christmas vacation

I'm about ready for classes to start up again. Why? Well, let's just say I'd like to meet whomever started Lowes and beat him with a garden hose. Home improvement. I hate it. I have a shirt with Homer that says DDIY - Don't Do It Yourself. But before this journey started, we had ripped out the carpet of our downstairs floor. At the time, our beloved dog of 13 years (best dog I've ever had) had begun to lose control of his functions. My wife and I both hate carpet anyways so out it came. We were going to put down a nice wood floor. Oops. I got into med school. So long salary. So long wood floor. Hello, concrete. Concrete in a stunning but functional gray with glue leftover from the carpet starts to look a bit tacky, even by my redneck standards. So as a present to us, my dad and brother helped, well drove really, a project to stain our concrete. My brother builds custom cabinets for a living, really nice stuff. For fun, my dad built his house from scratch on a whim. Me? Those construction genes must skipped me entirely. So needless to say, they know what they're doing and if they don't, they have enough experience to figure it out. If it were me, I would've quit after scraping the paint on the concrete for 5 minutes in futility. (photo credit to my wife on the pictures)

Quickrete advertises 3 EZ Steps - Prep, Stain, Seal. It's that simple....yeah, right. Here are the three of us prepping the floor. Want to know why it's expensive to have someone stain your concrete floor? The materials aren't terribly expensive when compared to wood or tile. But there's a LOT of prep work. My bro is on the left hand scraping the paint overspray with a putty knife. Not fun. My dad is happily grinding the concrete. It took the three of us two days to get the floor ready.

Next came the staining. There was a bit of a learning curve on that, like never, never, ever use a pump sprayer that has any metal parts in it when using an acid stain. They failed to mention that in the directions. I still should've figured that one out but to my credit, the acid didn't hurt skin so I thought brass would hold up to it for more than 3 minutes. There's a lot of waiting in between steps. At this point, it's stained and dry. I'm pulling out the leaf blower to remove any dust that's settled on it before sealing.

I sealed myself into a corner, well, out of the house really. I actually was smart enough to plan it that way. I then climbed a ladder into a window along the stairs. This was at 12:30 am so I'm more than a bit tired at this point, never mind inhaling fumes for 4 hours. It's still drying right now but so far it's looking like it'll be really pretty.

Here's what it looks like after drying about 12 hours. One of the cool things (or detriments to perfectionists) is that you never what the staining is going to pattern like. The concrete is highly hetergenous so you get a highly variable staining pattern. I think it makes it beautiful. After the initial round of stain dried, I went back with a squirt bottle to add some "character spots". See the stuff on it? That's hay...as in what horses eat. I needed all the fans I could get so I borrowed some from my dad which were stored in his barn. At the previous step, that stupid box fan blew for over 24 hours straight without so much as a stolon of hay errupting from it's crevices. But after I put the sealant on? It decides to vomit it out in great quantities. My wife wanted rustic...well, she got it.

All in all, I'm really pleased with it and very much graciously indebted to my dad and brother. I'm going to be providing them free healthcare for as long as I practice in return. I don't think many people realize the degree to which whole families kick in to support someone through med school. It's kinda like marriage. You're not just marrying your spouse. You're marrying their whole family. Same deal with med school. Everyone, not just the student, goes through it in some way. But I've had enough of this stuff. I'm ready for something cerebral now.

stupid, part deux

So, I got my board scores back from the biochem final. My wife says I need to be smacked down a bit to prevent me from getting a big head. By some miracle, I knocked the exam out of the park. Not every med school in the nation takes this one but of those that did, I scored in the top 1 percentile. When it got converted over to a number grade for our class, it was a 102.8....out of 100. It bumped my class average up to high pass, and only 1.8 points away from honors. Not sure how it happened. Only thing I can figure is that A) the profs did quite a good job at presenting to us the necessary material and B) this test was very different than the ones we take at school. As I said in the previous post, it was more doctory. It wasn't regurgitation. It was figuring out what ails a patient. That gives me a ton of confidence that I will actually be a good diagnostician. (I can't be a surgeon because despite performing thousands of surgeries on rodents (some quite complex and difficult) I shake pretty bad. It's one thing to have a mouse die on the table because one slipped. It's quite another thing to have a person.) I've had actual doctors tell me that I'll be good at this and then they get confused that I didn't seem to believe them. I guess I needed to prove it to myself. I also learned two other interesting things from this exam. 1 - nearly every single biochemical/metabolic disturbance leads to hepatosplenomegaly. Very non-diagnostic in these instances. Which leads me to #2. 2 - After reading about the 60th question of patient histories, it becomes tedious to read the same symptoms over and over and over . I could feel myself skimming to find the critical one. Hepatomegaly, fatigue, blah, blah, blah, blah, oh, they have lysosomal enzymes in their blood? That's I cell disease and the defect is in the mannose 6 phosphate process. Next! Now, I can completely understand how doctors don't appear to listen when you're reciting your complaints. Probably 90% of the patients in their waiting room have similar vague symptoms that are completely nondescript other than letting you know that something ain't right. They're looking for those 1 or 2 specific symptoms that let them zero in on a diagnosis. And they want you to hurry up and spit it out so they can figure out what's wrong and move on to the next patient. I need to not do that. The nondescript ailments are every bit as real and important to the patient as the diagnostic ones. After all, the discomfort of those general problems are probably what landed them in your clinic in the first place. I need to listen with both ears and full attention. That, and you never know when you might miss something.

pied piper of phlegm

The ingenuity and creativity of Sandy Hawkins is just plain cool. I am always impressed by innovators and inventors, people who are not only able to dream up new ideas, but they are also able to bring them from their mind to something tangible. http://www.popsci.com/bown/2009/innovator/pied-piper-mucus In a nutshell, this device is a simple tube with a reed-like flap that when blown, produces a frequency that immediately loosens phlegm in the lungs. So elegant in its simple physics. It's apparently being reviewed by the FDA for approval in Chronic Pulmonary Obstructive Disease (COPD). As someone who every winter often struggles with bronchitis, I'll probably want to try it out. I'm sure it'd have potential applications in cystic fibrosis patients, as well.

generics

Amidst all of the debate about the cost of healthcare, the concept of generics comes up a lot. What most people don't realize is that drug research companies actually have to do massive clinical trials involving thousands and thousands of people spending nearly a billion dollars in the process. With a price tag like that, there is obviously some vested interest in getting your formulation right. Self interest ain't a bad thing. Generic manufacturers do not have to do that. They just have to do a very small trial in a handful of people where the drug is given once and then blood levels are drawn. That's it. From what I've heard of other docs, generics tend to be ok for things where if the dose is off a bit, it won't matter much. Say you're taking an antiobiotic. The thing has been on the market for years, the synthesis is usually pretty straight forward, and there isn't much to the delivery. You're taking 500 mg of the stuff, sometimes twice a day. If the company is sloppy and only gets it partially right, it's not going to matter much if there is actually only 450 mg of the active compound in the pill. It'll still work. But for other drugs, say coumadin, the difference between the efficacious and lethal dose ain't that wide. There, it's not worth it to play around. Well, some new research from consumerlabs that just came out seems to expands that list. It seems that Teva had come under fire for their generic Wellbutrin, a common antidepressant and smoking cessation drug (and possibly weight loss when combined with another old drug, we'll see how the trials pan out). Well, their product is a slow release and so the synthesis gets a bit trickier. Patients started complaining and one site run by pharmacists (http://www.peoplespharmacy.com/) started to pick up on the signal. They passed on the information to the FDA and it prompted the FDA to require some more trials from Teva. When that'll get completed is anyone's guess and I suspect that the Teva probably knows it cut some corners and will quickly clean those up for the trial. Consumerlabs.com didn't wait. They tested it on their own and it turns out there more than just price differences between the brand and generic. The generic had vastly different kinetics of release which could explain the complaints of patients (wellbutrin without the slow release would need to be taken 3 times a day). So to recap, private citizens complained and a private website picked up on it. Then a private company addressed the complaints. Now consumers should be free to chose. But that's not the way it'll work. We'll need to wait on the ridiculously slow FDA. I think that this is a very salient point when debating a centralized healthcare system where bureaucrats in some far off distant land dictate what works instead of you and your doc deciding together what works best for you. Generics not working? It wouldn't be considered at all by that monolith when the cost savings are blinding them. http://www.peoplespharmacy.com/2007/10/12/generic-drug-eq/

Reason # 432

I was reminded on one of the reasons that medicine appealed to me. I had to go down to visit my gastroenterologist in order to switch meds due to insurance differences. Nothing really changed about my situation (I have some weird dysphagia that is controled with proton pump inhibitors) so we started talking shop. She was very supportive of my decision to enter med school and said that she was proud of me. When asked what year I'm in (my first), her face showed an obvious grimace at my reply. She hated the didactic part. In a nutshell, she said that she didn't remember *blankety blank* from that part of her medical training. This is from a doctor who's waiting room is peppered with numerous awards for her practice and care. She also said that I won't regret it. While it's possible to get burned out, there's always something else new to try with an MD. She loved her practice. And that was the heart of one of the reasons I chose medicine. Everybody got's gripes about what they do but at the end of the day, she made visible impacts in her patient's lives. I saw it firsthand. Want to know how fun it is to be out to dinner with your wife, or worse on a business trip with your CEO and CSO, and have food get stuck at the back of your throat? It won't go down and it won't go up. Let me tell ya, it ain't fun. And this doc helped me to treat that successfully. It was a good, yet not so subtle reminder that this will all be worth it in the end.

it is finished

Done. Breathe. It feels.....weird. While my grey matter can process objective data pretty quickly, it's quite slow to digest and ruminate over emotions. Below all the usual suspects of finishing - relief, joy, free time, etc - runs one that is a bit hard to describe. I am standing upon a continent and the earth begins to move. Something at my core seems to have emerged. A new land mass bubbling up from deep below through a fissure in the land mass. What it is, I don't know yet. The lava hasn't stopped flowing. After that it still must cool, changed by the weather and then colonized by life. Who knows what it will look like then? Or, among the cacophany of often disparate characters that is my psyche, a hereto unknown individual stands up and demands to be counted. Small at first, it is growing, morphing, becoming self aware, and changing with each rising and setting of the moon. Its voice grows as a wave resonates, it's hum growing until its vibrations are palpable.

stupid is as stupid does

When I was growing up, I was what my wife amicably dubbed me a "geek jock". I was the one with straight A's but I also tend to think a bit.....differently than others. I can't explain it. Sometimes my brain just functions off on its own wavelength. For example, whenever doing something stupid like soaking tennis balls in gasoline and then lighting them to kick around and play soccer, I was NOT the responsible one saying, "hmmmm, maybe this isn't so bright." No, I'm the one who had the saying "when doing something stupid, you gotta be smart about it" so I'd make sure we'd have a hose handy. Or, with bb gun wars, we had to wear raquetball goggles. Inevitably, I'd eventually end up doing something stupid and my friends would jab at me, "how can someone so smart be so stupid?" So fast forward a decade or two. It seems I haven't evolved past that point. I'm on cloud 9 after my block III exams. I'm pulling an honors in histo and I'm only 2 points away from high pass in biochem. During the final couple of lectures of the semester, the biochem profs keep talking about the National Board Medical Exam (NBME) and giving pointers on how to do well on it. It's somehow factored into our grade for biochem. Well, knowing absolutely nothing about med school, I just assume that they're referring to the Step I exam, which is the first of three licensing exams to become a doc. Step I is taken at the end of the sophomore year, though. Why do they keep talking about it now? Seems a bit odd. The light bulb is yet to go off. During the review for the final, the prof pulls out a bunch of questions from a website that are simulated NBME questions. They are, shall we say, a tad different than the ones I'm used to seeing on our exams. He'd read the question and then ask people to raise their hands for A, B, etc. I was doing pretty well. They started to get progressively harder and I was one of the few ones still raising my hand for an answer. I wasn't right all the time but I could at least formulate something better than a flip of the coin. Then they got ridiculously hard. The light bulb is yet to go off. Friday morning, I make sure to get to school a bit early so as not to risk getting stuck in traffic and missing the exam (that'd be bad). Got my ritual Chick-fil-a lunch and ipod jamming and I walk up to the wall to check out my seat assignment. I make sure I have the correct class and the title says "National Board Medical Exam Biochemistry". The light bulb begins to flicker. It's not bright 300-watt bulb, mind you. No, it's more like a half-burned out bulb from three Christmases past. But that little filament is starting to glow. Oh, shit. I quickly get my laptop out and go to blackboard. I download the part separate from the syllabus, all the stuff about contact info, whom to call in case of emergency, blah, blah, important details....wait, what was that? That part about the final? Oh, shit. Something about the final is from the NBME and must be passed in order to pass the course. Oh, shit. The light bulb is glowing in all its 3-watt glory now. I quickly race to the NBME website and pull up the biochem section. The questions really don't look much like the exam ones I'm used to. Have I mentioned that I don't do as well on standardized exams? It's because I think a tad differently. The exam is 125 questions and nearly every question presents a small paragraph of a patient case history. That makes for a lllloooonnngggg exam because you really have to think with every question. You can't just go into auto pilot and know that the 6th amino acid is the point of mutation for sickle cell anemia. It's much more.....doctory. Hey, wasn't I complaining about the material not being material to being a doctor? What's that about being careful what you wish for? We essentially had to diagnose what metabolic/biochemical problem was going on in each of these case histories. Let's just say I wasn't exactly prepared for it to the full extent that I could've been. Honestly, I would've kind of enjoyed it had I prepared by studying for this type of exam. But I learned a couple of good life lessons. #1 - Always, always, ALWAYS read the fine print. I did it for my mortgage. Why the hell didn't I do it for the full syllabus? #2 - This situation was probably very good training for becoming a doctor. I went into a situation completely blind, albeit through my own negligence. I didn't panic. I shutout any emotions about anger towards myself for dropping the ball. I kept my wits about me and I stayed focused on solving the problem. I have to pass this test, period......I'm sure I passed the test. You only had to get into the top 7th percentile which equates with getting about 36% of the correct answers. Talk about your curve. That should also speak towards the degree of difficulty, though. Whether I got a score good enough to get high pass in the class is another story. So even though my stupidity makes me think I may not be such a good doc sometimes, the way I reacted after the initial bout of stupidity reassures me that I am capable of being a good doc in the long run. I won't always get everything right initially but I'll always make it right in the long run.

Block III

Block III is done and in the bag. By some miracle, I aced it. I got a 95 on my histo/cell bio exam and a whopping 90 on my biochem. Not too shabby considering I earned a stunning 76 on my Block II biochem exam. Maybe studying really does help. Huh. Live and learn. I'm starting to remember how to be a student and in the process I'm remembering that when I wanted to be, I could actually be a pretty decent student. I'm also playing around with different learning styles and I seemed to have figured out some things that work well for me. That whole 'want' thingy seems to be a problem, though. When I could care less about a subject, I've yet to figure out a way to make myself care long enough to master more than one exam. We'll see how I do on the finals now. I'm determined to make honors in histo/cell biology. Biochem, well that's another story. I was shooting for a high pass (I was two points away as of Block III) but the final may have thrown a bit of a monkey wrench in that. That's another post, though.

alchemy

I'm driving down to the med center to take my first Block III exam. It's a cool crisp morning and the sun is brightly burning against a blue sky for the first time in several days. Rush is cranked up and belting out over the stereo via my ipod and traffic is light. The butterflies in my stomach are forming into attack formation. I am ready. And in an instant everything seems to take on a sharp and utter clarity. There are moments in life where everything seems to not so much pause as to come into focus. Alas, they are but brief moments and almost painful in the knowledge that quiet transcendance is emphemeral. The day to day grind will enter back into the picture. Things will become uncertain and pain rears its head again. One aches for that moment to last unto eternity, or at least through the day. That's not entirely true, or I should say accurate, as that paints an incomplete picture. Alchemy is often viewed as something to be scoffed at. Turn lead into gold? Crazy. But in its time, the alchemy tradition was one that was inherited from the Greeks. It was a rediscovery of modern man - one that sought to take the material elements of his world into his hands and fashion them into something of beauty and value. It was the beginnings of modern day chemistry. The ipod that transmits it's electronic signal over my car stereo is no different in spirit. It takes simple metals and electricity and turns them into piercingly touching sounds. And so are these moments of clarity in life. If you let them, they are moments of alchemy. Signals are sent and received across synapses. Memories are built. The psychological has become the physical. Transformation. Alchemy. To borrow a line from Rush coming out over my ipod: pleasure leaves a fingerprint as surely as mortal pain in memories they resonate and echo back again

last sprint

Well, it'll be the last of many, many, many sprints. Block III exams are tomorrow and then the week after that are the finals.....And then a Christmas break. Unlike Block I where I felt nervous, and Block II where nearly benign apathy had set in, for this final push I'm excited. I'm not exactly sure why but several reasons pop into my mind. The easy one is that I'll be done with this semester. I can be lazy and let my mind wander wherever it desires. I can drink beer and tinker in my yard (I have plans to dig a small pond). But if I go a bit deeper than idle relaxation, it signifies much more. Applying and getting into med school was a lot of work and effort, to be sure. But completing this semester makes it more concrete, more tangible, more expected. Before, everything was uncertain and filled with doubt. Now, it's starting to become familiar, average, routine. And that's a good thing at this stage. A very good thing.

oohhhhmmmmmmm

Over the past few years, I've grown more and more interested in what is described rather simplistically as the mind-body connection. It's common sense that the physical stimuli can alter our mental state. Pain hurts. But the converse is a bit more tricky. Can mental states alter the physical state. I'm sure everyone's known one of the positive thinking happy-go-lucky people. I'm sure their positive thinking works wonders for them. Some of us aren't so cheery, though. But what if you don't necessarily have to believe anything? What if simple mental exercises can still impact health? There's a growing body of evidence that says that it can. Here's an abstract from the recent American Heart Association's annual meeting. Patients with established coronary artery disease were randomized to usual care or usual care with meditation. The meditative group saw a 43% reduction in ALL cause mortality, not just cardiovascular disease. That's not a trivial thing. The caveats are that this was a very small trial (200 patients) with just African American participants. But if a pharmaceutical compound shows a 43% reduction in mortality in patients with established CAD, I can assure you that they'd be quite excited.