January 30, 2012

free lunch!

     Free Lunch!  That's what the sign said.  Attracts pretty much any med student since we're poor and in way too much debt.  That debt is about to get just a bit bigger.  That 'free lunch' cost me 800 big ones.  It was an advertisement for a prep course for the Step Exam.  Half our class used it last year and their average was well above the national average.  Sounds good to me.  I texted my wife I just bought an $800 lunch and it consisted of a burrito. 
     If I do Family Practice as a career, I want it to be because I choose to do Family Practice.  Not because my scores were so low that it was the only residency program I could get into.  So the next time somebody tells you doctors simply make too much money, think of my $800 burrito.  And the $150,000+ in loans.  And the nearly decade of lost salary that I'm giving up.  Nevermind the personal costs.  And then please ram your fist straight down their throat for me.  No, I guess the old adage is right.  There is no such thing as a free lunch.

January 28, 2012

THE test

     Right after we got back from Christmas vacation, we were required to attend a meeting with a couple of the deans, which needless to say is unusual.  She greeted us with, "welcome to one of your hardest semesters in your training."  In June, we take our first licensing exam known by the boring name of Step I.  Talk about the banality of evil.  Frankly, it's more than a little terrifying as it's a monster exam (8 hours) and pretty much determines one's eligibility for various residency programs.  And medicine keeps getting more and more complicated so there's more for us to know.  More diseases, more genetics, more molecular mechanisms, more drugs, more everything.  To illustrate that point, here's a few slides from a presentation recently given to us.

     The first one represents a question from someone taking the Step I in the 1980s.  It's easy.  It simply asks what drug do you give for thrush.  It gives the diagnosis to you right off the bat.  Yeah, patients do that all the time.  And it even uses the common term 'thrush' rather than the medicalese 'candidiasis'.  The answer is E. Nystatin (though, to be quite honest, the drug doesn't work that well, you have to take it 4 times a day by swishing it around in your mouth, and it tastes like crap - not exactly a wonder drug).

     Then in the 1990s, you are now required to first diagnosis the patient, and then figure out the therapy.  A bit harder as it's now a 2-step process but still not too difficult.

     Now fast forward to this decade.  Rather than a simple question and answer, it's now become a three step process.  First, you have to correctly diagnose the ailment.  Not too hard.  It's thrush.  Wait, what about the picture?  Is that really thrush?  Could it be a bacterium?  Nah, no bacterium looks like that.  Definitely a fungus.  But is it really a Candida species, or is it a different fungus which might alter therapy requirements?  Does Candida have a germ tube or was that whatsitsnamethatIcan'trecall?  They're trying to insert some fuzziness into the question.  But let's stick to our guns and say Candidiasis, aka thrush.  Second step.  What's the drug to give here?  It's still nystatin.  But that's not the question.  They want the mechanism of action of said drug.  So even if you know the mechanism of nystatin, you've first had to diagnose and identify the proper treatment before you can even get around to answering the question.  Or conversely, even if you know the first two but forgotten the mechanism, you're still boned.  It's now a three step process and you've got 60 seconds to answer the question or you start to fall behind.

     And I love this one.  Like before, you have to first identify the ailment of the patient.  It's alzheimer's.  And what goes wrong in alzheimer's?  Memory.  And what part of the brain is that?  Hippocampus.  All of those are relatively easy.  For me it gets substantially harder when I have to harken back to neuroanatomy and recall where the hippocampus is...on an MRI.  Now repeat this process all day long.  Oh, and you are to study for this while taking your regular classes.  Like I said, more than a little terrifying.

January 26, 2012

here it comes

     My dad has an admission date for the stem cell transplant.  It's March 1st.  He'll actually start with getting all the preliminary stuff (echo for the heart, PET scan, lung function, dentist, etc) starting February 15th.  On February 24th, he'll receive his first chemotherapy in the form of Rituxan as an outpatient.  He's had that one before.  The first couple of times, he had a moderate reaction to it but the last three he was fine with it (had them give the steroid before).  Then on March 1st, he gets admitted to the hospital.  That's when the chemo really starts in earnest as they lay waste to his bone marrow.  On March 8th, he receives that (hopefully) life giving stem cell transplant that someone (thank you whomever you are) graciously decided to donate. 
     I'll take this moment to again plug that you, the reader, consider becoming a potential marrow donor.  Just go to bethematch.org and they'll tell you what to do.  It's an inconvenience to you but potentially life saving for the recipient.  Not a bad trade.

January 25, 2012

How Doctors Die

An interesting article about what types of decisions doctors make at the end of life, at least anectdotally.

How Doctors Die

January 20, 2012

strength in weakness

     15th floor.  Leukemia and lymphoma ward.  My dad was admitted here twice, the second time the same day my brother died.  I knew the floor well.  I had finished up with my patient and was waiting for the elevator.  A phenomenal case.  History of FOUR different cancers.  Pulmonary embolism.  Triple coronary bypass.  A stroke.  And still alive and kicking at 80 years young.  Truly a touching experience.
    While waiting for the elevator a young guy walks slowly up with his IV pole.  He's big and broad shouldered.  I'm not exactly slight of frame but he towers over me.  Probably in his early 20s, he sports a baldness that could easily be fashionable but his absence of eyebrows says the lack of hair is due to far more grim reasons.  And below his eyebrows, his eyes catch me.  There is a yearning in them.  Something so elementally human which desired contact.  I hesitate but then decide to let my sorrow and weakness guide me into uncharted elements of human contact. 
    "Taking your pole for a walk, huh.  Have you named it yet?" I ask of him.  He must see some openess back in me which is surprising because I'm told that when I put on my white coat, I assume my old football persona.  A take charge quarterback.  But he sees something different and it comes out in his response.
    "Nah, not yet.....But I should.  It's been my sixth pole.....I've...I've just been angry for so long.  Ya know?  It took awhile to work through that."
    "It is hard.  I watched my brother fight his own battles with those poles."
    "Lymphoma?  How's he doing?" I sensed a hope in his voice that he wanted to hear a story with a happy ending.  Hear how someone beat this damned disease.  Sorry, partner.
    "He passed away this past May due to thymic cancer.  No, it's my dad who has lymphoma."
    "Geez.  You a doctor?"
    "Man, you're getting called to go into cancer."
    I grimly chuckle and reply, "I know.  You sound just like my wife."
    The elevator settles down onto the first floor and the doors open.  I turn to face him,grasp his hand firmly, look him straight in the eyes, and try with all my effort to convey compassion in my own eyes, "Hey, I wish you the best in your fight."
    "You, too.  And God don't make no mistakes."

    A wise and wizened rabbi had counseled our class to engage each patient more fully.  To not be so quick to put up our defences.  To not be afraid to show our humanity.  To truly connect as human beings.  To do everything nearly opposite of what we are doctors are trained to do.  And to do so we would be graced with a more rewarding career and less chance of burning out.  I think I just had my first experience with that being true.

January 18, 2012

it begins anew

"The mills of the gods grind slowly, but they grind exceedingly fine."  Sextus Empiricus ~2nd century AD

     As always, it begins with the phone call.  It's always a phone call.  My brother's disease.  My dad's first strange blood result.  I can remember exactly where I stood on each of these occasions.  This time it heralds that the process of stem cell transplant is starting anew for my dad.  Hope?  Or, cancer calling western medicine's bluff?  The gears of cancer begin to grind again.  Not that they ever stopped.  Perhaps we just stepped out of the mill these past few months.  I could lie and say that I took advantage of this time by making the most of it.  By making every moment count.  By embracing the extra time away from cancer and greeting it with a cheery and grateful disposition. 
     I had a friend whom I hadn't seen in awhile recently ask me how I was doing.  He asked it in a way that meant more than just the idle pleasantries of conversation.  "Surviving," was my answer.  It's not optimistic, but it is honest.  To survive each day, each hour, each minute, even if it feels like I'm failing.  Confront each challenge, even if it's weakly from my knees.  Honor each feeling, even those most hollow and empty.  Take stock of each sunset, even the bittersweet ones.  Not to capitulate but first, to endure.


     Finally, I have a day where I don't have to fight traffic and go to the med center.  An entire glorious day to be very productive while studying at home.  Uh-oh.

I don't know what congress is doing (I can guess they're misguided as usual) but if they're pissing off wikipedia and google, that ain't good for med students.  How the heck am I supposed to learn today?  I need to see about coinfections of HIV and Hepatitis B and how that's treated.  I gotta use a book now?  For rapidly changing fields, those things are outdated before they even hit the printing press.  Seriously, books?  Sigh.

January 14, 2012


     It's been awhile since I've posted.  I was locked out of my google/blogger account and didn't have time to trouble shoot it until now (finally figured it out, no thanks to google) so I'll be posting again after some fun weekend studying.

January 1, 2012


     It's the New Year.  Society dictates that I set goals about what I want to accomplish.  To quote my son, 'Meh'.  My goal is large enough that I don't need anymore to look at.  I looked to the past instead.  I went back and looked at some of my older blog posts.  A cognitive dissonance rapidly set in, to say the least.  Who the hell is writing this?  Why the hell is the guy writing this?  What the hell does he hope to gain?  Surely, he's embellishing this.  But if he's not, he must've really loved his brother...and still loves his family.  What lunatic would continue down a medical path after this happens to his family?  He must be a glutton for punishment.  I think if I were that guy, I probably would've cracked by now...............Only, I am that guy.  B-I-Z-A-R-R-E.