Remember to Exhale

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

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

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

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

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

"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

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

"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...