about to go our seperate aways; this was the last time we would officially assemble as a class of preclinical students. Hard to believe.

We move from lectures and small groups, where information has been spoon fed to us, to the real clinical world, where we learn from our patients. The third year became more real after we received our rotation schedules on Friday.

We will face an entirely new learning curve ahead. I am excited and apprehensive. I'm just pacing myself through the next weeks to get through the boards.

After we complete our life cycle final on Thursday, we become third years with half of an MD.

The Countdown Begins

2009-03-03T20:38:00.000-08:00

"It is what it is." This has become my new motto, whenever I am asked about how board prep is going. Quite frankly, it's almost like pushing a heavy boulder up a mountain that keeps getting steeper with no end in sight.

At the same time, I realize this time shall pass and we'll move forward. It's just a temporary inconvenience.

The countdown to test day has begin, as I reach the one month mark.

A typical day for me consists of the following:
1. Study
2. School (usually just small group sessions)
3. Study some more
4. Exercise
5. Eat
6. Study
7. Sleep

And then repeat.
It's very regimented and monotonous. Not too exciting. Just got get through the next month.

We'll find out our third year schedules on Friday, which will give me a sense of what to expect for the next year. Once I know where I will be, I'll be able to finally RSVP to all the weddings and graduations I'm supposed to attend.

Aside from ongoing boards prep, we enter our last week of life cycle next week with our final on Thursday. According to some of my classmates, attendance to lectures has dropped off (~20-30 students). So sad. It's that time of the year, when all the second years disappear to study. Sigh.

We now enter full test training. Let the endurance training and countdown begin...

Farewell to MSP

2009-02-19T20:36:00.000-08:00

I taught my last MSP session tonight. Potassium balance. It's hard to believe how fast the monthes have gone by. I've grown with my students, walking them through the first week of anatomy through the cardiovascular block through pulmonary block through the last renal MSP lesson. Tonight I bid farewell to MSP.

Teaching has always been a fresh breath of air in my learning and an opportunity to tell really unfunny jokes. Thanks to teaching MSP session, the first years actually know my name and invite me to their parties (I even received an invitation to an upcoming End of the Organs party on Saturday). It's like being a popular nerd. In a way, I have been reliving the first year vicariously through teaching and interacting with my students, as I address their questions and concerns about exams and life as medical student. The first year has become something of a blur, but becomes more clear when I interact with my students, who take me back to the first year.

It has been a privilege to work with such talented and bright students. They have taught me so much of myself and my capabilities; I can be funny (usually this in unintentionally and still deliver an education message). I will truly miss MSP and my students. Teaching has definitely been one of the most rewarding experiences of medical school thus far. I walk away with some new friends and a unique set of experiences that will ground me through my future educational endeavors.

On Tuesday, while I was teaching about potassium disorders, such as hyperkalemia and hypokalemia, I was thinking about the stages of development through pregnancy, infant and childhood. The reason being, I was in the process of studying for our second Lifecycle midterm that was on Wednesday. So, Tuesday was one long night, as I bounched from teaching renal physiology of potassium balance to studying the physiology of labor and congenital heart defects.

My mind is still racing. The exam is over. MSP is over. Surgical Skills, the elective I am coordinating, will wind down next week with the final lecture and scrubbing and gowning session. As I relinquish all my responsibilites, I still feel as though there is always something that needs to be done. Perhaps, I was just born this way-- born to be persistently active.

I am also in the process of inventing the perfect third year schedule, which involves ranking my preferences for the order of rotations and site. In the end, the schedule will be generated by a computer through this elaborate "lottery" system.

There is this one other thing that requires my complete attention-- studying for the boards. This has been a challenge, like no other, more a test of mental endurance. My strategy has become to minimize memorization and maximize understanding through integration, which is almost impossible with lots of memorization. It's a Catch-22. I knew that.

My mind is always trying to make sense of all these floating facts and trying to find the logic behind the complex disease processes; some have clear pathways, while other explanations make little or no sense. And sometimes, what we learn boils down to these bizarre mnemonics that are just memory tools to remember all those details we will inevitably forget. Sigh.

Studying continues. At least I will remember somethings from teaching MSP.

Don't Break my Hearts

2009-02-05T20:50:00.000-08:00

"Don't break my hearts." These were the closing words of our pathology lecturer.

We made our way to the pathology lab to examine a number of delicate hearts. It's ironic, we were instructed not to "break" these already broken hearts. Some hearts were the size of walnuts, while others barely fit in my palm. Each heart had some sort of congenital heart defect. Everything from holes in the walls of the chambers (atrial septal defects and ventral septal defects) to hearts that were missing an entire ventricle (hypoplastic left heart syndrome) to hearts that had the incorrect vessels paired with ventricles (transposition of the great vessels). These hearts had once beated inside the chest wall of developing fetuses and infants and eventually could no longer perform the job of a heart.

I was lucky to have met a five year-old child, who had a hypoplastic left heart on my pediatric preceptorship. When I had met him, there would be no way to know that this child, who loved Sponge Bob Square pants, had undergone numerous surgeries to repair his little heart. Today, I got to see what his heart looked like at one point in his life.

Using our examination skills, we attempted to identify each pathology. I have to say that this was my favorite pathology lab. I am simply fascinated by the heart. And seeing hearts with congenital heart defects reminds me about the complexities involved in developing the pump of our body.

This week has taken through pregnancy to birth to development. Earlier this week, I held a placenta in my hands. The flat structure, which looks like a really flattened cake, serves as a fetus' life line, providing nutrients and oxygen.

In lecture, we had the opportunity to meet families with young children. We were given the task of guessing the age of an infant and a child. It was hard to pay attention to the lecturer with kids in the room.

Today in small group, I played the role of pediatric resident as we ran a mock code that involved resuscitating an infant in respiratory distress. Although our infant was a stuffed gold and yellow tiger, we walked through the crucial steps required in managing the ABC's- airway, breathing and circulation, a task that awaits us in the wards.

Tomorrow, my doctoring group and I will be presenting an autopsy case about a 63 y/o female who suffered a myocardial infarct with a mysterious liver problem. We examined her gross specimens that had been stuffed in a white plastic bucket, including her heart, liver, spleen, lungs and GI tract, along with histology slides. As we pieced the organs together, we worked through a long differential to put together her medical story. I'll be sharing the liver part of her story.

On Monday, I helped teach instrument ties and suturing to first year medical student during the surgical skills elective. I also learned the horizontal mattress and this new suturing technique. It was so nice to finally work with my hands for a change.

The week has been extremely busy. My mind is definitely on overdrive (in a good way). I've squeezed in some board studying when I can, but I must admit there has really been no time. We all feel overextended. As we think about the boards, we simultaneously studying for lecture and ranking our program choices for our clerkships.

All in all, I look forward to the weekend. Although, I already know what I'll be doing...

There a break for some in site. Prom 2.0 will be held tomorrow night at the Academy of Sciences with an open bar. The oversold event promises to be even better than Prom 1.0. I have opted out of attending the festivities. Guess, I won't be breaking any hearts tomorrow.

2009-01-27T20:46:00.000-08:00

It's almost a month into the New Year. Glancing back at my previous entry, I realize I've already broke one of my resolutions (write more). I've been making tons of mental notes about interesting topics to write about in my blog, but have been struggling to find the time to transform all my mental post-its into actual entries.

Since the start of Life Cycle, we have learned about the complexities of development and embryology, taking a whirlwind tour of development from fertilization to the development of the fetus. We attended our last anatomy lab (forever) and histology lab (no more of those microscope slides). I presented my research poster at the UCSF Research Symposium and taught the mechanics of breathing during the pulmonary MSP session. I've also been busy getting the Surgical Skills elective rolling. I am preparing to teach my last MSP lesson in February and will be teaching suturing at the next surgical skills session.

It's been a busy. Time has become a scant commodity. I always find myself thinking- there are just not enough hours in a day. Right now, the time pinch is even more palpable. The second years have starting to slowly go into hibernation. By that, I mean they are becoming preoccupied with preparing for the boards and revisiting all those topics of medicine, we have since forgotten.

The exam looms on the horizon, an unwelcome presence all the time- in the library (in the form of First Aid books and other prep books), in our day-to-day conversations, in the lectures (with lecturers dropping the "B" word so much more), and in our tired faces. It's boards fever! And it's spreading, sucking the life and energy out of MS2's. I can feel it.

I've been trying to maintain balance. But balance has become more of predictable routine- school, study, exercise, eat, study, sleep and repeat all over again. Sounds fun, doesn't it? I have found time for friends and running, which has made all the difference.

I am trying to live by my motto: there will always be things that have to be done, but there is also a life to be lived.

As they say, every cloud has a silver lining. In our case, that sliver lining is in the form of thinking of the road ahead- clerkships. We are in the process of planning our third year rotation schedules, including making decisions about enrolling in either a structured or traditional program. And we also must start thinking about how to order our core rotations, which inclide family community medicine, internal medicine, surgery, pediatrics, neurology & psychiatry and OB/Gyn.

It's a matter of getting through the next months and then moving on to an even more exciting chapter of our medical training. When I start thinking about actually seeing patients, I am reminded of the reasons why I came to medical school.

The test shall pass. Life will go on.

New Year's Resolution

2009-01-03T09:31:00.000-08:00

I have had some time to think. The last three weeks of vacation were a welcome hiatus. I thoroughly enjoyed spending time with my family, running in the bitter cold, resting and eating three meals a day. It was such a blessing to catch up with my family and pet cats.

As far as a New Year's Resolution, I'm old enough to know the cardinal rule of making resolutions: it's probably better not to make resolutions, since you are likely to set yourself up for failure. OK, I admit it is a defeatist attitude- but it is true.

In actuality, I can think of a couple things (in no particular order):
1. Stay in good health (physical and mental)- train for a half-marathon
2. Try to use the phone more often when communicating with friends
3. Broaden my experiences outside the medical bubble
4. Find time for family and friends
5. Write and reflect more
6. Photograph more
7. Explore SF and beyond (which means actually going to museums and restaurants outside the sunset)
8. Study hard for the Boards and do well (without going crazy)
9. Avoid making endless lists of things "to do" (I'm already breaking this resolution with this list)

Break was a welcome change. I felt recharged when I arrived in SF on Sunday. Three days into the first week of life cycle, I'm settling back into the groove of school and my lists of things "to do."

It's hard to believe Life Cycle/Epilogue brings us to our last pre-clinical block. The boards exams are sandwiched between Lifecycle and our clinical clerkships.
"You're in your homestretch," said our course director on the first day of course.
It's so bittersweet. On one hand, we are culminating our preclinical years, attending our last lectures and labs and gearing for the transition to clerkships. We had our last official anatomy lab on Tuesday- male and female pelvic anatomy (what a way to end). On the other hand, we are also facing the biggest barrier to moving forward- the BOARDS exam (believe me, you'll hear more about this with subsequent essays). And the realization that we don't know anything. OK, a little bit of an overstatement.

"So have you hit the board books?" (A question I have been asked a couple of times already). Answer- No, but I probably should. Thanks.

We are realizing the testing has only began. Step 1 is numbered one, because it is the first of a series of tests we'll take. Hooray.

$495.00 equals the amount to take the Step 1 exam. I submitted my application for this 336-question, 8 hour test a couple of days. I guess the time has come to develop a study game plan.

Other than the looming boards, I have returned to my MSP obligations, which involve teaching sessions in the Pulmonary and Renal blocks. I also have been tying some last odds and ends as one of the coordinators of the Surgical Skills elective, which provides students with an opportunity to learn basic surgical techniques (knot tying and suturing). I am also organizing a poster to highlight my summer research that examined in-utero stem cell transplantation for an upcoming research symposium next week.

It's a busy week and a busier quarter. I'm calm. I wish I could say I'm ready, but I figure I'll take it one day at a time, one step at a time (no pun intended).

Stay tuned for the adventures.

33.5 Degrees of Hope

2008-12-22T14:05:00.000-08:00

Last week, I visited UCSF's Neuro-Intensive Care Nursery. I had the opportunity to learn more about the Nursery and photograph the nursery for a feature article for the UCSF School of Medicine's website. Visiting the nursery with my camera was truly a unique opportunity. My essay and some photographs are included below. It can also be viewed at the following site: http://medschool.ucsf.edu/news/features/patient_care/20081222_NICN.aspx

Teddy bear wallpaper lines the top of the room. Large machines beep, and tubes are covering most of the crib that holds Baby E. Her small body is covered in plastic. Her face is just visible underneath the breathing tube. Her head is covered with white gauze, holding a series of green and red wires in place, which are connected to an EEG machine to monitor her brain wave activity. A camera records her movements. Despite the loud noises of the Neuro-Intensive Care Nursery (NICN), her eyes remain closed as if she were completely oblivious to her critical state of health.

The UCSF Neuro-Intensive Care Nursery (NICN) is located on the 15th floor of Moffitt Hospital. The front windows show a panoramic view of the city, from the ocean to downtown. Family members mill in and out of the nursery.

Dr. Tom Shimotake, Co-Director of the UCSF Neuro-Intensive Care Nursery, had given me a tour and introduced me to Baby E. Baby E had been transferred from another hospital and admitted to the NICN the previous night. Though being born full-term, she was in critical condition.

Since opening in April of 2008, the NICN has seen referrals of this type quadruple. UCSF's NICN represents one of the first nurseries in the United States that specializes in treating infants who have experienced brain damage during birth because of asphyxia, which prevents oxygen flow to a newborn’s brain and can lead to irreversible injury of neurons.

The NICN integrates multiple technological and treatment modalities along with clinical trials, to optimize the monitoring and care of critically ill infants who are at high risk for developing cerebral palsy, mental retardation and other cognitive problems later in life.

We were joined by Deidre Jarrell, Baby E's nurse, who has been with the NICN since its inception. She has specialized training to care for infants like Baby E who have suffered brain damage at birth. She works 12-hour shifts, attends to Baby E and provides updates to family members, who can call anytime for information about the baby's status.

As we surround Baby E's crib, the infant would periodically stir or kick her tiny feet. Bags of fluid were perched above her, dripping clear liquid into her system. She was sedated, and a machine was breathing for her. She was lying on top of a blue blanket that was set to maintain her temperature close to 33.5 degrees Celsius.

Baby E is receiving cooling therapy, which involves inducing a hypothermic state for 72 hours. According to Dr. Shimotake, the cooling therapy prevents further brain injury in babies born in a hypoxic (oxygen-deprived) state. Cooling needs to be started within the first six hours of birth after asphyxiation to have a benefit, and this therapy is only for babies born full-term.

After 72 hours of the cooling therapy, Baby E's body temperature will be slowly increased (0.5 degrees Celsius per hour) to her normal temperature. Her brain will then be imaged with an MRI to assess the primary injury, including the location and severity, to help develop a prognosis and determine the next steps in her long-term treatment.

Infants will spend an average of 10-14 days in the NICN. While in the NICN, they receive specialized care from a multidisciplinary team that includes neonatologists, pediatric neurologists, epileptologists, specialized NICN nurses, neuroradiologists and occupational and physical therapists. Social services, another integral component of the NICN services, are available to families and healthcare providers to help cope with the emotional stress that comes with caring for critically ill infants.

Dr. Shimotake believes families play a central role in making decisions, and healthcare providers must remain sensitive and open to each family's desires. "We deal with very sick babies here, so we participate in some of the most emotionally intense moments in these families' lives. In addition to specialized care for the babies, we provide important information to families that they may need to make difficult decisions. We don't make decisions alone."

In working with critically ill infants, healthcare providers are sometimes faced with the delicate balance between prolonging life and making decisions about palliative care. Some infants arrive at the NICN and are monitored, treated and discharged. Some will develop long-term neurological abnormalities, requiring lifelong specialized care. And some will have life support withdrawn due to an irreversible brain injury that shows no sign of recovery.

Those infants who are discharged from the NICN will visit their regular pediatrician and undergo ongoing physical therapy and follow-up with physicians at the high-risk neonatology clinic. They and their parents meet with a number of specialists, including neonatologists, developmental psychologists, physical therapists and nutritionists.

***
As I watch Baby E, I wonder about her prognosis and life after the NICN. Will she be among the patients that gets life support withdrawn? Or will she regain her strength and go home to her family? How is her family coping, not being able to hold their baby, who is covered in tubes and connected to so many machines? How are they processing the endless amount medical information presented by Baby E's medical team?

Vacation

2008-12-22T08:45:00.000-08:00

One week of vacation has gone by in a blink of an eye.

I spent the first few days in San Francisco taking care of business, tying some loose ends. I finally made my way to Union Square last week for some aimless shopping. And then left SF.

I arrived at my parent's house on Thursday. Since arriving, I've been spending time with my family, catching up and eating some delicious traditional Indian meals. In between, I have braved the chilling cold to fit some runs in my day. It's cold, but so much flatter in Davis, a welcome change from the hills of SF (although I do miss the views). I have been reintroduced to a concept three complete meals and eight hours of sleep. This is the life.

To sum up- vacation has been relaxing so far. I'm working on writing something insightful. For now, I'll enjoying the simplicity of life and the smells of fresh food without thinking too much.

The Endless "To do" List

2008-12-15T11:39:00.000-08:00

M3 Mania has ended. I turned in my final today, proceeded to take the lung and prostate practical (almost mechanically). By now, tests have become a part of norm. We learn how to program our minds to ingest voluminous amounts of information in such short periods of time to answer question after question (and then we repeat the process). It's a well-oiled process for the most part. Except one big problem- retention. In the end, after an exam, you feel numb, knowing well that most of the information you meticulously hand wrote on multiple pieces of paper to committed to short term memory, will dissipate to a foregone memory. The reality of medical school.

When I walked out, I felt relieved but also unsure about what to do with myself. I have become so school-centric; my long to-do lists revolves around getting through material for small group or lecture, planning electives, preparing MSP sessions, etc. I can now attend to the growing list of things, some school-related (odds and ends), as well as a plethora of life things, namely shopping and social engagements.

The end of M3, which included cancer, blood disorders (leukemia, lymphoma and anemias) and epidemiology takes us to Christmas break. I am looking forward to spending time with my family. Outside of the cancer block, I was able to spend time in the pediatric intensive care unit in Oakland, working with a diverse spectrum of critically ill patients. I also had the pleasure and pure enjoyment of teaching cardiac anatomy and ischemic heart disease to first years during MSP sessions.

When we return from break sometime in January (not sure what date exactly) we start our last preclinical block (Life Cycle). A couple of weeks ago, our course directors sat us down and gave us that unwelcome talk about the "B" word, we have tried so hard to suppress. THE BOARDS have come upon us, infiltrating our subconscious and libraries with board review books. Not exactly sure when studying begins, just know it's going to be long, hard and epic. Overall, I'm apathetic to the exam. More concerned with getting it over with to move on to a "watershed moment" in our educational training- the wards. Hopefully, in the process I'll relearn all those important facts that have escaped.

Although we have become programmed professional information memorizes and test takers, I still can not believe how fast time has gone by. It was a year ago, when I finished my cardio exam and was preparing for clinical interlude. Now, I'm moving into uncharted study territory.

For now, I'll bask in being done. And with time, after some distraction (time to go shopping), I might actually look at the oh so endless "to do" list. I am hoping to reflect and write to process second year, looking at how I have changed and how far I have come.

From my year of medical school, I have learned that no matter how many things you have to do, you must always remember that you also have to live your life.

World AIDS Today

2008-12-01T22:28:00.000-08:00

1 in 10 San Franciscans living with AIDS does not receive primary care.

December 1st marks World AIDS Day, a day to raise awareness about the AIDS epidemic. Today was the 20th anniversary. AIDS sprung to our attention in the 1980's as a mysterious disease affecting predominately gay men. With the emergence of the disease came discrimination and mistreatment due to lack of understanding. Today, we know more about the AIDS and the virus (HIV) that is transmitted by blood, sex and breastfeeding, which can lead to the development of AIDS. And over the last two decades, we have seen the face of AIDS (it affects everyone).

Over 60 million people have been infected with HIV, a number that continues to grow. And the death toll continues to rises.

There is so much that has to be done to understand the virus, decrease transmission, fund treatment and support those living and dying with HIV and AIDS.

Today, we gathered together, each donning sign with a statistic. With our signs and red ribbons, we made our way to Parnassus Avenue (right in front of the main hospital), where we stood in solidarity, remembering those who have lost the fight and those that are continuing the battle the disease each day.

Chugging Gatorade

2008-11-26T16:02:00.000-08:00

The weather has transformed into the cold, bitter gray that is winter. For the last couple of days, I've been under the weather, chugging Gatorade and lemon-lime flavored carbonated beverages, while curled up in a ball on the sofa, staring aimlessly at the coagulation cascade page of the syllabus.

It definitely does not help when you know a little about the differential for fever, fatigue, headache and myalgias. You just start thinking way too much about which bug it could be.

Thankfully, I'm feeling much better in time for Thanksgiving. By tomorrow, hopefully, I can eat my fill of home cooked food.

We'll see...

M3 Mania I

2008-11-16T21:45:00.000-08:00

After today, we should now be able to complete a head to toe physical exam (theoretically). In our last patient education/physical exam session, we learned about how to complete a clinical breast exam, which involves a visual inspection (from four different views), lymph node palpation (in the axilla and near the collar bone) and the breast exam. Like the female and male pelvic exams, we were taught by patient educators who demonstrated the exams on themselves before walking us through each step of the exam, as well as teaching us important points about establishing rapport.

The breast exam is not just about the breast as we think of structures contained in the bra. In performing the breast exam, it helps to think of an imaginary rectangle drawn around the breast, starting from under the arm going up to the clavicle along the sternum and down just below the breast. Using a light, medium and deep palpation with the pads of our fingers, we feel the fatty and glandular tissue of the breast as we move our fingers in a cork-screw pattern vertically on the tissue.

As I performed the exam, I said aloud "light, medium and deep" to help coordinate my actions. To completed a thorough exam, when you are learning, it takes some time (more than 2 minutes). And it's always hard to make sense of what you are feeling; everything feels kinda of lumpy and bumpy. "Like a bunch of grapes," said our patient educator. And every patients tissue will obviously feel different.

In explaining the exam to our patients, our patient educator made a good point- we perform a thorough exam to establish a baseline, which will serve to us detect any change (the other "C" word), not just for cancer.

In completing my first breast exam, I know it will take lots of practice to master the fine art of detecting subtle tissue changes that may come in the form of pea-sized lumps. "One day, you may be saving lives," our educator said as we closed the session. Maybe.

Other than performing a clinical breast exam on one of the nicest and warmest days in November, I spent my Sunday indoors preparing for our first M3 exam. We transitioned from Infectious diseases to the mechanisms, methods and malignancies block, formerly known as the cancer, bench to bedside, block.

Preparing for this exam has been partly a walk down undergraduate memory lane, taking me back to the days of when I majored in genetics and studied cancer as part of my research. Revisiting the genetic basis of cancer and the molecular biology of tumorigenesis has been interesting, especially as we learn the connection and see how the science relates to the clinical picture of a disease that impacts so many people.

Having been personally affected by cancer, it is sometimes difficult to read about the studies that predict five-year survival of patients on certain drugs, or learn about how cancer can recur or metastasize to other organs. It's hard to focus on the biology of a disease, when you can't help but see a face of someone you love who has suffered from the disease. And at the same time, it is promising to hear about the advances made in treatment and understanding the disease.

All in all, this has been a somber block. And Studying for the tomorrow's exam has been especially difficult (story of my medical school life).
M3 Mania continues...homestretch!

What a Week!

2008-11-07T18:16:00.000-08:00

This has been one amazingly busy week! Perhaps, one of the most epic weeks of medical school and history.

Tuesday was unbelievable. With the swipe of a magic black marker, I cast my vote early in the morning, braving the cold and lines. I proudly wore my "I voted" sticker all day, knowing that we may make history.

During pediatric preceptorship, I completed my first pediatric neuro exam on a one and half year old girl, who was fast asleep when I arrived. She did not like tracking my penlight, but she did like the fluffy teddy bear. Later, we listened to a presentation from a pediatric cardiac thoracic surgeon, who spoke about how to repair congenital deformities involved with babies born with large vessel switching.

We did make history on Tuesday! I was brought to tears, as I watched the election results unfold. After 8 PM, when it was announced we had elected Barack Obama, I was elated. I am excited this welcome change.

Wednesday we made medical school history with our annual class play- MDTV, which was remarkable. I don't think I have ever laughed that hard. The mix of music videos, live skits, performances and video skits (that featured classmates, faculty members and first years), was one awesome production. I made an appearance in a couple of the video skits, namely a video titled "Girls gone Mild." (I really hope it does not end up on youtube).

I was also part of the final dance number, which was set to the song "Bye Bye Bye," with rewritten lyrics. After rehearsing (for what seemed like forever), we finally performed to a crowd of screaming medical students and faculty members (and the stage lights are super bright). It was quite an experience...I would love to take a dance class (if only I had the time).

After the end of the dance, we stayed on stage for the Final song number- "Seasons of Gloves." It was so heartwarming be in the company of my classmates as we sung (a slideshow of our first year flashed behind us as we swayed). The final hurrah that is our class play was extremely memorable. Now the curse of topping our class play gets passed to the Class of 2012, who must now hit the drawing board to devise an even better play.

Thursday was another long day. I taught my first cardiac MSP session. We moved from the anatomy labs to the chalk boards in the classroom. I taught cardiac anatomy, one of my favorite topics. I truly hear the the heart (seriously).

Friday is here. And the weekend, which means catch-up time and learning the language of cancer. I'll be spending time with family this weekend, so we'll see how much gets done.

Cheers to an unforgettable week!
***

Bye Bye Bye - Lyrics by Ning

We're done with this tonight
It's time to turn on the lights
We hope you thought it was tight
Hey baby, come on
We worked on this endlessly
So that we could help you see
That you're not in this med school business alone

We know that you can't take no more
It ain't no lie
You laughed so hard your abs are sore
Baby, bye bye bye

Right now everything's so new
But before you now it you're an MS2
It seems crazy, but it ain't no lie
Baby, bye bye bye

We know that this med school's tough
You probably feel like you already had enough
But you'll all make it and it ain't no lie
Baby bye bye bye

Just hit you with the truth
Life's better as an MS 2
I'll give you some good reasons baby, come on
No more anatomy
Just Life Cycle and I3
We study, take the boards and then we're gone
Goodbye to the Essential Core
It all flew by
We'll see what third year has in store
Baby, bye bye bye

All of us were just like you
But we all made it, now we're MS2s
You'll all make it and it ain't no lie
Baby, bye bye bye

We know that this med school's tough
Learning how to use a blood pressure cuff
You'll all make it and it ain't no lie
Baby bye bye bye

Being DNA Polymerase

2008-11-02T07:55:00.000-08:00

One genetic degree and two years of medical school later, I am amazed at what I have become. For Halloween, I probably selected one the most nerdy costumes (of all time). I was DNA Polymerase, the enzyme that replicates DNA.

My costume was complete with a homemade sign, spandex, loop earings, a replication fork necklace and an oversized shirt that read "How do you express yourself?"

It was funny watching people reading my sign and trying to figure it all out. My costume only works on the UCSF campus or around my science/medical school friends. So, I did have the perfect daytime and nighttime outfit.

I know...look what I have become- pretty scary!

Happy Halloween!!!

The Little Beating Hearts

2008-10-28T22:18:00.000-07:00

I listened to a baby's heart for the first time today. The bell of my stethoscope was humongous on the baby's small chest. I could hear the pounding and rapid heart rate of our six-month year old patient. I could also hear an amplified inspiratory stridor, every time he took a deep breath in. As I listened to the heart, the beeping monitors over his head registered his heart rate, pulse, and oxygen saturation.

Later on, I got to see a beating heart of a baby that had just undergone cardiac surgery to repair a congenital abnormality that required reconstructing the vasculature of the heart. The little heart was pounding.

Today was our first day of pediatric preceptorship. I spent my day at the Children's Hospital in Oakland in the Pediatric Intensive Care Unit. Within the PICU, there was a number of young patients of all ages with a spectrum of medical conditions. In our shift, we saw everything from newborns with congenital abnormalities to young children with lung problems to teenage victims of trauma.

"Pediatrics is about observation and integration," our preceptor said. For this reason, we first observe our patients before moving towards any examination. We started by standing at the foot of our first baby's crib and watched him breathe, observing him and noting any abnormal physical findings.

The 23-bed PICU was a bustling area. Some patients were asleep or sedated, while others were being attended to by family members or health care workers. In a corner bed, family members read letters aloud to a young girl, who was unresponsive.

The site of children in hospital beds attached to tubes and monitors was surreal. I am not used to seeing children in the hospital and it was difficult to take the entire site in. Listening to the cries of patients and watching family members circle over their loved one's bed was heart wrenching. I can not even imagine how families cope with critically ill children.

Today's shift in the PICU was an eye-opening experience. I look forward to our return visits to the PICU.

Farewell Bugz

2008-10-19T21:53:00.000-07:00

The fog settled in yesterday, blanketing the city; I got a glimpse of the speckles of the city lights, as I made by my way home late at night after a day of filling every crevice of my brain with details relating to the microorganisms that invade our world and our bodies, everything from bacteria to viruses to fungi to protozoa.

Friday marked the last day of I3 (the microbiology block). In lab, we got to see real life Schistosomes, organisms that are transmitted by snails and can penetrate through the skin of hosts and reek havoc in the veins of the bladder, colon or liver. (Another reason why you should be careful in fresh water). So, needless to say- we kept our fingers to ourselves while observing the cercaria (worm-like creatures) that were swarming in the water.

With our final tomorrow, I am amazed at how six weeks of infectious diseases has impacted my differential diagnosis for fever, chills, diarrhea and rash. I went from thinking about a handful of things to now making an endless list of possibilities. Such an expansion will invariably contract, so I've been warned by my seasoned resident friends.

For now, I bask in the joy of knowing that I have learned about so many rare diseases and organisms (some pretty crazy bugs), which I may or may not encounter in the years to come. They do exist out there. And I am little more obsessive about washing my hands and properly preparing my food.

Aside from extending my intellectual bounds as far as they can, like a rubber band that has been stretched to capacity, I am really exhausted and looking forward to the end of infectious diseases. We'll finally get a much-needed interblock break from all the bug madness.

Cheers to the end (it's almost here!)

Diagnosis

2008-10-14T20:45:00.000-07:00

With a diagnosis of sinusitis in a 43 year old man complaining about congestion and coughing, we completed our adult preceptorship. We walked into our preceptor's office just a year ago.

While spending time in an Allergist's office, I have seen my share of inflamed noses, heard all sorts of wheezes in lungs of patients with asthma, seen all shades of prurulent discharge on the back of patient's mouths and observed the prednisone injections. And I have met real patients from the community, so different from the standardized patients we are accustomed to seeing in the clinical skills center.

I have learned to take a full history and perform a directed physical exam (mostly for an upper respiratory infection). I have become versed in the language of immunology as it relates to asthma and allergies. I know to check for nystagmus anytime I suspect a eustachian tube obstruction.

I appreciate the time my preceptor took to teach me and for allowing me to enter his office.

Making a final diagnosis was a great culmination of preceptorship and a nice preview of what awaits us in the spring, when we venture into the wards.

From here, we move to working with "little people," as we soon start our pediatrics preceptorship. I am looking forward to the adventures that await us in the next phase of our medical training.

The 10 P's of Success

2008-10-12T20:26:00.000-07:00

A Department of Surgery chair, from a well-known medical school, shared some pearls with a crowd of 250 eager medical students at the American College of Surgeons Clinical Congress, Division of Education Medical Student Program, which is being held in San Francisco this year.

She listed the 10 P's of Success in Leadership in Academic Medicine.
1. Plan
2. Be Prepared
3. Pay Attention
4. Look at the Process
5. Be Persistent
6. Demonstrate Power
7. Find a Partner
8. Be Pleasant
9. Pace yourself
10. Don't take it Personally

She asked the audience members to add any additional P's. I volunteered the following- finding inner peace, especially in difficult situations and as a general rule to balance one's life.

Other P's audience members provided included the following:
-Pride
-Politics
-Passion
-Proactive
-Productive
-Appreciation
-Potluck?
-Perseverance
-Prayer
-Patience
-Pure
-Possibilities
-Play
-Perform (under pressure)
-Push (your personal boundaries)

I'll try to attend more of the ACS sessions to learn more about a field that had continuously intrigued me and remains an evolving interest.

Exam 1

2008-10-10T16:35:00.000-07:00

We clustered in front of Cole Hall, with our baked and store-bought goods in hand. Once everyone appeared, we slowly made our way to the lecture hall. I entered first, carrying a plate of home-made brownies (triple chocolate) and placed the plate in the front of the lecture hall. After me, another 30 or so classmates streamed down the stairs of the lecture hall with their desserts.

It was so heartwarming to bake for the first year medical students. Today was their first exam of medical school, a milestone for many students. I remember how nervous and anxious we all were, huddled in front of Cole Hall. And how refreshing it was to see the former second years bring baked goods for us.

I made sure to schedule time for baking yesterday. Lately, my life has become before PDA and schedule-centric (story of my life). I usually get the store-bought desserts, but I wanted to put some effort in this little project. I know how hard the first years have been working in anticipation for this exam; I have been helping teach anatomy during MSP and answering questions (content and non-content based).

In the end, I hope everyone does not get too caught up in the score on the exam. And just remember that it's "pass now or pass later," the mantra I recite to myself a lot more now.

With the exam almost done for most of the first years, I wanted to wish them all a hearty congratulations on completing your first exam--one of many more to come!

No Surprises

2008-10-07T20:01:00.000-07:00

"No Surprises." That was the lesson of today's lesson.

Last week was the female pelvic exam and today was the male pelvic exam. Our educator, reminded us that the the pelvic exam is not as simple as asking someone to "stick out their tongue." Like the female pelvic exam, there are many parts to the exam that take us to an entirely new physical exam territory.

Our educator emphasized the importance of remaining "nonjudgmental," when we start dealing with real patients from the real world, including real human sexual behaviors that may not seem normal to us. We gain to learn from our patients and in doing so, we must pay attention to our facial expressions, verbal and body language.

There were three main parts to the exam: the breast exam, pelvic exam and rectal exam.

Although breast cancer is most common in women, men can develop breast cancer. For this reason, it is important to perform the breast exam and teach patients to perform self-exams. The cases of breast cancer in males generally is more severe, because cancer often goes undetected.

The pelvic exam was not nearly as complicated as the female pelvic exam (there was no metal instruments). Most of the exam was external, involving visual inspection and palpation, with the exception of the classic hernia exam (turn your head and cough test). As our educator walked us through the motions, he explained how to be sensitive to our patients, including the golden rule of "no surprises," to stress the importance of open communication and clear explanations.

The last part of the exam is the dreaded rectal exam (uncomfortable for the patient and the examiner). Our educators had some great tips to help patients relax (because no one really relaxes if you tell them to "relax.") Lubrication and deep breathing exercises combined with Kegels may do the trick to help patients relax (or to help the examiner relax, at least).

As I mentally prepared myself for the rectal exam (specifically thinking about where my finger was to go), I realized how we have learned to palpate and navigate every corner of the body, including orifices, such as the anus. Using a wind-shield motion, I could feel the surface of the prostate gland and with a 360 degree rotation, I could feel the rectal wall (the anatomy can only be appreciated your finger has made it's way far enough up, in case your are interested in knowing).

The last exam will be the breast exam. After that, I will have learned the full head-to-toe physical.

We come a long way. It will be interesting when we start performing full physical exams on our patients. Hopefully, we'll remember the lessons our educators have taught us and have too many surprises.

Remember to Exhale

2008-09-30T19:59:00.001-07:00

Before inserting a speculum (a metallic instrument that helps better view the cervix) into any vagina, we always ask our patients to take a deep breath. The rule can be generalized to when we insert anything into the vagina. And on exhalation the speculum goes in. As I asked my patient to take a deep breath, my patient was watching me, giving me similar instructions.

"Eisha, breathe." Oh yeah, I forgot that part. Don't forget to exhale. In between handling the duck bill of the speculum, inserting the metallic monstrosity into the vaginal opening, pushing it through and looking into the metal mouth while opening the mouth to identify the cervix (which just pops out from nowhere), I must have forgotten to exhale (I certainly hope my face was not showing my apprehension).

Today was another milestone in my medical school life- completing my first female pelvic exam. It was thorough and complete (with a fair share of awkwardness and difficulty), including everything from examining the external and internal genitalia to the speculum exam to the rectovaginal exam.

It's a unique exam because your fingers are not only palpating and exploring new territories (I never knew my finger could go in that deep), they are also "seeing" for you. Although I have seen the Netter images of the uterus, vagina and pelvic muscles and dissected the pelvic viscera- I felt somewhat blind as I made my way around the fornices and uterus. It felt odd, relying solely on a finger in a small space to reveal the anatomy.

Our patient knows her body extremely well. With a hand mirror, she was able to verbally guide me through the exam, capable of engaging me in a conversation even while I nervously tried to readjust my finger to better palpate her uterus or cervix. She is an educator, who feels "empowered" to assist budding physicians and health care providers. She instructed us to "let go of any anxiety."

She prides herself in effectively training health care providers to perform the pelvic exam and develop rapport with patients. She was fantastic; I was impressed by her calming presence and extensive knowledge of her own anatomy.

"Everything you say or do must have intention," she said. The pelvic exam is like no other because your patient probably feels the most uncomfortable and vulnerable. (Any woman that has had to put her legs in stir-ups for the pelvic exam can attest to the discomfort and unpleasantness of the exam). For this reason, we must explain each step (especially since our patient can not see what we are doing down there) and we must be careful about what we say, and only say things that have a purpose in our exam. Word choice is pivotal. "Normal and healthy" are probably better descriptors than "perfect or beautiful."

Like anything else, practice makes perfect. I know it will take me a couple of exams before I can really understand the exam and know that I am, in fact, palpating an ovary and not just the vaginal wall (believe me, it's difficult the first time, at least for me). And I'll remember to exhale...

Bugz, Bugz, and More Bugz

2008-09-21T21:53:00.001-07:00

I have this urge to wash my hands every 10 minutes. I will never look at a rash the same way. I am frightened by any chief complaint that begins with fever, or stomach pains.

Over the past 11 days, I have been seen my differential diagnosis for fever expand. And do not get me started on diarrhea, a subject in itself.

We transitioned from immunology to microbiology/infectious diseases. Put simply, microbiology involves learning the autobiographies of criminal bacteria, which each have different shapes, life cycles, toxins and targets. And then we have to follow the crazy bugs through their disease rampages, as they tear through our tissues and evade our immune surveillance, causing inflammation and infections that are each so different and yet so similar in terms of clinical presentation.

Classic case: 25 y/o presents with fever, chills, muscle pains and sore throat.
(this could be 1 of like 20 diseases, and this is a conservative estimate).

The number of diseases caused by bacterial pathogens is impressive. Actually, it's amazing how we are surrounded by bacteria and how they colonize our tissues, and we somehow seem to be in some sort of equilibrium (until we get sick or eat something funny).

The funny thing about this block is the names of the bugs we have to know; they are unreal and unnatural. Bacteriologists fail to follow the rules of spelling we learned in elementary school. It's interesting how some scientists decide to name a bug after themselves. For example, Alexandre Yersin, a physician from the Pasteur Institute discovered the pathogen causing the plague and named it "Yersinia Pestis," after himself. Now, the black death will be connected to his last name. I do not know if I would want to attach my name to something like that.

I did learn that as a child we were already playing homage to Yersin and the black death, as we sang "Ring around the rosies," (refers to the red flea bite), "pocket full of posies" (people during the medieval times kept spices and herbs in their pockets to deodorize the smell of the dead bodies), "ashes, ashes, ashes- we all fall down" (victims coughed up dried blood and people suffering from the black death, would fall down to their death). I wonder who decides which nursery rhymes children learn.

The number of bugs we must learn for our Midterm tomorrow is magnanimous, like the volume of watery diarrhea expelled with cholera infection. On Friday, our professor (after teaching us the 10th bug at the end of the lecture hour), said something to the effect of: "This is the time that you are all probably hating medical school." (He was spot on; it is somewhat overwhelming to learn this much detail about bugs).

Although there is a massive amount of information to be internalized, I do find infectious diseases to be somewhat intriguing. All these years of hearing about pneumonia or meningitis or lyme disease and not know really know anything. Now, I know how serious these diseases are with an understanding of the microbiology of these bugs that have developed intricate methods to evade our immune systems. I am even more paranoid about washing my hands now.

With a fat pile of stack cards to be reviewed, I best be off to mastering these bugs rather than being phased by the microbial word that surrounds us.

Anatomy Lessons

2008-09-17T22:15:00.000-07:00

I can not get the smell out of my hands. Even after changing out of my scrubs, I still could smell the familiar scent of anatomy lab on me. And I have taken a shower and still can detect the odor of latex-presservative on my hands.

It was not so long ago, when I got my whiff of this odor when I first ventured onto the thirteenth floor for my first foray into anatomy.

The first years had their first anatomy class today. A day that seems like it was in another lifetime for me. Today, I was teaching abdominal muscles and viscera during my first MSP session.

It's funny how quick it comes back. I had not seen the abdominal muscles since last year and before I knew it, I was teaching the three layers, focusing on a method to teach that avoids simply memorizing. In this case, it involved a demonstration of grabbing in your pocket to grab a piece of candy (direction of external oblique), place the candy in your mouth (direction of internal oblique) and rubbing your stomach (direction of transversus abdominis). There was also an abdominal workout.

Last year at this time, I struggled to unzip the body bag and reflect the skin back to visualize the muscles and abdominal viscera. Today, I was actually teaching the muscles, maneuvering the viscera and muscles almost like a robot. Now, I can really appreciate the anatomy without having to worry about any test.

I guess I have come some way. It was a pleasure to teach the new students. I hope they can handle my unusual mannerisms, bad jokes and hyperactive personality (I swear teaching brings out these qualities and I am not normally like this). It is just so much fun to share my joy of medicine with others.

There are somethings that do not change- the smell of anatomy remains (still).

Cheers to a year of MSP!

Superhero Day

2008-09-15T18:36:00.000-07:00

Yesterday, I was madly searching through my closet and drawers for anything remotely resembling a superhero costume. I am so amazed at how normal my wardrobe is. Aside from lots of exotic scarfs and tunics, there was nothing that really caught my attention. So, I settled for spandex (bike pants), an over sized DNA shirt that read "How do you express yourself," a red and yellow pokadot scarf, socks emblazoned with red hot chili peppers, a big black beaded necklace and a mask of confidence.

I was to be "Super Eisha," for our MSP debut for the first years. As a way to introduce the teaching program to the first years, the group of 16 MSPs leaders decided to dress up in super hero outfits (mostly colorful spandex).

And with our cue, "Don't fear, MSP will come to the rescue," we streamed into the first year's lecture hall, making our grand entrance by running and screaming to the front, where we were introduced. Now, that's what you call making a first impression.

Although I was going for the superhero look, I ended up looking more like I was off some 1980's exercise video, with my hair tied back to the side and in my spandex. One word- hideous! At least, I was in the company of 15 other MSP teachers, who exuded excitement to teach the first years, starting with anatomy and later teaching organs physiology.

Later today, one of our MSP advisors, commended us. He wrote, "It was really fun to watch you guys do your thing. I'd sign up again in a heartbeat! And don't feel bad that they sat there looking puzzled/scared while you ran around screaming, you all did the same thing when we did our announcement last year. It's been highly studied
and the evidence is overwhelming that this is a limbic cortex associated
instinctual reaction to the sudden appearance of rockstar superheroes
(p<.001)

Well done!" I guess that's a nice way to put it.

After my superhero arrival, I walked out in my hero outfit (to some awkward stares) en route to my apartment, where I had to change into another costume- a black powersuit. Now, I know what Superman must feel (it is so hard to run around in spandex and then change). I rushed and quickly changed grabbed my black stilettos and ran to the Curricular Showcase, where I was presenting a poster outlining my summer curricular project.

For two hours, I stood and explained my project to faculty members and students. After the 10th time, I thought- I should have recorded myself speaking and had everyone click a button to hear the description.

It's been a long day. If only I had real superhero powers (right now, I'd pick the power of learning all the bugs we are supposed to have learned by now). I may not that power, but I do have spandex and I sure to know how to rock a 1980's workout outfit like no other!

Class of 2012 White Coat

2008-09-12T21:23:00.000-07:00

Last year around this time, I stood up in a freshly ironed white coat in the company of 150 medical school classmates and recited the Oath of Louis Lasagna, a modern version of the Hippocratic Oath. Today, I was reminded that I will be repeating that same oath in less than three years during graduation as I listened to the new first year medical students recite the same oath.

The sea of white coats spoke in unison. As they recited, I looked through my lens, snapping photographs. Frame by frame, I was reminded of a time not so long ago, when I just arrived on the UCSF campus, bright eyed and blissfully unaware.

The Dean welcomed the Class of 2012 in the presence of the faculty members, whose names and faces I have come to know. Addressing the new students and their families, he reminded students that when you put the white coat on, you are "accepting a sacred responsibility to your patients."

When I think back to my White Coat Ceremony, I remember the excitement and joy of being coated in a pristine white coat. In my three inch black stilettos, I hobbled on the stage (in my mind I was nervous and anxious and kept telling myself not to trip and to imagine that the stage was like a runway). I must have been one of the harder students to coat (the added height must have made it hard to slip the coat on). My mind was racing, but when my name was called, I made my way to get my coat from my mentor, in what seemed like a blink of an eye.

According to the President of the UCSF Alumni Association, the first white coat was worn in a medical settings 150 years. Surgeons were the first to wear the white coat, a symbol of cleanliness and sterility. Community doctors soon followed, picking up the coat and taking up the aseptic look, in an initial attempt to differentiate the physicians from the quacks, in what he described as a "massive publicity stunt."

The white coat ceremony is certainly one of the milestones in my medical school career. Everyone was all smiles; and it was contagious to be around such a happy group of students and family members.

I had privilege of taking photographs, as the "unofficial photographer." As such, I was was given a second-row seat (right behind the faculty members) and the liberty to roam around the floor. That's one of the best things about being a photographer, you make your canvas and gain unique vantage points and access. I saw the ceremony partially through my camera lens and through my experience being the recipient of a white coat. I was vicariously reliving the experience in my mind (some parts as clear as day, others hazy, and others completely forgotten).

It was simply a pleasure to be a part of an event that is so special and central to the incoming students and their families.

As I watched the new medical students receive their coats, it was amazing to see the happiness and pride in their faces, a mix of disbelief, relief, and something to the effect of "I have no idea about what I'm getting myself into, but I've heard this medicine thing is supposed to be good." The families were both proud and excited. And it was a pleasure to watch the families congratulate their medical student and pose in the post-ceremony photographs.

It was not so long ago, when I was standing in those photographs smiling widely, unaware about what would happen next. A year later, I'm still smiling.

New medical students, welcome to the family of short white coats! Best of luck (the medical school honeymoon has ended and the real fun is just about to begin).

***

Oath of Louis Lasagna
"I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help."

Whirlwind of Immunology

2008-09-10T16:05:00.000-07:00

"You guys and medical students all over the country have had your blood drawn right now," said our professor yesterday. She was referring to how medical students are typically used as experimental subjects in studying the relationship between stress and the release of cortisol, a steroid that affects our immune system. Apparently, medical students the day before a big exam represent one of the best stress model.
And increased stress (chronically) leads to suppressing the immune system, which explains why you are more likely to get sick right before the exam.

Do we really get that stressed over exams? Apparently we do (and research studies have shown that). While I was studying, I looked up at the T cell-mediated toxicity poster on my wall and realized I actually now knew what was going on. I know, I'm a big nerd for actually posting a poster about T cells on my wall. It just fills white space (I'm being serious).

I'm feeling more relieved right now.

After 11 days of immunology, we finally took our Final at 1 PM. For the last few days, I have been mastering (or trying to master) the language of nerd and watching my cortisol levels rise.

CD4, CD8, IL-2, IFN-gamma, IL-12, cytokines, MHC, APC, DC, CTL, CMI (just a few of the codes that have been drilled into my brain).

The immune system is complicated but one of the most intricately designed systems that mediates our body's defense to pathogens in a series of cell to cell interactions that is as elegant as a waltz dance. I have a deeper appreciation for a microscopic process that can selectively recognize and destroy a foreign particle, while discriminating between the gazillion self cells. With this foundation, I can view pathology with a new lens. If only I had microscopic glasses to actually see the intricate world of immune cells.

For the first time in medical school, we were given a written exam (no multiple choice). When I got the exam today, and saw the white spaces, I was reminded of the days of undergraduate education, when you studied to regurgitate. The strategy back for questions you were unsure about was to write everything that came to your mind and hope it made sense the poor grader. Today, I was really avoiding that. And writing a book causes my hand to hurt.

It seems like we move in light speed in second year.
Onward to bugs- Microbiology starts tomorrow!

Cheers to finishing Immunology!

Adopting a Sib

2008-09-07T16:59:00.000-07:00

This weekend, the incoming first years spent their weekend at the annual Medical School Camping Trip; the classic combination of team-building games, introductions, socializing and alcohol. My camping trip feels like it was in another lifetime. So, odd- you go from thinking about your classmates to being around them in the wilderness. The camping trip was one of my earliest memories of my classmates and medical school, reminding me it is somewhat reminiscent of high school in some respects.

The first year medical students will make their debut on Tuesday; crawling out of the summer vacation hide-outs and congregating on campus for a week of Orientation activities. Honestly, the first week is about repeatedly congratulating the medical students (over and over again) and explaining what medical school is about plus a plethora of socializing activities. And the week culminates with the White Coat Ceremony, one of the most memorable experiences in my life.

As second years, we have the opportunity to adopt little siblings. I selected my little sibling and finally contacted her (and got a response). I am so excited to meet her and share some pearls of wisdom.

When I officially adopted my sib, I was already thinking about the first order of business- a gift. I ended up getting her a pocket handbook to help her with doctoring, a pink pen light and a candy bar. I hope she likes it (or finds the gifts useful). I slipped her gift in her mailbox today.

When I meet her, I hope I can fulfill my siblings duties.

Year 2 has begun

2008-09-04T22:36:00.000-07:00

"To learn pelvic anatomy, you will need to pull your compact mirrors out," said our anatomy professor during the pelvic anatomy session. She was presenting a series of images of the male and female genitalia to prepare us for performing the pelvic exam. We will be expected to complete the pelvic exam in the next few weeks. (Stay tuned...)

Her words were met with some chuckles and whispers from the audience. We knew she was joking. But she was serious about encouraging each of us to study our own pelvic anatomy using a mirror.

When she mentioned this, I was reminded of the episode of "Sex and the City," when Charlotte struggled to use a mirror to visualize her own anatomy down there.

It hit me today. We are in the second year. We are really getting closer to becoming doctors. OK, I know this realization is a little overdue. Somewhere in between the immunology whirlwind and the pelvic anatomy overview, I realized how the expectations are so much higher.

Even in our learning, we have gone from patient cases to case conferences and journal club presentations. And we are moving toward performing a a full physical exam, by learning the pelvic exam.

The standardized patient interviews are not as straightforward as the first year interviews that followed a relatively predictable outline. The interviews are more complicated with patients that actually do not listen to you (sounds familiar to anyone you may know?), reminiscent of the real patients we will be encountering outside the walls of our classrooms, in the community and hospitals. Our doctoring facilitator echoed this sentiment, telling us that "the interviews in the second year are so much harder."

Although there are some curve balls being thrown at us, I suppose it's time. In a way, it's refreshing to push ourselves a little further. Even if that means being yelled at by our standardized patient interviewer or if it means that we will be soon sticking our fingers in some of the most unthinkable places.

The second year is upon us and quickly unraveling...

"B" Word

2008-08-26T22:33:00.000-07:00

On the second day of the second year of medical school, they finally dropped the "B" word.

During lunch, the School of Medicine and class representatives hosted the Med II Welcome Back Program. We were promised lunch, so most of the class remained after our Lymphocyte Development and Immunodeficiencies lecture. The falafel did not arrive right away. So, we all sat and waited while being regaled with announcements and updates.

We learned about what others did over the summer, including research (my group), traveling and non-medical activities. In addition to a plethora of announcements from the class reps and fellow classmates, we were introduced to the Student & Curricular Affairs staff (new and old faces) and a road map for the second year

During the second year overview, our faculty discussed our clerkship preparation and finally dropped the "B" word. You guessed it- the "Boards." Our second year will culminate with this monstrosity of an exam, or as one faculty member puts it "a big quiz," a rite of passage to third year, if you will.

To date, our faculty have done a great job safeguarding us from any needless board anxiety (mum has been the word). But now the floodgates have opened and we have been made aware.

In all honesty, most of us are fully aware of this exam on the horizon. I've pushed into the back of my mind. But now it's slowly making its way forward, akin to a cold, harsh reality that we will soon face.

Oh well. The "B" word is out and there is no taking that one word back.

The Return

2008-08-24T21:26:00.000-07:00

The sun finally shined. As I walking up to my friend's house to watch a movie, the warmth made me happy and a bit anxious; I was just thinking how our schedules would become so much busier.

It's hard to believe that we return to the start of our second year of medical school in less than 12 hours. Where did the summer go? It evaporated in the absence of SF heat.

8 weeks have elapsed. Looking back, my vacation was a pseudo-vacation; I spent most of the weeks in lab, pipetting and conducting basic science research. Long hours in lab. The days were regimented, a mix of experiments, reading dense articles and completing work for my curricular project. The evenings were more exciting and included any combination of the following: trips to the gym, running in the the park, swimming indoors, watching TV, eating dinner with friends, hanging out my brothers, reading and writing.

All in all, it was relaxing coming home and not having to study, or prepare for small group.

The carefree days are over. I have started the unthinkable (the reading for tomorrow's lecture) about the immune system. A focused examination of innate immune response is a bit futile, because my mind is elsewhere, pondering how we can be returning back to school so quickly (a blink of an eye).

It will be nice to be reunited with classmates and learn about what others did this summer. Other than that, I'm dreading the 8 AM lectures and studying. Oh well, the day was coming the moment we walked out of our BMB finals. It's time to move on.

Cheers to a great summer and here's to hoping for another promising year of medical school. Wish me luck!

23.

2008-08-21T15:39:00.000-07:00

There is something mysterious about the number of 23. In fact, the term "23 Enigma" has been coined to explain that 23 (and any permutation of 23 or any number related to 23) is somehow linked to all incidents and events. Very Interesting.

For some believers, 23 somehow may be the key to explaining how and why things happen. If good things happen, 23 is lucky. However, if bad things happen, 23 is unlucky. Ultimately, it comes down to the interpreter.

I'm struggling to decide what I should make of 23, two numbers- the previous one less than the latter. I suppose I would have more insight if I knew what to expect from my 23rd year of life. For now, I'm going to keep an open mind and hope 23 brings as much joy as 22.

My mother called me yesterday around 10 PM.
"Happy Birthday, Eisha. I'm calling you the day before your birthday because your were born after midnight." She said.

August 21st- my birthday. Growing up, I always had a bitter-sweet birthday; I was celebrating my birth along with the end of summer vacation. Somethings really do not change. I'm celebrating my 23rd birthday four days before the arrival of the storm that is the second year of medical school. I bought myself a gift: the immunology syllabus.

I celebrated a birthday earlier with some of my friends. The birthday cake was one of the best gifts ever. One of my best friends actually took the time to make the choclate ganash cake from scratch.

Looking back, I have to say I was blessed. 22 was a great year. I am thankful to God, my amazing parents, four brothers and sister, friends, classmates, teachers, blog readers and patients for truly enriching the texture of my life by providing me with everything from love to support to knowledge to patience to reassurance. I am here because you all have placed so much faith in me, giving me that energy that puts a smile on my face in the morning and allows me to move forward each step of the way.

22 was a year of so much change; the year I began my first year of medical school. A year of new relationships and friendships. A year filled with learning the art and science of medicine and becoming a part of something so great. A year of new discoveries and realizations.

22 was a year of many of firsts. It was the year, I met some of my best friends. It was the year I completed my first 12K. The year I learned to perform a physical exam and take a full patient history. It was the year I organized my first full dinner party. It was first time I took a sexual history in the company of 5 of my peers. It was the year I moved to SF and explored the new city that has become my second home. It was the year I made my first incision, drew my first vial of blood and injected my first immunization. It was the year I started my first blog and published some of my essays. It was year I took my camera in the OR to photograph a surgery. It was the year I went to prom (it was medical school prom). It was the year I learned to suture and tie surgical knots. It was the year I was given my short white coat and the year I recited an oath that will dictate my actions for years to come and the year I became 25% of a doctor.

It was the year I realized my life was going to change, as I move closer and closer to my goal of becoming a physician and as I began to learn the fine art of balance.

Overall, 22 was year of new beginnings.
As I start 23, I hope these beginnings in my professional and personal life burgeon and take on a life of their own. Although I dread returning to the regimented schedule of lecture and school (oh how I dread the 8 AM lectures), I know I need to simply pick up my feet and move forward, drawing on my experiences. I am looking forward to moving ahead through the second year medical school in anticipation for the start of clerkships that will get me closer to working directly with patients.

I guess there are a few other things I am hoping to accomplish during 23. In no particular order:

1. Complete the SF 1/2 Marathon
2. Make it to all the weddings I'm invited to (2008 seems to be year of weddings)
3. Do more than one pull-up
4. Fully integrate swimming into my workout regimen (I just rediscovered swimming this week and love it)
5. Continue reporting to this blog with insightful (and some not so insightful) entries
6. Survive Boards Hell (and maintain a semblance of a personal life that involves time with friends and working out)
7. Figure out "which kind of doctor I want to be"
8. Get better at balancing my life, which may involved learning to say "no"
9. Continue to writing essays, including non-medical essays
10. Continue to spend time with friends and family, cultivating the new relationships that have become so central to my life and my sanity
11. Take my camera to new places
12. TRAVEL!!! (somewhere exotic)
13. Regain the swimmers tan I lost to the SF fog
14. Mentor the first year medical students
15. Continue mastering the fine art of Indian cooking
16. Speak solely Punjabi with my parents to better my ability to speak the language of my childhood
17. Continue to maintain a regular workout regimen during MS3 rotations
18. Continue to explore SF (all the museums and neighborhoods)
19. Surf and one day swim in the Pacific Ocean (if it ever warms up)
20. Meet Prince Charming
21. Stay up to date with current events and become an informed voter (go Obama)
22. Improve my Spanish
23. Smile everyday and realize how lucky I am

With the day so young (and me one year older), I am looking forward to the proximal celebrations, including a trip to the Moma to visit the Frida Kahlo exhibit with friends followed by dinner and cake with my brothers. And tomorrow will be another dinner event (Thai food) with some of my newest and closest friends and whatever other festivities we can fit into the evening.

I suppose I have created an ambitious list. Above all, I hope 23 is another year of discovery and learning and less of the enigma it has been cut out to be.

Time will tell. For now, it is time to cease the day and live it to the fullest.

Happy Birthday!

Six Rules for Doctors (and Aspiring Doctors in Short White Coats)

2008-08-11T11:50:00.000-07:00

With two weeks remaining in my last summer vacation, I am beginning to dread the return of school. It's that same feeling I used to get right before dragging my feet to go back to school shopping. As my mom helped me fill the cart with pencils, notebooks, crayons and school supplies, I would realize I'd be leaving the carefree days of summer cartoons and frolicking for a regimented day in grammar school, full of worksheets and scheduled play time and discipline.

As I count my last days in lab (5 days), I realize I will be giving up my evenings to studying and all the other medical school commitments. Sigh. All good things to come to an end. We return August 26th.

I do still have some time remaining to muster some research results in the next five days (highly unlikely, but miracles do exist). I have reserved the last few days of summer for recharging (or spending my time with family and friends outside of SF and tying all those odds and ends).

While I was catching up on the current events on the NY Times, I came by this interesting piece outlining "Six Rules Doctors Need to Know," written by Dr. Robert Lamberts, a physician and blogger. He chronicles his thoughts about medicine and a variety of other interesting (and somewhat unrelated topics, such as "dogs driving cars") on his blog Musings of a Distractible Mind

Here are Dr. Rob's Six Rules ("they" refers to the patient):
Rule 1: They don’t want to be at your office.
Rule 2: They have a reason to be at your office.
Rule 3: They feel what they feel.
Rule 4: They don’t want to look stupid.
Rule 5: They pay for a plan.
Rule 6: The visit is about them.

Some basic Rules that are often not followed...

Just some points to ponder.

For more information: http://well.blogs.nytimes.com/2008/08/07/six-rules-doctors-need-to-know/

SF Marathon- 8.3.08

2008-08-03T15:21:00.000-07:00

The San Francisco Marathon is the only race that allows runners to run on the Golden Gate Bridge roadway. With over 15,000 participants in the full marathon, half marathon and 5K, the city streets were flooded with runners, making their way around the course. It was cloudy and cold, but not windy nor hot (the perfect running weather and not so pleasant spectator weather)

For the full marathoners, the course starts at the Embarcadero and continues through the piers, passing the Ferry Building, Transamerica Building, Coit Tower and Fisherman's Wharf. From here, runners pass Fort Mason and the Marina. Along the way, runners are rewarded with some breathtaking views of the city and bay. Runners continue through the Presidio, onward to the Golden Gate Bridge. They cross the bridge into Marin, at which point they turn around back onto the bridge and renter the Presidio, running alongside the Pacific Ocean. They continue running into the Golden Gate Park, passing by Stow Lake, Rose Garden and Conservatory of Flowers.

From the park, runners enter into Haight and continue towards the Mission until they enter Mission Bay, passing along the Baseball park. They begin the homestretch of the race that takes runners back to the Embarcadero to the finish line and cheering fans.

I had been toying with the idea of entering the half marathon, but when the fog rolled in during the summer months, I realized training for the 13 mile race would be compromised.

I was on hand today to provide medical support to the runners as a First Aid volunteer, as part of a group of health professionals from the UCSF.

We were situated at Camp Bravo, the second post-finish tent right next to the live music and awards ceremony stage. As we helped runners by providing basic first aid, we got to hear the "Sweet Home Alabama" and various other 1980's hits that I could not recognize.

In our red hats and shirts, we made our way through the post-finish line.

I was also there to support my older brother, who was running the Full 26.2 mile marathon. It's unimaginable how anyone can run that distance. He finished in under 4 hours and I am so amazed (and proud). He has been training diligently for this race, running (sunshine or no shine)- a rule I can not abide by.

It's inspiring to see him and other runners, making it the finish and then limping to loved ones.

Maybe, with some bending of my current training policy (a requirement of sun), I may train for the 1/2 Marathon next year and be one of those limping runners at the end, who are just joyed to be done.

10 mg of Exercise minus the Exercise

2008-07-31T16:10:00.000-07:00

Can you imagine one day being prescribed a pill that accomplishes the equivalent of thirty minutes of running or cardiovascular exercise. All this, without the sweat and pain? Seems too good to be true. But researchers may be one step closer to developing a pill that could be the answer to America's Obesity epidemic.

Scientists at the Salk Institute recently published a paper in Cell, reporting they had discovered 2 pills, Aicar and GW1516, that may be potential drug candidates. These drugs work by increasing endurance of mice that have been genetically engineered to be coach potatoes.

By examining mouse performance on treadmill, researchers have been able to demonstrate these drugs drastically increased mouse endurance. The findings were discussed in a recent New York Time’s Article titled Drugs Offer Promise of Fitness.

“One drug, known as Aicar, increased the mice’s endurance on a treadmill by 44 percent after just four weeks of treatment. A second drug, GW1516, supercharged the mice to a 75 percent increase in endurance, but had to be combined with exercise to have any effect.”

The drugs activate production of Type 1 muscle fibers, which contain a higher concentration of mitochondria, which produce energy during exercise. There are also

Type 2 muscle fiber, which do not contain as many mitochondria. Highly trained athletes have a higher number of Type 1 fibers, which allows them to perform at optimal levels—running marathons, swimming laps, cycling up steep hills, etc. For individuals with decrease fitness level, ie: coach potatoes, a great number of Type 2fibers are expected and a lower number of Type 1 fibers are present, which explains why such individuals tire easily when perform physical exercise.

The main investigator, Dr. Ronald M. Evans, has linked the increased Type 1 muscle production to a specific pathway—the PPAR-delta pathway, which has been linked to activates fat-burning processes in the body.

Dr. Evans may have discovered a potential therapeutic target. Pharmacy companies may soon be eying his discovery as a panacea to the solve a plethora of problems. If a drug was developed, it may be useful to help in treating obese or diabetic patients, who would not be otherwise able to reap the benefits of exercise.

Dr. Evans believes that “This is not just a free lunch, it’s pushing your genome toward a more enhanced genetic tone that impacts metabolism and muscle function. So instead of inheriting a great set-point you are using a drug to move your own genetics to a more activated metabolic state.”

It’s interesting how scientist are beginning to understand the complexities that lie in our bodies. Dr. Evan’s discovery gets to the molecular basis of muscle production and exercise. His research may have found a way to trick our mice into thinking they are actually exercising. I wonder if that same trick could work in humans. It will be interesting to see where this research goes.

For more information:
http://www.nytimes.com/2008/08/01/science/01muscle.html?_r=1&hp&oref=slogin#

My Essay is Live!

2008-07-28T11:50:00.000-07:00

When I opened my inbox, I was excited to get the following message:

"Good morning, Eisha!

Your essay has been added to our homepage http://medschool.ucsf.edu/

Thanks again for letting us publish this."

I am so excited to share my essay, "Exposed" with the UCSF community. As an aspiring writer, I hope my writing can reach an audience that extends beyond just myself. In sharing my experience with anatomy, I hope others can learn about a unique experience that really changes an individual.

If you are interested, please take a look at my essay.
It is always interesting to see how one's writing is described. On the UCSF School of Medicine website, I found the following description:

"Anatomy Exposed, a Probing Essay by a UCSF medical student explores what lies beneath the skin." Now, that's a great description!

Foggy Days

2008-07-21T10:29:00.000-07:00

I finally got to see the sun. Ok, let me qualify that statement- I got to see the sun and experience summer heat. A visit to my parents home this last weekend reminded me about a normal summer experience.

While visiting my parents, I realized a few things.

You know it's summer when you have to close the windows at noon to prevent heat from coming in and when you have to turn the fan to full power, just to tolerate breathing the warm air that circulates and fills the room.

You definitely knows it summer, when you step out for a run and start sweating the moment you start warming up and when you realize you are panting because you are thirsty (and only a mile has passed).

Oh, summer days. How I miss thee. I guess the novelty of summer is more what I miss. When I woke up on Monday morning back in SF, I was not surprised that the streets were black from condensation.

Overall, the summer has been treating me well. I've been searching for topics to write about, but realize that there is not too many interesting developments in my life. I spent the weekend with family, enjoying home-cooked meals and BBQ (we found an inventive use of the grill to heat up chocolate chip cookies) and reading novels.

I did just finish reading 1000 Splendid Suns, written by Khaled Hosseini, the author of Kite Runner. It was an interesting story about the plight of Afghani women set on the backdrop of the tumultuous history of the a country that continues to emerge in the forefront of media coverage.

***
If there is one word I can use to describe the epitome of my summer vacation, it would have to be ROUTINE. I spend my day in the lab, working out research problems that sometimes transcend my understanding while completing parts of my curricular project. That leaves late afternoon for a gym trip or running. I've been working on fitting in swimming (the weather just has not been that cooperative for a girl that is used to swimming under the blanket of the sun's glow). And evenings are left for Food Network, reruns of Sex and the City or surfing the web.

I'm working on writing a piece about DNA use in criminal investigations. I am also looking forward to photographing volunteers and patients at Clinica Martin Baro this Saturday.

With the sun shining and the weather looking promising right now (Wednesday), I think it maybe time for a run out to the ocean, if I can get out of lab at a decent hour and beat the impending arrival of SF summer fog.

Cheers to summer days!

Take 1, 2, 3, 4.....

2008-07-11T20:18:00.001-07:00

With the overhead lights arranged in a circle around the dissecting table, I looked into the view finder to see the scene. The blue towels covered the thorax and lower abdomen. The plastic body bag glistened as we toyed with the light.

Once the lights were arranged perfectly (or close to perfect) and the glare was reduced, we began filming the renal anatomy dissection in the anatomy lab.

As part of my curricular project, I am helping to produce a renal anatomy lab video for a renal anatomy lab that will be added to the first year curriculum next year. I am working with the an anatomist and surgeon to create this film and to write the syllabus that outlines the "Anatomical and Surgical Approach to the Kidney."

The surgical procedure that will be outlined in the syllabus is used to remove a kidney for radical nephrectomy in treatment of cancer as well as organ recovery for transplantation. With the incision made, my surgeon mentor, dissected away until we reached the right kidney. As he moved deeper in the abdomen, fluid flooded out (which required repeated blotting and a few movie takes).

He navigated through the peritoneum until he found the right kidney. With the right kidney in his hand, he carefully began the process of removing the kidney from the abdomen by severing and tying off the renal artery, vein and ureter. He pulled the kidney out of the cadever and bissected the kidney to show the interior anatomy with the pyramids and columns.

After filming this anatomy lab video, I have developed a new appreciation for movie producers. It takes a number of takes to get the cut just right and so much thought goes into creating each scene. And this is just the pre-production phase.

The next stage will involve revising and splicing the scenes to creat a fluid film that will instruct students how to remove the kidney. In the process, I too will learn this process (inside and out). Let the revision began...

End Scene

The Summer...

2008-07-01T20:36:00.000-07:00

I am used to sunshine, heat, long days and humidity during the summer time. As long as I can remember, I have associated being "hot" with the lazy days of summer. For some reason, it has not really hit me that is summer.

Perhaps, it is the rolling fog or the bone-chilling weather in San Francisco that makes it a little confusing. It feels like winter even though it is July 1st.

Well, I really can not complain- I'd take the fog over 100 degree heat any day!

I do not have much to report. I have started my basic science research. DNA extraction and PCR revisited. And I have also started my curriculum project, which involves integrating a surgical approach in the Organs Block. This week has been orientation, learning the ins and outs of developing learning objectives, storyboarding and laying out the direction of the project.

Overall, I am trying my best to stay on top of the list of things to do, while enjoying the summer nights with gym trips and time spent with my friends...my psuedovacation.

25% of an MD

2008-06-23T13:36:00.000-07:00

Yesterday, I was staring at the ocean, thinking about how beautiful the water looked and how I longed to be anywhere but the library. I was thinking about the old saying- "there is always light at the end of the tunnel." This may be true, but the creator of this saying did not realize that some tunnels are longer than others. And the tunnel that takes one through studying for the BMB final, is a really long one. At least now, I can see the light.

It's hard to believe that I am one quarter of a doctor. Ok, I say this preemptively contingent on passing our BMB cumulative final.

I will savor the moment and the feeling of being DONE! We are officially second year medical students, popularly know as MS2s, which means the expectation bar has just gotten so much higher. We can no longer use the excuse that "we are just first years..."

When I turned in my final to the BMB course directors, I realized that this is it. They looked at me, and said "Congratulations." It took me a second to register that they were referring to be being done with the first year of medical student.

There is something fulfilling of transitioning from being a first year medical student to a second year medical student. Although, I have yet to figure out what it really is. In this moment, I am just looking forward to 8 weeks of class-free days. Time to recollect myself and tend to the long list of things to do in San Francisco.

Just about a year ago, I was donning a black gown and square hat, during my college graduation, leaping away from college and inching towards medical school. I remember how excited I was to start medical school. There was the joy of venturing to a new city and a new life, a life that would allow me meet so many unique individuals and to live my lifelong dream of serving patients.

I had no idea what to expect. I was bright-eyed and ready to do most anything (ok not really). I was most looking forward to learning my patients stories and helping them as they coped with their medical conditions; I was excited about learning and becoming versed in all the common acronyms endemic to medical jargon. I was hopeful that I could touch my patients lives.

As I sit here reflecting and thinking back to a time not so long ago, I realize that the first year of medical has been unforgettable, surpassing my initial expectations. I have been humbled by being allowed to enter my patients lives in a whole new way, whether it be taking a medical history, performing a physical exam or assisting in a operation. I have been immersed in a unique learning experience that has taken me to new depths; I have surprised myself and seen myself grow, as I confront the social and cultural complexities of medicine.

I have been privileged to navigate the geography of the human body in anatomy lab, dissecting away skin, fascia and muscles to better view the organs of the body of our donor, who we know nothing about. I have learned so much and forgotten most of what was presented in lecture, but I do remember the patients I have worked with away and walk away with a deeper appreciation for the complexity of the human body, in all its strength and fragility. With a better understanding of the human body, I am poised to embark on the next stage of my medical school journey- working with patients and making medical diagnosis.

In less than a year (April 28, 2009), we will transition to the clerkships. I still struggle to translate my patent's chief complaint, history of present illness and symptoms into a diagnosis. The second year will hopefully allow me to better master this nebulous art. Time will tell...

With the first year pocketed away (pending no e-mail from the course directors), I will now attend to some MS 1 wrap-up activities. Here are the things I need to do:

1. Wash my white coat (it's getting a little dusty and the pockets are bulging, so I might need to purge some of the useless papers that have made residence in the pockets)
2. Bury the MS 1 syllabus somewhere in my closet (I won't be looking at these for some time)
3. Change my e-mail signature from Eisha Z, MS 1 to Eisha Z, MS 2
4. Clean my room (and apartment)
5. Write out my summer to do list.
6. Proceed to completing things on my San Francisco "to do" list (it's a long, ambitious list that mostly is concerned with visiting different neighborhoods, hiking, visiting museums, eating at specific restaurants, spending time with my friends, running, swimming, learning to surf, and the list goes on and on...)

I am looking to forward to the summer vacation. Albeit, it's not a vacation in the traditional sense; I will be sticking around San Francisco and completing a research project and curriculum.

In looking back to my first year, I have really enjoyed writing in this blog; I have no idea who reads this and what others think about me and my path in medicine. I certainly hope I have been able to share my thoughts and reflections to give others a closer view of medicine, as I begin to see medicine. Most importantly, I hope you have enjoyed reading and gained something. I look forward to continue writing (I need to update my profile to reflect that I am a second year medical student). If you stay tuned, you will invariably see some of my latest photographs, hear about my work and life.

For now, I am going to cease the day, knowing that I am 25% of the way to becoming a doctoring! Wow!

2 Days to go

2008-06-21T17:36:00.000-07:00

Today is the first day of summer. Everyone seems to be on summer vacation. Even the library has instituted summer hours (closing @ 7 PM).

I'm not quite feeling the summer vacation vibe yet. I am still counting down days to the end of BMB. Less than 2 days ago.

It's another sunny and warm day in SF and another day staring out the window, surrounded by my best study friends (laptop, colored pens, highligthers, piles of notes, handful of drug tables (that I'll need to memerize at some time, hopefully soon), the syllabus and Neuroanatomy text book). My human friends have been telling me that I am spending way to much time around these guys.

It's coming down to the homestretch and I am sure my brain is spilling information as I sit here.

The exam marathon study homestretch has begun (and it feels I still have so much to cover and understand)! It's the point in the race, when you feel like your body is going to give up due to sheer exhausation and pain from having run the previous distance, or the feeling that comes when you are looking up at the bottom of a really steep hill right before you start running the incline, when you know your muscles are completely done before you even start.

I'm at that mental point, realizing that although there is so much to get through, there is hope that this shall end and I will be done (soon)! Just like the runner, who is motivated to cross the finish, I am inching forward through the massive amount of information to finish the first year of medical school.

2 days to go (and lots of studying and reviewing to go)!

The View from the Inside

2008-06-20T16:41:00.001-07:00

I am just 3 days shy of being finished with my first year of medical school. As I sit here, studying (obviously), I can not help but note that today must be one of the clearest days in San Francisco. From my Fifth Floor seat in the library, I can see the ocean as it hugs the horizon, the water shimmering like little sparkles and zig zags.

The sun is shining, covering the city and adjacent neighborhood in a blanket of warmth. I can feel the heat radiating from the large window that stands between me, the table and the entire world outside. How I want to be outside, running to the ocean or laying the sun or sipping a cup of tea at some corner cafe.

Today was a medical school milestone. We had our last day of class today. Sitting from the back row, I just realized that in less than a year- we will all be scattered throughout the wards, taking care of patients. The days of academic instruction and the days of savoring my classmate's company are numbered...

To celebrate the end of BMB, the course directors awarded the case of day winners, who submitted the most correct responses to cases that were presented at 8:05 AM every morning. The winners received yellow authentic BMB shirts. And in the spirit of the Olympics, the 1st, 2nd and 3rd place winners got to stand on podiums. And to culminate, we all sang the star-spangled banner (I am not sure where this fits in celebrating).

It's hard to believe we have come this far (and it feels like we have just scratched the surface). Studying for this BMB final is just more thing to do on a long list that will follow us through the next few years. I am exhausted, overwhelmed and wondering how I will fit all this information in my already-full brain? We'll see if I can get creative with studying somehow as I brace for a weekend study marathon.

Back to staring out the window...

Less than 3 days to go!

Page 1027

2008-06-19T16:32:00.000-07:00

With some difficulty staying awake and some nodding off, I just read the last page of our BMB syllabus. I have officially finished the 1027th page of our massive syllabus.

The last sentence appropriately ties together the theme of the first year of medical school: "Physicians (in their positions of power influence and authority) are ideally situated to not only ease suffering but to assist their patients in moving beyond and above the painful challenges life has given them" (BMB Syllabus, pg 1027).

Now the challenge is understanding, synthesizing and internalizing the complex concepts threaded through the Brain, Mind and Behavior portions of the course. The picture is hazy with pieces scattered in my mind, power points slides, paragraphs in the syllabus, hand written notes and in the last tiny crevices in my brain.

I must now identify the salient pieces and somehow connect them to create a picture that captures the essence of the block.

With 4 days to go, hopefully this picture gets clear soon!

The Countdown has Begun!!!

2008-06-15T21:22:00.000-07:00

According to the countdown posted on my facebook page, there are 7 days and 16 hours (as I write this) standing between me and the end of the first year of medical school. Along with getting through this upcoming week of lectures, neurology apprenticeship, anesthesia simulator session, MSP, neuorpsychological small group and all the exam reviews sessions, I also need to pencil in time to study for the upcoming BMB cumulative final.

This last week was somewhat momentous. We had our first doctoring final, with mystery patients who presented with actual conditions. We had to perform different parts of the physical exam and reveal our findings; I performed the abdominal exam and the neurological exam. According to the director, the purpose of the exam was not to test us, but to make us realize how much we have learned since starting not so long ago.

We have certainly come along way. We are still completing checklists, but we have better insight into the purpose of why we do the things we do. The motions of palpating or percussing the abdominal are so much natural and less robotic. "I could tell that you were using your hands to feel for anything abnormal," my patient told me, after I completed abdominal exam.

We also had our last small essential core group session for the year. We ended with a neurogenetics session and a group picture. And we made our final trip to the Marena to visit our preceptor's office. We bid farewell to Honcho (the office dog), inflammed noses (purple on the inside) and allergy medicine.

It is odd. Whenever we plan bonfires, the days leading up to the weekend are sunny and warm and then all of a sudden the fogs rolls in on the day of the bonfire. That is San Francisco weather for you- unpredictable and bipolar at times. My friends were talking about this on Saturday as a group of us huddled close to keep ourselves warm during a bonfire at Ocean Beach.

Time with my friends and the bonfire, with all its warmth and glow, was exactly what I needed before I descend into the vortex of studying with limited social interaction. My favorite part of bonfires is definitely the smores, the perfect combination of crunchy (graham cracker), melted (chocolate) and gooey (marshmallow).

I have to admit, this weekend has been unproductive when it comes to studying, or perhaps I need to set more realistic expectations. There is just so much information. Going back to Day 1 of BMB, recalling all the intricacies of the neuroanatomy and all neural circuitry is going to take some work. It's hard enought to recall the information I learned last week. It's going to be that more challenging to relearn the massive amount of information that has invariably escaped my short term memory stores.

It can be discouraging studying at times (kind of feels like the image below). But I know this will pass...and what awaits us at the end is 2 months of summer vacation. Well a pseudo-vacation (I'll be doing research).

Cheers to the last week of BMB (the last full week of MS 1). It's amazing how in 7 days I will be 25% done with medical school, in what feels like a blink of an eye.

The Countdown has officially begun!!!

Weekend Joys

2008-06-07T18:11:00.000-07:00

There is always a calm before the storm.

After a 14-hr lecture week and the second midterm on Monday, we finally got to celebrate the end of the second part of BMB.

With 15 days and a cumulative final exam, standing between us and the end of our first year medical school, I am going to savor this weekend before I begin studying and reviewing all the complex concepts (we were supposed to have learned by now).

Since the start of medical school, I have been anxiously awaiting the Sex and City Movie release. To celebrate the end of our second exam, friends and love (as described by the hopeless romantic), a group of us went to Union Square and finally got our share of Carrie, Samantha, Miranda and Charlotte last night along with a trip to the Cheesecake Factory in Union Square (one more thing I can cross of my "SF To do" list).

I also made my way to Land's End by way of foot during my Saturday morning run and finally got to see Juno, a movie with some of the best quotes of all time.

I am looking forward to spending some much needed time with my closest friends and catching up, while I have a chance. And maybe studying...